Carbon nanotube-enhanced thermal destruction of cancer cells in a noninvasive radiofrequency field

BACKGROUND

Single-walled carbon nanotubes (SWNTs) have remarkable physicochemical properties that may have several medical applications. The authors have discovered a novel property of SWNTs-heat release in a radiofrequency (RF) field-that they hypothesized may be used to produce thermal cytotoxicity in malignant cells.

METHODS

Functionalized, water-soluble SWNTs were exposed to a noninvasive, 13.56-megahertz RF field, and heating characteristics were measured with infrared thermography. Three human cancer cell lines were incubated with various concentrations of SWNTs and then treated in the RF field. Cytotoxicity was measured by fluorescence-activated cell sorting. Hepatic VX2 tumors in rabbits were injected with SWNTs or with control solutions and were treated in the RF field. Tumors were harvested 48 hours later to assess viability.

RESULTS

The RF field induced efficient heating of aqueous suspensions of SWNTs. This phenomenon was used to produce a noninvasive, selective, and SWNT concentration-dependent thermal destruction in vitro of human cancer cells that contained internalized SWNTs. Direct intratumoral injection of SWNTs in vivo followed by immediate RF field treatment was tolerated well by rabbits bearing hepatic VX2 tumors. At 48 hours, all SWNT-treated tumors demonstrated complete necrosis, whereas control tumors that were treated with RF without SWNTs remained completely viable. Tumors that were injected with SWNTs but were not treated with RF also were viable.

CONCLUSIONS

The current results suggested that SWNTs targeted to cancer cells may allow noninvasive RF field treatments to produce lethal thermal injury to the malignant cells. Now, the authors are developing SWNTs coupled with cancer cell-targeting agents to enhance SWNT uptake by cancer cells while limiting uptake by normal cells.

Mammalian pharmacokinetics of carbon nanotubes using intrinsic near-infrared fluorescence

Individualized, chemically pristine single-walled carbon nanotubes have been intravenously administered to rabbits and monitored through their characteristic near-infrared fluorescence. Spectra indicated that blood proteins displaced the nanotube coating of synthetic surfactant molecules within seconds. The nanotube concentration in the blood serum decreased exponentially with a half-life of 1.0 +/- 0.1 h. No adverse effects from low-level nanotube exposure could be detected from behavior or pathological examination. At 24 h after i.v. administration, significant concentrations of nanotubes were found only in the liver. These results demonstrate that debundled single-walled carbon nanotubes are high-contrast near-infrared fluorophores that can be sensitively and selectively tracked in mammalian tissues using optical methods. In addition, the absence of acute toxicity and promising circulation persistence suggest the potential of carbon nanotubes in future pharmaceutical applications.

Intracellular gold nanoparticles enhance non-invasive radiofrequency thermal destruction of human gastrointestinal cancer cells

Background

Novel approaches to treat human cancer that are effective with minimal toxicity profiles are needed. We evaluated gold nanoparticles (GNPs) in human hepatocellular and pancreatic cancer cells to determine: 1) absence of intrinsic cytotoxicity of the GNPs and 2) external radiofrequency (RF) field-induced heating of intracellular GNPs to produce thermal destruction of malignant cells. GNPs (5 nm diameter) were added to 2 human cancer cell lines (Panc-1, Hep3B). 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and propidium iodide-fluorescence associated cell sorting (PI-FACS) assessed cell proliferation and GNP-related cytotoxicity. Other GNP-treated cells were exposed to a 13.56 MHz RF field for 1, 2, or 5 minutes, and then incubated for 24 hours. PI-FACS measured RF-induced cytotoxicity.

Results

GNPs had no impact on cellular proliferation by MTT assay. PI-FACS confirmed that GNPs alone produced no cytotoxicity. A GNP dose-dependent RF-induced cytotoxicity was observed. For Hep3B cells treated with a 67 μM/L dose of GNPs, cytotoxicity at 1, 2 and 5 minutes of RF was 99.0%, 98.5%, and 99.8%. For Panc-1 cells treated at the 67 μM/L dose, cytotoxicity at 1, 2, and 5 minutes of RF was 98.5%, 98.7%, and 96.5%. Lower doses of GNPs were associated with significantly lower rates of RF-induced thermal cytotoxicity for each cell line (P < 0.01). Cells not treated with GNPs but treated with RF for identical time-points had less cytotoxicity (Hep3B: 17.6%, 21%, and 75%; Panc-1: 15.3%, 26.4%, and 39.8%, all P < 0.01).

Conclusion

We demonstrate that GNPs 1) have no intrinsic cytotoxicity or anti-proliferative effects in two human cancer cell lines in vitro and 2) GNPs release heat in a focused external RF field. This RF-induced heat release is lethal to cancer cells bearing intracellular GNPs in vitro.

Male gender is associated with increased risk for postinjury pneumonia

Nosocomial pneumonia in trauma patients is a significant source of resource utilization and mortality. We have previously described increased rates of pneumonia in male trauma patients in a single institution study. In that study, female trauma patients had a lower incidence of postinjury pneumonia but a higher relative risk for mortality when they did develop pneumonia. We sought to investigate the hypothesis that male trauma patients have an increased incidence of postinjury pneumonia in a separate population-based dataset. Prospective data were collected on 30,288 trauma patients (26,231 blunt injuries, 4057 penetrating injuries) admitted to all trauma centers (n = 26) in Pennsylvania over 24 months (January 1996 to December 1997). Gender differences in pneumonia were determined for the entire dataset. A second analysis examined all blunt injury patients and excluded all patients with a hospital length of stay less than 24 h, eliminating patients who expired early after admission. In trauma patients with minor injury (ISS < 15), there was no significant difference between male and female patients in the rate of postinjury pneumonia (male 1.37%, female 1.11%). In the moderate-injury group (ISS > 15), male trauma patients had a significantly increased incidence of postinjury pneumonia (ISS 15-30, male 8.85%, female 6.45%; ISS > 30, male 24.35%, female 17.30%). Logistic regression analysis of blunt trauma patients revealed that gender, ISS, injury type, admission Revised Trauma Score (RTS), admission respiratory rate, history of cardiac disease, and history of cancer were all independent predictors of pneumonia. Trauma patients with nosocomial pneumonia had a significantly higher mortality rate (P < 0.001) than patients without pneumonia. There was no gender-specific difference in mortality among pneumonia patients. Male gender is significantly associated with an increased incidence of postinjury pneumonia. In contrast to our initial study, there was no gender difference in postinjury pneumonia mortality rates identified in this population-based study.

Accuracy of lymphatic mapping and sentinel lymph node biopsy after previous wide local excision in patients with primary melanoma

BACKGROUND

Sentinel lymph node (SLN) status is the most important prognostic factor with respect to the survival of patients with primary cutaneous melanoma. However, lymphatic mapping and SLN biopsies (LM/SLNBs) performed in patients who have had a wide local excision (WLE) may not accurately reflect the pathologic status of the draining lymph node basins. The purpose of this study was to assess the feasibility and accuracy of LM/SLNB in patients who have had a previous WLE.

METHODS

A single-institution database was examined to identify patients who had a WLE before LM/SLNB and patients who had a concomitant LM/SLNB. Primary clinicopathologic features (age, tumor thickness, and ulceration), SLN identification rate, SLN pathologic status, and the incidence and sites of recurrences were compared between patients with and without prior WLE.

RESULTS

Of the 1395 patients identified, 104 had WLE before LM/SLNB. The mean preoperative WLE radial margin was 1.4 cm (median, 1.0 cm). LM/SLNB was successful in 103 of 104 (99%) patients. Age, tumor thickness, incidence of ulceration, and incidence of SLN positivity in the group with prior WLE were similar to those of the cohort of patients who had concomitant LM/SLNB and WLE (n = 1291). In 97 (93%) of the 104 prior-WLE patients, the surgical defects were closed by either primary closure or skin graft; 7 patients (7%) had rotational flaps. The median follow-up of these 104 patients was 51 months. Among the prior-WLE group, 19 patients (18%) had a positive SLNB; of these 19 patients, 4 (21%) had recurrences (3 distant failures and 1 local and distant failure). There were no lymph node recurrences-in a mapped or unmapped basin-in these 104 patients with a negative or positive SLNB.

CONCLUSIONS

SLNs can be successfully identified and accurately reflect the status of the regional lymph node basin in carefully selected melanoma patients with a previous WLE. Prior WLE does not appear to adversely impact the ability to detect lymphatic metastases, although the utility of LM/SLNB in patients who have undergone extensive reconstruction of the primary excision site remains to be defined. Because more extensive surgery may be required to accomplish accurate lymph node staging in patients who have undergone prior WLE-including the possible removal of SLNs from additional lymph node basins and an additional surgical procedure-to minimize morbidity and cost, concomitant WLE and LM/SLNB is strongly preferred whenever possible.

A statewide population-based study of gender differences in trauma: validation of a prior single-institution study

BACKGROUND

Women usually have lower mortality rates than men do at any age. This pattern is observed for most causes of death from chronic diseases. Significant controversy still exists about gender differences in outcomes in trauma. We previously reported no differences in in-hospital mortality based on gender in a large single-institution study (n= 18,892) that had a significant limitation in that it was not population based. This current study was performed to validate our earlier findings in a separate, statewide, population-based dataset of trauma victims.

STUDY DESIGN

Prospective data were collected on 22,332 trauma patients (18,432 blunt, 3,900 penetrating) admitted to all trauma centers (n = 26) in Pennsylvania over 24 months (January 1996 to December 1997). Gender differences in in-hospital mortality were determined for the entire dataset and for the subsets of blunt and penetrating injury patients. A second analysis examined all blunt injury patients and excluded all patients with a hospital length of stay of less than 24 hours, eliminating patients who expired soon after admission. The null hypothesis was that female gender is protective in trauma outcomes.

RESULTS

Multiple logistic regression analysis identified age (odds ratio [OR] 1.03, confidence interval [CI] 1.02 to 1.03), Injury Severity Score (OR 1.06, CI 1.05 to 1.06), non-Caucasian race (OR 1.72, CI 1.39 to 2.15), blunt injury type (OR 0.327, CI 0.26 to 0.41), and Revised Trauma Score (OR 0.44, CI 0.41 to 0.47) as independent predictors of in-hospital mortality in trauma. Preexisting diseases, including cardiac disease (OR 1.53, CI 1.12 to 2.09) and malignancy (OR 4.08, CI 1.64 to 10.17), were also identified as independent predictors of in-hospital mortality in trauma. Female gender was not associated with decreased mortality (OR 0.83, CI 0.67 to 1.03, p = 0.093). A second multiple regression analysis in blunt trauma patients admitted for longer than 24 hours (which eliminated early deaths and patients with minor injuries) determined that in-hospital mortality was not significantly different in male or female blunt trauma patients stratified by Injury Severity Score and age. The same factors that were predictive of in-hospital mortality in the total dataset were also significant in this secondary analysis.

CONCLUSIONS

These population-based data confirm that female gender does not adversely affect in-hospital mortality in trauma when patients are appropriately stratified for other variables, including Injury Severity Score and age, that do significantly affect outcomes.

Pelvic exenteration affords safe and durable treatment for locally advanced rectal carcinoma

BACKGROUND

Treatment of locally advanced rectal carcinoma (LARC) often involves exenterative surgery, which can be associated with high perioperative morbidity and mortality. To assist in patient selection for radical surgery, we sought to determine clinicopathologic factors influencing recurrence and disease-free survival (DFS) of LARC.

METHODS

Consecutive patients with LARC undergoing exenterative surgery were retrospectively identified in our institutional database. Factors evaluated included age, sex, primary versus recurrent tumors, neoadjuvant or adjuvant chemoradiotherapy, resection margin status, recurrence, time to recurrence, and survival. The primary outcome was DFS. Secondary outcomes were overall survival and perioperative morbidity.

RESULTS

A total of 72 patients were identified; median age was 52 years, and median follow-up time was 30 months. The overall complication rate was 43%; rates were similar among the patients with primary (47%) or recurrent (37%) LARC. Primary or recurrent tumor status was the only factor significantly predictive of outcome after exenteration. Local recurrence rates were lower in the primary group (primary 22%, recurrent 52%, P = .05). A significant difference in 5-year DFS was found between primary and recurrent tumor (52% vs. 13%; P < .01). The median time to recurrence was longer in the patients with primary LARC (17 months vs. 8 months; P < .01).

CONCLUSIONS

The complication rates for pelvic exenteration remain high, but the morbidity can typically be managed without a clinically important increase in hospitalization. In primary LARC, an aggressive surgical approach provides most patients 5-year DFS. Select patients with recurrent LARC will also benefit from pelvic exenteration.

Severe anemia after gastrointestinal hemorrhage in a Jehovah's Witness: new treatment strategies

OBJECTIVE

Management of severe anemia in a critically ill Jehovah's Witness is challenging. In the past, conservative therapy was the only option available to the practitioner. Recently, new interventional treatment strategies have become available, including human and bovine hemoglobin substitutes and high-dose recombinant human erythropoietin.

DESIGN

Case report.

SETTING

Intensive care unit in a quaternary care center.

PATIENT

A patient with severe, life-threatening anemia caused by gastrointestinal hemorrhage who refused all blood products on religious grounds.

INTERVENTION

Bovine hemoglobin substitute and high-dose recombinant human erythropoietin.

CASE STUDY

A 50-yr-old Jehovah's Witness presented with massive upper gastrointestinal hemorrhage; initial hemoglobin was 3.5 g/dL. Endoscopy revealed a prepyloric ulcer, and hemorrhage control was achieved by epinephrine injections into the peri-ulcer mucosa. Despite control of hemorrhage, the patient became hemodynamically unstable. A total of 7 units of a bovine hemoglobin-based oxygen carrying compound (HBOC-201) was administered to enhance the patient's oxygen delivery. High-dose recombinant human erythropoietin was administered daily (500 units/kg). Hemoglobin levels were initially maintained and then slowly increased to a maximum of 7.6 g/dL on day 24 of therapy.

CONCLUSION

This case demonstrates that the concurrent administration of hemoglobin-based oxygen carriers and recombinant human erythropoietin in severe, life-threatening anemia (hemoglobin, 3.5 g/dL) was associated with patient survival and a significant increase in hemoglobin to 7.6 g/dL, without the administration of allogeneic blood. Hemoglobin-based oxygen carriers can adequately serve as initial therapy to maintain tissue oxygen delivery while awaiting the maximal effect of recombinant erythropoietin on bone marrow red blood cell production. High-dose recombinant human erythropoietin offers these patients the best chance for normalization of hematocrit and survival in the long term.

Intraoperative fluid administration is associated with perioperative outcomes in pancreaticoduodenectomy: a single center retrospective analysis

BACKGROUND

Recent studies on perioperative fluid administration in patients undergoing major abdominal surgery have suggested that increased fluid loads are associated with worse perioperative outcomes. However, results of retrospective analyses of the relationship between intraoperative fluid (IOF) administration and perioperative outcomes in patients undergoing pancreaticoduodenectomy (PD) are conflicted. We sought to investigate this relationship in patients undergoing PD at our academic center.

METHODS

A retrospective analysis of 124 patients undergoing PD from 2007 to 2012 was performed. IOF administration rate (ml/kg/hr) was correlated with perioperative outcomes. Outcomes were also stratified by preoperative serum albumin level.

RESULTS

Regression analyses were performed comparing independent perioperative variables, including IOF rate, to four outcomes variables: length of stay, severity of complications, number of complications per patient, and 30-day mortality. Both univariate and multivariate regression analyses showed IOF rate correlated with one or more perioperative outcomes. Patients with an albumin ≤ 3.0 g/dl who received more than the median IOF rate experienced more severe complications, while patients with an albumin >3.0 g/dl did not.

CONCLUSION

Increased IOF administration is associated with worse perioperative outcomes in patients undergoing PD. Patients with low preoperative serum albumin levels (≤ 3.0 g/dl) may be a group particularly sensitive to volume overload.

The role of focal liver ablation in the treatment of unresectable primary and secondary malignant liver tumors

Surgical resection is often the first-line treatment option for primary and select metastatic hepatic malignancies. A minority of patients with hepatocellular carcinoma undergo potentially curative resection. Similarly, patients with liver-only metastasis are candidates for resection less than 15% of the time because of bilobar disease in which resection would sacrifice too great a volume of hepatic parenchyma, tumor proximity to major vascular or biliary structures thus preventing adequate margins, or unfavorable tumor biology. Ablative techniques directed at tumor elimination while minimizing injury to the surrounding functional hepatic parenchyma may be offered to select patients with unresectable cancers. Radiofrequency ablation, percutaneous ethanol injection, transarterial chemoembolization, cryoablation, microwave coagulation, and laser-induced interstitial thermotherapy all offer potential local tumor control and occasionally achieve long-term disease-free survival. This review focuses on the indications, anticipated benefits, and limitations of these ablative techniques.

Small-bowel diverticulosis

Diffuse jejunoileal diverticulosis with pneumoperitoneum but without peritonitis is an uncommon but well-documented entity. Cases of jejunoileal diverticular perforation in which the perforation is evident are managed with resection of the diseased bowel and primary anastomosis. In the absence of an intraoperative finding of a perforation or an area of discrete inflammation, copious irrigation and closure of the abdomen is appropriate in cases of diffuse small-bowel diverticulosis.

Outcomes of microwave ablation for colorectal cancer liver metastases: a single center experience

BACKGROUND AND OBJECTIVES

Surgical management of colorectal cancer liver metastases continues to evolve to optimize oncologic outcomes while maximizing parenchymal preservation. Long-term data after intraoperative microwave ablation are limited. This study investigates outcomes and patterns of recurrence in patients who underwent intraoperative microwave ablation.

METHODS

A retrospective analysis of 33 patients who underwent intraoperative microwave ablation of colorectal cancer liver metastases from 2009 to 2013 at our institution was performed. Perioperative and long-term data were reviewed to determine outcomes and patterns of recurrence.

RESULTS

A total of 49 tumors were treated, ranging 0.5-5.5 cm in size. Median Clavien-Dindo classification was one. Median follow-up was 531 days, with 13 (39.4%) patients presenting with a recurrence. Median time to first recurrence was 364 days. In those patients, 1 (7.8%) presented with an isolated local recurrence in the liver. Only 1 of 7 ablated tumors greater than 3 cm recurred (14.3%). Overall survival was 35.2% at 4 years, with a 19.3% disease-free survival at 3.5 years. No perioperative variables predicted systemic or local recurrence.

CONCLUSION

Intraoperative microwave ablation is a safe and effective modality for use in the treatment of colorectal cancer liver metastases in tumors as large as 5.5 cm in size.

Impact of Textbook Oncologic Outcome Attainment on Survival After Gastrectomy: A Review of the National Cancer Database

BACKGROUND

Textbook oncologic outcome (TOO) is a composite outcome measure realized when all desired short-term quality metrics are met after an oncologic operation. This study examined the incidence and impact of achieving a TOO among patients undergoing resection of gastric adenocarcinoma.

METHODS

The 2004-2016 National Cancer Database was queried for patients who underwent curative gastrectomy. Textbook oncologic outcome was defined as having met five metrics: R0 resection, American Joint Committee on Cancer-compliant lymph node evaluation (n ≥ 15), no prolonged hospital stay (< 75th percentile by year), no 30-day readmission, and receipt of guideline-accordant systemic therapy.

RESULTS

Of 34,688 patients identified, 8249 (23.8 %) achieved TOO. The patients for whom TOO was achieved were more likely to have traveled farther (p < 0.001) and received care in an academic (p < 0.001) or very high case-volume facility (p < 0.001). The TOO group had a significanty higher median overall survival (OS) than the non-TOO group (80.5 vs 35.3 months; p < 0.001). The Kaplan-Meier curve showed that at 12 months, the survival probability estimate was 92 % for the TOO group versus 77 % for the non-TOO group. At 60 months (long-term survival), survival probability estimates remained higher for the TOO group (57 % vs 38 %). The results of the multivariate Cox regression model found that TOO attainment was significantly associated with a reduced risk of death (hazard ratio, 0.82; p < 0.001).

CONCLUSION

The TOO measure is associated with improved OS and reduced risk of death after gastrectomy for gastric adenocarcinoma. Unfortunately, in this study, TOO was obtained in only 23.8 % of cases.

Reduction of IL-10 and nitric oxide synthesis by SR31747A (sigma ligand) in RAW murine macrophages

BACKGROUND

There are several subtypes of sigma receptor, one of which is found throughout the immune system. SR31747A is a unique sigma ligand that possesses potent immune modulatory properties. Previous in vivo studies have documented that administration of SR31747A in murine models of sepsis resulted in decreased proinflammatory (IL-1, IL-6, TNF-alpha) and increased anti-inflammatory (IL-10) response (serum, splenocyte). Studies regarding the effect of this sigma ligand on purified macrophages are lacking. We therefore sought to investigate the effect of SR31747A in LPS-stimulated murine macrophages (RAW 264.7).

METHODS

RAW cells were incubated at 2.5 x 10(5) cells/well; controls were incubated with media alone, experimental groups contained LPS (0.01 microg) and SR31747A (1 nM, 10 nM, 100 nM, 1 microM, 10 microM). Supernatant and cells were harvested at 24 and 48 h. Concentrations of nitric oxide (Greiss reaction) and IL-10 were determined in the supernatant; cellular IL-10 mRNA was assessed.

RESULTS

SR31747A induced a dose-dependent reduction in NO and IL-10 protein release in LPS-stimulated murine macrophages. The decrease in IL-10 protein synthesis was paralleled by a significant dose-dependent reduction in IL-10 mRNA.

CONCLUSION

SR31747A is a novel immunomodulator that down regulates nitric oxide and IL-10 protein and mRNA expression. This in vitro reduction of IL-10 protein and mRNA expression is in contrast to previous in vivo murine studies. These data suggest that peripheral macrophages are not the source of the increased anti-inflammatory (IL-10) response induced by SR31747A.

Safety and efficacy of LigaSure usage in pancreaticoduodenectomy

BACKGROUND

Over recent years, use of the LigaSure™ vessel sealing device has increased in major abdominal surgery to include pancreaticoduodenectomy (PD). LigaSure™ use during PD has expanded to include all steps of the procedure, including the division of the uncinate margin. This introduces the potential for thermal major vascular injury or margin positivity. The aim of the present study was to evaluate the safety and efficacy of LigaSure™ usage in PD in comparison to established dissection techniques.

METHODS

One hundred and forty-eight patients who underwent PD from 2007 to 2012 at Robert Wood Johnson University Hospital were identified from a retrospective database. Two groups were recognized: those in which the LigaSure™ device was used (N = 114), and in those it was not (N = 34). Peri-operative outcomes were compared.

RESULTS

Vascular intra-operative complications directly caused by thermal injury from LigaSure™ use occurred in 1.8% of patients. Overall vascular intra-operative complications, uncinate margin positivity, blood loss, length of stay, and complication severity were not significantly different between groups. The mean operative time was 77 min less (P < 0.010) in the LigaSure™ group. Savings per case where the LigaSure™ was used amounted to $1776.73.

CONCLUSION

LigaSure™ usage during PD is safe and effective. It is associated with decreased operative times, which may decrease operative costs in PD.

Gastric remnant carcinoma: reevaluation of screening endoscopy

A 67-year-old male presented with complaints of chronic postprandial pain in the epigastric region. The patient had undergone a vagotomy, antrectomy, and loop gastrojejunostomy for peptic ulcer disease 25 years prior. Abdominal computed tomography (CT) revealed markedly thickened walls of the gastric remnant with infiltration of the adjacent fat planes. An esophagogastroscopy demonstrated erythematous, friable remnant mucosa. Gastric biopsies revealed invasive adenocarcinoma. At laparotomy a large tumor mass involving the gastric remnant and the antecolic loop gastrojejunostomy was identified. Further exploration revealed a firm nodule in the left lobe of the liver and several small nodules on the diaphragm and the lesser omentum. Biopsies confirmed metastatic adenocarcinoma at all sites. Curative resection was abandoned. Gastric remnant carcinoma (GRC) typically presents more than 20 years after resection for peptic ulcer disease and has a history of poor survival rates. With increased use of diagnostic endoscopy, GRC has been detected at earlier stages. Recent cohort studies demonstrate that GRC has similar survival rates after stage stratification when compared with primary proximal gastric carcinoma. The increased incidence of GRC in later decades (>20 years) after operation in conjunction with decreasing numbers of patients suggests that screening endoscopy should be considered on a 2- to 5-year basis in this population.

Advanced proximal colon cancer

BACKGROUND

Two recent studies have documented that sigmoidoscopy as a screening tool for colorectal cancers may miss advanced proximal colonic neoplasms. The purpose of this study was to assess the prevalence of distal synchronous lesions in patients with proximal colon cancer. We sought to determine if screening sigmoidoscopy would have missed these proximal colon cancers.

METHODS

Data were collected on all patients (n = 305) diagnosed with colorectal cancer over a 6-year period. Patients were stratified by age, sex, tumor location, presenting complaint, AJCC stage, and TNM classification. The colonoscopy results of patients diagnosed with proximal colon cancer were analyzed to determine the incidence of synchronous distal colon lesions.

RESULTS

Proximal colon cancer was diagnosed in 88 patients (29%). Of those studied, 45 (54%) did not have synchronous distal lesions detected by colonoscopy. The patients with proximal colon cancer were elderly (mean age 67), had advanced tumor size [59 patients (67%) T3/T4], and had advanced AJCC stages [37 patients (42%) stage III/IV]. Nearly all patients [84 (95%)] with proximal colon cancer were symptomatic.

CONCLUSION

In this study, the majority of patients with proximal colon cancer did not have a synchronous lesion in the distal colon. Current screening methods for colon cancer based on sigmoidoscopy would not have identified these proximal lesions. These findings support the incorporation of screening colonoscopy in protocols designed to identify early colon cancer.

Dose-painted intensity modulated radiation therapy improves local control for locally advanced pancreas cancer

Background. To evaluate the outcomes, adverse events, and therapeutic role of Dose-Painted Intensity-Modulated Radiation Therapy (DP-IMRT) for locally advanced pancreas cancer (LAPC). Methods. Patients with LAPC were treated with induction chemotherapy (n = 25) and those without metastasis (n = 20) received DP-IMRT consisting of 45 Gy to Planning Treatment Volume 1 (PTV1) including regional lymph nodes with a concomitant boost to the PTV2 (gross tumor volume + 0.5 cm) to either 50.4 Gy (n = 9) or 54 Gy (n = 11) in 25 fractions. DP-IMRT cases were compared to three-dimensional conformal radiation therapy (3D-CRT) plans to assess the potential relationship of radiation dose to adverse events. Kaplan-Meier and Cox regression analyses were used to calculate survival probabilities. The Fisher exact test and t-test were utilized to investigate potential prognostic factors of toxicity and survival. Results. Median overall and progression-free survivals were 11.6 and 5.9 months, respectively. Local control was 90%. Post-RT CA-19-9 levels following RT were predictive of survival (P = 0.02). Grade 2 and ≥grade 3 GI toxicity were 60% and 20%, respectively. In comparison to 3D-CRT, DP-IMRT plans demonstrated significantly lower V45 values of small bowel (P = 0.0002), stomach (P = 0.007), and mean liver doses (P = 0.001). Conclusions. Dose-escalated DP-IMRT offers improved local control in patients treated with induction chemotherapy for LAPC. Radiation-related morbidity appears reduced with DP-IMRT compared to 3D-CRT techniques, likely due to reduction in RT doses to organs at risk.

Preoperative Anemia in Colon Cancer: Assessment of Risk Factors

Anemia is common in cancer patients and is associated with reduced survival. Recent studies document that treatment of anemia with blood transfusion in cancer patients is associated with increased infection risk, tumor recurrence, and mortality. We therefore investigated the incidence of preoperative anemia in colorectal cancer and assessed risk factors for anemia. Prospective data were collected on 311 patients diagnosed with colorectal cancer over a 6-year period from 1994 through 1999. Patients were stratified by age, gender, presenting complaint, preoperative hematocrit, American Joint Committee on Cancer (AJCC) stage, and TNM classification. Discrete variables were compared using Pearson's Chi-square analysis. Continuous variables were compared using Student's t test. Differences were considered significant when P < 0.05. The mean age of the study cohort was 67 ± 9.2 with 98 per cent of the study population being male. The mean AJCC stage was 2.2 ± 1.2 and the mean preoperative hematocrit was 35 ± 7.9 with an incidence of 46.1 per cent. The most common presenting complaints were hematochezia (n = 59), anemia (n = 51), heme-occult-positive stool (n = 33), bowel obstruction (n = 26), abdominal pain (n = 21), and palpable mass (n = 13). Preoperative anemia was most common in patients with right colon cancer with an incidence of 57.6 per cent followed by left colon cancer (42.2%) and rectal cancer (29.8%). Patients with right colon cancer had significantly lower preoperative hematocrits compared with left colon cancer (33 ± 8.5 vs 36 ± 7.4; P < 0.01) and rectal cancer (33 ± 8.5 vs 38 ± 6.0; P < 0.0001). Patients with right colon cancer also had significantly increased stage at presentation compared with left colon cancer (2.3 ± 1.3 vs 2.1 ± 1.2; P < 0.02). Age was not a significant risk factor for preoperative anemia in colorectal cancer. We conclude that there is a high incidence of anemia in patients with colon cancer. Patients with right colon cancer had significantly lower preoperative hematocrits and higher stage of cancer at diagnosis. Complete colon evaluation with colonoscopy is warranted in patients with anemia to improve earlier diagnosis of right colon cancer. A clinical trial of preoperative treatment of anemic colorectal cancer patients with recombinant human erythropoietin is warranted.

Impact of Palliative Interventions on Survival of Patients with Unresected Pancreatic Cancer: Review of the 2010-2016 National Cancer Database

INTRODUCTION

Palliative interventions (PI) are offered to patients with pancreatic cancer with the aim of enhancing quality of life and improving overall survival (OS). The purpose of this study was to determine the impact of PI on survival amongst patients with unresected pancreatic cancer.

METHODS

Patients with stage I-IV unresected pancreatic adenocarcinoma were identified using the 2010-2016 National Cancer Database. The cohort was stratified by PI received: palliative surgery (PS), radiation therapy (RT), chemotherapy (CT), pain management (PM), or a combination (COM) of the preceding. Kaplan-Meier method with log-rank test was used to compare and estimate OS based on the PI received. A multivariate proportional hazards model was utilized to identify predictors of survival.

RESULTS

25,995 patients were identified, of which 24.3% received PS, 7.7% RT, 40.8% CT, 16.6% PM, and 10.6% COM. The median OS was 4.9 months, with stage III patients having the highest and stage IV the lowest OS (7.8 vs 4.0 months). Across all stages, PM yielded the lowest median OS and CT the highest (P < .001). Despite this, the stage IV cohort was the only group in which CT (81%) accounted for the largest proportion of PI received (P < .001). Although all PI were identified as positive predictors of survival on multivariate analysis, CT had the strongest association (HR .43; 95% CI, .55-.60, P = .001).

CONCLUSION

PI offers a survival advantage to patients with pancreatic adenocarcinoma. Further studies to examine the observed limited use of CT in earlier disease stages are warranted.

Racial disparities in the attainment of textbook oncologic outcomes following colectomy for colon cancer: a national cancer database cohort study

INTRODUCTION

Textbook oncologic outcome (TOO) is attained when all desired short-term quality metrics are met following an oncologic operation. The objective of this study was to determine the impact of race on TOO attainment following colectomy for colon cancer.

METHODS

The 2004-2017 National Cancer Database was queried for patients with non-metastatic colon cancer who underwent colectomy. TOO was defined as: negative margins (R0), adequate lymphadenectomy (LAD) (n ≥ 12), no prolonged length of stay (LOS), no 30-day readmission or mortality, and initiation of systemic therapy in ≤ 12 weeks. Racial groups were defined as White, Black, or Hispanic.

RESULTS

508,312 patients were identified of which 34% achieved TOO. Blacks attained the least TOO (31.4%) as well as the TOO criteria of adequate LAD (81.1%), no prolonged LOS (52.3%), and no 30-day readmission (89.7%). Hispanics were least likely to have met the criteria of R0 resection (94.3%), no 30-day mortality (87.3%), and initiation of systemic therapy in ≤ 12 weeks (81.8%). Patients who attained TOO had a higher median overall survival (OS) than those without TOO (148.2 vs. 84.2 months; P < 0.001). Hispanic TOO patients had the highest median OS (181.2 months), while White non-TOO patients experienced the lowest (80.2 months, P < 0.001). Multivariate logistic regression models suggest that Black and Hispanic patients are less likely to achieve TOO than their White counterparts.

CONCLUSIONS

Racial disparities exist in the achievement of TOO, with Blacks and Hispanics being less likely to attain TOO compared to their White counterparts.

Influence of contralateral prophylactic mastectomy on textbook outcome attainment at time of mastectomy

INTRODUCTION

The objective of this study was to determine the incidence of textbook oncologic outcome (TOO) and its impact on overall survival (OS) among patients with invasive ductal carcinoma (IDC) following modified radical mastectomy (MRM) versus MRM with contralateral prophylactic mastectomy (MRM ​+ ​CPM).

METHODS

The 2004-2017 National Cancer Database was queried for patients with IDC who underwent MRM and MRM ​+ ​CPM. TOO was defined as: resection with negative margins, adequate lymphadenectomy, length of stay ≤50th percentile, and no 30-day readmission or mortality.

RESULTS

87,573 patients were identified, of which 14.3% underwent MRM ​+ ​CPM. Logistic regression models revealed that MRM ​+ ​CPM is independently associated with a reduced likelihood of achieving TOO (AOR ​= ​0.71; P ​< ​0.001). MRM patients who achieved TOO had a higher median OS compared to those who did not (164.6 vs.142.2 months, P ​< ​0.001).

CONCLUSIONS

MRM ​+ ​CPM is associated with a lower incidence of TOO attainment compared to MRM.

Piperacillin/tazobactam for surgical prophylaxis during pancreatoduodenectomy: meta-analysis

BACKGROUND

Pancreatoduodenectomy is associated with an increased incidence of surgical-site infections, often leading to a significant rise in morbidity and mortality. This trend underlines the inadequacy of traditional antibiotic prophylaxis strategies. Hence, the aim of this meta-analysis was to assess the outcomes of antimicrobial prophylaxis, comparing piperacillin/tazobactam with traditional antibiotics.

METHODS

Upon registering in PROSPERO, the international prospective register of systematic reviews (CRD42023479100), a systematic search of various databases was conducted over the interval 2000-2023. This inclusive search encompassed a wide range of study types, including prospective and retrospective cohorts and RCTs. The subsequent data analysis was carried out utilizing RevMan 5.4.

RESULTS

A total of eight studies involving 2382 patients who underwent pancreatoduodenectomy and received either piperacillin/tazobactam (1196 patients) or traditional antibiotics (1186 patients) as antibiotic prophylaxis during surgery were included in the meta-analysis. Patients in the piperacillin/tazobactam group had significantly reduced incidences of surgical-site infections (OR 0.43 (95% c.i. 0.30 to 0.62); P < 0.00001) and major surgical complications (Clavien-Dindo grade greater than or equal to III) (OR 0.61 (95% c.i. 0.45 to 0.81); P = 0.0008). Subgroup analysis of surgical-site infections highlighted significantly reduced incidences of superficial surgical-site infections (OR 0.34 (95% c.i. 0.14 to 0.84); P = 0.02) and organ/space surgical-site infections (OR 0.47 (95% c.i. 0.28 to 0.78); P = 0.004) in the piperacillin/tazobactam group. Further, the analysis demonstrated significantly lower incidences of clinically relevant postoperative pancreatic fistulas (grades B and C) (OR 0.67 (95% c.i. 0.53 to 0.83); P = 0.0003) and mortality (OR 0.51 (95% c.i. 0.28 to 0.91); P = 0.02) in the piperacillin/tazobactam group.

CONCLUSION

Piperacillin/tazobactam as antimicrobial prophylaxis significantly lowers the risk of postoperative surgical-site infections, major surgical complications (complications classified as Clavien-Dindo grade greater than or equal to III), clinically relevant postoperative pancreatic fistulas (grades B and C), and mortality, hence supporting the implementation of piperacillin/tazobactam for surgical prophylaxis in current practice.

Can hepatocellular cancer screening increase the proportion of long-term survivors?

BACKGROUND/AIMS

Historically, only 10% of hepatocellular cancer (HCC) patients are diagnosed with early stage, potentially curable disease. We prospectively screened chronic hepatitis virus-infected patients to determine 1) the proportion diagnosed with potentially curable HCC, and 2) survival following curative therapy.

METHODOLOGY

The study included 5670 chronic hepatitis B (1,077, 19.0%), C (4,196, 74.0%), or both (397, 7.0%)-infected patients enrolled in a prospective screening program. Screening was every 6 months with serum alpha-fetoprotein (AFP) measurement and ultrasonography. Curative treatments included liver transplantation, resection, RFA, and/or ethanol injection.

RESULTS

HCC was diagnosed in 464 (8.2%) patients. Of 1006 cirrhotic patients, 462 (45.9%) developed HCC. Curative treatment was possible in 319 (68.7%). The 2- and 5-year overall survival rates in the curative treatment group were 65% and 28%, respectively, compared to 10% and 0% in the advanced disease group (p < 0.001).

CONCLUSION

Prospective screening of patients at high risk to develop HCC increases the proportion diagnosed with potentially curable disease. This may result in an increase of the number of long-term survivors. A screening strategy should focus on those patients with chronic hepatitis B or C virus infection that has progressed to cirrhosis since more than 40% of these patients will develop HCC.

Refractory Gastric Outlet Obstruction Due to a Duodenal Stricture in the Setting of a Cholecystoduodenal Fistula

Gastric outlet obstruction (GOO) is a clinical condition in which an underlying disease process leads to a lack of gastric emptying. The presentation and management of GOO due to a variety of benign and malignant causes have been researched; however, limited medical literature exists on the presentation and management of refractory GOO caused by a duodenal stricture secondary to a cholecystoduodenal fistula. This case report highlights the diagnostic challenges and the significance of timely intervention. This case of a 66-year-old female with GOO refractory to multiple endoscopic interventions demonstrates the presentation and management of such a rare cause of GOO and highlights the importance of surgical consultation in persistent GOO. The etiology of GOO varies widely, requiring a range of treatments from medical management to surgery. This case underscores the importance of identifying the cause to ensure effective treatment. Cholecystoduodenal fistulas are rare but significant, often necessitating surgical intervention when endoscopic procedures fail. Our patient had a duodenal stricture due to a cholecystoduodenal fistula, indicating the necessity for surgical consultation.