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Mosk CA, van Vugt JLA, de Jonge H, Witjes CD, Buettner S, Ijzermans JN, van der Laan L. Low skeletal muscle mass as a risk factor for postoperative delirium in elderly patients undergoing colorectal cancer surgery. Clin Interv Aging 2018; 13:2097-2106. [PMID: 30425464 PMCID: PMC6205536 DOI: 10.2147/cia.s175945] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Both low skeletal muscle mass (LSMM) and delirium are frequently seen in elderly patients. This study aimed to investigate the association between preoperative LSMM and postoperative delirium (POD) in elderly patients undergoing colorectal cancer (CRC) surgery and to design a model to predict POD. Patients and methods This is a retrospective observational cohort study. Patients aged 70 years or older undergoing CRC surgery from January 2013 to October 2015 were included in this study. The cross-sectional skeletal muscle area at the level of the third lumbar vertebra using computed tomography was adjusted for patients' height, resulting in the skeletal muscle index. The lowest quartile per sex was defined as LSMM. Short Nutritional Assessment Questionnaire for Residential Care and KATZ-Activities of Daily Living were used to define malnourishment and physical dependency, respectively. POD was diagnosed using the Delirium Observational Screening Scale and geriatricians' notes. Results Median age of the 251 included patients was 76 years (IQR, 73-80 years), of whom 56% of patients were males, 24% malnourished, and 15% physically impaired. LSMM and POD were diagnosed in 65 and 33 (13%) patients, respectively. POD occurred significantly more in patients with LSMM (25%) compared with patients without LSMM (10%), P=0.006. In the multivariate analysis, age, history of delirium, and LSMM were significantly associated with POD. In addition, this effect increased in patients with LSMM and malnourishment (P=0.019) or physical dependency (P=0.017). Conclusion Age, history of delirium, LSMM, and malnourishment or physical dependency were independently associated with POD. Our nomogram could be used to identify patients at an increased risk for delirium. These patients may benefit from intensive monitoring to prevent POD.
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Affiliation(s)
| | - Jeroen L A van Vugt
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands,
| | - Huub de Jonge
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Carlijn Dm Witjes
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands,
| | - Stefan Buettner
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands,
| | - Jan Nm Ijzermans
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands,
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Buettner S, Spolverato G, Kimbrough CW, Alexandrescu S, Marques HP, Lamelas J, Aldrighetti L, Gamblin TC, Maithel SK, Pulitano C, Weiss M, Bauer TW, Shen F, Poultsides GA, Marsh JW, IJzermans JNM, Koerkamp BG, Pawlik TM. The impact of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio among patients with intrahepatic cholangiocarcinoma. Surgery 2018; 164:411-418. [PMID: 29903509 DOI: 10.1016/j.surg.2018.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 05/02/2018] [Accepted: 05/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neutrophil-to-lymphocyte ratio and platelets-to-lymphocyte ratio may be host factors associated with prognosis. We sought to determine whether neutrophil-to-lymphocyte and platelets-to-lymphocyte ratio were associated with overall survival among patients undergoing surgery for intrahepatic cholangiocarcinoma. METHODS Patients who underwent resection for intrahepatic cholangiocarcinoma between 1990 and 2015 were identified from 12 major centers. Clinicopathologic factors and overall survival were compared among patients stratified by neutrophil-to-lymphocyte ratio and platelets-to-lymphocyte ratio. Risk factors identified on multivariable analysis were included in a prognostic model and the discrimination was assessed using Harrell's concordance index (C index). RESULTS A total of 991 patients were identified. Median neutrophil-to-lymphocyte ratio and platelets-to-lymphocyte ratio were 2.7 (interquartile range [IQR]: 2.0-4.0) and 109.6 (IQR: 72.4-158.8), respectively. Preoperative neutrophil-to-lymphocyte ratio was elevated (≥5) in 100 patients (10.0%) and preoperative platelets-to-lymphocyte ratio (≥190) in 94 patients (15.2%). Patients with low and high neutrophil-to-lymphocyte ratio and platelets-to-lymphocyte ratio generally had similar baseline characteristics with regard to tumor characteristics. Overall survival was 37.7 months (95% confidence interval [CI]: 32.7-42.6); 1-, 3-, and 5-year overall survival was 78.8%, 51.6%, and 39.3%, respectively. Patients with an neutrophil-to-lymphocyte ratio <5 had a median survival of 47.1 months (95% CI: 37.9-53.3) compared with a median survival of 21.9 months (95% CI: 4.8-39.1) among patients with an neutrophil-to-lymphocyte ratio ≥5 (P = .001). In contrast, patients who had a platelets-to-lymphocyte ratio <190 vs platelets-to-lymphocyte ratio ≥190 had comparable long-term survival (P > .05). On multivariable analysis, an elevated neutrophil-to-lymphocyte ratio was independently associated with decreased overall survival (hazard ratio: 1.04, 95% CI: 1.01-1.07; P = .002). Patients could be stratified into low- versus high-risk groups based on standard tumor-specific factors such as lymph node status, tumor size, number, and vascular invasion (C index 0.62). When neutrophil-to-lymphocyte ratio was added to the prognostic model, the discriminatory ability of the model improved (C index 0.71). CONCLUSION Elevated neutrophil-to-lymphocyte ratio was independently associated with worse overall survival and improved the prognostic estimation of long-term survival among patients with intrahepatic cholangiocarcinoma undergoing resection.
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Affiliation(s)
- Stefan Buettner
- Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | - Feng Shen
- Eastern Hepatobiliary Surgery Hospital, Shanghai, China
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53
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Gaspersz MP, Buettner S, Roos E, van Vugt JLA, Coelen RJS, Vugts J, Wiggers JK, Allen PJ, Besselink MG, Busch ORC, Belt EJ, D'Angelica MI, DeMatteo RP, de Jonge J, Kingham TP, Polak WG, Willemssen FEJA, van Gulik TM, Jarnagin WR, Ijzermans JNM, Groot Koerkamp B. A preoperative prognostic model to predict surgical success in patients with perihilar cholangiocarcinoma. J Surg Oncol 2018; 118:469-476. [PMID: 30132904 DOI: 10.1002/jso.25174] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 06/27/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with resectable perihilar cholangiocarcinoma (PHC) on imaging have a substantial risk of metastatic or locally advanced disease, incomplete (R1) resection, and 90-day mortality. Our aim was to develop a preoperative prognostic model to predict surgical success, defined as a complete (R0) resection without 90-day mortality, in patients with resectable PHC on imaging. STUDY DESIGN Patients with PHC who underwent exploratory laparotomy in three tertiary referral centers were identified. Multivariable logistic regression was performed to identify preoperatively available prognostic factors. A prognostic model was developed using data from two European centers and validated in one American center. RESULTS In total, 671 patients with PHC underwent exploratory laparotomy. In the derivation cohort, surgical success was achieved in 102 of 331 patients (30.8%). No resection was performed in 176 patients (53.2%) because of metastatic or locally advanced disease. Of the 155 patients (46.8%) who underwent a resection, 38 (24.5%) had an R1-resection. Of the remaining 117 (35.3%), 15 (12.8%) had 90-day mortality. Independent poor prognostic factors for surgical success were identified, and a preoperative prognostic model was developed with a concordance index of 0.71. External validation showed good concordance (0.70). CONCLUSION Surgical success was achieved in only 30% of patients with PHC undergoing exploratory laparotomy and could be predicted by age, cholangitis, hepatic artery involvement, lymph node metastases, and Blumgart stage.
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Affiliation(s)
- Marcia P Gaspersz
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Stefan Buettner
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Eva Roos
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Jeroen L A van Vugt
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert J S Coelen
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Jaynee Vugts
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jimme K Wiggers
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Peter J Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Olivier R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Eric J Belt
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | - Ronald P DeMatteo
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeroen de Jonge
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - T Peter Kingham
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Wojciech G Polak
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - François E J A Willemssen
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - William R Jarnagin
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Jan N M Ijzermans
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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54
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Erath JW, Buettner S, Weiler H, Vamos M, Von Jeinsen B, Heyl S, Schalk R, Mutlak H, Zeiher AM, Fichtlscherer S, Honold J. P2733Prognostic implications of preclinical airway management with laryngeal tube (LTS-D) or endotracheal tube in out-of-hospital cardiac arrest patients. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J W Erath
- JW Goethe University, Cardiology/Electrophysiology, Frankfurt am Main, Germany
| | - S Buettner
- JW Goethe University, Nephrology, Frankfurt am Main, Germany
| | - H Weiler
- JW Goethe University, Cardiology, Frankfurt am Main, Germany
| | - M Vamos
- JW Goethe University, Cardiology/Electrophysiology, Frankfurt am Main, Germany
| | - B Von Jeinsen
- JW Goethe University, Cardiology, Frankfurt am Main, Germany
| | - S Heyl
- JW Goethe University, Cardiology, Frankfurt am Main, Germany
| | - R Schalk
- JW Goethe University, Anaesthesiology, Frankfurt am Main, Germany
| | - H Mutlak
- JW Goethe University, Anaesthesiology, Frankfurt am Main, Germany
| | - A M Zeiher
- JW Goethe University, Cardiology, Frankfurt am Main, Germany
| | - S Fichtlscherer
- JW Goethe University, Cardiology, Frankfurt am Main, Germany
| | - J Honold
- JW Goethe University, Cardiology, Frankfurt am Main, Germany
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55
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Margonis GA, Buettner S, Andreatos N, Kim Y, Wagner D, Sasaki K, Beer A, Schwarz C, Løes IM, Smolle M, Kamphues C, He J, Pawlik TM, Kaczirek K, Poultsides G, Lønning PE, Cameron JL, Burkhart RA, Gerger A, Aucejo FN, Kreis ME, Wolfgang CL, Weiss MJ. Association of BRAF Mutations With Survival and Recurrence in Surgically Treated Patients With Metastatic Colorectal Liver Cancer. JAMA Surg 2018; 153:e180996. [PMID: 29799910 DOI: 10.1001/jamasurg.2018.0996] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance BRAF mutations are reportedly associated with aggressive tumor biology. However, in contrast with primary colorectal cancer, the association of V600E and non-V600E BRAF mutations with survival and recurrence after resection of colorectal liver metastases (CRLM) has not been well studied. Objective To investigate the prognostic association of BRAF mutations with survival and recurrence independently and compared with other prognostic determinants, such as KRAS mutations. Design, Setting, and Participants In this cohort study, all patients who underwent resection for CRLM with curative intent from January 1, 2000, through December 31, 2016, at the institutions participating in the International Genetic Consortium for Colorectal Liver Metastasis and had data on BRAF and KRAS mutational status were retrospectively identified. Multivariate Cox proportional hazards regression models were used to assess long-term outcomes. Interventions Hepatectomy in patients with CRLM. Main Outcomes and Measures The association of V600E and non-V600E BRAF mutations with disease-free survival (DFS) and overall survival (OS). Results Of 853 patients who met inclusion criteria (510 men [59.8%] and 343 women [40.2%]; mean [SD] age, 60.2 [12.4] years), 849 were included in the study analyses. Forty-three (5.1%) had a mutated (mut) BRAF/wild-type (wt) KRAS (V600E and non-V600E) genotype; 480 (56.5%), a wtBRAF/wtKRAS genotype; and 326 (38.4%), a wtBRAF/mutKRAS genotype. Compared with the wtBRAF/wtKRAS genotype group, patients with a mutBRAF/wtKRAS genotype more frequently were female (27 [62.8%] vs 169 [35.2%]) and 65 years or older (22 [51.2%] vs 176 [36.9%]), had right-sided primary tumors (27 [62.8%] vs 83 [17.4%]), and presented with a metachronous liver metastasis (28 [64.3%] vs 229 [46.8%]). On multivariable analysis, V600E but not non-V600E BRAF mutation was associated with worse OS (hazard ratio [HR], 2.76; 95% CI, 1.74-4.37; P < .001) and DFS (HR, 2.04; 95% CI, 1.30-3.20; P = .002). The V600E BRAF mutation had a stronger association with OS and DFS than the KRAS mutations (β for OS, 10.15 vs 2.94; β for DFS, 7.14 vs 2.27). Conclusions and Relevance The presence of the V600E BRAF mutation was associated with worse prognosis and increased risk of recurrence. The V600E mutation was not only a stronger prognostic factor than KRAS but also was the strongest prognostic determinant in the overall cohort.
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Affiliation(s)
| | - Stefan Buettner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nikolaos Andreatos
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yuhree Kim
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Doris Wagner
- Department of General Surgery, Medical University of Graz, Graz, Austria
| | - Kazunari Sasaki
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Andrea Beer
- Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Schwarz
- Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Inger Marie Løes
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Maria Smolle
- Division for Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Carsten Kamphues
- Department of General, Visceral and Vascular Surgery, Charité Campus Benjamin Franklin, University of Berlin-Charité, Berlin, Germany
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus.,Deputy Editor
| | - Klaus Kaczirek
- Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - George Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Per Eystein Lønning
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - John L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard A Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Armin Gerger
- Division for Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Federico N Aucejo
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Martin E Kreis
- Department of General, Visceral and Vascular Surgery, Charité Campus Benjamin Franklin, University of Berlin-Charité, Berlin, Germany
| | | | - Matthew J Weiss
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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56
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Barbon C, Margonis GA, Andreatos N, Rezaee N, Sasaki K, Buettner S, Damaskos C, Pawlik TM, He J, Wolfgang CL, Weiss MJ. Colorectal Liver Metastases: Does the Future of Precision Medicine Lie in Genetic Testing? J Gastrointest Surg 2018; 22:1286-1296. [PMID: 29644557 DOI: 10.1007/s11605-018-3766-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 03/27/2018] [Indexed: 02/06/2023]
Abstract
Colorectal liver metastases (CRLM) present an important clinical challenge in both surgical and medical oncology. Despite improvements in management, survival among patients undergoing resection of CRLM is still very variable and there is a paucity of clinical trial data and reliable biomarkers that could guide prognostic forecasts, treatment selection, and follow-up. Fortunately, recent advances in molecular biology and tumor sequencing have identified a number of critical genetic loci and proliferation markers that may hold the key to understanding the biologic behavior of CRLM; specifically, mutations of KRAS, BRAF, TP53, PIK3CA, APC, expression of Ki-67, and the presence of microsatellite instability appear to have a decisive impact on prognosis and response to treatment in patients with CRLM. While the applicability of genetic biomarkers in everyday clinical practice remains conditional on the development of inexpensive bedside sequencing, targeted therapies, and the conduct of appropriate clinical trials, the promise of personalized treatment may be closer to realization than ever before.
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Affiliation(s)
- Carlotta Barbon
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 608, Baltimore, MD, 21287, USA
| | - Georgios Antonios Margonis
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 608, Baltimore, MD, 21287, USA
| | - Nikolaos Andreatos
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 608, Baltimore, MD, 21287, USA
| | - Neda Rezaee
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 608, Baltimore, MD, 21287, USA
| | - Kazunari Sasaki
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 608, Baltimore, MD, 21287, USA
| | - Stefan Buettner
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 608, Baltimore, MD, 21287, USA
| | - Christos Damaskos
- Second Department of Propedeutic Surgery, "Laiko" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 608, Baltimore, MD, 21287, USA
| | - Christopher L Wolfgang
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 608, Baltimore, MD, 21287, USA
| | - Matthew J Weiss
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 608, Baltimore, MD, 21287, USA.
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57
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Janssen Q, Buettner S, Suker M, Margonis GA, Paniccia A, El-Rayes BF, Bahary N, Chau I, Hosein PJ, Ko AH, Lacy J, Jamieson N, Tinchon C, Kim KP, Besselink MG, Wilmink J, Homs MY, van Eijck CH, Katz MHG, Groot Koerkamp B. Neoadjuvant FOLFIRINOX in patients with (borderline) resectable pancreatic cancer: A systematic review and patient-level meta-analysis. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e16207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Stefan Buettner
- Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Georgios A Margonis
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Bassel F. El-Rayes
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Nathan Bahary
- University of Pittsburgh Medical Center Cancer Center Pavilion, Pittsburgh, PA
| | - Ian Chau
- Royal Marsden Hospital, London & Sutton, United Kingdom
| | - Peter Joel Hosein
- University of Miami Sylvester Comprehensive Cancer Center, Miami, FL
| | - Andrew H. Ko
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | - Jill Lacy
- Smilow Cancer Hospital, Yale University, New Haven, CT
| | - Nigel Jamieson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | | | - Kyu-Pyo Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, Republic of (South)
| | - Marc G. Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Johanna Wilmink
- Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
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Deshwar A, Margonis GA, Andreatos N, Barbon C, Wang J, Buettner S, Wagner D, Sasaki K, Beer A, Løes IM, Pikoulis E, Damaskos C, Garmpis N, Kamphues K, He J, Kaczirek K, Poultsides G, Lønning PE, Mischinger HJ, Aucejo FN, Kreis ME, Wolfgang CL, Weiss MJ. Double KRAS and BRAF Mutations in Surgically Treated Colorectal Cancer Liver Metastases: An International, Multi-institutional Case Series. Anticancer Res 2018; 38:2891-2895. [PMID: 29715113 DOI: 10.21873/anticanres.12535] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/06/2018] [Accepted: 03/08/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND While previously believed to be mutually exclusive, concomitant mutation of Kirsten rat sarcoma viral oncogene homolog (KRAS)- and V-raf murine sarcoma b-viral oncogene homolog B1 (BRAF)-mutated colorectal carcinoma (CRC), has been described in rare instances and been associated with advanced-stage disease. The present case series is the first to report on the implications of concurrent KRAS/BRAF mutations among surgically treated patients, and the largest set of patients with surgically treated colorectal liver metastasis (CRLM) and data on KRAS/BRAF mutational status thus far described. CASE SERIES We present cases from an international, multi-institutional cohort of patients that underwent hepatic resection for CRLM between 2000-2015 at seven tertiary centers. The incidence of KRAS/BRAF mutation in patients with CRLM was 0.5% (4/820). Of these cases, patient 1 (T2N1 primary, G13D/V600E), patient 2 (T3N1 primary, G12V/V600E) and patient 3 (T4N2 primary, G13D/D594N) succumbed to their disease within 485, 236 and 79 days respectively, post-hepatic resection. Patient 4 (T4 primary, G12S/G469S) was alive 416 days after hepatic resection. CONCLUSION The present case series suggests that the incidence of concomitant KRAS/BRAF mutations in surgical cohorts may be higher than previously hypothesized, and associated with more variable survival outcomes than expected.
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Affiliation(s)
- Amar Deshwar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, U.S.A
| | | | - Nikolaos Andreatos
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, U.S.A
| | - Carlotta Barbon
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, U.S.A
| | - Jaeyun Wang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, U.S.A
| | - Stefan Buettner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, U.S.A
| | - Doris Wagner
- Department of General Surgery, Medical University of Graz, Graz, Austria
| | - Kazunari Sasaki
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Andrea Beer
- Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Inger Marie Løes
- Department of Clinical Science, University of Bergen, and Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Emmanouil Pikoulis
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Christos Damaskos
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Garmpis
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Karsten Kamphues
- Department of General, Visceral and Vascular Surgery, Charite Campus Benjamin Franklin, Berlin, Germany
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, U.S.A
| | - Klaus Kaczirek
- Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - George Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - Per Eystein Lønning
- Department of Clinical Science, University of Bergen, and Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | | | - Federico N Aucejo
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Martin E Kreis
- Department of General, Visceral and Vascular Surgery, Charite Campus Benjamin Franklin, Berlin, Germany
| | - Christopher L Wolfgang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, U.S.A
| | - Matthew J Weiss
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, U.S.A.
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Margonis GA, Sasaki K, Gholami S, Kim Y, Andreatos N, Rezaee N, Deshwar A, Buettner S, Allen PJ, Kingham TP, Pawlik TM, He J, Cameron JL, Jarnagin WR, Wolfgang CL, D'Angelica MI, Weiss MJ. Genetic And Morphological Evaluation (GAME) score for patients with colorectal liver metastases. Br J Surg 2018; 105:1210-1220. [PMID: 29691844 DOI: 10.1002/bjs.10838] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 12/05/2017] [Accepted: 01/15/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND This study sought to develop a clinical risk score for resectable colorectal liver metastasis (CRLM) by combining clinicopathological and clinically available biological indicators, including KRAS. METHODS A cohort of patients who underwent resection for CRLM at the Johns Hopkins Hospital (JHH) was analysed to identify independent predictors of overall survival (OS) that can be assessed before operation; these factors were combined into the Genetic And Morphological Evaluation (GAME) score. The score was compared with the current standard (Fong score) and validated in an external cohort of patients from the Memorial Sloan Kettering Cancer Center (MSKCC). RESULTS Six preoperative predictors of worse OS were identified on multivariable Cox regression analysis in the JHH cohort (502 patients). The GAME score was calculated by allocating points to each patient according to the presence of these predictive factors: KRAS-mutated tumours (1 point); carcinoembryonic antigen level 20 ng/ml or more (1 point), primary tumour lymph node metastasis (1 point); Tumour Burden Score between 3 and 8 (1 point) or 9 and over (2 points); and extrahepatic disease (2 points). The high-risk group in the JHH cohort (GAME score at least 4 points) had a 5-year OS rate of 11 per cent, compared with 73·4 per cent for those in the low-risk group (score 0-1 point). Importantly, in cohorts from both the JHH and MSKCC (747 patients), the discriminatory capacity of the GAME score was superior to that of the Fong score, as demonstrated by the C-index and the Akaike information criterion. CONCLUSION The GAME score is a preoperative prognostic tool that can be used to inform treatment selection.
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Affiliation(s)
- G A Margonis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - K Sasaki
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S Gholami
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Y Kim
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - N Andreatos
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - N Rezaee
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Deshwar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S Buettner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - P J Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - T P Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - T M Pawlik
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - J He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - W R Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - C L Wolfgang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - M I D'Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - M J Weiss
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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60
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van Vugt JLA, Alferink LJM, Buettner S, Gaspersz MP, Bot D, Darwish Murad S, Feshtali S, van Ooijen PMA, Polak WG, Porte RJ, van Hoek B, van den Berg AP, Metselaar HJ, IJzermans JNM. A model including sarcopenia surpasses the MELD score in predicting waiting list mortality in cirrhotic liver transplant candidates: A competing risk analysis in a national cohort. J Hepatol 2018; 68:707-714. [PMID: 29221886 DOI: 10.1016/j.jhep.2017.11.030] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 11/22/2017] [Accepted: 11/27/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Frail patients with low model for end-stage liver disease (MELD) scores may be under-prioritised. Low skeletal muscle mass, namely sarcopenia, has been identified as a risk factor for waiting list mortality. A recent study proposed incorporating sarcopenia in the MELD score (MELD-Sarcopenia score). We aimed to investigate the association between sarcopenia and waiting list mortality, and to validate the MELD-Sarcopenia score (i.e. MELD + 10.35 * Sarcopenia). METHODS We identified consecutive patients with cirrhosis listed for liver transplantation in the Eurotransplant registry between 2007-2014 and measured skeletal muscle mass on computed tomography. A competing risk analysis was used to compare survival of patients with and without sarcopenia, and concordance (c) indices were calculated to assess performance of the MELD and MELD-Sarcopenia score. We created a nomogram of the best predictive model. RESULTS We included 585 patients with a median MELD score of 14 (interquartile range 9-19), of which 254 (43.4%) were identified as having sarcopenia. Median waiting list survival was shorter in patients with sarcopenia than those without (p <0.001). This effect was even more pronounced in patients with MELD ≤15. The discriminative performance of the MELD-Sarcopenia score (c-index 0.820) for three-month mortality was lower than MELD score alone (c-index 0.839). Apart from sarcopenia and MELD score, other predictive variables were occurrence of hepatic encephalopathy before listing and recipient age. A model including all these variables yielded a c-index of 0.851. CONCLUSIONS Sarcopenia was associated with waiting list mortality in liver transplant candidates with cirrhosis, particularly in patients with lower MELD scores. The MELD-Sarcopenia score was successfully validated in this cohort. However, incorporating sarcopenia in the MELD score had limited added value in predicting waiting list mortality. LAY SUMMARY In this study among patients with liver cirrhosis listed for liver transplantation, low skeletal muscle mass was associated with mortality on the waiting list, particularly in patients who were listed with low priority based on a low MELD score. However, adding these measurements to the currently used system for donor and organ allocation showed no added value.
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Affiliation(s)
- Jeroen Laurens Ad van Vugt
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.
| | | | - Stefan Buettner
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Marcia Patricia Gaspersz
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Daphne Bot
- Department of Dietetics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Shirin Feshtali
- Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Wojciech Grzegorz Polak
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Robert Jack Porte
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Aad Pieter van den Berg
- Department of Gastroenterology and Hepatology, University of Groningen University Medical Centre Groningen, Groningen, the Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Jan Nicolaas Maria IJzermans
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
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61
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Margonis GA, Buettner S, Wagner D, McVey J, Andreatos N, Beer A, Sasaki K, He J, Kaczirek K, Poultsides GA, Cameron JL, Mischinger HJ, Aucejo F, Wolfgang CL, Weiss MJ. Microsatellite instability in resectable colorectal liver metastasis: An international multi-institutional analysis. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.4_suppl.220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
220 Background: Microsatellite instability (MSI) is associated with favorable prognosis and distinct response to chemotherapy and immunotherapy for non-metastatic colorectal cancer (CRC). However, studies suggest that MSI may have minimal prognostic impact for widely metastatic CRC. Whether MSI is prognostic for the subset of patients with resectable colorectal liver metastases (CRLM) remains unknown. In this study, we analyze the impact of MSI status on patients with CRLM in the largest cohort reported to date. Methods: Patients who underwent curative-intent resection for CRLM between 2003 and 2017 in five participating tertiary centers and had available data on MSI status were included. Standard clinicopathologic and outcome data were collected. Survival was calculated using Kaplan-Meier analysis. Results: A total of 332 patients who met inclusion criteria were identified, of which 198 (59.6%) were male and 133 (40.7%) had rectal primary tumors. Sixteen patients (4.8%) were MSI positive. The majority of patients had T3 tumors (n = 193; 61.3%) and lymph node metastasis were present in 202 patients (64.5%). The median number of hepatic lesions was 1 [inter-quartile range (IQR):1-3] and median tumor diameter was 2.0 cm (1.2-3.5). Extrahepatic disease was present in 51 (15.7%) patients. Preoperative chemotherapy was administered to 220 (68.8%) patients. Of note, data on KRAS mutation status were available for the majority of the patients (95.5%). Baseline characteristics were similar between MSI positive and negative patients. At a median follow-up of 22.1 months, 154 (47.5%) patients experienced disease recurrence and 70 (21.1%) died. Importantly, neither disease-free survival (DFS, p = 0.168) nor overall survival (OS) were associated with MSI status (p = 0.759). Conclusions: MSI status did not appear to impact survival for patients with resectable CRLM. Additional research in larger cohorts from additional participating institutions is currently underway to assess these preliminary findings.
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Affiliation(s)
| | | | | | | | | | - Andrea Beer
- Medical University of Vienna, Vienna, Austria
| | | | - Jin He
- Johns Hopkins University School of Medicine, Baltimore, MD
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62
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Klaphake S, Buettner S, Ultee KH, van Rijn MJ, Hoeks SE, Verhagen HJ. Combination of endovascular revascularization and supervised exercise therapy for intermittent claudication: a systematic review and meta-analysis. J Cardiovasc Surg (Torino) 2018; 59:150-157. [PMID: 29327569 DOI: 10.23736/s0021-9509.18.10346-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Peripheral arterial disease is a major health concern in the Western world, often treated with endovascular revascularization (EVR) or supervised exercise therapy (SET). In this systematic review and meta-analysis, we assessed the outcomes after combination treatment of EVR and SET, compared with EVR or SET alone. EVIDENCE ACQUISITION We performed a systematic search of Embase, Medline, Web of Science, Cochrane Central and Google Scholar. Only randomized controlled trials comparing combination treatment with EVR or SET only, for patients with intermittent claudication due to femoropopliteal or aortoiliac peripheral artery disease, were included. Primary outcome was maximum walking distance (MWD) at 6 and 12 months' follow-up. Secondary outcomes included pain-free walking distance (PFWD), quality of life and adverse events. Pooled estimates of difference in walking distance between EVR plus SET, EVR only and SET only were calculated using random effects models. EVIDENCE SYNTHESIS Our search yielded 812 articles, of which 7 were finally included in the systematic review. Three studies reported the outcomes of combination treatment versus SET and three more reported the outcomes of combination versus EVR. Follow-up ranged between 6 and 24 months. Combination treatment was associated with a greater MWD at 6 months compared to EVR only or SET only, with a standardized mean difference (SMD) of 0.86 (95% CI: 0.15, 1.57) and 0.41 (95% CI: 0.17, 0.66), respectively. At twelve months no significant difference in maximum walking distance was observed between combination treatment compared to EVR (SMD 0.96 [95% CI: -0.44, 2.37]) or SET (SMD 0.52 [95% CI: -0.17, 1.20]). Compared to EVR only, the combination treatment was associated with a greater PFWD walking distance at 12 months (SMD 0.73 [95% CI 0.01, 1.45]). Most studies reported only minor differences in quality of life in favor of the combination treatment, or no difference at all. CONCLUSIONS Combination treatment of endovascular revascularization followed by SET shows a greater improvement in maximum walking distance at 6 months' follow-up compared to EVR only or SET only, while this difference was no longer present after 12 months.
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Affiliation(s)
- Sanne Klaphake
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands -
| | - Stefan Buettner
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Klaas H Ultee
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marie J van Rijn
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sanne E Hoeks
- Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Hence J Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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63
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Antoniou E, Andreatos N, Margonis GA, Papalois A, Wang J, Damaskos C, Garmpis N, Buettner S, Deshwar A, Pappas V, Weiss MJ, Pawlik TM, Pikoulis E. Systemic treatment and primary tumor location in patients with metastatic colorectal cancer. J BUON 2017; 22:1447-1456. [PMID: 29332337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE Tumor location (right-sided vs. left-sided) is known to exert a significant influence on the prognosis of primary colorectal cancer (CRC). Given the genetic continuity between primary and metastatic lesions, we aimed to summarize the existing literature on the prognostic implications of primary tumor site as well as to examine the response to chemotherapy by primary tumor location in patients with metastatic CRC (mCRC). METHODS A structured review of the literature was performed between 6/1/2016-7/1/2016 using the Pubmed database. Original research articles published between 1/1/2000- 07/01/2016 were considered eligible. The primary endpoints were overall survival (OS)/ progression free survival (PFS) and response to systemic treatment in patients with mCRC. RESULTS Eleven studies were included. Tumor site was a strong independent predictor of worse OS/PFS in 9 studies, with right-sided tumors having worse prognosis in all cases. Furthermore, 6 studies demonstrated an inferior response to systemic treatment or worse prognosis following the administration of specific regimens among patients with right-sided cancers. As such, there is significant evidence that right-sided lesions are associated with poor outcomes and resistance to systemic treatment. CONCLUSION Consequently, primary tumor location should be a consideration, when the administration of systemic therapy is contemplated in mCRC.
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Affiliation(s)
- Efstathios Antoniou
- Second Department of Propaedeutic Surgery, Laiko Hospital, University of Athens, Athens, Greece
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64
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Gaspersz MP, Buettner S, van Vugt JLA, Roos E, Coelen RJS, Vugts J, Belt EJ, de Jonge J, Polak WG, Willemssen FEJA, van Gulik TM, IJzermans JNM, Groot Koerkamp B. Conditional survival in patients with unresectable perihilar cholangiocarcinoma. HPB (Oxford) 2017; 19:966-971. [PMID: 28754366 DOI: 10.1016/j.hpb.2017.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/28/2017] [Accepted: 07/05/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Conditional survival is the life expectancy from a point in time for a patient who has survived a specific period after presentation. The aim of the study was to estimate conditional survival for patients with unresectable perihilar cholangiocarcinoma. METHODS Patients with unresectable perihilar cholangiocarcinoma from two academic hospitals in the Netherlands between 2002 and 2012 were assessed. A multivariable Cox proportional hazards analysis was performed to identify risk factors associated with overall survival. Survival was estimated using the Kaplan-Meier method to evaluate factors associated with overall survival. RESULTS In total, 572 patients were included. Overall survival was 42% at one year and 6% at three years. The conditional chance of surviving three years was 15% at 1 year and increased to 38% at 2 years. Independent poor prognostic factors for overall survival were age ≥65 years, tumor size >3 cm on imaging, bilirubin levels (>250 μmol/L), CA19-9 level at presentation (>1000 U/ml), and suspected distant metastases on imaging. The conditional survival of patients with and without these prognostic factors was comparable after patients survived the first two or more years. CONCLUSION The conditional chance of surviving for patients with unresectable perihilar cholangiocarcinoma increases with time. Poor prognostic factors become less relevant once patients have survived two years.
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Affiliation(s)
- Marcia P Gaspersz
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Stefan Buettner
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jeroen L A van Vugt
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Eva Roos
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Robert J S Coelen
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Jaynee Vugts
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Eric J Belt
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Jeroen de Jonge
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wojciech G Polak
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Jan N M IJzermans
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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65
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Buettner S, Ethun CG, Poultsides G, Tran T, Idrees K, Isom CA, Weiss M, Fields RC, Krasnick B, Weber SM, Salem A, Martin RC, Scoggins CR, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Koerkamp BG, Maithel SK, Pawlik TM. Surgical Site Infection Is Associated with Tumor Recurrence in Patients with Extrahepatic Biliary Malignancies. J Gastrointest Surg 2017; 21:1813-1820. [PMID: 28913712 PMCID: PMC5905431 DOI: 10.1007/s11605-017-3571-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 08/29/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical site infections (SSI) are one of the most common complications after hepato-pancreato-biliary surgery. Infectious complications may lead to an associated immune-modulatory effect that inhibits the body's response to cancer surveillance. We sought to define the impact of SSI on long-term prognosis of patients undergoing surgical resection of extrahepatic biliary malignancies (EHBM). METHODS Patients undergoing surgery for EHBM between 2000 and 2014 were identified using a large, multi-center, national cohort dataset. Recurrence free survival (RFS) was calculated and a multivariable Cox proportional hazards model was utilized to identify potential risk factors for RFS including SSI. RESULTS Seven hundred twenty-eight patients included in the analytic cohort; 236 (32.4%) patients had perihilar cholangiocarcinoma, 241 (33.1%) gallbladder cancer, and 251 (34.5%) distal cholangiocarcinoma. A major resection, liver resection, was performed in 205 (28.3%) patients, while 110 (15.2%) patients had a pancreaticoduodenectomy. The overall incidence of morbidity was 55.8%; among the 397 patients who experienced a complication, 161 patients specifically had an SSI. The SSI occurred as an infection of the surgical site (n = 70, 9.6%) or formation of an abscess in the operative bed (n = 91, 12.5%). SSI was associated with long-term survival as patients who experienced an SSI had a median RFS of 19.5 months compared with 30.5 months for those patients who did not have an SSI (HR 1.40, 95% CI 1.08-1.80; p = 0.01). Among 279 patients who had EHBM that had no associated lymph node metastases, well-to-moderate tumor differentiation, as well as an R0 resection margin, SSI remained associated with worse RFS (HR 1.84, 95% CI 1.03-3.29; p = 0.038), as well as overall survival (HR 1.87, 95% CI 1.18-2.97; p = 0.008). CONCLUSION SSI was a relatively common occurrence following surgery for EHBM as 1 in 10 patients experienced an SSI. In addition to standard tumor-specific factors, the occurrence of postoperative SSI was adversely associated with long-term survival.
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Affiliation(s)
- Stefan Buettner
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Cecilia G. Ethun
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Kamran Idrees
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Chelsea A. Isom
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew Weiss
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | | | - Carl Schmidt
- Department of Surgery, Ohio State University, Columbus, OH
| | - Eliza Beal
- Department of Surgery, Ohio State University, Columbus, OH
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
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66
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van Vugt JLA, Buettner S, Levolger S, Coebergh van den Braak RRJ, Suker M, Gaspersz MP, de Bruin RWF, Verhoef C, van Eijck CHC, Bossche N, Groot Koerkamp B, IJzermans JNM. Low skeletal muscle mass is associated with increased hospital expenditure in patients undergoing cancer surgery of the alimentary tract. PLoS One 2017; 12:e0186547. [PMID: 29088245 PMCID: PMC5663377 DOI: 10.1371/journal.pone.0186547] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 10/03/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Low skeletal muscle mass is associated with poor postoperative outcomes in cancer patients. Furthermore, it is associated with increased healthcare costs in the United States. We investigated its effect on hospital expenditure in a Western-European healthcare system, with universal access. METHODS Skeletal muscle mass (assessed on CT) and costs were obtained for patients who underwent curative-intent abdominal cancer surgery. Low skeletal muscle mass was defined based on pre-established cut-offs. The relationship between low skeletal muscle mass and hospital costs was assessed using linear regression analysis and Mann-Whitney U-tests. RESULTS 452 patients were included (median age 65, 61.5% males). Patients underwent surgery for colorectal cancer (38.9%), colorectal liver metastases (27.4%), primary liver tumours (23.2%), and pancreatic/periampullary cancer (10.4%). In total, 45.6% had sarcopenia. Median costs were €2,183 higher in patients with low compared with patients with high skeletal muscle mass (€17,144 versus €14,961; P<0.001). Hospital costs incrementally increased with lower sex-specific skeletal muscle mass quartiles (P = 0.029). After adjustment for confounders, low skeletal muscle mass was associated with a cost increase of €4,061 (P = 0.015). CONCLUSION Low skeletal muscle mass was independently associated with increased hospital costs of about €4,000 per patient. Strategies to reduce skeletal muscle wasting could reduce hospital costs in an era of incremental healthcare costs and an increasingly ageing population.
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Affiliation(s)
- Jeroen L. A. van Vugt
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
- * E-mail:
| | - Stefan Buettner
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Stef Levolger
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | | | - Mustafa Suker
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Marcia P. Gaspersz
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Ron W. F. de Bruin
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Cornelis Verhoef
- Department of Control and Compliance, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | | | - Niek Bossche
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Jan N. M. IJzermans
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
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67
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Zheng J, Chou JF, Gönen M, Vachharajani N, Chapman WC, Majella Doyle MB, Turcotte S, Vandenbroucke-Menu F, Lapointe R, Buettner S, Koerkamp BG, Ijzermans JNM, Chan CY, Goh BKP, Teo JY, Kam JH, Raj JP, Cheow PC, Chung AYF, Chow PKH, Ooi LLPJ, Balachandran VP, Kingham TP, Allen PJ, D’Angelica MI, DeMatteo RP, Jarnagin WR, Lee SY. Prediction of Hepatocellular Carcinoma Recurrence Beyond Milan Criteria After Resection: Validation of a Clinical Risk Score in an International Cohort. Ann Surg 2017; 266:693-701. [PMID: 28650354 PMCID: PMC8404085 DOI: 10.1097/sla.0000000000002360] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This study aims to validate a previously reported recurrence clinical risk score (CRS). SUMMARY OF BACKGROUND DATA Salvage transplantation after hepatocellular carcinoma (HCC) resection is limited to patients who recur within Milan criteria (MC). Predicting recurrence patterns may guide treatment recommendations. METHODS An international, multicenter cohort of R0 resected HCC patients were categorized by MC status at presentation. CRS was calculated by assigning 1 point each for initial disease beyond MC, multinodularity, and microvascular invasion. Recurrence incidences were estimated using competing risks methodology, and conditional recurrence probabilities were estimated using the Bayes theorem. RESULTS From 1992 to 2015, 1023 patients were identified, of whom 613 (60%) recurred at a median follow-up of 50 months. CRS was well validated in that all 3 factors remained independent predictors of recurrence beyond MC (hazard ratio 1.5-2.1, all P < 0.001) and accurately stratified recurrence risk beyond MC, ranging from 19% (CRS 0) to 67% (CRS 3) at 5 years. Among patients with CRS 0, no other factors were significantly associated with recurrence beyond MC. The majority recurred within 2 years. After 2 years of recurrence-free survival, the cumulative risk of recurrence beyond MC within the next 5 years for all patients was 14%. This risk was 12% for patients with initial disease within MC and 17% for patients with initial disease beyond MC. CONCLUSIONS CRS accurately predicted HCC recurrence beyond MC in this international validation. Although the risk of recurrence beyond MC decreased over time, it never reached zero.
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Affiliation(s)
- Jian Zheng
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joanne F. Chou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neeta Vachharajani
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - William C. Chapman
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Simon Turcotte
- Department of Surgery, Université de Montréal, Montreal, QC, Canada
| | | | - Réal Lapointe
- Department of Surgery, Université de Montréal, Montreal, QC, Canada
| | - Stefan Buettner
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Jan NM Ijzermans
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Chung Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Brian KP Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Jin Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Juinn Huar Kam
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Jeyaraj P. Raj
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Peng Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Alexander YF Chung
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Pierce KH Chow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Division of Surgical Oncology, National Cancer Center, Singapore, Singapore
| | - London LPJ Ooi
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | | | - T. Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter J. Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Ronald P. DeMatteo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William R. Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ser Yee Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
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Margonis GA, Amini N, Andreatos N, Deshwar A, Rezaee N, Buettner S, Wang J, Sasaki K, Wolfgang CL, Weiss MJ. Prognostic Relevance of KRAS Mutational Status in Patients with Resectable Colorectal Liver Metastases and Concurrent Extrahepatic Disease. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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van Vugt JLA, Buettner S, Alferink LJM, Bossche N, de Bruin RWF, Darwish Murad S, Polak WG, Metselaar HJ, IJzermans JNM. Low skeletal muscle mass is associated with increased hospital costs in patients with cirrhosis listed for liver transplantation-a retrospective study. Transpl Int 2017; 31:165-174. [DOI: 10.1111/tri.13048] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/24/2017] [Accepted: 08/26/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Jeroen L. A. van Vugt
- Department of Surgery; Division of HPB and Transplant Surgery; Erasmus MC University Medical Centre; Rotterdam the Netherlands
| | - Stefan Buettner
- Department of Surgery; Division of HPB and Transplant Surgery; Erasmus MC University Medical Centre; Rotterdam the Netherlands
| | - Louise J. M. Alferink
- Department of Gastroenterology and Hepatology; Erasmus MC University Medical Centre; Rotterdam the Netherlands
| | - Niek Bossche
- Department of Control and Compliance; Erasmus MC University Medical Centre; Rotterdam the Netherlands
| | - Ron W. F. de Bruin
- Department of Surgery; Division of HPB and Transplant Surgery; Erasmus MC University Medical Centre; Rotterdam the Netherlands
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology; Erasmus MC University Medical Centre; Rotterdam the Netherlands
| | - Wojciech G. Polak
- Department of Surgery; Division of HPB and Transplant Surgery; Erasmus MC University Medical Centre; Rotterdam the Netherlands
| | - Herold J. Metselaar
- Department of Gastroenterology and Hepatology; Erasmus MC University Medical Centre; Rotterdam the Netherlands
| | - Jan N. M. IJzermans
- Department of Surgery; Division of HPB and Transplant Surgery; Erasmus MC University Medical Centre; Rotterdam the Netherlands
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Margonis GA, Sasaki K, Andreatos N, Pour MZ, Shao N, Ghasebeh MA, Buettner S, Antoniou E, Wolfgang CL, Weiss M, Kamel IR, Pawlik TM. Increased kinetic growth rate during late phase liver regeneration impacts the risk of tumor recurrence after colorectal liver metastases resection. HPB (Oxford) 2017; 19:808-817. [PMID: 28602644 DOI: 10.1016/j.hpb.2017.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/26/2017] [Accepted: 05/08/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although experimental data strongly support the pro-tumorigenic role of postoperative liver regeneration, this hypothesis has not been clinically investigated. We aimed to examine the impact of liver regeneration determined by volumetric imaging on recurrence following resection of colorectal liver metastasis (CRLM). METHODS Resected liver volume was subtracted from total liver volume (TLV) to define postoperative remnant liver volume (RLVp). Early and late kinetic growth rates (KGR) were defined as the postoperative increases in liver volume within 2-3 and 8-10 months from surgery, respectively, divided by the corresponding time interval. RESULTS Median early and late KGR was 2.6%/month (IQR: -0.9 to 12.3) and 1.0%/month (IQR: -0.64 to 2.91), respectively. Late KGR predicted intrahepatic recurrence after 1 year from surgery (AUC 0.677, P = 0.011). Specifically, patients with a late KGR ≥1% had a higher cumulative risk of recurrence compared with patients with a KGR <1% (P = 0.038). In multivariate analysis, KGR ≥1% independently predicted recurrence (P = 0.027). DISCUSSION A KGR ≥1% during the late regeneration phase was associated with increased risk of intrahepatic recurrence. These data may inform the timing of adjuvant therapy administration and focus surveillance strategies for high-risk patients.
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Affiliation(s)
- Georgios A Margonis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kazunari Sasaki
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nikolaos Andreatos
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Manijeh Zargham Pour
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nannan Shao
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Stefan Buettner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Efstathios Antoniou
- Second Department of Propaedeutic Surgery, Athens University Medical School, Athens, Greece
| | | | - Matthew Weiss
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ihab R Kamel
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Van Vugt J, Buettner S, Alferink L, Bossche N, de Bruin R, Darwish Murad S, Polak W, Metselaar H, Ijzermans J. SUN-P072: Low Skeletal Muscle Mass is Associated with Increased Hospital Costs in Patients with Cirrhosis Listed for Liver Transplantation. Clin Nutr 2017. [DOI: 10.1016/s0261-5614(17)30555-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Hausmann D, Aksöz N, von Hardenberg J, Martini T, Westhoff N, Buettner S, Schoenberg SO, Riffel P. Prostate cancer detection among readers with different degree of experience using ultra-high b-value diffusion-weighted Imaging: Is a non-contrast protocol sufficient to detect significant cancer? Eur Radiol 2017; 28:869-876. [PMID: 28799090 DOI: 10.1007/s00330-017-5004-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/07/2017] [Accepted: 07/24/2017] [Indexed: 12/14/2022]
Abstract
AIM To evaluate the accuracy of a T2-weighted (T2w) - and a parallel transmit zoomed b = 2000 s/mm2 (b2000) - diffusion-weighted imaging sequence among three readers with different degrees of experience for prostate cancer (Pca) detection. METHODS Ninety-three patients with suspected Pca were enrolled. For b2000 a two-dimensional spatially-selective RF pulse using an echo-planar transmit trajectory was applied, and the field of view (FOV) was reduced to one-third. All three readers (Reader A: 7, B 4 and C <1 years of experience in prostate MRI) independently evaluated b2000 with regard to the presence of suspicious lesions that displayed increased signal. The results were compared to histopathology obtained by real-time MR/ultrasound fusion and systematic biopsy. RESULTS In 62 patients Pca was confirmed. One significant Pca (Gleason score (GS) 7b) was missed by Reader C. Overall, sensitivity/specificity/positive predictive value/negative predictive value were 90/71/86/79% for Reader A, 87/84/92/76% for Reader B and 85/74/87/72% for Reader C, respectively. Detection rates for significant Pca (GS >7a) were 100/100/94% for Readers A/B/C, respectively. Inter-reader agreement was generally good (Kappa A/B: 0.8; A/C: 0.82; B/C: 0.74). CONCLUSION B2000 in combination with a T2w could be useful to detect clinically significant Pca. KEY POINTS • Significant prostate cancer using zoomed ultra-high b-value DWI was detected. • Diagnostic performance among readers with different degrees of experience was good. • mp- MRI of the prostate using a comprehensive non-contrast protocol is clinically feasible.
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Affiliation(s)
- D Hausmann
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim, Germany.
| | - N Aksöz
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
| | - J von Hardenberg
- Department of Urology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - T Martini
- Department of Urology, University of Ulm, Ulm, Germany
| | - N Westhoff
- Department of Urology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - S Buettner
- Department of Statistics and Biomathematics, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - S O Schoenberg
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
| | - P Riffel
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
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Margonis GA, Buettner S, Andreatos N, Sasaki K, Pour MZ, Deshwar A, Wang J, Ghasebeh MA, Damaskos C, Rezaee N, Pawlik TM, Wolfgang CL, Kamel IR, Weiss MJ. Preoperative bevacizumab and volumetric recovery after resection of colorectal liver metastases. J Surg Oncol 2017; 116:1150-1158. [DOI: 10.1002/jso.24769] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 06/26/2017] [Indexed: 12/14/2022]
Affiliation(s)
| | - Stefan Buettner
- Department of Surgery; The Johns Hopkins Hospital; Baltimore Maryland
| | | | - Kazunari Sasaki
- Department of Surgery; The Johns Hopkins Hospital; Baltimore Maryland
| | | | - Ammar Deshwar
- Department of Surgery; The Johns Hopkins Hospital; Baltimore Maryland
| | - Jane Wang
- Department of Surgery; The Johns Hopkins Hospital; Baltimore Maryland
| | | | - Christos Damaskos
- Second Department of Propaedeutic Surgery; Laiko Hospital; University of Athens; Athens Greece
| | - Neda Rezaee
- Department of Surgery; The Johns Hopkins Hospital; Baltimore Maryland
| | - Timothy M. Pawlik
- Department of Surgery; The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center; Columbus Ohio
| | | | - Ihab R. Kamel
- Department of Radiology; The Johns Hopkins Hospital; Baltimore Maryland
| | - Matthew J. Weiss
- Department of Surgery; The Johns Hopkins Hospital; Baltimore Maryland
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Buettner S, Galjart B, van Vugt JLA, Bagante F, Alexandrescu S, Marques HP, Lamelas J, Aldrighetti L, Gamblin TC, Maithel SK, Pulitano C, Margonis GA, Weiss M, Bauer TW, Shen F, Poultsides GA, Marsh JW, IJzermans JNM, Groot Koerkamp B, Pawlik TM. Performance of prognostic scores and staging systems in predicting long-term survival outcomes after surgery for intrahepatic cholangiocarcinoma. J Surg Oncol 2017; 116:1085-1095. [DOI: 10.1002/jso.24759] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/15/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Stefan Buettner
- Department of Surgery; Johns Hopkins Hospital; Baltimore Maryland
- Department of Surgery; Erasmus MC University Medical Center; Rotterdam The Netherlands
| | - Boris Galjart
- Department of Surgery; Erasmus MC University Medical Center; Rotterdam The Netherlands
| | - Jeroen L. A. van Vugt
- Department of Surgery; Erasmus MC University Medical Center; Rotterdam The Netherlands
| | - Fabio Bagante
- Department of Surgery; Johns Hopkins Hospital; Baltimore Maryland
| | | | | | | | | | | | | | | | | | - Matthew Weiss
- Department of Surgery; Johns Hopkins Hospital; Baltimore Maryland
| | | | - Feng Shen
- Eastern Hepatobiliary Surgery Hospital; Shanghai China
| | | | - J. Wallis Marsh
- University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Jan N. M. IJzermans
- Department of Surgery; Erasmus MC University Medical Center; Rotterdam The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery; Erasmus MC University Medical Center; Rotterdam The Netherlands
| | - Timothy M. Pawlik
- Department of Surgery; Johns Hopkins Hospital; Baltimore Maryland
- The Ohio State University Wexner Medical Center; Columbus Ohio
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75
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Ethun CG, Postlewait LM, Le N, Pawlik TM, Buettner S, Poultsides G, Tran T, Idrees K, Isom CA, Fields RC, Jin LX, Weber SM, Salem A, Martin RCG, Scoggins C, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Kooby DA, Maithel SK. Association of Optimal Time Interval to Re-resection for Incidental Gallbladder Cancer With Overall Survival: A Multi-Institution Analysis From the US Extrahepatic Biliary Malignancy Consortium. JAMA Surg 2017; 152:143-149. [PMID: 27784058 DOI: 10.1001/jamasurg.2016.3642] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance The current recommendation is to perform re-resection for select patients with incidentally discovered gallbladder cancer. The optimal time interval for re-resection for both patient selection and long-term survival is not known. Objective To assess the association of time interval from the initial cholecystectomy to reoperation with overall survival. Design, Setting, and Participants This cohort study was conducted from January 1, 2000, to December 31, 2014 at 10 US academic institutions. A total of 207 patients with incidentally discovered gallbladder cancer who underwent reoperation and had available data on the date of their initial cholecystectomy were included. Exposures Time interval from the initial cholecystectomy to reoperation: group A: less than 4 weeks; group B: 4 to 8 weeks; and group C: greater than 8 weeks. Main Outcomes and Measures Primary outcome was overall survival. Results Of 449 patients with gallbladder cancer, 207 cases (46%) were discovered incidentally and underwent reoperation at 3 different time intervals from the date of the original cholecystectomy: group A: less than 4 weeks (25 patients, 12%); B: 4 to 8 weeks (91 patients, 44%); C: more than 8 weeks (91 patients, 44%). The mean (SD) ages of patients in groups A, B, and C were 65 (9), 64 (11), and 66 (12) years, respectively. All groups were similar for baseline demographics, extent of resection, presence of residual disease, T stage, resection margin status, lymph node involvement, and postoperative complications. Patients who underwent reoperation between 4 and 8 weeks had the longest median overall survival (group B: 40.4 months) compared with those who underwent early (group A: 17.4 months) or late (group C: 22.4 months) reoperation (log-rank P = .03). Group A and C time intervals (vs group B), presence of residual disease, an R2 resection, advanced T stage, and lymph node involvement were associated with decreased overall survival on univariable Cox regression. Only group A (hazard ratio, 2.63; 95% CI, 1.25-5.54) and group C (hazard ratio, 2.07; 95% CI, 1.17-3.66) time intervals (vs group B), R2 resection (hazard ratio, 2.69; 95% CI, 1.27-5.69), and advanced Tstage (hazard ratio, 1.85; 95% CI, 1.11-3.08) persisted on multivariable Cox regression analysis. Conclusions and Relevance The optimal time interval for re-resection for incidentally discovered gallbladder cancer appears to be between 4 and 8 weeks after the initial cholecystectomy.
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Affiliation(s)
- Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nina Le
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland3Deputy Editor, JAMA Surgery
| | - Stefan Buettner
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chelsea A Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Linda X Jin
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Charles Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Harveshp D Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Carl Schmidt
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus
| | - Eliza Beal
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Sasaki K, Margonis GA, Andreatos N, Zhang XF, Buettner S, Wang J, Deshwar A, He J, Wolfgang CL, Weiss M, Pawlik TM. The prognostic utility of the “Tumor Burden Score” based on preoperative radiographic features of colorectal liver metastases. J Surg Oncol 2017; 116:515-523. [DOI: 10.1002/jso.24678] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/24/2017] [Indexed: 12/23/2022]
Affiliation(s)
- Kazunari Sasaki
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Georgios A. Margonis
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Nikolaos Andreatos
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Xu-Feng Zhang
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Surgery; The Ohio State University Wexner Medical Center; Columbus Ohio
| | - Stefan Buettner
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Jaeyun Wang
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Amar Deshwar
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Jin He
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
| | | | - Matthew Weiss
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Timothy M. Pawlik
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Surgery; The Ohio State University Wexner Medical Center; Columbus Ohio
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77
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Ethun CG, Postlewait LM, Le N, Pawlik TM, Buettner S, Poultsides G, Tran T, Idrees K, Isom CA, Fields RC, Jin LX, Weber SM, Salem A, Martin RCG, Scoggins C, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Merchant N, Cardona K, Maithel SK. A Novel Pathology-Based Preoperative Risk Score to Predict Locoregional Residual and Distant Disease and Survival for Incidental Gallbladder Cancer: A 10-Institution Study from the U.S. Extrahepatic Biliary Malignancy Consortium. Ann Surg Oncol 2017; 24:1343-1350. [PMID: 27812827 PMCID: PMC6054592 DOI: 10.1245/s10434-016-5637-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND This study was designed to develop a more robust predictive model, beyond T-stage alone, for incidental gallbladder cancer (IGBC) for discovering locoregional residual (LRD) and distant disease (DD) at reoperation, and estimating overall survival (OS). T-stage alone is currently used to guide treatment for incidental gallbladder cancer. Residual disease at re-resection is the most important factor in predicting outcomes. METHODS All patients with IGBC who underwent reoperation at 10 institutions from 2000 to 2015 were included. Routine pathology data from initial cholecystectomy was utilized to create the gallbladder cancer predictive risk score (GBRS). RESULTS Of 449 patients with gallbladder cancer, 262 (58 %) were incidentally discovered and underwent reoperation. Advanced T-stage, grade, and presence of lymphovascular (LVI) and perineural (PNI) invasion were all associated with increased rates of DD and LRD and decreased OS. Each pathologic characteristic was assigned a value (T1a: 0, T1b: 1, T2: 2, T3/4: 3; well-diff: 1, mod-diff: 2, poor-diff: 3; LVI-neg: 1, LVI-pos: 2; PNI-neg: 1, PNI-pos: 2), which added to a total GBRS score from 3 to 10. The scores were separated into three risk-groups (low: 3-4, intermediate: 5-7, high: 8-10). Each progressive GBRS group was associated with an increased incidence LRD and DD at the time of re-resection and reduced OS. CONCLUSIONS By accounting for subtle pathologic variations within each T-stage, this novel predictive risk-score better stratifies patients with incidentally discovered gallbladder cancer. Compared with T-stage alone, it more accurately identifies patients at risk for locoregional-residual and distant disease and predicts long-term survival as it redistributes T1b, T2, and T3 disease across separate risk-groups based on additional biologic features. This score may help to optimize treatment strategy for patients with incidentally discovered gallbladder cancer.
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Affiliation(s)
- Cecilia G. Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Lauren M. Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Nina Le
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Timothy M. Pawlik
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Stefan Buettner
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Chelsea A. Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Linda X. Jin
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Robert C. G. Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY
| | - Charles Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | | | - Carl Schmidt
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Eliza Beal
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY
| | - Nipun Merchant
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN,Division of Surgical Oncology, Department of Surgery, University of Miami, Miami, FL
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
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Abstract
Intrahepatic cholangiocarcinoma (ICC) is the second most common malignancy arising from the liver. ICC makes up about 10% of all cholangiocarcinomas. It arises from the peripheral bile ducts within the liver parenchyma, proximal to the secondary biliary radicals. Histologically, the majority of ICCs are adenocarcinomas. Only a minority of patients (15%) present with resectable disease, with a median survival of less than 3 years. Multidisciplinary management of ICC is complicated by large differences in disease course for individual patients both across and within tumor stages. Risk models and nomograms have been developed to more accurately predict survival of individual patients based on clinical parameters. Predictive risk factors are necessary to improve patient selection for systemic treatments. Molecular differences between tumors, such as in the epidermal growth factor receptor status, are promising, but their clinical applicability should be validated. For patients with locally advanced disease, several treatment strategies are being evaluated. Both hepatic arterial infusion chemotherapy with floxuridine and yttrium-90 embolization aim to downstage locally advanced ICC. Selected patients have resectable disease after downstaging, and other patients might benefit because of postponing widespread dissemination and biliary obstruction.
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Affiliation(s)
- Stefan Buettner
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jeroen LA van Vugt
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jan Nm IJzermans
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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79
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Margonis GA, Sasaki K, Andreatos N, Nishioka Y, Sugawara T, Amini N, Buettner S, Hashimoto M, Shindoh J, Pawlik TM. Prognostic impact of complications after resection of early stage hepatocellular carcinoma. J Surg Oncol 2017; 115:791-804. [DOI: 10.1002/jso.24576] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 01/11/2017] [Accepted: 01/13/2017] [Indexed: 12/18/2022]
Affiliation(s)
| | - Kazunari Sasaki
- Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Nikolaos Andreatos
- Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Yujiro Nishioka
- Hepatobiliary Surgery Division; Department of Digestive Surgery; Toranomon Hospital; Tokyo Japan
| | - Toshitaka Sugawara
- Hepatobiliary Surgery Division; Department of Digestive Surgery; Toranomon Hospital; Tokyo Japan
| | - Neda Amini
- Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Stefan Buettner
- Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Masaji Hashimoto
- Hepatobiliary Surgery Division; Department of Digestive Surgery; Toranomon Hospital; Tokyo Japan
| | - Junichi Shindoh
- Hepatobiliary Surgery Division; Department of Digestive Surgery; Toranomon Hospital; Tokyo Japan
| | - Timothy M. Pawlik
- Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore Maryland
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80
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Tran T, Ethun CG, Pawlik TM, Buettner S, Idrees K, Isom CA, Fields RC, Krasnick B, Weber SM, Salem A, Martin RCG, Scoggins CR, Shen P, Mogal H, Schmidt CR, Beal EW, Hatzaras I, Shenoy R, Maithel SK, Poultsides GA. Histologic classification and grading enhances gallbladder cancer staging: A population-based prognostic score validated by the U.S. Extrahepatic Biliary Malignancy Consortium. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.4_suppl.356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
356 Background: Beyond the most common adenocarcinoma type, several gallbladder cancer (GBC) histologies have been described as being associated with more favorable (papillary) or less favorable outcome (adenosquamous, mucinous, signet ring). We sought to examine the added value of histologic type and grade on the existing AJCC staging system for resected GBC. Methods: Patients who underwent resection of GBC from 1988-2013 were identified using the Surveillance Epidemiology End Results (SEER) registry. A prognostic score was created by assigning points for T stage, N stage, grade and histology based on the regression coefficient in multivariate analysis. The score was externally validated using the US Extrahepatic Biliary Malignancy Consortium (USEBMC) database (2000-2015) and compared with the AJCC staging system. Results: Of 7,915 patients identified in SEER, 83% had adenocarcinoma, 7% papillary, 4% adenosquamous, 4% mucinous, and 2% signet ring. In the USEBMC database, the frequencies of the respective histologies were 86, 9, 2, 1 and 2%. Median survival per histologic type, for SEER and USEBMC respectively, were 45 and 110 mos for papillary, 16 and 24 mos for adenocarcinoma, 14 and 12mos for mucinous, 8 and 4mos for adenosquamous, and 9 and 15mos for signet ring (P between histologies < 0.001 for both cohorts). On multivariate analysis, T stage, N stage, grade and histology were independent predictors of survival. The developed prognostic score, based on points for each of these 4 variables, showed excellent discriminatory ability both in the SEER and USEBMC cohorts. The AUC for the prognostic score was significantly improved compared with the AJCC system (0.69 vs. 0.64,both P < 0.001 using SEER, and 0.76 vs. 0.66,both P < 0.001 using USEBMC). Conclusions: The incorporation of histology and grade into the TNM system allows for a simple and accurate tool to determine prognosis following resection of GBC. [Table: see text]
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Affiliation(s)
- Thuy Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Cecilia Grace Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Timothy M. Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stefan Buettner
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Chelsea A Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan C. Fields
- Washington University School of Medicine St Louis, Saint Louis, MO
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Sharon M. Weber
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Perry Shen
- Division of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Harveshp Mogal
- Division of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Carl Richard Schmidt
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Eliza W Beal
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, NY
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, NY
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81
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Tran T, Ethun CG, Pawlik TM, Buettner S, Idrees K, Isom CA, Fields RC, Krasnick B, Weber SM, Salem A, Martin RCG, Scoggins CR, Shen P, Mogal H, Schmidt CR, Beal EW, Hatzaras I, Shenoy R, Maithel SK, Poultsides GA. Actual 5-year survivors following resection of hilar cholangiocarcinoma. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.4_suppl.352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
352 Background: Although several studies have reported on actuarial survival outcomes following resection of hilar cholangiocarcinoma, the characteristics of patients who actually reached the 5-year milestone have not been adequately described. Methods: Patients who underwent resection for hilar cholangiocarcinoma from 2000-2015 in 10 US academic institutions participating in the Extrahepatic Biliary Malignancy Consortium were analyzed. Patients alive at last encounter with less than 5 years of follow-up were excluded. The clinicopathologic characteristics, perioperative, and long-term outcomes of actual 5-yr survivors and of patients who died within 5 years were compared. Results: Of 328 patients explored, 257 (78%) underwent curative resection and had an actuarial 5-year survival of 17%. After excluding 63 survivors with < 5 years follow-up, 194 patients were further classified as 5-year survivors (n = 23, 12%) and non-5-yr survivors. None of the 5-yr survivors had preoperative systemic biliary sepsis, portal vein embolization, T3 tumors with unilateral portal vein or hepatic artery invasion, or T4 tumors necessitating main portal vein or hepatic artery resection. However, actual 5-year survival was still achieved in the setting of bile duct resection only, R1 margins, poor differentiation, lymphovascular or perineural invasion, nodal metastasis, intraoperative blood transfusion, and serious postoperative complications. Five-year survival did not equal cure, as five 5-year survivors experienced disease recurrence, 2 before and 3 after the 5-year mark. There were ten actual 7-year survivors and four actual 10-year survivors. Conclusions: Although nodal metastasis, poor differentiation, and R1 margins are established predictors of poor outcome for hilar cholangiocarcinoma, the mere presence of these factors does not preclude patients from achieving a 5-year survival. In contrast, preoperative biliary sepsis, T3 or T4 stage, and the necessity for vascular resection and reconstruction appear to be prohibitive in reaching the 5-year milestone. This information can be utilized in the perioperative counseling of patients with this challenging malignancy.
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Affiliation(s)
- Thuy Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Cecilia Grace Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Timothy M. Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stefan Buettner
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Chelsea A Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan C. Fields
- Washington University School of Medicine St Louis, Saint Louis, MO
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Sharon M. Weber
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Perry Shen
- Division of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Harveshp Mogal
- Division of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Carl Richard Schmidt
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Eliza W Beal
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, NY
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, NY
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82
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Buettner S, Koerkamp BG, Ejaz A, Buisman FE, Kim Y, Margonis GA, Alexandrescu S, Marques HP, Lamelas J, Aldrighetti L, Gamblin TC, Maithel SK, Pulitano C, Bauer TW, Shen F, Poultsides GA, Marsh JW, IJzermans JNM, Pawlik TM. The effect of preoperative chemotherapy treatment in surgically treated intrahepatic cholangiocarcinoma patients-A multi-institutional analysis. J Surg Oncol 2017; 115:312-318. [PMID: 28105651 DOI: 10.1002/jso.24524] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 10/30/2016] [Accepted: 11/21/2016] [Indexed: 12/31/2022]
Abstract
INTRODUCTION While preoperative chemotherapy (pCT) is utilized in many intra-abdominal cancers, the use of pCT among patients with intrahepatic cholangiocarcinoma (ICC) remains ill defined. As such, the objective of the current study was to examine the impact of pCT among patients undergoing curative-intent resection for ICC. METHODS Patients who underwent hepatectomy for ICC were identified from a multi-institutional international cohort. The association between pCT with peri-operative and long-term clinical outcomes was assessed. RESULTS Of the 1 057 patients who were identified and met the inclusion criteria, 62 patients (5.9%) received pCT. These patients were noticed to have more advanced disease. Median OS (pCT:46.9 months vs no pCT:37.4 months; P = 0.900) and DFS (pCT: 34.1 months vs no pCT: 29.1 months; P = 0.909) were similar between the two groups. In a subgroup analysis of propensity-score matched patients, there was longer OS (pCT:46.9 months vs no pCT:29.4 months) and DFS (pCT:34.1 months vs no pCT:14.0 months); however this did not reach statistical significance (both P > 0.05). CONCLUSION In conclusion, pCT utilization among patients with ICC was higher among patients with more advanced disease. Short-term post-operative outcomes were not affected by pCT use and receipt of pCT resulted in equivalent OS and DFS following curative-intent resection.
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Affiliation(s)
- Stefan Buettner
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland.,Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Aslam Ejaz
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Florian E Buisman
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yuhree Kim
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | | | | | | | | | | | | | | | | | - Todd W Bauer
- University of Virginia, Charlottesville, Virginia
| | - Feng Shen
- Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | | | - J Wallis Marsh
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jan N M IJzermans
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Timothy M Pawlik
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
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83
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Margonis GA, Sasaki K, Kim Y, Samaha M, Buettner S, Amini N, Antoniou E, Pawlik TM. Tumor Biology Rather Than Surgical Technique Dictates Prognosis in Colorectal Cancer Liver Metastases. J Gastrointest Surg 2016; 20:1821-1829. [PMID: 27384430 DOI: 10.1007/s11605-016-3198-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 06/22/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The interplay of tumor biology and surgical margin status after resection for colorectal liver metastasis (CRLM) remains controversial. Consequently, we sought to determine the impact of surgical margin status on overall survival (OS) stratified by KRAS mutational status. MATERIALS AND METHODS Four hundred eighty-five patients with known KRAS mutational status were identified. Clinicopathologic and long-term survival data were collected and assessed. RESULTS On pathology, most patients (n = 380; 78.3 %) had an R0 margin, while 105 (21.7 %) had an R1. Roughly two thirds of tumors were KRAS wild type (wtKRAS) (n = 307, 63.3 %), while 36.7 % (n = 178) had KRAS mutations (mutKRAS). Median and 5-year OS of the entire cohort was 65.8 months and 53.8 %, respectively. An R1 resection was associated with worse 5-year OS compared with R0 (42.4 % vs. 57.1 %; hazard ratio (HR) 1.82, 95 % CI 1.28-2.57; P = 0.001). After controlling for KRAS status, the survival benefit associated with an R0 resection persisted only among patients with wtKRAS tumors (HR 2.16, 95 % CI 1.42-3.30; P < 0.001). In contrast, surgical margin had no impact on OS among patients with mutKRAS tumors (5-year OS R0, 40.7 % vs. R1, 46.7 %; HR 1.34, 95 % CI 0.73-2.48; P = 0.348). CONCLUSION The impact of margin status differed by KRAS mutation status. An R0 margin only provided a survival benefit to patients with wtKRAS tumors. Tumor biology and not surgical technique determined prognosis.
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Affiliation(s)
| | - Kazunari Sasaki
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yuhree Kim
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mario Samaha
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stefan Buettner
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neda Amini
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Efstathios Antoniou
- Second Department of Propaedeutic Surgery, Laiko Hospital, University of Athens, Athens, Greece
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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84
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Margonis GA, Gani F, Buettner S, Amini N, Sasaki K, Andreatos N, Ethun CG, Poultsides G, Tran T, Idrees K, Isom CA, Fields RC, Krasnick B, Weber SM, Salem A, Martin RC, Scoggins C, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Maithel SK, Pawlik TM. Rates and patterns of recurrence after curative intent resection for gallbladder cancer: a multi-institution analysis from the US Extra-hepatic Biliary Malignancy Consortium. HPB (Oxford) 2016; 18:872-878. [PMID: 27527802 PMCID: PMC5094487 DOI: 10.1016/j.hpb.2016.05.016] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/18/2016] [Accepted: 05/30/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gallbladder cancer is a relatively rare malignancy. The current study aimed to define the incidence and patterns of recurrence following gallbladder cancer resection. METHODS Using a multi-institutional cohort we identified 217 patient undergoing curative intent surgery for gallbladder cancer. Patterns of recurrence were classified as locoregional and distant recurrence. RESULTS At last follow-up, 76 patients (35.0%) had experienced a recurrence (locoregional only, n = 12, 15.8%; distant only, n = 50, 65.8%; locoregional and distant, n = 14, 18.4%). Median time to recurrence was 9.5 months (IQR 4.7-17.6) and was not associated with recurrence site (all p > 0.05). On multivariable analysis, T3 disease (HR = 8.44, p = 0.014), lymphovascular invasion (HR = 4.24, p < 0.001) and residual disease (HR = 2.04, p = 0.042) were associated with an increased risk of recurrence. Patients who recurred demonstrated a worse 1-, 3- and 5-year OS (1-year OS: 91.3% vs. 68.6%, p = 0.001, 3-year OS: 79.3% vs. 28.7%, p < 0.001, and 5-year OS: 75.9% vs. 16.0%, p < 0.001). After adjusting for other risk factors, recurrence was independently associated with a decreased OS (HR = 3.71, p = 0.006). Of note, receipt of adjuvant therapy was associated with improved OS (HR = 0.56, p = 0.027) among those patients who developed a tumor recurrence. DISCUSSION Over one-third of patients experienced a recurrence after gallbladder cancer surgery. While chemotherapy did not decrease the rate of recurrence, patients who experienced recurrence after administration of adjuvant treatment faired better than patients who did not receive adjuvant therapy.
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Affiliation(s)
| | - Faiz Gani
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Stefan Buettner
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Neda Amini
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kazunari Sasaki
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Cecilia G. Ethun
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Kamran Idrees
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chelsea A. Isom
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Charles Scoggins
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Harveshp D. Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Carl Schmidt
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | - Eliza Beal
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY, USA
| | - Shishir K. Maithel
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA,Department of Surgery, Ohio State University, Columbus, OH, USA,Correspondence Timothy M. Pawlik, Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Wexner Medical Center at the Ohio State University, 395 W. 12th Avenue, Suite 670, Columbus, OH 43210, USA. Tel: +1 (614) 293 8701. Fax: +1 (614) 293 4063.Department of SurgeryDepartment of SurgeryThe Urban Meyer III and Shelley Meyer Chair for Cancer ResearchWexner Medical Center at the Ohio State University600 N. Wolfe Street395 W. 12th Avenue, Suite 670ColumbusOH43210USA
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85
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Postlewait LM, Ethun CG, Le N, Pawlik TM, Buettner S, Poultsides G, Tran T, Idrees K, Isom CA, Fields RC, Krasnick B, Weber SM, Salem A, Martin RC, Scoggins C, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Vitiello G, Cardona K, Maithel SK. Proposal for a new T-stage classification system for distal cholangiocarcinoma: a 10-institution study from the U.S. Extrahepatic Biliary Malignancy Consortium. HPB (Oxford) 2016; 18:793-799. [PMID: 27506989 PMCID: PMC5061021 DOI: 10.1016/j.hpb.2016.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 07/13/2016] [Accepted: 07/14/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Seventh AJCC distal cholangiocarcinoma T-stage classification inadequately separates patients by survival. This retrospective study aimed to define a novel T-stage system to better stratify patients after resection. METHODS Curative-intent pancreaticoduodenectomies for distal cholangiocarcinoma (1/2000-5/2015) at 10 US institutions were included. Relationships between tumor characteristics and overall survival (OS) were assessed and incorporated into a novel T-stage classification. RESULTS 176 patients (median follow-up: 24mo) were included. Current AJCC T-stage was not associated with OS (T1: 23mo, T2: 20mo, T3: 25mo, T4: 12mo; p = 0.355). Tumor size ≥3 cm and presence of lymphovascular invasion (LVI) were associated with decreased OS on univariate and multivariable analyses. Patients were stratified into 3 groups [T1: size <3 cm and (-)LVI (n = 69; 39.2%); T2: size ≥3 cm and (-)LVI or size <3 cm and (+)LVI (n = 82; 46.6%); and T3: size ≥3 cm and (+)LVI (n = 25; 14.2%)]. Each progressive proposed T-stage was associated with decreased median OS (T1: 35mo; T2: 20mo; T3: 8mo; p = 0.002). CONCLUSION Current AJCC distal cholangiocarcinoma T-stage does not adequately stratify patients by survival. This proposed T-stage classification, based on tumor size and LVI, better differentiates patient outcomes after resection and could be considered for incorporation into the next AJCC distal cholangiocarcinoma staging system.
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Affiliation(s)
- Lauren M. Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Cecilia G. Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Nina Le
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Timothy M. Pawlik
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Stefan Buettner
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chelsea A. Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Robert C.G. Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Charles Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Harveshp D. Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Carl Schmidt
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Eliza Beal
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | | | | | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA,Correspondence Shishir K. Maithel, Winship Cancer Institute, Division of Surgical Oncology, 1365C Clifton Road NE, 2nd Floor, Atlanta, GA 30322, USA. Tel: +1 404 778 5777 (office). Fax: +1 404 778 4255.Winship Cancer InstituteDivision of Surgical Oncology1365C Clifton Road NE2nd FloorAtlantaGA30322USA
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Buettner S, van Vugt JLA, Gani F, Koerkamp BG, Margonis GA, Ethun CG, Poultsides G, Tran T, Idrees K, Isom CA, Fields RC, Krasnick B, Weber SM, Salem A, Martin RCG, Scoggins C, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Maithel SK, Guglielmi A, IJzermans JNM, Pawlik TM. A Comparison of Prognostic Schemes for Perihilar Cholangiocarcinoma. J Gastrointest Surg 2016; 20:1716-24. [PMID: 27412318 PMCID: PMC5450027 DOI: 10.1007/s11605-016-3203-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/27/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Although widely used, the 7th edition American Joint Committee on Cancer (AJCC) staging system for perihilar cholangiocarcinoma (PHC) may be limited. Disease-specific nomograms have been proposed as a better means to predict long-term survival for individual patients. We sought to externally validate a recently proposed nomogram by Memorial Sloan Kettering Cancer Center (MSKCC) for PHC, as well as identify factors to improve the prediction of prognosis for patients with PHC. METHODS Four hundred seven patients who underwent surgery for PHC between 1988 and 2014 were identified using an international, multi-center database. Standard clinicopathologic and outcome data were collected. The predictive power of the AJCC staging system and nomogram were assessed. RESULTS Median survival was 24.4 months; 3- and 5-year survival was 37.2 and 20.8 %, respectively. The AJCC 7th edition staging system (C-index 0.570) and the recently proposed PHC nomogram (C-index 0.587) both performed poorly. A revised nomogram based on age, lymphovascular invasion, perineural invasion, and lymph node metastases performed better (C-index 0.682). The calibration plot of the revised PHC nomogram demonstrated good calibration. CONCLUSION The 7th edition AJCC staging system and the MSKCC nomogram had a poor ability to predict long-term survival for individual patients with PHC. A revised nomogram provided more accurate prediction of survival, but will need to be externally validated.
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Affiliation(s)
- Stefan Buettner
- Department of Surgery, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA,Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeroen L. A. van Vugt
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Faiz Gani
- Department of Surgery, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Georgios Antonios Margonis
- Department of Surgery, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Cecilia G. Ethun
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Kamran Idrees
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chelsea A. Isom
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Charles Scoggins
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Harveshp D. Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Carl Schmidt
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | - Eliza Beal
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY, USA
| | - Shishir K. Maithel
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Alfredo Guglielmi
- Department of Surgery, Verona University Medical Center, Verona, Italy
| | - Jan N. M. IJzermans
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
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87
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Margonis GA, Sasaki K, Andreatos N, Kim Y, Merath K, Wagner D, Wilson A, Buettner S, Amini N, Antoniou E, Pawlik TM. KRAS Mutation Status Dictates Optimal Surgical Margin Width in Patients Undergoing Resection of Colorectal Liver Metastases. Ann Surg Oncol 2016; 24:264-271. [PMID: 27696170 DOI: 10.1245/s10434-016-5609-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND The optimal tumor-free margin width remains controversial and may be inappropriate to investigate without considering differences in the underlying tumor biology. METHODS R1 resection was defined as margin clearance less than 1 mm. R0 resection was further divided into 3 groups: 1-4, 5-9, and ≥10 mm. The impact of margin width on overall survival (OS) relative to KRAS status [wild type (wtKRAS) vs. mutated (mutKRAS)] was assessed. RESULTS A total of 411 patients met inclusion criteria. Median patient age was 58 years (interquartile range, 49.7-66.7); most patients were male (n = 250; 60.8 %). With a median follow-up of 28.3 months, median and 5-year OS were 69.8 months and 55.1 %. Among patients with wtKRAS tumors, although margin clearance of 1-4 mm or more was associated with improved OS compared to R1 (all P < 0.05), no difference in OS was observed when comparing margin clearance of 1-4 mm to the 5-9 mm and the ≥10 mm groups (all P > 0.05). In contrast, among patients with mutKRAS tumors, all three groups of margin clearance (1-4, 5-9, and ≥10 mm) fared no better in terms of 5-year survival compared to R1 resection (all P > 0.05). CONCLUSIONS While a 1-4 mm margin clearance in patients with wtKRAS tumors was associated with improved survival, wider resection width did not confer an additional survival benefit. In contrast, margin status-including a 1 cm margin-did not improve survival among patients with mutKRAS tumors.
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Affiliation(s)
- Georgios A Margonis
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.,Second Department of Propaedeutic Surgery, Laiko Hospital, University of Athens, Athens, Greece
| | - Kazunari Sasaki
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Yuhree Kim
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Katiuscha Merath
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Doris Wagner
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ana Wilson
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Stefan Buettner
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Neda Amini
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Efstathios Antoniou
- Second Department of Propaedeutic Surgery, Laiko Hospital, University of Athens, Athens, Greece
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
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88
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Buettner S, Margonis GA, Kim Y, Gani F, Ethun CG, Poultsides GA, Tran T, Idrees K, Isom CA, Fields RC, Krasnick B, Weber SM, Salem A, Martin RCG, Scoggins CR, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Maithel SK, Pawlik TM. Changing Odds of Survival Over Time among Patients Undergoing Surgical Resection of Gallbladder Carcinoma. Ann Surg Oncol 2016; 23:4401-4409. [PMID: 27495279 DOI: 10.1245/s10434-016-5470-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND While survival after malignancies is traditionally reported as actuarial survival, conditional survival (CS) may be more clinically relevant by accounting for "accrued" survival time as time progresses. We sought to compare actuarial and CS among patients with gallbladder carcinoma (GBC) . METHODS A total of 312 patients who underwent curative intent surgery for GBC between 2000 and 2014 were identified using a multi-institutional database. Overall survival (OS) was estimated using the Kaplan-Meier method. CS was calculated as the probability of surviving an additional 3 years at year "x" after surgery using the formula CS3 = S(x+3)/Sx. RESULTS Among all patients, the median actuarial OS was 24.8 months (IQR 13.3-88.9). While actuarial survival decreased over time, 3-year CS (CS3) increased, with CS3 at 2 years after surgery noted to be 61.8 % compared with the 5-year actuarial OS of 31.6 %. Factors associated with reduced actuarial OS were positive margin status (HR 3.61, 95 % CI 2.47-5.26), increasing tumor size (HR = 1.02, 95 % CI 1.01-1.02), higher tumor grade (HR 2.98, 95 % CI 1.47-6.04), residual disease at repeat resection (HR = 2.78, 95 % CI 1.49-3.49, p < 0.001), and lymph node metastasis (HR = 1.95, 95 % CI 1.39-2.75, all p < 0.001). The calculated CS3 exceeded the actuarial survival within each high-risk patient subgroup. For example, patients with residual disease at repeat resection had an actuarial survival 23.1 % at 5 years versus a CS3 of 56.3 % in patients alive at 2 years (Δ = 33.2 %). CONCLUSIONS CS provides a more accurate, dynamic estimate for survival, especially among high-risk patients. CS estimates can be used to accurately predict survival and guide clinical decision making.
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Affiliation(s)
- Stefan Buettner
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Yuhree Kim
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Faiz Gani
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Cecilia G Ethun
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - George A Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Kamran Idrees
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chelsea A Isom
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Robert C G Martin
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | | | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Harveshp D Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Carl Schmidt
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | - Eliza Beal
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY, USA
| | - Shishir K Maithel
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Timothy M Pawlik
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.
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89
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Buettner S, Wilson A, Margonis GA, Gani F, Ethun CG, Poultsides GA, Tran T, Idrees K, Isom CA, Fields RC, Krasnick B, Weber SM, Salem A, Martin RCG, Scoggins CR, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Maithel SK, Pawlik TM. Assessing Trends in Palliative Surgery for Extrahepatic Biliary Malignancies: A 15-Year Multicenter Study. J Gastrointest Surg 2016; 20:1444-52. [PMID: 27121233 PMCID: PMC5450034 DOI: 10.1007/s11605-016-3155-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 04/18/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Extrahepatic biliary malignancies are often diagnosed at an advanced stage. We compared patients with unresectable perihilar cholangiocarcinoma (PHCC) and gallbladder cancer (GBC) who underwent a palliative procedure versus an aborted laparotomy. METHODS Seven hundred seventy-seven patients who underwent surgery for PHCC or GBC between 2000 and 2014 were identified. Uni- and multivariable analyses were performed to identify factors associated with outcome. RESULTS Utilization of preoperative imaging increased over time (CT use, 80.1 % pre-2009 vs. 90 % post-2009) (p < 0.001). The proportion of the patients undergoing curative-intent resection also increased (2000-2004, 67.0 % vs. 2005-2009, 74.5 % vs. 2010-2014, 78.8 %; p = 0.001). The planned surgery was aborted in 106 (13.7 %) patients and 94 (12.1 %) had a palliative procedure. A higher incidence of postoperative complications (19.2 vs. 3.8 %, p = 0.001) including deep surgical site infections (8.3 vs. 1.1 %), bleeding (4.8 vs. 0 %), bile leak (6.0 vs. 0 %) and longer length of stay (7 vs. 4.5 days) were observed among the patients who underwent a palliative surgical procedure versus an aborted non-therapeutic, non-palliative laparotomy (all p < 0.05). OS was comparable among the patients who underwent a palliative procedure (8.7 months) versus an aborted laparotomy (7.8 months) (p = 0.23). CONCLUSION Increased use of advanced imaging modalities was accompanied by increased curative-intent surgery. Compared with patients in whom surgery was aborted, patients who underwent surgical palliation demonstrated an increased incidence of postoperative morbidity with comparable survival.
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Affiliation(s)
- Stefan Buettner
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Ana Wilson
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Georgios Antonis Margonis
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Faiz Gani
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Cecilia G. Ethun
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Kamran Idrees
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chelsea A. Isom
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | | | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Harveshp D. Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Carl Schmidt
- Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Eliza Beal
- Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY, USA
| | - Shishir K. Maithel
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
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90
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Sasaki K, Margonis GA, Wilson A, Kim Y, Buettner S, Andreatos N, Gani F, Amini N, Spolverato G, Pawlik TM. Prognostic Implication of KRAS Status after Hepatectomy for Colorectal Liver Metastases Varies According to Primary Colorectal Tumor Location. Ann Surg Oncol 2016; 23:3736-3743. [PMID: 27352204 DOI: 10.1245/s10434-016-5361-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Right-sided and left-sided colorectal cancer (CRC) is known to differ in their molecular carcinogenic pathways. We sought to investigate the variable prognostic implication of KRAS mutation after hepatectomy for colorectal liver metastases (CRLM) according to the site of primary CRC. METHODS A total of 426 patients who underwent a curative-intent hepatic resection and whose KRAS status was available were identified. Clinicopathologic characteristics and long-term outcomes were stratified by KRAS status (wild type vs. mutant type) and primary tumor location (right-sided vs. left-sided). Cecum, right and transverse colon were defined as right-sided, whereas left colon and rectum were defined as left-sided. RESULTS Among patients with a right-sided CRC, 5-year recurrence-free survival (RFS) and overall survival (OS) were not correlated with KRAS status (wild type: 30.8 and 47.2 % vs. mutant type: 38.5 and 49.1 %, respectively) (both P > 0.05). Specifically, mutant-type KRAS was not associated with either RFS or OS on multivariable analysis (hazard ratio [HR] 1.51, 95 % confidence interval [CI] 0.73-3.14, P = 0.23 and HR 1.03, 95 % CI 0.51-2.08, P = 0.95, respectively). In contrast, among patients who underwent resection of CRLM from a left-sided primary CRC, 5-year RFS and OS were worse among patients with mutant-type KRAS (wild type: 23.7 and 57.2 % vs. mutant type: 19.6 and 38.2 %, respectively) (both P < 0.05). On multivariable analysis, mutant-type KRAS remained independently associated with worse RFS and OS among patients with a left-sided primary CRC (HR 1.57, 95 % CI 1.01-2.44, P = 0.04 and HR 1.81, 95 % CI 1.11-2.96, P = 0.02, respectively). CONCLUSIONS KRAS status has a variable prognostic impact after hepatic resection for CRLM depending on the site of the primary CRC. Future studies examining the impact of KRAS status on prognosis after hepatectomy should take into account the primary CRC tumor site.
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Affiliation(s)
- Kazunari Sasaki
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Ana Wilson
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Yuhree Kim
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Stefan Buettner
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Faiz Gani
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Neda Amini
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Gaya Spolverato
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
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91
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Margonis GA, Kim Y, Sasaki K, Samaha M, Buettner S, Amini N, Pawlik TM. Activating KRAS mutation is prognostic only among patients who receive preoperative chemotherapy before resection of colorectal liver metastases. J Surg Oncol 2016; 114:361-7. [DOI: 10.1002/jso.24319] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 05/21/2016] [Indexed: 01/27/2023]
Affiliation(s)
| | - Yuhree Kim
- Department of Surgery; The Johns Hopkins Hospital; Baltimore Maryland
| | - Kazunari Sasaki
- Department of Surgery; The Johns Hopkins Hospital; Baltimore Maryland
| | - Mario Samaha
- Department of Surgery; The Johns Hopkins Hospital; Baltimore Maryland
| | - Stefan Buettner
- Department of Surgery; The Johns Hopkins Hospital; Baltimore Maryland
| | - Neda Amini
- Department of Surgery; The Johns Hopkins Hospital; Baltimore Maryland
| | - Timothy M. Pawlik
- Department of Surgery; The Johns Hopkins Hospital; Baltimore Maryland
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92
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Buettner S, Margonis GA, Kim Y, Gani F, Ethun CG, Poultsides G, Tran T, Idrees K, Isom CA, Fields RC, Krasnick B, Weber SM, Salem A, Martin RC, Scoggins CR, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Maithel SK, Pawlik TM. Conditional probability of long-term survival after resection of hilar cholangiocarcinoma. HPB (Oxford) 2016; 18:510-7. [PMID: 27317955 PMCID: PMC4913135 DOI: 10.1016/j.hpb.2016.04.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 03/24/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND While traditional survival analyses focus on factors determined at the time of surgery, conditional survival (CS) estimates prognosis relative to time following treatment. We sought to compare actuarial and CS among patients undergoing curative intent surgery for hilar cholangiocarcinoma. METHODS 242 patients undergoing surgery between 2000 and 2014 were identified using a multi-institutional database. CS was calculated as the probability of surviving an additional 3 years, given that the patient had already survived "x" years from surgery. RESULTS Median patient age was 67 years (IQR: 57-73) and most patients were male (n = 140, 57.9%). Lymph node metastases were noted in 79 (32.6%) patients while an R0 margin was obtained in 66.1% (n = 160). Median OS was 22.3 months. Actuarial survival decreased over time from 46.3% at 2 years following surgery to 18.2% at 5 years; in contrast, the 3-year CS (CS3) increased with time (CS3 at 2 years was 39.3% versus 54.4% at 5 years). CS3 exceeded actuarial survival for high-risk patients with patients with perineural invasion demonstrating an actuarial survival of 15.4% at 5 years versus CS3 of 37.6% at 2 years following surgery (Δ = 22.2%). CONCLUSIONS CS provides a more accurate, dynamic estimate for survival, especially among high-risk patients.
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Affiliation(s)
- Stefan Buettner
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Yuhree Kim
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Faiz Gani
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Cecilia G. Ethun
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Kamran Idrees
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chelsea A. Isom
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | | | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Harveshp D. Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Carl Schmidt
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | - Eliza Beal
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY, USA
| | - Shishir K. Maithel
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA,Correspondence: Timothy M. Pawlik, Division of Surgical Oncology, John L. Cameron Professor of Alimentary Surgery, Department of Surgery, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA. Tel: +1 (410) 502 2387. Fax: +1 (410) 502 2388.
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Gani F, Buettner S, Margonis GA, Ethun CG, Poultsides G, Tran T, Idrees K, Isom CA, Fields RC, Krasnick B, Weber SM, Salem A, Martin RCG, Scoggins C, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Maithel SK, Pawlik TM. Assessing the impact of common bile duct resection in the surgical management of gallbladder cancer. J Surg Oncol 2016; 114:176-80. [PMID: 27198742 DOI: 10.1002/jso.24283] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 04/23/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although radical re-resection for gallbladder cancer (GBC) has been advocated, the optimal extent of re-resection remains unknown. The current study aimed to assess the impact of common bile duct (CBD) resection on survival among patients undergoing surgery for GBC. METHODS Patients undergoing curative-intent surgery for GBC were identified using a multi-institutional cohort of patients. Multivariable Cox-proportional hazards regression was performed to identify risk factors for a poor overall survival (OS). RESULTS Among the 449 patients identified, 26.9% underwent a concomitant CBD resection. The median number of lymph nodes harvested did not differ based on CBD resection (CBD, 4 [IQR: 2-9] vs. no CBD, 3 [IQR: 1-7], P = 0.108). While patients who underwent a CBD resection had a worse OS, after adjusting for potential confounders, CBD resection did not impact OS (HR = 1.40, 95%CI 0.87-2.27, P = 0.170). Rather, the presence of advanced disease (T3: HR = 3.11, 95%CI 1.22-7.96, P = 0.018; T4: HR = 7.24, 95%CI 1.70-30.85, P = 0.007) and the presence of disease at the surgical margin (HR = 2.58, 95%CI 1.26-5.31, P = 0.010) were predictive of a worse OS. CONCLUSIONS CBD resection did not yield a higher lymph node count and was not associated with an improved survival. Routine CBD excision in the re-resection of GBC is unwarranted and should only be performed selectively. J. Surg. Oncol. 2016;114:176-180. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Faiz Gani
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Stefan Buettner
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Cecilia G Ethun
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Kamran Idrees
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chelsea A Isom
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Robert C G Martin
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Charles Scoggins
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Harveshp D Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Carl Schmidt
- Department of Surgery, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Eliza Beal
- Department of Surgery, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, New York
| | - Shishir K Maithel
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Timothy M Pawlik
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
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94
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Buettner S, Gani F, Amini N, Spolverato G, Kim Y, Kilic A, Wagner D, Pawlik TM. The relative effect of hospital and surgeon volume on failure to rescue among patients undergoing liver resection for cancer. Surgery 2016; 159:1004-12. [DOI: 10.1016/j.surg.2015.10.025] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 09/01/2015] [Accepted: 10/23/2015] [Indexed: 01/18/2023]
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95
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Margonis GA, Amini N, Buettner S, Besharati S, Kim Y, Sobhani F, Kamel IR, Pawlik TM. Impact of early postoperative platelet count on volumetric liver gain and perioperative outcomes after major liver resection. Br J Surg 2016; 103:899-907. [DOI: 10.1002/bjs.10120] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/13/2015] [Accepted: 01/05/2016] [Indexed: 12/17/2022]
Abstract
Abstract
Background
Although perioperative platelet count has been associated with postoperative morbidity and mortality, its impact on liver regeneration has not been examined directly. This study sought to determine the impact of platelet count on liver regeneration after major liver resection using cross-sectional imaging volumetric assessment.
Methods
Patients who underwent major liver resection between 2004 and 2015 and had available data on immediate postoperative platelet count, as well as preoperative and postoperative CT images, were identified retrospectively. Resected liver volume was subtracted from total liver volume (TLV) to define postoperative remnant liver volume (RLVp). The liver regeneration index was defined as the relative increase in liver volume within 2 months ((RLV2m – RLVp)/RLVp, where RLV2m is the remnant liver volume around 2 months after surgery). The association between platelet count, liver regeneration and outcomes was assessed.
Results
A total of 99 patients met the inclusion criteria. Overall, 25 patients (25 per cent) had a low platelet count (less than 150 × 109/l), whereas 74 had a normal–high platelet count (at least 150 × 109/l). Despite having comparable clinicopathological characteristics and RLVp/TLV at surgery (P = 0·903), the relative increase in liver volume within 2 months was considerably lower in the low-platelet group (3·9 versus 16·5 per cent; P = 0·043). Patients with a low platelet count had an increased risk of postoperative complications (72 versus 38 per cent; P = 0·003), longer hospital stay (8 versus 6 days; P = 0·004) and worse median overall survival (24·5 versus 67·3 months; P = 0·005) than those with a normal or high platelet count.
Conclusion
After major liver resection, a low postoperative platelet count was associated with inhibited liver regeneration, as well as worse short- and long-term outcomes. Immediate postoperative platelet count may be an early indicator to identify patients at increased risk of worse outcomes.
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Affiliation(s)
- G A Margonis
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - N Amini
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S Buettner
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S Besharati
- Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Y Kim
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - F Sobhani
- Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - I R Kamel
- Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - T M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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96
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Metzger SC, Koehm M, Wichmann JL, Buettner S, Scholtz JE, Beeres M, Kerl JM, Albrecht MH, Hammerstingl R, Vogl TJ, Bauer RW. Dual-Energy CT in Patients with Suspected Gouty Arthritis: Effects on Treatment Regimen and Clinical Outcome. Acad Radiol 2016; 23:267-72. [PMID: 26749327 DOI: 10.1016/j.acra.2015.10.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 10/02/2015] [Accepted: 10/30/2015] [Indexed: 12/11/2022]
Abstract
RATIONALE AND OBJECTIVES This investigation aimed to evaluate the impact on treatment regimen and clinical outcome of dual-energy computed tomography (DECT) in patients with suspected gouty arthritis. MATERIALS AND METHODS We retrospectively analyzed electronic medical records (EMR) of 39 patients (36 male, 3 female; age range, 36-85 years) who underwent DECT of peripheral joints because of suspected gouty arthritis. We assessed the prior medical history, lab results, treatment regimen, and medications before and after DECT, and changes in subjective severity of symptoms as stated by patients in the EMR. The presence of monosodium urate (MSU) crystals in the index joint was verified with DECT. RESULTS Several patients had a prior diagnosis of gout (n = 9), hyperuricemia (n = 6), rheumatoid arthritis (n = 3), or psoriatic arthritis (n = 3). Elevated uric acid blood levels were detected in 32 patients (82%) before DECT. On DECT, MSU crystals were detected in 23 patients (59%). Of the 36 cases, the current treatment regimen was modified after DECT to gout-specific therapy in 22 cases and other rheumatic diseases were targeted in 14 cases. Several medications were prescribed more frequently based after DECT compared to before DECT imaging, including steroids (n = 20 vs. n = 12, respectively), colchicine (n = 13 vs. n = 4, respectively), and urate-lowering medication (n = 18 vs. n = 11, respectively). A subjective reduction of clinical symptoms during cumulative follow-up was reported by 34 patients (87.2%). CONCLUSIONS Both positive and negative findings of MSU crystals on DECT have a significant impact on the treatment regimen and clinical outcome of patients with suspected gouty arthritis and facilitate differentiation from other rheumatic diseases.
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Affiliation(s)
- Sarah C Metzger
- Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Michaela Koehm
- Department of Rheumatology, Clinic of the Goethe University, Frankfurt
| | - Julian L Wichmann
- Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Stefan Buettner
- Department of Nephrology, Clinic of the Goethe University, Frankfurt
| | - Jan-Erik Scholtz
- Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Martin Beeres
- Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - J Matthias Kerl
- Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Moritz H Albrecht
- Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Renate Hammerstingl
- Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Ralf W Bauer
- Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany.
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97
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Buettner S, Ethun CG, Maithel SK, Poultsides GA, Tran T, Idrees K, Isom CA, Fields RC, Krasnick B, Weber SM, Salem AI, Martin RCG, Scoggins CR, Shen P, Mogal H, Schmidt CR, Beal EW, Hatzaras I, Shenoy R, Pawlik TM. Conditional survival probability of long-term survival after resection of peri-hilar cholangiocarcinoma. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
212 Background: Traditional survival analyses focus on factors determined at the time of surgery and may not be accurate over time. Conditional survival (CS) estimates future prognosis based on survival time accrued following treatment. We sought to define differences between actuarial and CS among patients after resection of peri-hilar cholangiocarcinoma (PHCC). Methods: 242 patients who underwent resection for PHCC between 2000-2014 were identified from 10 major HPB centers. Cox regression models were used to evaluate factors associated with overall survival. CS was calculated as the probability of surviving an additional 3 years at “x” years after surgery using the formula CS3=S(x+3)/Sx. Results: Median patient age was 67 yrs (IQR:57-73) and the majority (73.6%) of patients had a major hepatic resection. Surgical margin status was R0 (n=160; 66.1%) or R1 (n=82; 33.9%). Tumor grade was well- (n=43; 19.1%), moderate- (n=131; 58.2%) or poorly- (n=51; 22.6%) differentiated. Most patients had T1 (13.8%) or T2 (66.4%) disease, while a smaller subset had T3 (17.3%) or T4 (2.6%) disease. Lymph node metastases were present in 79 (32.6%) patients. While actuarial survival decreased over time from 46.3% at 2 years to 18.2% at 5 years following surgery, 3-year CS increased over time among those patients who survived. The CS3 at 2 years (i.e. the probability of surviving to postoperative year 5 after having already survived to year 2) was 39.3% and increased to 54.4% at year 5 (Table). Factors associated with worse OS included lymph node metastases (HR 1.71; 95%CI, 1.24-2.36) and perineural invasion (HR 1.54; 95%CI, 1.02-2.33) (both P<0.05). CS3 for high-risk patients exceeded the actuarial survival, e.g. patients with perineural invasion had an actuarial survival of 15.4% at 5 years vs. a CS3 at 2 years of 37.6% (Δ=22.2%). Conclusions: CS provides a more dynamic means to estimate future survival among patients who have accrued survival time, especially in high-risk patients who were predicted to have short survival times. [Table: see text]
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Affiliation(s)
- Stefan Buettner
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Cecilia Grace Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute of Emory University, Atlanta, GA
| | | | | | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Chelsea A Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Sharon M. Weber
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ahmed I. Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Perry Shen
- Division of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Harveshp Mogal
- Division of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Carl Richard Schmidt
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Eliza W Beal
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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98
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Ethun CG, Postlewait LM, Pawlik TM, Buettner S, Poultsides GA, Tran T, Idrees K, Isom CA, Fields RC, Jin L, Weber SM, Salem AI, Scoggins CR, Shen P, Mogal H, Schmidt CR, Beal EW, Hatzaras I, Shenoy R, Maithel SK. A novel pathology-based preoperative risk score to predict distant and locoregional residual disease and survival for incidentally discovered gallbladder cancer: A 10-institution study from the US Extrahepatic Biliary Malignancy Consortium. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
202 Background: T-stage alone is currently used to guide treatment for incidentally discovered gallbladder cancer. We aimed to develop a more robust predictive model for discovering distant or locoregional residual disease at the time of re-resection. Methods: All patients with incidentally discovered gallbladder cancer who underwent re-resection at 10 institutions from 2000-2015 were included. We utilized routine pathology data from initial cholecystectomy to create a gallbladder cancer predictive risk score (GBRS) for finding distant or locoregional residual disease at re-resection and predicting overall survival (OS). Results: Of 449pts with gallbladder cancer, 262 (58%) were incidentally discovered and underwent attempted re-resection. Advanced T-stage, grade, and lymphovascular (LVI) and perineural (PNI) invasion were all associated with increased rates of distant and locoregional residual disease, and decreased OS. Each pathologic characteristic was assigned a value (T1a: 0, T1b: 1, T2: 2, T3/4: 3; well diff: 1, mod diff: 2, poor diff: 3; LVI neg: 1, LVI pos: 2; PNI neg: 1, PNI pos: 2), which were added for a total GBRS score ranging from 3-10. The scores were then separated into 3 risk groups (Low: 3-4; Intermediate: 5-7; High: 8-10). Each progressive GBRS group was associated with an increased risk of finding distant and isolated locoregional residual disease at the time of re-resection, and was associated with reduced median OS (Table). Conclusions: By accounting for pathologic variations within each T-stage, this novel predictive risk-score redistributes T1b, T2, and T3 disease across separate risk-groups and more accurately identifies patients with incidentally discovered gallbladder cancer at risk for distant and locoregional residual disease, and decreased long-term survival. This score may help to better optimize treatment strategy for patients with incidentally discovered gallbladder cancer. [Table: see text]
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Affiliation(s)
- Cecilia Grace Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Lauren McLendon Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stefan Buettner
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Chelsea A Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Linda Jin
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ahmed I. Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Charles Raben Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Harveshp Mogal
- Division of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Carl Richard Schmidt
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Eliza W Beal
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY
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99
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Ethun CG, Postlewait LM, Pawlik TM, Buettner S, Poultsides GA, Tran T, Idrees K, Isom CA, Fields RC, Jin L, Weber SM, Salem AI, Scoggins CR, Shen P, Mogal H, Schmidt CR, Beal EW, Hatzaras I, Shenoy R, Maithel SK. The optimal time-interval to re-resection for incidentally discovered gallbladder cancer: A multi-institution analysis from the US Extrahepatic Biliary Malignancy Consortium. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
201 Background: Current recommendation is to perform re-resection for select patients with incidentally discovered gallbladder cancer. The interval time to re-resection that optimizes both patient selection and long-term survival is not known. Methods: All patients with incidentally discovered gallbladder cancer who underwent re-resection at 10 institutions from 01/2000-05/2015 were included. The interval time to re-resection was analyzed. Primary outcome was overall survival (OS). Results: Of 449pts with gallbladder cancer, 233 (52%) were discovered incidentally and underwent attempted re-resection at 3 different time-intervals from the date of original cholecystectomy: Group A: 0-4wks (49pts, 21%); B: 4-8wks (91pts, 39%); C: > 8wks (93pts, 40%). All 3 groups were similar with regards to T-stage, LN involvement, grade, and post-operative complications. Group A tended to have distant disease found less frequently at the time of re-resection (11% vs 20% vs 19%; p = 0.38) and was least likely to have residual disease on pathologic analysis (29% vs 47% vs 49%; p = 0.048). Despite these findings, patients who underwent attempted re-resection between 4-8 weeks had the longest median OS (Group B: 40.4mo) compared to those who underwent early (Group A: 18.1mo) or late (Group C: 23.6mo) re-exploration (p = 0.015). A 4-8 week time interval to re-resection, presence of residual disease, advanced T-stage, LN involvement, high grade, and positive margin were associated with decreased OS on UV Cox regression (all p < 0.05). Only a 4-8 week time interval to re-resection (HR 0.43, 95%CI 0.21-0.90; p = 0.02), advanced T-stage (HR 2.65, 95%CI 1.16-6.09; p = 0.02), and margin positivity (HR 2.46, 95%CI 1.16-5.22; p = 0.02) persisted on MV analysis. Conclusions: The optimal time-interval for attempted re-resection for incidentally discovered gallbladder cancer appears to be between 4-8 weeks after the date of the original cholecystectomy.
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Affiliation(s)
- Cecilia Grace Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Lauren McLendon Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stefan Buettner
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Chelsea A Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Linda Jin
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ahmed I. Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Charles Raben Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Harveshp Mogal
- Division of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Carl Richard Schmidt
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Eliza W Beal
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY
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100
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Tran T, Ethun CG, Pawlik TM, Buettner S, Idrees K, Isom CA, Fields RC, Krasnick B, Weber SM, Salem AI, Martin RCG, Scoggins CR, Shen P, Mogal H, Schmidt CR, Beal EW, Hatzaras I, Shenoy R, Maithel SK, Poultsides GA. Gallbladder cancer presenting with jaundice: Uniformly fatal or still potentially curable? J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
336 Background: The prognosis of patients with gallbladder cancer (GBC) who present with jaundice has historically been considered dismal, however recent Eastern literature has demonstrated that surgical resection can be associated with long-term survival. The objective of this study was to utilize a contemporary, Western, multi-institutional dataset to examine the prognostic significance of preoperative jaundice on short- and long-term outcomes after GBC resection. Methods: Patients with GBC managed surgically from 2000 to 2015 in 10 academic institutions participating in the U.S. Extrahepatic Biliary Malignancy Consortium were stratified based on the presence of preoperative jaundice (bilirubin > 3 mg/ml or requiring preoperative biliary drainage). Postoperative morbidity, mortality, and overall survival were compared. Results: Of 449 patients with GBC evaluated for resection, 301 (67%) eventually underwent curative-intent resection. Resectability for cure was much lower in patients with preoperative jaundice (48% vs. 79%, p < 0.001). Of 273 patients who underwent curative-intent resection and had available preoperative bilirubin levels, 53 (19%) had preoperative jaundice and were noted to have tumors of T3/4 stage (63% vs 42%, P = 0.008), with lymph node metastasis (63% vs. 41%; p = 0.014), lymphovascular invasion (68% vs 39%; p = 0.003), and R1 margins (37 vs. 9%; p < 0.001). Patients with jaundice more commonly required CBD (55% vs 32%, P = 0.004), major liver (25% vs. 7%; p < 0.001) and portal vein resection (8% vs. 0.5%; p = 0.006), as well as intraoperative blood transfusion (29 % vs. 11%; p = 0.002). Overall morbidity (57% vs. 38%; p = 0.031) and in-hospital mortality (7.5% vs. 1.4%; p = 0.029) rates were higher in patients with jaundice. Overall survival after curative-intent resection was worse in patients with jaundice (median 12 vs 33 months; p < 0.001). Conclusions: Half of GBC patients presenting with jaundice are not resectable for cure and when they are, their 5-year survival is 12%. These patients should not be excluded from multidisciplinary treatment strategies that include surgery, however expectations should be clearly set and selection should be cautious.
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Affiliation(s)
- Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Cecilia Grace Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stefan Buettner
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Chelsea A Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan C. Fields
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Sharon M. Weber
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ahmed I. Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Harveshp Mogal
- Division of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Carl Richard Schmidt
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Eliza W Beal
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY
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