Surgical Oncology Insight最新文献

Background

Extramammary Paget’s Disease (EMPD) is a rare intraepithelial neoplasm that often presents in anogenital regions, primarily affecting older, female, and Asian patients. Clinical progression is insidious, with delay in diagnosis up to years common. This study sought to investigate contemporary trends in incidence and survival across sexes.

Methods

Retrospective review of EMPD patients in 22 SEER registries from 2004 to 2020. Cases were categorized by primary disease site. Additional data included race, sex, ethnicity, age, disease stage, treatment type, and time to treatment. Age-adjusted incidence rates were calculated from 2000 to 2020. Kaplan-Meier curves estimated survival and univariable and multivariable Cox proportional hazards models examined factors associated with all-cause mortality.

Results

3608 patients were included: 1179 male and 2429 female. 76.2 % of patients had documented treatment with 32.4 % experiencing a 3 + month delay. Incidence was greatest among Asian patients, with a rate 2x greater than white patients, however, the APC was only significant among white patients (+1.22 %). Ten-year survival estimate was 63.0 % in female patients versus 53.4 % in male patients (p < 0.001). On multivariable analysis, older age, advanced stage, and treatment delay were associated with worsened overall survival, while surgery alone decreased the risk of mortality in comparison to no cancer-directed treatment.

Conclusions

Over the past 20 years, the incidence of EMPD has risen across sexes, with survival significantly worsened by older age, advanced stage, and delay in treatment. In addition, primary surgical treatment, when performed early with complete resection, may decrease the long-term mortality risk.

Background

Patients undergoing pancreatic resection who decline blood transfusion represent a clinical challenge. While bloodless medicine programs are valuable, their impact remains unclear, especially for those with borderline-resectable and locally advanced pancreatic ductal adenocarcinoma (PDAC).

Methods

Retrospective review of institutional databases identified patients who did not accept blood transfusion and underwent pancreatic resection from 2013–2022. We collated hemoglobin values, interventions to minimize symptomatic anemia, and patient outcomes.

Results

Thirteen patients were identified. Median age was 63 years (range: 52–75 years) and eight (61.5 %) were female. All procedures were performed electively for invasive malignancy with PDAC as the most common diagnosis (11/13; 84.6 %) and pancreaticoduodenectomy as the most common procedure (11/13; 84.6 %). Vascular involvement was common in the 11 patients with PDAC (borderline-resectable: 7/11; 63.6 % and locally advanced: 3/11; 27.3 %), as was the use of multi-agent chemotherapy (n = 10) and preoperative radiotherapy (n = 8) prior to surgery. Median blood loss was 400 mL (range: 100–2200 mL). Intraoperative measures included acute normovolemic hemodilution in one patient and red blood cell salvage in three patients. Median preoperative hemoglobin was 12.3 g/dL (range: 10.3–14.2 g/dL) and median nadir hemoglobin was 9.2 g/dL (range: 5.2–11.8 g/dL). Median hospital stay was 10 days (range: 6–42 days). Thirty-day mortality was 0 % and one-year overall survival was 69.2 % with median follow-up of 26.4 months.

Conclusion

Pancreatic resections can be performed safely in patients who decline blood transfusion, even with borderline-resectable and locally advanced PDAC. Avoiding transfusions and employing blood-conservation techniques does not appear to detrimentally impact survival.

Utilization of minimally invasive surgery (MIS) has grown significantly over the past three decades, changing the face of surgical oncology practice. Changes to educational programming have been more scattered. Surgical training has undergone a major transformation with duty hour restrictions, decreased autonomy, and increased technology in the workplace. Despite increasing exposure to laparoscopic and robotic approaches, there is a lack of standardized training in residency, fellowship and beyond. As a result, surgeons report feeling ill-equipped for independent MIS oncology practice. While long term data is limited, several models of MIS curriculum implementation exist in gastrointestinal, hepato-pancreatico-biliary, and colorectal surgery. The aim of this review is to describe the current state of robotic training in surgical oncology and offer directions for future research and practice.

The peritoneum is a common site of early dissemination of gastric cancer (GC) as well as a common site of recurrence after curative gastrectomy. Peritoneal metastasis (PM) is a major cause of morbidity and mortality in patients with GC and is associated with poor prognosis, making treatment of peritoneal disease is an important target for improving survival. The development of standardized methods to assess extent of peritoneal disease, an increased understanding of intraperitoneal chemotherapy, and improvements in systemic chemotherapy have renewed interest in the curative-intent treatment of GCPM. The different approaches of locoregional therapy for GCPM includes surgical resection, intraperitoneal chemotherapy, and a combination of the two. Surgical resection involves gastrectomy and/or a cytoreductive surgery (CRS) with removal of all visible disease. Intraperitoneal (IP) chemotherapy can involve administering heated chemotherapy usually at the time of surgery i.e., Hyperthermic Intraperitoneal Chemotherapy (HIPEC) or laparoscopically in the neoadjuvant setting i.e., NL-HIPEC, chemotherapy given immediately post-op i.e., Early Post-operative Intraperitoneal Chemotherapy (EPIC), multiple infusions of non-heated chemotherapy i.e. Normothermic Intraperitoneal Chemotherapy Long Term (NIPEC-LT) or the newer technique of Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC). This review provides an overview of these different locoregional treatment modalities and summarizes the evolution of the techniques, regimens, and applications of IP chemotherapy. It highlights the multitude of options available, the promising yet heterogenous existing literature and the exciting ongoing work that will hopefully help establish the role of locoregional therapy in GCPM.

The nipple sparing mastectomy (NSM) has allowed for targeted tumor extirpation while maintaining the breast skin envelope and nipple-areola complex. Initially, the indications for this reconstructive technique were quite narrow, but ongoing investigation have expanded the indications and safety profile of the NSM from an oncologic and reconstructive standpoint. Historically, patients with elevated body mass index, macromastia, high-grade ptosis, and ongoing tobacco use were deemed high-risk candidates for ischemic complications. Development and utilization of numerous techniques have allowed the NSM to be offered more frequently to these high-risk candidates. Specifically, many methods including single-stage and multi-stage/delay techniques have been developed for the patient with high-grade ptosis.

Background

Despite the reported rising trend of early-onset CRC incidence globally, little is known about the clinical profile and primary CRC surgical outcome in Tanzania and sub-Saharan Africa. This study aimed to analyze the clinicopathological features and short-term surgical outcomes of early-onset CRC patients undergoing primary surgery.

Methodology

The patients who underwent primary CRC surgery and whose diagnosis was confirmed by histopathology were identified and reviewed from prospectively maintained medical records. Clinicopathological characteristics and short-term surgical outcomes were analyzed and compared between groups.

Results

A total of 225 patients were included in this study, there were 137 patients in the late-onset CRC group and 88 in the early-onset group. After a 1:1 ratio PSM, there were 86 patients in each group. The overall proportion of early-onset CRC patients was 39.1 %. With regards to baseline characteristics of gender, tumor stage, tumor location, and presenting symptoms, there was no significant difference between early-onset and late-onset CRC patient groups before and after propensity score Matching (PSM) analysis (p > 0.05). After PSM, Early-onset CRC patients had a significantly higher proportion of Signet-ring cell histology (p = 0.007) and a higher rate of overall postoperative complications, (p = 0.043). The multivariate analyses showed that early-onset CRC patients (p = 0.048, OR=2.14, 95 % CI=1.01–4.53) and emergency surgery (p = 0.011, OR=2.79, 95 % CI=1.27–6.13) were significant predictors of overall postoperative complications

Conclusion

Early-onset CRC patients showed a significantly higher proportion of Signet-ring cell histology (poorly differentiated) and overall short-term postoperative complications. The early-onset CRC patients and emergency surgery were significant predictors of overall short-term postoperative complications

Background

The prevalence of missing data in the National Cancer Database (NCDB) has marked implications on clinical care and research. The objective of this study was to enhance the NCDB by decreasing rates of missingness and adding new variables using automated statistical methodology.

Methods

One health system’s NCDB data from 2011–2021 was linked to electronic health record (EHR). Variables with frequent missingness and new clinically significant variables not yet included in the NCDB including patient Eastern Cooperative Oncology Group (ECOG) score, specific chemotherapy regimen, American Society of Anesthesiologists Physical Status Classification (ASA class), and discrete surgical procedure were identified in structured and unstructured EHR data. After automated incorporation of structured data from EHR, a natural language processing tool incorporating rule-based algorithms was designed to further extract variables from unstructured notes. Rates of missingness were compared between the original NCDB and the enhanced dataset, and example multivariable models were run to assess for altered model performance with reduced missingness and the addition of new clinically significant variables (chemotherapy regimen).

Results

A total of 6050 patients with NCDB records were linked to their EHR data. Prior to enhancement, rates of missingness for key variables ranged from 2.0% to 5.3%. Following dataset enhancement, missingness was significantly reduced, with relative missingness being reduced between 31.9% to 68.0%. Of the new variables added, 1367 (22.6%) of 6050 patients gained ECOG score, and 1099 (57.8%) of 1901 who received chemotherapy gained their chemotherapy regimen. Of 2989 who underwent surgery, 979 (32.8%) gained their procedure name and 621 (20.8%) gained ASA class. Comparison of the multivariable models demonstrated significant differences between the original NCDB and the enhanced dataset. Specifically, when replacing the binary predictor for chemotherapy in the original NCDB data with discrete regimens, the effect of ethnicity diminished, and the effect of radiation became significant.

Discussion

We applied statistical methodology to reduce rates of missingness in existing variables and add new variables to enrich the NCDB. While further refinement is needed to decrease missingness in new variables, this automated methodology can replace or augment manual chart review and improve the ability of to use the NCDB to study unanswered questions leading to clinical advancements in oncology.

Over the last several decades, the treatment of breast cancer has evolved from a reliance on radical surgery to less invasive treatments incorporating systemic therapy (e.g., chemotherapy and endocrine therapy) and radiotherapy, which has allowed for breast conservation surgery and improved survival. Accordingly, the management of breast cancer today is perhaps the best example of multidisciplinary cancer care. Surgeons work closely with radiologists, medical oncologists, radiation oncologists, and other specialists to design the optimal treatment plan for their patients. This cross-disciplinary collaboration and communication is especially well-illustrated in the neoadjuvant approach to breast cancer management. Neoadjuvant therapy provides several advantages to patients with newly diagnosed early-stage breast cancer. Current neoadjuvant regimens include chemo-immunotherapy for patients with triple negative disease, chemotherapy with human epidermal growth factor-2 (HER2) targeted therapy for patients with HER2+ disease, and chemotherapy or endocrine therapy for patients with hormone receptor positive/HER2- cases. As many studies have shown, tumor biology impacts the response to neoadjuvant therapy, including rates of pathologic complete response. Neoadjuvant approaches continue to grow in complexity, calling for increased cross-specialty understanding of its indications and treatment algorithms. Therefore, in this review we discuss contemporary neoadjuvant therapy approaches, with a focus on the interplay between imaging, systemic therapy, radiotherapy, and surgical management.

Background

Surgeon-performed intraoperative ultrasound-guided wire localization (IOL) offers an improved patient experience and decreased cost compared to preoperative localization by radiology, yet literature on this technique is sparse. Here we evaluate the safety and margin positivity rate after surgeon-performed IOL for breast cancer.

Methods

Patients with biopsy-proven breast malignancy and planned breast conservation who underwent IOL by a single breast surgeon between 2017–2023 and had follow-up at our institution were retrospectively identified. Patient and tumor characteristics, method of diagnosis, imaging findings, use of oncoplastic surgery, and follow-up data were analyzed.

Results

A total of 137 IOLs were performed for biopsy-proven ductal carcinoma in situ (DCIS) or invasive cancer. The median patient age was 69 years. Most patients had a non-palpable tumor (n = 104, 76.5%). 84.6% of patients underwent pre-operative biopsy by ultrasound guidance, 12.5% by stereotactic guidance, and 2.9% by MRI. In total, 7.3% of patients (n = 10) had positive margins, including 2 with invasive disease at the margin and 8 with DCIS at the margin. Nine patients underwent re-excision for positive or close margins, of which 8 had successful margin-negative breast conservation and 1 patient underwent mastectomy. Thirty-day postoperative complications occurred in 21 patients (15.3%). Of these, most (n = 19, 90.4%) had minor complications including seroma (n = 14), cellulitis (n = 3), and skin allergy (n = 2). At median follow-up of 20.4 months, no patients experienced recurrence.

Conclusions

In our single-surgeon series, IOL is a safe technique for localization of invasive carcinoma and DCIS with margin positivity, re-excision, and postoperative complication rates within previously published ranges.

Synopsis

This study evaluates the safety of and re-excision rates after intraoperative surgeon-performed ultrasound-guided wire localization (IOL) for breast cancer. Results demonstrate margin positivity and re-excision rates equivalent to or lower than rates reported in literature utilizing preoperative localization techniques.