Predictors of Timely Initiation and Completion of Adjuvant Chemotherapy in Stage II/III Colorectal Adenocarcinoma

Background: Adjuvant chemotherapy (AC) for colorectal cancer (CRC) has led to substantial improvement in survival. Several clinical trials advocate the initiation of AC within 6-8 weeks of surgical resection based on evidence of improved survival with early initiation of AC. We aim to evaluate factors that predict initiation and completion of AC, subsequently improving survival. Methods: We identified 451 patients who underwent resection for CRC between 2014 and 2022. One hundred ten patients had stage II/III colorectal cancer who underwent resection followed by AC. Multivariable logistic regression analysis was performed to identify factors significantly predicting delay in AC >8 weeks. Secondary outcomes included chemotherapy completion rate, recurrence-free survival, and overall survival. Results: The final analysis included 110 patients. The median time to initiation of adjuvant chemotherapy (TIAC) was 6.9 weeks (IQR: 5.8-9.5). In total, 36.4% of patients had a delay >8 weeks to initiation of AC, and only 40% completed treatment. The surgical approach (open vs laparoscopic vs robotic) had no effect on the TIAC. On multivariable logistic regression analysis, preoperative albumin ≥3.5 (OR = .31; 95% CI: .12-.80) was an independent predictor of timely initiation of AC. Completion of AC was associated with a higher overall survival. Discussion: Preoperative nutritional status predicted delay in initiation of AC. Patients with a delay in AC beyond eight weeks had a lower rate of AC completions and worse survival. It is imperative to optimize this aspect of treatment as it correlates with survival.

Low Rates of Colorectal Cancer Screening in Our Patients' First-Degree Relatives: Are We Failing Them?

BACKGROUND

Guidelines recommend screening those with a family history of early-onset colorectal cancer at age 40 or 10 years before the age of their relative's diagnosis. Currently, there is no literature reporting the screening rate in these individuals and no protocols are in place to identify and target this population for screening awareness.

OBJECTIVE

Assess adherence to current screening guidelines among FDRs of patients with early-onset colorectal cancer.

DESIGN

Retrospective and qualitative study involving a telephone survey where patients were asked about relative's screening status and barriers to screening.

SETTINGS

Two community-based institutions between January 2018-December 2021.

PATIENTS

Individuals diagnosed with early-onset colorectal cancer who had undergone surgery at our institutions.

MAIN OUTCOME MEASURES

Rate of screening in first-degree relatives of our patients with early-onset colorectal cancer. Other factors measured included demographics, clinicopathologic characteristics and screening barriers.

RESULTS

Thirty-six patients were identified. Survey response rate was 66.6% (n=24). A total of 88 first-degree relatives who met criteria for screening resulted, with 67.1% (n=59) having a known screening status. Of the 59 with known screening status, it was reported that only 44% (n=26) have undergone screening. Patients of African American race, stage III/IV disease, Medicare/Medicaid and living within Baltimore City County were more likely to have family members with unknown or no screening. Lack of insurance coverage was the most common barrier noted 12.5% (n=3); whereas 54.1% (n=13) reported no barriers to screening.

LIMITATIONS

Retrospective design.

CONCLUSIONS

Most first-degree relatives of patients diagnosed with early-onset colorectal cancer do not undergo colorectal cancer screening. This could be attributed to the lack of protocols that could guarantee these individuals are informed of their elevated risk and the different options available for screening. Furthermore, our study suggests that racial and socioeconomic disparities exist among high-risk patients who should pursue screening. See Video Abstract.

Risk factors for post-operative VTE following colorectal surgery: Is caprini score enough?

BACKGROUND

Post-operative colorectal venous thromboembolism (VTE) rates range between 1 and 3%. Often, surgeons utilize risk assessment models, like the modified Caprini, to determine need for prophylaxis. However, studies reveal additional unaccounted risk factors like preoperative serum albumin level, perioperative blood transfusion, emergency surgery, and preoperative steroid use.

METHODS

This was a multicenter, retrospective study conducted between January 2021-December 2021. The primary endpoint was to assess the VTE rate within 30 days post-operatively.

RESULTS

Overall, incidence rate was 1.75%. Of these, 53% underwent urgent/emergent surgery and 60% had perioperative blood transfusions. Twelve patients had a known preoperative serum albumin level, with 66% being less than 3.5 ​g/dL. Only 30% of patients had a high Caprini risk score. No patient had preoperative steroid use.

CONCLUSION

The study suggests considering urgent/emergent surgeries, low preoperative albumin levels, and blood transfusions for enhanced VTE screening and prophylaxis in post-operative colorectal patients.

Impact of Surgical Resident Education and EMR Standardization in Enhancing ERAS Adherence and Outcomes in Colorectal Surgery

OBJECTIVE

Our study aimed at investigating the degree of adherence to ERAS pathway at our institution and to evaluate the role of providing resident education and a standardized EMR order set in improving adherence and patient surgical outcomes.

DESIGN

The study is prospective in nature and consists of two phases with a preintervention cohort to assess adherence to ERAS protocol and a postintervention cohort to evaluate improvement in adherence and patient outcomes. Adherence with the ERAS protocol was assessed across preoperative, intraoperative, and postoperative phases.

SETTING

The study took place at MedStar Franklin Square Medical Center in Baltimore, Maryland, involving inpatient care at a surgical ward.

PARTICIPANTS

During the preintervention phase, patients undergoing elective colorectal surgery were identified over 6 months (N = 77), and their adherence to the ERAS protocol was assessed. Following the intervention of surgical resident and faculty education sessions on the ERAS protocol and the implementation of a standardized order set in the Electronic Medical Record, a postintervention cohort (N = 54) was selected for comparison over another 6 months.

RESULTS

Among 77 patients who underwent elective colorectal surgery, the adherence rate to ERAS protocol was notably below 80% for most elements of the postoperative phase. When pre- and postintervention cohorts were compared, there were no significant differences in the baseline demographics and perioperative variables. After the implementation of our intervention, adherence rates were significantly improved in 7 out of 8 ERAS protocol elements of the postintervention phase. Among primary outcome measures, readmission rate (24.7% vs.9.4%; p = 0.022) and length of stay (7.3 ± 4.5 vs. 5.5 ± 3.6; p = 0.014) were significantly lower in the postintervention cohort. Although the rate of postoperative complications did not decrease significantly (33.8% vs. 31.5%; p = 0.284), there were fewer patients with postoperative ileus and surgical site infections. Outcomes were evaluated based on an 8-point score of postoperative ERAS elements. A significant decrease in mean length of stay and readmission rates is observed when at least 5 elements are completed, emphasizing the ERAS pathway's importance as a complementary bundle.

CONCLUSION

Our study highlights the impact of resident education and electronic medical record standardization on ERAS adherence in colorectal surgery. This multidisciplinary approach improves adherence, reduces hospital stay, and enhances communication among healthcare providers for better patient outcomes.

Intraoperative Radiation Therapy as a Safe Alternative to Whole Breast Radiation for Treatment of Minimally Invasive Breast Cancers: A Retrospective Cohort Study

BACKGROUND

Intraoperative radiation therapy (IORT) in select populations is a viable alternative to whole breast radiation therapy (WBRT) in the treatment of biopsy-proven localized invasive and non-invasive breast cancer. We aim to assess recurrence and complication rates following IORT in lumpectomy patients at a community hospital in Baltimore City.

METHODS

An IRB-approved retrospective cohort study was conducted on consecutive cases of lumpectomy with IORT from 2013 through 2020 by a single surgeon. Patient demographics, tumor and operative characteristics, and complications were retrieved from electronic medical records. Primary outcomes were postoperative complications and local recurrence rates.

RESULTS

The final cohort included 117 patients with mean follow-up time of 2.60 + 1.78 years. Mean age was 69.84 + 8.77 years. Thirty-three (28.21%) of patients developed a seroma. Odds of seroma formation were mildly significant for skin spacing [OR: 1.18, 95% CI: (1.02-1.37)] and balloon fill volume [1.04 (1.00-1.08)], but not for age, BMI, diabetes, former or current smoking status, history of WBRT, tumor size, or balloon size. Three (2.6%) patients had local recurrence. Odds of local recurrence were mildly significant for increased tumor size [1.14 (1.04-1.24)] and not significant for any other covariates.

CONCLUSIONS

IORT exposure did not confer higher rates of complications and the local recurrence rate mirrored that of the general population undergoing lumpectomy and WBRT. This study demonstrates the need for equitable treatment options based on individual needs: IORT is a safe alternative to WBRT in certain subpopulations, especially those with physical, social, or personal limitations preventing participation in a 3- to 7-week time commitment of WBRT.

Detecting Somatic Mutations for Well-Differentiated Pancreatic Neuroendocrine Tumors in Endoscopic Ultrasound-Guided Fine Needle Aspiration with Next-Generation Sequencing

BACKGROUND

Pancreatic neuroendocrine tumors (PanNETs) exhibit heterogenous behavior, whereby some small tumors are aggressive with a propensity for metastasis. Detection of somatic mutations associated with aggressive biology may help with patient stratification and surgical decision-making in patients with well-differentiated PanNETs. Using next-generation sequencing (NGS), we investigated the feasibility of detecting somatic mutations in endoscopic ultrasound-guided, fine-needle aspiration (EUS-FNA) specimens and determining the mutational concordance between the EUS-FNA specimens and the primary tumors.

METHODS

Thirty-eight patients with well-differentiated, nonfunctioning PanNETs were obtained from two tertiary referral centers. Patient demographic characteristics and tumor, clinicopathologic features were collected. Tissue from both the EUS-FNA specimen and the primary tumor was extracted from archival tissue blocks. NGS using a panel of ten genes was performed on both samples.

RESULTS

In our series, the median age was 61.1 years. Tumors were predominantly left-sided (60.5%) and unifocal (94.7%). The median tumor size was 2.2 cm. NGS detected somatic mutations in 29% of primary tumors and 36.8% of EUS-FNA specimens. In primary tumors, DAXX/ATRX mutations were predominantly detected (63.6%). In EUS-FNA specimens, MEN1 mutations were predominantly detected (64.3%). Among non-wild-type specimens, mutational concordance was achieved in 31.6% of cases. In 11 patients with a detectable mutation in the primary tumor, a mutation was detected in the EUS-FNA specimen in 45.5% of cases, with a mutational concordance of 54.5%.

CONCLUSIONS

NGS can detect somatic mutations in EUS-FNA specimens of well-differentiated PanNETs. Efforts to improve detection sensitivity and mutational concordance are required to overcome current technical limitations.

Resected Early-Onset Pancreatic Cancer: Practices and Outcomes in an International Dual-Center Study

BACKGROUND

Early-onset pancreatic cancer (EOPC), defined as age ≤ 45 years at diagnosis, accounts for 3% of all pancreatic cancer cases. Although differences in tumor biology have been suggested, available data are sparse and specific treatment recommendations are lacking. This study explores the clinicopathological features and oncologic outcomes of resected EOPC.

PATIENTS AND METHODS

Patients with EOPC undergoing resection between 2002 and 2018 were identified from the Heidelberg University Hospital and Johns Hopkins University registries. Median overall survival (OS) and recurrence-free survival (RFS) were analyzed, and prognostic factors were identified.

RESULTS

The final cohort included 164 patients, most of whom had pancreatic ductal adenocarcinoma (PDAC, n = 136; 82.9%) or IPMN-associated pancreatic cancer (n = 17; 10.4%). Twenty (12.1%) patients presented with stage 1 disease, 42 (25.6%) with stage 2, 75 (45.7%) with stage 3, and 22 (13.4%) with oligometastatic stage 4 disease. Most patients underwent upfront resection (n = 113, 68.9%), whereas 51 (31.1%) individuals received preoperative treatment. Median OS and RFS were 26.0 and 12.4 months, respectively. Stage-specific median survival was 70.6, 41.8, 23.8, and 16.9 months for stage 1, 2, 3, and 4 tumors, respectively. Factors independently associated with shorter OS and RFS were R1 resections and AJCC stages 3 and 4. Notably, AJCC 3-N2 and AJCC 3-T4 tumors had a median OS of 20 months versus 29.5 months, respectively.

CONCLUSION

Despite frequently presenting with advanced disease, oncologic outcomes in EOPC patients are satisfactory even in locally advanced cancers, justifying aggressive surgical approaches. Further research is needed to tailor current guidelines to this rare population.

Tailoring Adjuvant Chemotherapy to Biologic Response Following Neoadjuvant Chemotherapy Impacts Overall Survival in Pancreatic Cancer

BACKGROUND

The role of postoperative chemotherapy in patients with resected pancreatic cancer who receive neoadjuvant treatment is unknown. Clinicians use changes in CA19-9 and histopathologic scores to assess treatment response. We sought to investigate if CA19-9 normalization in response to NAT can help guide the need for postoperative treatment.

METHODS

Patients with elevated baseline CA19-9 (CA19-9 > 37U/mL) who received NAT followed by surgery between 2011 and 2019 were retrospectively reviewed. Treatment response was determined by CA19-9 normalization following NAT and histopathologic scoring. The role of postoperative chemotherapy was analyzed in light of CA19-9 normalization and histopathologic response.

RESULTS

We identified and included 345 patients. Following NAT, CA19-9 normalization was observed in 125 patients (36.2%). CA19-9 normalization was associated with a favorable histopathologic response (41.6% vs 23.2%, p < 0.001) and a lower ypT (p < 0.001) and ypN stage (p = 0.003). Receipt of adjuvant chemotherapy was associated with improved overall survival in patients in whom CA19-9 did not normalize following NAT (26.8 vs 16.4 months, p = 0.008). In patients who received 5FU-based NAT and in whom CA19-9 did not normalize, receipt of 5FU-based adjuvant chemotherapy was associated with improved OS (p = 0.014).

CONCLUSION

CA19-9 normalization in response to NAT was associated with favorable outcomes and can serve as a biomarker for treatment response. In patients where CA19-9 did not normalize, receipt of postoperative chemotherapy was associated with improved OS. These patients also benefited from additional 5FU-based postoperative chemotherapy following 5FU-based NAT.

Cancer-cell-derived sialylated IgG as a novel biomarker for predicting poor pathological response to neoadjuvant therapy and prognosis in pancreatic cancer

BACKGROUND

Neoadjuvant therapy (NAT) is increasingly applied in pancreatic ductal adenocarcinoma (PDAC); however, accurate prediction of therapeutic response to NAT remains a pressing clinical challenge. Cancer-cell-derived sialylated immunoglobulin G (SIA-IgG) was previously identified as a prognostic biomarker in PDAC. This study aims to explore whether SIA-IgG expression in treatment-naïve fine needle aspirate (FNA) biopsy specimens could predict the pathological response (PR) to NAT for PDAC.

METHODS

Endoscopic ultrasonography-guided FNA biopsy specimens prior to NAT were prospectively obtained from 72 patients with PDAC at the Johns Hopkins Hospital. SIA-IgG expression of PDAC specimens was assessed by immunohistochemistry. Associations between SIA-IgG expression and PR, as well as patient prognosis, were analyzed. A second cohort enrolling surgically resected primary tumor specimens from 79 patients with PDAC was used to validate the prognostic value of SIA-IgG expression.

RESULTS

SIA-IgG was expressed in 58.3% of treatment-naïve FNA biopsies. Positive SIA-IgG expression at diagnosis was associated with unfavorable PR and can serve as an independent predictor of PR. The sensitivity and specificity of SIA-IgG expression in FNA specimens in predicting an unfavorable PR were 63.9% and 80.6%, respectively. Both positive SIA-IgG expression in treatment-naïve FNA specimens and high SIA-IgG expression in surgically resected primary tumor specimens were significantly associated with shorter survival.

CONCLUSIONS

Assessment of SIA-IgG on FNA specimens prior to NAT may help predict PR for PDAC. Additionally, SIA-IgG expression in treatment-naïve FNA specimens and surgically resected primary tumor specimens were predictive of the prognosis for PDAC.

Robot-Assisted Diagnostic Laparoscopy: A Safe and Feasible Adjunct to the Management of Massive Spontaneous Pneumoperitoneum

Pneumoperitoneum is the abnormal presence of free air in the peritoneal cavity. Oftentimes, it is a surgical emergency requiring exploratory laparotomy as most cases of pneumoperitoneum are due to perforated hollow viscus. However, not all pneumoperitoneum cases are surgical; nonsurgical pneumoperitoneum can arise from thoracic, abdominal, gynecologic, and other causes. We present a case of a 35-year-old male who developed a non-surgical pneumoperitoneum in the setting of drug overdose. The patient underwent robot-assisted diagnostic laparoscopy without findings of perforation or other pathology. Resolution of pneumoperitoneum was evidenced on follow-up computed tomography scan. This case emphasizes the importance of diagnostic laparoscopy in the setting of a confusing clinical picture and the feasibility of utilizing the robotic approach in hemodynamically stable patients.

Prognostic value of tumor-associated N1/N2 neutrophil plasticity in patients following radical resection of pancreas ductal adenocarcinoma

BACKGROUND

As an integral part of the tumor microenvironment (TME), tumor-associated neutrophils play a crucial role in tumor development. The objective of this study was to investigate the plasticity of tumor-associated N1 and N2 neutrophils in the TME of pancreatic ductal adenocarcinoma (PDAC), along with its impact on survival and association with immune infiltrations.

METHODS

The primary and validation cohorts including 90 radical resection patients from September 2012 to May 2016 and 29 radical resection patients from September 2018 to October 2019, respectively, with complete survival data, were enrolled. Immunofluorescence staining was used to identify tumor-associated N1 and N2 neutrophils, and the N1/N2 ratio was used to evaluate N1 and N2 plasticity. Thereafter, the association between tumor-associated N1/N2 neutrophil plasticity, clinical features, and immune infiltrations was investigated.

RESULTS

There was a significant increase in tumor-associated N2 neutrophils compared with tumor-associated N1 neutrophils. Low N1/N2 ratios were associated with the poorer differentiation of tumors, easier lymph node metastases, and a higher TNM stage. The median overall survival (OS) and recurrence-free survival (RFS) of the high tumor-associated N1 neutrophil group were significantly longer than those of the low group, while the tumor-associated N2 neutrophils played an opposite role. The multivariable analysis revealed that a high N1/N2 ratio was a significant prognostic indicator for OS and RFS. In addition, tumor-associated N1/N2 neutrophils showed an opposite correlation with tumor-infiltrating CD8⁺ T cells and Tregs.

CONCLUSION

The plasticity of tumor-associated N1/N2 neutrophils was identified as a crucial prognostic indicator that might reflect the TME and immune escape in patients with PDAC. On further investigation and validation, our findings may be used to further stratify patients with varying prognoses to optimize treatment.

Predictors, Patterns, and Timing of Recurrence Provide Insight into the Disease Biology of Invasive Carcinomas Arising in Association with Intraductal Papillary Mucinous Neoplasms

OBJECTIVES

To identify predictors, patterns, and timing of recurrence after resection of invasive carcinomas arising in association with an IPMN.

BACKGROUND

Postoperative management of an invasive carcinoma arising in association with an intraductal papillary mucinous neoplasm (IPMN), a biologically distinct entity from PanIN-derived pancreatic ductal adenocarcinoma (PDAC), remains largely based on guidelines for PanIN-derived PDAC. To minimize treatment failure and inform disease-specific management, cancer recurrence must be better characterized.

METHODS

Patients were identified from a prospectively maintained registry between 1996 and 2018. Predictors of recurrence were evaluated by employing Cox regression models to determine risk-adjusted hazard ratios (HR) with 95% confidence intervals (95%CI). The patterns and timing of recurrence were recognized and compared utilizing a log-rank test, respectively.

RESULTS

Of the 213 patients included, 92 (43.2%) recurred with a median RFS of 23.7 months (16.7-30.7). The predominant pattern of recurrence included any systemic (65.2%). The median time to local recurrence was longer than systemic (21.6 versus 11.4 months, p = 0.05). Poor differentiation [HR: 3.01, 95%CI (1.06-8.61)] and nodal disease [N1, HR: 2.23, 95%CI (1.12-4.60); and N2, HR: 5.67 95%CI (2.93-10.99)] emerged as independent predictors of systemic recurrence. For local-specific recurrences, poor differentiation [HR: 3.73, 95%CI (1.04-13.45)] and an R1 margin [high-grade dysplasia or invasive carcinoma; HR: 2.66, 95%CI (1.14-6.21)] emerged as independent predictors.

CONCLUSIONS

The predominant pattern of recurrence after resection of invasive carcinomas arising in association with IPMNs is systemic, and occurs earlier than local recurrence. Poor differentiation and nodal disease are associated with systemic recurrence while poor differentiation and an R1 margin are associated with local recurrence. Future studies should investigate the role of systemic (chemotherapy) versus local (radiation) therapies and surveillance strategies in a personalized manner.

Primary Balloon Angioplasty Versus Hydrostatic Dilation for Arteriovenous Fistula Creation in Patients with Small-Caliber Cephalic Veins: A Systematic Review and Meta-Analysis

BACKGROUND

For arteriovenous fistula (AVF) presence of a venous segment with adequate diameter is essential which is lacking in many patients. To find the optimal augmentation technique in patients with small-caliber cephalic vein (i.e., cephalic vein diameter <3 mm), studies compared primary balloon angioplasty (PBA) versus hydrostatic dilation (HD); however, it remained debatable. This systematic review seeks to determine which technique is preferable.

METHODS

We searched MEDLINE, PubMed, Embase, and Google Scholar. Primary outcomes were 6-month primary patency, reintervention, and working AVF. Secondary outcomes were immediate success, the AVF's maturation time (day), and surgical site infection.

RESULTS

Three randomized controlled trials yielding 180 patients were included, of which 89 patients were in the PBA group. The odds ratio (OR) of primary patency was significantly higher in the PBA group (OR 6.09, 95% confidence interval [CI], 2.36-15.76, P = 0.0002), the OR of reintervention was significantly lower in the PBA group (OR 0.16, 95% CI, 0.06-0.42, P = 0.0002), and the OR of working AVF was greater in PBA group (OR 4.22, 95% CI, 1.31-13.59, P = 0.02). The OR of immediate success was significantly greater in the PBA group (OR 11.42, 95% CI, 2.54-51.42, P = 0.002), and the AVF maturation time was significantly shorter in patients who underwent PBA (mean difference -20.32 days, 95% CI, -30.12 to -10.52, P = 0.0001). The certainty of the evidence was high.

CONCLUSIONS

PBA of small cephalic veins with diameter ≤2.5 cm is a safe, feasible, and efficacious augmentation method for AVF creation. This technique achieves favorable maturation outcomes, and PBA is superior to the standard hydrostatic dilatation technique.

Postoperative Chemotherapy is Associated with Improved Survival in Patients with Node-Positive Pancreatic Ductal Adenocarcinoma After Neoadjuvant Therapy

BACKGROUND

Postoperative chemotherapy following pancreatic cancer resection is the standard of care. The utility of postoperative chemotherapy for patients who receive neoadjuvant therapy (NAT) is unclear.

METHODS

Patients who underwent pancreatectomy after NAT with FOLFIRINOX or gemcitabine-based chemotherapy for non-metastatic pancreatic adenocarcinoma (2015-2019) were identified. Patients who received less than 2 months of neoadjuvant chemotherapy or died within 90 days from surgery were excluded.

RESULTS

A total of 427 patients (resectable, 22.2%; borderline resectable, 37.9%; locally advanced, 39.8%) were identified with the majority (69.3%) receiving neoadjuvant FOLFIRINOX. Median duration of NAT was 4.1 months. Following resection, postoperative chemotherapy was associated with an improved median overall survival (OS) (28.7 vs. 20.4 months, P = 0.006). Risk-adjusted multivariable modeling showed negative nodal status (N0), favorable pathologic response (College of American Pathologists score 0 & 1), and receipt of postoperative chemotherapy to be independent predictors of improved OS. Regimen, duration, and number of cycles of NAT were not significant predictors. Thirty-four percent (60/176) of node-positive and 50.1% (126/251) of node-negative patients did not receive postoperative chemotherapy due to poor functional status, postoperative complications, and patient preference. Among patients with node-positive disease, postoperative chemotherapy was associated with improved median OS (27.2 vs. 10.5 months, P < 0.001). Among node-negative patients, postoperative chemotherapy was not associated with a survival benefit (median OS, 30.9 vs. 36.9 months; P = 0.406).

CONCLUSION

Although there is no standard NAT regimen for patients with pancreatic cancer, postoperative chemotherapy following NAT and resection appears to be associated with improved OS for patients with node-positive disease.

Association of Matrix Metalloproteinase 7 Expression With Pathologic Response After Neoadjuvant Treatment in Patients With Resected Pancreatic Ductal Adenocarcinoma

Importance

The use of neoadjuvant therapy (NAT) in resectable pancreatic ductal adenocarcinoma (PDAC) remains controversial. A favorable pathologic response (complete or marked tumor regression) to NAT is associated with better outcomes in patients with resected PDAC. The role of NAT for early systemic control compared with immediate surgical resection for PDAC is under investigation. In the era of precision medicine, biomarkers for patient selection and prediction of therapy response are crucial.

Objective

To evaluate the use of assessment for protein expression on fine-needle aspiration (FNA) biopsy specimens in predicting pathologic response to NAT in treatment-naive patients.

Design, Setting, and Participants

This was a single-institution prognostic study from a high-volume center for pancreatic cancer. All specimens were obtained between January 1, 2009, and December 31, 2018, with a median (SE) follow-up of 20.2 (1.4) months. Analysis of the data was performed from October 1, 2019, to April 30, 2021. Targeted RNA sequencing of frozen FNA biopsy specimens from a discovery cohort of 23 patients was performed to identify genes with aberrant expression that was associated with patients' pathologic response to NAT. Immunohistochemical staining was performed on an additional 80 FNA biopsy specimens to assess expression of matrix metalloproteinase 7 (MMP-7) and its association with pathologic response. Receiver operating characteristic curves for prediction of favorable pathologic response were determined.

Results

In the discovery cohort (12 [52.1%] male; 3 [13.0%] Black and 20 [86.9%] White), RNA sequencing showed that lower MMP-7 expression was associated with favorable pathologic response (College of American Pathologists system scores of 0 [complete response] and 1 [marked response]). In the validation cohort (40 [50.0%] female; 9 [11.3%] Black and 71 [88.7%] White), patients with negative MMP-7 expression were significantly more likely to have a favorable pathologic response (odds ratio, 21.25; 95% CI, 6.19-72.95; P = .001). Receiver operating characteristic curves for prediction of favorable pathologic response from multivariable Cox proportional hazards regression modeling showed that MMP-7 expression increased the area under the curve from 0.726 to 0.906 (P < .001) even after stratifying by resectability status. The positive predictive value and negative predictive value of MMP-7 protein expression on FNA biopsy specimens in predicting unfavorable pathologic response (scores of 2 [partial response] or 3 [poor or no response]) were 88.2% and 73.9%, respectively.

Conclusions and Relevance

Assessment of MMP-7 expression on FNA biopsy specimens at the time of diagnosis may help identify patients who would benefit the most from NAT.

Pathological treatment response has different prognostic implications for pancreatic cancer patients treated with neoadjuvant chemotherapy or chemoradiotherapy

BACKGROUND

Pathological treatment effect of resected pancreatic adenocarcinoma after neoadjuvant therapy has prognostic implications. The impact for patients who received chemotherapy alone or chemoradiotherapy is not well defined.

METHODS

Patients with localized pancreatic adenocarcinoma who had pancreatectomy after neoadjuvant therapy at 3 centers from 2011 to 2017 were retrospectively analyzed. The chemotherapy and chemoradiotherapy groups were evaluated separately.

RESULTS

Of 525 patients, 148 received neoadjuvant chemotherapy and 377 received chemoradiotherapy. The chemoradiotherapy group had a better treatment effect (score 0: 10%, score 1: 30%, score 2: 42%, and score 3: 18%) than the chemotherapy group (score 0: 2%, score 1: 8%, score 2: 35%, and score 3: 55%) (P < .001). Median overall survival was similar between the 2 groups (25.8 vs 26.4 months). Median overall survival for score 0/1, 2, or 3 was 72.2, 38.5, and 20.0 months in the chemotherapy group and 37.9, 24.5, and 19.0 months in the chemoradiotherapy group. Score 2 in the chemotherapy group was associated with better overall survival compared to score 3 (adjusted hazard ratio: 0.49, P = .005), whereas only combined score 0/1 reached significance over score 2 for the chemoradiotherapy group (hazard ratio: 0.63, P = .006).

CONCLUSION

The prognostic significance of pathological treatment effect for localized pancreatic adenocarcinoma differs for patients receiving neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy.

Germline Variants in DNA Damage Repair Genes: An Emerging Role in the Era of Precision Medicine in Pancreatic Adenocarcinoma

Pancreatic adenocarcinoma is a lethal disease that is projected to become the second most common cause of cancer deaths by 2030. The role of adjuvant therapy after surgical resection has been established by several clinical trials to prolong survival and improve outcomes. Multiagent chemotherapy seems to be the most promising approach to counteract early recurrence and improve survival; however, in the era of precision medicine, patient selection and individualized therapy seems to hold the key to desirable superior outcomes. Several cancer susceptibility genes have been proven to be associated with an increased risk of pancreatic cancer, both familial and sporadic cases. The role of genomic profiling for germline variants has been extensive and of limited clinical value, considering their low prevalence in pancreatic ductal adenocarcinoma (PDAC). However, an accumulating body of evidence from several studies in the past decade have successfully shown a recognizable value of germline variants in risk assessment and patient stratification. Recently, anti-PD-1 therapy (pembrolizumab) has been FDA-approved for use in solid malignancies with a Mismatch repair deficiency or high Microsatellite instability. Several trials have evaluated the role of poly (ADP-ribose) polymerase (PARP) inhibitors in patients harboring germline BRCA1/2 mutations. Finally, germline variants in DNA damage response genes and particularly deleterious ones have the potential to guide therapy after surgical resection and serve as biomarkers to predict survival. The dire need to address challenges for applying precision medicine in real-life clinical settings for PDAC patients lies in further characterizing the genetic and molecular processes through translational research.

Comprehensive Analysis of Somatic Mutations in Driver Genes of Resected Pancreatic Ductal Adenocarcinoma Reveals KRAS G12D and Mutant TP53 Combination as an Independent Predictor of Clinical Outcome

BACKGROUND

Prognosis in pancreatic ductal adenocarcinoma (PDAC) remains poor despite improved systemic therapies and surgical techniques. The identification of biomarkers to advance insight in tumor biology and achieve better individualized prognostication could help improve outcomes. Our aim was to elucidate the prognostic role of the four main driver mutations (KRAS, TP53, SMAD4, CDKN2A) and their combinations in resected PDAC.

PATIENTS AND METHODS

A retrospective analysis was conducted utilizing the cBioPortal database and National Cancer Institute's Cancer Genomic Atlas (TCGA) on patients in whom next-generation sequencing was performed on upfront resected PDAC from 2012 to 2020. Multivariable Cox regression was implemented to elucidate risk-adjusted predictors of overall (OS) and recurrence-free survival (RFS). Results were validated employing a Johns Hopkins Hospital (JHH) cohort.'

RESULTS

In the discovery cohort (n = 587), increased number of mutated driver genes was associated with worse OS (p = 0.047). Specifically, patients with mutations in ≥ 2 driver genes had worse OS than ≤ 1 mutated gene (18.2 versus 32.3 months, p = 0.033). Co-occurrence of mutant (mt)KRAS p.G12D with mtTP53 (median OS, 25.9 months) conferred better prognosis than co-occurrence of other mtKRAS variants (p.G12V/R/other) with mtTP53 (median OS, 16.9 months, p = 0.038). The findings were validated using a JHH cohort. Multivariable risk-adjustment found co-occurrence of mtKRAS p.G12D with mtTP53 to be an independent predictor of beneficial OS and RFS [HR (95% CI): 0.18 (0.03-0.81) and 0.31 (0.11-0.89) respectively].

CONCLUSION

In chemo-naïve resected PDAC, combinations of mutations in the four driver genes are associated with prognosis. In patients with combined mtKRAS and mtTP53, KRAS p.G12D variant confers a better OS and RFS.

Technical progress in robotic pancreatoduodenectomy: TRIANGLE and periadventitial dissection for retropancreatic nerve plexus resection

PURPOSE

The resection of retropancreatic nerve plexuses for pancreatic head cancer became standard of care during open pancreatoduodenectomy to minimize local recurrences. Since more surgical centers are progressing on the learning curve, robotically-assisted pancreatoduodenectomy is now increasingly performed with decreasing anatomic exclusion criteria. To achieve comparable and favorable oncologic outcomes, advanced surgical techniques should be transferred and implemented when performing robotic resections.

METHODS

The nomenclature and anatomic principles of retropancreatic nerve plexuses and three different levels of dissections are utilized based on established definitions.

RESULTS

The en bloc dissection in the "TRIANGLE" area (triangular-shaped retropancreatic space enclosed by the common hepatic artery, superior mesenteric artery, and superior mesenteric vein/portal vein) and the periadventitial dissection of arteries for non-tunica media-invading tumors were executed robotically. Both can be utilized to achieve a radical dorsal and medial margin. Video recordings are provided to illustrate varying TRIANGLE dissections.

CONCLUSION

To accomplish oncologic non-inferiority, established principles from open pancreatic resections can be incorporated precisely and safely, overcoming the lack of haptic feedback while exploiting the technological advantages of the robotically-assisted platform.

Primary Tumor Resection for Rectal Cancer With Unresectable Liver Metastases: A Chance to Cut Is a Chance for Improved Survival

Background: About half of the patients with rectal cancer will develop liver metastasis during the course of their illness. Unfortunately, a large proportion of these metastases are unresectable. Surgical resection of the primary tumor vs. palliative treatment in patients with unresectable synchronous liver metastases remains controversial.

Methods: Patients with rectal cancer with surgically unresectable liver metastases were identified from the Surveillance, Epidemiology, and End Results (SEER) database from January 1, 2010, to December 31, 2015. According to different treatment modalities, patients were divided into a primary tumor resection group and a non-resection group. Rates of primary tumor resection and survival were calculated for each year. Kaplan–Meier methods and Cox regression models were used to assess long-term survival. Multivariable logistic regression models were used to evaluate factors potentially associated with primary tumor resection.

Results: Among 1,957 patients, 494 (25.2%) had undergone primary tumor resection. Patients with primary tumor resection had significantly better 5-year survival rate (27.2 vs. 5.6%, P < 0.001) compared to the non-resection group. Chemoradiotherapy with primary site resection was associated with the longest mean and 5-year OS (44.7 months, 32.4%). The Cox regression analyses of the subgroup indicated that patients who underwent primary tumor resection had improved survival compared with those who did not undergo resection in all 25 subgroups. Factors associated with primary tumor resection were well or moderately differentiated tumor grade, undergoing radiation, and primary tumor size <5 cm.

Conclusions: The majority of patients with rectal cancer with unresectable liver metastases did not undergo primary tumor resection. Our results indicate that resection of the primary tumor appears to offer the greatest chance of survival. Prospective studies are needed to confirm these results.

Robotic transanal minimally invasive surgery: a case series

INTRODUCTION

This study describes the experience with robot-assisted transanal minimally invasive surgery (rTAMIS) at a single institution. TAMIS has become a popular minimally invasive technique for local excision of well-selected rectal lesions. rTAMIS has been proposed as another option as it improves the ergonomics of conventional laparoscopic techniques.

METHODS

Retrospective case series of patients with rectal lesions who underwent rTAMIS. Patient demographics, final pathology, surgical and admission details, and clinical outcomes were recorded. Successful procedures were defined as having negative margins on final pathology.

RESULTS

A total of 16 patients underwent rTAMIS by a single surgeon between April 2018 and December 2019. Mean age of patients was 63 years. Final pathologies were negative for tumor (n = 4), tubulovillous adenoma (n = 4), tubulovillous adenoma with high-grade dysplasia (n = 4), and invasive rectal adenocarcinoma (n = 4). 43% were located in the middle rectum and 56% were located in the distal rectum. Mean maximum diameter was 4.1 cm (IQR 2-3.1 cm). Negative margins were seen in 100% of the excision cases, and 100% were intact. Mean operative time was 87 min (IQR 54.8-97.3 min), and median length of stay was 0 days (IQR 0-1 days). Postoperative complications included incontinence (n = 1) and abscess formation (n = 2). rTAMIS provided curative treatment for 12/16 patients, and the remaining 4 patients received the appropriate standard of care for their respective pathologies.

CONCLUSIONS

Robot-assisted TAMIS is a safe alternative to laparoscopic TAMIS for resection of appropriate rectal polyps and early rectal cancers. rTAMIS may provide a modality for resecting larger or more proximal rectal lesions due to the wristed instruments and superior visualization with the robotic camera. Future studies should focus on comparing outcomes between robotic and laparoscopic TAMIS, and whether rTAMIS allows for the removal of larger, more complex lesions, which may save patients from a more morbid radical proctectomy.

Inappropriate Transfer of Burn Patients: A 5-Year Retrospective at a Single Center

OBJECTIVE

Burn injuries have an annual incidence exceeding 40,000. The Burn Center Referral Criteria published by the American Burn Association (ABA) serve to guide health centers in determining appropriateness of patient transfer to a specialized center. With inappropriate transfer rates reaching up to 77%, reliance on the ABA criteria is critical as the decision to transfer a patient can impose significant costs to both the patient and healthcare system. The aim of this study is to evaluate the appropriateness of all burn patient transfers to a single burn center over a 5-year period and assess the potential role of telemedicine to optimize the assessment and care of this patient population.

METHODS

A 5-year retrospective review was conducted to all burn patients transferred or consulted for transfer to our burn center between January 2013 and January 2017. After application of inclusion and exclusion criteria, 767 cases were analyzed, with 612 ultimately being transferred. Outcome measures included basic clinical and demographic information, as well as logistical burn and transfer data such as percent total body surface area and transfer distance. After data collection, 5-year descriptive trends were analyzed, and the ABA criteria were applied to each patient case to evaluate appropriateness of transfer. Patients transferred despite not meeting at least one of the ABA criteria were classified as inappropriately transferred.

RESULTS

A total of 25 patients (3.2%) were found to be inappropriate transfers. Statistical analysis compared appropriately transferred patients (n = 587) with those inappropriately transferred. Overall, inappropriately transferred patients were more likely to have superficial partial thickness burns (76% vs 46%, P = 0.05), were less likely to need surgery (4% vs 22%, P < 0.05), and had a higher incidence of upper extremity burns (32% vs 4%, P < 0.01).

CONCLUSIONS

Our study increases awareness of the most commonly seen presentation of inappropriately transferred burn patients over a 5-year period at our center. Given the advent of telemedicine, the ability of institutions to pinpoint a subset of patients most vulnerable to inappropriate transfer will allow for a streamlining of resources that will serve to benefit both patients and the health system.

Silent and formidable foe: neuroendocrine tumours of the gallbladder

Neuroendocrine neoplasms of the gallbladder occur infrequently, with the diagnosis being incidental in most cases. We present a case of an 81-year-old African American woman who initially presented with acute suppurative cholecystitis, found on pathology to have a moderately differentiated infiltrating adenocarcinoma. A partial hepatic resection with periportal lymph node dissection was planned which was subsequently aborted intraoperatively due to the presence of diffuse carcinomatosis. Pathology of the cancerous lesions revealed neuroendocrine carcinoma. Gallbladder neuroendocrine tumours demonstrate no specific clinical features. Given its often late presentation, neuroendocrine tumours of the gallbladder pose a therapeutic and prognostic challenge.

Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis

Background

For more than a century, appendicectomy has been the treatment of choice for appendicitis. Recent trials have challenged this view. This study assessed the benefits and harms of antibiotic therapy compared with appendicectomy in patients with non‐perforated appendicitis.

Methods

A comprehensive search was conducted for randomized trials comparing antibiotic therapy with appendicectomy in patients with non‐perforated appendicitis. Key outcomes were analysed using random‐effects meta‐analysis, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results

Five studies including 1116 patients reported major complications in 25 (4·9 per cent) of 510 patients in the antibiotic and 41 (8·4 per cent) of 489 in the appendicectomy group: risk difference −2·6 (95 per cent c.i. –6·3 to 1·1) per cent (low‐quality evidence). Minor complications occurred in 11 (2·2 per cent) of 510 and 61 (12·5 per cent) of 489 patients respectively: risk difference −7·2 (−18·1 to 3·8) per cent (very low‐quality evidence). Of 550 patients in the antibiotic group, 47 underwent appendicectomy within 1 month: pooled estimate 8·2 (95 per cent c.i. 5·2 to 11·8) per cent (high‐quality evidence). Within 1 year, appendicitis recurred in 114 of 510 patients in the antibiotic group: pooled estimate 22·6 (15·6 to 30·4) per cent (high‐quality evidence). For every 100 patients with non‐perforated appendicitis, initial antibiotic therapy compared with prompt appendicectomy may result in 92 fewer patients receiving surgery within the first month, and 23 more experiencing recurrent appendicitis within the first year.

Conclusion

The choice of medical versus surgical management in patients with clearly uncomplicated appendicitis is value‐ and preference‐dependent, suggesting a change in practice towards shared decision‐making is necessary.

Limitations of each evolving