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Sok C, Sandhu S, Shah H, Ajay PS, Russell MC, Cardona K, Maegawa F, Maithel SK, Sarmiento J, Goyal S, Kooby DA, Shah MM. Simple Preoperative Imaging Measurements Predict Postoperative Pancreatic Fistula After Pancreatoduodenectomy. Ann Surg Oncol 2024; 31:1898-1905. [PMID: 37968411 PMCID: PMC10922305 DOI: 10.1245/s10434-023-14564-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/22/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE Postoperative pancreatic fistula is a potentially devastating complication after pancreatoduodenectomy (PD). The purpose of this study was to identify features on preoperative computed tomography (CT) imaging that correlate with an increased risk of postoperative pancreatic fistula (POPF). METHODS Patients who underwent PD at our high-volume pancreatic surgery center from 2019 to 2021 were included if CT imaging was available within 8 weeks of surgical intervention. Pancreatic neck thickness (PNT), abdominal wall thickness (AWT), and intra-abdominal distance from pancreas to peritoneum (PTP) were measured by two board-certified radiologists who were blinded to the clinical outcomes. Radiographic measurements, as well as preoperative patient characteristics and intraoperative data, were assessed with univariate and multivariable analysis (MVA) to determine risk for clinically relevant POPF (CR-POPF, grades B and C). RESULTS A total of 204 patients met inclusion criteria. Median PTP was 5.8 cm, AWT 1.9 cm, and PNT 1.3 cm. CR-POPF occurred in 33 of 204 (16.2%) patients. MVA revealed PTP > 5.8 cm (odds ratio [OR] 2.86, p = 0.023), PNT > 1.3 cm (OR 2.43, p = 0.047), soft pancreas consistency (OR 3.47, p = 0.012), and pancreatic duct size ≤ 3.0 mm (OR 4.55, p = 0.01) as independent risk factors for CR-POPF after PD. AWT and obesity were not associated with increased risk of CR-POPF. Patients with PTP > 5.8 cm or PNT > 1.3 cm were significantly more likely to suffer a major complication after PD (39.6% vs. 22.3% and 40% vs. 22.1%, p < 0.008). CONCLUSIONS Patients with a thick pancreatic neck and increased intra-abdominal girth have a heightened risk of CR-POPF after pancreatoduodenectomy, and they experience more serious postoperative complications. We defined a simple CT scan-based measurement tool to identify patients at increased risk of CR-POPF.
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Affiliation(s)
- Caitlin Sok
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Sameer Sandhu
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Hardik Shah
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Pranay S Ajay
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Felipe Maegawa
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Juan Sarmiento
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Subir Goyal
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health of Emory University, Atlanta, GA, USA
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Mihir M Shah
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA.
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Sok C, Sandhu S, Shah H, Ajay PS, Russell MC, Cardona K, Maegawa F, Maithel SK, Sarmiento J, Goyal S, Kooby DA, Shah MM. ASO Visual Abstract: Simple Preoperative Imaging Measurements Predict Postoperative Pancreatic Fistula After Pancreatoduodenectomy. Ann Surg Oncol 2024; 31:1947-1948. [PMID: 38110750 DOI: 10.1245/s10434-023-14730-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Affiliation(s)
- Caitlin Sok
- Division of Surgical Oncology, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Sameer Sandhu
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Hardik Shah
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Pranay S Ajay
- Division of Surgical Oncology, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Maria C Russell
- Division of Surgical Oncology, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Felipe Maegawa
- Division of Surgical Oncology, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Juan Sarmiento
- Division of Surgical Oncology, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Subir Goyal
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health of Emory University, Atlanta, GA, USA
| | - David A Kooby
- Division of Surgical Oncology, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Mihir M Shah
- Division of Surgical Oncology, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA.
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Behrens S, Lillemoe HA, Dineen SP, Russell MC, Visser B, Berman RS, Farma JM, Grubbs E, Davis JL. ASO Visual Abstract: Perceptions of Readiness for Practice After Complex General Surgical Oncology Fellowship: A Survey Study. Ann Surg Oncol 2024; 31:1204. [PMID: 38036928 DOI: 10.1245/s10434-023-14667-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Shay Behrens
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Heather A Lillemoe
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean P Dineen
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Maria C Russell
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Brendan Visser
- Department of General Surgery, Stanford Hospital, Stanford, CA, USA
| | - Russell S Berman
- Division of Surgical Oncology, Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Jeffrey M Farma
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Elizabeth Grubbs
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeremy L Davis
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA.
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Behrens S, Lillemoe HA, Dineen SP, Russell MC, Visser B, Berman RS, Farma JM, Grubbs E, Davis JL. Perceptions of Readiness for Practice After Complex General Surgical Oncology Fellowship: A Survey Study. Ann Surg Oncol 2024; 31:31-41. [PMID: 37936022 PMCID: PMC10695882 DOI: 10.1245/s10434-023-14524-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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/16/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Surgical subspecialty training aims to meet the needs of practicing surgeons and their communities. This study investigates career preparedness of Complex General Surgical Oncology (CGSO) fellowship graduates, identifies factors associated with practice readiness, and explores potential opportunities to improve the current training model. METHODS The Society of Surgical Oncology partnered with the National Cancer Institute to conduct a 36-question survey of CGSO fellowship graduates from 2012 to 2022. RESULTS The overall survey response rate was 38% (221/582) with a slight male predominance (63%). Forty-six percent of respondents completed their fellowship after 2019. Factors influencing fellowship program selection include breadth of cancer case exposure (82%), mentor influence (66%), and research opportunities (38%). Overall, graduates reported preparedness for practice; however, some reported unpreparedness in research (18%) and in specific clinical areas: thoracic (43%), hyperthermic intraperitoneal chemotherapy (HIPEC) (15%), and hepato-pancreato-biliary (15%) surgery. Regarding technical preparedness, 70% reported being "very prepared". Respondents indicated lack of preparedness in robotic (63%) and laparoscopic (33%) surgery approaches. Suggestions for training improvement included increased autonomy and case volumes, program development, and research infrastructure. Current practice patterns by graduates demonstrated discrepancies between ideal contracts and actual practice breakdowns, particularly related to the practice of general surgery. CONCLUSIONS This study of CGSO fellowship graduates demonstrates potential gaps between trainee expectations and the realities of surgical oncology practice. Although CGSO fellowship appears to prepare surgeons for careers in surgical oncology, there may be opportunities to refine the training model to better align with the needs of practicing surgical oncologists.
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Affiliation(s)
- Shay Behrens
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Heather A Lillemoe
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean P Dineen
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Maria C Russell
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Brendan Visser
- Department of General Surgery, Stanford Hospital, Stanford, CA, USA
| | - Russell S Berman
- Division of Surgical Oncology, Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Jeffrey M Farma
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Elizabeth Grubbs
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeremy L Davis
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA.
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Lee RM, Russell MC. Is Screening for Hepatocellular Carcinoma Effective? Adv Surg 2023; 57:73-86. [PMID: 37536863 DOI: 10.1016/j.yasu.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Hepatocellular carcinoma occurs primarily in patients with cirrhosis and is an important cause of cancer death. Screening for hepatocellular carcinoma every 6 months with ultrasound with or without alpha fetoprotein measurement is recommended by multiple professional societies. There are no randomized controlled trials in patients with cirrhosis documenting the effectiveness of screening in improving survival, however, making screening controversial. There are multiple retrospective and cohort studies, as well as pooled analyses that do show an association of screening with earlier stage at diagnosis, increased receipt of curative intent treatment, and improved overall survival. Though these studies are limited by lead and length time biases, they make compelling arguments in favor of screening. Additional research into barriers to receiving screening, barriers to receiving treatment, and the optimal screening modalities given the shift of cirrhosis etiology in the United States are needed to further improve patient outcomes.
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Affiliation(s)
- Rachel M Lee
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Maria C Russell
- Department of Surgery, Division of Surgical Oncology, Emory University, Emory University Hospital Midtown, 9th Floor MOT, 550 Peachtree Street, Atlanta, GA 30308, USA.
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Ajay PS, Eng NL, Sok CP, Mustin DE, Cardona K, Sarmiento JM, Shah MM, Russell MC, Maithel SK, Kooby DA. Early experience with robotic central pancreatectomy with patient-reported outcomes and comparison with open central pancreatectomy. J Surg Oncol 2023. [PMID: 37021327 DOI: 10.1002/jso.27266] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Robotic central pancreatectomy (CP) has emerged in recent years as a noninferior approach to open CP and may offer improved patient-reported outcomes and reduction in incisional hernias. METHODS All patients who underwent open and robotic CP between (2013 and 2022) were selected, and perioperative outcomes were analyzed. Patients who underwent robotic CP were interviewed over the phone to assess patient-reported postoperative outcomes. RESULTS A total of 18 CP operations (56%-open vs. 44%-robotic) were identified. The overall median age was 67 years (interquartile range: 60-72), and 50% (n = 9) of patients were female. Median length of surgery was statistically longer for robotic CP (411 vs. 138 min, p = 0.002); all other intraoperative variables were similar. Postoperatively, a similar number of patients in the open and robotic cohorts developed clinically significant postoperative pancreatic fistulas (37.5% vs. 30%, p = 1) and major complications (37.5% vs. 20%, p = 0.60), respectively. No patients in the robotic cohort developed an incisional hernia, compared to 40% (n = 4) in open (p = 0.08). All patients returned to a baseline level of activity and reported a high quality of life. CONCLUSION With the exception of longer operative times, robotic CP is a noninferior, definitive resection technique for select lesions of the middle pancreas. Additionally, the robotic approach may result in a reduction in incisional hernia development.
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Affiliation(s)
- Pranay S Ajay
- Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nina L Eng
- Department of General Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Caitlin P Sok
- Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Danielle E Mustin
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Juan M Sarmiento
- Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mihir M Shah
- Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maria C Russell
- Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David A Kooby
- Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
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Bonanno A, Dixon M, Binongo J, Force SD, Sancheti MS, Pickens A, Kooby DA, Staley CA, Russell MC, Cardona K, Shah MM, Gillespie TW, Fernandez F, Khullar O. Recovery of Patient-reported Quality of Life After Esophagectomy. Ann Thorac Surg 2023; 115:854-861. [PMID: 36526007 DOI: 10.1016/j.athoracsur.2022.12.015] [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] [Received: 11/05/2021] [Revised: 11/20/2022] [Accepted: 12/06/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Esophagectomy is an important, but potentially morbid, operation used to treat benign and malignant conditions that may significantly impact patient quality of life (QOL). Patient-reported outcomes (PROs) are measures of QOL that come directly from patient self-report. This study characterizes patterns of change and recovery in PROs in the first year after esophagectomy. METHODS Longitudinal QOL scores measuring physical function, pain, and dyspnea were obtained from esophagectomy patients during all clinic visits. PRO scores were obtained using the National Institutes of Health-sponsored Patient-Reported Outcomes Measurement Information System from April 2018 to February 2021. Mean PRO scores over 100 days after surgery were compared with baseline PRO scores using mixed-effects modeling with compound symmetry correlational structure. RESULTS One hundred three patients with PRO results were identified. Reasons for esophagectomy were malignancy (87.4%), achalasia (5.8%), stricture (5.8%), and dysplasia (1.0%). When comparing mean PRO scores at visits ≤ 50 days after surgery with preoperative PRO scores, physical function scores declined by 27.3% (P < .001), whereas dyspnea severity and pain interference scores had increased by 24.5% (P < .001) and 17.1% (P < .001), respectively. Although recovery occurred over the course of the 100 days after surgery, mean physical function scores and dyspnea scores were still 12.7% (P = .02) and 26.4% (P = .001) worse, respectively, than mean preoperative levels. CONCLUSIONS Despite declines in QOL scores immediately after esophagectomy, recovery back toward baseline was observed during the first 100 days. These findings are of considerable importance when counseling patients regarding esophagectomy, tracking recovery, and implementing quality improvement initiatives. Further long-term follow-up is needed to determine recovery beyond 100 days.
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Affiliation(s)
- Alicia Bonanno
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Meredith Dixon
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jose Binongo
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Seth D Force
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Manu S Sancheti
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Allan Pickens
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - David A Kooby
- Division of Surgical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Charles A Staley
- Division of Surgical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Maria C Russell
- Division of Surgical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Kenneth Cardona
- Division of Surgical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Mihir M Shah
- Division of Surgical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Theresa W Gillespie
- Division of Surgical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Felix Fernandez
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Onkar Khullar
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
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Mason MC, Russell MC, Massarweh NN. Adjuvant Therapy for Pancreatic Adenocarcinoma-Leaving No Rock Unturned. JAMA Oncol 2023; 9:305-307. [PMID: 36480184 DOI: 10.1001/jamaoncol.2022.5786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Meredith C Mason
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Nader N Massarweh
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Surgery and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
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Leder Macek AJ, Wang A, Turgeon MK, Lee RM, Russell MC, Porembka MR, Alterio R, Ju M, Kronenfeld J, Goel N, Datta J, Maker AV, Fernandez M, Richter H, Berman RS, Correa-Gallego C, Lee AY. Diagnostic laparoscopy is underutilized in the staging of gastric adenocarcinoma regardless of hospital type: An US safety net collaborative analysis. J Surg Oncol 2022; 126:649-657. [PMID: 35699351 PMCID: PMC10029827 DOI: 10.1002/jso.26972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/12/2022] [Accepted: 05/22/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Diagnostic laparoscopy (DL) is a key component of staging for locally advanced gastric adenocarcinoma (GA). We hypothesized that utilization of DL varied between safety net (SNH) and affiliated tertiary referral centers (TRCs). METHODS Patients diagnosed with primary GA eligible for DL were identified from the US Safety Net Collaborative database (2012-2014). Clinicopathologic factors were analyzed for association with use of DL and findings on DL. Overall survival (OS) was analyzed by Kaplan-Meier method. RESULTS Among 233 eligible patients, 69 (30%) received DL, of which 24 (35%) were positive for metastatic disease. Forty percent of eligible SNH patients underwent DL compared to 21.5% at TRCs. Lack of insurance was significantly associated with decreased use of DL (OR 0.48, p < 0.01), while African American (OR 6.87, p = 0.02) and Asian race (OR 3.12, p ≤ 0.01), signet ring cells on biopsy (OR 3.14, p < 0.01), and distal tumors (OR 1.62, p < 0.01) were associated with increased use. Median OS of patients with a negative DL was better than those without DL or a positive DL (not reached vs. 32 vs. 12 months, p < 0.005, Figure 1). CONCLUSIONS Results from DL are a strong predictor of OS in GA; however, the procedure is underutilized. Patients from racial minority groups were more likely to undergo DL, which likely accounts for higher DL rates among SNH patients.
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Affiliation(s)
- Aleeza J. Leder Macek
- Department of Surgery, Division of Surgical Oncology, NYU Langone Health, New York, New York, USA
| | - Annie Wang
- Department of Surgery, Division of Surgical Oncology, NYU Langone Health, New York, New York, USA
| | - Michael K. Turgeon
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Rachel M. Lee
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Maria C. Russell
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Matthew R. Porembka
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Rodrigo Alterio
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Michelle Ju
- Department of Surgery, Division of Surgical Oncology, Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, Florida, USA
| | - Joshua Kronenfeld
- Department of Surgery, Division of Surgical Oncology, Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, Florida, USA
| | - Neha Goel
- Department of Surgery, Division of Surgical Oncology, Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, Florida, USA
| | - Jashodeep Datta
- Department of Surgery, Division of Surgical Oncology, Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, Florida, USA
| | - Ajay V. Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Manuel Fernandez
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Harry Richter
- Department of Surgery, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois, USA
| | - Russell S. Berman
- Department of Surgery, Division of Surgical Oncology, NYU Langone Health, New York, New York, USA
| | - Camilo Correa-Gallego
- Department of Surgery, Division of Surgical Oncology, NYU Langone Health, New York, New York, USA
| | - Ann Y. Lee
- Department of Surgery, Division of Surgical Oncology, NYU Langone Health, New York, New York, USA
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Lee RM, Darby R, Medin CR, Haser GC, Mason MC, Miller LS, Staley CA, Maithel SK, Russell MC. Implementation of a Hepatocellular Carcinoma Screening Program for At-risk Patients Safety-Net Hospital: A Model for National Dissemination. Ann Surg 2022; 276:545-553. [PMID: 35837969 PMCID: PMC9675906 DOI: 10.1097/sla.0000000000005582] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to enhance hepatocellular carcinoma (HCC) screening to achieve earlier diagnosis of patients with hepatitis C (HCV) cirrhosis in our Safety-Net population. BACKGROUND Adherence to HCC screening guidelines at Safety-Net hospitals is poor. Only 23% of patients with HCC at our health system had a screening exam within 1-year of diagnosis and 46% presented with stage IV disease. HCV-induced cirrhosis remains the most common etiology of HCC (75%) in our patients. METHODS In the setting of an established HCV treatment clinic, an HCC screening quality improvement initiative was initiated for patients with stage 3 fibrosis or cirrhosis by transient elastography. The program consisted of semiannual imaging. Navigators scheduled imaging appointments and tracked compliance. RESULTS From April 2018 to April 2021, 318 patients were enrolled (mean age 61 years, 81% Black race, 38% uninsured). Adherence to screening was higher than previously reported: 94%, 75%, and 74% of patients completed their first, second, and third imaging tests. Twenty-two patients (7%) were diagnosed with HCC; 55% stage I and 14% stage IV. All patients were referred and 13 (59%) received treatment. Median time to receipt of treatment was 77 days (range, 32-282). Median overall survival for treated patients was 32 months. CONCLUSIONS Implementation of an HCC screening program at a safety-net hospital is feasible and facilitated earlier diagnosis in this study. Patient navigation and tracking completion of imaging tests were key components of the program's success. Next steps include expanding the program to additional at-risk populations.
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Affiliation(s)
- Rachel M Lee
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Rapheisha Darby
- Grady Liver Clinic, Primary Care Centers, Grady Memorial Hospital, Atlanta, GA
| | - Caroline R Medin
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Grace C Haser
- Department of Medicine, Division of General Internal Medicine, Emory University, Atlanta, GA
| | - Meredith C Mason
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Lesley S Miller
- Department of Medicine, Division of General Internal Medicine, Emory University, Atlanta, GA
| | - Charles A Staley
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Shishir K Maithel
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Maria C Russell
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
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Edwards GC, Wong SL, Russell MC, Winslow ER, Shaffer VO, Pawlik TM. Society for Surgery of the Alimentary Tract Health Care Quality and Outcomes Committee Webinar: Addressing Disparities. J Gastrointest Surg 2022; 26:997-1005. [PMID: 35318595 DOI: 10.1007/s11605-022-05300-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/09/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Gretchen C Edwards
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandra L Wong
- Department of Surgery, Dartmouth-Hitchcock and Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Maria C Russell
- Department of Surgery, Winship Cancer Institute at Emory University, Atlanta, GA, USA
| | - Emily R Winslow
- Department of Surgery, Medstar Georgetown Medical Center, Washington, DC, USA
| | - Virginia O Shaffer
- Department of Surgery, Winship Cancer Institute at Emory University, Atlanta, GA, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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12
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Nash R, Russell MC, Miller-Kleinhenz JM, Collin LJ, Ross-Driscoll K, Switchenko JM, McCullough LE. Understanding gastrointestinal cancer mortality disparities in a racially and geographically diverse population. Cancer Epidemiol 2022; 77:102110. [PMID: 35144126 PMCID: PMC8923985 DOI: 10.1016/j.canep.2022.102110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 01/13/2022] [Accepted: 01/16/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Gastrointestinal (GI) cancers represent a diverse group of diseases. We assessed differences in geographic and racial disparities in cancer-specific mortality across subtypes, overall and by patient characteristics, in a geographically and racially diverse US population. METHODS Clinical, sociodemographic, and treatment characteristics for patients diagnosed during 2009-2014 with colorectal cancer (CRC), pancreatic cancer, hepatocellular carcinoma (HCC), or gastric cancer in Georgia were obtained from the Surveillance, Epidemiology, and End Results Program database. Patients were classified by geography (rural or urban county) and race and followed for cancer-specific death. Multivariable Cox proportional hazards models were used to calculate stratified hazard ratios (HR) and 95% confidence intervals (CIs) for associations between geography or race and cancer-specific mortality. RESULTS Overall, 77% of the study population resided in urban counties and 33% were non-Hispanic Black (NHB). For all subtypes, NHB patients were more likely to reside in urban counties than non-Hispanic White patients. Residing in a rural county was associated with an overall increased hazard of cancer-specific mortality for HCC (HR = 1.15, 95% CI = 1.02-1.31), pancreatic (HR = 1.11, 95% CI = 1.03-1.19), and gastric cancer (HR = 1.17, 95% CI = 1.03-1.32) but near-null for CRC. Overall racial disparities were observed for CRC (HR = 1.18, 95% CI = 1.11-1.25) and HCC (HR = 1.12, 95% CI = 1.01-1.24). Geographic disparities were most pronounced among HCC patients receiving surgery. Racial disparities were pronounced among CRC patients receiving any treatment. CONCLUSION Geographic disparities were observed for the rarer GI cancer subtypes, and racial disparities were pronounced for CRC. Treatment factors appear to largely drive both disparities.
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Affiliation(s)
- Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | - Maria C Russell
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Lindsay J Collin
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Katherine Ross-Driscoll
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lauren E McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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13
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Nizam W, Fackche N, Pessoa B, Kubi B, Cloyd JM, Grotz T, Fournier K, Dineen S, Veerapong J, Baumgartner JM, Clarke C, Patel SH, Wilson GC, Lambert L, Abbott DE, Vande Walle KA, Lee B, Raoof M, Maithel SK, Russell MC, Zaidi MY, Johnston FM, Greer JB. Prognostic Significance of Preoperative Tumor Markers in Pseudomyxoma Peritonei from Low-Grade Appendiceal Mucinous Neoplasm: a Study from the US HIPEC Collaborative. J Gastrointest Surg 2022; 26:414-424. [PMID: 34506026 DOI: 10.1007/s11605-021-05075-1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/07/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tumor markers are commonly utilized in the diagnostic evaluation, treatment decision making, and surveillance of appendiceal tumors. In this study, we aimed to determine the prognostic significance of elevated preoperative tumor markers in patients with pseudomyxoma peritonei secondary to low-grade appendiceal mucinous neoplasm who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. METHODS Using a multi-institutional database, eligible patients with measured preoperative tumor markers [carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9), or cancer antigen 125 (CA-125)] were identified. Univariate and multivariate Cox-proportional hazards regression analysis assessed relationships between normal and elevated serum tumor markers with progression-free and overall survival in the context of multiple clinicopathologic variables. RESULTS zTwo hundred and sixty-four patients met criteria. CEA was the most commonly measured tumor marker (97%). Patients who had any elevated tumor marker had a higher peritoneal carcinomatosis index (PCI) as compared to those with normal range markers. Elevated CEA and CA 19-9 levels were individually associated with longer inpatient length of stay, requirement for intraoperative transfusion, and incomplete cytoreduction. Utilization of neoadjuvant chemotherapy, increased PCI score, elevated CA 19-9 (p = 0.007), and CA-125 levels (p = 0.01) were predictive of decreased progression-free survival on univariate analysis. However, in a multivariate model, only elevated PCI was a statistically significant predictor of progression-free survival. CONCLUSION Elevated preoperative tumor markers indicate a higher burden of disease but are not independently associated with survival in this retrospective multi-institutional cohort. Further prospective studies are needed to clarify the utility of these markers in this patient population.
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Affiliation(s)
- Wasay Nizam
- Department of Surgery, Johns Hopkins University, 600 N. Wolfe Street/Blalock 609, Baltimore, MD, 21287, USA
| | - Nadege Fackche
- Department of Surgery, Johns Hopkins University, 600 N. Wolfe Street/Blalock 609, Baltimore, MD, 21287, USA
| | - Bernardo Pessoa
- Department of Surgery, Johns Hopkins University, 600 N. Wolfe Street/Blalock 609, Baltimore, MD, 21287, USA
| | - Boateng Kubi
- Department of Surgery, Johns Hopkins University, 600 N. Wolfe Street/Blalock 609, Baltimore, MD, 21287, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Travis Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Jula Veerapong
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
| | - Joel M Baumgartner
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
| | - Callisia Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Laura Lambert
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Daniel E Abbott
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Kara A Vande Walle
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Byrne Lee
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, USA
| | - Mustafa Raoof
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, USA
| | - Maria C Russell
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, USA
| | - Mohammad Y Zaidi
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University, 600 N. Wolfe Street/Blalock 609, Baltimore, MD, 21287, USA
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University, 600 N. Wolfe Street/Blalock 609, Baltimore, MD, 21287, USA.
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Shah MM, Ajay PS, Meltzer RS, Jajja MR, Gullickson CR, Cardona K, Russell MC, Sarmiento JM, Maithel SK, Kooby DA. The aborted Whipple: Why, and what happens next? J Surg Oncol 2022; 125:642-645. [PMID: 35015302 DOI: 10.1002/jso.26781] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 12/15/2021] [Accepted: 12/19/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND For patients with periampullary adenocarcinoma (PAC), pancreatoduodenectomy (PD) provides the best survival. Surgery on a subset of patients is aborted during PD. We analyzed these patients. METHODS Patients who underwent laparotomy for planned PD for PAC were identified (2006-2019). From operative notes, we identified the subset with intraoperative decision to abort. Patient, treatment, and outcome data were analyzed. The subset with pancreatic ductal adenocarcinoma (PDAC) was analyzed for survival. RESULTS Only 6.7% (n = 55/819) of cases were aborted. Majority 78% (n = 43) had pathologically-confirmed diagnoses at time of surgery, and 18.2% (n = 10) received preoperative chemotherapy. Reasons for aborted PD included: distant metastases (65.5%, n = 36) and local invasion (34.5%, n = 19). Of patients with metastatic disease, 75% (n = 27) had liver metastases. Eighty-nine percent (n = 49) of patients underwent at least one palliative bypass procedure and 81.8% (n = 45) had both gastric and biliary bypass. Patients with computed tomography (CT) scans before surgery more commonly had missed metastatic disease (79.2% CT compared to 54.8% magnetic resonance imaging [MRI], χ2 = 3.54, p = 0.059). In PDAC, 61.4% (n = 27/44) were aborted for metastatic disease and 38.7% (n = 17/44) for local invasion. Median overall survival for all PDAC patients after aborted PD was 334 days. CONCLUSION Majority of pancreatoduodenectomies for periampullary adenocarcinoma are done to completion. Liver metastases is the most common reason for aborting. Preoperative MRI may help identify hepatic metastases.
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Affiliation(s)
- Mihir M Shah
- Department of Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Pranay S Ajay
- Department of Surgical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rebecca S Meltzer
- Department of General Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Mohammad R Jajja
- Division of Transplantation, University of Alabama, Birmingham, Alabama, USA
| | - Cricket R Gullickson
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kenneth Cardona
- Department of Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maria C Russell
- Department of Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Juan M Sarmiento
- Department of Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shishir K Maithel
- Department of Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David A Kooby
- Department of Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
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Turgeon MK, Lee RM, Keilson JM, Ju MR, Porembka MR, Alterio RE, Kronenfeld J, Datta J, Goel N, Wang A, Lee AY, Fernandez M, Richter H, Maker AV, Maithel SK, Russell MC. Is there a difference in utilization of a perioperative treatment approach for gastric cancer between safety net hospitals and tertiary referral centers? J Surg Oncol 2021; 124:551-559. [PMID: 34061369 PMCID: PMC8394621 DOI: 10.1002/jso.26554] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/15/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Perioperative therapy is a favored treatment strategy for gastric cancer. We sought to assess utilization of this approach at safety net hospitals (SNH) and tertiary referral centers (TRC). MATERIALS AND METHODS Patients in the US Safety Net Collaborative (2012-2014) with resectable gastric cancer across five SNH and their sister TRC were included. Primary outcomes were receipt of neoadjuvant chemotherapy (NAC) and perioperative therapy. RESULTS Of 284 patients, 36% and 64% received care at SNH and TRC. The distribution of Stage II/III resectable disease was similar across facilities. Receipt of NAC at SNH and TRC was similar (56% vs. 46%, p = 0.27). Compared with overall clinical stage, 38% and 36% were pathologically downstaged at SNH and TRC, respectively. Among patients who received NAC, those who also received adjuvant chemotherapy at SNH and TRC were similar (66% vs. 60%, p = 0.50). Asian race and higher clinical stage were associated with receipt of perioperative therapy (both p < 0.05) while treatment facility type was not. CONCLUSIONS There was no difference in utilization of a perioperative treatment strategy between facility types for patients with gastric cancer. Pathologic downstaging from NAC was similar across treatment facilities, suggesting similar quality and duration of therapy. Treatment at an SNH is not a barrier to receiving standard-of-care perioperative therapy for gastric cancer.
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Affiliation(s)
- Michael K. Turgeon
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Rachel M. Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jessica M. Keilson
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Michelle R. Ju
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Matthew R. Porembka
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Rodrigo E. Alterio
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Joshua Kronenfeld
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jashodeep Datta
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Neha Goel
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Annie Wang
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York City, New York, USA
| | - Ann Y. Lee
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York City, New York, USA
| | - Manuel Fernandez
- Division of Surgical Oncology, Department of Surgery, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Harry Richter
- Division of Surgical Oncology, Department of Surgery, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Ajay V. Maker
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Maria C. Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
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Kronenfeld JP, Collier AL, Turgeon MK, Ju M, Alterio R, Wang A, Fernandez M, Porembka MR, Richter H, Lee AY, Russell MC, Merchant NB, Maker AV, Datta J. Attrition during neoadjuvant chemotherapy for gastric adenocarcinoma is associated with decreased survival: A United States Safety-Net Collaborative analysis. J Surg Oncol 2021; 124:1317-1328. [PMID: 34379324 DOI: 10.1002/jso.26638] [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: 06/28/2021] [Revised: 07/25/2021] [Accepted: 07/26/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) is standard management for localized gastric cancer (GC). Attrition during NAC due to treatment-related toxicity or functional decline is considered a surrogate for worse biologic outcomes; however, data supporting this paradigm are lacking. We investigated factors predicting attrition and its association with overall survival (OS) in GC. METHODS Patients with nonmetastatic GC initiating NAC were identified from the US Safety-Net Collaborative (2012-2014). Patient/treatment-related characteristics were compared between attrition/nonattrition cohorts. Cox models determined factors associated with OS. RESULTS Of 116 patients initiating NAC, attrition during prescribed NAC occurred in 24%. No differences were observed in performance status, comorbidities, treatment at safety-net hospital, or clinicopathologic factors between cohorts. Despite absence of distinguishing factors, attrition was associated with worse OS (median: 11 vs. 37 months; p = 0.01) and was an independent predictor of mortality (hazard ratio [HR]: 4.7, 95% confidence interval [CI]: 1.5-15.2; p = 0.02). Fewer patients with attrition underwent curative-intent surgery (39% vs. 89%; p < 0.001). Even in patients undergoing surgical exploration (n = 89), NAC attrition remained an independent predictor of worse OS (HR: 50.8, 95% CI: 3.6-717.8; p = 0.004) despite similar receipt of adjuvant chemotherapy. CONCLUSION Attrition during NAC for nonmetastatic GC is independently associated with worse OS, even in patients undergoing surgery. Attrition during NAC may reflect unfavorable tumor biology not captured by conventional staging metrics.
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Affiliation(s)
- Joshua P Kronenfeld
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Amber L Collier
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Michael K Turgeon
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Michelle Ju
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Rodrigo Alterio
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Annie Wang
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Manuel Fernandez
- Division of Surgical Oncology, Department of Surgery, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Matthew R Porembka
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Harry Richter
- Division of Surgical Oncology, Department of Surgery, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Ann Y Lee
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jashodeep Datta
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
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Kronenfeld JP, Ryon EL, Goldberg D, Lee RM, Yopp A, Wang A, Lee AY, Luu S, Hsu C, Silberfein E, Russell MC, Merchant NB, Goel N. Survival inequity in vulnerable populations with early-stage hepatocellular carcinoma: a United States safety-net collaborative analysis. HPB (Oxford) 2021; 23:868-876. [PMID: 33487553 PMCID: PMC8205960 DOI: 10.1016/j.hpb.2020.11.1150] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/12/2020] [Accepted: 11/24/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Access to health insurance and curative interventions [surgery/liver-directed-therapy (LDT)] affects survival for early-stage hepatocellular carcinoma (HCC). The aim of this multi-institutional study of high-volume safety-net hospitals (SNHs) and their tertiary-academic-centers (AC) was to identify the impact of type/lack of insurance on survival disparities across hospitals, particularly SNHs whose mission is to minimize insurance related access-to-care barriers for vulnerable populations. METHODS Early-stage HCC patients (2012-2014) from the US Safety-Net Collaborative were propensity-score matched by treatment at SNH/AC. Overall survival (OS) was the primary outcome. Multivariable Cox proportional-hazard analysis was performed accounting for sociodemographic/clinical parameters. RESULTS Among 925 patients, those with no insurance (NI) had decreased curative surgery, compared to those with government insurance (GI) and private insurance [PI, (PI-SNH:60.5% vs. GI-SNH:33.1% vs. NI-SNH:13.6%, p < 0.001)], and decreased median OS (PI-SNH:32.1 vs. GI-SNH:22.8 vs. NI-SNH:9.4 months, p = 0.002). On multivariable regression controlling for sociodemographic/clinical parameters, NI-SNH (HR:2.5, 95% CI:1.3-4.9, p = 0.007) was the only insurance type/hospital system combination with significantly worse OS. CONCLUSION NI-SNH patients received less curative treatment than other insurance/hospitals types suggesting that treatment barriers, beyond access-to-care, need to be identified and addressed to achieve survival equity in early-stage HCC for vulnerable populations (NI-SNH).
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Affiliation(s)
- Joshua P Kronenfeld
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA
| | - Emily L Ryon
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA
| | - David Goldberg
- Division of Digestive Health and Liver Disease, Department of Medicine, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Rachel M Lee
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, 1365-C Clifton Road NE Atlanta, 30322, Georgia
| | - Adam Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, 2201 Inwood Rd 3rd Floor Suite 500, Dallas, TX 75390, USA
| | - Annie Wang
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, 160 East 34th Street, 3rd Floor, New York, NY, 10016, USA
| | - Ann Y Lee
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, 160 East 34th Street, 3rd Floor, New York, NY, 10016, USA
| | - Sommer Luu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Cary Hsu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Eric Silberfein
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Maria C Russell
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, 1365-C Clifton Road NE Atlanta, 30322, Georgia
| | - Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA
| | - Neha Goel
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA.
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18
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Turgeon MK, Lee RM, Gamboa AC, Yopp A, Ryon EL, Goel N, Wang A, Lee AY, Luu S, Hsu C, Silberfein E, Maithel SK, Russell MC. Impact of hepatitis C treatment on long-term outcomes for patients with hepatocellular carcinoma: a United States Safety Net Collaborative Study. HPB (Oxford) 2021; 23:422-433. [PMID: 32778389 PMCID: PMC7970452 DOI: 10.1016/j.hpb.2020.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 03/25/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Widespread HCV treatment for hepatocellular carcinoma (HCC) patients remains limited. Our aim was to evaluate the association of HCV treatment with survival and assess barriers to treatment. METHODS Patients in the U.S. Safety Net Collaborative with HCV and HCC were included. Primary outcome was overall survival (OS). Secondary outcomes were recurrence-free survival (RFS) and barriers to receiving HCV treatment. RESULTS Of 941 patients, 57% received care at tertiary referral centers (n=533), 74% did not receive HCV treatment (n=696), 6% underwent resection (n=54), 17% liver transplant (n=163), 50% liver-directed therapy (n=473), and 7% chemotherapy (n=60). HCV treatment was associated with improved OS compared to no HCV treatment (70 vs 21 months, p<0.01), persisting across clinical stages, HCC treatment modalities, and treatment facilities (all p<0.01). Surgical patients who received HCV treatment had improved RFS compared to those who did not (91 vs 80 months, p=0.03). On MVA, HCV treated patients had improved OS and RFS. On MVA, factors associated with failure to receive HCV treatment included Black race, higher MELD, and advanced clinical stage (all p<0.05). CONCLUSION HCV treatment for HCC patients portends improved survival, regardless of clinical stage, HCC treatment, or facility type. Efforts must address barriers to HCV treatment.
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Affiliation(s)
- Michael K Turgeon
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA.
| | - Rachel M Lee
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Adriana C Gamboa
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Adam Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Emily L Ryon
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Neha Goel
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Annie Wang
- Division of Surgical Oncology, Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Ann Y Lee
- Division of Surgical Oncology, Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Sommer Luu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Cary Hsu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Eric Silberfein
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Shishir K Maithel
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Maria C Russell
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA.
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19
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Ryon EL, Kronenfeld JP, Lee RM, Yopp A, Wang A, Lee AY, Luu S, Hsu C, Silberfein E, Russell MC, Goel N, Merchant NB, Datta J. Surgical management of hepatocellular carcinoma patients with portal vein thrombosis: The United States Safety Net and Academic Center Collaborative Analysis. J Surg Oncol 2021; 123:407-415. [PMID: 33125746 PMCID: PMC8221282 DOI: 10.1002/jso.26282] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 06/25/2020] [Revised: 10/11/2020] [Accepted: 10/17/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Although consensus guidelines generally discourage any surgical management (ASM; i.e., resection and/or transplantation) in patients with hepatocellular carcinoma (HCC) and portal vein thrombosis (PVT), recent series from Asia have challenged this paradigm. METHODS Patients from the US Safety Net Collaborative database (2012-2014) with localized HCC and radiographically confirmed PVT were propensity-score matched based on demographic and clinicopathologic factors associated with receipt of ASM and overall survival (OS). OS was compared between patients undergoing ASM and those not selected for surgery. RESULTS Of 1910 HCC patients, 207 (14.5%) had localized disease and PVT. The majority received either liver-directed therapies (LDTs; 34%) and/or targeted systemic therapies (36%). Twenty-one patients (10.1%) underwent ASM (resection [n = 11], transplantation [n = 10]); a third experienced any complication with no 30-day mortalities. Independent predictors of undergoing ASM were younger age, recent hepatology consultation, and lower model of end-stage liver disease (MELD) score. After matching for age, comorbidities, MELD, tumor size, receipt of LDT, or systemic therapy, OS was significantly longer for patients selected for ASM versus non-ASM patients (median not reached vs. 5.8 months, p < .001). CONCLUSION In a large North American multi-institutional cohort, a minority of HCC patients with PVT were selected for ASM. Resection or transplantation was associated with improved survival and may have a role in the multimodality management in selected patients.
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Affiliation(s)
- Emily L. Ryon
- Sylvester Comprehensive Cancer Center; Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Joshua P. Kronenfeld
- Sylvester Comprehensive Cancer Center; Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Rachel M. Lee
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - Adam Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, Dallas, TX
| | - Annie Wang
- Division of Surgical Oncology, Department of Surgery, New York University, Langone Health, New York, NY
| | - Ann Y. Lee
- Division of Surgical Oncology, Department of Surgery, New York University, Langone Health, New York, NY
| | - Sommer Luu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Cary Hsu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Eric Silberfein
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Maria C. Russell
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - Neha Goel
- Sylvester Comprehensive Cancer Center; Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Nipun B. Merchant
- Sylvester Comprehensive Cancer Center; Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Jashodeep Datta
- Sylvester Comprehensive Cancer Center; Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
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20
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Vitiello GA, Wang A, Lee RM, Russell MC, Yopp A, Ryon EL, Goel N, Luu S, Hsu C, Silberfein E, Correa-Gallego C, Berman RS, Lee AY. Surgical resection of early stage hepatocellular carcinoma improves patient survival at safety net hospitals. J Surg Oncol 2021; 123:963-969. [PMID: 33497478 DOI: 10.1002/jso.26381] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 11/19/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Surgical resection is indicated for hepatocellular carcinoma (HCC) patients with Child A cirrhosis. We hypothesize that surgical intervention and survival are limited by advanced HCC presentation at safety net hospitals (SNHs) versus academic medical centers (AMCs). METHODS Patients with HCC and Child A cirrhosis in the US Safety Net Collaborative (2012-2014) were evaluated. Demographics, clinicopathologic features, operative characteristics, and outcomes were compared between SNHs and AMCs. Liver transplantation was excluded. Kaplan-Meier and Cox proportional-hazards models were used to identify the effect of surgery on overall (OS). RESULTS A total of 689 Child A patients with HCC were identified. SNH patients frequently presented with T3/T4 stage (35% vs. 24%) and metastases (17% vs. 8%; p < .05). SNH patients were as likely to undergo surgery as AMC patients (17% vs. 18%); however, SNH patients were younger (56 vs. 64 years), underwent minor hepatectomy (65% vs. 38%), and frequently harbored well-differentiated tumors (23% vs. 2%; p < .05). On multivariate analysis, surgical resection and stage, but not hospital type, were associated with improved OS. CONCLUSIONS Although SNH patients present with advanced HCC, survival outcomes for early stage HCC are similar at SNHs and AMCs. Identifying barriers to early diagnosis at SNH may increase surgical candidacy and improve outcomes.
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Affiliation(s)
- Gerardo A Vitiello
- Department of Surgery, New York University Langone Health, New York, New York, USA
| | - Annie Wang
- Department of Surgery, New York University Langone Health, New York, New York, USA
| | - Rachel M Lee
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Maria C Russell
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Adam Yopp
- Department of Surgery, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Emily L Ryon
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Neha Goel
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sommer Luu
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Cary Hsu
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Eric Silberfein
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Russell S Berman
- Department of Surgery, New York University Langone Health, New York, New York, USA
| | - Ann Y Lee
- Department of Surgery, New York University Langone Health, New York, New York, USA
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21
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Nash R, Miller-Kleinhenz JM, Russell MC, Collin LJ, Ross-Driscoll K, Switchenko JM, McCullough LE. Abstract PO-168: Association between geography and cause-specific mortality in gastrointestinal cancers in Georgia. Cancer Epidemiol Biomarkers Prev 2020. [DOI: 10.1158/1538-7755.disp20-po-168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background: Cancers of the gastrointestinal system represent a diverse range of diseases with different etiologies, from screening-detectable colorectal cancer (CRC) to pancreatic cancer, often diagnosed at late stage and highly lethal. While racial disparities have been observed for some of these cancers, the impact of geography is less understood. Georgia is an ideal place to examine disparities in geography because it has a diverse setting and population, with approximately 25% of residents living in a rural area and nearly one-third identifying as non-Hispanic Black (NHB), according to the 2010 decennial census. Methods: We obtained clinical (age at diagnosis, tumor stage, tumor size), sociodemographic (e.g., insurance status, marital status, SES index), and treatment information (e.g., receipt of surgery, lymph node biopsy/removal) on nearly 30,000 NHB and non-Hispanic White (NHW) men and women aged 18 years and older, diagnosed with CRC, hepatocellular carcinoma (HCC), pancreatic cancer or gastric cancer between 2009 and 2014 in Georgia from the population-based Surveillance, Epidemiology, and End Results (SEER) Program.
Patients were classified as residing in a metro or non-metro county at diagnosis according to 2013 rural-urban continuum codes. Multivariable Cox proportional hazards models were used to calculate the hazard ratios (HRs) and corresponding 95% confidence intervals (95% CI) for the association between residing in a non- metro versus metro county and cause-specific mortality, stratified by patient characteristics. Results: Over 75% of the study population resided in a metro county at diagnosis, with the highest proportion among HCC cases (81%) and the lowest proportion among CRC cases (76%). Overall, NHBs were more likely to reside in metro counties (82%) than NHWs (74%). The average length of follow-up varied by cancer site and metro status, ranging from 35 months (CRC in metro areas) to 4 months (pancreatic cancer in non-metro areas). For all cancer sites, patients in metro counties were more likely to be younger, single, have localized disease (except gastric cancer), and receive surgery of the primary site. By comparison, patients in non-metro counties were more likely to be diagnosed at older ages, have Medicaid, and be widowed. Residing in a non-metro county was associated with higher cause- specific mortality among the youngest patients (age 18-49 years) for pancreatic cancer (HR=1.4, 95% CI: 1.1, 1.9) and gastric cancer (HR=1.8, 95% CI: 1.2, 2.6). We also observed a higher hazard of mortality for residing in a non-metro compared to metro county among NHB HCC patients (HR=1.3, 95% CI: 1.0, 1.7) and never married gastric cancer patients (HR=1.5, 95% CI: 1.1, 2.1). Associations among CRC patients were less robust. Conclusion: Our results suggest residing in a non-metro county is associated with higher mortality among some groups diagnosed with rarer gastrointestinal cancers. Geographic differences in access to diagnosis and treatment may contribute to this disparity.
Citation Format: Rebecca Nash, Jasmine M. Miller-Kleinhenz, Maria C. Russell, Lindsay J. Collin, Katherine Ross-Driscoll, Jeffrey M. Switchenko, Lauren E. McCullough. Association between geography and cause-specific mortality in gastrointestinal cancers in Georgia [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-168.
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Affiliation(s)
- Rebecca Nash
- 1Rollins School of Public Health, Emory University, Atlanta, GA,
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22
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Williams H, Jajja MR, Hashmi SS, Maxwell D, Cardona K, Maithel SK, Russell MC, Sarmiento JM, Winer JH, Kooby DA. Association of ABO blood group with survival following pancreatoduodenectomy for pancreatic ductal adenocarcinoma. HPB (Oxford) 2020; 22:1557-1562. [PMID: 32146119 DOI: 10.1016/j.hpb.2020.01.004] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 12/06/2019] [Accepted: 01/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Existing research suggests patients with blood group O are less likely to develop pancreatic ductal adenocarcinoma (PDAC) compared to those with non-O blood groups, and that survival from PDAC may be affected by ABO blood type. This study assessed survival outcomes in PDAC patients who underwent pancreatoduodenectomy (PD) in one health system. METHODS From 2010 to 2017, demographic, operative, chemotherapy and survival data for patients undergoing PD at Emory Healthcare were reviewed. Patients with blood type AB were excluded due to small sample size. The relationship between ABO blood group and survival was analyzed using Kaplan-Meier survival curves and multivariate cox proportional regression analysis. RESULTS Of 449 PDAC patients assessed, 204 (45.4%), 60 (13.4%) and 185 (41.2%) were blood groups A, B and O, respectively. Patients were well matched in clinicopathologic characteristics. Median survival did not differ by blood group (p = 0.82), and this relationship remained insignificant on cox regression analysis (p = 0.15). On multivariate analysis, lymph node positivity (p < 0.001) and increasing age (p = 0.001) were associated with reduced survival. CONCLUSION In contrast to recent reports, this larger study found that blood group did not impact overall survival among patients undergoing PD for PDAC.
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Affiliation(s)
| | - Mohammad R Jajja
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Salila S Hashmi
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
| | - Daniel Maxwell
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Kenneth Cardona
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Maria C Russell
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Juan M Sarmiento
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Joshua H Winer
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - David A Kooby
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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23
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Leiting JL, Day CN, Harmsen WS, Cloyd JM, Abdel-Misih S, Fournier K, Lee AJ, Dineen S, Dessureault S, Veerapongh J, Baumgartner JM, Clarke C, Mogal H, Russell MC, Zaidi MY, Patel SH, Morris MC, Hendrix RJ, Lambert LA, Abbott DE, Pokrzywa C, Raoof M, Eng O, Johnston FM, Greer J, Grotz TE. The impact of HIPEC vs. EPIC for the treatment of mucinous appendiceal carcinoma: a study from the US HIPEC collaborative. Int J Hyperthermia 2020; 37:1182-1188. [PMID: 33040617 DOI: 10.1080/02656736.2020.1819571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Mucinous appendiceal carcinoma is a rare malignancy that commonly spreads to the peritoneum leading to peritoneal metastases. Complete cytoreduction with perioperative intraperitoneal chemotherapy (PIC) is the mainstay of treatment, administered as either hyperthermic intra peritoneal chemotherapy (HIPEC) or early post-operative intraperitoneal chemotherapy (EPIC). Our goal was to assess the perioperative and long term survival outcomes associated with these two PIC methods. MATERIALS AND METHODS Patients with mucinous appendiceal carcinoma were identified in the US HIPEC Collaborative database from 12 academic institutions. Patient demographics, clinical characteristics, and survival outcomes were compared among patients who underwent HIPEC vs. EPIC with inverse probability weighting (IPW) used for adjustment. RESULTS Among 921 patients with mucinous appendiceal carcinoma, 9% underwent EPIC while 91% underwent HIPEC. There was no difference in Grade III-V complications between the two groups (18.5% for HIPEC vs. 15.0% for EPIC, p=.43) though patients who underwent HIPEC had higher rates of readmissions (21.2% vs. 8.8%, p<.01). Additionally, PIC method was not an independent predictor for overall survival (OS) or recurrence-free survival (RFS) after adjustment on multivariable analysis. CONCLUSIONS Among patients with mucinous appendiceal carcinoma, both EPIC and HIPEC appear to be associated with similar perioperative and long-term outcomes.
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Affiliation(s)
- Jennifer L Leiting
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - William S Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sherif Abdel-Misih
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Morsani College of Medicine, Tampa, FL, USA
| | - Sophie Dessureault
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Morsani College of Medicine, Tampa, FL, USA
| | - Jula Veerapongh
- Department of Surgery, Division of Surgical Oncology, University of California, San Diego, CA, USA
| | - Joel M Baumgartner
- Department of Surgery, Division of Surgical Oncology, University of California, San Diego, CA, USA
| | - Callisia Clarke
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Harveshp Mogal
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Maria C Russell
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Mohammad Y Zaidi
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ryan J Hendrix
- Department of Surgery, Division of Surgical Oncology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Laura A Lambert
- Peritoneal Surface Malignancy Program Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, WI, USA
| | - Courtney Pokrzywa
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, WI, USA
| | - Mustafa Raoof
- Department of Surgery, Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Oliver Eng
- Department of Surgery, Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | | | - Jonathan Greer
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
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24
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Gamboa AC, Ethun CG, Postlewait LM, Lopez-Aguiar AG, Zhelnin K, Krasinskas A, El-Rayes BF, Russell MC, Kooby DA, Staley CA, Cardona K, Maithel SK. HSP90 expression and early recurrence in gastroenteropancreatic neuroendocrine tumors: Potential for a novel therapeutic target. Surg Oncol 2020; 35:460-465. [PMID: 33080545 DOI: 10.1016/j.suronc.2020.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/27/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Heat shock protein (HSP)-90 promotes tumor growth and is overexpressed in many malignancies. HSP90 expression profile and its potential as a therapeutic target in primary and metastatic neuroendocrine tumors (NETs) are not known. METHODS HSP90 cytoplasmic expression and Ki-67 index were re-reviewed and scored by a pathologist blinded to all other clinicopathologic variables for patients who underwent resection of primary and metastatic gastroenteropancreatic (GEP) neuroendocrine tumors at a single institution (2000-2013). Primary outcome was recurrence-free survival (RFS). RESULTS Of 263 tumors reviewed, 73% (n = 191) were primary GEP NETs, and 12% (n = 31) were NET liver metastases. Of the primary GEP-NETs, mean age was 56 years, 42% were male; 53% (n = 103) were pancreatic and 23% (n = 44) were small bowel. HSP90 expression was high in 34% (n = 64) and low in 66% (n = 127). Compared to low expression, high HSP90 was associated with advanced T-stage (T3/T4) (47 vs 27%; p = 0.02). Among patients who underwent curative-intent resections for primary, non-metastatic NETs (n = 145), high HSP90 was independently associated with worse RFS (HR 5.09, 95% CI 1.65-15.74; p = 0.005), after accounting for positive margin, LN involvement, increased tumor size, site of primary tumor, and Ki-67. When assessing NET liver metastases, 13% (n = 4) had high HSP90 expression and 87% (n = 26) had low expression. Patients with liver metastases with high HSP90 tended to have worse 1- and 3-year progression-free survival (25%, 25%) compared to those with low HSP90 (69%, 49%; p = 0.059). CONCLUSION HSP90 exhibits differential expression in resected GEP-NETs and liver metastases. High cytoplasmic expression is associated with early disease recurrence, even after accounting for other adverse pathologic factors. HSP90 inhibition may be a potential therapeutic target for neuroendocrine tumors.
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Affiliation(s)
- Adriana C Gamboa
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Alexandra G Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Kristen Zhelnin
- Department of Pathology, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Alyssa Krasinskas
- Department of Pathology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Bassel F El-Rayes
- Department of Hematology Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Charles A Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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25
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Lee RM, Gamboa AC, Turgeon MK, Zaidi MY, Kimbrough C, Leiting J, Grotz T, Lee AJ, Fournier K, Powers B, Dineen S, Baumgartner JM, Veerapong J, Mogal H, Clarke C, Wilson G, Patel S, Hendrix R, Lambert L, Pokrzywa C, Abbott DE, LaRocca CJ, Raoof M, Greer J, Johnston FM, Staley CA, Cloyd JM, Maithel SK, Russell MC. A novel preoperative risk score to optimize patient selection for performing concomitant liver resection with cytoreductive surgery/HIPEC. J Surg Oncol 2020; 123:187-195. [PMID: 33002202 DOI: 10.1002/jso.26239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 04/05/2020] [Revised: 08/25/2020] [Accepted: 09/09/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND While parenchymal hepatic metastases were previously considered a contraindication to cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC), liver resection (LR) is increasingly performed with CRS/HIPEC. METHODS Patients from the US HIPEC Collaborative (2000-2017) with invasive appendiceal or colorectal adenocarcinoma undergoing primary, curative intent CRS/HIPEC with CC0-1 resection were included. LR was defined as a formal parenchymal resection. Primary endpoints were postoperative complications and overall survival (OS). RESULTS A total of 658 patients were included. About 83 (15%) underwent LR of colorectal (58%) or invasive appendiceal (42%) metastases. LR patients had more complications (81% vs. 60%; p = .001), greater number of complications (2.3 vs. 1.5; p < .001) per patient and required more reoperations (22% vs. 11%; p = .007) and readmissions (39% vs. 25%; p = .014) than non-LR patients. LR patients had decreased OS (2-year OS 62% vs. 79%, p < .001), even when accounting for peritoneal carcinomatosis index and histology type. Preoperative factors associated with decreased OS on multivariable analysis in LR patients included age < 60 years (HR, 3.61; 95% CI, 1.10-11.81), colorectal histology (HR, 3.84; 95% CI, 1.69-12.65), and multiple liver tumors (HR, 3.45; 95% CI, 1.21-9.85) (all p < .05). When assigning one point for each factor, there was an incremental decrease in 2-year survival as the risk score increased from 0 to 3 (0: 100%; 1: 91%; 2: 58%; 3: 0%). CONCLUSIONS As CRS/HIPEC + LR has become more common, we created a simple risk score to stratify patients considered for CRS/HIPEC + LR. These data aid in striking the balance between an increased perioperative complication profile with the potential for improvement in OS.
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Affiliation(s)
- Rachel M Lee
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Adriana C Gamboa
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael K Turgeon
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mohammad Y Zaidi
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Charles Kimbrough
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jennifer Leiting
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic , Rochester, Minnesota, USA
| | - Travis Grotz
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Gastrointestinal Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew J Lee
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Keith Fournier
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Gastrointestinal Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Benjamin Powers
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA.,Department of Oncologic Sciences, Morsani College of Medicine, Tampa, Florida, USA
| | - Sean Dineen
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA.,Department of Oncologic Sciences, Morsani College of Medicine, Tampa, Florida, USA
| | - Joel M Baumgartner
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, University of California, San Diego, California, USA
| | - Jula Veerapong
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, University of California, San Diego, California, USA
| | - Harveshp Mogal
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Callisia Clarke
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Gregory Wilson
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sameer Patel
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ryan Hendrix
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgical Oncology, Health Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Laura Lambert
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Courtney Pokrzywa
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin, USA
| | - Christopher J LaRocca
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mustafa Raoof
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan Greer
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Fabian M Johnston
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Charles A Staley
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Shishir K Maithel
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Maria C Russell
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA
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Kronenfeld JP, Ryon EL, Goldberg D, Lee RM, Yopp A, Wang A, Lee AY, Luu S, Hsu C, Silberfein E, Russell MC, Livingstone AS, Merchant NB, Goel N. Disparities in Presentation at Time of Hepatocellular Carcinoma Diagnosis: A United States Safety-Net Collaborative Study. Ann Surg Oncol 2020; 28:1929-1936. [PMID: 32975686 DOI: 10.1245/s10434-020-09156-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/30/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND While hepatocellular carcinoma (HCC) is ideally diagnosed outpatient by screening at-risk patients, many are diagnosed in Emergency Departments (ED) due to undiagnosed liver disease and/or limited access-to-healthcare. This study aims to identify sociodemographic/clinical factors associated with being diagnosed with HCC in the ED to identify patients who may benefit from improved access-to-care. METHODS HCC patients diagnosed between 2012 and 2014 in the ED or an outpatient setting [Primary Care Physician (PCP) or hepatologist] were identified from the US Safety-Net Collaborative database and underwent retrospective chart-review. Multivariable regression identified predictors for an ED diagnosis. RESULTS Among 1620 patients, median age was 60, 68% were diagnosed outpatient, and 32% were diagnosed in the ED. ED patients were more likely male, Black/Hispanic, uninsured, and presented with more decompensated liver disease, aggressive features, and advanced clinical stage. On multivariable regression, controlling for age, gender, race/ethnicity, poverty, insurance, and PCP/navigator access, predictors for ED diagnosis were male (odds ratio [OR] 1.6, 95% confidence interval [CI]: 1.1-2.2, p = 0.010), black (OR 1.7, 95% CI: 1.2-2.3, p = 0.002), Hispanic (OR 1.6, 95% CI: 1.1-2.6, p = 0.029), > 25% below poverty line (OR 1.4, 95% CI: 1.1-1.9, p = 0.019), uninsured (OR 3.9, 95% CI: 2.4-6.1, p < 0.001), and lack of PCP (OR 2.3, 95% CI: 1.5-3.6, p < 0.001) or navigator (OR 1.8, 95% CI: 1.3-2.5, p = 0.001). CONCLUSIONS The sociodemographic/clinical profile of patients diagnosed with HCC in EDs differs significantly from those diagnosed outpatient. ED patients were more likely racial/ethnic minorities, uninsured, and had limited access to healthcare. This study highlights the importance of improved access-to-care in already vulnerable populations.
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Affiliation(s)
- Joshua P Kronenfeld
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Emily L Ryon
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David Goldberg
- Division of Digestive Health and Liver Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rachel M Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Adam Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Annie Wang
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Ann Y Lee
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Sommer Luu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Cary Hsu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Eric Silberfein
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Alan S Livingstone
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Neha Goel
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA.
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Lee RM, Gamboa AC, Turgeon MK, Yopp A, Ryon EL, Kronenfeld JP, Goel N, Wang A, Lee AY, Luu S, Hsu C, Silberfein E, Maithel SK, Russell MC. Dissecting disease, race, ethnicity, and socioeconomic factors for hepatocellular carcinoma: An analysis from the United States Safety Net Collaborative. Surg Oncol 2020; 35:120-125. [PMID: 32871546 DOI: 10.1016/j.suronc.2020.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 05/21/2020] [Revised: 06/25/2020] [Accepted: 08/06/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Racial/ethnic and socioeconomic disparities are assumed to negatively affect treatment and outcomes for hepatocellular carcinoma (HCC). Our aim was to investigate the interaction of racial/ethnic and socioeconomic factors with stage of disease and type of treatment facility in receipt of treatment and overall survival (OS) of patients with HCC. METHODS All patients with primary HCC in the US Safety-Net Collaborative database (2012-2014) were included. Patients were categorized into "safety-net" or "tertiary referral center" based on where they received treatment. Socioeconomic factors were determined at the zip-code level and included median income and percent of adults who graduated from high-school. Primary outcomes were receipt of treatment and OS. RESULTS On MV Cox regression, neither race/ethnicity, median income, nor care provided at a SNH were associated with decreased OS (all p > 0.05). Independent predictors of decreased OS included lack of insurance (HR 1.34), less educational attainment (HR 1.59) higher MELD score (HR 1.07), higher stage at diagnosis (II:HR 1.34, III:HR 2.87, IV:HR 3.23), and not receiving treatment (HR 3.94) (all p < 0.05). Factors associated with not receiving treatment included history of alcohol abuse (OR 0.682), increasing MELD (OR 0.874), higher stage at diagnosis (III: OR 0.234, IV: OR 0.210) and care at a safety net facility (OR 0.424) There were no racial/ethnic or socioeconomic disparities in receipt of treatment. CONCLUSIONS There is no intrinsic or direct association of race/ethnicity, socioeconomic status, or being treated at select safety-net hospitals with worse outcomes. Poor liver function, no insurance, and advanced stage of presentation are the main determinants of not receiving treatment and decreased survival.
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Affiliation(s)
- Rachel M Lee
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA.
| | - Adriana C Gamboa
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Michael K Turgeon
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Adam Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Emily L Ryon
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Joshua P Kronenfeld
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Neha Goel
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Annie Wang
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Ann Y Lee
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Sommer Luu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Cary Hsu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Eric Silberfein
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Shishir K Maithel
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Maria C Russell
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
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Lee RM, Gamboa AC, Turgeon MK, Yopp A, Ryon EL, Kronenfeld JP, Goel N, Wang A, Lee AY, Luu S, Hsu C, Silberfein E, Maithel SK, Russell MC. The Evolving Landscape of Hepatocellular Carcinoma : A US Safety Net Collaborative Analysis of Etiology of Cirrhosis. Am Surg 2020; 86:865-872. [PMID: 32721171 DOI: 10.1177/0003134820939934] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hepatitis C virus (HCV) has historically been the most common cause of cirrhosis and hepatocellular carcinoma (HCC) in the United States. With improved HCV treatment, cirrhosis secondary to other etiologies is increasing. Given this changing epidemiology, our aim was to determine the impact of cirrhosis etiology on overall survival (OS) in patients with HCC. METHODS All patients with cirrhosis and primary HCC from the US Safety Net Collaborative (2012-2014) database were included. Patients were grouped into "safety net" and "academic" based on where they received their care. The primary outcome was the OS. RESULTS 1479 patients were included. The average age was 60 years and 78% (n = 1156) were male. 56% (n = 649) received care at academic and 44% (n = 649) at safety net hospitals. The median model for end-stage liver disease (MELD) was 10 (IQR 8-16). Median OS was 23 months. Etiology of cirrhosis was viral hepatitis 56% (n = 612), alcohol abuse 14% (n = 152), alcohol and hepatitis 23% (n = 251), and other 7% (n = 85). Patients with alcohol-related cirrhosis (alcohol alone or with hepatitis) were younger (59 vs 62 years), more likely to be male (86% vs 75%), treated at a safety net facility (45% vs 35%), uninsured (17% vs 13%), and had a higher MELD (median 12 vs 10) (all P < .003). They were less likely to have been screened for HCC within 1 year of diagnosis (20% vs 29%) and to receive treatment (69% vs 81%), and more likely to present with stage IV disease (21% vs 15%) (all P < .001). Patients with alcohol-related cirrhosis had decreased OS (5-year OS 24% vs 40%, P < .001), which persisted in a subset analysis of both academic and safety net populations. CONCLUSION Although not significant on MVA, alcohol-related cirrhosis is associated with all factors that correlate with decreased survival from HCC. Efforts must focus on this vulnerable patient population to optimize screening, treatment, and outcomes.
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Affiliation(s)
- Rachel M Lee
- 1371 Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Adriana C Gamboa
- 1371 Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Michael K Turgeon
- 1371 Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Adam Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Emily L Ryon
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Joshua P Kronenfeld
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Neha Goel
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Annie Wang
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Ann Y Lee
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Sommer Luu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Cary Hsu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Eric Silberfein
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Shishir K Maithel
- 1371 Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Maria C Russell
- 1371 Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
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Eng NL, Mustin DE, Lovasik BP, Turgeon MK, Gamboa AC, Shah MM, Cardona K, Sarmiento JM, Russell MC, Maithel SK, Switchenko JM, Kooby DA. Relationship between Cancer Diagnosis and Complications Following Pancreatoduodenectomy for Duodenal Adenoma. Ann Surg Oncol 2020; 28:1097-1105. [PMID: 32691338 DOI: 10.1245/s10434-020-08767-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) for duodenal adenoma (DA) resection may be associated with excessive surgical risk for patients with potentially benign lesions, given the absence of pancreatic duct obstruction. We examined factors associated with final malignant pathology and evaluated the postoperative course of patients with DA versus pancreatic ductal adenocarcinoma (PDAC). METHODS We retrospectively analyzed patients with DA who underwent PD from 2008 to 2018 and assessed the accuracy rate of preoperative biopsy and factors associated with final malignant pathology. Complications for DA patients were compared with those of matched PDAC patients. RESULTS Forty-five consecutive patients who underwent PD for DA were identified, and the preoperative biopsy false negative rate was 29. Factors associated with final malignant pathology included age over 70 years, preoperative biliary obstruction, and common bile duct diameter > 8 mm (p < 0.05). Compared with patients with PDAC (n = 302), DA patients experienced more major complications (31% vs. 15%, p < 0.01), more grade C postoperative pancreatic fistulas (9% vs. 1%, p < 0.01), and greater mortality (7% vs. 2%, p < 0.05). Propensity score matched patients with DA had more major complications following PD (32% vs. 12%, p < 0.05). CONCLUSIONS Preoperative biopsy of duodenal adenomas is associated with a high false-negative rate for malignancy, and PD for DA is associated with higher complication rates than PD for PDAC. These results aid discussion among patients and surgeons who are considering observation versus PD for DA, especially in younger patients without biliary obstruction, who are less likely to harbor malignancy.
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Affiliation(s)
- Nina L Eng
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Danielle E Mustin
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Brendan P Lovasik
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael K Turgeon
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Adriana C Gamboa
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mihir M Shah
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Kenneth Cardona
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Juan M Sarmiento
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Maria C Russell
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Shishir K Maithel
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health of Emory University, Atlanta, GA, USA
| | - David A Kooby
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.
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Maxwell DW, Jajja MR, Ferez-Pinzon A, Pouch SM, Cardona K, Kooby DA, Maithel SK, Russell MC, Sarmiento JM. Bile cultures are poor predictors of antibiotic resistance in postoperative infections following pancreaticoduodenectomy. HPB (Oxford) 2020; 22:969-978. [PMID: 31662223 DOI: 10.1016/j.hpb.2019.10.016] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/30/2019] [Accepted: 10/03/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bile cultures (BC) have routinely been used to guide empiric antibiotic therapy for developing postoperative infections. The ability of BCs to predict sensitivity and resistance patterns (SRP) of site of infection cultures (SOIC) remains controversial. The aim was to assess the concordance of pathogens and SRPs between paired BC/SOICs. METHODS Medical records of consecutive patients undergoing pancreaticoduodenectomy were reviewed between 2014 and 2018. BC/SOIC pathogens and SRPs were compared on a patient-by-patient basis and concordance (K) was assessed. RESULTS Common patient characteristics of 522 included patients were 65-years-old, Caucasian (75.5%), male (54.2%), malignant indication (79.3%), and preoperative biliary stent (59.0%). Overall, 275 (89.6%) BCs matured identifiable isolates with 152 (55.2%) demonstrating polymicrobial growth. Ninety-two (17.6%) SOICs were obtained: 48 and 44 occurred in patients with and without intraoperative BCs. Stents were associated with bacteriobilia (85.7%, K = 0.947, p < 0.001; OR 22.727, p < 0.001), but not postoperative infections (15.2%; K = 0.302, p < 0.001; OR 1.428, p = 0.122). Forty-eight patients demonstrated paired BC/SOICs to evaluate. Pathogenic concordance of this group was 31.1% (K = 0.605, p < 0.001) while SRP concordance of matched pathogens was 46.7% (K = 0.167, p = 0.008). CONCLUSION Bile cultures demonstrate poor concordance with the susceptibility/resistance patterns of postoperative infections following pancreaticoduodenectomy and may lead to inappropriate antibiotic therapies.
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Affiliation(s)
| | - Mohammad Raheel Jajja
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Stephanie M Pouch
- Department of Infectious Disease, Emory University, Atlanta, GA, USA
| | - Kenneth Cardona
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - David A Kooby
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Maria C Russell
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Juan M Sarmiento
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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Fisher SB, Kim SC, Kooby DA, Cardona K, Russell MC, Delman KA, Staley CA, Maithel SK. Gastrointestinal Stromal Tumors: A Single Institution Experience of 176 Surgical Patients. Am Surg 2020. [DOI: 10.1177/000313481307900707] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Large single-institution series of patients undergoing resection for gastrointestinal stromal tumors (GIST) are lacking. Clinicopathologic characteristics and postoperative outcomes were retrospectively collected and analyzed from patients undergoing resection for GIST from 2002 to 2011. One hundred seventy-six patients were identified; 156 underwent resection of primary nonmetastatic disease. KIT mutations were identified in 131 patients (84.0%). Of the 156 patients with primary disease, the most common site was the stomach (75.6%). Tumors were categorized as very low (24.4%), low (35.9%), intermediate (12.2%), high (24.4%), or unknown (3.2%) risk. Symptomatic patients more often had high risk (35.6 vs 9.8%; P < 0.0001) and larger tumors (7.3 vs 3.0 cm; P < 0.0001). Forty-seven patients (30.1%) underwent laparoscopic resection (LR). Compared with open surgery, LR was performed for smaller tumors (3.8 vs 6.2 cm; P = 0.002). Positive margin rates were similar (4.3% LR vs 10.2% open; P = 0.346). Median follow-up for the 156 patients with primary tumors was 32.9 months; mean overall survival was 120.9 months (median not reached). Of the 20 patients with metastatic GIST (excluded from above analysis), five patients (25.0%) died of disease with a median follow-up of 15.9 months. Most patients with resectable primary GIST have a favorable prognosis. The presence of symptoms directly related to GIST may be associated with a poor prognosis and is likely related to increased tumor size. Laparoscopic resection is well tolerated and does not appear to compromise outcomes in well-selected patients. Highly selected patients with metastatic disease may benefit from resection.
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Affiliation(s)
- Sarah B. Fisher
- Department of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Steven C. Kim
- Department of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - David A. Kooby
- Department of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Kenneth Cardona
- Department of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Maria C. Russell
- Department of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Keith A. Delman
- Department of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Charles A. Staley
- Department of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Shishir K. Maithel
- Department of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
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Turgeon MK, Gamboa AC, Rupji M, Lee RM, Switchenko JM, El-Rayes BF, Russell MC, Cardona K, Kooby DA, Staley CA, Maithel SK, Shah MM. Should Signet Ring Cell Histology Alter the Treatment Approach for Clinical Stage I Gastric Cancer? Ann Surg Oncol 2020; 28:97-105. [PMID: 32524459 DOI: 10.1245/s10434-020-08714-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Surgery alone is standard-of-care for stage I gastric adenocarcinoma; however, clinicians can offer preoperative therapy for clinical stage I disease with signet ring cell histology, given its presumed aggressive biology. We aimed to assess the validity of this practice. METHODS The National Cancer Database (2004-2015) was reviewed for patients with clinical stage I signet ring cell gastric adenocarcinoma who underwent treatment with surgery alone, perioperative chemotherapy, neoadjuvant therapy, or adjuvant therapy. Analysis was stratified by preoperative clinical/pathologic stage. Primary outcome was overall survival (OS). RESULTS Of 1018 patients, median age was 60 years (±14); 53% received surgery alone (n = 542), 5% received perioperative chemotherapy (n = 47), 12% received neoadjuvant therapy (n = 125), and 30% received adjuvant therapy (n = 304). For clinical stage I disease, surgery alone was associated with an improved 5-year OS rate (71%) versus perioperative chemotherapy (58%), neoadjuvant therapy (38%), or adjuvant therapy (52%) [overall p < 0.01]. For pathologic stage I, surgery alone had equivalent or improved survival compared with perioperative, neoadjuvant, and adjuvant therapy (5-year OS: 78% vs. 89% [p = 0.77] vs. 64% [p = 0.04] vs. 84% [p = 0.99]). Adjuvant therapy was associated with improved 5-year OS compared with pretreatment for those patients upstaged (37%) to pathologic stage II/III (55% vs. 36% and 34% vs. 7%; all p < 0.01). CONCLUSIONS This stage-specific study demonstrates improved survival with surgery alone for clinical stage I signet ring cell gastric adenocarcinoma. Despite 37% of clinical stage I patients being upstaged to pathologic stage II/III, adjuvant therapy offers a favorable rescue strategy, with improved outcomes compared with those treated preoperatively. Surgery alone also affords similar or improved survival for pathologic stage I disease versus multimodality therapy. This study challenges the bias to overtreat stage I signet ring cell gastric adenocarcinoma.
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Affiliation(s)
- Michael K Turgeon
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA.,Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Adriana C Gamboa
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Manali Rupji
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Rachel M Lee
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Bassel F El-Rayes
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, USA
| | - Maria C Russell
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - David A Kooby
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Charles A Staley
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Mihir M Shah
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA. .,Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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Gamboa AC, Rupji M, Switchenko JM, Lee RM, Turgeon MK, Meyer BI, Russell MC, Cardona K, Kooby DA, Maithel SK, Shah MM. Optimal timing and treatment strategy for pancreatic cancer. J Surg Oncol 2020; 122:457-468. [PMID: 32470166 DOI: 10.1002/jso.25976] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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: 04/04/2020] [Revised: 04/29/2020] [Accepted: 05/02/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND For pancreatic adenocarcinoma (PDAC), no studies have established any association between earlier treatment initiation and long-term outcomes. In addition, an optimal type of initial treatment for the localized disease remains ill-defined. METHODS Patients in the National Cancer Database (2004-2015) with clinical stage I (CS-I) and II (CS-II) PDAC who underwent curative-intent resection were included. Optimal time from diagnosis-to-treatment including neoadjuvant chemotherapy, neoadjuvant chemoradiation, or upfront surgery was assessed. An optimal type of treatment was evaluated. The primary outcome was overall survival (OS). RESULTS Among 29 167 patients, starting any treatment within 0 to 6 weeks was associated with improved median OS compared with 7 to 12 weeks (21.0 vs 20.1 months; P = .004). This persisted when accounting for sex, race, and Charlson-Deyo score (hazard ratio [HR], 0.94; P = 0.02) and on subset analysis for CS-I (23.5 vs 21.8 months; P = .04) and CS-II (19.4 vs 18.3 months; P = .03). Neoadjuvant chemotherapy was associated with improved OS compared with neoadjuvant chemoradiation (25.6 vs 22.7 months; P < .0001) or US (25.6 vs 20.1 months; P < .0001) even when accounting for sex, race, and Charlson-Deyo score (neoadjuvant chemoradiation: HR, 0.86; P < .001; US: HR, 0.79; P < .001). This improvement persisted in subset analysis with NC compared with neoadjuvant chemoradiation (CS-I: 28.6 vs 25.0 months; CS-II: 25.0 vs 22.9 months; both P < .0001) and to US (CS-I: 28.6 vs 22.9 months; CS-II: 24.7 vs 18.4 months; both P < .0001). On multivariable analysis for each CS-I/CS-II, NC remained associated with 20% improved survival compared with neoadjuvant chemoradiation or upfront surgery. CONCLUSIONS For PDAC, initiation of therapy within 6 weeks from diagnosis is associated with improved survival, with neoadjuvant chemotherapy associated with the best survival compared with neoadjuvant chemoradiation or upfront surgery.
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Affiliation(s)
- Adriana C Gamboa
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Manali Rupji
- Bioinformatics and Biostatistics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Rachel M Lee
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Michael K Turgeon
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Benjamin I Meyer
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Maria C Russell
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kenneth Cardona
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - David A Kooby
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mihir M Shah
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Gamboa AC, Meyer BI, Switchenko JM, Rupji M, Lee RM, Turgeon MK, Russell MC, Cardona K, Kooby DA, Maithel SK, Shah MM. Should adenosquamous esophageal cancer be treated like adenocarcinoma or squamous cell carcinoma? J Surg Oncol 2020; 122:412-421. [PMID: 32462769 DOI: 10.1002/jso.25990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 05/08/2020] [Revised: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Esophageal adenocarcinoma (AC) and squamous cell carcinoma (SCC) have distinct outcomes, treatment strategies, and response profiles to therapy. Adenosquamous carcinoma (ASC) is thought to behave more aggressively than each of its counterparts. The aim of this study is to determine ifASC is best managed as AC or SCC. METHODS National Cancer Database (2004-2015) was queried for patients with nonmetastatic esophageal ASC. The analysis was stratified by clinical node-negative (cN0) or clinical node-positive (cN1-3). Treatment was categorized into chemoradiation alone, surgery alone, or preoperative chemoradiation followed by surgery. The primary outcome was 5-year overall survival (OS). RESULTS Among 352 patients, 43% were cN0 (n = 151), 57% were cN1-3 (n = 201) and 55% had chemoradiation alone (n = 194), 15% surgery alone (n = 53), and 30% preoperative chemoradiation (n = 105). Among patients who had preoperative chemoradiation, 20% had pathologic complete response (n = 17). For either cN0 or cN1-3, Charlson-Deyo Comorbidity Index did not differ among the treatment groups(all p > 0.05). On Kaplan-Meier analysis for cN0, treatment with surgery alone had comparable OS to preoperative chemoradiation (47% vs 34%; P = .5) and each had improved OS compared to chemoradiation alone (30%; P = .02; P = .06). On univariate analysis for cN0, clinical T category was not associated with OS. For cN1-3, however, preoperative chemoradiation was associated with improved OS when compared to chemoradiation alone or surgery alone (27% vs 19% vs 0%; P < .001). This persisted when accounting for age and clinical T category (hazard ratio: 0.45; P < .001). CONCLUSION Esophageal ASC behaves more like AC in response to chemoradiation and survival based on treatment modality. A complete response to chemoradiation is only 20% unlike what has been shown for SCC, where chemoradiation is an acceptable definitive therapy. Esophageal ASC should be managed more like AC.
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Affiliation(s)
- Adriana C Gamboa
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Benjamin I Meyer
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Manali Rupji
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Rachel M Lee
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Michael K Turgeon
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Maria C Russell
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kenneth Cardona
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - David A Kooby
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mihir M Shah
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Lopez-Aguiar AG, Postlewait LM, Ethun CG, Zaidi MY, Zhelnin K, Krasinskas A, Russell MC, Kooby DA, Cardona K, El-Rayes BF, Maithel SK. STAT3 Inhibition for Gastroenteropancreatic Neuroendocrine Tumors: Potential for a New Therapeutic Target? J Gastrointest Surg 2020; 24:1138-1148. [PMID: 31144189 DOI: 10.1007/s11605-019-04261-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 05/06/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are highly vascular neoplasms treated similarly, irrespective of tumor location. The expression of pro-angiogenic factors (STAT3, VEGF, and HIF-1α) and their association with adverse pathologic factors and disease recurrence following resection remains unclear. METHODS All patients with non-metastatic GEP-NETs who underwent curative-intent resection from 2000 to 2013 were included. Immunohistochemistry was performed for pro-angiogenic factors, Ki-67 index, and CD31 using tissue microarrays made in triplicate by a pathologist blinded to other clinicopathologic variables. Primary outcome was a 3-year recurrence-free survival (3-yrRFS); secondary outcomes were correlation of pro-angiogenic factors with Ki-67 index, adverse pathologic factors, and CD31 expression, a marker of microvascular density. RESULTS Of 144 GEP-NETs resected, STAT3 expression was high in 12 (8%) and low in 132 (92%) pts. High STAT3 expression was associated with worse 3-yrRFS compared to low expression (55% vs 84%; p = 0.003). High VEGF expression had a 3-yrRFS of 76% vs 82% for low expression (p = 0.09). HIF-1α expression was not associated with RFS. Ki-67 ≥ 3% was associated with worse 3-yrRFS (≥ 3%: 51% vs < 3%: 84%; p < 0.001), as was the presence of increased microvascular density (CD31 > median: 75% vs CD31 < median: 86%; p = 0.04). High STAT3 expressing tumors were more likely to have a Ki-67 ≥ 3% (42% vs 7%; p < 0.001). LVI was present in 82% of high STAT3 tumors compared to only 50% with low STAT3 (p = 0.058). CD31 expression was similar between groups (58% vs 49%; p = 0.5). CONCLUSIONS In resected GEP-NETs, high STAT3 expression is associated with an increased Ki-67 index, presence of lymphovascular invasion and worse 3-yr RFS. STAT3 may be a novel therapeutic target for patients undergoing resection of high-risk tumors.
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Affiliation(s)
- Alexandra G Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road NE, 2nd Floor, Atlanta, GA, 30322, USA
| | - Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road NE, 2nd Floor, Atlanta, GA, 30322, USA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road NE, 2nd Floor, Atlanta, GA, 30322, USA
| | - Mohammad Y Zaidi
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road NE, 2nd Floor, Atlanta, GA, 30322, USA
| | - Kristen Zhelnin
- Department of Pathology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Alyssa Krasinskas
- Department of Pathology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road NE, 2nd Floor, Atlanta, GA, 30322, USA
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road NE, 2nd Floor, Atlanta, GA, 30322, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road NE, 2nd Floor, Atlanta, GA, 30322, USA
| | - Bassel F El-Rayes
- Department of Hematology Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road NE, 2nd Floor, Atlanta, GA, 30322, USA.
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Gamboa AC, Aveson VG, Zaidi MY, Lee RM, Jarnagin WR, Allen PJ, Drebin JA, Peter Kingham T, DeMatteo RP, Sarmiento JM, Russell MC, Cardona K, Kooby DA, D'Angelica MI, Maithel SK. Lending a hand for laparoscopic distal pancreatectomy: the optimal approach? HPB (Oxford) 2020; 22:690-701. [PMID: 31601508 PMCID: PMC8385644 DOI: 10.1016/j.hpb.2019.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 04/24/2019] [Revised: 07/15/2019] [Accepted: 09/14/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Both minimally invasive surgery (MIS) and open approaches for distal pancreatectomy are acceptable. MIS options include total laparoscopic/robotic (TLR) and hand-assist laparoscopy (HAL). When considering safety profile and specimen quality, the optimal approach is unknown. METHODS Patients who underwent distal pancreatectomy from 2010-2018 at two major academic institutions were included. Converted procedures were categorized into final approach. Ninety-day perioperative/pathologic outcomes of MIS and open were compared. Subset analyses between TLR vs HAL and HAL vs open were performed. Intent-to-treat analysis was performed. RESULTS Among 1006 patients, resection was performed by MIS in 35% (n = 352), open in 65% (n = 654). MIS had similar patient comorbidity profile as open but had increased operative time (183 vs 162 min; p < 0.01), lower estimated-blood-loss (EBL; 131 vs 341 mL; p < 0.01), fewer intraoperative blood transfusions (1.4 vs 5%; p < 0.01), shorter LOS (5.2 vs 7.2 days; p < 0.01). Tumor size was smaller (3.2 vs 4.4 cm; p < 0.01) with lower lymph node (LN) yield (14 vs 16; p < 0.01). When comparing HAL (n = 109) to TLR (n = 243), despite increased prior abdominal operations (60 vs 43%; p = 0.008), HAL had shorter operative time (167 vs 191 min; p < 0.01), similar length-of-stay (LOS; 5.4 vs 5.1 days; p = 0.27), and readmission rate (15 vs 13%; p = 0.47). When comparing HAL to open, the advantages of TLR approach persisted including lower EBL (171 vs 342 mL; p < 0.01), and shorter LOS (5.4 vs 7.2 days; p < 0.01). Although HAL had smaller tumors, it had a similar LN yield (16 vs 16; p = 0.80), and higher R0-rate (97 vs 83%; p < 0.01). CONCLUSION Hand-assist laparoscopy is safe and feasible for distal pancreatectomy as operative time, complication profile, lymph node yield, and R0-rates are similar to open procedures, while maintaining the associated the advantages of a total laparoscopic/robotic approach with reduced blood loss and shorter length-of-stay.
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Affiliation(s)
- Adriana C Gamboa
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Victoria G Aveson
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mohammad Y Zaidi
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Rachel M Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - William R Jarnagin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter J Allen
- Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC, USA
| | - Jeffrey A Drebin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - T Peter Kingham
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ronald P DeMatteo
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Juan M Sarmiento
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Michael I D'Angelica
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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Lee RM, Liu Y, Gamboa AC, Staley CA, Kooby D, Russell MC, Cardona K, Maithel SK. Differences in outcome for patients with cholangiocarcinoma: Racial/ethnic disparity or socioeconomic factors? Surg Oncol 2020; 34:126-133. [PMID: 32891317 DOI: 10.1016/j.suronc.2020.04.007] [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] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/13/2020] [Accepted: 04/05/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Inequities in cancer survival are well documented. Whether disparities in overall survival (OS) result from inherent racial differences in underlying disease biology or socioeconomic factors (SEF) is not known. Our aim was to define the association of race/ethnicity and SEF with OS in pts with cholangiocarcinoma (CCA). METHODS Patients with CCA of all sites and stages in the National Cancer Data Base (2004-13) were included. Racial/ethnic groups were defined as non-Hispanic White (NH-W), non-Hispanic Black (NH-B), Asian, and Hispanic. Income and education were based on census data for patients' zip code. Income was defined as high (≥$63,000) vs low (<$63,000). Primary outcome was OS. RESULTS 27,151 patients were included with a mean age of 68 yrs; 51% were male. 78% were NH-W, 8% NH-B, 8% Hispanic, and 6% Asian. 56% had Medicare, 33% private insurance, 7% Medicaid, and 4% were uninsured. 67% had low income. 19% lived in an area where >20% of adults did not finish high school. NH-B and Hispanic patients had more unfavorable SEF including uninsured status, low income, and less formal education than NH-W and Asian pts (all p < 0.001). They were also younger, more likely to be female and to have metastatic disease (all p < 0.001). Despite this, NH-B race and Hispanic ethnicity were not associated with decreased OS. Male sex, older age, non-private insurance, low income, lower education, non-academic facility, location outside the Northeast, higher Charlson-Deyo score, worse grade, larger tumor size, and higher stage were all associated with decreased OS (all p < 0.001). On MV analysis, along with adverse pathologic factors, type of insurance (p = 0.003), low income (p < 0.001), and facility type and location of treatment (p < 0.001) remained associated with decreased OS; non-white race/ethnicity was not. CONCLUSIONS Disparities in survival exist in CCA, however they are not driven by race/ethnicity. Non-privately insured and low-income patients had decreased OS, as did patients treated at non-academic centers and outside the Northeast. This suggests that decreased ability to access and afford care results in worse outcomes, rather than biological differences amongst racial/ethnic groups.
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Affiliation(s)
- Rachel M Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Yuan Liu
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Adriana C Gamboa
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Charles A Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - David Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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Turgeon MK, Gamboa AC, Rupji M, Lee RM, Switchenko JM, Russell MC, Cardona K, Kooby DA, Staley CA, Maithel SK, Shah MM. Should signet-ring cell histology alter the treatment approach for clinical stage I gastric cancer? J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.321] [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
321 Background: Upfront surgery is standard of care for stage I gastric cancer. Despite this, many clinicians administer preoperative therapy for clinical stage I disease with signet ring cell histology, given its aggressive biology. We aimed to assess the validity of this practice. Methods: The National Cancer Database (2004-2015) was reviewed for pts with non-metastatic signet ring cell gastric cancer who underwent treatment with surgery alone, perioperative chemotherapy, neoadjuvant therapy, or adjuvant therapy. Analysis was stratified by preoperative clinical stage and pathologic stage. Primary outcome was overall survival (OS). Results: Of 3000 pts, median age was 61 (IQR: 51-70). 34% were clinical stage I (n = 1018) of which 53% received surgery alone (n = 542), 5% perioperative chemotherapy (n = 47), 12% neoadjuvant therapy (n = 125), and 30% adjuvant therapy (n = 304). Median follow-up was 26 mos. For clinical stage I disease, surgery alone was associated with improved median OS (108 mos) when compared to perioperative chemotherapy (80 mos), neoadjuvant therapy (41 mos), or adjuvant therapy (73 mos, all p < 0.001). For pathologic stage I, surgery alone had equivalent survival to perioperative and adjuvant therapy (5-yr OS: 81 vs 82 vs 79%, p = 0.22). Concordance between clinical and pathologic stage I was 56%, specifically, 41% of clinical stage I pts were upstaged to pathologic stage II (44%) and stage III (56%). Adjuvant therapy for these pts was associated with improved median OS compared to pretreatment (perioperative chemotherapy / neoadjuvant therapy) for those upstaged to pathologic stage II (122 vs 37mos, p < 0.001) or stage III (40 vs 18mos, p < 0.001) disease. Conclusions: Our stage-stratified study demonstrates improved survival with upfront surgery for clinical stage I signet ring cell gastric cancer. Despite 41% of clinical stage I pts being upstaged to stage II or III on final pathology, adjuvant therapy offers a favorable rescue strategy, with improved outcomes compared to those treated preoperatively. Surgery alone also affords similar survival for pathologic stage I disease compared to multimodal therapy. This study challenges the intrinsic bias to over-treat stage I signet ring cell gastric cancer.
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Affiliation(s)
- Michael K. Turgeon
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - Adriana C. Gamboa
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - Manali Rupji
- Winship Cancer Institute, Emory University, Atlanta, GA
| | - Rachel M. Lee
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | | | - Maria C. Russell
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - Kenneth Cardona
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - David A. Kooby
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - Charles A. Staley
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | | | - Mihir M. Shah
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
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Lee RM, Gamboa AC, Turgeon MK, Grotz TE, Fournier KF, Dineen SP, Veerapong J, Clarke C, Patel SH, Henrix RJ, Lambert LA, Abbott DE, Raoof M, Johnston FM, Staley CA, Cloyd J, Maithel SK, Russell MC. A novel preoperative risk score to optimize patient selection for performing concomitant liver resection with cytoreductive surgery/HIPEC. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.37] [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
37 Background: While parenchymal hepatic metastases were previously considered a contraindication to cytoreductive surgery(CRS) and heated intraperitoneal chemotherapy(HIPEC), liver resection(LR) is increasingly performed concomitantly with CRS/HIPEC. As this practice continues to expand, identification of preoperative factors associated with poor outcomes is paramount. Methods: Patients from the US HIPEC Collaborative(2000-2017) with invasive appendiceal or colorectal adenocarcinoma undergoing primary, curative intent CRS/HIPEC with CC0-1 resection were included. LR was defined as a formal parenchymal resection. Primary endpoints were postoperative complications and overall survival(OS). Results: 658 patients were included. Average age was 54 years and 45% were male; 83 (15%) underwent liver resection of colorectal (58%) or invasive appendiceal (42%) metastases. Liver resection patients had more complications (81 vs 60%; p = 0.001), greater number of complications (2.3 vs 1.5; p < 0.001), and required more reoperations (22 vs 11%; p = 0.007) and readmissions (39 vs 25%; p = 0.014) than non-liver resection patients. Liver resection patients had decreased OS (2-year OS 62% vs 79%, p < 0.001), which persisted on multivariable Cox regression when accounting for PCI and histology type. Preoperative factors associated with decreased OS on multivariable analysis in patients undergoing liver resection included age < 60 years (HR:3.61), colorectal histology (HR:3.84), and multiple liver tumors (HR:3.45) (all p < 0.05). When assigning one point for each factor, there was an incremental decrease in 2-yr survival as the risk score increased from 0 to 3 (0: 100%; 1: 91%; 2: 58%; 3: 0%; p < 0.001). Conclusions: As concurrent liver resection with CRS/HIPEC has become more common, we created a simple risk score to stratify patients considered for CRS/HIPEC with liver resection. These data aid in striking the balance between an increased perioperative complication profile with the potential for improvement in overall survival.
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Affiliation(s)
- Rachel M. Lee
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - Adriana C. Gamboa
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - Michael K. Turgeon
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | | | | | - Sean Patrick Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL
| | - Jula Veerapong
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA
| | - Callisia Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Sameer H. Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ryan James Henrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Laura A. Lambert
- Division of Surgical Oncology, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Daniel Erik Abbott
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI
| | - Mustafa Raoof
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | | | - Charles A. Staley
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - Jordan Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Maria C. Russell
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
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Gamboa AC, Meyer BI, Switchenko JM, Rupji M, Lee RM, Turgeon MK, Russell MC, Cardona K, Kooby DA, Maithel SK, Shah MM. Should adenosquamous esophageal carcinoma be treated like adenocarcinoma or squamous cell carcinoma? J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.323] [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
323 Background: Adenocarcinoma and squamous cell carcinoma of the esophagus have distinct outcomes, treatment strategies, and response profiles to therapy. Adenosquamous carcinoma (ASC) is thought to behave more aggressively than each of its counterparts. Our aim was to determine if ASC is best managed as adenocarcinoma or squamous cell carcinoma. Methods: The National Cancer Database (2004-15) was queried for patients with non-metastatic, esophageal ASC. Analysis was stratified by clinical node negative (cN0) or node positive (cN1-3) according to AJCC 8th edition. Treatment types were categorized into chemoradiation alone, surgery alone, or preoperative chemoradiation followed by surgery. Primary outcome was overall survival (OS). Results: Among 352 pts, median age was 67 yrs, 80% were male (n = 281). Median f/u was 46 mos. 43% were cN0 (n = 151), 57% were cN1-3 (n = 201). 55% had chemoradiation alone (n = 194), 15% had surgery alone (n = 53) and 30% had preoperative chemoradiation (n = 105). Of pts who had preoperative chemoradiation, 20% had pathologic complete response (n = 17). For either cN0 or cN1-3, Charlson-Deyo Comorbidity Index did not differ among the treatment groups (all p > 0.05). On KM analysis for cN0 disease, treatment with surgery alone had a comparable 5-yr OS to preoperative chemoradiation (47 vs 34% p = 0.5) and each had improved 5-yr OS compared to chemoradiation alone (30%; p = 0.02; p = 0.06). On UV analysis for patients with cN0 disease, clinical T-stage was not associated with 5-yr OS. For patients with cN1-3 disease, however, preoperative chemoradiation was associated with improved 5-yr OS when compared to chemoradiation alone or surgery alone (27 vs 19 vs 0% p < 0.001). This persisted even when accounting for age and clinical T-stage (HR 0.45 p < 0.001). Conclusions: Esophageal adenosquamous carcinoma behaves more like adenocarcinoma both in response to chemoradiation and survival outcomes based on the treatment modality. The complete response rate to chemoradiation is only 20% unlike what has been shown for squamous cell carcinoma, where chemoradiation is an acceptable definitive therapy. Esophageal adenosquamous carcinoma should be managed like adenocarcinoma and not squamous cell carcinoma.
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Affiliation(s)
- Adriana C. Gamboa
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - Benjamin I Meyer
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | | | - Manali Rupji
- Winship Cancer Institute, Emory University, Atlanta, GA
| | - Rachel M. Lee
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | | | - Maria C. Russell
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - Kenneth Cardona
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - David A. Kooby
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | | | - Mihir M. Shah
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
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Lee RM, Zaidi MY, Gamboa AC, Speegle S, Kimbrough CW, Cloyd JM, Leiting JL, Grotz TE, Lee AJ, Fournier KF, Powers BD, Dineen SP, Baumgartner J, Veerapong J, Clarke CN, Sussman JJ, Patel S, Hendrix RJ, Lambert LA, Vande Walle KA, Abbott DE, LaRocca CJ, Raoof M, Fackche N, Johnston FM, Staley CA, Maithel SK, Russell MC. What is the Optimal Preoperative Imaging Modality for Assessing Peritoneal Cancer Index? An Analysis From the United States HIPEC Collaborative. Clin Colorectal Cancer 2019; 19:e1-e7. [PMID: 31974019 DOI: 10.1016/j.clcc.2019.12.002] [Citation(s) in RCA: 12] [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: 09/13/2019] [Revised: 10/30/2019] [Accepted: 12/05/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Radiographic prediction of peritoneal carcinomatosis index (PCI) can improve patient selection for cytoreductive surgery. We aimed to determine the correlation of computed tomography (CT)-predicted PCI (CT-PCI) and magnetic resonance imaging (MRI)-predicted PCI (MRI-PCI) with intraoperative-PCI, and if a preoperative-PCI cutoff is associated with incomplete cytoreduction. PATIENTS AND METHODS Patients from the US HIPEC Collaborative (2000-2017) with appendiceal, colorectal, or peritoneal mesothelioma (PM) histology who underwent cytoreductive surgery were included. Pearson correlation coefficients were used to determine correlation between preoperative and intraoperative-PCI values. Fisher r-to-z transformation was used to compare correlations. RESULTS A total of 488 patients were included. Of these, 34% had noninvasive appendiceal, 30% invasive appendiceal, 28% colorectal, and 8% PM histology. CT-PCI was correlated with intraoperative-PCI for patients with noninvasive and invasive appendiceal and colorectal histologies (r = 0.689, 0.554, and 0.571; all P < .001), but not PM (r = 0.188; P = .295). MRI-PCI was correlated with intraoperative-PCI for all histologies (non-invasive appendiceal: r = 0.591; P = .002; invasive appendiceal: r = 0.848; P < .001; colorectal: r = 0.729; P < .001; PM: r = 0.890; P = .007). Comparing CT and MRI, correlations were similar in noninvasive appendiceal and colorectal histologies; MRI was better for invasive appendiceal and PM (P = .005 and P = .021, respectively). Twenty-eight (6%) patients underwent an incomplete cytoreduction (cytoreduction score, 2-3). PCI greater than 15 was associated with cytoreduction score of 2 to 3 for both CT and MRI (CT-PCI: odds ratio, 3.0; P = .033; MRI-PCI: odds ratio, 7.6; P = .071). CONCLUSIONS In this multi-institutional cohort, CT and MRI-PCI correlate well with intraoperative-PCI. MRI appears to be superior for invasive appendiceal and peritoneal mesothelioma. External validation in a larger population is needed.
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Affiliation(s)
- Rachel M Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Mohammad Y Zaidi
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Adriana C Gamboa
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Shelby Speegle
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Charles W Kimbrough
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jennifer L Leiting
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - Andrew J Lee
- Division of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Keith F Fournier
- Division of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Benjamin D Powers
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL
| | - Sean P Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL
| | - Joel Baumgartner
- Division of Surgical Oncology, Department of Surgery, University of California San Diego, San Diego, CA
| | - Jula Veerapong
- Division of Surgical Oncology, Department of Surgery, University of California San Diego, San Diego, CA
| | - Callisia N Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Sameer Patel
- Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Ryan J Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Laura A Lambert
- Huntsman Cancer Institute, Division of Surgical Oncology, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Kara A Vande Walle
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI
| | - Daniel E Abbott
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI
| | - Christopher J LaRocca
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Mustafa Raoof
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Nadege Fackche
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | | | - Charles A Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA.
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Shaib WL, Zakka K, Hoodbhoy FN, Belalcazar A, Kim S, Cardona K, Russell MC, Maithel SK, Sarmiento JM, Wu C, Akce M, Alese OB, El-Rayes BF. In-hospital 30-day mortality for older patients with pancreatic cancer undergoing pancreaticoduodenectomy. J Geriatr Oncol 2019; 11:660-667. [PMID: 31706832 DOI: 10.1016/j.jgo.2019.10.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/01/2019] [Accepted: 10/16/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Surgical resection remains the only potentially curative therapy for pancreatic ductal adenocarcinoma (PDAC). There is paucity of literature about morbidity and mortality in older patients with PDAC undergoing pancreaticoduodenectomy. This retrospective analysis evaluates the in-hospital 30-day mortality of this population utilizing the Nationwide Inpatient Sample (NIS) database. SUBJECTS AND METHODS All US patients hospitalized for pancreaticoduodenectomy (Whipple procedure) were included. Data was obtained from the NIS provided by the Agency for Healthcare Research and Quality. Pancreaticoduodenectomy diagnoses were identified using Clinical Classifications Software codes based on ICD-9 between 2007 and 2010. Univariable and multivariable analyses were performed using the logistic model, weighted chi-square test, and generalized linear model. RESULTS A total of 6149 patient discharges for pancreaticoduodenectomy were identified. Mean age was 64.9 years (SD ± 12.3); 21% of patients were ≥ 76 years of age. Majority were White (N = 5257, 77.9%) with a male:female ratio of 1. Patients aged 76 and older (OR: 1.76; 1.36-2.28; p < .001), Hispanics (OR: 1.40; 0.92-2.13; p = .12), and high comorbidity score (OR: 5.70; 3.44-9.46; p < .001) were found to be associated with a higher risk of 30-day in-hospital mortality. In the multivariable analysis, advanced age (>76) remained a significant predictor of longer in-hospital length of stay (OR: 1.09; 1.04-1.14; p < .001) and 30-day in-hospital mortality (OR 1.46; 1.07-2.00; p = .016). The 30-day in-hospital mortality rate for all patients across all years was 3.24%, for patients >76 years 4.11% and for patients <76 years 2.77%. Patients who underwent surgery at teaching hospitals (OR: 0.61; 0.42-0.88; p = .008) had a lower risk of 30-day in-hospital mortality compared to non-teaching hospitals. CONCLUSION In-hospital 30 day mortality was higher in selected older patients with PDAC undergoing pancreaticoduodenectomy. Mortality was lower at high volume and teaching centers. Further stringent selection criteria are needed to decrease mortality in the older population.
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Affiliation(s)
- Walid L Shaib
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia.
| | - Katerina Zakka
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Farhan N Hoodbhoy
- College of Arts and Sciences, Boston University, Boston, MA, United States of America
| | - Astrid Belalcazar
- Eastern Maine Medical Center Cancer Care, Brewer, ME, United States of America
| | - Sungjin Kim
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Kenneth Cardona
- Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
| | - Maria C Russell
- Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
| | - Shishir K Maithel
- Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
| | - Juan M Sarmiento
- General Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
| | - Christina Wu
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mehmet Akce
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Olatunji B Alese
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bassel F El-Rayes
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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DePalo DK, Lee RM, Lopez-Aguiar AG, Gamboa AC, Rocha F, Poultsides G, Dillhoff M, Fields RC, Idrees K, Nathan H, Abbott D, Maithel SK, Russell MC. Interaction of race and pathology for neuroendocrine tumors: Epidemiology, natural history, or racial disparity? J Surg Oncol 2019; 120:919-925. [PMID: 31385621 PMCID: PMC6791745 DOI: 10.1002/jso.25662] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 07/26/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Although minority race has been associated with worse cancer outcomes, the interaction of race with pathologic variables and outcomes of patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs) is not known. METHODS Patients from the US Neuroendocrine Study Group (2000-2016) undergoing curative-intent resection of GEP-NETs were included. Given few patients of other races, only Black and White patients were analyzed. RESULTS A total of 1143 patients were included. Median age was 58 years, 49% were male, 14% Black, and 86% White. Black patients were more likely to be uninsured (7% vs 2%, P = .011), and to have symptomatic bleeding (13% vs 7%, P = .009), emergency surgery (7% vs 3%, P = .006), and positive lymph nodes (LN) (47% vs 36%, P = .021). However, Black patients had improved 5-year recurrence-free survival (RFS) (90% vs 80%, P = .008). Quality of care was comparable between races, seen by similar LN yield, R0 resections, postoperative complications, and need for reoperation/readmission (all P > .05). While both races were more likely to have pancreas-NETs, Black patients had more small bowel-NETs (22% vs 13%, P < .001). LN positivity was prognostic for pancreas-NETs (5-year RFS 67% vs 83%, P = .001) but not for small-bowel NETs. CONCLUSIONS Black patients with GEP-NETs had more adverse characteristics and higher LN positivity. Despite this, Black patients have improved RFS. This may be attributed to the epidemiologic differences in the primary site of GEP-NETs and variable prognostic value of LN-positive disease.
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Affiliation(s)
- Danielle K. DePalo
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Rachel M. Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Alexandra G. Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Adriana C. Gamboa
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Flavio Rocha
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Mary Dillhoff
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hari Nathan
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Daniel Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Maria C. Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Gamboa AC, Liu Y, Lee RM, Zaidi MY, Staley CA, Russell MC, Cardona K, Sullivan PS, Maithel SK. A novel preoperative risk score to predict lymph node positivity for rectal neuroendocrine tumors: An NCDB analysis to guide operative technique. J Surg Oncol 2019; 120:932-939. [PMID: 31448820 PMCID: PMC6791747 DOI: 10.1002/jso.25679] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 08/06/2019] [Accepted: 08/10/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND/OBJECTIVE Staging and type of resection for rectal neuroendocrine tumors (R-NETS) relies on preoperative identification of lymph node (LN) involvement. Study objective was to develop a Preoperative Rectal Stratification Score (PReSS) for LN-positivity and to assess the association of PReSS with overall survival (OS). METHODS All patients in the National Cancer Database (2004-2014) with non-metastatic/nonfunctional R-NETS were included. Tumor size was divided into three categories (<1, 1-2, and ≥2 cm). RESULTS Among 383 patients, median age was 57 years, 52% were male (n = 200), median tumor size was 1.4 cm, 43% had positive LNs (n = 163). On univariate analysis, age > 60, poorly differentiated grade, depth of invasion past submucosa, and size >1 cm were associated with LN positivity. On multivariable analysis, depth of invasion past submucosa, and increasing tumor size >1 cm remained associated with LN positivity. As these can be determined preoperatively, incidence of LN positivity was determined for each combination of tumor size and depth of invasion. Each variable was assigned a score to create a PReSS of four groups (0-3) associated with an increasing rate of LN-positivity (PReSS group 0: 11%, 1: 38%, 2: 50%, 3: 78%, P < .01). PReSS correlated with 10-year OS (PReSS 0: 90%; 1: 81%; 2: 59%; 3: 41%). CONCLUSION For R-NETS, depth of invasion and tumor size predict LN positivity and both can be obtained preoperatively. PReSS incorporates both variables and stratifies tumors into four risk groups of progressively increasing LN positivity and should be used to guide surgical approach.
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Affiliation(s)
- Adriana C. Gamboa
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Yuan Liu
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Rachel M. Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mohammad Y. Zaidi
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Charles A. Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Maria C. Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Patrick S. Sullivan
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Duininck G, Lopez-Aguiar AG, Lee RM, Miller L, Dariushnia S, Wu C, Alese OB, Lin JY, Wedd J, Adams A, Maithel SK, Russell MC. Optimizing cancer care for hepatocellular carcinoma at a safety-net hospital: The value of a multidisciplinary disease management team. J Surg Oncol 2019; 120:1365-1370. [PMID: 31642056 DOI: 10.1002/jso.25738] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 02/18/2019] [Accepted: 10/08/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatitis C (HCV) is the primary etiology of hepatocellular carcinoma (HCC) in the US multidisciplinary disease management teams (DMT) that optimize oncologic care. The impact of DMT for HCC in safety-net hospitals is unknown. METHODS Patients diagnosed with HCC from 2009 to 2016 at Grady Memorial Hospital (GMH) were included. The primary aim was to evaluate referrals to care, receipt of therapy, and overall survival (OS) after DMT formation. Screening patterns of HCV patients for HCC were also examined. RESULTS Of 204 HCC patients, median age was 58 years, with 81% male, 83% black. 46% presented with stage 4 disease, 53% had treatment with median OS 9.8 months. DMT formation was associated with increased referrals to surgery (49% vs 30%; P = .02), liver-directed therapy (58% vs 31%; P = .001), and radiation (13% vs 3%; P = .019). Patients were also more likely to get treatment (59% vs 41%; P = .026), with improved median OS (30.7 vs 4.9 months; P < .001). DMT did not alter HCV screening for HCC (23%). HCV patients screened for HCC had earlier stage disease (P = .001). CONCLUSION Implementation of a DMT at GMH is associated with increased HCC patients referred for/receiving treatment, as well as improved survival. Few patients with HCV at risk for HCC are screened, despite DMT. Future efforts should aim to establish screening programs for HCV patients at risk for HCC.
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Affiliation(s)
- Grace Duininck
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Alexandra G Lopez-Aguiar
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Rachel M Lee
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Lesley Miller
- Department of Internal Medicine, Division of General Medicine and Geriatrics, Emory University, Atlanta, Georgia
| | - Sean Dariushnia
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University, Atlanta, Georgia
| | - Christina Wu
- Department of Hematology and Oncology, Emory University, Atlanta, Georgia
| | - Olatunji B Alese
- Department of Hematology and Oncology, Emory University, Atlanta, Georgia
| | - Jolinta Y Lin
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Joel Wedd
- Department of Internal Medicine, Division of Digestive Diseases, Transplant Hepatology, Emory University, Atlanta, Georgia
| | - Andrew Adams
- Department of Surgery, Division of Transplantation, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Maria C Russell
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Gamboa AC, Liu Y, Lee RM, Zaidi MY, Staley CA, Kooby DA, Winer JH, Shah MM, Russell MC, Cardona K, Maithel SK. Duodenal neuroendocrine tumors: Somewhere between the pancreas and small bowel? J Surg Oncol 2019; 120:1293-1301. [PMID: 31621090 DOI: 10.1002/jso.25731] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 09/18/2019] [Accepted: 09/22/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND While sub-2 cm pancreatic neuroendocrine tumors (NETs) are often observed, small bowel-NETs undergo resection and lymphadenectomy regardless of size. Aim was to define the natural history of duodenal (D-NETs), determine the role of resection, and define the factors associated with overall survival (OS) after resection. METHODS National Cancer Database (2004-2014) was queried for the patients with nonmetastatic/nonfunctional D-NETs. Local resection (LR): local excision/polypectomy/excisional biopsy. Anatomic resection (AR): radical surgery. Tumor size was divided into less than 1 cm, 1 to 2 cm, and ≥2 cm. Propensity score weighting was used to create balanced resection and no-resection cohorts. The primary endpoint was OS. RESULTS Among 5502 patient, the median age was 65 years. The median follow-up was 49 months. The median tumor size was 0.8 cm. Resection was performed in 72% (n = 3954; LR: 61%, AR: 39%). Lymph node (LN) resection was performed in 26% (43% had metastasis). A total of 74% had negative margins. Resection and no-resection cohorts were propensity score weighted for age/sex/race/Charlson-Deyo score/tumor grade (all independently associated with OS on multivariable analysis). Resection was associated with improved median OS compared to no resection in all sizes (<1 cm: median not reached vs 194 months; 1-2 cm: median not reached vs 56 months; >2 cm: median not reached vs 90 months; all P < .01). Subset analysis of each resection size cohort demonstrated that neither type of resection, LN retrieval, LN positivity, or margin status was associated with OS (all P > .05). CONCLUSION Patients with nonmetastatic and nonfunctional D-NETS should be considered for resection regardless of tumor size. Given the lack of prognostic value, the resection type and extent of LN retrieval should be tailored to each patient's clinical picture and safety profile.
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Affiliation(s)
- Adriana C Gamboa
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Yuan Liu
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Rachel M Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mohammad Y Zaidi
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Charles A Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Joshua H Winer
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mihir M Shah
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Zaidi MY, Lee RM, Gamboa AC, Speegle S, Cloyd JM, Kimbrough C, Grotz T, Leiting J, Fournier K, Lee AJ, Dineen S, Dessureault S, Kelly KJ, Kotha NV, Clarke C, Gamblin TC, Patel SH, Lee TC, Hendrix RJ, Lambert L, Ronnekleiv-Kelly S, Pokrzywa C, Blakely AM, Lee B, Johnston FM, Fackche N, Russell MC, Maithel SK, Staley CA. Preoperative Risk Score for Predicting Incomplete Cytoreduction: A 12-Institution Study from the US HIPEC Collaborative. Ann Surg Oncol 2019; 27:156-164. [PMID: 31602579 DOI: 10.1245/s10434-019-07626-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND For patients with peritoneal carcinomatosis undergoing cytoreductive surgery with heated intraperitoneal chemotherapy (CRS/HIPEC), incomplete cytoreduction (CCR2/3) confers morbidity without survival benefit. The aim of this study is to identify preoperative factors which predict CCR2/3. METHODS All patients who underwent curative-intent CRS/HIPEC of low/high-grade appendiceal, colorectal, or peritoneal mesothelioma cancers in the 12-institution US HIPEC Collaborative from 2000 to 2017 were included (n = 2027). The primary aim is to create an incomplete-cytoreduction risk score (ICRS) to predict CCR2/3 CRS utilizing preoperative data. ICRS was created from a randomly selected cohort of 50% of patients (derivation cohort) and verified on the remaining patients (validation cohort). RESULTS Within our derivation cohort (n = 998), histology was low-grade appendiceal neoplasms in 30%, high-grade appendiceal tumor in 41%, colorectal tumor in 22%, and peritoneal mesothelioma in 8%. CCR0/1 was achieved in 816 patients and CCR 2/3 in 116 patients. On multivariable analysis, preoperative factors associated with incomplete cytoreduction were male gender [odds ratio (OR) 3.4, p = 0.007], presence of ascites (OR 2.8, p = 0.028), cancer antigen (CA)-125 ≥ 40 U/mL (OR 3.4, p = 0.012), and carcinoembryonic antigen (CEA) ≥ 4.2 ng/mL (OR 3.2, p = 0.029). Each preoperative factor was assigned a score of 0 or 1 to form an ICRS from 0 to 4. Scores were grouped as zero (0), low (1-2), or high (3-4). Incidence of CCR2/3 progressively increased by risk group from 1.6% in zero to 13% in low and 39% in high. When ICRS was applied to the validation cohort (n = 1029), this relationship was maintained. CONCLUSION The incomplete cytoreduction risk score incorporates preoperative factors to accurately stratify the risk of CCR2/3 resection in CRS/HIPEC. This score should not be used in isolation, however, to exclude patients from surgery.
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Affiliation(s)
- Mohammad Y Zaidi
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road, NE; Building C, 2nd Floor, Atlanta, GA, 30322, USA
| | - Rachel M Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road, NE; Building C, 2nd Floor, Atlanta, GA, 30322, USA
| | - Adriana C Gamboa
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road, NE; Building C, 2nd Floor, Atlanta, GA, 30322, USA
| | - Shelby Speegle
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road, NE; Building C, 2nd Floor, Atlanta, GA, 30322, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Charles Kimbrough
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Travis Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jennifer Leiting
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Sophie Dessureault
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Kaitlyn J Kelly
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, USA
| | - Nikhil V Kotha
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, USA
| | - Callisia Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - T Clark Gamblin
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tiffany C Lee
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ryan J Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Laura Lambert
- Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Sean Ronnekleiv-Kelly
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Courtney Pokrzywa
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Andrew M Blakely
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Byrne Lee
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | | | - Nadege Fackche
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road, NE; Building C, 2nd Floor, Atlanta, GA, 30322, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road, NE; Building C, 2nd Floor, Atlanta, GA, 30322, USA
| | - Charles A Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road, NE; Building C, 2nd Floor, Atlanta, GA, 30322, USA.
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Lee RM, Liu Y, Gamboa AC, Zaidi MY, Kooby DA, Shah MM, Cardona K, Russell MC, Maithel SK. Race, ethnicity, and socioeconomic factors in cholangiocarcinoma: What is driving disparities in receipt of treatment? J Surg Oncol 2019; 120:611-623. [PMID: 31301148 PMCID: PMC6752195 DOI: 10.1002/jso.25632] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 04/26/2019] [Accepted: 06/28/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Race/ethnicity and socioeconomic factors are associated with worse cancer outcomes. Our aim was to determine the association of these factors with receipt of surgery and multimodality therapy for cholangiocarcinoma. METHODS Patients with cholangiocarcincoma in the National Cancer Database were identified. Racial/ethnic groups were defined as non-Hispanic White, non-Hispanic Black, Asian, and Hispanic. Socioeconomic factors were insurance status, income, and education. RESULTS Of 12 095 patients with non-metastatic cholangiocarcinoma, 42% received surgery. Black race was associated with decreased odds of receiving surgery (odds ratio [OR]: 0.66l; P < .001) compared to White patients. Socioeconomic factors accounted for 21% of this disparity. Accounting for socioeconomic and clinicopathologic variables, Black race (OR: 0.73; P < .001), uninsured status (OR: 0.43; P < .001), and Medicaid insurance (OR: 0.63; P < .001) were all associated with decreased receipt of surgery. Of 4808 patients who received surgery, 47% received multimodality therapy. There were no racial/ethnic or socioeconomic differences in receipt of multimodality therapy once patients accessed surgical care. Similar results were seen in patients with advanced disease who received chemotherapy as primary treatment. CONCLUSION Racial/ethnic and socioeconomic disparities exist in treatment for cholangiocarcinoma, however only for primary treatment. In patients who received surgery or chemotherapy, there were no disparities in receipt of multimodality therapy. This emphasizes the need to improve initial access to health care for minority and socioeconomical disadvantaged patients.
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Affiliation(s)
- Rachel M. Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Yuan Liu
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Adriana C. Gamboa
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mohammad Y. Zaidi
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - David A. Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mihir M. Shah
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Maria C. Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Gamboa AC, Zaidi MY, Lee RM, Speegle S, Switchenko JM, Lipscomb J, Cloyd JM, Ahmed A, Grotz T, Leiting J, Fournier K, Lee AJ, Dineen S, Powers BD, Lowy AM, Kotha NV, Clarke C, Gamblin TC, Patel SH, Lee TC, Lambert L, Hendrix RJ, Abbott DE, Vande Walle K, Lafaro K, Lee B, Johnston FM, Greer J, Russell MC, Staley CA, Maithel SK. Optimal Surveillance Frequency After CRS/HIPEC for Appendiceal and Colorectal Neoplasms: A Multi-institutional Analysis of the US HIPEC Collaborative. Ann Surg Oncol 2019; 27:134-146. [PMID: 31243668 DOI: 10.1245/s10434-019-07526-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND No guidelines exist for surveillance following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for appendiceal and colorectal cancer. The primary objective was to define the optimal surveillance frequency after CRS/HIPEC. METHODS The U.S. HIPEC Collaborative database (2000-2017) was reviewed for patients who underwent a CCR0/1 CRS/HIPEC for appendiceal or colorectal cancer. Radiologic surveillance frequency was divided into two categories: low-frequency surveillance (LFS) at q6-12mos or high-frequency surveillance (HFS) at q2-4mos. Primary outcome was overall survival (OS). RESULTS Among 975 patients, the median age was 55 year, 41% were male: 31% had non-invasive appendiceal (n = 301), 45% invasive appendiceal (n = 435), and 24% colorectal cancer (CRC; n = 239). With a median follow-up time of 25 mos, the median time to recurrence was 12 mos. Despite less surveillance, LFS patients had no decrease in median OS (non-invasive appendiceal: 106 vs. 65 mos, p < 0.01; invasive appendiceal: 120 vs. 73 mos, p = 0.02; colorectal cancer [CRC]: 35 vs. 30 mos, p = 0.8). LFS patients had lower median PCI scores compared with HFS (non-invasive appendiceal: 10 vs. 19; invasive appendiceal: 10 vs. 14; CRC: 8 vs. 11; all p < 0.01). However, on multivariable analysis, accounting for PCI score, LFS was still not associated with decreased OS for any histologic type (non-invasive appendiceal: hazard ratio [HR]: 0.28, p = 0.1; invasive appendiceal: HR: 0.73, p = 0.42; CRC: HR: 1.14, p = 0.59). When estimating annual incident cases of CRS/HIPEC at 375 for non-invasive appendiceal, 375 invasive appendiceal and 4410 colorectal, LFS compared with HFS for the initial two post-operative years would potentially save $13-19 M/year to the U.S. healthcare system. CONCLUSIONS Low-frequency surveillance after CRS/HIPEC for appendiceal or colorectal cancer is not associated with decreased survival, and when considering decreased costs, may optimize resource utilization.
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Affiliation(s)
- Adriana C Gamboa
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Mohammad Y Zaidi
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Rachel M Lee
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shelby Speegle
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Joseph Lipscomb
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ahmed Ahmed
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Travis Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jennifer Leiting
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean Dineen
- Department of Surgery, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | | | - Andrew M Lowy
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
| | - Nikhil V Kotha
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
| | - Callisia Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - T Clark Gamblin
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tiffany C Lee
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Laura Lambert
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ryan J Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Daniel E Abbott
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Kara Vande Walle
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Kelly Lafaro
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Byrne Lee
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | | | - Jonathan Greer
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Maria C Russell
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Charles A Staley
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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Kotha NV, Baumgartner JM, Veerapong J, Cloyd JM, Ahmed A, Grotz TE, Leiting JL, Fournier K, Lee AJ, Dineen SP, Dessureault S, Clarke C, Mogal H, Zaidi MY, Russell MC, Patel SH, Sussman JJ, Dhar V, Lambert LA, Hendrix RJ, Abbott DE, Pokrzywa C, Lafaro K, Lee B, Greer JB, Fackche N, Lowy AM, Kelly KJ. Primary Tumor Sidedness is Predictive of Survival in Colon Cancer Patients Treated with Cytoreductive Surgery With or Without Hyperthermic Intraperitoneal Chemotherapy: A US HIPEC Collaborative Study. Ann Surg Oncol 2019; 26:2234-2240. [PMID: 31016486 DOI: 10.1245/s10434-019-07373-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The clinical relevance of primary tumor sidedness is not fully understood in colon cancer patients with peritoneal metastasis treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS This was a retrospective cohort study of a multi-institutional database of patients with peritoneal surface malignancy at 12 participating high-volume academic centers from the US HIPEC Collaborative. RESULTS Overall, 336 patients with colon primary tumors who underwent curative-intent CRS with or without HIPEC were identified; 179 (53.3%) patients had right-sided primary tumors and 157 (46.7%) had left-sided primary tumors. Patients with right-sided tumors were more likely to be older, male, have higher Peritoneal Cancer Index (PCI), and have a perforated primary tumor, but were less likely to have extraperitoneal disease. Patients with complete cytoreduction (CC-0/1) had a median disease-free survival (DFS) of 11.5 months (95% confidence interval [CI] 7.6-15.3) versus 13.1 months (95% CI 9.5-16.8) [p = 0.158] and median overall survival (OS) of 30 months (95% CI 23.5-36.6) versus 45.4 months (95% CI 35.9-54.8) [p = 0.028] for right- and left-sided tumors; respectively. Multivariate analysis revealed that right-sided primary tumor was an independent predictor of worse DFS (hazard ratio [HR] 1.75, 95% CI 1.19-2.56; p =0.004) and OS (HR 1.72, 95% CI 1.09-2.73; p = 0.020). CONCLUSION Right-sided primary tumor was an independent predictor of worse DFS and OS. Relevant clinicopathologic criteria, such as tumor sidedness and PCI, should be considered in patient selection for CRS with or without HIPEC, and guide stratification for clinical trials.
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Affiliation(s)
- Nikhil V Kotha
- Department of Surgery, University of California, San Diego, San Diego, CA, USA
| | - Joel M Baumgartner
- Department of Surgery, University of California, San Diego, San Diego, CA, USA
| | - Jula Veerapong
- Department of Surgery, University of California, San Diego, San Diego, CA, USA
| | - Jordan M Cloyd
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | - Ahmed Ahmed
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | | | | | - Keith Fournier
- Department of Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Lee
- Department of Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Sean P Dineen
- Department of Surgery, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | | | - Callisia Clarke
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Harveshp Mogal
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Sameer H Patel
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Jeffrey J Sussman
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Vikrom Dhar
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Laura A Lambert
- Department of Surgery, Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Ryan J Hendrix
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Courtney Pokrzywa
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Kelly Lafaro
- Department of Surgery, City of Hope Cancer Center, Duarte, CA, USA
| | - Byrne Lee
- Department of Surgery, City of Hope Cancer Center, Duarte, CA, USA
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Nadege Fackche
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Andrew M Lowy
- Department of Surgery, University of California, San Diego, San Diego, CA, USA
| | - Kaitlyn J Kelly
- Department of Surgery, University of California, San Diego, San Diego, CA, USA.
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