7.13 CA19-9 Levels Can Predict Findings at Diagnostic Laparoscopy in Pancreatic Cancer:A Prospective Study

Posted on December 22, 2014

S. Gopinath1, U. Ballehaninna1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2Rutgers University, New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 3Saint George’s University,Department Of Surgery,Grenada, Grenada, Grenada

Introduction: Serum CA 19-9 levels assessment is a cornerstone of pancreatic cancer management as it plays an important role in the diagnosis, prognosis, response to treatment and staging.  To date very few studies have assessed whether preoperative serum CA 19-9 levels can reliably predict laparoscopic findings, in terms of both resectability and the identification of  pancreatic cancer metastases in pancreatic cancer patients deemed resectable on traditional imaging studies. 

Methods: Clinico-pathologic characteristics including serum CA 19-9 levels were prospectively collected in 58 patients with pancreatic cancer deemed resectable by preoperative work up.  Intraoperative data collection included findings at laparoscopy (peritoneal and liver metastasis) and/or operative exploration (resectable or unresectable). Wilcoxon-Rank- Sum test was used to determine whether preoperative serum CA 19-9 levels correlated with findings at laparoscopy, assess tumor resectability and staging.

Results:Fifty-eight patients with pancreatic cancer underwent diagnostic laparoscopy followed by surgical exploration with curative intent. Mean age was 67.5 years (range, 43-88 years).  Preoperative serum CA 19-9 levels in these patients ranged from 2-3344 u/ml. Peritoneal or liver metastasis was identified by laparoscopy in 23 patients (40%) whereas 35 patients (60%) underwent curative pancreatic resection. Mean serum CA 19-9 levels for resectable tumors were 927.5 u/ml (range; 9-6137) compared to 2362.9 u/ml (range 2-26871) in unresectable tumors. A mean serum CA 19-9 level of 2362.9 u/ml was statistically significant in predicting inoperable pancreatic tumor at the time of laparoscopy.  A linear correlation of serum CA 19-9 levels with pancreatic cancer stage was also observed (Figure)

Conclusion:Preoperative serum CA 19-9 levels have excellent correlation with diagnostic laparoscopy findings in regards to determining pancreatic cancer resectability. Given the wide range of serum CA-19-9 levels observed in this small study, large scale studies are necessary to more precisely define more narrow  serum CA-1-9-9 levels that can be used clinically to accurately predict pancreatic cancer stage and to differentiate resectable from unresectable pancreatic cancer.

 

7.14 Safety and efficacy of intraoperative radiotherapy in treating locally advanced pancreatic cancer

Posted on December 22, 2014

X. Che1, Y. Chen1, J. Zhang1, C. Wang1  1Cancer Hospital Chinese Academy Of Medical Sciences,Department Of Abdominal Surgical Oncology,Beijing, BEIJING, China

Introduction: Several studies have shown that intraoperative radiotherapy provides a marginal increase in the survival rate for patients with resectable pancreatic cancer. For locally advanced unresectable pancreatic cancer patients, however, the result was scarce and inconsistent. The aim of present study is to assess the safety and efficacy of intraoperative radiotherapy in unresectable pancreatic cancer.

Methods: From January 2008 to October 2013, 176 cases of locally advanced pancreatic cancer were treated with intraoperative radiotherapy and postoperative concurrent chemoradiotherapy and chemotherapy including 61 T3 cases and 115 T4 cases; maximum diameter of tumor: 3-9cm with an average of 5.1 ± 1.5cm; diameter of  applicator for IORT: 4-10cm with an average of 5.9 ± 1.0cm; irradiation intensity:6-15Mev with an average of 11.6 ± 1.1Mev; irradiation dose:1000-2000cGry with an average of 1400 ± 245cGry.

Results:Intraoperative blood loss of intraoperative radiotherapy was 50.5ml in average, postoperative pancreatic fistula was 4%, delayed gastric emptying was 9.9%, and the differences were not statistically significant compared with surgery alone. There was no level 3 or more hematologic toxicity. 49 patients were treated with intraoperative radiotherapy plus postoperative concurrent chemoradiotherapy and chemotherapy: median survival time was 14.7 months and survival rate for 1 year was 65%; rate of pain relief was 72%. As for conventional chemoradiotherapy without intraoperative radiotherapy, median survival time was 11.1 months, survival rate for 1 year was 23% and rate of pain relief was 41%. 

Conclusion:In conclusion, intraoperative radiotherapy may be delivered safely and effectively in combination with chemoradiotherapy for patients with locally advanced unresectable pancreatic cancer.

 

7.15 Preoperative Platelet to Lymphocyte Ratio is a Prognostic Factor for Pancreatic Cancer.

Posted on December 22, 2014

Y. Shirai1, H. Shiba1, T. Horiuchi1, R. Iwase1, K. Haruki1, K. Abe1, Y. Fujiwara1, K. Furukawa1, S. Onda1, D. Hata1, T. Sakamoto1, Y. Futagawa1, Y. Toyama1, Y. Ishida1, K. Yanaga1  1The Jikei University School Of Medicine,Department Of Surgery,Tokyo, TOKYO, Japan

Introduction

Pancreatic cancer is one of the most common digestive cancers, and only 10-20% are operable disease. There are several prognostic indices such as tumor size, nodal involvement, resection margin status, and tumor differentiation. However, preoperative estimation of oncological prognosis remains to be established. In several reports, preoperative platelet to lymphocyte ratio (PLR) and neutrophil to lymphocyte ratio (NLR) are significant prognostic indicators in digestive malignancies. The objective of this study was to evaluate whether preoperative PLR or NLR is a significant prognostic index in resected pancreatic invasive ductal adenocarcinoma.

Methods

A total of 131 patients who underwent pancreatic resection for pancreatic invasive ductal adenocarcinoma were available from prospective maintained database. The patients were divide into two groups as PLR <150 or ≥150, and as NLR <5 or NLR ≥5, respectively. Survival data were analyzed using the Log-rank test for univariate analysis and Cox proportional hazards for multivariate analysis. P value <0.05 was judged as significant.

Results

The preoperative PLR was a significant prognostic index by Kaplan-Meier and Log rank tests. The median Overall Survival in patients with PLR <150 was 38.6 months, which was significantly better than 17.6 months for PLR ≥150 (p=0.001). The PLR retained its significance on multivariate analysis (HR, 1.688; 95 % CI, 1.045–2.726; p = 0.032) along with tumor size (p=0.035), resection margin status (p=0.048), and tumor differentiation (p=0.002).

Conclusion

The preoperative PLR is a significant independent prognostic index in resected pancreatic invasive ductal adenocarcinoma.

 

7.16 Should I Stay or Should I Go Now: Factors Influencing High Length of Stay After Pancreatectomy

Posted on December 22, 2014

M. Radomski1, A. Zureikat1, S. M. Novak1, J. Steve1, J. Marsh1, K. K. Lee1, A. Tsung1, D. Bartlett1, H. J. Zeh1, M. E. Hogg1  1University Of Pittsburgh,Pittsburgh, PA, USA

Introduction: In this healthcare climate, much scrutiny is being paid to cost, readmission, and length of stay (LOS).  Complex pancreatic surgeries have been associated with prolonged postoperative courses.  Many studies have looked at overall data and low outliers for pancreaticoduodenectomy.  However, little exists on high outliers and factors that contribute to prolonged stays.  We sought to evaluate the contribution of social, preoperative, operative, and postoperative patient related factors to extended LOS in major pancreatic resections.

Methods: A retrospective review of a single institution’s pancreaticoduodenectomies (PD) and distal pancreatectomies (DP) was performed from 6/2009 to 3/2014 for all pathologies and technical approaches. Interquartile ranges (IQR) were calculated and the highest quartile was evaluated and compared to the lower three quartiles.

Results:A total of 350 PD (42% open) and 127 DP (21% open) patients were analyzed with a 3rd IQR of >14 and >8 days respectively. Social factors including race, distance, insurance status, and marital status were not significant for PD; however, divorce was associated with longer LOS in DP (p<0.0001).  Pre-operative characteristics of higher age (p=0.0003), age adjusted Charlson Comorbidity Index (p=0.002), body mass index (p=0.01), and American Society of Anesthesia assessment (ASA, p=0.005) were associated with increased LOS in PD; whereas, only higher ASA (p=0.0188) was associated in DP.  Albumin, Ca19-9, previous abdominal surgery, and neoadjuvant therapy were not significant for PD or DP.  Increased operative time (p=0.009), blood loss (EBL, p=0.03), and transfusion (p=0.03) all were associated with longer LOS in PD; however, only EBL (p=0.03) was associated with longer LOS in DP.  A trend toward more LOS outliers was seen in the open PD group (p=0.06) compared with robotic, but not in the DP group (p=0.63). For the PD group, pancreatic fistula (p<0.0001), delayed gastric emptying (p<0.0001), and pseudoaneurysm (p<0.0001) were associated with extended hospitalizations.  No specific post-operative complications led to increased LOS in the DP group but the high LOS group was more likely to have had any complication (p=0.007) compared to the rest of the cohort.  High LOS outliers were more likely to go to skilled nursing facilities, acute care facilities, and rehab than home in both PD (p=<0.0001) and DP (p=0.005) groups.  The high LOS group had more readmission in the PD group (p=0.005) but not in the DP group (p=0.64).

Conclusion:More patient pre-, intra-, and post-operative factors lead to high LOS outliers seen in the PD group than the DP group; but the DP group also had a social factor associated with increased LOS.  Pre- and Intraoperative factors are hard to change, but further subgroup analysis in the PD group looking at management of specific complications and physician related factors may help identify better or sooner management to decrease LOS for these factors.

7.17 The Bipedicled, Conjoined Deep Inferior Epigastric Perforator (DIEP) Flap: a Concept in Evolution

Posted on December 22, 2014

P. G. Koolen1, B. T. Lee1, H. Erhard3, D. Greenspun2  1Beth Israel Dearoness Medical Center,Division Of Plastic Surgery,Boston, MA, USA 2Greenwich Hospital,Division Of Plastic Surgery,Greenwich, CT, USA 3Albert Einstein College Of Medicine,Division Of Plastic Surgery,Bronx, NY, USA

Introduction:

Autologous tissue transfer remains a mainstay for reconstruction of the breast. The deep inferior epigastric perforator artery (DIEP) flap has become a primary option at many institutions, yielding satisfactory aesthetic results. This type of reconstruction remains a challenge in thin patients with scant abdominal tissue or in previously irradiated breasts. Previous studies have described the use of stacked DIEP flaps, divided at the midline. We report on a modification with the use of a bipedicled, conjoined DIEP flap in thin patients; this avoids division of preexisting midline vasculature. 

Methods:

Patients undergoing a bipedicled, conjoined DIEP flap procedure for unilateral breast reconstruction over the course of two years were included in this study. Pre-operative imaging was obtained using MRA or CTA to support surgical planning of the primary and secondary vascular pedicles. Utilization of the entire abdomen was required for volume and the vascular networks were isolated on both sides. The primary flap was anastomosed to the internal mammary vessels and inset medially, whereas the secondary flap was folded towards the lateral side and a vascular anastomosis was performed from the secondary pedicle to side branches of the primary pedicle (Figure 1). Surgical technique was standardized for consistency.

Results:

We report on our experience with 27 patients undergoing bipedicled, conjoined, stacked DIEP flaps for unilateral (n=25) or bilateral (n=2) breast reconstruction. Important advantages included good volume, projection, ability to sculpt the flap, and creation of a teardrop shaped breast mound. In patients with previous radiation, the additional skin supplied by using both sides of the abdomen allowed for extensive replacement of damaged mastectomy skin. The secondary flap has blood supply across the midline as well as the second vascular pedicle and had “supercharged” perfusion, unlike in stacked flaps where the midline tissue is divided.
 

Conclusion:

Bipedicled, conjoined DIEP flap procedures are a reliable modification in patients requiring the entire abdominal tissue volume to create a unilateral breast. In using both vascular pedicles and preserving the midline blood supply, this allows for maximal perfusion of both flaps. This modification can be used in thin patients with limited abdominal tissue and does not require contralateral reduction procedures or use of alternative flaps.  
 

7.18 The Impact of Tumescent Technique on Outcomes of Autologous Breast Reconstruction

Posted on December 22, 2014

C. R. Vargas1, P. G. Koolen1, J. A. Ricci1, B. T. Lee1  1Beth Israel Deaconess Medical Center,Surgery / Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:
Use of the tumescent dissection technique during mastectomy has been reported to facilitate development of a hydrodissection plane, to shorten operating time, to reduce operative blood loss, and to provide additional local anesthesia.  Despite these advantages, the impact of this technique on post-operative outcomes remains unclear.  Several prior studies have suggested that tumescent dissection has a negative impact on post-operative complications following immediate implant placement, however, the effect on autologous reconstruction has not been clearly established.

Methods:
A retrospective review was conducted, using a prospectively maintained database, of all immediate autologous breast reconstruction procedures performed at a single academic center between January 2004 and December 2013.  Electronic patient records were queried for age, BMI, diabetes, active smoking, pre-reconstruction radiation therapy, mastectomy weight, and tumescent technique during mastectomy.  Mastectomy weight was divided into quartiles for improved clinical interpretation.  All post-operative occurrences of breast hematoma, seroma, and mastectomy skin necrosis were also collected.

Results:
A total of 698 immediate autologous post-mastectomy breast reconstruction flaps were performed during the study period; mean patient age was 49.3±8.3 years and average mastectomy weight was 769.3±413 grams.  49.2% of the mastectomies were performed using the tumescent dissection technique.  Univariate analysis revealed no significant difference in the incidence of breast hematoma (p=0.779), seroma (p=0.180), or mastectomy skin necrosis (p=0.688) in patients who underwent tumescent dissection during mastectomy.  Multivariate analysis, adjusted for clustering related to bilateral reconstruction, also demonstrated no significant association between the use of tumescent technique and post-operative breast hematoma (p=0.978), seroma (p=0.340), or mastectomy skin necrosis (p=0.759) after covariate adjustment.

Conclusion:
Use of the tumescent dissection technique during mastectomy is not significantly associated with adverse outcomes following autologous breast reconstruction.  Despite concern for its impact on implant reconstruction, our findings suggest that the tumescent method can be used safely in conjunction with autologous procedures.

7.19 From Free Flaps to Freestyle Locoregional Perforator Subunit Flaps- a Paradigm Shift over 230 Cases.

Posted on December 22, 2014

M. W. Findlay1,2,3,4, S. Sinha2, A. Rotman2, J. Ting2, S. Fairbank1, T. Wu2, F. Behan2  1Stanford University,Division Of Plastic And Reconstructive Surgery,Palo Alto, CA, USA 2The Peter MacCallum Cancer Centre,Divison Of Surgical Oncology,East Melbourne, VIC, Australia 3The University Of Melbourne,Department Of Surgery Royal Melbourne Hospital,Parkville, VIC, Australia 4Monash University,Combined Plastic And Reconstructive Surgery Unit,Clayton, VIC, Australia

Introduction: Perforator-based locoregional flaps provide tissue reconstruction with a shorter operative time, length of stay and fewer complications than free flaps in the head and neck. However, the vascular pedicles for common locoregional flaps can be compromised by previous surgery and/or injury and outcomes data based on large case series are lacking within the literature. Our practice has evolved from ‘random’ Keystone flaps to bespoke freestyle perforator subunit-based flaps over the past 6 years and we examined the outcomes data of over 230 cases during this time to examine the outcomes from our approach relative to large published series of free flap reconstructions.

Methods: Over 230 flaps performed over a 6-year period at two clinical centres within Australia were reviewed with institutional ethics approval.  The technique for perforator selection, flap design, elevation and closure are described using operative sequences along with our modifications to subunit-based reconstruction using Keystone flap principles. Prospectively collected data including patient comorbidities, pathology, defect size, flap type and perioperative complications were combined with retrospective data such as complication profile and length of follow up for the analysis. 

Results:Over 230 flaps were performed in the period between 2006 and 2012 for defects ranging from 4cm2 to 121cm2. Median patient age was 76 (range 19-98 years) with an average of 2 comorbidities per patient. The median operative time was under 100 minutes (inclusive of resective time). There was one peri-operative death (Day 5 post-op), 7 major complications including one complete flap loss and 4 partial flap losses requiring operative management. Pre- or post-operative radiotherapy and/or chemotherapy were associated with increased risk of complications.

Conclusion:An analysis of the outcomes from over 230 perforator-based island flaps in the head and neck demonstrates comparable results to free flap reconstruction, but with the added benefits provided by locoregional reconstruction. Our technique has evolved from ‘random’ Keystone flaps through to bespoke flaps based on specific perforators for esthetic unit reconstruction with shorter operative times and lower morbidity than free flap reconstruction.

 

7.20 Occult Neoplasms in Appendicitis: A Single-Institution Experience of 1793 Appendectomies

Posted on December 22, 2014

C. M. Forleiter1, J. A. Schwartz1, D. Y. Lee1, G. J. Kim1  1Mount Sinai School Of Medicine,Mount Sinai Roosevelt Hospital / Department Of Surgery,New York, NY, USA

Introduction: The incidence of appendiceal neoplasms may have been underreported in the past. Patients undergoing incidental appendectomies or appendectomies for chronic appendicitis may be at a higher risk for an occult appendiceal neoplasm. 

Methods:  Retrospective review of a pathology specimen database spanning four years at a tertiary care hospital center.  

Results: A total of 1,793 appendectomy specimens were evaluated.  There were 31 (1.7%) appendiceal neoplasms.  Fourteen neoplasms were discovered in 1,337 (1.0%) cases of acute appendicitis compared to 2 in 41 (4.9%) cases of chronic and 15 in 415 (3.6%) cases of incidental appendectomies (p < 0.001).  Patients with carcinoid tumors were significantly younger compared to others (p = 0.0001).  On multivariate analysis, indication for operation was the only significant factor for predicting a tumor.

Conclusion: Patients undergoing interval or incidental appendectomies may be at a higher risk for appendiceal neoplasm compared to other indications.  Younger patients may be at a higher risk of occult appendiceal carcinoid neoplasms than other age groups.  Pathologic diagnosis in specific high-risk patient groups may be the only way to effectively capture these tumors for optimal treatment. 
 

7.01 The Safety of Esophago-Gastrectomy in Patients Older than 80 Years: Risk vs. Benefits

Posted on December 22, 2014

M. Melis1, A. Masi1,2, A. Pinna1, I. Hatzaras1,2, S. Cohen1, R. S. Berman1, G. Ballantyne1, H. Pachter1, E. Newman1  1New York University School Of Medicine,New York, NY, USA

Introduction: Gastro-esophageal surgery can generally be performed with mortality lower than 5% and morbidity of 30-50%, but little is known about results of esophagectomy and gastrectomy in octogenarians. We investigated outcomes after resection of stomach and/or distal esophagus for cancer in patients ≥ 80 year-old.

Methods: From our gastro-esophageal cancer database we identified 289 patients who underwent surgery (1990-2010) for cancer. We categorized patients into two groups, according to age at time of surgery: Group O (≥ 80 year-old) and Group Y (< 80 year-old). The study end-points were overall morbidity, 30-day mortality, overall survival (OS). Differences between groups were evaluated using t-test or chi-squared test. Survival was compared using Kaplan–Meier analysis and log-rank test.

Results: There were 50 patients in group O (mean age 85) and 239 in Group Y (mean age 64.3). As expected, octogenarians had worse ECOG performance status (PS ≤ 1: 84% vs. 91.2%, p < 0.001) and higher incidence of specific comorbidities. Operative time, blood loss, AJCC stage, and status of resection margins were similar between groups. Octogenarians had similar 30-day morbidity (36.0% vs. 37.7%, p=0.82) and post-operative mortality (6% vs. 2.5%, p=1.96). At median follow-up of 21.8 months OS was 13.1 and 29.2 months respectively in Group O and Y (p=0.10)

Conclusions: In our experience, despite a higher incidence of pre-operative co-morbidities, early and long-term post-operative outcomes in octogenarians were similar to those of younger patients. Radical surgery can be safely offered to carefully selected octogenarians with gastric or esophageal cancer.

7.02 Sentinel Lymph Node Mapping for Cutaneous Squamous Cell Cancer

Posted on December 22, 2014

M. A. Bartz-Kurycki1,2, R. S. Krouse1,2  1Southern Arizona VA Health Care System,Tucson, ARIZONA, USA 2University Of Arizona,Surgery,Tucson, AZ, USA

Introduction: Cutaneous squamous cell cancers (cSCC) are typically non-aggressive, although certain features may indicate possible nodal metastasis. As sentinel node (SLN) mapping may be of utility for high risk cSCC, it is important to evaluate patients who have undergone this procedure.

Methods: A prospective database has been developed by a single surgeon who cares for the majority of aggressive cSCC at the Southern Arizona Veterans Affairs Healthcare System. Patients with multiple poor prognostic indicators (age >75, immunocompromised, differentiation, site of tumor, size of tumor, histologic subtype) were offered SLN. The reason for not offering SLN was poor clinical status. Patient characteristics and screening tests were evaluated.

Results: 68 patients with cSCC underwent SLN over 9 years. All patients were male. 5.98% (4/68) patients had positive metastatic cSCC; 3 patients had false negatives seen with nodal recurrences. Screening tests showed a sensitivity of 57.1% and accuracy of 94.1%. Patients with positive SLN (at time of operation or recurrence) were more likely to have moderately to poorly differentiated tumors, be immunocompromised, or age > 75.  All patients with positive nodes had at least 3 poor prognostic indicators.

Conclusion: SLN mapping likely has utility for cSCC patients with multiple poor prognostic indicators. As most patients have head and neck tumors, there are more likely to be false negatives and close follow-up is indicated.

 

7.03 Sentinel Lymph Node Biopsy Is Accurate In Merkel Cell Cancer

Posted on December 22, 2014

A. C. Gasior1, A. Gingrich1, S. Deas1, J. Mammen1  1University Of Kansas,Surgery,Kansas City, KS, USA

Introduction:
Merkel cell cancer (MCC) is a rare and aggressive cutaneous neuroendocrine neoplasm. Sentinel lymph node biopsy (SLNB) is often used to assess for nodal metastases in breast cancer and melanoma, but the accuracy of SLNB for MCC is less well described with false negative rates varying from 0 to 50% (most studies based on administrative databases without consistent follow-up).  In this study, we evaluated a single institution retrospective database of patients diagnosed with MCC to establish the accuracy of SLNB.

Methods:
After IRB approval, a single institution database was created spanning from January 2007 through December 2013. Patients had the standard SLNB technique of dual tracer evaluation (vital blue dye and radiolabelled sulfur colloid.) Patients were scheduled for surveillance every 6 months after surgery. Descriptive and chi-square analysis were used for statistical evaluation.

Results:
Of our 17 patients, the majority (64.7%) were male and over 66 years of age (52.9%). 15 patients (88.2%) had SLNB. The mean number of lymph nodes removed for sentinel lymph node biopsy was 2.6. 13/15 (86.7%) of SLNB were negative. Neither age, cancer site, nor size were independent predictors of nodal positivity. Of the 2 patients with positive SLNBs, only one patient had non-sentinel nodes (3/15) positive on subsequent lymphadenectomy. Of patients with negative SLNBs, there was no evidence of lymph basin only recurrence at follow-up in any patients (false negative rate of 0%).  Median length of follow-up was 12 months. 

Conclusion:
Previous MCC studies show extent of disease at presentation to be the greatest factor predictive of survival.  In our study of early clinical stage MCC, patient factors were not identified to predict pathologic nodal involvement.   In one of the largest series of patients with MCC evaluated with SLNB, the false negative rate was identified to be 0% suggesting that SLNB is an accurate technique to stage MCC patients for nodal metastases.

7.04 Goblet Cell Neuroendocrine Carcinomatosis treated with Cytoreductive Surgery and HIPEC

Posted on December 22, 2014

R. W. Randle1, K. F. Griffith1, K. R. Swett2, J. H. Stewart1, P. Shen1, E. A. Levine1, K. I. Votanopoulos1  1Wake Forest University Baptist Medical Center,Surgery,Winston-Salem, NORTH CAROLINA, USA 2Wake Forest University Baptist Medical Center,Biostatistics,Winston-Salem, NORTH CAROLINA, USA

Introduction:  Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an aggressive treatment for patients suffering with peritoneal carcinomatosis.  It is commonly applied to low-grade mucinous tumors of the appendix disseminated throughout the peritoneal cavity, yet some high volume centers have extended this therapy to carcinomatosis from a variety of more aggressive primary malignancies.  Therefore we decided to review our experience with CRS-HIPEC for patients with carcinomatosis from goblet cell neuroendocrine carcinomas.

Methods:  Patients with carcinomatosis and final pathology confirming goblet cell features were identified in a prospectively maintained database of 1069 CRS-HIPEC procedures performed between 1991 and 2013.  Patient demographics, disease characteristics, morbidity, mortality, and survival were reviewed.  

Results:  A total of 25 patients with goblet cell neuroendocrine carcinomatosis underwent CRS-HIPEC during the study period.  Tumors originated in the appendix in 23 (92%) patients and in the colon in 2 (8%).  Patients were generally young (mean age 53 years) and otherwise healthy (84% without comorbidities) with good performance status (92% ECOG 0 or 1).  The mean number of visceral resections was 3.6, and complete cytoreduction of all macroscopic disease was accomplished in 36% prior to HIPEC.  The 30-day major morbidity and mortality were 36% and 8%, respectively.  Median overall survival for all patients was 16.5 months.  In univariate analysis, significant predictors of decreased survival included worse performance status (hazard ration [HR] 2.2, 95% confidence interval [CI] 1.1–4.4, p=0.03) and nodal involvement (HR 9.6, 95% CI 1.2–73.8, p=0.03).  Despite similar volume of peritoneal disease, patients with negative nodes had better survival than those with positive nodes (median overall survival 32.7 months vs. 9.9 months), respectively (p=0.01).  While complete cytoreduction was associated with longer survival following CRS-HIPEC in all patients (R0/R1 median overall survival 28.5 months vs. R2 median overall survival 9.9 months, p=0.19) and in those with nodal disease (R0/R1 median overall survival 16.5 months vs. R2 median overall survival 8.5 months, p=0.07), neither observed difference reached statistical significance.

Conclusion:  CRS-HIPEC may improve survival in patients with node negative goblet cell neuroendocrine carcinomatosis when a complete cytoreduction is achieved.  Patients with disease not amenable to complete cytoreduction should not be offered CRS-HIPEC.

 

7.05 Recurrence and Prognostic Factors after Cytoreductive Surgery and HIPEC for Appendiceal Cancer

Posted on December 22, 2014

M. Mavros1, L. Bijelic1, U. Hyder1, A. Firoozmand1, C. Ihemelandu1, P. Sugarbaker1  1MedStar Washington Hospital Center,Department Of Surgery,Washington, DC, USA

Introduction: Appendiceal cancer most commonly metastasizes to the peritoneum. Cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC) has become the leading treatment modality for peritoneal metastases. We sought to analyze clinical outcomes after CRS and HIPEC for appendiceal cancer in a recent cohort of patients treated at a large referral center and identify prognostic factors and predictors of recurrence.

Methods: Patients undergoing CRS with HIPEC for appendix cancer in a large tertiary care referral center between January 2007 and December 2009 were identified. Prospectively collected data were analyzed, including standard preoperative, intraoperative, and postoperative variables; the impact of prior surgical score (PSS), peritoneal cancer index (PCI), and completeness of cytoreduction score (CCS) was specifically assessed. Multivariate Cox regression models were developed to identify factors independently predicting overall survival and recurrence.

Results: A total of 134 patients were analyzed. Median age was 51 years and 53% were female. Roughly half had previous abdominal operations (PSS≥2, 53%), extensive peritoneal dissemination (PCI≥21, 52%), or the PMCA variant (54%); few had lymph node metastases (11%). Median operative time was 9 hours, and most of the patients received RBC (73%) or FFP (47%) transfusions; 30-day mortality was 0.7%. Half of the patients underwent early postoperative intraperitoneal chemotherapy (49%), and a large proportion experienced at least one postoperative complication (minor, 37%; major, 25%). Overall survival (OS) at 5 years was 74.4%; 5-year recurrence-free survival (RFS) of patients with a complete cytoreduction (CCS≤1) was 65.5%. Factors independently predicting shorter survival included the PMCA variant [Hazards Ratio (HR)=12.74, 95% CI: 3.77–43.05)], lymph node metastasis [HR=2.58 (1.15–5.79)], and incomplete cytoreduction [CCS≥2, HR=5.93 (2.85–12.34)]. Similarly, factors predicting recurrence included the PMCA variant [HR=7.03 (3.35–14.78)] and lymph node metastasis [HR=4.00 (1.74–9.19)]. An incomplete cytoreduction was associated with the PMCA variant (p<0.001), but also more advanced peritoneal disease (PCI≥11, p=0.012) and prior abdominal surgeries (PSS≥2, p=0.033).

Conclusion: CRS with HIPEC can be performed with acceptable morbidity and mortality at an experienced referral center and achieve long term survival for patients with advanced appendix cancer. Histologic subtype and lymph node metastasis, along with complete cytoreduction are the most important predictors of overall survival. Efforts should be made for timely definitive CRS/HIPEC, avoiding prior non-definitive abdominal operations when possible.

7.06 Advanced Nutritional Support after Esophagectomy for Esophageal Cancer

Posted on December 22, 2014

S. Ajmal1, T. Ng1, A. M. Blakely1, W. G. Cioffi1, T. J. Miner1  1Brown University School Of Medicine,Department Of Surgery,Providence, RI, USA

Introduction:  Various modalities are employed to provide nutritional support to patients after esophagectomy for esophageal cancer. Routine Jejunostomy tubes are placed in patients with esophageal cancer to provide nutritional supplementation in perioperative setting. Total parenteral nutrition is also utilized when patients have complications or delayed oral intake. We sought to study the utility and complications associated with these nutritional support modalities.

Methods:  We performed a retrospective chart review of all adult patients who underwent esophagectomy for esophageal cancer from 2001 to 2014 at a single tertiary care institution. We reviewed the utility of jejunostomy tube and complications associated with jejunostomy tubes.

Results: 182 patients underwent esophagectomy for esophageal cancer during the study period. Esphageal cancer types included 158 adenocarcinomas, 15 squamous cell carcinomas, 8 high grade dysplasias and 1 neuroendocrine tumor. 107 patients had Transhiatal resection, 55 had Ivor-lewis esophagectomy, 9 had Thoraco-abdominal resection and 10 patients had Three incision esophagectomy. 181 patients had a jejunostomy tube placed. At the time of discharge 88 (48.6%) patients were receiving nutrition through tube feeds. Out of these 88 patients, 34 (18.7%) had partial tube reliance while 53 (29.3%) had total tube reliance. 6 patients (3.3%) needed both jejunostomy tube feeds and total parenteral nutrition (TPN) while only one patient was just placed on TPN. Patient group that required tube feeds on discharge were more likely to have a complicated course than patients not on tube feeds (61 vs 12; p<0.05). Out of 181 patients with jejunostomy tubes, only 1 patient required surgical intervention due to catheter related complication. No mortality was reported due to catheter related complications.

Conclusion: Our data reveals that a significant number of patients require tube feeds at discharge. Serious morbidity secondary to jejunostomy feeding tube was rare. This further supports the current practice of placing routine feeding J-tubes for esophagectomies.

 

7.07 Patient Demographics and Clinical Outcomes in Pancreatic Cancer Based on Histological Subtype.

Posted on December 22, 2014

N. Poulsen1, S. Patil1, R. S. Chamberlain1  2Saint George’s University,Grenada, Grenada, Grenada 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA

Introduction:  Pancreatic ductal adenocarcinoma (PDC) makes up more than 90% of pancreatic tumors; however, other less common histological subtypes exist including acinar cell carcinoma (ACC), islet cell tumors (IC), neuroendocrine tumors (NE) and squamous cell carcinoma (SCC). While information on the clinical course, management and outcomes associated with adenocarcinoma of the pancreas has been extensively studied, information on other histological subtypes is limited. 

Methods:  Data on 100,727 patients with pancreatic cancer from the Surveillance Epidemiology and End Results (SEER) database (1973- 2008) was abstracted. Patients with PDC, ACC, IT, NE, and SCC were separately analyzed for age, gender, race, stage, treatment, and long-term survival. Categorical variables were compared using the Chi square test, and continuous variables were compared using ANOVA.

Results: PDC (N=95,271; 94.6%) was the most common form of pancreatic cancer identified followed by NE (N=2,922; 2.90%), IC (N=1,845; 1.83%), SCC (N=355; 0.34%) and ACC tumors (N=334; 0.33%). Pancreatic cancer occurs most commonly in Caucasian men in the 6th decade of life, however patients with IC tumors and NE tumors were significantly younger than those with PDC, ACC and SCC. All five subtypes presented most commonly with metastatic disease (PDC: 57.2%; ACC: 48.8%; IC: 48.3%; NE: 60.8%; and SCC: 60.0%). Overall survival was 1.43 years. Patients with IC tumors had the greatest mean survival (5.08 years), followed by NE tumors (2.96 years), ACC (2.79 years), and PDC/SCC (1.31 years each) (p< 0.001). Mortality was significantly greater in patients with SCC and PDC (96.3% and 93.9% respectively, p<0.001) compared to all other subtypes. Combination surgery and radiation therapy demonstrates the greatest 5- and 10-year survival rate in patients with PDC (19% and 10%), ACC (54% and 37%), and SCC (25% and 13%) (p<0.001). Surgical intervention alone demonstrates the greatest 5- and 10-year survival in IC tumors (74% and 56%) and NE tumors (76% and 58%) (p< 0.001). PDC and SCC had the lowest 5- and 10-year survival for all treatment modalities.

Conclusion: Pancreatic cancer is a devastating disease with an overall mortality greater than 65% independent of histological subtype. PDC and SCC demonstrate the lowest mean survival, highest mortality and appear to follow a similar clinical course independent of treatment modality. Despite an overall mortality rate of 66% and a mean survival of 5 years, pancreatic IC tumors are the most indolent pancreatic tumors. Surgical intervention appears to offer the greatest survival benefit to patients with IC and NE tumors, while combined surgical and radiation therapy appears to offer the greatest survival benefit to patients with PDC, SCC and ACC.      

7.08 Effect of High-Grade Disease on Colon Cancer Outcomes

Posted on December 22, 2014

R. Amri1,2, L. G. Bordeianou1,2, P. Sylla1,2, D. L. Berger1,2  1Massachusetts General Hospital,General And Gastrointestinal Surgery,Boston, MA, USA 2Harvard Medical School,Surgery,Brookline, MA, USA

Introduction:
Tumor grade is one of the cardinal characteristics used in the surgical pathological assessment of a malignancy. High-grade disease invariably has a negative impact on the eventual outcomes of the concerned malignancy. We aimed to measure the magnitude of its influence as well as its stage-independent effect in colon cancer. 

Methods:
All patients treated surgically at our center (2004 through 2011) with known disease grade were included in an institutional review board-approved database. We measured the relative risk (RR) of encountering distant and nodal spread of the disease in baseline pathology, as well as the risk of recurrence and overall and disease-specific mortality. In addition, a multivariate logistic regression adjusted for stage was used to assess the stage-adjusted odds ratio (OR).

Results:
A total of 961 patients with specified tumor grade were included for analysis. Of these, 191 (19.9%) patients had high-grade disease on baseline pathology. These patients were invariably at far higher risk of lymph node metastasis (63.7 vs. 38.2%; RR: 1.67) and metastatic presentation (30.9 vs. 15.3%; RR: 2.02) (both P<0.001). These baseline differences also led to a significantly higher risk of poor outcomes (all P<0.001), including disease recurrence (23.5 vs. 11.8%; RR: 1.99), overall mortality (56.5 vs. 31.8%; RR: 1.77) and colon cancer-specific mortality (34.6 vs. 16.6%; RR: 2.08). All of these findings were still statistically significant and within the same order of magnitude after adjusting of odds ratios for baseline staging in multivariate analysis.

Conclusion:
High-grade disease on baseline colon cancer surgical pathology is associated with a considerably higher rate of nodal and distant metastasis. As a result, the colon cancer-related mortality doubles for patients with high-grade disease. More interestingly, all of these findings were shown to be independent of baseline staging, confirming that high tumor grade is a stage-independent factor greatly influencing colon cancer outcomes and mortality.
 

7.09 Colon Cancer Patients with Inflammatory Bowel Disease Do Not Necessarily Have Worse Outcomes

Posted on December 22, 2014

R. Amri1,2, L. G. Bordeianou1,2, P. Sylla1,2, D. Berger1,2  1Massachusetts General Hospital,General And Gastrointestinal Surgery,Boston, MA, USA 2Harvard Medical School,Surgery,Boston, MA, USA

Introduction:
Inflammatory bowel disease (IBD) is associated with a high risk of developing colon cancer. Its relationship with the eventual outcomes is less evident, although recent reports have indicated that comorbid IBD may be associated with worse survival. We therefore aimed to review characteristics of colon cancer associated with IBD in our population.

Methods:
We evaluated outcomes of a patient cohort operated on for colon cancer between 2004 through 2011 in a public tertiary care center in a state providing universal healthcare, focusing on comparing surgical pathological characteristics and long-term outcomes between IBD patients and the remainder of the population.

Results:
We included 1071 patients, of whom 38 (3.5%) had a concurrent diagnosis of IBD: 21 (2.0%) having Crohn’s, 16 (1.5%) having ulcerative colitis, and 1 patient with a mixed form. IBD patients were significantly younger (median age 59.5 vs. 67 years; P<0.001). These patients had a significantly higher rate of high-grade disease (33.3 vs. 19.4%; P=0.034) and borderline significantly higher rates of AJCC stage I disease (36.8 vs. 24.4%; P=0.06). In terms of outcomes however, no statistically significant differences were encountered between patients with or without IBD. Clinically significant but not statistically significant differences demonstrated lower rates of lymph-node metastasis (31.6 vs. 40.6%; P=0.27) and metastatic presentation (13.2 vs, 17%; P=0.54), as well as better outcomes in terms of metastatic recurrence (9.1 vs. 12.7%; P=0.55), and colon cancer mortality (26.3 vs. 35.6% P=0.27). Point estimates in multivariate analysis adjusted for age and staging where appropriate showed no changes in these trends.

Conclusion:
IBD patients who develop colon cancer appear to have relatively better staging and outcomes compared to non-IBD patients. These differences were present despite significantly higher-grade disease on presentation. More aggressive tumor characteristics in colon cancer patients with comorbid IBD fit the findings in earlier literature, while slightly better outcomes in IBD patients are an uncommon finding. This incongruence may potentially be explained by regular surveillance in patients with IBD, which may provide a protective effect through early detection of cancers. Differences with earlier reports in outcomes and staging could potentially be related to universal healthcare in our state, facilitating comprehensive IBD follow-up at our center. These findings suggest that under adequate and regular follow up, IBD patients are not necessarily inherently worse off when diagnosed with colon cancer.

7.10 Predicting Success in Small Renal Mass Biopsy

Posted on December 22, 2014

J. M. Prince1, E. M. Bultman2, A. Drewry1, J. L. Hinshaw2, E. J. Abel1  1University Of Wisconsin,Department Of Urology,Madison, WI, USA 2University Of Wisconsin,Department Of Radiology,Madison, WI, USA

Introduction:   Percutaneous biopsy may provide important information for patients with small renal masses (SRM) prior to treatment.  However, 15-20% of patients undergoing biopsy receive indeterminate results, and thus do not benefit from the procedure.  The objective of this study was to evaluate clinical and anatomical factors that are predictive of obtaining indeterminate results from percutaneous SRM biopsy.

Methods:   Comprehensive clinical and anatomical factors were reviewed for consecutive SRM (≤4cm) patients treated with renal mass biopsy at the University of Wisconsin Hospital from 2000 to 2014.  Univariable and multivariable logistic regression analysis was performed to determine which factors were associated with indeterminacy. 

Results:  A total of 413 SRM biopsies were performed in 386 patients.  The median tumor size was 2.35 cm (IQR 1.90-2.95).  15.5% of the masses were cystic and 84.5% were solid.  Enhancement (>20 HU ) was seen in 84.0%, while 5.3% were pseudo-enhancing (10-20 HU), and 1.9% were non-enhancing.  A skin-to-tumor distance of ≥14 cm was observed in 4.1% of the masses.  Similar to previous studies, we observed an indeterminate rate of 17.4% in the entire cohort and among cystic lesions, the indeterminate rate was 43.8%.

After multivariable analysis, independent predictors of indeterminate biopsy included: cystic features (OR 4.91, 95% CI 2.46-9.83, p < 0.0001), tumor diameter (OR 0.59, 95% CI 0.39-0.90, p = 0.015), skin-to-tumor distance ≥14cm (OR 4.29, 95% CI 1.50-12.25, p = 0.0065), and radiographic enhancement (OR 3.61, 95% CI 1.52-8.56, p = 0.0036).

Other factors evaluated but not significant to predict indeterminate biopsy included: exophytic shape, hemorrhage, necrosis, fat content, calcifications, type of imaging modality used prior to and for guidance during biopsy, biopsy type (i.e. core or fine needle aspiration), patient BMI, proximity to adjacent organs, anteroposterior and polar positioning within the kidney and laterality of the mass.

Conclusion:  Four independent predictors for indeterminate biopsy are described including: cystic features, mean mass size, enhancement ≤20 HU, and skin-to-tumor distance ≥14cm.  These factors can be used to identify patients with a significant risk for a non-diagnostic biopsy result and facilitate better patient selection for this procedure.

7.11 Robotic and Laparoscopic Surgery for Colorectal Cancer Offer Comparable 3-5 Year Oncologic Outcomes

Posted on December 22, 2014

F. G. Wilder1,2, A. Burnett1, J. Oliver1, R. J. Chokshi1  1Rutgers – New Jersey Medical School,Surgery,Newark, NJ, USA 2Memorial Sloan-Kettering Cancer Center,New York, NY, USA

Introduction: Robotic surgery has been demonstrated to be a viable option for the resection of benign and malignant colorectal diseases. However, data thus far is lacking with regards to long-term oncologic outcomes. We sought to compare the longer term oncologic outcomes of robotic versus laparoscopic resection of colorectal cancer.

Methods: A literature search was performed using the Pubmed, EMBASE, Cochrane, and Medline databases for studies published between 2000 and 2014.  Search terms were: colon, rectal, robot, cancer, laparoscopic, oncologic and outcomes.  Studies that compared the overall and disease free survival of robotic versus laparoscopic surgery for patients with colon or rectal cancer were included.  Meta-analysis was performed using OpenMeta[Analyst] for Windows 8.

Results:There were 5 studies published between 2000-2014 that reported on overall survival (OS), disease free survival (DFS), lymph node (LN) extraction, circumferential resection margin (CRM), short and long-term recurrence. 317 patients across the 5 studies underwent either totally robotic or hybrid (robotic-assisted) resection of colon or rectal cancer.  Mean DFS with laparoscopic resection versus robotic resection was 86.2% (±4.4) and 86.9% (±4.0), respectively.  Mean OS with laparoscopic resection versus robotic resection was 93.4% (±3.2) and 91.3% (±4.1), respectively. Except for the Park study whose values were at 5 years, all groups reported DFS and OS at 3 years. At 5 years, Park found a DFS of 78.7% (±4.5) for LCS and 81.9% (±3.3) for RCS.  OS was 93.5% (±3.2) for LCS and 92.8% (±2.2) for RCS.  Robotic surgery was associated with slightly smaller resection margins (0.318cm, p=0.042), resection of fewer nodes (2.173 fewer nodes, p=0.0001), but equivalent odds of a positive CRM (OR 1.08, p=0.859).  

Conclusion: Robotic surgery offers comparable overall and disease free survival when compared to laparoscopic surgery for colorectal cancer.  However, longer-term follow up and larger patient populations need to be studied before official recommendations can be made.

 

6.15 The Impact of Obesity on Operative Time in Elective Colorectal Surgery Procedures

Posted on December 22, 2014

H. Saiganesh1, D. Stein1, J. L. Poggio1  1Drexel University College Of Medicine,Department Of Surgery, Division Of Colorectal Surgery,Philadelphia, Pa, USA

Introduction: Obesity currently affects more than a third of the US population and is associated with increased surgical complications. Compared to all other subspecialties, colorectal surgery is the most affected by the increasing trend in obese surgical patients. Operative time has been found to have the greatest impact on hospital costs and physician workload. This study was conducted to determine whether obesity has a direct impact on operative time in elective colorectal surgical procedures using a high-powered, nationally representative patient sample.

Methods: A retrospective analysis was conducted on 45,362 patients who underwent open and laparoscopic ileocolic resections, partial colectomies, and low pelvic anastomoses using ACS-NSQIP data from 2005 to 2009. Operative time (in minutes) was the main outcome variable, while body mass index (in kg/m^2) was the main independent variable. Body mass index was divided into three classes: normal (<25), overweight/obese (25-35), and morbidly obese (>35). A univariate linear model was used to analyze the relationship while controlling for confounding factors such as demographics and preoperative conditions. Statistical significance was established at p < 0.05.

Results: Morbidly obese patients were found to have longer operative times than did normal patients across each individual colorectal surgical procedure (p < 0.001), ranging from a mean difference of 17.8 minutes for open ileocolic resections to 56.6 minutes for laparoscopic low pelvic anastomoses with colostomies.

Conclusions: BMI, as an objective measure of obesity, is a direct, statistically significant independent predictor of operative time across elective colorectal surgery procedures. We suggest future studies to further discuss the modification of surgical reimbursement to account for the greater procedural and temporal costs in treating obese patients.

 

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