From Machine Learning to Patient Outcomes: A Comprehensive Review of AI in Pancreatic Cancer

Pancreatic cancer is a highly aggressive and difficult-to-detect cancer with a poor prognosis. Late diagnosis is common due to a lack of early symptoms, specific markers, and the challenging location of the pancreas. Imaging technologies have improved diagnosis, but there is still room for improvement in standardizing guidelines. Biopsies and histopathological analysis are challenging due to tumor heterogeneity. Artificial Intelligence (AI) revolutionizes healthcare by improving diagnosis, treatment, and patient care. AI algorithms can analyze medical images with precision, aiding in early disease detection. AI also plays a role in personalized medicine by analyzing patient data to tailor treatment plans. It streamlines administrative tasks, such as medical coding and documentation, and provides patient assistance through AI chatbots. However, challenges include data privacy, security, and ethical considerations. This review article focuses on the potential of AI in transforming pancreatic cancer care, offering improved diagnostics, personalized treatments, and operational efficiency, leading to better patient outcomes.

Role of Adjuvant Chemotherapy in Early-Stage Combined Small Cell Lung Cancer

BACKGROUND

The role of adjuvant therapy in completely resected primary tumors that have components of both non-small cell lung cancer and small cell lung cancer (combined SCLC) is poorly understood. We sought to determine the potential benefits of adjuvant chemotherapy in patients who undergo complete resection for early-stage combined SCLC.

METHODS

Overall survival of patients with pathologic T1-2 N0 M0 combined SCLC who underwent complete resection in the National Cancer Database from 2004 to 2017, stratified by adjuvant chemotherapy vs surgery alone, was evaluated by multivariable Cox proportional hazards modeling and propensity score-matched analysis. Patients treated with induction therapy and those who died within 90 days of surgery were excluded from analysis.

RESULTS

Of 630 patients who had pT1-2 N0 M0 combined SCLC during the study period, 297 patients (47%) underwent complete R0 resection. Adjuvant chemotherapy was administered to 63% of patients (n = 188), and 37% of patients underwent surgery alone (n = 109). In unadjusted analysis, the 5-year overall survival was 61.6% (95% CI, 50.8-70.7) for patients who underwent surgery alone and 66.4% (95% CI, 58.4-73.3) for patients who underwent adjuvant chemotherapy. In multivariable and propensity score-matched analysis, there were no significant differences in overall survival between adjuvant chemotherapy and surgery alone (adjusted hazard ratio, 1.16; 95% CI, 0.73-1.84). These findings were consistent when limited to patients who underwent lobectomies or to healthier patients who have at most 1 major comorbidity.

CONCLUSIONS

In this national analysis, patients with pT1-2 N0 M0 combined SCLC treated with surgical resection alone have similar outcomes to those who undergo adjuvant chemotherapy.

Suicide among Cancer Patients: Current Knowledge and Directions for Observational Research

Cancer is a major public health concern associated with an increased risk of psychosocial distress and suicide. The reasons for this increased risk are still being characterized. The purpose of this study is to highlight existing observational studies on cancer-related suicides in the United States and identify gaps for future research. This work helps inform clinical and policy decision-making on suicide prevention interventions and ongoing research on the detection and quantification of suicide risk among cancer patients. We identified 73 peer-reviewed studies (2010-2022) that examined the intersection of cancer and suicide using searches of PubMed and Embase. Overall, the reviewed studies showed that cancer patients have an elevated risk of suicide when compared to the general population. In general, the risk was higher among White, male, and older cancer patients, as well as among patients living in rural areas and with lower socioeconomic status. Future studies should further investigate the psychosocial aspects of receiving a diagnosis of cancer on patients' mental health as well as the impact of new treatments and their availability on suicide risk and disparities among cancer patients to better inform policies.

Deaths Due to COVID-19 in Patients With Cancer During Different Waves of the Pandemic in the US

Importance

With the ongoing relaxation of guidelines to prevent COVID-19 transmission, particularly in hospital settings, medically vulnerable groups, such as patients with cancer, may experience a disparate burden of COVID-19 mortality compared with the general population.

Objective

To evaluate COVID-19 mortality among US patients with cancer compared with the general US population during different waves of the pandemic.

Design, Setting, and Participants

This cross-sectional study used data from the Center for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database to examine COVID-19 mortality among US patients with cancer and the general population from March 1, 2020, to May 31, 2022. The number of deaths due to COVID-19 during the 2021 to 2022 winter Omicron surge was compared with deaths during the preceding year's COVID-19 winter surge (when the wild-type SARS-CoV-2 variant was predominant) using mortality ratios. Data were analyzed from July 21 through August 31, 2022.

Exposures

Pandemic wave during which the wild-type variant (December 2020 to February 2021), Delta variant (July 2021 to November 2021), or Omicron variant (December 2021 to February 2022) was predominant.

Main Outcomes and Measures

Number of COVID-19 deaths per month.

Results

The sample included 34 350 patients with cancer (14 498 females [42.2%] and 19 852 males [57.8%]) and 628 156 members of the general public (276 878 females [44.1%] and 351 278 males [55.9%]) who died from COVID-19 when the wild-type (December 2020-February 2021), Delta (July 2021-November 2021), and winter Omicron (December 2021-February 2022) variants were predominant. Among patients with cancer, the greatest number of COVID-19 deaths per month occurred during the winter Omicron period (n = 5958): at the peak of the winter Omicron period, there were 18% more deaths compared with the peak of the wild-type period. In contrast, among the general public, the greatest number of COVID-19 deaths per month occurred during the wild-type period (n = 105 327), and at the peak of the winter Omicron period, there were 21% fewer COVID-19 deaths compared with the peak of the wild-type period. In subgroup analyses by cancer site, COVID-19 mortality increased the most, by 38%, among patients with lymphoma during the winter Omicron period vs the wild-type period.

Conclusions and Relevance

Findings of this cross-sectional study suggest that patients with cancer had a disparate burden of COVID-19 mortality during the winter Omicron wave compared with the general US population. With the emergence of new, immune-evasive SARS-CoV-2 variants, many of which are anticipated to be resistant to monoclonal antibody treatments, strategies to prevent COVID-19 transmission should remain a high priority.

Risk of suicide among stroke survivors in the United States

BACKGROUND

Stroke is the largest cause of disability and the 5th leading cause of death in the United States. Suicide is the 12th leading cause of death in the United States. However, little is known about the risk of suicide among people with a prior stroke.

OBJECTIVES

Using Multiple Cause of Death data (1999-2020) from the Centers for Disease Control and Prevention WONDER database, we examined via cross-sectional analysis the risk of suicide among survivors of stroke as compared to the general U.S. population and among subgroups within the United States.

METHODS

We assessed disparities in suicide rate among patients with stroke stratified by sex, race, urbanization levels, and census regions using the CDC WONDER multiple cause of death database. Standardized mortality rates were calculated to compare the suicide rate of stroke patients with the rates among demographic-matched cohorts and the general United States population.

RESULTS

As compared to the general population, stroke survivors had an elevated risk of suicide. Black stroke survivors had a lower rate of suicide as compared to the general population, while White stroke survivors and those in nonmetropolitan areas had an elevated risk compared to the general population.

CONCLUSION

There was a slightly elevated risk of suicide among people with a prior stroke in the United States. This risk may be elevated among White people and among people living in nonmetropolitan areas.

Suicide Risk Among Patients With Heart Disease and Heart Failure

Heart disease is the leading cause of death in the United States (US). Suicide is the 12th leading cause of death. However, little is known about the risk of suicide in patients with heart disease and heart failure. Using Multiple Cause of Death data from the Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) database, we used a cross-sectional analysis to examine the risk of suicide in patients with heart disease and heart failure as compared with the general US population and in subgroups within the US. We assessed suicide rate in patients with heart disease and heart failure in the US population as a whole and stratified by race, time, urbanization levels, and census regions using the CDC WONDER Multiple Cause of Death database. Standardized mortality rates were calculated as observed deaths divided by expected deaths. As compared with the general population, patients with heart disease and heart failure had an elevated risk of suicide. This was true across racial and geographic subgroups. There was an elevated risk of suicide in patients with heart disease and heart failure in the United States. For heart disease, there were particular elevations in the Western US, and there was a particular elevation in Black Americans compared with the age-matched population.

Clinical outcomes of radiation therapy for transgender and gender-expansive people with cancer

Introduction

Approximately 1.6 million people in the US identify as transgender, many of whom undergo gender-affirming medical or surgical therapies. While transgender individuals are diagnosed with cancer at similar rates as those who are cisgender, the impacts of radiation therapy on outcomes of gender-affirming care in transgender, nonbinary, and gender-expansive people with cancer are understudied. We report on the experiences and outcomes of transgender and gender-expansive patients receiving radiation therapy for cancer treatment.

Methods

This study is a multi-institutional retrospective review of patients evaluated from 2005-2019 identified as transgender or gender-expansive in the medical record and treated with radiation therapy.

Results

We identified 23 patients who received radiation to 32 sites, including 12 (38%) to the brain, head, or neck, 8 (25%) to the thorax, and 7 (22%) to the pelvis. Seventeen patients (74%) received gender-affirming hormone therapy and 13 patients (57%) underwent gender-affirming surgery. Four patients had pelvic radiation before or after gender-affirming pelvic surgery, including two trans women who had pelvic radiation after vaginoplasty. Four patients had radiation to the chest or thorax and gender-affirming chest or breast surgery, including two trans men with breast cancer. Two pediatric patients developed hypopituitarism and hypogonadism secondary to radiation therapy and, as adults, changed their hormone replacement therapy to affirm their transgender identities.

Discussion

Transgender people with cancer undergo radiation therapy for a wide range of cancers. Understanding their prior gender-affirming medical or surgical treatments and future gender affirmation goals may identify important considerations for their oncologic care.

Intrinsic and extrinsic regulation of rhabdomyolysis susceptibility by Tango2

Rhabdomyolysis is a clinical emergency characterized by severe muscle damage, resulting in the release of intracellular muscle components, which leads to myoglobinuria and, in severe cases, acute kidney failure. Rhabdomyolysis is caused by genetic factors linked to increased disease susceptibility in response to extrinsic triggers. Recessive mutations in TANGO2 result in episodic rhabdomyolysis, metabolic crises, encephalopathy and cardiac arrhythmia. The underlying mechanism contributing to disease onset in response to specific triggers remains unclear. To address these challenges, we created a zebrafish model of Tango2 deficiency. Here, we demonstrate that the loss of Tango2 in zebrafish results in growth defects, early lethality and increased susceptibility of skeletal muscle defects in response to extrinsic triggers, similar to TANGO2-deficient patients. Using lipidomics, we identified alterations in the glycerolipid pathway in tango2 mutants, which is critical for membrane stability and energy balance. Therefore, these studies provide insight into key disease processes in Tango2 deficiency and have increased our understanding of the impacts of specific defects on predisposition to environmental triggers in TANGO2-related disorders.

Primary clear cell adenocarcinoma of the lung: a national analysis

Background

Primary clear cell adenocarcinoma of the lung (CCAL) is a rare form of lung cancer with poorly understood clinical features. We sought to investigate the clinicopathological characteristics and independent prognostic factors of primary CCAL.

Methods

Overall survival (OS) of patients with CCAL in the National Cancer Database (NCDB) from 2004 to 2017 was compared to lung adenocarcinoma using Kaplan-Meier analysis, multivariable Cox proportional hazards modeling, and propensity score matching. Independent prognostic indicators for patients with CCAL were determined using multivariable Cox proportional hazards analysis.

Results

A total of 1,396 CCAL and 462,360 lung adenocarcinoma patients were included in our analysis. When compared to patients diagnosed with lung adenocarcinoma, those diagnosed with CCAL were more likely to be younger, white, reside farther from a hospital, have higher Charlson/Deyo comorbidity condition (CDCC) scores, have private insurance, have T1, N0, M0 status. In unadjusted analysis, patients with CCAL had better survival than those with lung adenocarcinoma, although no significant differences in survival were found between the two groups with multivariable Cox proportional hazards and propensity score-matched analyses.

Conclusions

In this national analysis, we found that the clinicopathological characteristics of CCAL are distinct from those of lung adenocarcinoma, but CCAL is not itself an independent predictor of survival after multivariable adjustment or propensity score-matched analysis.

Using Renin Activity to Guide Mineralocorticoid Receptor Antagonist Therapy in Patients with Low Renin and Hypertension

BACKGROUND

Mineralocorticoid receptor antagonists (MRAs) are often empirically used for patients with low-renin hypertension (LRH) or probable primary aldosteronism (PA) who decline surgery. However, the optimal approach to MRA therapy is unknown. Studies have shown that a rise in renin is an effective biomarker of prevention of cardiovascular complications of PA. This study aimed to determine whether empiric MRA therapy in patients with LRH or probable PA targeting unsuppressed renin is associated with a decrease in blood pressure and/or proteinuria.

METHODS

Retrospective single-center cohort study from 2005 to 2021 included adults with LRH or probable PA (renin activity <1.0 ng/ml/h and detectable aldosterone levels). All patients were empirically treated with an MRA, targeting renin ≥1.0 ng/ml/h.

RESULTS

Out of 39 patients studied, 32 (82.1%) achieved unsuppressed renin. Systolic and diastolic blood pressure decreased from 148.0 and 81.2 to 125.8 and 71.6 mm Hg, respectively (P < 0.001 for both). Similar blood pressure reductions were seen whether patients had high (>10 ng/dl) or low (<10 ng/dl) aldosterone levels. The majority (24/39; 61.5%) of patients had at least one baseline anti-hypertensive medication stopped. Among the six patients who had detectable proteinuria and albumin-to-creatinine (ACR) measurements post-treatment, the mean ACR decreased from 179.0 to 36.1 mg/g (P = 0.03). None of the patients studied had to completely stop treatment due to adverse reactions.

CONCLUSIONS

Empiric MRA therapy in patients with LRH or probable PA targeting unsuppressed renin can safely and effectively improve blood pressure control and reduce proteinuria.

Dynamic regulation of inter-organelle communication by ubiquitylation controls skeletal muscle development and disease onset

Ubiquitin-proteasome system (UPS) dysfunction is associated with the pathology of a wide range of human diseases, including myopathies and muscular atrophy. However, the mechanistic understanding of specific components of the regulation of protein turnover during development and disease progression in skeletal muscle is unclear. Mutations in KLHL40, an E3 ubiquitin ligase cullin3 (CUL3) substrate-specific adapter protein, result in severe congenital nemaline myopathy, but the events that initiate the pathology and the mechanism through which it becomes pervasive remain poorly understood. To characterize the KLHL40-regulated ubiquitin-modified proteome during skeletal muscle development and disease onset, we used global, quantitative mass spectrometry-based ubiquitylome and global proteome analyses of klhl40a mutant zebrafish during disease progression. Global proteomics during skeletal muscle development revealed extensive remodeling of functional modules linked with sarcomere formation, energy, biosynthetic metabolic processes, and vesicle trafficking. Combined analysis of klh40 mutant muscle proteome and ubiquitylome identified thin filament proteins, metabolic enzymes, and ER-Golgi vesicle trafficking pathway proteins regulated by ubiquitylation during muscle development. Our studies identified a role for KLHL40 as a regulator of ER-Golgi anterograde trafficking through ubiquitin-mediated protein degradation of secretion-associated Ras-related GTPase1a (Sar1a). In KLHL40 deficient muscle, defects in ER exit site vesicle formation and downstream transport of extracellular cargo proteins result in structural and functional abnormalities. Our work reveals that the muscle proteome is dynamically fine-tuned by ubiquitylation to regulate skeletal muscle development and uncovers new disease mechanisms for therapeutic development in patients.

Inpatient Satisfaction With Surgical Resident Care After Elective General and Oncologic Surgery

OBJECTIVE

To investigate inpatient satisfaction with surgical resident care.

BACKGROUND

Surgical trainees are often the primary providers of care to surgical inpatients, yet patient satisfaction with surgical resident care is not well characterized or routinely assessed.

METHODS

English-speaking, general surgery inpatients recovering from elective gastrointestinal and oncologic surgery were invited to complete a survey addressing their satisfaction with surgical resident care. Patients positively identified photos of surgical senior residents and interns before completing a modified version of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS). Adapted S-CAHPS items were scored using the "top-box" method.

RESULTS

Ninety percent of recruited patients agreed to participate (324/359, mean age=62.2, 50.3% male). Patients were able to correctly identify their seniors and interns 85% and 83% of the time, respectively ( P =0.14). On a 10-point scale, seniors had a mean rating of 9.23±1.27 and interns had a mean rating of 9.01±1.49 ( P =0.14). Ninety-nine percent of patients agreed it was important to help in the education of future surgeons.

CONCLUSIONS

Surgical inpatients were able to recognize their resident physicians with high frequency and rated resident care highly overall, suggesting that they may serve as a willing source of feedback regarding residents' development of core competencies such as interpersonal skills, communication, professionalism, and patient care. Future work should investigate how to best incorporate patient evaluation of surgical resident care routinely into trainee assessment to support resident development.

The Role of Artificial Intelligence in the Detection and Implementation of Biomarkers for Hepatocellular Carcinoma: Outlook and Opportunities

Liver cancer is a leading cause of cancer-related death worldwide, and its early detection and treatment are crucial for improving morbidity and mortality. Biomarkers have the potential to facilitate the early diagnosis and management of liver cancer, but identifying and implementing effective biomarkers remains a major challenge. In recent years, artificial intelligence has emerged as a promising tool in the cancer sphere, and recent literature suggests that it is very promising in facilitating biomarker use in liver cancer. This review provides an overview of the status of AI-based biomarker research in liver cancer, with a focus on the detection and implementation of biomarkers for risk prediction, diagnosis, staging, prognostication, prediction of treatment response, and recurrence of liver cancers.

Machine Learning Improves the Prediction of Responses to Immune Checkpoint Inhibitors in Metastatic Melanoma

Pretreatment LDH is a standard prognostic biomarker for advanced melanoma and is associated with response to ICI. We assessed the role of machine learning-based radiomics in predicting responses to ICI and in complementing LDH for prognostication of metastatic melanoma. From 2008-2022, 79 patients with 168 metastatic hepatic lesions were identified. All patients had arterial phase CT images 1-month prior to initiation of ICI. Response to ICI was assessed on follow-up CT at 3 months using RECIST criteria. A machine learning algorithm was developed using radiomics. Maximum relevance minimum redundancy (mRMR) was used to select features. ROC analysis and logistic regression analyses evaluated performance. Shapley additive explanations were used to identify the variables that are the most important in predicting a response. mRMR selection revealed 15 features that are associated with a response to ICI. The machine learning model combining both radiomics features and pretreatment LDH resulted in better performance for response prediction compared to models that included radiomics or LDH alone (AUC of 0.89 (95% CI: [0.76-0.99]) vs. 0.81 (95% CI: [0.65-0.94]) and 0.81 (95% CI: [0.72-0.91]), respectively). Using SHAP analysis, LDH and two GLSZM were the most predictive of the outcome. Pre-treatment CT radiomic features performed equally well to serum LDH in predicting treatment response.

Potential Immunotherapy Targets for Liver-Directed Therapies, and the Current Scope of Immunotherapeutics for Liver-Related Malignancies

Liver cancer, including hepatocellular carcinoma and intrahepatic cholangiocarcinoma, is increasing in incidence and mortality across the globe. An improved understanding of the complex tumor microenvironment has opened many therapeutic doors and led to the development of novel pharmaceuticals targeting cellular signaling pathways or immune checkpoints. These interventions have significantly improved tumor control rates and patient outcomes, both in clinical trials and in real-world practice. Interventional radiologists play an important role in the multidisciplinary team given their expertise in minimally invasive locoregional therapy, as the bulk of these tumors are usually in the liver. The aim of this review is to highlight the immunological therapeutic targets for primary liver cancers, the available immune-based approaches, and the contributions that interventional radiology can provide in the care of these patients.

Primary and Metastatic Lung Cancer: Rationale, Indications, and Outcomes of Thermal Ablation

The widespread use of imaging as well as the efforts conducted through screening campaigns has dramatically increased the early detection rate of lung cancer. Historically, the management of lung cancer has heavily relied on surgery. However, the increased proportion of patients with comorbidities has given significance to less invasive therapeutic options like minimally invasive surgery and image-guided thermal ablation, which could precisely target the tumor without requiring general anesthesia or a thoracotomy. Thermal ablation is considered low-risk for lung tumors smaller than 3 cm that are located in peripheral lung and do not involve major blood vessels or airways. The rationale for ablative therapies relies on the fact that focused delivery of energy induces cell death and pathologic necrosis. Image-guided percutaneous thermal ablation therapies are established techniques in the local treatment of hepatic, renal, bone, thyroid and uterine lesions. In the lung, and specifically in the setting of metastatic disease, the 3 main indications for lung ablation are to serve as (1) curative intent, (2) as a strategy to achieve a chemo-holiday in oligometastatic disease, and (3) in oligoprogressive disease. Following these premises, the current paper aims to review the rationale, indications, and outcomes of thermal ablation as a form of local therapy in the treatment of primary and metastatic lung disease.

Role of artificial intelligence in risk prediction, prognostication, and therapy response assessment in colorectal cancer: current state and future directions

Artificial Intelligence (AI) is a branch of computer science that utilizes optimization, probabilistic and statistical approaches to analyze and make predictions based on a vast amount of data. In recent years, AI has revolutionized the field of oncology and spearheaded novel approaches in the management of various cancers, including colorectal cancer (CRC). Notably, the applications of AI to diagnose, prognosticate, and predict response to therapy in CRC, is gaining traction and proving to be promising. There have also been several advancements in AI technologies to help predict metastases in CRC and in Computer-Aided Detection (CAD) Systems to improve miss rates for colorectal neoplasia. This article provides a comprehensive review of the role of AI in predicting risk, prognosis, and response to therapies among patients with CRC.

Quality of life of patients with paraurethral cysts

Background. Paraurethral cyst (PC) is often found in women aged 20–60 years. The prevalence of PC in the female population is 1–6 %. Since PC are often located in the distal urethra and lie close to the genitals of a woman, the symptoms associated with this disease cause women both physical and psychological suffering.

Aim. To assess the quality of life of women with PC.

Materials and methods. The study included female individuals (n = 106) aged 18–60 years, in whom PC were detected during examination of the perineal region. The quality of life of the patients was assessed on the basis of the health quality questionnaire – SF-36.

Results. The average volume of the PC in the observed women was 3.2 ± 1.3 cm. In the observed women, the intensity of pain in the perineum was directly proportional to the duration of the disease: up to a year – 86.3 ± 4.1; from one to three years – 76.4 ± 8.3; more than three years – 64.4 ± 9.2 (p <0.05). In this regard, in this category of patients, indicators of physical activity, psychological health and role functioning due to emotional state were reduced. Repeatedor constant pain during urination and during sexual activity causes severe distress, which affects the quality of life of patients with cystic formations in the paraurethral region.

Conclusion. In women with PC on the background of dyspareunia up to 3 years and more, physical and psychological aspects of health suffer.

Open, Video- and Robot-Assisted Thoracoscopic Lobectomy for Stage II-IIIA Non-Small Cell Lung Cancer

BACKGROUND

This study compares the short- and long-term outcomes of open vs robotic vs video-assisted thoracoscopic surgery (VATS) lobectomy for stage II-IIIA non-small-cell lung cancer (NSCLC).

METHODS

Outcomes of patients with stage II-IIIA NSCLC (excluding T4 tumors) who received open and minimally invasive surgery (MIS) lobectomy in the National Cancer Database from 2010 to 2017 were assessed using propensity score-matched analysis.

RESULTS

A propensity score-matched analysis of 4652 open and 4652 MIS patients demonstrated a decreased median length of stay associated with MIS compared with open lobectomy (5 vs 6 days; P < .001). There were no significant differences in 30-day mortality, 30-day readmission, or overall survival between the open and MIS groups. A propensity score-matched analysis of 1186 VATS and 1186 robotic patients showed that compared with VATS, the robotic approach was associated with no significant differences in 30-day mortality, 30-day readmission, and overall survival. However, the robotic group had a decreased median length of stay compared with VATS (4 vs 5 days; P < .001). The conversion rate was also significantly lower for robotic compared with VATS lobectomy (8.9% vs 15.9%, P < .001).

CONCLUSIONS

No significant differences were found in long-term survival between open and MIS lobectomy and between VATS and robotic lobectomy for stage II-IIIA NSCLC. However, the MIS approach was associated with a decreased length of stay compared with the open approach. The robotic approach was associated with decreased length of stay and decreased conversion rate compared with the VATS approach.

Image-Guided Percutaneous and Transarterial Therapies for Primary and Metastatic Lung Cancer

Lung cancer is the leading cause of cancer mortality in the world. A significant proportion of patients with lung cancer are not candidates for surgery and must resort to other treatment alternatives. Rapid technological advancements in fields like interventional radiology have paved the way for valid treatment modalities like image-guided percutaneous and transarterial therapies for treatment of both primary and metastatic lung cancer. The rationale of ablative therapies relies on the fact that focused delivery of energy induces tumor destruction and pathological necrosis. Image-guided percutaneous thermal ablation therapies are established techniques in the local treatment of hepatic, renal, bone, thyroid, or uterine lesions. In the lung, the 3 main indications for lung ablation include local curative intent, a strategy to achieve a chemoholiday in oligometastatic disease, and recently, oligoprogressive disease. Transarterial therapies include a set of catheter-based treatments that involve delivering embolic and/or chemotherapeutic agents directed into the target tumor via the supplying arteries. This article provides a comprehensive review of the various techniques available and discusses their applications and associated complications in primary and metastatic lung cancer.

An Investigation of Cancer-Directed Surgery for Different Histologic Subtypes of Malignant Pleural Mesothelioma

BACKGROUND

The role of cancer-directed surgery in the treatment of stage I-IIIA malignant pleural mesothelioma (MPM) by histologic subtypes remains controversial. The objective of this study was to evaluate the survival of the different histologic subtypes for stage I-IIIA MPM stratified by cancer-directed surgery and nonoperative management.

RESEARCH QUESTION

How is the histologic subtype of MPM, clinical stage of MPM, and use of cancer-directed surgery for MPM associated with overall survival?

STUDY DESIGN AND METHODS

Overall survival of patients with stage I-IIIA epithelioid, sarcomatoid, and biphasic MPM in the National Cancer Database from 2004 through 2017 who underwent cancer-directed surgery (ie, surgery with or without chemotherapy or radiation) or chemotherapy with or without radiation (nonoperative management) was evaluated using Kaplan-Meier analysis, multivariate Cox proportional hazards analysis, and propensity score-matched analysis.

RESULTS

Of 2,285 patients with stage I-IIIA MPM who met inclusion criteria, histologic subtype was epithelioid in 71% of patients, sarcomatoid in 12% of patients, and biphasic in 17% of patients. Median survival was 20 months in the epithelioid group, 8 months in the sarcomatoid group, and 13 months in the biphasic group (P < .01). Among patients who underwent surgery, median survival was 25 months in the epithelioid group, 8 months in the sarcomatoid group, and 15 months in the biphasic group (P < .01). In multivariate Cox proportional hazards analyses, surgery was associated with improved survival in the epithelioid group (P < .01) but not in the sarcomatoid (P = .63) or biphasic (P = .21) groups. These findings were consistent in propensity score-matched analyses for each MPM histologic type.

INTERPRETATION

In this national analysis, cancer-directed surgery was found to be associated with improved survival for stage I-IIIA epithelioid MPM, but not for biphasic or sarcomatoid MPM.

PSUN53 Using Renin Activity to Guide Mineralocorticoid Receptor Antagonist Therapy in Patients with Low-Renin Hypertension

Emerging studies show that beyond a phenotype of overt primary aldosteronism, there exists a prevalent phenotype of renin-independent aldosterone production among patients with low-renin hypertension (LRH). Mineralocorticoid receptor antagonist (MRA) therapy to induce an increase in renin is associated with favorable outcomes in primary aldosteronism. Whether a similar approach is beneficial for all patients with low-renin hypertension is not known. We evaluated whether treatment of patients with LRH with MRAs to increase renin is associated with a decrease in blood pressure and/or proteinuria.

We have conducted a prospective observational cohort study of consecutive patients from the practice of co-author A.T. between 2005 and 2021. Patients were included if they had hypertension with suppressed (< 1.0 ng/ml/h) plasma renin activity (PRA) and detectable aldosterone levels but favored empiric medical therapy over further diagnostic testing. All patients were subsequently treated with an MRA. MRA was started at 25-50 mg daily of spironolactone (women) or eplerenone (men) and the dose was gradually increased in 25-50 mg increments to target a PRA ≥ 1.0 ng/ml/h or the maximal tolerated dose. Blood pressure, albumin-to-creatinine ratio (ACR), and other patient characteristics at baseline vs. after unsuppressed renin was achieved were compared using a paired-samples t-test.

The mean age of 31 study patients who achieved unsuppressed PRA was 67.9 (SD 11.9) and 14 (45.2%) were women. The mean baseline aldosterone was 14.9 ng/dL (SD 9.4); 13 (41.9%) patients had baseline aldosterone < 10.0 ng/dL. Most (21/31; 67.7%) patients had baseline PRA below the assay detection limit. The mean baseline potassium was 4.2 (SD 0.46); one (3.2%) patient had baseline hypokalemia (K < 3.5 mEql/dL). The mean final PRA was 4.78 (SD 5.64) ng/ml/h. The median (IQR) MRA dose required to achieve unsuppressed PRA was 75 (50 to 200) mg. The mean systolic and diastolic blood pressure decreased from 144.9 (SD 14.9) and 79.2 mm Hg (SD 15.0) at baseline to 124.7 (SD 11.1) and 71.5 mm Hg (SD 10.8), respectively, after achievement of unsuppressed PRA (P < 0.001 for both). The mean number of anti-hypertensive medications decreased from 3.4 (SD 1.3) at baseline to 2.5 (SD 1.5) after achievement of unsuppressed PRA (P < 0.001). Among the six (19.4%) patients who had proteinuria, the mean ACR decreased from 179.0 (SD 102.1) at baseline to 36.1 (SD 49.2) mg/g after achievement of unsuppressed PRA (P = 0.007). Three (9.7%) and seven (22.6%) patients had to have their MRA dose decreased due to symptomatic hypotension and hyperkalemia, respectively.

These findings suggest that suppressed renin may be sufficient to identify patients who could benefit from MR blockade. Treatment of patients with suppressed renin with sufficient MRA dose to achieve its unsuppression could lower both elevated blood pressure and proteinuria.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Prevalence of abnormalities on cardiac MRI in unselected patients after recovery from acute SARS-CoV-2 infection and correlation with markers of immunity and coagulation: the SETANTA study

Background

Previous studies have reported ongoing cardiac inflammation as assessed by cardiac magnetic resonance imaging (CMR) in a significant proportion of patients several months after recovery from SARS-CoV-2 infection, many of whom had no or minimal symptoms at the time of infection.

Purpose

The aim of SETANTA was to investigate the prevalence of cardiac abnormalities by CMR in unselected patients in Ireland after acute SARS-CoV-2 infection and the correlation with immunological response and biomarkers of coagulation.

Methods

This was a prospective, observational, community-based study (clinicaltrials.gov identifier NCT04823182). Consecutive patients recovered from recent SARS-CoV-2 infection at 3 primary care sites were invited to participate. Key inclusion/exclusion criteria and outcomes of interest are shown in Figure 1.

Results

100 participants were enrolled (Feb-Sept 2021) at a median of 188 (IQR, 125, 246) days after positive SARS-CoV-2 swab. At index infection, 18% and 35% reported severe and moderate symptoms, respectively; 14% were hospitalized; 3% were admitted to intensive care for ventilatory support. At enrolment, 83% had ongoing symptoms. 85% had detectable SARS-CoV-2 antigens. CMR and laboratory findings are shown in Figure 1.

Conclusion

Among an unselected cohort of patients recovered from acute SARS-CoV2 infection, we report a low prevalence of cardiac abnormalities by CMR, despite a high prevalence of moderate/severe symptoms at presentation and a high prevalence of persistent symptoms. Correlation with biomarkers of immunity and coagulation will be available at ESC 2022.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): WomenAsOne

Tension-driven multi-scale self-organisation in human iPSC-derived muscle fibers

Human muscle is a hierarchically organised tissue with its contractile cells called myofibers packed into large myofiber bundles. Each myofiber contains periodic myofibrils built by hundreds of contractile sarcomeres that generate large mechanical forces. To better understand the mechanisms that coordinate human muscle morphogenesis from tissue to molecular scales, we adopted a simple in vitro system using induced pluripotent stem cell-derived human myogenic precursors. When grown on an unrestricted two-dimensional substrate, developing myofibers spontaneously align and self-organise into higher-order myofiber bundles, which grow and consolidate to stable sizes. Following a transcriptional boost of sarcomeric components, myofibrils assemble into chains of periodic sarcomeres that emerge across the entire myofiber. More efficient myofiber bundling accelerates the speed of sarcomerogenesis suggesting that tension generated by bundling promotes sarcomerogenesis. We tested this hypothesis by directly probing tension and found that tension build-up precedes sarcomere assembly and increases within each assembling myofibril. Furthermore, we found that myofiber ends stably attach to other myofibers using integrin-based attachments and thus myofiber bundling coincides with stable myofiber bundle attachment in vitro. A failure in stable myofiber attachment results in a collapse of the myofibrils. Overall, our results strongly suggest that mechanical tension across sarcomeric components as well as between differentiating myofibers is key to coordinate the multi-scale self-organisation of muscle morphogenesis.

Genetic Testing and/or Counseling for Colorectal Cancer by Health Insurance Type

Genetic testing is increasingly used in clinical practice to assist with the diagnosis of genetic diseases and/or provide information about disease risk, and genetic counseling supports patient understanding of test results before and/or after genetic testing. Therefore, access to genetic testing and counseling is important for patient care. Health insurance coverage is a major determinant of access to health care in the United States. Uninsured individuals are less likely to have a regular source of health care than their insured counterparts. Different health insurance types and benefits also influence access to health care. Data on the association of health insurance and uptake of genetic testing and/or counseling for cancer risk are limited. Using data from the National Health Interview Survey, we examined the uptake of genetic testing and/or counseling for colorectal cancer (CRC) risk by health insurance type. We found that only a small proportion of individuals undergo genetic testing and/or counseling for CRC risk (0.8%), even among subgroups of individuals at risk due to family or personal history (3.7%). Insured individuals were more likely to undergo genetic testing and/or counseling for CRC risk, particularly those with Military and Private insurance plans, after adjusting for various demographic, socioeconomic, and health risk covariates. Further investigations are warranted to examine potential disparities in access and health inequities.

Image-Guided Percutaneous Ablation for Primary and Metastatic Tumors

Image-guided percutaneous ablation methods have been further developed during the recent two decades and have transformed the minimally invasive and precision features of treatment options targeting primary and metastatic tumors. They work by percutaneously introducing applicators to precisely destroy a tumor and offer much lower risks than conventional methods. There are usually shorter recovery periods, less bleeding, and more preservation of organ parenchyma, expanding the treatment options of patients with cancer who may not be eligible for resection. Image-guided ablation techniques are currently utilized for the treatment of primary and metastatic tumors in various organs including the liver, pancreas, kidneys, thyroid and parathyroid, prostate, lung, bone, and soft tissue. This article provides a brief review of the various imaging modalities and available ablation techniques and discusses their applications and associated complications in various organs.

A multisite study of medical student perspectives on the core surgical clerkship

BACKGROUND

The surgical clerkship is the primary surgical learning experience for medical students. This study aims to understand student perspectives on the surgery clerkship both before and after the core surgical rotation.

METHODS

Medical students at 4 academic hospitals completed pre and postclerkship surveys that included open-ended questions regarding (1) student learning goals and concerns and (2) how surgical clerkship learning could be enhanced. Thematic analysis was performed, and interrater reliability was calculated.

RESULTS

Ninety-one percent of students completed both a pre and postclerkship survey (n =162 of 179), generating 320 preclerkship and 270 postclerkship responses. Mean kappa coefficients were 0.83 and 0.82 for pre and postclerkship primary themes, respectively. Thematic analysis identified 5 broad themes: (1) core learning expectations, (2) understanding surgical careers, culture, and work, (3) inhabiting the role of a surgeon, (4) inclusion in the surgical team, and (5) the unique role of the medical student on clinical clerkships. Based on these themes, we propose a learner-centered model of a successful surgical clerkship that satisfies discrete student learning and goals and career objectives while ameliorating the challenges of high-stakes clinical surgical environments such as the operating room.

CONCLUSION

Understanding student perspectives on the surgery clerkship, including preclerkship motivations and concerns and postclerkship reflections on surgical learning, revealed potential targets of intervention to improve the surgery clerkship. Future investigation may elucidate whether the proposed model of the elements of a successful surgery clerkship learning facilitates improvement of the surgical learning environment and enhanced surgical learning.

The Resident-Run Minor Surgery Clinic: A Four-Year Analysis of Patient Outcomes, Satisfaction, and Resident Education

OBJECTIVE

A resident-run minor surgery clinic was developed to increase resident procedural autonomy. We evaluated whether 1) there was a significant difference between complications and patient satisfaction when procedures were independently performed by surgical residents vs. a surgical attending and 2) if participation was associated with an increase in resident procedural confidence.

DESIGN

Third year general surgery residents participated in a weekly procedure clinic from 2014-2018. Post-procedure complications and patient satisfaction were compared between patients operated on by residents vs. the staff surgeon. Residents were surveyed regarding their confidence in independently performing a variety of clinic-based patient care tasks.

SETTING

Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program.

PARTICIPANTS

Post-graduate year three general surgery residents that ran the clinic as part of a general surgery rotation.

RESULTS

1230 patients underwent 1592 procedures (612 in resident clinic, 980 in attending clinic). There was no significant difference in the 30-day complication rate between patients operated on by the resident vs. attending (2.5% vs. 1.9%, p = 0.49). 459 patient satisfaction surveys were administered with a 79.1% response rate. There was no significant difference in the overall quality of care rating between residents and the attending surgeon (87.5% top-box rating vs. 93.1%, p = 0.15). Twenty-one residents completed both a pre- and post-rotation survey (77.8% response rate). The proportion of residents indicating that they could independently perform a variety of patient care tasks significantly increased across the rotation (all p < 0.05).

CONCLUSION

Mid-level general surgery residents can independently perform office-based procedures without detriment to safety or patient satisfaction. The resident-run procedure clinic serves as an environment for residents to grow in confidence in both technical and non-technical skills. Given the high rate at which patients provide resident feedback, future work may investigate how to best incorporate patient derived evaluations into resident assessment.

The Surgical Knowledge "Growth Curve": Predicting ABSITE Scores and Identifying "At-Risk" Residents

OBJECTIVE

Resident performance on the American Board of Surgery In-Training Examination (ABSITE) is used for evaluation of surgical knowledge and guides resident selection for institutional remediation programs. Remediation thresholds have historically been based on ABSITE percentile scores; however, this does not account for predictors that can impact a resident's exam performance. We sought to identify predictors of yearly ABSITE performance to help identify residents "at-risk" for performing below their expected growth trajectory.

DESIGN

The knowledge of the residents, as measured by standardized ABSITE scores, was modeled as a function of the corresponding postgraduate year via a linear mixed effects regression model. Additional model covariates included written USMLE-1-3 examination scores, gender, number of practice questions completed, and percentage correct of practice questions. For each resident, the predicted ABSITE standard score along with a 95% bootstrap prediction interval was obtained. Both resident-specific and population-level predictions for ABSITE standard scores were also estimated.

SETTING

The study was conducted at a single, large academic medical center (Massachusetts General Hospital, Boston, MA).

PARTICIPANTS

Six years of general surgery resident score reports at a single institution between 2014 and 2019 were deidentified and analyzed.

RESULTS

A total of 376 score reports from 130 residents were analyzed. Covariates that had a significant effect on the model included USMLE-1 score (PGY1: p = 0.013; PGY2: p = 0.007; PGY3: p = 0.011), USMLE-2 score (PGY1: p < 0.001; PGY2: p < 0.001; PGY3: p < 0.001; PGY4: p < 0.001; PGY5: p = 0.032), male gender (PGY1: p = 0.003; PGY2: p < 0.001; PGY3: p < 0.001; PGY4: p = 0.008), and number of practice questions completed (p=0.003). Five residents were identified as having "fallen off" their predicted knowledge curve, including a single resident on 2 occasions. Population prediction curves were obtained at 7 different covariate percentile levels (5%, 10%, 25%, 50%, 75%, 90%, and 95%) that could be used to plot predicted resident knowledge progress.

CONCLUSION

Performance on USMLE-1 and -2 examinations, male gender, and number of practice questions completed were positive predictors of ABSITE performance. Creating residency-wide knowledge growth curves as well as individualized predictive ABSITE performance models allows for more efficient identification of residents potentially at risk for poor ABSITE performance and structured monitoring of surgical knowledge progression.

Identification of Specific Educational Targets to Improve the Student Surgical Clerkship Experience

BACKGROUND

This study describes the relationship between medical student perception of surgery, frequency of positive surgery clerkship activities, and overall surgical clerkship experience.

METHODS

Medical students at four academic hospitals completed pre- and post-clerkship surveys assessing 1) surgery clerkship activities/experiences and 2) perceptions of surgery during the 2017-2018 academic year.

RESULTS

Ninety-one percent of students completed both a pre- and post-clerkship survey (n = 162 of 179). Student perception of surgery significantly improved across the clerkship overall (P < 0.0001) and for 7 of 21 specific items. Eighty-six percent of students agreed that the clerkship was a meaningful experience. Sixty-six percent agreed that the operating room was a positive learning environment. Multivariable logistic regression identified one-on-one mentoring from a resident (OR [95% CI] = 2.12 [1.11-4.04], P = 0.02) and establishing a meaningful relationship with a surgical patient (OR = 2.21 [1.12-4.37], P = 0.02) as activities predictive of student agreement that the surgical clerkship was meaningful. Making an incision (OR = 2.92 [1.54-5.56], P = 0.001) and assisting in dissection (OR = 1.67 [1.03-2.69], P = 0.035) were predictive of student agreement that the operating room was a positive learning environment. Positive student perception of surgery before the clerkship was associated with increased frequency of positive clerkship activities including operative involvement (r = 0.26, P = 0.001) and relationships with surgical attendings (r = 0.20, P = 0.01), residents (r = 0.41, P < 0.0001), and patients (r = 0.24, P = 0.003).

CONCLUSIONS

Interventions to improve surgery clerkship quality should target enhancing student relationships with residents and surgical patients as well as providing opportunity for student operative involvement beyond just suturing. In addition, fostering positive perceptions of surgery in the preclinical period may increase meaningfulness and experience with the later surgery clerkship.

Feasibility and Perceived Usefulness of Using Head-Mounted Cameras for Resident Video Portfolios

BACKGROUND

There is limited guidance on how to longitudinally administer simulation materials or to incorporate video recordings into assessment portfolios of simulated surgical skills.

MATERIALS AND METHODS

We launched a longitudinal weekly simulation curriculum for PGY1-PGY3 surgical residents based on the ACS/APDS Curriculum. Residents underwent monthly objective structured assessment of technical skills (OSATS) while wearing head-mounted cameras. Videos of OSATS performance accrued into individual online video portfolios. Residents were surveyed about their attitudes toward video recording.

RESULTS

Twenty-seven general surgical residents participated, completing 161 OSATS encompassing 11 distinct skills and generating 258 videos of simulated skills performance. The overall survey response rate was 88%. Residents viewed the curriculum favorably overall, and 36.4% of residents accessed their videos. Of those who did not watch their videos, 78.6% cited not having enough time, whereas 28.6% did not think the videos would be useful. Over 95% of surveyed residents expressed interest in having a video library of attending-performed procedures, 59.1% were interested in having their own operations recorded, and 45.5% were interested in video-based coaching.

CONCLUSIONS

Residents viewed longitudinal administration of the ACS/APDS Curriculum positively. Although video recording in simulation is feasible, resident interest may be higher for intraoperative recordings than for simulated skills.

A Pilot Study of Inpatient Satisfaction Rating of Surgical Resident Care

OBJECTIVE

To describe inpatient satisfaction with surgical resident care given the increasing importance of patient satisfaction as a quality metric.

DESIGN

Surgical inpatients were invited to complete a survey that addressed their satisfaction with and attitudes regarding surgical resident care. The survey was based on the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS). Patients were required to positively identify photos of resident physicians prior to providing ratings. Adapted S-CAHPS items were scored using the "top-box" method.

SETTING

Massachusetts General Hospital, a tertiary academic center.

PARTICIPANTS

General surgery inpatients recovering from elective, major abdominal surgery were recruited on postoperative days 2 to 4.

RESULTS

Ninety-one percent of approached patients participated (102/112, mean age = 62.9, 51.6% male). Patients positively identified both seniors and interns 88% of the time. Thirteen seniors and 19 interns were rated, with 1 to 14 evaluations per trainee. Overall quality of care ratings for seniors and interns were 9.35 and 9.09, respectively (0-10 scale, 10 = "best possible care"). Sixty-three percent of senior resident evaluations and 60% of intern evaluations received a score of 10. The proportion of residents receiving top-box scores ranged from 59.5% to 97.7% depending on the item. Forty percent of senior resident and 38% of intern evaluations received top-box scores for all 8 items. Over 96% of patients reported strong or moderate agreement with the statements "I feel it is important to help in the education of future surgeons."

CONCLUSIONS

Surgical inpatients willingly completed ratings about their surgery residents, typically can recognize their resident physicians, and rate quality of care highly. Despite many high ratings, there is room for improvement in some S-CAHPS domains. These results indicate patients are a valuable source of feedback regarding a resident's progress in several core competencies such as interpersonal skills, communication, professionalism, and patient care.