Journal of Surgical Oncology最新文献

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.

Introduction: This study aimed to develop and validate an aesthetic grading tool (AGT) for bilateral DIEP flap breast reconstruction and investigate the correlation of BREAST-Q scores with perceived aesthetic outcomes.

Methods: The AGT utilized a Likert scale to rate aesthetic outcomes based on photographs of post-reconstruction breasts. The validation involved iterative testing with healthcare providers and patients. A two-way mixed effects model estimated the intraclass correlation coefficients (ICC) to assess intra-rater and inter-rater reliability. Pearson Correlation Coefficients explored the relationship between aesthetic ratings and BREAST-Q Satisfaction with Breasts scores.

Results: The AGT demonstrated substantial intra-rater reliability (ICC = 0.74, 95% CI: 0.64-0.79) and moderate to very strong inter-rater reliability across respondents after iterative revisions (ICC = 0.75, 95% CI: 0.59-0.91). Pearson Correlation analysis revealed no significant relationship between AGT scores and BREAST-Q scores when surveying healthcare providers (mean = 0.145, 95% CI: [-0.35, 0.32], p = 0.94) (median = 0.06, 95% CI: [-0.28, 0.87], p = 0.73) or patients (mean = 0.15, 95% CI: [-0.19, 0.46], p = 0.41) (median = 0.17, 95% CI: [-0.17, 0.48], p = 0.32).

Conclusion: The AGT provides a validated, reliable measure for assessing aesthetic outcomes in bilateral DIEP flap reconstruction. The lack of correlation with BREAST-Q scores indicates that BREAST-Q may not be a reliable proxy for assessing aesthetic outcomes.

Background: Patients with or at risk for breast cancer may opt for risk-reducing gynecologic surgeries, including bilateral salpingo-oophorectomies and/or total abdominal hysterectomy. The timing and safety of combining these procedures with autologous breast reconstruction (ABR) are debated. This study assesses the impact of concurrent ABR and gynecologic surgeries on clinical and patient-reported outcomes.

Methods: Female patients who underwent ABR from 2010 to 2023 were included. Three groups were compared: (1) same-day ABR with gynecologic surgery, (2) staged ABR and gynecologic surgery, and (3) ABR alone. Clinical and patient-reported outcomes included operative time, length of stay (LOS), complications, return to the operating room, and BREAST-Q Physical Well-Being of the Abdomen scores.

Results: A total of 2288 patients were included. Of these, 66 had simultaneous surgeries (Group 1), 256 had staged surgeries (Group 2), and 1966 had ABR alone (Group 3). There were no meaningful differences in operative time, return to the operating room, LOS, or overall complication rates. Seroma occurrence was significantly lower in Group 3 than Group 2 (6.1% vs. 6.3% vs. 3.5%; p = 0.046) which emerged during pairwise comparisons. BREAST-Q Physical Well-Being of the Abdomen scores did not significantly differ among the three cohorts at preoperative, 6-month postoperative, and 1-year postoperative time points.

Conclusion: The findings indicate that simultaneous ABR and gynecologic surgeries do not significantly impact complication rates, operative times, hospital stays, or patient-reported abdominal well-being, supporting that simultaneous surgery as a safe and efficient approach for appropriate patients.

Backgrounds: Currently, there is a lack of evidence of prehabilitation during neoadjuvant chemotherapy (NAC) to prevent pneumonia of older patients. This study aimed to investigate the association of preoperative physical fitness after NAC with post-esophagectomy pneumonia in older patients with locally advanced esophageal cancer (LAEC).

Methods: This single-center exploratory prospective cohort study included 80 patients aged ≥ 65 years with LAEC scheduled for curative esophagectomy after NAC between 2021 and 2023. The post-NAC short incremental shuttle walk test (ISWT) by sex was established using the Youden index. The association of the post-NAC short ISWT with postoperative pneumonia was investigated via Firth's penalized logistic regression model with statistical significance set as two-tailed p < 0.05.

Results: A total of 69 patients were analyzed. The mean post-NAC ISWT values were 353.5 m. Short ISWT distance was defined as ≤ 395 and ≤ 195 m for men and women, respectively. Postoperative pneumonia developed in 17 (25%) patients. Short post-NAC ISWT distance was significantly associated with postoperative pneumonia (adjusted odds ratio: 1.840, 95%CI: 1.760-28.440, p = 0.004).

Conclusions: Decline in physical fitness was associated with post-esophagectomy pneumonia, which may be a key targeted factor of prehabilitation during NAC for older patients with LAEC.

Introduction: Malignant melanoma is a heterogeneous disease, with varying outcomes depending on the patient's race and ethnicity. Advanced stages can be tackled by novel targeted therapies and immunotherapy. We aimed to investigate the real-world data in Latino-Hispanic patients diagnosed with Stage III melanoma residing in Peru, a region marked by limited resources and healthcare infrastructure.

Methods: Patients diagnosed with Stage III melanoma at the Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru were included from the years 2010 to 2020. Cox regression analysis was used to assess prognostic factors.

Results: Four hundred twelve patients were included, the median age of diagnosis was 63 years, with a male predominance (55.6%). Most of the patients presented with a lesion in the lower extremities (77.4%), acral lentiginous melanoma (35.4%), and ulcerated tumors (72.3%). 64.1% were diagnosed with Stage IIIC, and 27.2% received interferon-alpha therapy. With a median follow-up of 36 months, the relapse-free survival and overall survival rates were 26% and 78% at 3 years follow-up, respectively. Prognostic factors of event-free survival (EFS) were greater age (HR = 1.015, 95% CI: 1.005-1.025), ulcerated lesions (HR = 1.855, 95% CI: 1.221-2.820), N category, and the administration of interferon therapy (HR = 0.680, 95% CI: 0.488-0.947). While worse overall survival (OS) was associated with greater ages (HR = 1.032, 95% CI: 1.011-1.053) and the presence of ulceration (HR = 2.992, 95% CI:1.142-7.835).

Conclusion: Stage III melanoma in the Hispanic-Latino population from Peru has worse survival rates than other races and populations despite similar prognostic factors of worse EFS and OS. In resource-limited settings, reducing barriers to receiving healthcare and broadening access to contemporary immunotherapy and targeted therapy are crucial measures to improve outcomes in patients with advanced melanoma.

Background and methods: The incidence of pancreatic cancer is increasing, and up to 55% of patients present with metastatic disease at the time of diagnosis. Many patients also develop metastatic disease following surgical resection. The impact of metastatic patterns on outcomes has not been described. A retrospective chart review was conducted of patients with pancreatic adenocarcinoma treated at a tertiary care center from 2012 to 2023. Patients who presented with metastatic disease or developed metastatic disease during their treatment course were identified. Univariate analysis was performed to identify factors associated with specific metastatic patterns. Kaplan-Meier survival curves were estimated for metastatic sites and stratified by treatment.

Results: Of the 330 patients identified, 192 (58.2%) presented with locoregional disease and underwent curative intent surgery before developing metastases, and 138 (41.8%) presented initially with metastatic disease. Median overall survival (OS) with metastases for all patients was 6 months. For patients who underwent curative intent surgery, OS was significantly worse for those who developed peritoneal metastasis compared to patients who developed other sites of metastases (median OS 5.4 vs. 9.2 months, p = 0.0005).

Conclusion: The development of peritoneal metastases after surgery for pancreatic cancer is associated with worse OS compared to other sites of metastatic disease.

Background and objectives: Immediate lymphatic reconstruction (ILR) performed to prevent breast cancer related lymphedema is not consistently covered by insurance payors in the United States.

Methods: Retrospective review was performed on a prospective database of ILR candidates from 2018 to 2022. Candidates were identified as patients with clinical axillary lymph node involvement at the time of breast cancer diagnosis. Patient demographics, insurance type, and development of lymphedema were recorded.

Results: One hundred and eighty ILR candidates were identified, 50 of whom underwent ILR. Non-ILR patients were more likely to be of black race, have Medicaid health insurance, earn lower median household income, and have lower rates of out-of-pocket payment when not covered by insurance. In 40 cases where ILR was indicated but not performed, 55% were due to financial reasons. After a minimum of 1 year follow up, 14.6% (6/41) of patients who underwent ILR had lymphedema, compared with 12.5% (9/72) of patients who had no clinical indication for ILR and 40% (10/25) of patients who did not undergo ILR when clinically indicated (p = 0.012).

Conclusions: Disparities in insurance coverage and financial resources may adversely impact access and outcomes in patients clinically indicated for ILR.

Introduction: Racial disparities in minimally invasive surgery (MIS) utilization across gastrointestinal (GI) cancers are not well characterized. We evaluated racial/ethnic disparities in the use of MIS approaches and associated outcomes.

Methods: We analyzed a cohort of patients with GI cancer in the National Cancer Database (2010-2020). Multinomial logistic regression was used to evaluate associations between race/ethnicity and approach. Logistic regression was used to assess 30-day readmission and 90-day mortality. Cox regression was used to analyze overall survival. Models were adjusted for demographics, clinical characteristics, cancer factors, and facility features.

Results: Of the 839 398 patients included, 76.9% were White, 11.6% Black, 6.6% Hispanic/Latino, 4.0% Asian, and 0.3% Indigenous. Compared with patients of White race, the odds of robotic surgery were lower for Black (OR 0.89, 95% CI 0.86-0.93) and Indigenous patients (OR 0.72, 95% CI 0.59-0.89), but higher for Hispanic/Latino (OR 1.12, 95% CI 1.08-1.17) and Asian patients (OR 1.27, 95% CI 1.21-1.34). Indigenous patients had higher odds of readmission (OR 1.41, 95% CI 1.23-1.62), 90-day mortality (OR 1.31, 95% CI 1.11-1.54), and worse overall survival (HR 1.11, 95% CI 1.05-1.18).

Conclusion: Indigenous and Black patients have lower utilization of minimally invasive approaches and worse outcomes in GI cancer care.