Pub Date : 2024-04-10DOI: 10.1016/j.soi.2024.100049
Betsy J. Valdez , Madison Grumley , Shu-Ching Chang , Jennifer K. Keller , Janie G. Grumley , Javier I.J. Orozco
Introduction
Breast cancer among patients under 50 years old accounts for 18% of new cases. Few studies have reported current trends in clinical-pathologic features and treatment patterns for young patients. We evaluated these trends in a modern cohort of breast cancer patients under 50.
Methods
We identified women with breast cancer from the National Cancer Database from 2004–2017. Patients were grouped into 18–29, 30–39, 40–49, and ≥ 50-year cohorts. Proportions and temporal comparisons between demographic, clinicopathologic features, and treatment types were evaluated. Temporal trends across sequential periods were performed.
Results
Of the 2387,902 patients selected, 554,941 (23.3%) were younger than 50. During 2004–2017, the proportions remained stable in the 18–29 (0.5–0.6%) and 30–39 (4.5–5%) age groups, while decreasing in the 40–49 group (absolute difference: −4.8%, p < 0.001). Overall, in those younger than 50, early-stage breast cancer (clinical stage 0-II) increased by 3.9%, while stages III and IV decreased by 2.7% and 1.3% (p < 0.001), respectively. Mastectomy rates and neoadjuvant systemic therapy use increased by 10.4% and 9.8%, respectively (p < 0.001) in all groups under 50.
Conclusions
Despite stable proportions in the youngest age groups (18–29 and 30–39), a noteworthy decrease in the 40–49 age group was observed, suggesting potential shifts in disease detection. The rise in early-stage disease and neoadjuvant systemic therapies should theoretically translate into an increase in the number of breast-conserving candidates. However, the increase in mastectomies highlights the need to better understand the factors influencing treatment decisions in this population.
{"title":"Contemporary trends in breast cancer in females under the age of fifty: An NCDB study","authors":"Betsy J. Valdez , Madison Grumley , Shu-Ching Chang , Jennifer K. Keller , Janie G. Grumley , Javier I.J. Orozco","doi":"10.1016/j.soi.2024.100049","DOIUrl":"https://doi.org/10.1016/j.soi.2024.100049","url":null,"abstract":"<div><h3>Introduction</h3><p>Breast cancer among patients under 50 years old accounts for 18% of new cases. Few studies have reported current trends in clinical-pathologic features and treatment patterns for young patients. We evaluated these trends in a modern cohort of breast cancer patients under 50.</p></div><div><h3>Methods</h3><p>We identified women with breast cancer from the National Cancer Database from 2004–2017. Patients were grouped into 18–29, 30–39, 40–49, and ≥ 50-year cohorts. Proportions and temporal comparisons between demographic, clinicopathologic features, and treatment types were evaluated. Temporal trends across sequential periods were performed.</p></div><div><h3>Results</h3><p>Of the 2387,902 patients selected, 554,941 (23.3%) were younger than 50. During 2004–2017, the proportions remained stable in the 18–29 (0.5–0.6%) and 30–39 (4.5–5%) age groups, while decreasing in the 40–49 group (absolute difference: −4.8%, <em>p</em> < 0.001). Overall, in those younger than 50, early-stage breast cancer (clinical stage 0-II) increased by 3.9%, while stages III and IV decreased by 2.7% and 1.3% (<em>p</em> < 0.001), respectively. Mastectomy rates and neoadjuvant systemic therapy use increased by 10.4% and 9.8%, respectively (<em>p <</em> 0.001) in all groups under 50.</p></div><div><h3>Conclusions</h3><p>Despite stable proportions in the youngest age groups (18–29 and 30–39), a noteworthy decrease in the 40–49 age group was observed, suggesting potential shifts in disease detection. The rise in early-stage disease and neoadjuvant systemic therapies should theoretically translate into an increase in the number of breast-conserving candidates. However, the increase in mastectomies highlights the need to better understand the factors influencing treatment decisions in this population.</p></div>","PeriodicalId":101191,"journal":{"name":"Surgical Oncology Insight","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-04-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2950247024000586/pdfft?md5=1ee2c56bc8c0b434adc4ab788db534f6&pid=1-s2.0-S2950247024000586-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140553974","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-07DOI: 10.1016/j.soi.2024.100047
Sara P. Ginzberg , Saiesh Kalva , Jacqueline M. Soegaard Ballester , Daniel A. Pryma , Susan J. Mandel , Rachel R. Kelz , Heather Wachtel
Background
With the release of the 2015 management guidelines, the American Thyroid Association narrowed the indications for postoperative radioactive iodine (RAI) in well-differentiated thyroid cancer. However, the adoption of new guidelines varies between healthcare entities. The goal of this study was to characterize the appropriateness of RAI use within our health system, before and after the 2015 guideline changes.
Methods
In this retrospective cohort study, we identified patients who were treated for well-differentiated thyroid cancer between 2011–2020. Patients were characterized as “undertreated,” “appropriately treated,” or “overtreated” with RAI. Variation in RAI use was assessed using interrupted time series and multivariable logistic regression analyses.
Results
Among 6310 patients, the mean age was 50 ± 15 years, and 74% were female. There was an immediate drop in the likelihood of receiving RAI after the release of the 2015 guidelines (p = 0.016), and the likelihood of receiving RAI therapy continued to significantly decline over time (OR 0.83, p < 0.001). Despite this trend in the absolute rate of RAI use, there was a significant increase in overtreatment with RAI after the release of the 2015 guidelines (p < 0.001), indicating imperfect uptake of the new criteria. Two hospitals within the health system were identified as disproportionate contributors to overtreatment (Hospital 4: OR 6.50, p < 0.001; Hospital 6: OR 8.63, p < 0.001).
Conclusions
While the use of postoperative RAI was largely appropriate across our health system, rates of guideline adherence differed between hospitals. Efforts to standardize treatment protocols systemwide may enable more rapid and consistent uptake of new management guidelines.
背景随着 2015 年管理指南的发布,美国甲状腺协会缩小了分化良好的甲状腺癌术后放射性碘(RAI)的适应症范围。然而,不同医疗机构采用新指南的情况各不相同。本研究的目的是描述 2015 年指南变更前后我们医疗系统内 RAI 使用的适当性。方法在这项回顾性队列研究中,我们确定了 2011-2020 年间接受过良好分化甲状腺癌治疗的患者。患者的特点是 RAI 治疗 "不足"、"适当治疗 "或 "过度治疗"。结果6310名患者中,平均年龄为50±15岁,74%为女性。2015 年指南发布后,接受 RAI 治疗的可能性立即下降(p = 0.016),随着时间的推移,接受 RAI 治疗的可能性继续显著下降(OR 0.83,p <0.001)。尽管 RAI 的绝对使用率呈上升趋势,但在 2015 年指南发布后,RAI 过度治疗的情况明显增加(p <0.001),这表明对新标准的吸收并不完善。结论虽然在我们的医疗系统中,术后 RAI 的使用在很大程度上是适当的,但不同医院对指南的遵守率却不尽相同。在全系统范围内统一治疗方案的努力可能会使新的管理指南得到更快、更一致的采纳。
{"title":"Implementation of the 2015 American Thyroid Association guideline changes across a health system: A quality improvement opportunity","authors":"Sara P. Ginzberg , Saiesh Kalva , Jacqueline M. Soegaard Ballester , Daniel A. Pryma , Susan J. Mandel , Rachel R. Kelz , Heather Wachtel","doi":"10.1016/j.soi.2024.100047","DOIUrl":"https://doi.org/10.1016/j.soi.2024.100047","url":null,"abstract":"<div><h3>Background</h3><p>With the release of the 2015 management guidelines, the American Thyroid Association narrowed the indications for postoperative radioactive iodine (RAI) in well-differentiated thyroid cancer. However, the adoption of new guidelines varies between healthcare entities. The goal of this study was to characterize the appropriateness of RAI use within our health system, before and after the 2015 guideline changes.</p></div><div><h3>Methods</h3><p>In this retrospective cohort study, we identified patients who were treated for well-differentiated thyroid cancer between 2011–2020. Patients were characterized as “undertreated,” “appropriately treated,” or “overtreated” with RAI. Variation in RAI use was assessed using interrupted time series and multivariable logistic regression analyses.</p></div><div><h3>Results</h3><p>Among 6310 patients, the mean age was 50 ± 15 years, and 74% were female. There was an immediate drop in the likelihood of receiving RAI after the release of the 2015 guidelines (p = 0.016), and the likelihood of receiving RAI therapy continued to significantly decline over time (OR 0.83, p < 0.001). Despite this trend in the absolute rate of RAI use, there was a significant increase in overtreatment with RAI after the release of the 2015 guidelines (p < 0.001), indicating imperfect uptake of the new criteria. Two hospitals within the health system were identified as disproportionate contributors to overtreatment (Hospital 4: OR 6.50, p < 0.001; Hospital 6: OR 8.63, p < 0.001).</p></div><div><h3>Conclusions</h3><p>While the use of postoperative RAI was largely appropriate across our health system, rates of guideline adherence differed between hospitals. Efforts to standardize treatment protocols systemwide may enable more rapid and consistent uptake of new management guidelines.</p></div>","PeriodicalId":101191,"journal":{"name":"Surgical Oncology Insight","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-04-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2950247024000562/pdfft?md5=8adf612906ee053997d53b416d27a719&pid=1-s2.0-S2950247024000562-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140543364","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-06DOI: 10.1016/j.soi.2024.100046
Mohammad S. Farooq , Giorgos C. Karakousis , Robert S. Krouse
Malignant bowel obstruction (MBO) is defined as a mechanical/functional/radiologic obstruction of the gastrointestinal tract beyond the Ligament of Treitz in the presence of a known primary or metastatic abdominopelvic malignancy. Though numerous retrospective studies have been conducted on the outcomes of various treatment modalities, there is a tremendous heterogeneity of MBO definitions, clinical presentations, and offered treatments. Few prospective studies or randomized trials exist, making it difficult to ascertain generalizable data and develop applicable clinical guidelines. In this review, a systematic computerized search was conducted on PubMed for high quality data on MBO epidemiology, pathophysiology, and treatment modalities, with a particular focus on comprehensive systematic literature reviews. The current standard of care for medical, surgical, and endoscopic treatment of MBO was discussed in detail. Historical data was contextualized and the latest findings of the first randomized-controlled clinical trial (SWOG S1316) studying surgical vs. non-surgical treatment of MBO was critically appraised. These findings give insight on how to optimize future trial design, measure comprehensive quality of life outcomes, and develop clinical practice guidelines in line with patient-specific goals of treatment.
{"title":"Malignant bowel obstruction: Historical lessons, current trends, and future directions","authors":"Mohammad S. Farooq , Giorgos C. Karakousis , Robert S. Krouse","doi":"10.1016/j.soi.2024.100046","DOIUrl":"https://doi.org/10.1016/j.soi.2024.100046","url":null,"abstract":"<div><p>Malignant bowel obstruction (MBO) is defined as a mechanical/functional/radiologic obstruction of the gastrointestinal tract beyond the Ligament of Treitz in the presence of a known primary or metastatic abdominopelvic malignancy. Though numerous retrospective studies have been conducted on the outcomes of various treatment modalities, there is a tremendous heterogeneity of MBO definitions, clinical presentations, and offered treatments. Few prospective studies or randomized trials exist, making it difficult to ascertain generalizable data and develop applicable clinical guidelines. In this review, a systematic computerized search was conducted on PubMed for high quality data on MBO epidemiology, pathophysiology, and treatment modalities, with a particular focus on comprehensive systematic literature reviews. The current standard of care for medical, surgical, and endoscopic treatment of MBO was discussed in detail. Historical data was contextualized and the latest findings of the first randomized-controlled clinical trial (SWOG S1316) studying surgical vs. non-surgical treatment of MBO was critically appraised. These findings give insight on how to optimize future trial design, measure comprehensive quality of life outcomes, and develop clinical practice guidelines in line with patient-specific goals of treatment.</p></div>","PeriodicalId":101191,"journal":{"name":"Surgical Oncology Insight","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-04-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2950247024000550/pdfft?md5=1fa59ab0c5d4b7d97582dd3d90b34884&pid=1-s2.0-S2950247024000550-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140558080","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-06DOI: 10.1016/j.soi.2024.100045
Hyun Park , Catherine Lewis , Neda Dadgar , Christopher Sherry , Shelly Evans , Staci Ziobert , Ashten Omstead , Ali Zaidi , Kunhong Xiao , Sohini Ghosh , David L. Bartlett , Albert Donnenberg , Vera Donnenberg , Patrick L. Wagner
Background
Malignant pleural effusions (MPE) and malignant ascites (MA) are serious complications of advanced cancer, marked by debilitating symptoms and limited treatment options. Based on a wealth of previous literature implicating the cytokine IL-6 as a central mediator in the pathogenesis of MPE and MA, the Regional Immuno-Oncology Trial 2 (RIOT-2) clinical protocol was developed to explore intra-cavitary delivery of tocilizumab, an IL-6 receptor antagonist, as treatment for these conditions.
Methods
This phase I clinical trial (NCT 06016179) is being conducted to assess the safety and pharmacokinetics of intra-cavitary tocilizumab administration to patients with MPE and MA. Eligible patients are those with pleural effusion or peritoneal ascites due to metastatic cancer who are scheduled to undergo standard-of-care catheter placement for pleural or peritoneal drainage. Following catheter placement, patients will receive a starting dose of tocilizumab 0.5 µg/mL via intra-pleural or intra-peritoneal implantable catheters. Weekly escalating doses of tocilizumab will be given over four weeks. Primary endpoints are frequency and type of adverse events, while secondary endpoints include pharmacokinetic and immunological parameters. This single-center study will proceed until 12 patients have been treated.
Discussion
Inhibition of the IL-6 signaling pathway with tocilizumab is hypothesized to be a rational mitigating treatment strategy for the maladaptive intra-cavitary immune environment in patients with MPE and MA. The RIOT-2 study aims to assess the safety of intra-cavitary tocilizumab therapy, administered via indwelling catheters. Pharmacologic and translational immunologic findings generated by this study could pave the way for future research into clinical applications of intra-cavitary immunotherapy.
Trial registration
The trial is registered at ClinicalTrials.gov; NCT06016179 (registered on August 29th, 2023).
{"title":"Intra-pleural and intra-peritoneal tocilizumab therapy for managing malignant pleural effusions and ascites: The Regional Immuno-Oncology Trial (RIOT)−2 study protocol","authors":"Hyun Park , Catherine Lewis , Neda Dadgar , Christopher Sherry , Shelly Evans , Staci Ziobert , Ashten Omstead , Ali Zaidi , Kunhong Xiao , Sohini Ghosh , David L. Bartlett , Albert Donnenberg , Vera Donnenberg , Patrick L. Wagner","doi":"10.1016/j.soi.2024.100045","DOIUrl":"https://doi.org/10.1016/j.soi.2024.100045","url":null,"abstract":"<div><h3>Background</h3><p>Malignant pleural effusions (MPE) and malignant ascites (MA) are serious complications of advanced cancer, marked by debilitating symptoms and limited treatment options. Based on a wealth of previous literature implicating the cytokine IL-6 as a central mediator in the pathogenesis of MPE and MA, the Regional Immuno-Oncology Trial 2 (RIOT-2) clinical protocol was developed to explore intra-cavitary delivery of tocilizumab, an IL-6 receptor antagonist, as treatment for these conditions.</p></div><div><h3>Methods</h3><p>This phase I clinical trial (NCT 06016179) is being conducted to assess the safety and pharmacokinetics of intra-cavitary tocilizumab administration to patients with MPE and MA. Eligible patients are those with pleural effusion or peritoneal ascites due to metastatic cancer who are scheduled to undergo standard-of-care catheter placement for pleural or peritoneal drainage. Following catheter placement, patients will receive a starting dose of tocilizumab 0.5 µg/mL via intra-pleural or intra-peritoneal implantable catheters. Weekly escalating doses of tocilizumab will be given over four weeks. Primary endpoints are frequency and type of adverse events, while secondary endpoints include pharmacokinetic and immunological parameters. This single-center study will proceed until 12 patients have been treated.</p></div><div><h3>Discussion</h3><p>Inhibition of the IL-6 signaling pathway with tocilizumab is hypothesized to be a rational mitigating treatment strategy for the maladaptive intra-cavitary immune environment in patients with MPE and MA. The RIOT-2 study aims to assess the safety of intra-cavitary tocilizumab therapy, administered via indwelling catheters. Pharmacologic and translational immunologic findings generated by this study could pave the way for future research into clinical applications of intra-cavitary immunotherapy.</p></div><div><h3>Trial registration</h3><p>The trial is registered at ClinicalTrials.gov; NCT06016179 (registered on August 29th, 2023).</p></div>","PeriodicalId":101191,"journal":{"name":"Surgical Oncology Insight","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-04-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2950247024000549/pdfft?md5=e1559fabef892cf19d198e75d0644760&pid=1-s2.0-S2950247024000549-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140540482","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-03-30DOI: 10.1016/j.soi.2024.100042
Catherine Lewis , Neda Dadgar , Mehrdokht Najafi , Hyun Park , Christopher Sherry , Alyssa Lucas , Ali Zaidi , Kunhong Xiao , Ashten Omstead , Albert Donnenberg , David L. Bartlett , Vera Donnenberg , Patrick L. Wagner
Background
Intra-tumoral immunotherapy has shown potential in treating advanced cancers. Delivery challenges have limited exploration of these modalities in intra-abdominal tumors. In this study, we explore the safety of injecting intra-abdominal tumors with lipopolysaccharide (LPS) from Escherichia coli 0113. This agonist of toll-like receptor 4 (TLR4) holds promise as an agent to enhance the anti-tumor immune response within the tumor microenvironment.
Methods
This Phase I study will recruit adult patients with peritoneal metastases from gastrointestinal primary malignancies who have at least two suitable intra-abdominal soft tissue tumors for injection. LPS will be administered as a single 1 μg dose during diagnostic laparoscopy in patients in whom a subsequent interval laparotomy is planned. A control injection of saline will be injected into a second lesion. Primary outcome is safety, with secondary outcomes being biomarkers of the tumor immune microenvironment in pre- and post-treatment biopsies.
Results
The primary endpoint is to determine the safety (frequency and nature of adverse events) following intra-tumoral LPS injection. Adverse events will be classified using Common Terminology Criteria for Adverse Events. Secondary endpoints include cellular and molecular biomarkers of immune response. The study will proceed until twelve patients have completed the protocol.
Discussion
Patients undergoing standard-of-care laparoscopy in preparation for interval cytoreductive surgery may be ideal candidates for intra-tumoral immunotherapy. This study seeks to establish the safety of using E. coli LPS for injection into intra-abdominal tumors and to establish precedent for interval tumor immune microenvironment assessment as a window-of-opportunity concept in the context of abdominal metastatic disease.
Trial Registration
The trial is registered at Clinical Trials.gov; NCT05751837 (registered February 28th, 2023).
{"title":"Intra-tumoral immunomodulatory therapy for advanced abdominal cancers using lipopolysaccharide: The Regional Immuno-Oncology Ttrial-1 (RIOT-1) protocol (NCT05751837)","authors":"Catherine Lewis , Neda Dadgar , Mehrdokht Najafi , Hyun Park , Christopher Sherry , Alyssa Lucas , Ali Zaidi , Kunhong Xiao , Ashten Omstead , Albert Donnenberg , David L. Bartlett , Vera Donnenberg , Patrick L. Wagner","doi":"10.1016/j.soi.2024.100042","DOIUrl":"https://doi.org/10.1016/j.soi.2024.100042","url":null,"abstract":"<div><h3>Background</h3><p>Intra-tumoral immunotherapy has shown potential in treating advanced cancers. Delivery challenges have limited exploration of these modalities in intra-abdominal tumors. In this study, we explore the safety of injecting intra-abdominal tumors with lipopolysaccharide (LPS) from <em>Escherichia coli</em> 0113. This agonist of toll-like receptor 4 (TLR4) holds promise as an agent to enhance the anti-tumor immune response within the tumor microenvironment.</p></div><div><h3>Methods</h3><p>This Phase I study will recruit adult patients with peritoneal metastases from gastrointestinal primary malignancies who have at least two suitable intra-abdominal soft tissue tumors for injection. LPS will be administered as a single 1 μg dose during diagnostic laparoscopy in patients in whom a subsequent interval laparotomy is planned. A control injection of saline will be injected into a second lesion. Primary outcome is safety, with secondary outcomes being biomarkers of the tumor immune microenvironment in pre- and post-treatment biopsies.</p></div><div><h3>Results</h3><p>The primary endpoint is to determine the safety (frequency and nature of adverse events) following intra-tumoral LPS injection. Adverse events will be classified using Common Terminology Criteria for Adverse Events. Secondary endpoints include cellular and molecular biomarkers of immune response. The study will proceed until twelve patients have completed the protocol.</p></div><div><h3>Discussion</h3><p>Patients undergoing standard-of-care laparoscopy in preparation for interval cytoreductive surgery may be ideal candidates for intra-tumoral immunotherapy. This study seeks to establish the safety of using <em>E. coli</em> LPS for injection into intra-abdominal tumors and to establish precedent for interval tumor immune microenvironment assessment as a window-of-opportunity concept in the context of abdominal metastatic disease.</p></div><div><h3>Trial Registration</h3><p>The trial is registered at Clinical Trials.gov; NCT05751837 (registered February 28th, 2023).</p></div>","PeriodicalId":101191,"journal":{"name":"Surgical Oncology Insight","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-03-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2950247024000513/pdfft?md5=ee1f05eb1c690b51594ce75e285671c4&pid=1-s2.0-S2950247024000513-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140342409","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-03-29DOI: 10.1016/j.soi.2024.100043
Wini Zambare , Joao Miranda , Natally Horvat , J. Joshua Smith
The Organ Preservation in patients with Rectal Adenocarcinoma (OPRA) trial is a randomized, non-blinded, phase II prospective study that investigated total neoadjuvant therapy (TNT) and a selective “watch-and-wait” (WW) approach in locally advanced rectal cancer (LARC). It compared two TNT regimens: induction chemotherapy-chemoradiotherapy (INCT-CRT) and chemoradiotherapy-consolidation chemotherapy (CRT-CNCT). Depending on tumor response, patients were offered WW or surgery. The primary endpoint was disease-free survival (DFS), hypothesizing that patients who underwent TNT with selective WW would have improved DFS compared to historical rates. Secondary endpoints included organ preservation (OP) and overall survival, hypothesizing that differences between INCT-CRT and CRT-CNCT could indicate a superior regimen. Results demonstrated treatment of LARC with TNT and selective WW allows for OP in approximately half of patients without negatively impacting oncologic outcomes such as DFS. The data show that a CRT-CNCT regimen had higher rates of OP, lower rates of tumor regrowth, and similar DFS compared to INCT-CRT. Lastly, DFS does not differ between patients who undergo immediate TME versus TME after regrowth. Thus, patients treated with TNT who achieve a clinical complete response (cCR) can safely undergo WW with the potential for OP. Current research to improve TNT and enhance cCR will expand the utility of the WW approach, including the intensification of neoadjuvant chemotherapy (Janus trial), comparing short-course and long-course CRT prior to CNCT (ENSEMBLE and German trials), utilizing fluoropyrimidine-chemotherapy with and without oxaliplatin in the context of WW (CHOW trial), and exploring less invasive operative approaches for early-stage tumors (NEO and NEO-RT trials).
Synopsis
The OPRA trial demonstrates treatment of locally advanced rectal cancer using total neoadjuvant therapy with selective “watch-and-wait” allows organ preservation in approximately half of patients without negatively impacting oncologic outcomes. For widespread adoption of “watch-and-wait”, data from accruing prospective trials are needed to demonstrate its viability across diverse clinical settings.
{"title":"Assessing the OPRA trial for surgical oncologists: Safety and feasibility of a total neoadjuvant therapy approach in patients with rectal cancer","authors":"Wini Zambare , Joao Miranda , Natally Horvat , J. Joshua Smith","doi":"10.1016/j.soi.2024.100043","DOIUrl":"10.1016/j.soi.2024.100043","url":null,"abstract":"<div><p>The Organ Preservation in patients with Rectal Adenocarcinoma (OPRA) trial is a randomized, non-blinded, phase II prospective study that investigated total neoadjuvant therapy (TNT) and a selective “watch-and-wait” (WW) approach in locally advanced rectal cancer (LARC). It compared two TNT regimens: induction chemotherapy-chemoradiotherapy (INCT-CRT) and chemoradiotherapy-consolidation chemotherapy (CRT-CNCT). Depending on tumor response, patients were offered WW or surgery. The primary endpoint was disease-free survival (DFS), hypothesizing that patients who underwent TNT with selective WW would have improved DFS compared to historical rates. Secondary endpoints included organ preservation (OP) and overall survival, hypothesizing that differences between INCT-CRT and CRT-CNCT could indicate a superior regimen. Results demonstrated treatment of LARC with TNT and selective WW allows for OP in approximately half of patients without negatively impacting oncologic outcomes such as DFS. The data show that a CRT-CNCT regimen had higher rates of OP, lower rates of tumor regrowth, and similar DFS compared to INCT-CRT. Lastly, DFS does not differ between patients who undergo immediate TME versus TME after regrowth. Thus, patients treated with TNT who achieve a clinical complete response (cCR) can safely undergo WW with the potential for OP. Current research to improve TNT and enhance cCR will expand the utility of the WW approach, including the intensification of neoadjuvant chemotherapy (Janus trial), comparing short-course and long-course CRT prior to CNCT (ENSEMBLE and German trials), utilizing fluoropyrimidine-chemotherapy with and without oxaliplatin in the context of WW (CHOW trial), and exploring less invasive operative approaches for early-stage tumors (NEO and NEO-RT trials).</p></div><div><h3>Synopsis</h3><p>The OPRA trial demonstrates treatment of locally advanced rectal cancer using total neoadjuvant therapy with selective “watch-and-wait” allows organ preservation in approximately half of patients without negatively impacting oncologic outcomes. For widespread adoption of “watch-and-wait”, data from accruing prospective trials are needed to demonstrate its viability across diverse clinical settings.</p></div>","PeriodicalId":101191,"journal":{"name":"Surgical Oncology Insight","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-03-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2950247024000525/pdfft?md5=31a05d5057285e38e3e37e8b6861776d&pid=1-s2.0-S2950247024000525-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140400957","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-03-29DOI: 10.1016/j.soi.2024.100044
Christina M. Stuart , Adam R. Dyas , Michael R. Bronsert , Catherine G. Velopulos , William G. Henderson , Richard D. Schulick , Robert A. Meguid
Objective
Growing evidence supports the impact of sociodemographics on cancer outcomes. The objective of this study was to examine the Social Vulnerability Index (SVI) and its association with oncologic presentation and subsequent treatments across 8 major cancers.
Methods
This was a retrospective-cohort study using one institution’s contribution to the National Cancer Database (2011–2021). Patients were grouped into low SVI (<75th percentile) and high SVI (≥75th percentile) cohorts. Un-adjusted comparison between groups was performed followed by multivariable regression to control for the effect of demographic characteristics on oncologic presentation, and for demographic and oncologic characteristics on subsequent treatments. A subgroup analysis was performed comparing cancers that have national screening protocols versus those without.
Results
Of 12,712 cases, 2842 (22.4%) were in the high SVI group and 9870 (77.6%). After risk-adjustment, high SVI patients presented at more advanced T-stage (odds ratio 1.09, 95% confidence interval 1.00–1.19); N-stage (1.11, 1.01–1.23); M stage (1.16, 1.03–1.30); and overall stage (1.14, 1.04–1.24) and were more frequently not recommended for surgery (1.15, 1.01–1.32) or chemotherapy (1.20, 1.07–1.38). Screening protocols tended to increase the association between high SVI and advanced oncologic presentation. After adjustment high SVI remained significantly associated with decreased odds of survival (0.85, 0.79 - 0.91).
Conclusions
High SVI is associated with advanced stage presentation and decreased likelihood of being recommended surgery or chemotherapy even after risk-adjustment. Differences in presentation stage are predominantly driven by cancers with screening protocols and ultimately high SVI is associated with decreased odds of survival.
目的越来越多的证据表明,社会人口统计学对癌症预后有影响。本研究旨在研究社会脆弱性指数(SVI)及其与 8 种主要癌症的肿瘤表现和后续治疗的关系。方法这是一项回顾性队列研究,使用了一家机构对国家癌症数据库(2011-2021 年)的贡献。患者被分为低 SVI 组(第 75 百分位数)和高 SVI 组(≥第 75 百分位数)。组间进行未调整比较,然后进行多变量回归,以控制人口统计学特征对肿瘤表现的影响,以及人口统计学和肿瘤学特征对后续治疗的影响。结果 在 12712 个病例中,高 SVI 组有 2842 例(22.4%),低 SVI 组有 9870 例(77.6%)。经过风险调整后,高 SVI 患者的 T 期(几率比 1.09,95% 置信区间 1.00-1.19)、N 期(1.11,1.01-1.23)、M 期(1.16,1.03-1.30)和总期(1.14,1.04-1.24)更晚,更常不被建议手术(1.15,1.01-1.32)或化疗(1.20,1.07-1.38)。筛查方案往往会增加高 SVI 与晚期肿瘤表现之间的关联。结论即使在风险调整后,高 SVI 仍与晚期表现和被建议手术或化疗的可能性降低有关。发病阶段的差异主要是由采用筛查方案的癌症造成的,最终高 SVI 与生存几率下降有关。
{"title":"The association between social vulnerability and oncologic stage and treatment in the United States","authors":"Christina M. Stuart , Adam R. Dyas , Michael R. Bronsert , Catherine G. Velopulos , William G. Henderson , Richard D. Schulick , Robert A. Meguid","doi":"10.1016/j.soi.2024.100044","DOIUrl":"https://doi.org/10.1016/j.soi.2024.100044","url":null,"abstract":"<div><h3>Objective</h3><p>Growing evidence supports the impact of sociodemographics on cancer outcomes. The objective of this study was to examine the Social Vulnerability Index (SVI) and its association with oncologic presentation and subsequent treatments across 8 major cancers.</p></div><div><h3>Methods</h3><p>This was a retrospective-cohort study using one institution’s contribution to the National Cancer Database (2011–2021). Patients were grouped into low SVI (<75th percentile) and high SVI (≥75th percentile) cohorts. Un-adjusted comparison between groups was performed followed by multivariable regression to control for the effect of demographic characteristics on oncologic presentation, and for demographic and oncologic characteristics on subsequent treatments. A subgroup analysis was performed comparing cancers that have national screening protocols versus those without.</p></div><div><h3>Results</h3><p>Of 12,712 cases, 2842 (22.4%) were in the high SVI group and 9870 (77.6%). After risk-adjustment, high SVI patients presented at more advanced T-stage (odds ratio 1.09, 95% confidence interval 1.00–1.19); N-stage (1.11, 1.01–1.23); M stage (1.16, 1.03–1.30); and overall stage (1.14, 1.04–1.24) and were more frequently not recommended for surgery (1.15, 1.01–1.32) or chemotherapy (1.20, 1.07–1.38). Screening protocols tended to increase the association between high SVI and advanced oncologic presentation. After adjustment high SVI remained significantly associated with decreased odds of survival (0.85, 0.79 - 0.91).</p></div><div><h3>Conclusions</h3><p>High SVI is associated with advanced stage presentation and decreased likelihood of being recommended surgery or chemotherapy even after risk-adjustment. Differences in presentation stage are predominantly driven by cancers with screening protocols and ultimately high SVI is associated with decreased odds of survival.</p></div>","PeriodicalId":101191,"journal":{"name":"Surgical Oncology Insight","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-03-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2950247024000537/pdfft?md5=bff9198643f9805869c300d2376e128c&pid=1-s2.0-S2950247024000537-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140342410","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-03-26DOI: 10.1016/j.soi.2024.100041
Savana Kuhn , Kate Vawter , Allison Wells , Hanna Jensen , Judy Bennett , Emmanouil Giorgakis , Michail N. Mavros
Objectives
We sought to define the attributable morbidity of multivisceral resection (MVR) during distal/subtotal pancreatectomy (DP) in patients with pancreatic ductal adenocarcinoma (PDAC).
Methods
This retrospective review of patients with PDAC used the 2014–2019 pancreas-targeted American College of Surgeons National Surgical Quality Improvement Program database. Operations DP versus MVR were compared based on demographics, comorbidities, intraoperative variables, and postoperative outcomes. Univariate and multivariable logistic regression models assessed morbidity and mortality.
Results
Of 3353 distal pancreatectomies, 124 (4%) were MVR. MVR patients were more likely male (56% versus 49%) and smokers (24% versus 18%) but less likely obese (18% versus 29%) or diabetic (21% versus 30%). MVR operations were longer (median 4.3 versus 3.8 h) and involved partial colectomy (100%), gastrectomy (28%), adrenalectomy (20%), and enterectomy (13%). MVR patients had higher unadjusted rates of mortality (2.4% versus 1.1%), serious morbidity (30.7% versus 14.1%), and overall morbidity (61% versus 36%). MVR patients had higher adjusted risk for serious morbidity [odds ratio (OR) 2.13, 95% confidence intervals: 1.28–3.43] and infectious complications [OR 2.75 (1.73–4.31)], but not mortality [OR 1.05 (0.04–3.73)], although the mortality analyses were underpowered.
Conclusions
Concurrent MVR during DP doubled the risk of postoperative complications. This should be considered during the sequencing of cancer-directed care and preoperative planning.
{"title":"Multivisceral resection morbidity for left pancreas cancer","authors":"Savana Kuhn , Kate Vawter , Allison Wells , Hanna Jensen , Judy Bennett , Emmanouil Giorgakis , Michail N. Mavros","doi":"10.1016/j.soi.2024.100041","DOIUrl":"https://doi.org/10.1016/j.soi.2024.100041","url":null,"abstract":"<div><h3>Objectives</h3><p>We sought to define the attributable morbidity of multivisceral resection (MVR) during distal/subtotal pancreatectomy (DP) in patients with pancreatic ductal adenocarcinoma (PDAC).</p></div><div><h3>Methods</h3><p>This retrospective review of patients with PDAC used the 2014–2019 pancreas-targeted American College of Surgeons National Surgical Quality Improvement Program database. Operations DP versus MVR were compared based on demographics, comorbidities, intraoperative variables, and postoperative outcomes. Univariate and multivariable logistic regression models assessed morbidity and mortality.</p></div><div><h3>Results</h3><p>Of 3353 distal pancreatectomies, 124 (4%) were MVR. MVR patients were more likely male (56% versus 49%) and smokers (24% versus 18%) but less likely obese (18% versus 29%) or diabetic (21% versus 30%). MVR operations were longer (median 4.3 versus 3.8 h) and involved partial colectomy (100%), gastrectomy (28%), adrenalectomy (20%), and enterectomy (13%). MVR patients had higher unadjusted rates of mortality (2.4% versus 1.1%), serious morbidity (30.7% versus 14.1%), and overall morbidity (61% versus 36%). MVR patients had higher adjusted risk for serious morbidity [odds ratio (OR) 2.13, 95% confidence intervals: 1.28–3.43] and infectious complications [OR 2.75 (1.73–4.31)], but not mortality [OR 1.05 (0.04–3.73)], although the mortality analyses were underpowered.</p></div><div><h3>Conclusions</h3><p>Concurrent MVR during DP doubled the risk of postoperative complications. This should be considered during the sequencing of cancer-directed care and preoperative planning.</p></div>","PeriodicalId":101191,"journal":{"name":"Surgical Oncology Insight","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2950247024000501/pdfft?md5=a73b58c30547f70f195b31639dd06536&pid=1-s2.0-S2950247024000501-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140327742","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-03-09DOI: 10.1016/j.soi.2024.100040
Kathleen Doyle , Christina M. Theodorou , Julianne J.P. Cooley , Theresa H. Keegan , Erin G. Brown
Purpose
Pediatric oncology patients are at increased risk of unplanned readmissions, but factors associated with readmissions are largely unknown. We aimed to identify patients at increased risk for readmission and characterize unplanned readmissions for pediatric surgical oncology patients.
Methods
Patients < 20 years with a first primary solid organ cancer who underwent definitive oncologic surgery from 2005–2017 were identified in the California Cancer Registry linked to statewide hospitalization data. Unplanned 30-day readmissions from their definitive surgery were defined as acute medical problems and/or surgical complications not related to planned admissions for chemotherapy, radiation, or rehabilitation. Multivariable logistic regression identified factors associated with unplanned 30-day readmission.
Results
2507 pediatric oncology patients were identified. Median age was 10 years. 49.2% had a 30-day readmission (n = 1233), and 36.7% (n = 452) of these readmissions were unplanned. In multivariable models, those at highest risk of unplanned readmission were < 1 year old (OR 2.72, CI 1.72–4.29) and 1–5 years (OR 1.64, CI 1.20–2.24) vs. ages 13–19; had metastatic disease at diagnosis (OR 1.6, CI 1.1–2.1); and had central nervous system (CNS) tumors (OR 2.5, CI 1.6–3.9), hepatic tumors (OR 2.3, 95% CI 1.2–4.2), or soft tissue/extraosseous sarcomas (OR 2.2, CI 1.3–3.9). Longer initial hospitalizations were associated with a higher likelihood of unplanned readmission (10 days vs. 7 days, p < 0.0001).
Conclusion
Unplanned readmissions after surgery for pediatric oncology patients are prevalent. Younger children and those with more advanced/complex disease are at highest risk of unplanned readmissions. Interventions should focus on preventing readmissions in these patients, specifically.
{"title":"Factors associated with unplanned readmissions in pediatric surgical oncology patients","authors":"Kathleen Doyle , Christina M. Theodorou , Julianne J.P. Cooley , Theresa H. Keegan , Erin G. Brown","doi":"10.1016/j.soi.2024.100040","DOIUrl":"https://doi.org/10.1016/j.soi.2024.100040","url":null,"abstract":"<div><h3>Purpose</h3><p>Pediatric oncology patients are at increased risk of unplanned readmissions, but factors associated with readmissions are largely unknown. We aimed to identify patients at increased risk for readmission and characterize unplanned readmissions for pediatric surgical oncology patients.</p></div><div><h3>Methods</h3><p>Patients < 20 years with a first primary solid organ cancer who underwent definitive oncologic surgery from 2005–2017 were identified in the California Cancer Registry linked to statewide hospitalization data. Unplanned 30-day readmissions from their definitive surgery were defined as acute medical problems and/or surgical complications not related to planned admissions for chemotherapy, radiation, or rehabilitation. Multivariable logistic regression identified factors associated with unplanned 30-day readmission.</p></div><div><h3>Results</h3><p>2507 pediatric oncology patients were identified. Median age was 10 years. 49.2% had a 30-day readmission (n = 1233), and 36.7% (n = 452) of these readmissions were unplanned. In multivariable models, those at highest risk of unplanned readmission were < 1 year old (OR 2.72, CI 1.72–4.29) and 1–5 years (OR 1.64, CI 1.20–2.24) vs. ages 13–19; had metastatic disease at diagnosis (OR 1.6, CI 1.1–2.1); and had central nervous system (CNS) tumors (OR 2.5, CI 1.6–3.9), hepatic tumors (OR 2.3, 95% CI 1.2–4.2), or soft tissue/extraosseous sarcomas (OR 2.2, CI 1.3–3.9). Longer initial hospitalizations were associated with a higher likelihood of unplanned readmission (10 days vs. 7 days, p < 0.0001).</p></div><div><h3>Conclusion</h3><p>Unplanned readmissions after surgery for pediatric oncology patients are prevalent. Younger children and those with more advanced/complex disease are at highest risk of unplanned readmissions. Interventions should focus on preventing readmissions in these patients, specifically.</p></div>","PeriodicalId":101191,"journal":{"name":"Surgical Oncology Insight","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-03-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2950247024000495/pdfft?md5=4e0170c76158d6eec8c08a4b06790683&pid=1-s2.0-S2950247024000495-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140122503","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-03-08DOI: 10.1016/j.soi.2024.100039
Julia Kohn , Julia Frebault , Qi Wang , Sonja Boatman , Alexander Troester , Christine Jensen , Schelomo Marmor , Wolfgang B. Gaertner , Imran Hassan , Paolo Goffredo
Introduction
Due to the watershed vasculature and lymphatic drainage of splenic flexure (SF) neoplasms, and their exclusion from large clinical trials, optimal management remains debated. This study evaluated extent of resection and surgical approach for SF adenocarcinoma and their respective outcomes.
Methods
Adults with stage I-III splenic flexure adenocarcinoma were identified in the National Cancer Database (2004–2020) and categorized by surgical management.
Results
Of 7412 patients, 4264 (58%) underwent extended colectomy (EC). The cohorts were overall similar, though more patients with stage I disease were managed with segmental colectomy (SC) (24% vs. 20%, p < 0.01). Those undergoing EC had longer hospital stays (LOS) and greater odds of readmission. Use of robotic-assisted surgery was higher in SC (9% vs. 7%, p < 0.01) and increased from 1% in 2010 to 24% in 2020. This approach was independently associated with a shorter LOS than open surgery. Despite a higher number of lymph nodes examined (median 18 vs. 16), EC and SC had similar nodal (both 37%, p = 0.95) and margin involvement (both 4%, p = 0.39). Five-year survival after EC and SC was similar (75% vs. 76%, p = 0.6). Patients undergoing robotic surgery had significantly lower odds of positive surgical margins and experienced an improved prognosis.
Conclusions
EC and SC were performed at similar rates for SF adenocarcinoma, while the use of robotic surgery increased over time. Neither extent of resection nor surgical approach significantly impacted oncologic outcomes. These data indicate that surgical decision-making should be balanced between tumor- and patient-specific considerations, morbidity of extended colectomy, and surgeon preference.
Synopsis
In a national cohort of splenic flexure cancers, segmental and extended colectomy were associated with comparable rates of negative margins, nodal involvement, and survival. Robotic assist increased over time without impacting oncologic outcomes. Surgical procedure and approach should thus be tailored to clinical condition and surgeon preference.
导言由于脾曲(SF)肿瘤的分水岭血管和淋巴引流,以及它们被排除在大型临床试验之外,最佳治疗方法仍存在争议。本研究评估了脾曲腺癌的切除范围和手术方法及其各自的疗效。方法从美国国家癌症数据库(2004-2020年)中识别出I-III期脾曲腺癌成人患者,并按手术治疗进行分类。结果在7412例患者中,4264例(58%)接受了扩大结肠切除术(EC)。两组患者的总体情况相似,但更多 I 期患者接受了节段性结肠切除术(SC)(24% 对 20%,P < 0.01)。接受结肠切除术的患者住院时间(LOS)更长,再次入院的几率更大。SC手术中机器人辅助手术的使用率更高(9% vs. 7%,p <0.01),从2010年的1%增至2020年的24%。与开放手术相比,机器人辅助手术的住院时间更短。尽管检查的淋巴结数量较多(中位数18对16),但EC和SC的结节(均为37%,P = 0.95)和边缘受累(均为4%,P = 0.39)情况相似。EC和SC术后的五年生存率相似(75% vs. 76%,p = 0.6)。接受机器人手术的患者出现手术切缘阳性的几率明显降低,预后也有所改善。切除范围和手术方式对肿瘤预后均无明显影响。这些数据表明,手术决策应在肿瘤和患者特异性考虑因素、扩大结肠切除术的发病率以及外科医生的偏好之间取得平衡。简介在全国脾曲癌队列中,分段结肠切除术和扩大结肠切除术的阴性边缘率、结节受累率和生存率相当。随着时间的推移,机器人辅助手术越来越多,但对肿瘤结果没有影响。因此,手术过程和方法应根据临床情况和外科医生的偏好而定。
{"title":"Surgical approach to splenic flexure adenocarcinoma of the colon: Less is more?","authors":"Julia Kohn , Julia Frebault , Qi Wang , Sonja Boatman , Alexander Troester , Christine Jensen , Schelomo Marmor , Wolfgang B. Gaertner , Imran Hassan , Paolo Goffredo","doi":"10.1016/j.soi.2024.100039","DOIUrl":"https://doi.org/10.1016/j.soi.2024.100039","url":null,"abstract":"<div><h3>Introduction</h3><p>Due to the watershed vasculature and lymphatic drainage of splenic flexure (SF) neoplasms, and their exclusion from large clinical trials, optimal management remains debated. This study evaluated extent of resection and surgical approach for SF adenocarcinoma and their respective outcomes.</p></div><div><h3>Methods</h3><p>Adults with stage I-III splenic flexure adenocarcinoma were identified in the National Cancer Database (2004–2020) and categorized by surgical management.</p></div><div><h3>Results</h3><p>Of 7412 patients, 4264 (58%) underwent extended colectomy (EC). The cohorts were overall similar, though more patients with stage I disease were managed with segmental colectomy (SC) (24% <em>vs.</em> 20%, p < 0.01). Those undergoing EC had longer hospital stays (LOS) and greater odds of readmission. Use of robotic-assisted surgery was higher in SC (9% <em>vs.</em> 7%, p < 0.01) and increased from 1% in 2010 to 24% in 2020. This approach was independently associated with a shorter LOS than open surgery. Despite a higher number of lymph nodes examined (median 18 <em>vs.</em> 16), EC and SC had similar nodal (both 37%, p = 0.95) and margin involvement (both 4%, p = 0.39). Five-year survival after EC and SC was similar (75% <em>vs.</em> 76%, p = 0.6). Patients undergoing robotic surgery had significantly lower odds of positive surgical margins and experienced an improved prognosis.</p></div><div><h3>Conclusions</h3><p>EC and SC were performed at similar rates for SF adenocarcinoma, while the use of robotic surgery increased over time. Neither extent of resection nor surgical approach significantly impacted oncologic outcomes. These data indicate that surgical decision-making should be balanced between tumor- and patient-specific considerations, morbidity of extended colectomy, and surgeon preference.</p></div><div><h3>Synopsis</h3><p>In a national cohort of splenic flexure cancers, segmental and extended colectomy were associated with comparable rates of negative margins, nodal involvement, and survival. Robotic assist increased over time without impacting oncologic outcomes. Surgical procedure and approach should thus be tailored to clinical condition and surgeon preference.</p></div>","PeriodicalId":101191,"journal":{"name":"Surgical Oncology Insight","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-03-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2950247024000483/pdfft?md5=d46c68fb981bdfa682b015c20a279c6d&pid=1-s2.0-S2950247024000483-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140122502","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}