Journal of Surgical Oncology最新文献

Background: Medicare Part D covers outpatient prescription drugs for elderly beneficiaries, but requires full cost coverage once the coverage gap threshold is reached. We assessed the impact of reaching Medicare Part D threshold on out-of-pocket costs (OOP), timely treatment, and outcomes for patients with gastrointestinal (GI) cancer.

Methods: Individuals newly diagnosed with GI cancer between 2007 and 2019 were identified from the SEER-Medicare database. OOP costs were calculated for the year of diagnosis. Multivariable regression models compared timely surgical care and mortality risk among patients who did and did not reach the coverage gap threshold.

Results: Among 35 745 Medicare beneficiaries diagnosed with colorectal (50.7%), pancreatic (19%), and liver (30.4%) cancer, median age was 76 years (IQR: 71-82), and 56.6% were female. Notably, 48.9% (17 479) of patients reached the Medicare Part D threshold in the year of cancer diagnosis. Mean OOP cost for patients who reached the threshold was $1060 (SD: $1417) vs. $268 (SD: $270, p < 0.0001) for individuals who did not. On multivariable analysis, patients who reached the threshold were more likely to delay [OR: 1.13, 95% CI: 1.03-1.24] or not receive surgery [OR: 1.40, 95% CI: 1.27-1.54], and had a higher risk of 5-year mortality [HR 5-year: 1.12, 95% CI: 1.09-1.15, p < 0.0001] regardless of comorbidity status, cancer site, and disease stage.

Conclusion: Reaching the coverage gap threshold was associated with delayed or non receipt of surgical treatment, which resulted in increased long-term mortality. Lowering the Part D threshold through policy adjustments may reduce financial strain and improve health outcomes for cancer patients.

Background: Opioid crisis is a national issue with significant economic burden and marked increase in opioid-related deaths, particularly following surgical procedures. Reducing opioid requirements while maintaining effective analgesia is critically challenging, perioperatively. Multimodal drug regimens and guided regional anesthesia (RA) have been adopted to address this issue. We aimed to assess postoperative opioid consumption in patients undergoing open pancreatoduodenectomy based on the routes of RA administration: open versus ultra-sound guided.

Methods: This retrospective cohort study was conducted at Emory University Saint Joseph's Hospital, encompassing patients who underwent open pancreatoduodenectomy (PD) from 2020 to 2022 who received ultrasound-guided RA (U-RA) or open RA (O-RA). Patient demographics, surgical details, and postoperative outcomes, including opioid consumption measured in morphine milligram equivalents (MME) at 24, 48, and 72 h, were analyzed. Multivariable linear regression identified predictors of postoperative opioid use.

Results: Of 95 patients, 47 met inclusion criteria: 27 received U-RA and 20 O-RA. Preoperative and intraoperative characteristics were similar between patients receiving O-RA and U-RA. A lower opioid requirement was noted in the O-RA group compared to the U-RA group at all time points. (24 h: 6.5 vs. 18, p = 0.004; 48 h: 18 vs. 37, p = 0.001; 72 h: 30.5 vs. 57, p = 0.002). On multivariable analysis, only route of regional anesthesia was independently associated with reduced opioid use across all time points (24 h: mean difference = -5.75, 95% CI: -11.3, -0.18; 48 h: mean difference = -16.95, 95% CI: -27.5, -6.4; 72 h: mean difference = -20.39, 95% CI: -35.4, -5.3) Patient age, gender, race, obesity, neoadjuvant chemotherapy, small pancreatic duct, and pancreatic fistula were not independently associated with opioid use.

Conclusions: O-RA may offer a better approach than U-RA in minimizing opioid consumption after open PD. These findings suggest the incorporation of O-RA for upper abdominal surgeries to decrease the necessity of postoperative opioids.

Background and objectives: Soft tissue sarcomas (STSs) are rare but can be devastating. Paradigm shifts in adjuvant treatment have expanded the availability of limb salvage; however, a subset of patients still require amputation. The aim of this study was to examine the impact of patient, disease, and practice-related factors on rates of amputation in STS.

Methods: All adults undergoing resection for STS of the extremities were tabulated from the 2004-2021 National Cancer Database (NCDB). Multivariable models were utilized to evaluate risk factors for undergoing amputation.

Results: Of 31 805 patients, 1880 (6%) underwent amputation. Those who underwent amputation were younger (57 vs. 60, p < 0.001), more commonly Black (12% vs. 9%, p < 0.00), and more frequently Medicaid insured (11% vs. 6%, p < 0.001). Amputation patients experienced a longer time from diagnosis to surgery, compared to limb salvage patients (46 [23-91] vs. 37 days [9-93], p < 0.001). Amputation was associated with a significantly greater hazard of overall mortality over 10 years following resection (HR 1.66, p < 0.001).

Conclusion: We report significant race-, income-, and insurance-based disparities in amputation risk and overall survival for patients with STS of the extremities. We also report a significantly increased risk of amputation for patients with delayed clinical presentation. Multidisciplinary sarcoma care teams should be aware of these disparities.

Background and objectives: Neuroblastoma, the most common extracranial solid tumor in children, is rare in adults. This study compares patient characteristics, disease patterns, and treatments among adults, adolescents, and children with neuroblastoma.

Methods: We queried the National Cancer Database (2004-2019) for neuroblastoma cases. Patient and tumor characteristics, treatments, and 5-year overall survival (5-OS) were compared between adults (≥ 18 years), adolescents (10-17 years), and children (0-9 years). Kaplan-Meier curves and Cox regression assessed survival differences.

Results: Among 6350 neuroblastoma patients, 256 (4.0%) were adults, 222 (3.5%) were adolescents, and 5872 (92.5%) were children. Tumors were largest in adolescents (9.7 cm), followed by adults (8.0 cm) and children (6.7 cm) (p < 0.001). Adults were less likely to have tumors in the adrenal glands (34.0% vs. children: 54.7%, adolescents: 43.2%, p < 0.001) and had lower rates of metastasis (10.9% vs. 19.3% and 19.4%, p < 0.001). Compared to children, adults received less chemotherapy, immunotherapy, and bone marrow transplants (p < 0.001). 5-OS was worse in adults (65.8%), followed by adolescents (70.4%) and children (78.2%) (p < 0.001). After adjustment, adults (aHR: 2.27; 95% CI, 1.71-3.01) and adolescents (aHR: 2.02; 95% CI, 1.54-2.64) had higher hazards of death compared to children.

Conclusions: Adults and adolescents with neuroblastoma have distinct clinical features and lower survival than children, underscoring the need for tailored treatment approaches for older patients.

Level of evidence: III.

Background and objectives: Since the publication of the German Cooperative Oncology Group Selective Lymphadenectomy Trial and Multicenter Selective Lymphadenectomy Trial II (MSLT2) trials, the treatment paradigm for node-positive melanoma has shifted from completion lymph node dissection (LND) to nodal ultrasound surveillance. We sought to identify the impact of this practice change on postoperative outcomes in a national cohort.

Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients diagnosed with truncal/extremity malignant melanoma who underwent axillary/inguinal LND. Patients diagnosed with head/neck melanoma with subsequent cervical LND were also analyzed separately. Trends in case volumes, clinicodemographic patient characteristics, and postoperative outcomes were analyzed using univariate and multivariate analyses.

Results: There has been a reduction of patients undergoing axillary/inguinal LND in the post-MSLT2 era (24.1% vs. 19.0%, p < 0.01). Furthermore, these patients are older (63 vs. 59 years, p < 0.01) and have worse systemic comorbidities (ASA class 3+ +54% vs. 42%, p <0.01). Despite this, postoperative outcomes remain unchanged. For cervical LND, no significant changes in case volumes or clinicodemographic factors were found. Apart from an increase in superficial skin infections in the post-MSLT2 cohort, postoperative outcomes remain largely unchanged.

Conclusions: Continued efforts should be made to optimize patient selection and maintain acceptable postoperative morbidity for LND as it becomes more sparingly utilized in the care of patients with melanoma.

Lymphedema is a chronic, dynamic, and multifaceted disease that is effectively treated by surgery. However, there is a lack of consensus in the field about the ideal technique; is it better to perform one surgery type at a time (the "single-malt whisky" approach), or combine different procedures in a single surgery (the "cocktail" approach)? Here, we review advances in these opposing camps, compare outcomes, and discuss potential paradigm shifts in the surgical treatment of lymphedema.

Background: Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are a rare and biologically diverse group of tumors that are challenging to image. ⁶⁸Ga-DOTATATE PET/CT is the most sensitive imaging tool for these tumors, and while its use has increased over time, its clinical impact remains unclear, particularly for clinical scenarios involving surveillance after treatment. We sought to reassess its clinical utility across all stages.

Methods: Retrospective study of pathologically confirmed GEP-NET patients between 1/1/2020 and 9/1/2022 at a tertiary care center. Demographic, clinical, and radiographic data were analyzed. The primary objective was to determine if PET/CT use was associated with a change in clinical management. The secondary objective was to determine if PET/CT was superior in identifying primary or metastatic lesions compared to traditional imaging.

Results: One hundred twenty-four patients with GEP-NETs underwent 207 PET/CT scans. The majority of scans were obtained for disease surveillance (70.2%) or staging (37.9%), and the remaining (3.2%) were used to aid in diagnosis or before PRRT initiation (3.2%). Following PET/CT scan, 51 patients (41.1%) had a change in clinical management, with change being higher among those with metastatic disease (44.9% vs. 14.5%). Of the 124, 72 patients had traditional imaging available for comparison. In this subgroup, 34 patients (47.2%) had new lesions identified on PET/CT that were not identified using traditional imaging resulting in a change in management in 79.4% favoring patients with M1 versus M0 disease (26.9% M0 vs. 58.7% M1, p = 0.010).

Conclusion: ⁶⁸Ga-DOTATATE PET/CT imaging is clinically most useful for initial staging and in surveillance and monitoring response to therapy in the metastatic setting. It is least useful for surveillance in the early-stage setting and does not support its use following curative intent surgery. It remains superior to unlabeled imaging in sensitivity and the additional disease burden detected is highly likely to change management.

Background and objectives: Standard treatment of patients with stage II/III esophageal or gastroesophageal junction (E/GEJ) cancer involves neoadjuvant chemoradiation (nCRT), resection, and immunotherapy. Our trial evaluated the addition of perioperative avelumab to standard treatments.

Methods: Patients with resectable E/GEJ cancers received avelumab with nCRT and adjuvant avelumab after resection. Primary endpoints for phase I and II portions were safety and pathologic complete response (pCR) rate, respectively. Secondary endpoints included recurrence-free survival (RFS), surgical complication prevalence, and R0 resection rate.

Results: Twenty-two patients enrolled in the study. Median follow-up during data cutoff was 23.9 months. There were no dose-limiting toxicities during the run-in phase. Nineteen patients (86.4%) underwent resection with R0 resection rate of 78.9% and with pCR rate of 26%. Most common treatment-related adverse events (TRAE) were cytopenias from chemoradiation. Aside from one grade ≥ 3 avelumab-related hypersensitivity, no grade ≥ 3 avelumab TRAEs were seen. Median RFS was not reached, and 1-year RFS and overall survival were 71% and 81%, respectively. The study was terminated before full planned accrual due to standard practice change based on the CheckMate 577 trial.

Conclusions: The addition of perioperative avelumab to nCRT was tolerable and demonstrated promising outcomes.