Surgical Oncology Insight最新文献

Background

Neurovascular involvement of extremity neoplasms is historically considered a contraindication for limb-salvage surgery, due to concerns of limb dysfunction secondary to motor and/or sensory loss. Theoretically, large nerve defects may be amenable to reconstruction using grafts, but the outcomes of these techniques in irradiated oncologic patients remain unclear.

Methods

This study investigates reconstruction of oncologic nerve defects in the extremities in patients who underwent (neo)adjuvant radiotherapy. A retrospective series of ten patients with extremity sarcoma is provided, with six lower extremity and four upper extremity cases. Reconstruction consisted of nerve grafting with or without the addition of tendon transfers. The mean duration of clinical follow-up was 42.5 months.

Results

Nerve graft reconstruction led to recovery of motor or sensory function in eight out of ten patients thereby allowing functional limb preservation, with none of the patients developing significant neuropathic pain, a common complication in oncologic resections of the extremities with nerve involvement or following amputation. Thus, radiotherapy does not seem to completely preclude successful graft reconstruction of large oncologic extremity nerve defects.

Conclusions

Although the oncologic disease itself is associated with significant mortality, the results of the nerve reconstruction were encouraging despite the concomitant use of radiation. Based on the available data and literature, we recommend to at least discuss the option of graft-based nerve reconstruction with affected patients if relevant characteristics such as patient comorbidities and the viability of recipient muscle are favorable.

Synopsis

In this study, the results of nerve graft reconstruction of large sarcoma-related nerve defects were evaluated. This type of reconstruction seems feasible even in irradiated limbs, thereby aiding in functional limb preservation.

Ultrasound provides essential diagnostic and therapeutic applications in almost every medical and surgical field. In breast surgery, the importance of ultrasound cannot be overstated as it plays a critical role in both radiographic and tissue diagnosis, and can be used to guide surgical resection. Newer, cheaper, and more portable ultrasounds facilitate its use in the clinic and the operating room, making it a cost-effective, patient-centered tool in the management of benign and malignant breast conditions. This paper provides an overview of the evolution of breast ultrasound in surgical practice, its potential underuse in surgery, and explores emerging applications in breast surgery. Lastly, we identify opportunities for improvement in education, training, and access to ultrasound to overcome some of the barriers to ultrasound use by surgeons.

Introduction

Axillary surgery has been de-escalated in invasive breast carcinoma and may be omitted in certain age groups. Up to 10–20 % of patients with ductal carcinoma in-situ (DCIS) will have an element of invasion. Therefore, SLNB is indicated to rule out nodal metastasis. Our purpose was to identify the rate and possible risk factors for lymph node metastasis in DCIS, and to measure oncological outcome of positive SLNB in this group.

Methods

A retrospective analysis was performed on 113 female patients with DCIS, who underwent mastectomy and SLNB. Their clinical and radiological features, as well as pre and post-operative histopathological characteristics were evaluated and data was reported over an average follow up period of 48 months.

Result

DCIS was upgraded to invasive cancer in 11 patients out of 113 (9.7 %). Five patients had positive SLNB (4.4 %), one micro-metastasis (0.8 %) and four macro-metastasis (3.5 %) All the five underwent axillary lymph node dissection (ALND) and all additional nodes retrieved were negative. High nuclear grade, Her2 neu overexpression, and palpable mass showed higher odds of association with metastasis to sentinel nodes. However, due to the low event rate, the association did not reach statistical significance. Seven patients (6.2 %) developed lymphedema, 4 of which after SLNB only. No regional recurrence was reported among our study sample.

Conclusion

This study confirms the very low rate of positive SLNB in patients with DCIS. It is time to de-escalate axillary surgery for patients with DCIS undergoing mastectomy and consider delayed SLNB for high risk group of patients.

Introduction

Approximately 5 % of patients with new breast cancer diagnoses have stage IV disease and 10 % of these patients have liver-confined metastases. The surgical management of synchronous liver metastases remains controversial.

Methods

The National Cancer Database was queried for patients presenting with liver-confined stage IV breast cancer between 2010 and 2018. The cohort was stratified by surgical management: no surgery [NS], primary breast tumor resection [BR], liver resection [LR], and primary breast tumor and liver resection [BR + LR]. The primary outcome was overall survival (OS). Additionally, a retrospective institutional review of patients who underwent surgical intervention and/or microwave ablation from 2013 - 2023 is presented.

Results

In the NCDB, we identified 3747 patients: 2115 NS, 1458 BR, 22 LR, and 134 BR + LR. Median time to primary resection was 5.5 months (IQR 1.2 – 7.1). Median OS was 49.3 months (46.7 – 53.1). Patients receiving BR + LR had the highest unadjusted 5-year OS (68.9 %), followed by BR (52.4 %), NS (36.8 %), and LR (30.6 %). This association was preserved in an adjusted analysis for BR + LR (HR 0.34, 0.24 – 0.47; p < 0.01). The institutional cohort consisted of 8 patients with a median follow-up of 3.6 years who underwent BR + LR after a median of 16 cycles of chemotherapy, yielding 100 % OS.

Conclusions

A minority of patients who present with liver-confined stage IV breast cancer will undergo any operation, though BR+LR was associated with improved survival. Hepatic metastasectomy may be considered in highly selected patients.

Synopsis

Multivariable analysis of an NCDB cohort of 3747 patients presenting with de novo metastatic breast cancer confined to the liver between 2010–2018 demonstrates an association between improved overall survival and combined resection of both the primary breast tumor and hepatic metastases.

Background

The oncology patient population is vulnerable to elevated levels of anxiety and depression. These states of psychological distress have been associated with negative effects on treatment course and outcomes, but reported prevalence rates are varied. The General Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) questionnaires are screening tools that can be utilized to assess the levels of anxiety and depression, respectively.

Methods

This prospective, surgeon-blinded study assessed the preoperative prevalence of anxiety and depression in patients with abdominal malignancies who underwent curative-intent resection. Postoperative outcomes and survival were assessed.

Results

Overall, 218 patients were enrolled and included in the final analysis. Patients were stratified into groups by severity of anxiety and depression. 67 (31 %) patients reported at least mild anxiety as defined by GAD-7 score of 5 +, and 74 (34 %) patients reported at least mild depression, as defined by PHQ-9 score of 5 +. Functional status as defined by Eastern Cooperative Oncology Group scores was associated with anxiety (P = 0.003) and depression (P = 0.024). Depression was associated with race and ethnicity (P = 0.014) and marital status (P = 0.021), with Hispanic/Latino and unpartnered patients reporting higher rates of depression.

Conclusion

Anxiety and depression are common in the surgical oncology population, affecting a third of the patient population in this prospective study. In addition to a thorough social assessment, the GAD-7 and PHQ-9 questionnaires can be utilized preoperatively to identify patients with psychological distress.

Synopsis

Anxiety and depression were assessed preoperatively in patients with abdominal malignancies who underwent curative-intent resection. These states of psychological distress were highly prevalent, affecting a third of the population, and significantly associated with certain vulnerable groups.

Background

Warfarin has been shown to reduce cancer risk via Vitamin K related AXL tyrosine kinase inhibition. Although AXL has been implicated in disease progression and therapy resistance in preclinical melanoma models, there are no clinical studies evaluating the impact of warfarin on melanoma prognosis. Hence, we sought to evaluate the relationship between warfarin and survival in melanoma.

Methods

We conducted a retrospective population-based cohort study of melanoma patients aged ≥ 65 years diagnosed between 2009–2013 from the Surveillance, Epidemiology, and End Results-Medicare database. Patients were grouped according to warfarin therapy 6 months prior and after melanoma diagnosis. Univariable and multivariable Cox proportional hazards models were used to compare overall (OS) and melanoma-specific survival (MSS) between groups.

Results

Overall, 10,778 patients with invasive melanoma were included. 13.2 % were prescribed warfarin, with atrial fibrillation being the most common indication (74.1 %). Warfarin prescription was associated with older age, male sex, and a greater number of comorbidities (all p < 0.001). Patients prescribed warfarin more frequently presented with ulceration, T3 and T4 disease, and stage II disease (all p < 0.05). Warfarin prescription was associated with greater MSS and OS in multivariable models (MSS adjusted hazard ratio [aHR] 0.72, 95 % CI 0.54–0.96, p = 0.02; OS aHR 0.88, 95 % CI 0.79–0.99, p = 0.04).

Conclusions

Warfarin was associated with greater MSS and OS among melanoma patients. These findings highlight the potential for Vitamin K related pathways to impact cancer specific activity. Further study of AXL and Vitamin K inhibition will be of significant interest in melanoma, targeted strategies actively under investigation.

Background

The PRIORITY-CONNECT 2 pilot trial will establish the feasibility and acceptability of a virtual multimodal programme following gastrointestinal cancer surgery. The secondary aims are to obtain pilot data on the likely difference in key outcomes, data elements that will guide future implementation studies, and to identify barriers and facilitators that inform the development and execution of a substantive randomised clinical effectiveness trial of teleprehabilitation/rehabilitation.

Methods

This is a multicentre, assessor-blinded, pilot, randomised controlled trial utilising a Hybrid Type I effectiveness-implementation design. 20 participants undergoing major gastrointestinal cancer surgery will be randomised (1:1 allocation) to attend a virtual multimodal prehabilitation-rehabilitation hub (intervention group), delivered before (1–6 weeks) and after (up to 3 months) surgery plus usual care, or to usual care alone (control group). An individualised intervention will be delivered by an experienced multidisciplinary team including a physiotherapist, psychologist, dietitian, nurse, social worker, and a geriatrician. Outcomes will be collected at baseline, 1–2 days before surgery, during the hospital stay, day of discharge from hospital, and 3 months postoperatively. The primary outcomes will be feasibility and acceptability of the virtual multimodal hub. Secondary outcomes assess the rate of postoperative complications within 30 days after surgery, quality of life, the number of days at home within 30 and 90 days after surgery, healthcare use, and implementation outcomes.

Discussion

The PRIORITY-CONNECT 2 pilot trial will generate findings about the feasibility and acceptability of delivering an evidence-based virtual multimodal preoperative (prehabilitation) and postoperative (rehabilitation) intervention targeting patients having major gastrointestinal cancer surgery.

Trial registration

This trial was registered prospectively with the National Library of Medicine ClinicalTrials.gov Registry (NCT06212700) on 8th January 2024.

Background

Oncology navigation programs offer information and assistance to patients diagnosed with cancer and have evolved significantly along disease-specific care pathways. However, there is limited information on how to prioritize navigation services to meet the unique and complex needs of patients with peritoneal surface malignancies (PSMs). To define the navigation needs of PSM patients, we conducted a survey-based study to quantify the relative importance of various cancer-related stressors as perceived by patients, caregivers, and providers.

Methods

A questionnaire was administered to PSM patients or caregivers and providers involved in the care of PSM patients, and the assessed measures of disease or treatment-related stress were compared among subgroups consisting of patients and caregivers vs. providers.

Results

Of the 72 PSM patients and caregivers surveyed, 93.1 % identified stressors related to receiving treatment to be somewhat or extremely challenging. Relative to patients/caregivers, providers tended to significantly over-prioritize the navigation domains of family care, transportation, long-distance travel, financial, insurance, work-related, and legal stress. Our survey data illustrates gaps between the experience of stressors among PSM patients/caregivers and the perceptions of providers.

Conclusions

PSM programs should align resources with the navigation needs as experienced by patients and caregivers, while recognizing that providers tend to emphasize logistical considerations over cancer-related emotional distress. PSM-specific navigation pathways could improve the experience and satisfaction level of patients undergoing treatment for this complex condition.

Synopsis

The authors report results of a survey provided to peritoneal surface malignancy patients, caregivers and providers. This analysis illustrates gaps between how patients and caregivers experience navigation needs and how providers perceive those needs.

Background

The readability of cancer educational content often exceeds the average reading level of the U.S. population. This study evaluated the readability of online educational material for the five deadliest cancers in the US.

Methods

We assessed the readability of diagnosis and treatment information across 34 NCCN member institution websites. Readability was analyzed using four validated formulas: Fry Readability Score, Flesch-Kincaid Grade Level, Gunning-Fog Index, and Simple Measure of Gobbledygook. The primary outcome was the mean organizational readability level for each resource, and secondary outcomes included differences in readability between diagnosis and treatment materials and an analysis of sentence and word complexity.

Results

The mean readability level across 34 websites was 13 ± 1.96, equivalent to a university freshman level. Treatment materials were significantly harder to read than diagnosis materials (14 ± 1.8 vs. 12 ± 1.8, p < 0.01) across all cancers. Readability varied significantly depending on the type of cancer, with material relating to the diagnosis of pancreatic cancer requiring the highest educational level (13 ± 1.9) and material relating to treating breast cancer requiring the lowest reading proficiency (12 ± 1.7). Furthermore, the analysis demonstrated that cancer diagnosis materials contained a lower median percentage of complex and long words than treatment materials but had a higher percentage of long sentences.

Conclusions

These findings underscore the need for organizations to prioritize matching the nation’s literacy levels. Despite the growing reliance on online resources for patient education, the current readability levels hinder patient comprehension

Introduction

In non-metastatic appendiceal adenocarcinoma, the relationship between the number of lymph nodes harvested and overall survival is unknown. The objective of this study was to determine whether the number of lymph nodes harvested impacts survival in patients with mucinous and non-mucinous appendiceal cancer.

Methods

Retrospective cohort analysis was conducted in patients who underwent surgery for appendiceal adenocarcinoma in the SEER database from 2000–2019. Exclusion criteria included patients without the number of regional nodes harvested/node positivity, missing survival data, stage IV disease, and certain subtypes of appendiceal tumors. The primary outcome was 10-year overall survival.

Results

A total of 1651 patients were identified, 1101 with mucinous and 550 with non-mucinous cancer. The majority of patients were male (54 %) and between the ages of 50–74 (52 %). Mean ± SD number of lymph nodes harvested was 17.04 ± 10.41. The ten-year survival rates for patients with mucinous appendiceal cancer were 43–74 % and 25–68 % for non-mucinous cancer, depending on AJCC stage. Multivariate Cox-regression analysis displayed that the number of lymph nodes harvested was an independent predictor of survival (p < 0.0001). The optimal threshold predicted by Cox-regression for maximal survival benefit was harvest of a minimum of 15 nodes for mucinous and 12 for non-mucinous cancer. Additionally, for mucinous cancer, per each additional 3 nodes harvested past 15, the 10-year risk of mortality decreased by 7 % (HR 0.93 (0.88 to 0.98), p < 0.001).

Conclusions

The number of lymph nodes harvested is an independent predictor of survival for patients with appendiceal adenocarcinoma. To maximize this survival benefit, a minimum of 15 regional lymph nodes must be harvested for mucinous and 12 for non-mucinous cancer.