Ablation techniques or active surveillance compared to surgical resection in patients with low-risk papillary thyroid cancer: a systematic review and meta-analysis

BACKGROUND

The global prevalence of thyroid cancer is on the rise. About one-third of newly diagnosed thyroid cancer cases comprise low-risk papillary thyroid cancer (1.5 cm or more minor). While surgical removal remains the prevailing approach for managing low-risk papillary thyroid cancer (LPTC) in patients, other options such as active surveillance (AS), radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) are also being considered as viable alternatives. This study evaluated and compared surgical thyroid resection (TSR) versus non-surgical (NS) methods for treating patients with LPTC.

METHODS

The study encompassed an analysis of comparisons between surgical thyroid resection (TSR) and alternative approaches, including active surveillance (AS), radiofrequency ablation (RFA), microwave ablation (MWA), or laser ablation (LA). The focus was on patients with biopsy-confirmed low-risk papillary thyroid cancer (LPTC) of less than 1.5 cm without preoperative indications of local or distant metastasis. The primary outcomes assessed were recurrence rates, disease-specific mortality, and quality of life (QoL). Data were collected from prominent databases, including Cochrane Database, Embase, MEDLINE, and Scopus, from inception to June 3rd, 2020. The CLARITY tool was utilized to evaluate bias risk. The analysis involved odds ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes, as well as mean differences (MD) and standardized mean differences (SMD) for continuous outcomes. The study is registered on PROSPERO under the identifier CRD42021235657.

RESULTS

The study incorporated 13 retrospective cohort studies involving 4034 patients. Surgical thyroid resection (TSR), active surveillance (AS), and minimally invasive techniques like radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) were performed in varying proportions of cases. The analysis indicated that specific disease mortality rates were comparable among AS, MWA, and TSR groups. The risk of recurrence, evaluated over different follow-up periods, showed no significant differences when comparing AS, RFA, MWA, or LA against TSR. Patients undergoing AS demonstrated better physical health-related quality of life (QoL) than those undergoing TSR. However, no substantial differences were observed in the overall mental health domain of QoL when comparing AS or RFA with TSR. The risk of bias was moderate in nine studies and high in four.

CONCLUSION

Low-quality evidence indicates comparable recurrence and disease-specific mortality risks among patients with LPTC who underwent ablation techniques or active surveillance (AS) compared to surgery. Nevertheless, individuals who opted for AS exhibited enhanced physical quality of life (QoL). Subsequent investigations are warranted to validate these findings.

Downstaging after preoperative chemoradiation for locally advanced rectal cancer is associated with better survival than pathologic stage 0-1 disease treated with upfront surgery

BACKGROUND AND OBJECTIVES

It is unknown how patients with locally advanced rectal cancer with significant response to preoperative radiotherapy/chemoradiotherapy fare relative to patients with true pathologic 0-1 disease undergoing upfront surgery. We aimed to determine whether survival is improved in locally advanced rectal cancer downstaged to pathologic stage 0-1 disease compared to true pathologic stage 0-1 tumors.

METHODS

A retrospective review of the National Cancer Database between 2004 and 2016 was conducted. Three groups were identified: (1) clinical stage 2-3 disease downstaged to pathologic stage 0-1 disease after radiotherapy, (2) clinical stage 2-3 disease not downstaged after radiotherapy, and (3) true pathologic 0-1 tumors undergoing upfront surgery. The primary endpoint was overall survival and was compared using Kaplan-Meier and multivariate Cox regression analyses.

RESULTS

The study population consisted of 59,884 patients. Of the 40,130 patients with locally advanced rectal cancer treated with preoperative radiation, 12,670 (31.5%) had significant downstaging (group 1), while 27,460 (68.4%) had no significant downstaging (group 2). A total of 19,754 had pathologic 0-1 disease treated with upfront resection (group 3). On Kaplan-Meier analysis, downstaged patients had significantly better overall survival compared to both non-downstaged and true pathologic stage 0-1 patients (median 156 vs. 99 and 136 months, respectively, p < 0.001). On multivariate analysis, downstaged patients had significantly better survival (HR 0.88, p < 0.001) compared to true pathologic 0-1 patients.

CONCLUSIONS

Locally advanced rectal cancer downstaged after preoperative radiotherapy has significantly better survival compared to true pathologic stage 0-1 disease treated with upfront surgery. Response to chemoradiotherapy likely identifies a subset of patients with a particularly good prognosis.

Novel antibiotic irrigation device versus standard O-ring wound retractor in the prevention of surgical site infection following colorectal resection

PURPOSE

We sought to compare the effectiveness of a novel antibiotic irrigation device to the standard O-ring wound retractor in preventing surgical site infections (SSIs) following colorectal resections.

METHODS

This single-arm clinical trial included patients undergoing colorectal resections utilizing the novel device. A retrospective cohort of patients undergoing the same procedures with the O-ring retractor was selected as the control group. The primary outcome assessed was SSI. Secondary outcomes assessed were overall complications, hospital length of stay (LOS), and 30-day readmission. A univariable and multivariable logistic regression model was built to evaluate the association between SSI as the outcome variable and the use of the novel device as the main independent variable. The model was adjusted for any confounding variables.

RESULTS

Eighty-six novel device cases and 170 O-ring retractor cases were enrolled. There were no significant differences between the two groups in terms of demographics and preoperative comorbidities. Cases with the novel device had fewer Pfannenstiel incisions (1.2% vs. 14.6%, p < 0.001). There were no other significant differences in intraoperative variables. SSI rates were significantly lower in the novel device group (1.2% vs. 9.1%, p = 0.014). There were no other significant differences in postoperative complications. Multivariable logistic regression with backward elimination showed that the use of the novel device was significantly more effective against SSI by 92.5% compared to the use of the O-ring retractor.

CONCLUSION

The novel device may contribute to lower SSI rates compared to the O-ring retractor following colorectal resection.

Does coffee affect bowel recovery following minimally invasive colorectal operations? A three-armed randomized controlled trial

PURPOSE

Previous studies have suggested that coffee may shorten the postoperative ileus period. We sought to evaluate the impact of both coffee and caffeine on shortening the return of postoperative bowel function following minimally invasive colectomy.

METHODS

This was a single-center, randomized controlled clinical trial conducted in a tertiary hospital. Patients undergoing an elective robotic or laparoscopic small or large bowel operation were included in this study. Patients were randomized into one of three groups: warm water, decaffeinated coffee, and caffeinated coffee. Subjects were assigned to drink a 4-oz cup three times daily starting on postoperative day one. The primary endpoint was time to first bowel movement. Secondary endpoints included time to first flatus, length of hospital stay, and postoperative morbidity.

RESULTS

A total of 99 patients were included in this study: 31 warm water, 31 decaffeinated coffee, and 37 caffeinated coffee. The groups were similar in age and sex (p = 0.51 and 0.91, respectively). Mean (SD) time to the first bowel movement in days was 2.94 (1.4), 2.58 (1.2), and 2.86 (1.3), respectively (p = 0.53). There were no significant differences observed in postoperative morbidity (p = 0.52) between groups. Multivariate linear regression analysis did not reveal a statistically significant association between any interventions and time to first bowel movement or length of hospital stay.

CONCLUSIONS

Coffee (caffeinated or decaffeinated) does not expedite the return of bowel function following minimally invasive operation.

TRIAL REGISTRATION

https://classic.

CLINICALTRIALS

gov/ct2/show/NCT02639728 NCT02639728.

Hartmann's Reversal is More Complex Than Elective Left Colectomy

BACKGROUND

Hartmann's reversal (HR) is associated with significant technical complexity and morbidity. The decision to perform HR is difficult and up to 50% of patients with colostomies do not undergo a reversal. To better guide surgeons and patients with this decision, we sought to assess the surgical risks and outcomes of HR as compared to elective left colectomy (LC).

METHODS

We conducted a retrospective analysis of a prospective database at a tertiary medical center. Patients undergoing elective Hartmann's reversal and left colectomy between January 2014 and November 2021 were identified. We compared preoperative variables, intraoperative events, and short-term postoperative outcomes.

RESULTS

135 patients were identified: 30 HR and 105 LC. There were no significant differences in demographics or preoperative comorbidities between HR and LC. There were more open and fewer robotic cases in HR (23.3% vs 2.9%, P < .0001; 46.6% vs 76.0%, P < .01). Total operative time was significantly longer in HR than LC (261.8 vs 211.7 minutes, P = .02). There was a significantly higher percentage of intraoperative complications in HR (13.3% vs 1.9%, P < .01). There was a significantly higher rate of minor postoperative complications in HR than LC (46.7% vs 26.7%, P = .04), but not major (6.7% vs 5.8%, P = .85). Time to first flatus/bowel movement was significantly longer in HR than LC (3.6 vs 2.5 days, P < .001).

CONCLUSION

Hartmann's reversal is a more technically challenging operation than elective left colectomy and is associated with significantly higher rates of intraoperative and minor postoperative complications. Future studies should focus on mitigating these risk factors to optimize patient outcomes.

Robotic colorectal procedures: does operative start time impact short-term outcome?

BACKGROUND

Previous publications revealed more complications in afternoon versus morning surgeries. With much attention given to robotic surgery outcomes, we sought to evaluate whether morning versus afternoon start time matters.

METHODS

In a retrospective review of a prospective database, 210 robotic colorectal surgeries were grouped into 97 morning versus 113 afternoon cases. Preoperative risk factors, intraoperative events, and 30-day postoperative outcomes were compared. An independent samples t-test, Fisher's exact test, and linear regression were used for categorical and continuous variables.

RESULTS

Morning patients were significantly younger than afternoon patients (59.5 vs. 65.5, p = 0.004), but there were no significant differences in gender, mean BMI, Charlson Comorbidity Index score, total operative time, console time, estimated blood loss, indications for surgery, and resection type. Morning patients had a significantly shorter mean length of stay (6.0 vs. 8.0 days, p = 0.021), but no significant differences in overall postoperative complications (0.30 vs. 0.30, p = 0.715), wound infection (5.2% vs. 7.1%, p = 0.564), anastomotic leak (0% vs. 2.7%, p = 0.251), ileus/small bowel obstruction (29.9% vs. 22.1%, p = 0.199), and 30-day readmission (8.2% vs. 7.1%, p = 1.000). When analyzing time of day as a continuous variable, we found no significant associations with intra- or postoperative complications.

CONCLUSION

We found no correlation between surgery start time and intra- or postoperative outcomes. This can be partly attributed to these cases being non-emergent and performed primarily by two experienced surgeons with highly trained operating room robotic staff in a large volume tertiary center. This, along with decreased fatigue attributed to superior ergonomics of robotic surgery, may have mitigated previously reported differences between morning and afternoon procedures.

Minimally invasive right versus left colectomy for cancer: does robotic surgery mitigate differences in short-term outcomes?

Studies comparing right (RC) and left colectomies (LC) show higher rates of ileus in RC and higher wound infection and anastomotic leak rates in LC. However, prior studies did not include robotic procedures. We compared short-term outcomes of laparoscopic and robotic RC and LC for cancer, with sub-analysis of robotic procedures. In a retrospective review of a prospective database, preoperative factors, intraoperative events, and 30-day postoperative outcomes were compared. Student's t tests and Chi-square tests were used for continuous and categorical variables, respectively. A logistic binomial regression was performed to assess whether type of surgery was associated with postoperative complications. Between January 2014 and August 2020, 115 patients underwent minimally invasive RC or LC for cancer. Sixty-eight RC [30 (44.1%) laparoscopic, 38 (55.9%) robotic] and 47 LC [13 (27.6%) laparoscopic, 34 (72.4%) robotic] cases were included. On univariate analysis, RC patients had significantly higher overall postoperative complications but no differences in rates of ileus/small bowel obstruction, wound infection, time to first flatus/bowel movement, length of hospital stay, and 30-day readmissions. On multivariate analysis, there was no significant difference in overall complications and laparoscopic surgery had a 2.5 times higher likelihood of complications than robotic surgery. In sub-analysis of robotic cases, there was no significant difference among all outcome variables. Previously reported outcome differences between laparoscopic RC and LC for cancer may be mitigated by robotic surgery.

Role of right hemicolectomy in patients with low-grade appendiceal mucinous adenocarcinoma

BACKGROUND

There is little consensus with regards to the most appropriate surgical management for low-grade appendiceal mucinous adenocarcinomas (LAMA), though right hemicolectomy is usually recommended.

METHODS

The SEER database was queried for all patients with non-metastatic LAMA. Disease specific and overall survival was compared by surgery type: 1) appendectomy, 2) formal right hemicolectomy 3) non-formal colectomy (including ileocecectomy).

RESULTS

A total of 579 patients with non-metastatic LAMA were identified. 133 (23%), 404 (70%), and 42 (7%) of patients had stage I, II, and III disease, respectively. 99 (17.1%) had appendectomy, 87 (15%) had non-formal colectomy, and 302 (52.2%) had formal right hemicolectomy. We observed no significant differences in disease specific or overall survival by surgery type. Controlling for age and stage, surgery type was not a significant predictor of disease specific or overall survival.

CONCLUSION

In patients with localized LAMA, right hemicolectomy did not increase disease specific or overall survival. Right hemicolectomy should be reserved for LAMA patients with positive margins post appendectomy.

"But His Yelp Reviews Are Awful!": Analysis of General Surgeons' Yelp Reviews

Background

Patients use Web-based platforms to review general surgeons. However, little is known about the free-form text and structured content of the reviews or how they relate to the physicians’ characteristics or their practices.

Objective

This observational study aimed to analyze the Web-based reviews of general surgeons on the west side of Los Angeles.

Methods

Demographics, practice characteristics, and Web-based presence were recorded. We evaluated frequency and types of Yelp reviews and assigned negative remarks to 5 categories. Tabulated results were evaluated using independent t test, one-way analysis of variance, and Pearson correlation analysis to determine associations between the number of total and negative reviews with respect to practice structure and physician characteristics.

Results

Of the 146 general surgeons, 51 (35%) had at least 1 review and 29 (20%) had at least 1 negative review. There were 806 total reviews, 679 (84.2%) positive reviews and 127 (15.8%) negative reviews. The negative reviews contained a total of 376 negative remarks, categorized into physician demeanor (124/376, 32.9%), clinical outcomes (81/376, 22%), office or staff (83/376, 22%), scheduling (44/376, 12%), and billing (44/376, 12%). Surgeons with a professional website had significantly more reviews than those without (P=.003). Surgeons in private practice had significantly more reviews (P=.002) and more negative reviews (P=.03) than surgeons who were institution employed. A strong and direct correlation was found between a surgeon’s number of reviews and number of negative reviews (P<.001).

Conclusions

As the most common category of complaints was about physician demeanor, surgeons may optimize their Web-based reputation by improving their bedside manner. A surgeon’s Web presence, private practice, and the total number of reviews are significantly associated with both positive and negative reviews.

Abstract 2882: p53MVA therapy in patients with refractory gastrointestinal malignancies primes robust CD8+ T cell responses

PURPOSE: To conduct a Phase I safety trial of a Modified Vaccinia Ankara vaccine delivering wild type human p53 (p53MVA) in patients with refractory gastrointestinal malignancies.

EXPERIMENTAL DESIGN: Three patients were vaccinated with 108 pfu p53MVA followed by nine patients at 5.6 x 108 pfu. Toxicity was classified using the NCI Common Toxicity Criteria and clinical responses were assessed by CT scan. Peripheral blood samples were collected pre vaccine and post vaccination for immunophenotyping and assessment of p53MVA induced immune response.

RESULTS: p53MVA immunization was well tolerated at both doses, with no adverse events above grade 2. Induction of strong T cell and antibody responses to the MVA backbone were apparent. CD4+ and CD8+ T cells showing enhanced recognition of a p53 overlapping peptide library were detectable after the first immunization, particularly in the CD8+ T cell compartment (p=0.03). However in most patients this did not expand further with the second and third immunization. Some patients exhibited a decline in myeloid-derived suppressor cells post vaccine, but this was not statistically significant. The frequency of PD-1+ T cells detectable in patients PBMC was significantly higher than healthy controls. Furthermore, the frequency of PD-1+ CD8+ T cells showed an inverse correlation with the peak CD8+ T cell response to p53 (p=0.02).

CONCLUSION: p53MVA was well tolerated and induced robust CD8+ T cell responses. Combination of p53MVA with immune checkpoint inhibition could improve sustained immune responses and lead to clinical benefit.

Citation Format: Nicola Hardwick, Mary Carroll, Teodora Kaltcheva, Dajun Qian, Jonathan Espenschied, Lucille Leong, Peiguo Chu, Joseph Kim, Joseph Chao, Marwan Fakih, Joshua Ellenhorn, Don Diamond, Vincent Chung. p53MVA therapy in patients with refractory gastrointestinal malignancies primes robust CD8+ T cell responses. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2882. doi:10.1158/1538-7445.AM2014-2882

Clinical and functional properties of novel VHL mutation (X214L) consistent with Type 2A phenotype and low risk of renal cell carcinoma

Sorrell AD, Lee S, Stolle C, Ellenhorn J, Grix A, Kaelin Jr WG, Weitzel JN. Clinical and functional properties of novel VHL mutation (X214L) consistent with Type 2A phenotype and low risk of renal cell carcinoma.

This report describes clinical characteristics in families with a Type 2A phenotype and functional properties of a novel von Hippel Lindau variant (X214L). Pedigrees were analyzed. Analysis of von Hippel Lindau (VHL) coding exons and flanking intronic sequences in DNA from a proband with pheochromocytoma and islet cell tumor was performed. Western blot assays for VHL protein (pVHL), HIFα, and Jun B were conducted using VHL null renal clear carcinoma cell lines that were engineered to produce wild-type or X214L mutant pVHL. Pedigree analysis indicated that the variant tracked with disease and the same or similar VHL point mutations were identified in several Type 2A families. The predicted 14 amino acid extended pVHL variant, when reintroduced into VHL null cells, was stable and retained the ability to downregulate HIFα in a hydroxylation-dependent manner. In contrast, the variant was defective with respect to downregulation of JunB. pVHL X214L, like other pVHL variants associated with a low risk of clear cell renal carcinoma, largely preserves the ability to downregulate HIF. In contrast, this variant, like other pVHL variants linked to Type 2A disease, fails to suppress JunB. This underscores that JunB may play a role in the pathogenesis of Type 2A VHL disease.

Selection Criteria for Complete Cytoreduction after Cytoreductive Surgery for Peritoneal Surface Malignancy: Lessons Learned from Our First Series of Patients

The appropriate selection criteria for complete cytoreduction in patients with peritoneal surface malignancies have not been determined. We performed a retrospective analysis of all patients receiving cytoreductive surgery (CRS) during the study period of 2004 to 2008 to determine appropriate selection criteria for successful complete cytoreduction. During the study period, 38 patients underwent attempted CRS. Cytoreduction was scored complete, incomplete, or not reported in 53 per cent (n = 20), 37 per cent (n = 14), and 11 per cent (n = 4), respectively. Median overall survival for compete and incomplete cytoreduction was 56 months versus 5 months ( P = 0.011), respectively. Compared with incomplete cytoreduction, patients receiving complete cytoreduction were more likely to have a lower Peritoneal Cancer Index (PCI) and not have received preoperative systemic chemotherapy (CT). Univariate analysis verified PCI greater than 20 (hazard ratio [HR], 0.048; CI, 0.004 to 0.515; P = 0.01) and CT (HR, 0.17; 0.004 to 0.77; P = 0.021) as predictors of incomplete cytoreduction. Small bowel (100%), periportal region (33%), and mesentery (27%) were the most common sites of residual disease. In conclusion, PCI less than 20 and the need for preoperative chemotherapy should be strongly considered when selecting patients with peritoneal surface malignancy for attempted cytoreduction. Early evaluation of the small bowel, mesentery, and periportal region for resectability prevents unnecessary surgery.

Selection criteria for complete cytoreduction after cytoreductive surgery for peritoneal surface malignancy: lessons learned from our first series of patients

The appropriate selection criteria for complete cytoreduction in patients with peritoneal surface malignancies have not been determined. We performed a retrospective analysis of all patients receiving cytoreductive surgery (CRS) during the study period of 2004 to 2008 to determine appropriate selection criteria for successful complete cytoreduction. During the study period, 38 patients underwent attempted CRS. Cytoreduction was scored complete, incomplete, or not reported in 53 per cent (n = 20), 37 per cent (n = 14), and 11 per cent (n = 4), respectively. Median overall survival for compete and incomplete cytoreduction was 56 months versus 5 months (P = 0.011), respectively. Compared with incomplete cytoreduction, patients receiving complete cytoreduction were more likely to have a lower Peritoneal Cancer Index (PCI) and not have received preoperative systemic chemotherapy (CT). Univariate analysis verified PCI greater than 20 (hazard ratio [HR], 0.048; CI, 0.004 to 0.515; P = 0.01) and CT (HR, 0.17; 0.004 to 0.77; P = 0.021) as predictors of incomplete cytoreduction. Small bowel (100%), periportal region (33%), and mesentery (27%) were the most common sites of residual disease. In conclusion, PCI less than 20 and the need for preoperative chemotherapy should be strongly considered when selecting patients with peritoneal surface malignancy for attempted cytoreduction. Early evaluation of the small bowel, mesentery, and periportal region for resectability prevents unnecessary surgery.

Human papillomavirus infection as a prognostic factor in oropharyngeal squamous cell carcinomas treated in a prospective phase II clinical trial

The aim of this study was to determine the presence of high-risk HPV-16 in patients with HNSCC, assess the impact of HPV status on treatment response and survival in this select cohort treated with combined modality therapy and to identify the differences in HIF-1alpha and VEGF expression in HPV-positive and -negative tumors.

PATIENTS AND METHODS

Patients had resectable, untreated stage III, IV HNSCC of the oral cavity, oropharynx, hyopharynx or larynx, and stage II cancer of the base of tongue, hypopharynx and larynx. HPV status was determined by conventional PCR in fresh frozen biopsy samples and by Taqman PCR assay on formalin-fixed, paraffin-embedded specimens. HIF-1alpha and VEGF expression were assessed by quantitative real-time PCR (RT-PCR). Multivariate Cox proportional hazards regression analysis was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) based on HPV status.

RESULTS

HPV-16 was detected in 14 of 24 evaluable cases. There were no significant differences in response rates after neoadjuvant chemotherapy (86% vs. 90%) in HPV-positive and HPV-negative patients, respectively. There was a trend toward better progression-free (HR=0.15, 95% CI=0.002-12.54; p=0.06) and overall survival (HR=0.14, 95% CI=0.001-14.12; p=0.10) for HPV-positive patients. In a subset of 13 fresh frozen samples, RT-PCR revealed a significant increase in VEGF mRNA levels in HPV-positive tumors (p<0.01). No difference was seen for HIF-1alpha expression.

CONCLUSION

HPV presence portended a better prognosis in patients with oropharyngeal SCC treated with a multimodality treatment in a prospective clinical trial. The level of VEGF mRNA was up-regulated in HPV-16-positive tumors possibly through an HIF-1 independent manner.

Skin-sparing mastectomy: a survey based approach to defining standard of care

Skin-sparing mastectomy (SSM) followed by immediate reconstruction has been advocated as an effective treatment option for patients with early-stage breast carcinoma. It markedly improves the quality of breast reconstruction through preservation of the natural skin envelope and a smaller incision. The purpose of this study was to investigate general surgeons' attitudes towards SSM. A postal questionnaire survey of California general surgeons was conducted regarding SSM. Of 370 respondents who stated they performed breast cancer surgery, 331 perform mastectomy for cancer with planned immediate reconstruction. Ninety per cent of respondents did not feel that SSM resulted in higher rates of local recurrence. In addition, 70 per cent felt that the cosmetic results of immediate breast reconstruction after SSM were better than those after a standard mastectomy. Despite this, only 61 per cent perform SSM in most cases when immediate breast reconstruction is planned. The majority of general surgeons perform SSM and therefore it should be considered standard of care. Despite a growing body of literature demonstrating high rates of patient satisfaction and long-term oncologic safety with SSM, there remains significant variation in practice patterns among general surgeons. Additional effort in general surgery education regarding the feasibility and safety of SSM is needed.

Skin-Sparing Mastectomy: A Survey Based Approach to Defining Standard of Care

Skin-sparing mastectomy (SSM) followed by immediate reconstruction has been advocated as an effective treatment option for patients with early-stage breast carcinoma. It markedly improves the quality of breast reconstruction through preservation of the natural skin envelope and a smaller incision. The purpose of this study was to investigate general surgeons’ attitudes towards SSM. A postal questionnaire survey of California general surgeons was conducted regarding SSM. Of 370 respondents who stated they performed breast cancer surgery, 331 perform mastectomy for cancer with planned immediate reconstruction. Ninety per cent of respondents did not feel that SSM resulted in higher rates of local recurrence. In addition, 70 per cent felt that the cosmetic results of immediate breast reconstruction after SSM were better than those after a standard mastectomy. Despite this, only 61 per cent perform SSM in most cases when immediate breast reconstruction is planned. The majority of general surgeons perform SSM and therefore it should be considered standard of care. Despite a growing body of literature demonstrating high rates of patient satisfaction and long-term oncologic safety with SSM, there remains significant variation in practice patterns among general surgeons. Additional effort in general surgery education regarding the feasibility and safety of SSM is needed.

Robotic surgery for gastrointestinal malignancies

BACKGROUND

This report describes our initial experience with the use of robotic-assisted surgery for the treatment of gastrointestinal (GI) malignancies.

METHODS

Between November 2004 and July 2007, 73 robotic procedures (26 female, 47 male) for GI cancer were performed and retrospectively reviewed. Procedures included 25 oesophagectomies, 11 gastrectomies and 37 rectal resections. The median body mass index (BMI) for this patient population was 26.

RESULTS

The median operative times for rectal, oesophageal and gastric resections were 285, 482 and 430 min, respectively. There were three conversions. Major postoperative morbidity was 16% for rectal, 32% for oesophageal and 9% for gastric procedures. The leak rate was 11% for rectal, 16% for oesophageal and 9% for gastric anastomoses. Median length of stay was 4, 11 and 5 days, respectively. The median number of lymph nodes harvested was 13, 22, and 26 for rectal, oesophageal and gastric lymphadenectomies, respectively. At a median follow-up of 9 months, one patient developed a port site recurrence; 30 day mortality was zero.

CONCLUSION

This initial experience suggests that the robotic approach is safe and feasible for a variety of radical oncological surgical procedures.

Adjuvant radiation therapy is associated with improved survival for gallbladder carcinoma with regional metastatic disease

BACKGROUND

Gallbladder carcinoma is a rare malignancy and is associated with dismal outcomes. The aim of this study was to better define the role of adjuvant radiation therapy in the management of gallbladder carcinoma.

METHODS

The Surveillance, Epidemiological, and End Results (SEER) survey from the National Cancer Institute was queried from 1992 to 2002. Retrospective analysis was done. The end-point of the study was overall survival.

RESULTS

There were a total of 3,187 cases of gallbladder carcinoma in the registry from 1992 to 2002. Of the surgical group, 35% were stage I, 36% were stage II, 6% were stage III, and 21% were stage IV. Adjuvant radiation was used in 17% of the cases. The median survival for those patients receiving adjuvant radiation therapy was 14 months compared to an 8 months median survival for those treated without adjuvant radiation therapy (P < or = 0.001). The survival benefit associated with radiation use was only presenting those patients with regional spread (P = 0.0001) and tumors infiltrating the liver (P = 0.011).

CONCLUSION

The use of adjuvant radiation therapy is associated with improved survival in patients with locally advanced gallbladder cancer or gallbladder cancer with regional disease.

Radical surgery is not necessary following neoadjuvant chemotherapy in stage III-IV resectable, non-laryngeal head and neck cancer (NLHNC)

16501

Background: Traditionally, following neoadjuvant chemotherapy (NC), head and neck surgeons have insisted in performing radical surgery regardless of the response to NC. This prospective study evaluates the results of conservative surgery following NC in resectable stage III-IV non-laryngeal head and neck cancer (NLHNC). Methods: Between 1993 and 2003, 70 patients with NLHNC were treated with one of the following NC: Cisplatin and 5FU (17.1%); Cisplatin, 5FU, Leucovorin, and Taxotere (58.6%); Cisplatin, 5FU, and Taxol (24.3%). After three courses of NC, patients were reevaluated to determine the need for local therapy. Local excision or biopsy was performed for patients with near-complete pathological response (n-CPR) or patients with a complete pathological response (CPR). Radical surgery was reserved for patients with partial response (PPR). All patients received radiation to the primary and neck. Results: The median follow up was 35 months, median disease-free survival was 33.4 months and 3-year overall survival was 71.4% for the entire group. Thirty-five patients (50.0%) had a complete pathological response (CPR), 11 (15.7%) had a complete clinical response (CCR) and no pathological staging, 5 patients (7.1%) had a n-CPR, and 19 patients (27.1%) had a partial pathological response (PPR). Primary surgery is shown in the following table : At the time of the last follow up, 1/35 (2.9%) patients with CPR had a local recurrence (LR) at the primary and 5/11 (45.5%) patients with CCR and no pathological staging had a LR; in 3/6 (50%) patients with LR the primary was controlled with salvage surgery. Seven of eleven (63.6%) patients with PPR had a LR, only one achieved local control with salvage surgery. Conclusions: Complete pathological response at the primary site is a good predictor of long term local control in NLHNC. Radical surgery, is not necessary in non-laryngeal head and neck cancers following a complete pathological response at the primary site.

[Table: see text]

No significant financial relationships to disclose.

Improved survival with radiation therapy in early pancreatic adenocarcinoma

15036

Background: Although chemoradiation is often used following pancreatic cancer resection, recent studies have questioned the role of radiation therapy in this setting. The objective of this study was to determine the effect of adjuvant radiation therapy following pancreatectomy in patients with node-negative (N0) pancreatic cancer. Methods: The Surveillance, Epidemiology, and End Results (SEER) registry was used to identify patients with N0 pancreatic adenocarcinoma who had undergone curative-intent resection between 1988–2003. Kaplan-Meier survival curves were constructed to compare overall survival between patients ± adjuvant radiation therapy. Multivariate Cox regression analysis was performed to determine the prognostic significance of radiation therapy when additional clinicopathologic factors were assessed. The analysis also examined the potential treatment selection bias of patients with survival <3 months. Results: Query of the SEER database identified 2342 surgical patients with N0 disease. The median survival for these patients was 18 months. 889 (60.1%) patients were treated with radiation. There was no difference in gender or grade between radiation and non-radiation groups; however, radiation patients were younger (63 vs. 67 years, p<0.001) and had a greater proportion of T3 lesions (p=0.002). Radiation patients had significantly improved survival compared to non-radiation patients (20.0 vs. 15.0 months, p<0.001). On multivariate analysis, radiation therapy (HR 0.72, p<0.001), age, grade, T-stage, and tumor location were independent predictors of survival. When patients with survival <3 months were excluded from analysis, no difference in survival between radiation and non- radiation was noted (20.0 vs. 19.0 months, p=0.096). However, on subset analysis, patients with T3 tumors demonstrated improved survival with the addition of radiation (24.0 vs 16.0 months, p=0.002) and on multivariate analysis radiation therapy was an independent predictor of improved overall survival (HR 0.87, p=0.027). Conclusions: Radiation treatment is associated with improved survival in operable N0 pancreatic cancer and its use should be considered in patients with early stage N0 disease. The greatest impact of radiation therapy use appears to occur with T3 tumors.

No significant financial relationships to disclose.

Pilot series of robot-assisted laparoscopic subtotal gastrectomy with extended lymphadenectomy for gastric cancer

BACKGROUND

Robotic surgery is evolving as a therapeutic tool for thoracic and urologic applications; however, its use in gastric cancer surgery has not been extensively reported. The objective of this pilot series was to assess the feasibility of using robotic surgery in performing an extended lymphadenectomy for gastric cancer.

METHODS

Between June 2005 and July 2006, seven patients (3 female, 4 male) underwent combined laparoscopic subtotal gastrectomy with omentectomy and robot-assisted extended lymphadenectomy using the da Vinci Surgical System for early distal gastric tumors. The mean age of the patients was 64 years. Tumor staging ranged from 0 to II. Six patients had adenocarcinoma and one patient had a high-grade dysplastic adenoma.

RESULTS

All procedures were completed successfully without conversion. The median operating time was 420 min. There was one intraoperative complication requiring a colon resection for a devascularized segment. The median number of nodes harvested was 24 (range = 17-30). Resection margins were negative in all specimens. Patients were hospitalized a median of 4 days (range = 3-9). Thirty-day mortality was 0%. Patients resumed a solid diet a median of 4 days postoperatively. Median followup was 9 (range = 0-10) months. There have been no tumor recurrences to date.

CONCLUSION

Extended lymphadenectomy for gastric cancer using robotic surgery is safe and allows for an adequate lymph node retrieval. Our preliminary results suggest that this novel technique offers short hospital stays and low morbidity for patients undergoing surgical resection of distal gastric malignancies. Future studies will be necessary to better define the role of robotic surgery in gastric cancer treatment.