Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Global parental leave in surgical careers: differences according to gender, geographical regions and surgical career stages

BACKGROUND

There is a lack of information regarding the provision of parental leave for surgical careers. This survey study aims to evaluate the experience of maternity/paternity leave and views on work-life balance globally.

METHODS

A 55-item online survey in 24 languages was distributed via social media as per CHERRIES guideline from February to March 2020. It explored parental leave entitlements, attitude towards leave taking, financial impact, time spent with children and compatibility of parenthood with surgical career.

RESULTS

Of the 1393 (male : female, 514 : 829) respondents from 65 countries, there were 479 medical students, 349 surgical trainees and 513 consultants. Consultants had less than the recommended duration of maternity leave (43.8 versus 29.1 per cent), no paid maternity (8.3 versus 3.2 per cent) or paternity leave (19.3 versus 11.0 per cent) compared with trainees. Females were less likely to have children than males (36.8 versus 45.6 per cent, P = 0.010) and were more often told surgery is incompatible with parenthood (80.2 versus 59.5 per cent, P < 0.001). Males spent less than 20 per cent of their salary on childcare and fewer than 30 hours/week with their children. More than half (59.2 per cent) of medical students did not believe a surgical career allowed work-life balance.

CONCLUSION

Surgeons across the globe had inadequate parental leave. Significant gender disparity was seen in multiple aspects.

Strategies for the delay of surgery in the management of resectable hepatobiliary malignancies during the COVID-19 pandemic

Objective

We aimed to review data about delaying strategies for the management of hepatobiliary cancers requiring surgery during the covid-19 pandemic.

Background

Given the covid-19 pandemic, many jurisdictions, to spare resources, have limited access to operating rooms for elective surgical activity, including cancer, thus forcing deferral or cancellation of cancer surgeries. Surgery for hepatobiliary cancer is high-risk and particularly resource-intensive. Surgeons must critically appraise which patients will benefit most from surgery and which ones have other therapeutic options to delay surgery. Little guidance is currently available about potential delaying strategies for hepatobiliary cancers when surgery is not possible.

Methods

An international multidisciplinary panel reviewed the available literature to summarize data relating to standard-of-care surgical management and possible mitigating strategies to be used as a bridge to surgery for colorectal liver metastases, hepatocellular carcinoma, gallbladder cancer, intrahepatic cholangiocarcinoma, and hilar cholangiocarcinoma.

Results

Outcomes of surgery during the covid-19 pandemic are reviewed. Resource requirements are summarized, including logistics and adverse effects profiles for hepatectomy and delaying strategies using systemic, percutaneous and radiation ablative, and liver embolic therapies. For each cancer type, the long-term oncologic outcomes of hepatectomy and the clinical tools that can be used to prognosticate for individual patients are detailed.

Conclusions

There are a variety of delaying strategies to consider if availability of operating rooms decreases. This review summarizes available data to provide guidance about possible delaying strategies depending on patient, resource, institution, and systems factors. Multidisciplinary team discussions should be leveraged to consider patient- and tumour-specific information for each individual case.

Abstract PD1-06: A phase 1b dose-escalation and expansion study of the BCL-2 inhibitor venetoclax combined with tamoxifen in ER and BCL-2–positive metastatic breast cancer (MBC)

Background: Venetoclax, a potent and selective inhibitor of the survival protein BCL-2 (recently approved in CLL and in development in other hematopoietic malignancies), has yet to be evaluated in pts with solid tumors. BCL-2 is overexpressed in ˜85% of ER+ breast cancer. Pre-clinical findings using patient-derived xenograft breast tumor models suggest that venetoclax synergizes with endocrine therapy by increasing apoptosis. Here we report mBEP, an investigator-initiated phase 1b study of venetoclax with tamoxifen in 33 pts with ER+ (&gt;1%), BCL-2+ (&gt;10%, 2-3+ intensity) and HER2– MBC.

Methods: We conducted a 3+3 dose escalation study comprising cohorts receiving venetoclax 200, 400, 600 or 800 mg/d with tamoxifen 20 mg/d (continued until progression). The primary endpoint was to determine the maximum tolerated dose (MTD), define dose-limiting toxicities (DLTs) and identify the recommended phase 2 dose (RP2D). In a dose expansion phase (at the RP2D), secondary endpoints including safety and tolerability, response at 24 wks (RECIST v1.1), clinical benefit rate (CBR) and progression-free survival (PFS) were studied.

Results: In the escalation phase (n=15 pts), treatment was well tolerated with no DLTs or high-grade (Gd 3/4) adverse events observed, apart from asymptomatic on-target lymphopenia (Gd 3, 2/15 pts). MTD was not reached. The 800 mg/d dose was selected as the RP2D and the cohort expanded to include 24 pts with ≥24 wks follow up (range 24-105 wks). Fifteen pts had received prior regimens for MBC (median 3, range 1-9) that included tamoxifen in 5/15.

For the RP2D cohort (n=24), overall responses (OR) included 1 CR (4%) and 12 PR (50%), with 5 SD (21%), corresponding to a CBR of 75%. The 9 pts treated in the first line setting experienced a 78% OR (7/9 pts) and 11% SD (1/9 pts), equating to an 89% CBR. The data are immature for determining median PFS for the RP2D cohort (currently 40+ wks).

Treatment responses were pre-empted by metabolic responses (FDG-PET) at 4 wks (seen in 13/16 (81%) pts studied), and correlated with serial changes in circulating tumor DNA (ctDNA). Intriguingly, responses and clinical benefit were observed in pts with plasma-detected ESR1 mutations (4/10 and 7/10, respectively).

The most common treatment-related AEs (CTCAE v4.0) for all pts were lymphopenia in 29/33 (88%; 57% Gd 1-2, 30% Gd 3-4), neutropenia in 24/33 (73%; 67% Gd 1-2, 6% Gd 3), nausea in 22/33 (67%; all ≤Gd 2), anemia in 13/33 (39%; 33% Gd 1-2, 6% G3), thrombocytopenia in 11/33 (33%; all ≤Gd 2), vomiting in 11/33 (33%, all ≤Gd 2), diarrhea in 10/33 (30%; 24% Gd 1-2, 6% Gd 3), infection in 9/33 (27%; 18% Gd 2, 9% Gd 3) and fatigue in 7/33 (21%; all ≤Gd 2). There was one possible treatment-related SAE (infection).

Conclusions: In the first clinical study to evaluate venetoclax in a solid tumor, we demonstrate that combining venetoclax with endocrine therapy has a tolerable safety profile and elicits remarkable activity in ER+ and BCL-2+ MBC. These findings support further investigation of combination therapy for patients with BCL-2-positive breast cancer.

Sponsor: The Royal Melbourne Hospital (ACTRN12615000702516)

Citation Format: Lindeman GJ, Lok SW, Whittle JR, Siow ZR, Bergin AR, Dawson S-J, Desai J, Gray DH, Liew D, Mann GB, Murugasu A, Roberts AW, Rosenthal MA, Shackleton K, Sherman P, Silva MJ, Teh C, Travers A, Vaillant F, Visvader JE. A phase 1b dose-escalation and expansion study of the BCL-2 inhibitor venetoclax combined with tamoxifen in ER and BCL-2–positive metastatic breast cancer (MBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD1-06.

Facilitators and barriers to cervical cancer screening among Chinese Canadian women

BACKGROUND

Chinese Canadian women have higher cervical cancer incidence, and lower Pap testing, rates than the general Canadian population. Predisposing, enabling and reinforcing factors associated with ever having a Pap test, and having a recent Pap test within the last 2 years, were assessed in Chinese women in British Columbia using the PRECEDE-PROCEED model.

METHOD

Chinese women (n=512) between the ages of 20 and 79 years and residing in Greater Vancouver were interviewed about Pap testing, health care, traditional health beliefs, acculturation and sociodemographic characteristics. Two analyses were done, comparing women who had ever and never had a Pap test, and comparing women who had and had not received a recent Pap test. Focus groups and qualitative interviews ensured cultural sensitivity in the survey questionnaire.

RESULTS

Seventy-six percent reported ever having a Pap test and 57% reported having a Pap test within the last 2 years. Traditional health beliefs were not associated with ever or recent Pap testing. However, belief that Pap testing prevented cancer and general knowledge about the Pap test were associated with screening. Concern about pain/discomfort with the test, availability of time, culturally sensitive health care services and recommendation for Pap testing by a physician were also associated with screening. Factors differed for ever, and recently, having a Pap test.

INTERPRETATION

Pap testing is less common among Chinese Canadian women. Continuing education about Pap testing is recommended for physicians serving underscreened Chinese women. Culturally and linguistically appropriate educational materials are needed for the Chinese community.

M-ficolin is expressed on monocytes and is a lectin binding to N-acetyl-D-glucosamine and mediates monocyte adhesion and phagocytosis of Escherichia coli

Ficolins are a group of multimeric proteins that contain collagen-like and fibrinogen-like (FBG) sequences. Three types of ficolins have been characterized: H-, L- and M-ficolins. Both H- and L-ficolins have demonstrated lectin activities. In the present study, the FBG domain of M-ficolin was expressed and shown to bind to N-acetyl-D-glucosamine. M-ficolin mRNA was expressed in monocytes but not in the more differentiated macrophages and dendritic cells. By flow cytometry, surface biotinylation and immunoprecipitation, we showed that M-ficolin was associated with the surface of promonocytic U937 cells. M-ficolin transiently expressed in COS-7 cells was also clearly detected on the cell surface by immunoprecipitation. By flow cytometry, M-ficolin was detected on peripheral blood monocytes but not on lymphocytes or granulocytes. Immobilized rabbit anti-M-ficolin F(ab')2 mediated U937 cell adhesion, and the antibody also inhibited phagocytosis of Escherichia coli K-12 by U937 cells. Therefore, M-ficolin might act as a phagocytic receptor or adaptor on circulating monocytes for micro-organism recognition and may potentially mediate monocyte adhesion.

Unenhanced helical computerized tomography for the evaluation of patients with acute flank pain

PURPOSE

We determined the value of unenhanced helical computerized tomography (CT) in the diagnosis of acute flank pain in 105 patients evaluated for suspected stone disease.

MATERIALS AND METHODS

Noncontrasted spiral CT was done in 105 consecutive patients seen in our emergency department to evaluate acute flank pain. All CT studies were reviewed for the presence of ureteral or renal calculi, perinephric or periureteral stranding, presence and degree of pelvicalicectasis or other radiological findings. If necessary, an excretory urogram was performed to confirm the presence or absence of urinary stones. Patients were followed to determine clinical outcome including the need for urological intervention.

RESULTS

Of the 49 patients determined to have stones 24 (49%) had spontaneous stone passage, 10 (20%) had improved symptoms without documented stone passage and 14 (29%) required surgical intervention. In 29 of 51 patients (57%) with negative CT readings for stone disease a diagnosis was established by other intra-abdominal findings. In 21 patients (41%) no clinical diagnosis could be established, and 1 scan in a patient with a distal ureteral calculus was interpreted as falsely positive. These findings yielded a sensitivity of 98%, specificity 98% and overall accuracy 96% for diagnosing ureteral stones.

CONCLUSIONS

Despite the limitations of helical CT in evaluating renal function and nonobstructing ureteral calculi, noncontrasted CT is a sensitive imaging modality for the detection of urinary tract calculi and obstruction. The majority of our patients required no further imaging to determine the need for urological intervention. At our institution spiral CT has become the standard method to evaluate patients with acute flank pain leading to more rapid turnover in the emergency department at similar or even reduced cost to conventional excretory urography.

A critical evaluation of high density lipoprotein cholesterol as an index of coronary artery disease risk in Malaysians

Fasting serum specimens from (a) 217 male and 46 female patients with coronary artery disease (CAD), aged 35-75 years, who had undergone angioplasty (PTCA) / coronary artery bypass graft (CABG), and (b) 160 apparently healthy controls (106 males, 54 females, aged 30-75 years), were assessed for serum lipid profile. Both sex and ethnicity significantly influenced the levels of serum high density lipoprotein cholesterol (HDLC); in the controls, females had higher HDLC levels than males (46.7 mg/dl vs 38.5 mg/dl, p<0.00l), while the Indian males possessed significantly lower HDLC values than the male Malay or Chinese. HDLC, triglycerides (TG) and the atherogenic index- LDLC/HDLC ratio were significantly different between the CAD patients and the healthy controls, while total cholesterol (TC) and LDLC did not seem to be of diagnostic value. Serum HDLC was lower in the CAD patients compared to the healthy controls in both sexes (p<0.001), either expressed as HDLC per se or as % HDLC. This observation combined with the odds ratio (OR) values of 0.24 and 0.28 for HDLC and % HDLC respectively in males, firmly establishes HDL as a protective factor of CAD in Malaysians. Significance testing for the X2 values associated with the OR values for the various lipid indices, together with the findings on the receiver-operating characteristices (ROC) curves, i.e. plots of sensitivity vs 1-specificity, indicated that HDLC, % HDLC and TQ were equally efficient as a means of risk assessment to CAD in Malaysians.

Thrombotic thrombocytopenic purpura (TTP) complicating leptospirosis: a previously undescribed association

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Influenza virus infection of newborn rats: virulence of recombinant strains prepared from influenza virus strain A/Okuda/57

Infant rats were infected intranasally with wild influenza virus strains, attenuated strain A/Okuda/57 or recombinants prepared from these parents. The growth of viruses in the turbinates or lungs, and the ability of virus infections to potentiate subsequent bacterial infection by Haemophilus influenzae (HIb) were measured. The two wild strains of virus and a recombinant strain WRL105, known to be virulent for man, reached titres of 10(5.1)--10(6.5) EBID50/ml in the turbinates of infant rats 48 h after infections; infection by these viruses was followed by HIb bacteraemia in 77--92% and meningitis in 58--75% of animals. In contrast, virus strains known to be attenuated for man grew to lower titres in infant-rat turbinates and promoted a lower incidence of systemic infection by HIb than the virulent strains. A comparison of the various results of infection of infant rats with influenza virus strains of known pathogenicity for man indicated that the subsequent incidence of HIb bacteraemia was the most discriminating measurement of virus virulence; the range of yields of attenuated virus in rat turbinates overlapped that of virulent strains. These results, together with those of previous studies, indicate that the behaviour of influenza viruses in infant rats is an indication of virus virulence for man, and could provide a test of virulence that would facilitate the development of live attenuated virus vaccines for human use.