1
|
Goodman RS, Patrinely JR, Stone CA, Zimmerman E, Donald RR, Chang SS, Berkowitz ST, Finn AP, Jahangir E, Scoville EA, Reese TS, Friedman DL, Bastarache JA, van der Heijden YF, Wright JJ, Ye F, Carter N, Alexander MR, Choe JH, Chastain CA, Zic JA, Horst SN, Turker I, Agarwal R, Osmundson E, Idrees K, Kiernan CM, Padmanabhan C, Bailey CE, Schlegel CE, Chambless LB, Gibson MK, Osterman TJ, Wheless LE, Johnson DB. Accuracy and Reliability of Chatbot Responses to Physician Questions. JAMA Netw Open 2023; 6:e2336483. [PMID: 37782499 PMCID: PMC10546234 DOI: 10.1001/jamanetworkopen.2023.36483] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/22/2023] [Indexed: 10/03/2023] Open
Abstract
Importance Natural language processing tools, such as ChatGPT (generative pretrained transformer, hereafter referred to as chatbot), have the potential to radically enhance the accessibility of medical information for health professionals and patients. Assessing the safety and efficacy of these tools in answering physician-generated questions is critical to determining their suitability in clinical settings, facilitating complex decision-making, and optimizing health care efficiency. Objective To assess the accuracy and comprehensiveness of chatbot-generated responses to physician-developed medical queries, highlighting the reliability and limitations of artificial intelligence-generated medical information. Design, Setting, and Participants Thirty-three physicians across 17 specialties generated 284 medical questions that they subjectively classified as easy, medium, or hard with either binary (yes or no) or descriptive answers. The physicians then graded the chatbot-generated answers to these questions for accuracy (6-point Likert scale with 1 being completely incorrect and 6 being completely correct) and completeness (3-point Likert scale, with 1 being incomplete and 3 being complete plus additional context). Scores were summarized with descriptive statistics and compared using the Mann-Whitney U test or the Kruskal-Wallis test. The study (including data analysis) was conducted from January to May 2023. Main Outcomes and Measures Accuracy, completeness, and consistency over time and between 2 different versions (GPT-3.5 and GPT-4) of chatbot-generated medical responses. Results Across all questions (n = 284) generated by 33 physicians (31 faculty members and 2 recent graduates from residency or fellowship programs) across 17 specialties, the median accuracy score was 5.5 (IQR, 4.0-6.0) (between almost completely and complete correct) with a mean (SD) score of 4.8 (1.6) (between mostly and almost completely correct). The median completeness score was 3.0 (IQR, 2.0-3.0) (complete and comprehensive) with a mean (SD) score of 2.5 (0.7). For questions rated easy, medium, and hard, the median accuracy scores were 6.0 (IQR, 5.0-6.0), 5.5 (IQR, 5.0-6.0), and 5.0 (IQR, 4.0-6.0), respectively (mean [SD] scores were 5.0 [1.5], 4.7 [1.7], and 4.6 [1.6], respectively; P = .05). Accuracy scores for binary and descriptive questions were similar (median score, 6.0 [IQR, 4.0-6.0] vs 5.0 [IQR, 3.4-6.0]; mean [SD] score, 4.9 [1.6] vs 4.7 [1.6]; P = .07). Of 36 questions with scores of 1.0 to 2.0, 34 were requeried or regraded 8 to 17 days later with substantial improvement (median score 2.0 [IQR, 1.0-3.0] vs 4.0 [IQR, 2.0-5.3]; P < .01). A subset of questions, regardless of initial scores (version 3.5), were regenerated and rescored using version 4 with improvement (mean accuracy [SD] score, 5.2 [1.5] vs 5.7 [0.8]; median score, 6.0 [IQR, 5.0-6.0] for original and 6.0 [IQR, 6.0-6.0] for rescored; P = .002). Conclusions and Relevance In this cross-sectional study, chatbot generated largely accurate information to diverse medical queries as judged by academic physician specialists with improvement over time, although it had important limitations. Further research and model development are needed to correct inaccuracies and for validation.
Collapse
Affiliation(s)
| | - J. Randall Patrinely
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cosby A. Stone
- Department of Allergy, Pulmonology, and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eli Zimmerman
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rebecca R. Donald
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sam S. Chang
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sean T. Berkowitz
- Vanderbilt Eye Institute, Department of Ophthalmology, Vanderbilt University Medical, Nashville, Tennessee
| | - Avni P. Finn
- Vanderbilt Eye Institute, Department of Ophthalmology, Vanderbilt University Medical, Nashville, Tennessee
| | - Eiman Jahangir
- Department of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth A. Scoville
- Department of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tyler S. Reese
- Department of Rheumatology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Debra L. Friedman
- Department of Pediatric Hematology/Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Julie A. Bastarache
- Department of Allergy, Pulmonology, and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yuri F. van der Heijden
- Department of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jordan J. Wright
- Department of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nicholas Carter
- Division of Trauma and Surgical Critical Care, University of Miami Miller School of Medicine, Miami, Florida
| | - Matthew R. Alexander
- Department of Cardiovascular Medicine and Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer H. Choe
- Department of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cody A. Chastain
- Department of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John A. Zic
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sara N. Horst
- Department of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Isik Turker
- Department of Cardiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Rajiv Agarwal
- Department of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Evan Osmundson
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kamran Idrees
- Department of Surgical Oncology & Endocrine Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Colleen M. Kiernan
- Department of Surgical Oncology & Endocrine Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chandrasekhar Padmanabhan
- Department of Surgical Oncology & Endocrine Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina E. Bailey
- Department of Surgical Oncology & Endocrine Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cameron E. Schlegel
- Department of Surgical Oncology & Endocrine Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lola B. Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael K. Gibson
- Department of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Travis J. Osterman
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lee E. Wheless
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Douglas B. Johnson
- Department of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
2
|
Kiernan CM, Thomas G, Patel A, Fan R, Ye F, Willmon PA, Solórzano CC. Does the Use of Probe-based Near-infrared Autofluorescence Parathyroid Detection Benefit Parathyroidectomy?: A Randomized Single-center Clinical Trial. Ann Surg 2023; 278:549-558. [PMID: 37389537 PMCID: PMC10836830 DOI: 10.1097/sla.0000000000005985] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVE To evaluate the benefits of probe-based near-infrared autofluorescence (NIRAF) parathyroid identification during parathyroidectomy. BACKGROUND Intraoperative parathyroid gland identification during parathyroidectomy can be challenging, while additionally requiring costly frozen sections. Earlier studies have established NIRAF detection as a reliable intraoperative adjunct for parathyroid identification. METHODS Patients undergoing parathyroidectomy for primary hyperparathyroidism were prospectively enrolled by a senior surgeon (>20 years experience) and a junior surgeon (<5 years experience), while being randomly allocated to the probe-based NIRAF or control group. Data collected included procedure type, number of parathyroids identified with high confidence by the surgeon and the resident, number of frozen sections performed, parathyroidectomy duration, and number of patients with persistent disease at the first postoperative visit. RESULTS One hundred sixty patients were randomly enrolled under both surgeons to the probe group (n=80) versus control (n=80). In the probe group, parathyroid identification rate of the senior surgeon improved significantly from 3.2 to 3.6 parathyroids per patient ( P <0.001), while that of the junior surgeon also rose significantly from 2.2 to 2.5 parathyroids per patient ( P =0.001). Parathyroid identification was even more prominent for residents increasing significantly from 0.9 to 2.9 parathyroids per patient ( P <0.001). Furthermore, there was a significant reduction in frozen sections utilized in the probe group versus control (17 vs 47, P =0.005). CONCLUSION Probe-based NIRAF detection can be a valuable intraoperative adjunct and educational tool for improving confidence in parathyroid gland identification, while potentially reducing the number of frozen sections required.
Collapse
Affiliation(s)
- Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Giju Thomas
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - Anuradha Patel
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Run Fan
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Parker A Willmon
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| |
Collapse
|
3
|
Beninato T, Duh QY, Long KL, Kiernan CM, Miller BS, Patel S, Randle RW, Wachtel H, Zanocco KA, Zern NK, Drake FT. Challenges and controversies in adrenal surgery: A practical approach. Curr Probl Surg 2023; 60:101374. [PMID: 37770163 DOI: 10.1016/j.cpsurg.2023.101374] [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] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Affiliation(s)
- Toni Beninato
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Quan-Yang Duh
- Veterans Affairs Medical Center, San Francisco, San Francisco, CA
| | | | - Colleen M Kiernan
- Vanderbilt University Medical Center, Veterans Affairs Medical Center, Tennessee Valley Health System, Nashville, TN
| | - Barbra S Miller
- Division of Surgical Oncology, The Ohio State University, Columbus, OH
| | - Snehal Patel
- Emory University School of Medicine, Atlanta, GA
| | | | | | - Kyle A Zanocco
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
| | | | | |
Collapse
|
4
|
Kiernan CM, Solόrzano CC. New Techniques for Intraoperative Parathyroid Localization. Adv Surg 2023; 57:209-223. [PMID: 37536854 DOI: 10.1016/j.yasu.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 08/05/2023]
Abstract
Accurate identification of abnormal parathyroid glands (PGs) during parathyroidectomy and thyroidectomy can be challenging even for experienced surgeons given PGs variable location, size, and similar appearance to surrounding tissue. Inadvertent removal or devascularization of healthy PGs can lead to transient or permanent hypoparathyroidism. Permanent hypoparathyroidism is associated with increased rates of renal insufficiency, seizures, skeletal abnormalities, increased costs, decreased quality of life, and increased mortality. Conversely, the inability to identify and remove hyperfunctioning PGs results in failed parathyroidectomy which can result in need for reoperations that are associated with increased technical difficulty, operative duration, rates of hypoparathyroidism and recurrent laryngeal nerve damage, and cost.
Collapse
Affiliation(s)
- Colleen M Kiernan
- Department of Surgery, Vanderbilt University Medical Center, 2220 Pierce Avenue, 597 Preston Research Building, Nashville, TN 37232, USA.
| | - Carmen C Solόrzano
- Department of Surgery, John L. Sawyers Chair in Surgical Sciences, Vanderbilt University Medical Center, 1161 21st Avenue South, D-4314 Medical Center North, Nashville, TN 37232, USA
| |
Collapse
|
5
|
Collins RA, Wang TS, Dream S, Solórzano CC, Kiernan CM. ASO Visual Abstract: Adoption of Robotic Adrenalectomy: A Two-Institution Study of Surgeon Learning Curve. Ann Surg Oncol 2023; 30:4179. [PMID: 37040051 DOI: 10.1245/s10434-023-13492-6] [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] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Affiliation(s)
- Reagan A Collins
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Tracy S Wang
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sophie Dream
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| |
Collapse
|
6
|
Wachtel H, Dickson P, Fisher SB, Kiernan CM, Solórzano CC. Adrenal Metastasectomy in the Era of Immuno- and Targeted Therapy. Ann Surg Oncol 2023:10.1245/s10434-023-13474-8. [PMID: 37079202 DOI: 10.1245/s10434-023-13474-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 03/26/2023] [Indexed: 04/21/2023]
Abstract
Adrenal metastasectomy has an increasing role in multimodality oncologic care for diverse primary cancer types. In this review, we discuss the epidemiology, evaluation, and contemporary best practices in the management of adrenal metastases from various primaries. Initial evaluation of suspected adrenal metastases should include diagnostic imaging to assess the extent of tumor involvement and determine surgical resectability, as well as biochemical evaluation for hormone secretion. Biopsy has a minimal role and should only be performed in tumors that are established to be non-hormone secreting and when the biopsy results would change clinical management. Adrenal metastasectomy is associated with survival benefit in selected patients. We suggest that adrenal metastasectomy has the greatest benefit in four clinical scenarios: (1) disease limited to the adrenal gland in which adrenalectomy renders the patient disease-free; (2) isolated progression in the adrenal gland in the setting of otherwise controlled metastatic extra-adrenal disease; (3) need for palliation of symptoms related to adrenal metastases; or (4) in the context of tissue-based clinical trials. Both minimally invasive and open adrenalectomy techniques are safe and appear to have equivalent oncologic outcomes. Minimally invasive approaches are favored when technically feasible while maintaining oncologic principles. A multidisciplinary evaluation including clinicians with expertise in the primary cancer type is essential to the successful management of adrenal metastases.
Collapse
Affiliation(s)
- Heather Wachtel
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Paxton Dickson
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sarah B Fisher
- Division of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
7
|
Collins RA, Wang TS, Dream S, Solórzano CC, Kiernan CM. Adoption of Robotic Adrenalectomy: A Two-Institution Study of Surgeon Learning Curve. Ann Surg Oncol 2023:10.1245/s10434-023-13406-6. [PMID: 37040047 DOI: 10.1245/s10434-023-13406-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/08/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Robotic adrenalectomy is feasible and safe, yet concerns over increased operative times and the learning curve (LC) for proficiency have limited its adoption. This study aimed to assess the LC for robotic adrenalectomy. METHODS This is a two-institution retrospective review of consecutive unilateral minimally invasive adrenalectomies performed by four high-volume adrenal surgeons between 2007 and 2022. Two surgeons transitioned from laparoscopic to robotic adrenalectomy, and two surgeons adopted the approach, with proctoring, after completion of fellowship training without robotic experience. Operative time and complications were analyzed. Multivariable regression was used to identify factors associated with operative time. The number of cases required to overcome the LC was determined using the LC-cumulative-sum (LC-CUSUM) analysis. RESULTS Of 457 adrenalectomies, 182 (40%) were laparoscopic and 275 (60%) robotic. The robotic approach was associated with shorter median operative time (106 vs 119 min; p = 0.002), fewer complications (6% vs 13%; p = 0.018), and fewer conversions to open adrenalectomy (1% vs 4%; p = 0.030), with no difference between the senior and junior surgeons. On adjusted analysis, factors associated with increased operative time were male sex (p < 0.001), BMI > 30 kg/m2 (p < 0.001), and higher gland weight (p < 0.001). The LC-CUSUM analysis showed proficiency after 8-29 procedures. Compared with the first 10 cases, there was a mean reduction in operative time of 14 min after 10-20 cases, 28 min after 20-30 cases, and 29 min after > 30 cases, regardless of surgeon experience. DISCUSSION With dedicated teams and proctoring, robotic adrenalectomy can be safely adopted at high-volume centers with a minimal LC.
Collapse
Affiliation(s)
- Reagan A Collins
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Tracy S Wang
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sophie Dream
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| |
Collapse
|
8
|
Thomas G, Kiernan CM, Willmon PA, Haugen E, Luckenbaugh AN, Barocas DA, Baregamian N, Mahadevan-Jansen A, Solόrzano CC. Label-Free Enhancement of Adrenal Gland Visualization Using Near-Infrared Autofluorescence for Surgical Guidance. World J Surg 2023; 47:350-360. [PMID: 36184672 DOI: 10.1007/s00268-022-06755-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND During adrenalectomy, surgeons have traditionally relied on their subjective visual skills to distinguish adrenal glands (AGs) from retroperitoneal fat and surrounding structures, while ultrasound and exogenous contrast agents have been employed for intraoperative AG visualization, all of which have their limitations. We present a novel label-free approach that uses near-infrared autofluorescence (NIRAF) detection, which demonstrates potential for enhanced intraoperative AG visualization and efficient tumor resection during adrenalectomies. METHODS Patients undergoing adrenalectomy or nephrectomy were enrolled for this feasibility study. NIRAF emitted beyond 800 nm was detected in vivo from AGs and surrounding tissues during open adrenalectomies or nephrectomies. NIRAF was also measured ex vivo in excised AGs following robotic adrenalectomies. NIRAF images of tissues were captured using near-infrared (NIR) camera systems, whereas NIRAF intensities were recorded concurrently using fiber-optic probe-based NIR devices. Normalized NIRAF intensities (expressed as mean ± standard error) were analyzed and compared. RESULTS Among the 55 enrolled patients, NIRAF intensity was elevated significantly for AGs versus retroperitoneal fat and other structures. NIR images of AGs also revealed a distinct demarcation of NIRAF between adrenal cortex and other periadrenal structures. NIRAF intensity in AGs was decreased markedly in malignant adrenal tumors, while benign adrenal cortical tumors and healthy adrenal cortex exhibited the strongest NIRAF levels. CONCLUSIONS Our preliminary findings indicate that NIRAF detection could be a promising label-free technology to enhance intraoperative AG visualization and holds immense potential for effective tumor demarcation during cortical-sparing adrenalectomies or adrenal-conserving surgeries.
Collapse
Affiliation(s)
- Giju Thomas
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN, 37235, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, 37235, USA
| | - Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA
| | - Parker A Willmon
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN, 37235, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, 37235, USA
| | - Ezekiel Haugen
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN, 37235, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, 37235, USA
| | - Amy N Luckenbaugh
- Division of Urologic Oncology, Department of Urology, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Daniel A Barocas
- Division of Urologic Oncology, Department of Urology, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Naira Baregamian
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA
| | - Anita Mahadevan-Jansen
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN, 37235, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, 37235, USA
| | - Carmen C Solόrzano
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA.
| |
Collapse
|
9
|
St Amour TC, Demarchi MS, Thomas G, Triponez F, Kiernan CM, Solόrzano CC. Educational Review: Intraoperative Parathyroid Fluorescence Detection Technology in Thyroid and Parathyroid Surgery. Ann Surg Oncol 2023; 30:973-993. [PMID: 36481865 DOI: 10.1245/s10434-022-12807-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/01/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Accurate parathyroid gland (PG) identification is a critical yet challenging component of cervical endocrine procedures. PGs possess strong near-infrared autofluorescence (NIRAF) compared with other tissues in the neck. This property has been harnessed by image- and probe-based near-infrared fluorescence detection systems, which have gained increasing popularity in clinical use for their ability to accurately aid in PG identification in a rapid, noninvasive, and cost-effective manner. All NIRAF technologies, however, cannot differentiate viable from devascularized PGs without the use of contrast enhancement. Here, we aim to provide an overview of the rapid evolution of these technologies and update the surgery community on the most recent advancements in the field. METHODS A PubMed literature review was performed using the key terms "parathyroid," "near-infrared," and "fluorescence." Recommendations regarding the use of these technologies in clinical practice were developed on the basis of the reviewed literature and in conjunction with expert surgeons' opinions. RESULTS The use of near-infrared fluorescence detection can be broadly categorized as (1) using parathyroid NIRAF to identify both healthy and diseased PGs, and (2) using contrast-enhanced (i.e., indocyanine green) near-infrared fluorescence to evaluate PG perfusion and viability. Each of these approaches possess unique advantages and disadvantages, and clinical trials are ongoing to better define their utility. CONCLUSIONS Near-infrared fluorescence detection offers the opportunity to improve our collective ability to identify and preserve PGs intraoperatively. While additional work is needed to propel this technology further, we hope this review will be valuable to the practicing surgeon.
Collapse
Affiliation(s)
- Taylor C St Amour
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marco Stefano Demarchi
- Department of Thoracic and Endocrine Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Giju Thomas
- Department of Biomedical Engineering, Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN, USA
| | - Frederic Triponez
- Department of Thoracic and Endocrine Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Colleen M Kiernan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carmen C Solόrzano
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. .,Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| |
Collapse
|
10
|
Baregamian N, Sekhar KR, Krystofiak ES, Vinogradova M, Thomas G, Mannoh E, Solórzano CC, Kiernan CM, Mahadevan-Jansen A, Abumrad N, Freeman ML, Weiss VL, Rathmell JC, Rathmell WK. Engineering functional 3-dimensional patient-derived endocrine organoids for broad multiplatform applications. Surgery 2023; 173:67-75. [PMID: 36400581 PMCID: PMC9939934 DOI: 10.1016/j.surg.2022.09.027] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recent advancements in 3-dimensional patient-derived organoid models have revolutionized the field of cancer biology. There is an urgent need for development of endocrine tumor organoid models for medullary thyroid carcinoma, adrenocortical carcinoma, papillary thyroid carcinoma, and a spectrum of benign hyperfunctioning parathyroid and adrenal neoplasms. We aimed to engineer functionally intact 3-dimensional endocrine patient-derived organoids to expand the in vitro and translational applications for the advancement of endocrine research. METHODS Using our recently developed fine needle aspiration-based methodology, we established patient-derived 3-dimensional endocrine organoid models using prospectively collected human papillary thyroid carcinoma (n = 6), medullary thyroid carcinoma (n = 3), adrenocortical carcinoma (n = 3), and parathyroid (n = 5). and adrenal (n = 5) neoplasms. Multiplatform analyses of endocrine patient-derived organoids and applications in oncoimmunology, near-infrared autofluorescence, and radiosensitization studies under 3-dimensional in vitro conditions were performed. RESULTS We have successfully modeled and analyzed the complex endocrine microenvironment for a spectrum of endocrine neoplasms in 3-dimensional culture. The endocrine patient-derived organoids recapitulated complex tumor microenvironment of endocrine neoplasms morphologically and functionally and maintained cytokine production and near-infrared autofluorescence properties. CONCLUSION Our novel engineered endocrine patient-derived organoid models of thyroid, parathyroid and adrenal neoplasms represent an exciting and elegant alternative to current limited 2-dimensional systems and afford future broad multiplatform in vitro and translational applications, including in endocrine oncoimmunology.
Collapse
Affiliation(s)
- Naira Baregamian
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Konjeti R Sekhar
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Giju Thomas
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN
| | - Emmanuel Mannoh
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN
| | - Carmen C Solórzano
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Colleen M Kiernan
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Naji Abumrad
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Michael L Freeman
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Vivian L Weiss
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Jeffrey C Rathmell
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - W Kimryn Rathmell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
11
|
Lillemoe HA, Hanna DN, Baregamian N, Solórzano CC, Terhune KP, Geevarghese SK, Kiernan CM. The use of an educational time-out in thyroid and parathyroid surgery to move the needle in periprocedural education. Surgery 2023; 173:84-92. [PMID: 36216620 DOI: 10.1016/j.surg.2022.07.027] [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] [Received: 02/17/2022] [Revised: 05/19/2022] [Accepted: 07/19/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND As surgical training shifts toward a competency-based paradigm, deliberate practice for procedures must be a point of focus. The purpose of this study was to assess the impact of an educational time-out intervention on educational experience and operative performance in endocrine surgery. METHODS For 12 months, third-year general surgery residents used the educational time-out to establish an operative step of focus for thyroidectomy and parathyroidectomy procedures. Data were collected using the System for Improving and Measuring Procedural Learning application and post-rotation surveys. The Zwisch scale was used to classify supervision, with meaningful autonomy defined as passive help or supervision only. RESULTS Eight residents and 3 attending surgeons performed the educational time-out for a total of 211 operations (93% completion rate). At the end of each rotation, there was improvement in the frequency of goal setting. There was strong agreement (90%) that the intervention strengthened the educational experience. For most cases (52%), the residents were rated at active help. Residents performed a median of 3/6 thyroidectomy steps at meaningful autonomy and a median of 2/5 parathyroidectomy steps at meaningful autonomy. Review of the qualitative data revealed that optimal feedback was provided in 46% of cases. CONCLUSION The educational time-out strengthened educational experiences. Stepwise procedural data revealed the varying levels of supervision that exist within an operation. Broader implementation of this intervention could facilitate competency-based procedural education.
Collapse
Affiliation(s)
- Heather A Lillemoe
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN; Department of Surgical Oncology, The University of Texas at MD Anderson Cancer Center, Houston, TX.
| | - David N Hanna
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Naira Baregamian
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Carmen C Solórzano
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Kyla P Terhune
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Colleen M Kiernan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
12
|
Baechle JJ, Smith PM, Kiernan CM. ASO Author Reflections: Clinical Predictors of Pseudohypoxia Cluster Type Pheochromocytomas. Ann Surg Oncol 2022; 29:3547-3548. [PMID: 35366697 DOI: 10.1245/s10434-022-11638-6] [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] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/06/2022] [Indexed: 11/18/2022]
Affiliation(s)
| | - Paula Marincola Smith
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| |
Collapse
|
13
|
Baechle JJ, Smith PM, Ortega CA, Wang TS, Solórzano CC, Kiernan CM. Clinical Predictors of Pseudohypoxia-Type Pheochromocytomas. Ann Surg Oncol 2022; 29:3536-3546. [PMID: 35233740 DOI: 10.1245/s10434-022-11419-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 01/16/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Pheochromocytomas (PCCs) are rare tumors of neural crest origin with divergent transcriptional and metabolic profiles associated with mutational cluster types. Pseudohypoxia-type (PHT) PCCs have a poor prognosis; however diagnostic genetic testing is not always available. We aimed to investigate clinical parameters predictive of PHT PCCs. METHODS Patients who underwent resection and genetic testing for PCC at two academic centers from 2006-2020 were retrospectively studied. Patients with PHT mutations (SDH-AF2/B/C/D, VHL) were compared to non-pseudohypoxia-type (nonPHT) PCCs to identify widely available clinical parameters predictive of PHT PCCs. Demographic, clinical, and pathologic characteristics were compared using student's T and ANOVA tests. Operative hemodynamic instability was defined as systolic blood pressure (SBP) > 200 mmHg, SBP increase of > 30% relative to baseline, and/or heart rate (HR) > 110 bpm. Mann-Whitney U test was used to assess area under the curve (AUC), sensitivity, and specificity. Recursive partitioning was used to model predictive thresholds for PHT PCC and develop a predictive score. RESULTS Of the 79 patients included in the cohort, 17 (22%) had PHT and 62 (78%) had nonPHT PCCs. PCC patients with > 2 of the examined predictive clinical parameters (preoperative weight loss [> 10% body weight], elevated preoperative hematocrit [> 50%], normal baseline heart rate [< 100 bpm], and normal plasma metanephrines [< 0.60 nmol/L]) were more likely to have PHT PCCs (AUC = 0.831, sensitivity = 0.882, specificity = 0.694, all p < 0.001). CONCLUSIONS Widely available preoperative clinical parameters including indicators of erythropoiesis (hemoglobin, hematocrit, and red blood cell count), baseline heart rate, plasma metanephrines, and weight loss may be useful predictors of PHT PCCs and may help guide management of PCCs when genetic testing is unavailable/delayed.
Collapse
Affiliation(s)
- J J Baechle
- School of Medicine, Meharry Medical College, Nashville, TN, USA
| | - P Marincola Smith
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C A Ortega
- School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - T S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - C C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| |
Collapse
|
14
|
Kiernan CM, Solorzano CC. Commentary on “Differences in the Clinicopathologic Behavior of Oncocytic Adrenocortical Neoplasms and Conventional Adrenocortical Carcinomas” by Shirali et al. Ann Surg Oncol 2022; 29:5364-5366. [DOI: 10.1245/s10434-022-11649-3] [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] [Received: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 11/18/2022]
|
15
|
Srougi V, Bancos I, Daher M, Lee JE, Graham PH, Karam JA, Henriquez A, Mckenzie TJ, Sada A, Bourdeau I, Poirier J, Vaidya A, Abbondanza T, Kiernan CM, Rao SN, Hamidi O, Sachithanandan N, Hoff AO, Chambo JL, Almeida MQ, Habra MA, Fragoso MCBV. Cytoreductive Surgery of the Primary Tumor in Metastatic Adrenocortical Carcinoma: Impact on Patients' Survival. J Clin Endocrinol Metab 2022; 107:964-971. [PMID: 34850915 PMCID: PMC9122637 DOI: 10.1210/clinem/dgab865] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The role of cytoreduction of adrenocortical carcinoma (ACC) remains poorly understood. OBJECTIVE To analyze the impact of cytoreductive surgery of the primary tumor in patients with metastatic ACC. DESIGN AND SETTING We performed a multicentric, retrospective paired cohort study comparing the overall survival (OS) in patients with metastatic ACC who were treated either with cytoreductive surgery (CR group) or without cytoreductive surgery (no-CR group) of the primary tumor. Data were retrieved from 9 referral centers in the American-Australian-Asian Adrenal Alliance collaborative research group. PATIENTS Patients aged ≥18 years with metastatic ACC at initial presentation who were treated between January 1, 1995, and May 31, 2019. INTERVENTION Performance (or not) of cytoreductive surgery of the primary tumor. MAIN OUTCOME AND MEASURES A propensity score match was done using age and the number of organs with metastasis (≤2 or >2). The main outcome was OS, determined from the date of diagnosis until death or until last follow-up for living patients. RESULTS Of 339 patients pooled, 239 were paired and included: 128 in the CR group and 111 in the no-CR group. The mean follow-up was 67 months. Patients in the no-CR group had greater risk of death than did patients in the CR group (hazard ratio [HR] = 3.18; 95% CI, 2.34-4.32). Independent predictors of survival included age (HR = 1.02; 95% CI, 1.00-1.03), hormone excess (HR = 2.56; 95% CI, 1.66-3.92), and local metastasis therapy (HR = 0.41; 95% CI, 0.47-0.65). CONCLUSION Cytoreductive surgery of the primary tumor in patients with metastatic ACC is associated with prolonged survival.
Collapse
Affiliation(s)
- Victor Srougi
- Division of Urology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Division of Urology, Hospital Moriah, São Paulo, Brazil
| | - Irina Bancos
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - Marilyne Daher
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul H Graham
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose A Karam
- Department of Urology and Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Travis J Mckenzie
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alaa Sada
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Isabelle Bourdeau
- Division of Endocrinology and Research Center, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
| | - Jonathan Poirier
- Division of Endocrinology and Research Center, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Tiffany Abbondanza
- Center for Adrenal Disorders, Division of Endocrinology Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sarika N Rao
- Division of Endocrinology, Mayo Clinic, Jacksonville, FL, USA
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nirupa Sachithanandan
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Melbourne, Australia
| | - Ana O Hoff
- Unidade de Suprarrenal, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jose L Chambo
- Division of Urology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Madson Q Almeida
- Unidade de Suprarrenal, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Mouhammed Amir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria C B V Fragoso
- Unidade de Suprarrenal, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
16
|
Baechle JJ, Smith PM, Ortega CA, Wang TS, Solórzano CC, Kiernan CM. ASO Visual Abstract: Clinical Predictors of Pseudohypoxia-Type Pheochromocytoma. Ann Surg Oncol 2022. [DOI: 10.1245/s10434-022-11507-2] [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: 11/18/2022]
|
17
|
Edwards GC, Martin RL, Samuels LR, Wyman K, Bailey CE, Kiernan CM, Snyder RA, Dittus RS, Roumie CL. Association of Adherence to Quality Metrics with Recurrence or Mortality among Veterans with Colorectal Cancer. J Gastrointest Surg 2021; 25:2055-2064. [PMID: 33169321 DOI: 10.1007/s11605-020-04804-2] [Citation(s) in RCA: 4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/15/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The National Comprehensive Cancer Network has defined metrics for colorectal cancer; however, the association of metric adherence with patient clinical outcomes remains underexplored. The study aim was to evaluate the association of National Comprehensive Cancer Network metric adherence with recurrence and mortality in Veterans with nonmetastatic colorectal cancer. METHODS Veterans with stage I-III colorectal cancer who underwent non-emergent resection from 2001 to 2015 at a single Veterans Affairs Medical Center were included. The primary predictor was completion of eligible National Comprehensive Cancer Network metrics. The primary outcome was a composite of recurrence or all-cause death in three phases of care: surgical (up to 6 months after resection), treatment (6-18 months after resection), and surveillance (18 months-3 years after resection). Hazard ratios were estimated via Cox proportional hazards regression in a propensity score-weighted cohort. RESULTS A total of 1107 electronic medical records of patients undergoing colorectal surgery were reviewed, and 379 patients were included (301 colon and 78 rectal cancer). In the surgical phase, the weighted analysis yielded a hazard ratio of 0.37 (95% confidence interval 0.12-1.13) for metric-adherent patients compared with non-adherent patients. In the treatment and surveillance phases, the hazard ratios for metric-adherent care were 0.68 (95% confidence interval 0.25-1.85) and 0.91 (95% confidence interval 0.31-2.68), respectively. CONCLUSIONS The National Comprehensive Cancer Network guideline metric adherence was associated with a lower rate of recurrence and death in the surgical phase of care among stage I-III patients with resected colorectal cancer.
Collapse
Affiliation(s)
- Gretchen C Edwards
- Department of General Surgery, Vanderbilt University Medical Center & Tennessee Valley Healthcare System - Veterans Health Administration, Medical Center North, Suite CCC-4312, 1161 21st Avenue South, Nashville, TN, 37232-2730, USA. .,Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System - Veterans Health Administration, Nashville, TN, USA.
| | - Richard L Martin
- Department of Medicine, Division of Medical Oncology, Vanderbilt University Medical Center & Tennessee Valley Healthcare System - Veterans Health Administration, Nashville, TN, USA
| | - Lauren R Samuels
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System - Veterans Health Administration, Nashville, TN, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kenneth Wyman
- Department of Medicine, Division of Medical Oncology, Vanderbilt University Medical Center & Tennessee Valley Healthcare System - Veterans Health Administration, Nashville, TN, USA
| | - Christina E Bailey
- Department of General Surgery, Division of Surgical Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colleen M Kiernan
- Department of General Surgery, Vanderbilt University Medical Center & Tennessee Valley Healthcare System - Veterans Health Administration, Medical Center North, Suite CCC-4312, 1161 21st Avenue South, Nashville, TN, 37232-2730, USA.,Department of General Surgery, Division of Surgical Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rebecca A Snyder
- Departments of Surgery and Public Health, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Robert S Dittus
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System - Veterans Health Administration, Nashville, TN, USA.,Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christianne L Roumie
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System - Veterans Health Administration, Nashville, TN, USA.,Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
18
|
Lubitz CC, Kiernan CM, Toumi A, Zhan T, Roth MY, Sosa JA, Tuttle RM, Grubbs EG. Patient Perspectives on the Extent of Surgery and Radioactive Iodine Treatment for Low-Risk Differentiated Thyroid Cancer. Endocr Pract 2021; 27:383-389. [PMID: 33840638 PMCID: PMC10028733 DOI: 10.1016/j.eprac.2021.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 01/07/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To understand patient perspective regarding recommended changes in the 2015 American Thyroid Association (ATA) guidelines. Specifically, in regard to active surveillance (AS) of some small differentiated thyroid cancer (DTC), performance of less extensive surgery for low-risk DTC, and more selective administration of radioactive iodine (RAI). METHODS An online survey was disseminated to thyroid cancer patient advocacy organizations and members of the ATA to distribute to the patients. Data were collected on demographic and treatment information, and patient experience with DTC. Patients were asked "what if" scenarios on core topics, including AS, extent of surgery, and indications for RAI. RESULTS Survey responses were analyzed from 1546 patients with DTC: 1478 (96%) had a total thyroidectomy, and 1167 (76%) underwent RAI. If there was no change in the overall cancer outcome, 606 (39%) of respondents would have considered lobectomy over total thyroidectomy, 536 (35%) would have opted for AS, and 638 (41%) would have chosen to forego RAI. Moreover, (774/1217) 64% of respondents wanted more time with their clinicians when making decisions about the extent of surgery. A total of 621/1167 of patients experienced significant side effects with RAI, and 351/1167 of patients felt that the risks of treatment were not well explained. 1237/1546 (80%) of patients felt that AS would not be overly burdensome, and quality of life was the main reason cited for choosing AS. CONCLUSION Patient perspective regarding choice in the management of low-risk DTC varies widely, and a large proportion of DTC patients would change aspects of their care if oncologic outcomes were equivalent.
Collapse
Affiliation(s)
- Carrie C Lubitz
- Massachusetts General Hospital Institute for Technology Assessment, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
| | - Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, Tennessee
| | - Asmae Toumi
- Massachusetts General Hospital Institute for Technology Assessment, Boston, Massachusetts
| | - Tiannan Zhan
- Massachusetts General Hospital Institute for Technology Assessment, Boston, Massachusetts
| | - Mara Y Roth
- Department of Medicine, Division of Metabolism, Endocrinology, and Nutrition, University of Washington, Seattle Cancer Care Alliance, Seattle, Washington
| | - Julie A Sosa
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - R Michael Tuttle
- Endocrinology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elizabeth G Grubbs
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
19
|
Kiernan CM, Thomas G, Baregamian N, Solόrzano CC. Initial clinical experiences using the intraoperative probe-based parathyroid autofluorescence identification system-PTeye™ during thyroid and parathyroid procedures. J Surg Oncol 2021; 124:271-281. [PMID: 33866558 DOI: 10.1002/jso.26500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 12/30/2020] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVE The Food and Drug Administration has cleared a probe-based near-infrared autofluorescence (NIRAF) detection system called PTeye™ as an adjunct tool for label-free intraoperative parathyroid gland (PG) identification. Since PTeye™ has been investigated only in a "blinded" manner to date, this study describes the preliminary impressions of PTeye™ when used by surgeons without being blinded to the device output. METHODS Patients undergoing thyroid and parathyroid procedures were prospectively recruited. Target tissues were intraoperatively assessed with PTeye™. The surgeon's confidence in PG identification was recorded concomitantly with NIRAF parameters that were output in real-time from PTeye™. RESULTS A retrospective review of prospectively collected data on 83 patients was performed. PTeye™ was used for interrogating 336 target tissues in 46 parathyroid and 37 thyroid procedures. PTeye™ yielded an overall accuracy of 94.3% with a positive predictive value of 93.0% and a negative predictive value of 100%. An increase in confidence for intraoperative PG identification with PTeye™ was observed by all three participating high-volume surgeons, irrespective of their level of accrued surgical experience. CONCLUSIONS Probe-based NIRAF detection with PTeye™ can be a valuable adjunct device to intraoperatively identify PGs for surgeons of varied training and experience.
Collapse
Affiliation(s)
- Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Giju Thomas
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, Tennessee, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Naira Baregamian
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carmen C Solόrzano
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
20
|
Baechle JJ, Smith PM, Kiernan CM. Correction to: ASO Author Reflections: Cumulative GRAS Score Predicts Outcomes After Resection for Adrenal Cortical Carcinoma. Ann Surg Oncol 2021; 28:868. [PMID: 33598862 DOI: 10.1245/s10434-021-09732-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Paula Marincola Smith
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| |
Collapse
|
21
|
Baechle JJ, Marincola Smith P, Solórzano CC, Tran TB, Postlewait LM, Maithel SK, Prescott J, Pawlik T, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Shirley LA, Fields RC, Jin L, Abbott DE, Ronnekleiv-Kelly S, Sicklick JK, Yopp A, Mansour J, Duh QY, Seiser N, Votanopoulos K, Levine EA, Poultsides G, Kiernan CM. Cumulative GRAS Score as a Predictor of Survival After Resection for Adrenocortical Carcinoma: Analysis From the U.S. Adrenocortical Carcinoma Database. Ann Surg Oncol 2021; 28:6551-6561. [PMID: 33586069 DOI: 10.1245/s10434-020-09562-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 12/21/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare but aggressive malignancy, and many prognostic factors that influence survival remain undefined. Individually, the GRAS (Grade, Resection status, Age, and Symptoms of hormone hypersecretion) parameters have demonstrated their prognostic value in ACC. This study aimed to assess the value of a cumulative GRAS score as a prognostic indicator after ACC resection. METHODS A retrospective cohort study of adult patients who underwent surgical resection for ACC between 1993 and 2014 was performed using the United States Adrenocortical Carcinoma Group (US-ACCG) database. A sum GRAS score was calculated for each patient by adding one point each when the criteria were met for tumor grade (Weiss criteria ≥ 3 or Ki67 ≥ 20%), resection status (micro- or macroscopically positive margin), age (≥ 50 years), and preoperative symptoms of hormone hypersecretion (present). Overall survival (OS) and disease-free survival (DFS) by cumulative GRAS score were analyzed by the Kaplan-Meier method and log-rank test. RESULTS Of the 265 patients in the US-ACCG database, 243 (92%) had sufficient data available to calculate a cumulative GRAS score and were included in this analysis. The 265 patients comprised 23 patients (10%) with a GRAS of 0, 52 patients (21%) with a GRAS of 1, 92 patients (38%) with a GRAS of 2, 63 patients (26%) with a GRAS of 3, and 13 patients (5%) with a GRAS of 4. An increasing GRAS score was associated with shortened OS (p < 0.01) and DFS (p < 0.01) after index resection. CONCLUSION In this retrospective analysis, the cumulative GRAS score effectively stratified OS and DFS after index resection for ACC. Further prospective analysis is required to validate the cumulative GRAS score as a prognostic indicator for clinical use.
Collapse
Affiliation(s)
- Jordan J Baechle
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,School of Medicine, Meharry Medical College, Nashville, TN, USA
| | | | - Carmen C Solórzano
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thuy B Tran
- Department of Surgery, Stanford Medical Center, Stanford, CA, USA
| | - Lauren M Postlewait
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jason Prescott
- Department of Surgery, The Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Timothy Pawlik
- Department of Surgery, The Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ioannis Hatzaras
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Rivfka Shenoy
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | | | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Linda Jin
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Daniel E Abbott
- Department of General Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sean Ronnekleiv-Kelly
- Department of General Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Adam Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Colleen M Kiernan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| |
Collapse
|
22
|
Baechle JJ, Smith PM, Kiernan CM. ASO Author Reflections: Cumulative GRAS Score Predicts Outcomes After Resection for Adrenal Cortical Carcinoma. Ann Surg Oncol 2021; 28:6562-6563. [PMID: 33532879 DOI: 10.1245/s10434-021-09616-5] [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] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/08/2021] [Indexed: 11/18/2022]
Affiliation(s)
| | - Paula Marincola Smith
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| |
Collapse
|
23
|
Wrenn SM, Wang TS, Toumi A, Kiernan CM, Solórzano CC, Stephen AE. Practice patterns for surgical management of low-risk papillary thyroid cancer from 2014 to 2019: A CESQIP analysis. Am J Surg 2020; 221:448-454. [PMID: 32933747 DOI: 10.1016/j.amjsurg.2020.07.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 06/17/2020] [Revised: 07/22/2020] [Accepted: 07/31/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patients with low-risk-PTC who undergo thyroid lobectomy (TL) have comparable disease-specific survival with lower morbidity than total thyroidectomy (TT). We aim to describe the surgical management of low-risk-PTC using the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP). METHOD CESQIP thyroidectomies of PTC tumors <4 cm were analyzed from 2014 to 2019 (n = 740). Postoperative outcomes were compared. Subgroup analysis examined temporal and institutional trends, and stratified for tumor size. Statistics utilized t-test, ANOVA, and Chi-squared. RESULTS TT patients had greater hypoparathyroidism, operative time, and length-of-stay (all p < 0.001). Incidence of TL decreased with increasing tumor size (24.2% for <1 cm, 15.8% for 1-2 cm, 6.1% for 2-4 cm). TL rates increased from 2.0% in 2014 to 21.2% in 2018-19. Completion thyroidectomy was recommended in 12.0% of TL subjects. There was significant variation in TL rate by institution (p < .001). CONCLUSIONS For low-risk-PTC, TT remained the most commonly utilized operation. TL rates increased following release of the new ATA guidelines. TT was associated with higher perioperative morbidity. Further insight is needed to understand factors influencing operative approach.
Collapse
Affiliation(s)
- Sean M Wrenn
- Massachusetts General Hospital, Department of Surgery, Division of Surgical Oncology, USA; Brigham and Women's Hospital, Department of Surgery, Division of Endocrine Surgery, USA; Rush University Medical Center, Department of Surgery, Division of Surgical Oncology, USA.
| | - Tracy S Wang
- Medical College of Wisconsin, Department of Surgery, Division of Endocrine Surgery, USA
| | - Asmae Toumi
- Massachusetts General Hospital, Department of Surgery, Division of Surgical Oncology, USA
| | - Colleen M Kiernan
- Vanderbilt University, Department of Surgery, Division of Surgical Oncology, USA
| | - Carmen C Solórzano
- Vanderbilt University, Department of Surgery, Division of Surgical Oncology, USA
| | - Antonia E Stephen
- Massachusetts General Hospital, Department of Surgery, Division of Surgical Oncology, USA
| |
Collapse
|
24
|
Abstract
According to the Endocrine Society Clinical Practice Guidelines, the goal of treating overt Cushing's syndrome is to control cortisol levels or more importantly its actions at its receptor in order to eliminate the end organ effects and treat comorbidities associated with hypercortisolism. This chapter will review the surgical management of hypercortisolism. It will be subdivided into two main sections: the management of: (I) ACTH-dependent; and (II) ACTH-independent (adrenal) hypercortisolism. The perioperative factors that surgeons should consider after the diagnosis has been made will also be discussed. Lastly, the utilization of robotic surgery for adrenalectomy and the perceived benefits and potential pitfalls of this approach when treating patients with hypercortisolism will be reviewed.
Collapse
|
25
|
Helmink BA, Roland CL, Kiernan CM, Wargo JA. Toxicity of Immune Checkpoint Inhibitors: Considerations for the Surgeon. Ann Surg Oncol 2020; 27:1533-1545. [PMID: 31965370 DOI: 10.1245/s10434-019-08183-0] [Citation(s) in RCA: 4] [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] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The use of immunotherapeutic agents, specifically immune checkpoint inhibitors (ICIs) for solid malignancies, is rapidly rising, and many new agents and treatment combinations are in development. However, ICIs have a unique side-effect profile of immune-related adverse events (irAEs) compared with chemotherapeutic agents or targeted therapies. METHODS In this report the diverse spectrum of irAEs is highlighted using two patients with metastatic melanoma undergoing treatment with ICIs. We supplement these case reports with a brief literature review of the data regarding the safety of surgical intervention in patients taking irAEs. RESULTS The report describes the basic approach to the detection and management of irAEs, notes important perioperative considerations, and discusses the safety of surgical intervention for these patients. CONCLUSIONS Overall, these irAEs represent a diverse group of pathologies with variable timing and sometimes subtle presentation requiring careful monitoring and heightened clinical suspicion for potential toxicity by all providers, including surgeons.
Collapse
Affiliation(s)
- Beth A Helmink
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Colleen M Kiernan
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Jennifer A Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA. .,Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA.
| |
Collapse
|
26
|
Prendergast KM, Smith PM, Tran TB, Postlewait LM, Maithel SK, Prescott JD, Pawlik TM, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Shirley LA, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Votanopoulos KI, Levine EA, Poultsides GA, Solórzano CC, Kiernan CM. Features of synchronous versus metachronous metastasectomy in adrenal cortical carcinoma: Analysis from the US adrenocortical carcinoma database. Surgery 2019; 167:352-357. [PMID: 31272813 DOI: 10.1016/j.surg.2019.05.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/09/2019] [Accepted: 05/19/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Adrenocortical carcinoma is a rare, aggressive cancer. We compared features of patients who underwent synchronous versus metachronous metastasectomy. METHODS Adult patients who underwent resection for metastatic adrenocortical carcinoma from 1993 to 2014 at 13 institutions of the US adrenocortical carcinoma group were analyzed retrospectively. Patients were categorized as synchronous if they underwent metastasectomy at the index adrenalectomy or metachronous if they underwent resection after recurrence of the disease. Factors associated with overall survival were assessed by univariate analysis. RESULTS In the study, 84 patients with adrenocortical carcinoma underwent metastasectomy; 26 (31%) were synchronous and 58 (69%) were metachronous. Demographics were similar between groups. The synchronous group had more T4 tumors at the index resection (42 vs 3%, P < .001). The metachronous group had prolonged median survival after the index resection (86.3 vs 17.3 months, P < .001) and metastasectomy (36.9 vs 17.3 months, P = .007). Synchronous patients with R0 resections had improved survival compared to patients with R1/2 resections (P = .008). Margin status at metachronous metastasectomy was not associated with survival (P = .452). CONCLUSION Select patients with metastatic adrenocortical carcinoma may benefit from metastasectomy. Patients with metachronous metastasectomy have a more durable survival benefit than those undergoing synchronous metastasectomy. This study highlights need for future studies examining differences in tumor biology that could explain outcome disparities in these distinct patient populations.
Collapse
Affiliation(s)
| | | | - Thuy B Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Lauren M Postlewait
- 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
| | - Jason D Prescott
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - 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
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH
| | | | - 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 General Surgery, 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
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | | | | | | |
Collapse
|
27
|
Yang Y, Malakorn S, Maldonado K, Bednarski BK, Kiernan CM, Thirumurthi S, Chang GJ, You YN. The Pelvis-First Approach for Robotic Proctectomy in Patients with Redundant Abdominal Colon. Ann Surg Oncol 2019; 26:2514-2515. [PMID: 31102088 DOI: 10.1245/s10434-019-07416-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Robotic surgery is increasingly performed for low rectal cancer.1 A redundant sigmoid colon makes retraction and pelvic dissection challenging. We present a 'pelvis-first' approach to robotic proctectomy where pelvic dissection occurs prior to colonic mobilization. METHODS A 26-year-old woman was diagnosed with a clinical T3N1 rectal adenocarcinoma at 3 cm from the anal verge. The patient had Lynch syndrome, with a germline mutation in the PMS2 gene. A near-complete clinical response was observed after neoadjuvant chemoradiation (NCRT), and the patient wished to delay surgery and permanent colostomy. Additional FOLFOX was administered and led to a complete clinical response. After 2.5 months of watchful delay of surgery, the tumor regrew, and the patient then underwent robotic abdominoperineal resection (APR). RESULTS Initial exploration revealed a highly redundant sigmoid colon. A pelvis-first approach was undertaken. The colon was left tethered and outside of the pelvis during the pelvic dissection. The levator ani was divided transabdominally. Vascular dissection and left colon mobilization were completed after pelvic dissection.2 The specimen was removed transanally, obviating the need for abdominal incision. An end colostomy was created laparoscopically, and the perineum was closed primarily after omental flap. The patient recovered without complications. CONCLUSIONS The 'pelvis-first' approach to proctectomy is advantageous for patients with a highly redundant sigmoid colon. Transabdominal division of the levator ani during APR ensures excellent circumferential margin. Although Lynch syndrome-associated rectal cancer can show excellent response to NCRT,3 patients undergoing watchful delay of surgery require close monitoring and prompt triggering of salvage proctectomy when tumor regrowth is observed.4,5.
Collapse
Affiliation(s)
- Yun Yang
- Department of General Surgery, Chinese PLA General Hospital, Beijing, China.,Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, PO Box 301402, Houston, TX, 77230, USA
| | - Songphol Malakorn
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, PO Box 301402, Houston, TX, 77230, USA
| | - Kelly Maldonado
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, PO Box 301402, Houston, TX, 77230, USA
| | - Brian K Bednarski
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, PO Box 301402, Houston, TX, 77230, USA
| | - Colleen M Kiernan
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, PO Box 301402, Houston, TX, 77230, USA
| | - Selvi Thirumurthi
- Department of Gastroenterology Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, PO Box 301402, Houston, TX, 77230, USA
| | - Y Nancy You
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, PO Box 301402, Houston, TX, 77230, USA.
| |
Collapse
|
28
|
Kiernan CM, Wang T, Perrier ND, Grubbs EG, Solórzano CC. Bilateral Neck Exploration for Sporadic Primary Hyperparathyroidism: Use Patterns in 5,597 Patients Undergoing Parathyroidectomy in the Collaborative Endocrine Surgery Quality Improvement Program. J Am Coll Surg 2019; 228:652-659. [DOI: 10.1016/j.jamcollsurg.2018.12.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/19/2018] [Indexed: 01/12/2023]
|
29
|
Abstract
Since the first description of laparoscopic adrenalectomy (LA) for pheochromocytoma and Cushing syndrome in 1992, the utilization of and indications for a minimally invasive approach to the adrenal gland have vastly expanded. Although minimally invasive adrenalectomy has been established as the preferred approach for patients with benign tumors of the adrenal gland, minimally invasive adrenalectomy for cancer remains controversial. In this article, the authors review the indications for minimally invasive adrenalectomy for adrenal nodules suspicious for, or established to represent, a primary malignancy or a site of metastatic cancer.
Collapse
Affiliation(s)
- Colleen M Kiernan
- Department of Surgical Oncology, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | - Jeffrey E Lee
- Department of Surgical Oncology, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| |
Collapse
|
30
|
Marincola Smith P, Kiernan CM, Solórzano CC. ASO Author Reflections: Additional Organ Resection in Adrenocortical Carcinoma. Ann Surg Oncol 2018; 25:872-873. [PMID: 30324471 DOI: 10.1245/s10434-018-6910-y] [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] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Paula Marincola Smith
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colleen M Kiernan
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carmen C Solórzano
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| |
Collapse
|
31
|
Chotai PN, Kiernan CM, Solorzano CC. Prospective Evaluation of the Utility of Intraoperative Parathyroid Monitoring during Intended Bilateral Neck Exploration for Primary Sporadic Hyperparathyroidism. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.329] [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: 10/28/2022]
|
32
|
Ethun CG, Poorman CE, Postlewait LM, Tran TB, Prescott JD, Pawlik TM, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solórzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Staley CA, Poultsides GA, Maithel SK. A Novel T-Stage Classification System for Adrenocortical Carcinoma: Proposal from the U.S. Adrenocortical Carcinoma Study Group. VideoEndocrinology 2018. [DOI: 10.1089/ve.2017.0115] [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] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Cecilia G. Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Caroline E. Poorman
- 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
| | - Thuy B. Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Jason D. Prescott
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M. Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tracy S. Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, New York
| | - John E. Phay
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - 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 General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jason K. Sicklick
- Department of Surgery, University of California San Diego, San Diego, California
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, California
| | - Adam C. Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John C. Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, California
| | | | | | | | - Edward A. Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Charles A. Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - George A. Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| |
Collapse
|
33
|
Kiernan CM, Smith PM, Feng Z, Solórzano CC. Robotic Resection of an 8 mm Nonexophitic Pancreatic Insulinoma. VideoEndocrinology 2018. [DOI: 10.1089/ve.2018.0129] [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] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Colleen M. Kiernan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Zuliang Feng
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carmen C. Solórzano
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
34
|
Marincola Smith P, Kiernan CM, Tran TB, Postlewait LM, Maithel SK, Prescott J, Pawlik T, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay J, Shirley LA, Fields RC, Jin L, Weber S, Salem A, Sicklick J, Gad S, Yopp A, Mansour J, Duh QY, Seiser N, Votanopoulos K, Levine EA, Poultsides G, Solórzano CC. Role of Additional Organ Resection in Adrenocortical Carcinoma: Analysis of 167 Patients from the U.S. Adrenocortical Carcinoma Database. Ann Surg Oncol 2018; 25:2308-2315. [PMID: 29868977 DOI: 10.1245/s10434-018-6546-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare and aggressive cancer. This report describes factors and outcomes associated with resection of extra-adrenal organs en bloc during index adrenalectomy. METHODS Patients who underwent ACC resection for non-metastatic disease from 1993 to 2014 at 13 participating institutions of the US-ACC Group were included in the study. Factors associated with en bloc resection were assessed by uni- and multivariate analysis. The primary end point was overall survival. RESULTS In this study, 167 patients were included and categorized as adrenalectomy with en bloc resection (AdEBR) if they had extra-adrenal organs removed or adrenalectomy (Ad) if they did not. The demographics were similar between the AdEBR (n = 68, 40.7%) and Ad groups, including age, gender, race, American Society of Anesthesiology (ASA) class, and body mass index (BMI). The AdEBR group had larger tumors (13 vs. 10 cm), more open operations (97.1 vs. 63.6%), and more lymph node dissections (LNDs) (36.8 vs. 12.1%). The most common organs removed were kidney (55.9%), liver (27.9%), and spleen (23.5%). Multiple organs were removed in 38.2% (n = 26) of the patients. Margin-negative resections were similar between the two groups. In the multivariate Cox regression adjusted for T and N stages, LND, margin, size, and hormone hypersecretion, en bloc resection was not associated with improved survival (hazard ratio [HR], 1.42; p = 0.323). CONCLUSION The study findings validated current practice by showing that en bloc resection should occur at index adrenalectomy for ACC when a T4 lesion is suspected pre- or intraoperatively, or when it is necessary to avoid tumor rupture. However, in this study, when a negative margin resection was otherwise achieved, removal of extra-adrenal organs en bloc was not associated with additional survival benefit.
Collapse
Affiliation(s)
- Paula Marincola Smith
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building 2220 Pierce Ave, Nashville, TN, 37232, USA
| | - Colleen M Kiernan
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building 2220 Pierce Ave, Nashville, TN, 37232, USA
| | - Thuy B Tran
- Stanford University School of Medicine, Stanford, CA, USA
| | - Lauren M Postlewait
- 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
| | - Jason Prescott
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy Pawlik
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tracy S Wang
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jason Glenn
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Rivka Shenoy
- New York University School of Medicine, New York, NY, USA
| | - John Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | | | - Ryan C Fields
- Barnes-Jewish Hospital and the Alvin J. Siteman Comprehensive Cancer Center, Washington University School of Medicine, St Louis, MO, USA
| | - Linda Jin
- Barnes-Jewish Hospital and the Alvin J. Siteman Comprehensive Cancer Center, Washington University School of Medicine, St Louis, MO, USA
| | - Sharon Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jason Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Adam Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Carmen C Solórzano
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building 2220 Pierce Ave, Nashville, TN, 37232, USA.
| |
Collapse
|
35
|
Kiernan CM, Weiss VL, Mehrad M, Ely K, Baregamian N, Solórzano CC. New terminology—noninvasive follicular neoplasm with papillary-like nuclear features (NIFTP) and its effect on the rate of malignancy at a single institution. Surgery 2018; 163:55-59. [DOI: 10.1016/j.surg.2017.04.041] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/04/2017] [Accepted: 04/19/2017] [Indexed: 12/23/2022]
|
36
|
Poorman CE, Ethun CG, Postlewait LM, Tran TB, Prescott JD, Pawlik TM, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solórzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Staley CA, Poultsides GA, Maithel SK. A Novel T-Stage Classification System for Adrenocortical Carcinoma: Proposal from the US Adrenocortical Carcinoma Study Group. Ann Surg Oncol 2017; 25:520-527. [PMID: 29164414 DOI: 10.1245/s10434-017-6236-1] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND The 7th AJCC T-stage system for adrenocortical carcinoma (ACC), based on size and extra-adrenal invasion, does not adequately stratify patients by survival. Lymphovascular invasion (LVI) is a known poor prognostic factor. We propose a novel T-stage system that incorporates LVI to better risk-stratify patients undergoing resection for ACC. METHOD Patients undergoing curative-intent resections for ACC from 1993 to 2014 at 13 institutions comprising the US ACC Group were included. Primary outcome was disease-specific survival (DSS). RESULTS Of the 265 patients with ACC, 149 were included for analysis. The current T-stage system failed to differentiate patients with T2 versus T3 disease (p = 0.10). Presence of LVI was associated with worse DSS versus no LVI (36 mo vs. 168 mo; p = 0.001). After accounting for the individual components of the current T-stage system (size, extra-adrenal invasion), LVI remained a poor prognostic factor on multivariable analysis (hazard ratio 2.14, 95% confidence interval 1.05-4.38, p = 0.04). LVI positivity further stratified patients with T2 and T3 disease (T2: 37 mo vs. median not reached; T3: 36 mo vs. 96 mo; p = 0.03) but did not influence survival in patients with T1 or T4 disease. By incorporating LVI, a new T-stage classification system was created: [T1: ≤ 5 cm, (-)local invasion, (+/-)LVI; T2: > 5 cm, (-)local invasion, (-)LVI OR any size, (+)local invasion, (-)LVI; T3: > 5 cm, (-)local invasion, (+)LVI OR any size, (+)local invasion, (+)LVI; T4: any size, (+)adjacent organ invasion, (+/-)LVI]. Each progressive new T-stage group was associated with worse median DSS (T1: 167 mo; T2: 96 mo; T3: 37 mo; T4: 15 mo; p < 0.001). CONCLUSIONS Compared with the current T-stage system, the proposed T-stage system, which incorporates LVI, better differentiates T2 and T3 disease and accurately stratifies patients by disease-specific survival. If externally validated, this T-stage classification should be considered for future AJCC staging systems.
Collapse
Affiliation(s)
- Caroline E Poorman
- 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
| | - Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Thuy B Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jason D Prescott
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Linda X Jin
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sharon M Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Charles A Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - George A Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA. .,Division of Surgical Oncology, Winship Cancer Institute, 1365C Clifton Road NE, 2nd Floor, Atlanta, GA, 30322, USA.
| |
Collapse
|
37
|
Poorman CE, Postlewait LM, Ethun CG, Tran TB, Prescott JD, Pawlik TM, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Staley CA, Poultsides GA, Maithel SK. Blood Transfusion and Survival for Resected Adrenocortical Carcinoma: A Study from the United States Adrenocortical Carcinoma Group. Am Surg 2017. [DOI: 10.1177/000313481708300735] [Citation(s) in RCA: 11] [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] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Perioperative blood transfusion is associated with decreased survival in pancreatic, gastric, and liver cancer. The effect of transfusion in adrenocortical carcinoma (ACC) has not been studied. Patients with available transfusion data undergoing curative-intent resection of ACC from 1993 to 2014 at 13 institutions comprising the United States Adrenocortical Carcinoma Group were included. Factors associated with blood transfusion were determined. Primary and secondary end points were recurrence-free survival (RFS) and overall survival (OS), respectively. Out of 265 patients, 149 were included for analysis. Out of these, 57 patients (38.3%) received perioperative transfusions. Compared to nontransfused patients, transfused patients more commonly had stage 4 disease (46% vs 24%, P = 0.01), larger tumors (15.8 vs 10.2 cm, P < 0.001), inferior vena cava involvement (24.6% vs 5.4%, P = 0.002), additional organ resection (78.9% vs 36.3%, P < 0.001), and major complications (29% vs 2%, P < 0.001). Transfusion was associated with decreased RFS (8.9 vs 24.7 months, P = 0.006) and OS (22.8 vs 91.0 months, P < 0.001). On univariate Cox regression, transfusion, stage IV, hormonal hypersecretion, and adjuvant therapy were associated with decreased RFS. On multivariable analysis, only transfusion [hazard ratio (HR) = 1.7, 95% confidence interval (CI) 51.0–2.9, P = 0.04], stage IV (HR = 3.2, 95% CI = 1.7–5.9, P < 0.001), and hormonal hypersecretion (HR = 2.6, 95% CI = 1.5–4.2, P < 0.001) were associated with worse RFS. When applying this model to OS, similar associations were seen (transfusion HR = 2.0, 95% CI = 1.1–3.8, P = 0.02; stage 4 HR = 6.2, 95% CI = 3.1–12.4, P < 0.001; hormonal hypersecretion HR = 3.5, 95% CI = 1.9–6.4, P < 0.001). There was no difference in outcomes between patients who received 1 to 2 units versus >2 units of packed red blood cells in median RFS (8.9 vs 8.4 months, P = 0.95) or OS (26.5 vs 18.6 months, P = 0.63). Peri-operative transfusion is associated with earlier recurrence and decreased survival after curative-intent resection of ACC. Strategies and protocols to minimize blood transfusion should be developed and followed.
Collapse
Affiliation(s)
- Caroline E. Poorman
- 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
| | - Cecilia G. Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Thuy B. Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Jason D. Prescott
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M. Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tracy S. Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, New York
| | - John E. Phay
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Ryan C. Fields
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Linda X. Jin
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Sharon M. Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jason K. Sicklick
- Department of Surgery, University of California San Diego, San Diego, California
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, California
| | - Adam C. Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John C. Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, California
| | | | | | | | - Edward A. Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Charles A. Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - George A. Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| |
Collapse
|
38
|
Poorman CE, Postlewait LM, Ethun CG, Tran TB, Prescott JD, Pawlik TM, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Staley CA, Poultsides GA, Maithel SK. Blood Transfusion and Survival for Resected Adrenocortical Carcinoma: A Study from the United States Adrenocortical Carcinoma Group. Am Surg 2017; 83:761-768. [PMID: 28738949 PMCID: PMC6054878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Perioperative blood transfusion is associated with decreased survival in pancreatic, gastric, and liver cancer. The effect of transfusion in adrenocortical carcinoma (ACC) has not been studied. Patients with available transfusion data undergoing curative-intent resection of ACC from 1993 to 2014 at 13 institutions comprising the United States Adrenocortical Carcinoma Group were included. Factors associated with blood transfusion were determined. Primary and secondary end points were recurrence-free survival (RFS) and overall survival (OS), respectively. Out of 265 patients, 149 were included for analysis. Out of these, 57 patients (38.3%) received perioperative transfusions. Compared to nontransfused patients, transfused patients more commonly had stage 4 disease (46% vs 24%, P = 0.01), larger tumors (15.8 vs 10.2 cm, P < 0.001), inferior vena cava involvement (24.6% vs 5.4%, P = 0.002), additional organ resection (78.9% vs 36.3%, P < 0.001), and major complications (29% vs 2%, P < 0.001). Transfusion was associated with decreased RFS (8.9 vs 24.7 months, P = 0.006) and OS (22.8 vs 91.0 months, P < 0.001). On univariate Cox regression, transfusion, stage IV, hormonal hypersecretion, and adjuvant therapy were associated with decreased RFS. On multivariable analysis, only transfusion [hazard ratio (HR) = 1.7, 95% confidence interval (CI) =1.0-2.9, P = 0.04], stage IV (HR = 3.2, 95% CI = 1.7-5.9, P < 0.001), and hormonal hypersecretion (HR = 2.6, 95% CI = 1.5-4.2, P < 0.001) were associated with worse RFS. When applying this model to OS, similar associations were seen (transfusion HR = 2.0, 95% CI = 1.1-3.8, P = 0.02; stage 4 HR = 6.2, 95% CI = 3.1-12.4, P < 0.001; hormonal hypersecretion HR = 3.5, 95% CI = 1.9-6.4, P < 0.001). There was no difference in outcomes between patients who received 1 to 2 units versus >2 units of packed red blood cells in median RFS (8.9 vs 8.4 months, P = 0.95) or OS (26.5 vs 18.6 months, P = 0.63). Perioperative transfusion is associated with earlier recurrence and decreased survival after curative-intent resection of ACC. Strategies and protocols to minimize blood transfusion should be developed and followed.
Collapse
|
39
|
Kiernan CM, Solórzano CC. Bethesda Category III, IV, and V Thyroid Nodules: Can Nodule Size Help Predict Malignancy? J Am Coll Surg 2017; 225:77-82. [PMID: 28223197 DOI: 10.1016/j.jamcollsurg.2017.02.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/05/2017] [Accepted: 02/07/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The association of tumor size with malignancy in thyroid nodules with indeterminate cytology (atypia of undetermined significance [AUS]/follicular lesion of undetermined significance [FLUS], suspicious for follicular neoplasm [SFN]/Hürthle cell neoplasm [HCN], and suspicious for malignancy [SM]) has not been clearly studied. STUDY DESIGN We retrospectively identified 1,104, patients who underwent thyroid FNA and subsequent thyroidectomy. Patients with indeterminate cytology were reviewed. The size of the nodule was determined by ultrasound. Malignancy was confirmed by final histology. Logistic regression modeling was performed to determine if nodule size was associated with malignancy. RESULTS There were 461 (42%) patients who had indeterminate cytology by FNA. The median nodule size of all indeterminate lesions was 2.1 cm (range 0.5 to 10 cm). The median nodule size for AUS/FLUS was 2.1 cm (range 0.7 to 8 cm), for SFN was 2.4 cm (range 0.5 to 10 cm), for HCN was 2.2 cm (range 0.5 to 9.3 cm), and for SM was 1.6 cm (range 0.5 to 6 cm). On final histology, 121 (28%) index lesions were malignant (AUS 23%; FLUS 14%; SFN 22%; HCN 25%; SM 69%). On logistic regression, nodule size was not associated with increased odds of malignancy in all lesions with indeterminate cytology (odds ratio [OR] 0.83; 95% CI 0.76 to 1.00; p = 0.051). Nodule size was not associated with malignancy in the index nodule of AUS/FLUS, SFN, or SM lesions. Increased nodule size was associated with malignancy in HCN lesions (OR 2.17; 95% CI 1.16 to 4.04; p = 0.01). CONCLUSIONS The findings of this study suggest that larger HCN nodules are more likely to be malignant. Nodule size alone was not predictive of malignancy in patients with AUS/FLUS, SFN, or SM. Clinical picture, institution-specific malignancy rates, and molecular testing continue to be important factors guiding treatment.
Collapse
Affiliation(s)
- Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
40
|
Lee CW, Salem AI, Schneider DF, Leverson GE, Tran TB, Poultsides GA, Postlewait LM, Maithel SK, Wang TS, Hatzaras I, Shenoy R, Phay JE, Shirley L, Fields RC, Jin LX, Pawlik TM, Prescott JD, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Weber SM. Minimally Invasive Resection of Adrenocortical Carcinoma: a Multi-Institutional Study of 201 Patients. J Gastrointest Surg 2017; 21:352-362. [PMID: 27770290 PMCID: PMC5263186 DOI: 10.1007/s11605-016-3262-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [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: 05/23/2016] [Accepted: 08/24/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVES Minimally invasive surgery for adrenocortical carcinoma (ACC) is controversial. We sought to evaluate the perioperative and long-term outcomes following minimally invasive (MIS) and open resection (OA) of ACC in patients treated with curative intent surgery. METHODS Retrospective data from patients who underwent adrenalectomy for primary ACC at 13 tertiary care cancer centers were analyzed, including demographics, clinicopathological, and operative outcomes. Outcomes following MIS were compared to OA. RESULTS A total of 201 patients were evaluated including 47 MIS and 154 OA. There was no difference in utilization of MIS approach among institutions (p = 0.24) or 30-day morbidity (29.3 %, MIS, vs. 30.9 %, OA; p = 0.839). The only preoperatively determined predictor for MIS was smaller tumor size (p < 0.001). There was no difference in rates of intraoperative tumor rupture (p = 0.612) or R0 resection (p = 0.953). Only EBL (p = 0.038) and T stage (p = 0.045) were independent prognostic indicators of overall survival after adjusting for significant factors. The surgical approach was not associated with overall or disease-free survival. CONCLUSION MIS adrenalectomy may be utilized for preoperatively determined ACC ≤ 10.0 cm; however, OA should be utilized for adrenal masses with either preoperative or intraoperative evidence of local invasion or enlarged lymph nodes, regardless of size.
Collapse
Affiliation(s)
- Christina W. Lee
- Department of Surgery, University Of Wisconsin School Of Medicine and Public Health - Madison, WI USA
| | - Ahmed I. Salem
- Department of Surgery, University Of Wisconsin School Of Medicine and Public Health - Madison, WI USA
| | - David F. Schneider
- Department of Surgery, University Of Wisconsin School Of Medicine and Public Health - Madison, WI USA
| | - Glen E. Leverson
- Department of Surgery, University Of Wisconsin School Of Medicine and Public Health - Madison, WI USA
| | - Thuy B. Tran
- Department of Surgery, Stanford University - Palo Alto, CA USA
| | | | | | - Shishir K. Maithel
- Department of Surgery, Emory University School of Medicine - Atlanta, GA USA
| | - Tracy S. Wang
- Department of Surgery, Medical College Of Wisconsin - Milwaukee, WI USA
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine - New York, NY USA
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine - New York, NY USA
| | - John E. Phay
- Department of Surgery, Ohio State University - Columbus, OH USA
| | | | - Ryan C. Fields
- Department of Surgery, Washington University - St. Louis, MO USA
| | - Linda X. Jin
- Department of Surgery, Washington University - St. Louis, MO USA
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine - Baltimore, MD USA
| | - Jason D. Prescott
- Department of Surgery, Johns Hopkins University School of Medicine - Baltimore, MD USA
| | - Jason K. Sicklick
- Department of Surgery, University Of California - San Diego - San Diego, CA USA
| | - Shady Gad
- Department of Surgery, University Of California - San Diego - San Diego, CA USA
| | - Adam C. Yopp
- Department of Surgery, University Of Texas Southwestern Medical Center - Dallas, TX USA
| | - John C. Mansour
- Department of Surgery, University Of Texas Southwestern Medical Center - Dallas, TX USA
| | - Quan-Yang Duh
- Department of Surgery, University Of California - San Francisco - San Francisco, CA USA
| | - Natalie Seiser
- Department of Surgery, University Of California - San Francisco - San Francisco, CA USA
| | - Carmen C. Solorzano
- Department of Surgery, Vanderbilt University Medical Center - Nashville, TN USA
| | - Colleen M. Kiernan
- Department of Surgery, Vanderbilt University Medical Center - Nashville, TN USA
| | | | - Edward A. Levine
- Department of Surgery, Wake Forest University School of Medicine - Winston-Salem, NC USA
| | - Sharon M. Weber
- Department of Surgery, University Of Wisconsin School Of Medicine and Public Health - Madison, WI USA
| |
Collapse
|
41
|
Tran TB, Postlewait LM, Maithel SK, Prescott JD, Wang TS, Glenn J, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Hatzaras I, Shenoy R, Pawlik TM, Norton JA, Poultsides GA. Actual 10-year survivors following resection of adrenocortical carcinoma. J Surg Oncol 2016; 114:971-976. [PMID: 27633419 PMCID: PMC5278771 DOI: 10.1002/jso.24439] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [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] [Received: 08/23/2016] [Accepted: 08/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy with limited therapeutic options beyond surgical resection. The characteristics of actual long-term survivors following surgical resection for ACC have not been previously reported. METHOD Patients who underwent resection for ACC at one of 13 academic institutions participating in the US Adrenocortical Carcinoma Group from 1993 to 2014 were analyzed. Patients were stratified into four groups: early mortality (died within 2 years), late mortality (died within 2-5 years), actual 5-year survivor (survived at least 5 years), and actual 10-year survivor (survived at least 10 years). Patients with less than 5 years of follow-up were excluded. RESULTS Among the 180 patients available for analysis, there were 49 actual 5-year survivors (27%) and 12 actual 10-year survivors (7%). Patients who experienced early mortality had higher rates of cortisol-secreting tumors, nodal metastasis, synchronous distant metastasis, and R1 or R2 resections (all P < 0.05). The need for multi-visceral resection, perioperative blood transfusion, and adjuvant therapy correlated with early mortality. However, nodal involvement, distant metastasis, and R1 resection did not preclude patients from becoming actual 10-year survivors. Ten of twelve actual 10-year survivors were women, and of the seven 10-year survivors who experienced disease recurrence, five had undergone repeat surgery to resect the recurrence. CONCLUSION Surgery for ACC can offer a 1 in 4 chance of actual 5-year survival and a 1 in 15 chance of actual 10-year survival. Long-term survival was often achieved with repeat resection for local or distant recurrence, further underscoring the important role of surgery in managing patients with ACC. J. Surg. Oncol. 2016;114:971-976. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Thuy B. Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | | | | | - Jason D. Prescott
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tracy S. Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John E. Phay
- Department of Surgery, Ohio State University, Columbus, Ohio
| | - Kara Keplinger
- Department of Surgery, Ohio State University, Columbus, Ohio
| | - 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, Wisconsin
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jason K. Sicklick
- Department of Surgery, University of California San Diego, San Diego, California
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, California
| | - Adam C. Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John C. Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, California
| | | | | | | | - Edward A. Levine
- Department of Surgery, Wake Forest Baptist Medical Center, Winston Salem, North Carolina
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Ohio State University, Columbus, Ohio
| | - Jeffrey A. Norton
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - George A. Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
42
|
Kiernan CM, Whiteside MA, Solorzano CC. Cancer Registries: Can We Improve the Quality of Thyroid Cancer Data? Ann Surg Oncol 2016; 24:1202-1207. [DOI: 10.1245/s10434-016-5612-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Indexed: 11/18/2022]
|
43
|
Margonis GA, Amini N, Kim Y, Tran TB, Postlewait LM, Maithel SK, Wang TS, Evans DB, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Moses LE, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Poultsides GA, Pawlik TM. Incidence of Perioperative Complications Following Resection of Adrenocortical Carcinoma and Its Association with Long-Term Survival. World J Surg 2016; 40:706-714. [PMID: 26546184 DOI: 10.1007/s00268-015-3307-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The association of postoperative complications with long-term oncologic outcomes remains unclear. We sought to determine the incidence of complications among patients who underwent surgery for adrenocortical carcinoma (ACC) and define the relationship of morbidity with long-term survival. METHODS Patients who underwent surgery for ACC between 1993 and 2014 were identified from 13 academic institutions participating in the US ACC group study. The incidence and type of the postoperative complications, the factors associated with them as well their association with long-term survival were analyzed. RESULTS A total of 265 patients with median age of 52 years (IQR 44-63) were identified; at surgery, the majority of patients underwent an open abdominal procedure (n = 169, 66.8%). A postoperative complication occurred in 99 patients for a morbidity of 37.4%; five patients (1.9%) died in hospital. Factors associated with morbidity included a thoraco-abdominal operative approach (reference: open abdominal; OR 2.85, 95% CI 1.00-8.18), and a hormonally functional tumor (OR 3.56, 95% CI 1.65-7.69) (all P < 0.05). Presence of any complication was associated with a worse long-term outcome (median survival: no complication, 58.9 months vs. any complication, 25.1 months; P = 0.009). In multivariate analysis, after adjusting for patient- and disease-related factors postoperative infectious complications independently predicted shorter overall survival (hazard ratio (HR) 5.56, 95% CI 2.24-13.80; P < 0.001). CONCLUSION Postoperative complications were independently associated with decreased long-term survival after resection for ACC. The prevention of complications may be important from an oncologic perspective.
Collapse
Affiliation(s)
- Georgios Antonios Margonis
- Department of Surgery, Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Neda Amini
- Department of Surgery, Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Yuhree Kim
- Department of Surgery, Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Thuy B Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Lindsey E Moses
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sharon M Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - George A Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Timothy M Pawlik
- Department of Surgery, Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| |
Collapse
|
44
|
Kim Y, Margonis GA, Prescott JD, Tran TB, Postlewait LM, Maithel SK, Wang TS, Evans DB, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem AI, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Poultsides GA, Pawlik TM. Nomograms to Predict Recurrence-Free and Overall Survival After Curative Resection of Adrenocortical Carcinoma. JAMA Surg 2016; 151:365-73. [PMID: 26676603 DOI: 10.1001/jamasurg.2015.4516] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Adrenocortical carcinoma (ACC) is a rare but aggressive endocrine tumor, and the prognostic factors associated with long-term outcomes after surgical resection remain poorly defined. OBJECTIVES To define clinicopathological variables associated with recurrence-free survival (RFS) and overall survival (OS) after curative surgical resection of ACC and to propose nomograms for individual risk prediction. DESIGN, SETTING, AND PARTICIPANTS Nomograms to predict RFS and OS after surgical resection of ACC were proposed using a multi-institutional cohort of patients who underwent curative-intent surgery for ACC at 13 major institutions in the United States between March 17, 1994, and December 22, 2014. The dates of our study analysis were April 15, 2015, to May 12, 2015. MAIN OUTCOMES AND MEASURES The discriminative ability and calibration of the nomograms to predict RFS and OS were tested using C statistics, calibration plots, and Kaplan-Meier curves. RESULTS In total, 148 patients who underwent surgery for ACC were included in the study. The median patient age was 53 years, and 65.5% (97 of 148) of the patients were female. One-third of the patients (35.1% [52 of 148]) had a functional tumor, and the median tumor size was 11.2 cm. Most patients (77.7% [115 of 148]) underwent R0 resection, and 8.8% (13 of 148) of the patients had N1 disease. Using backward stepwise selection of clinically important variables with the Akaike information criterion, the following variables were incorporated in the prediction of RFS: tumor size of at least 12 cm (hazard ratio [HR], 3.00; 95% CI, 1.63-5.70; P < .001), positive nodal status (HR, 4.78; 95% CI, 1.47-15.50; P = .01), stage III/IV (HR, 1.80; 95% CI, 0.95-3.39; P = .07), cortisol-secreting tumor (HR, 2.38; 95% CI, 1.27-4.48; P = .01), and capsular invasion (HR, 1.96; 95% CI, 1.02-3.74; P = .04). Factors selected as predicting OS were tumor size of at least 12 cm (HR, 1.78; 95% CI, 1.00-3.17; P = .05), positive nodal status (HR, 5.89; 95% CI, 2.05-16.87; P = .001), and R1 margin (HR, 2.83; 95% CI, 1.51-5.30; P = .001). The discriminative ability and calibration of the nomograms revealed good predictive ability as indicated by the C statistics (0.74 for RFS and 0.70 for OS). CONCLUSIONS AND RELEVANCE Independent predictors of survival and recurrence risk after curative-intent surgery for ACC were selected to create nomograms predicting RFS and OS. The nomograms were able to stratify patients into prognostic groups and performed well on internal validation.
Collapse
Affiliation(s)
- Yuhree Kim
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Georgios A Margonis
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jason D Prescott
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thuy B Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | | | | | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine in St Louis, Missouri
| | - Linda X Jin
- Department of Surgery, Washington University School of Medicine in St Louis, Missouri
| | - Sharon M Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Ahmed I Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Shady Gad
- Department of Surgery, University of California, San Diego
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco
| | - Natalie Seiser
- Department of Surgery, University of California, San Francisco
| | | | | | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - George A Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
45
|
Gerry JM, Tran TB, Postlewait LM, Maithel SK, Prescott JD, Wang TS, Glenn JA, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Hatzaras I, Shenoy R, Pawlik TM, Norton JA, Poultsides GA. Lymphadenectomy for Adrenocortical Carcinoma: Is There a Therapeutic Benefit? Ann Surg Oncol 2016; 23:708-713. [PMID: 27590329 DOI: 10.1245/s10434-016-5536-1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Lymph node metastasis is an established predictor of poor outcome for adrenocortical carcinoma (ACC); however, routine lymphadenectomy during surgical resection of ACC is not widely performed and its therapeutic role remains unclear. METHODS Patients undergoing margin-negative resection for localized ACC were identified from a multi-institutional database. Patients were stratified into 2 groups based on the surgeon's effort or not to perform a lymphadenectomy as documented in the operative note. Clinical, pathologic, and outcome data were compared between the 2 groups. RESULTS Of 120 patients who met inclusion criteria from 1993 to 2014, 32 (27 %) underwent lymphadenectomy. Factors associated with lymphadenectomy were tumor size (12 vs. 9.5 cm; p = .007), palpable mass at presentation (26 vs. 12 %; p = .07), suspicious lymph nodes on preoperative imaging (44 vs. 7 %; p < .001), and need for multivisceral resection (78 vs. 36 %; p < .001). Median number of lymph nodes harvested was higher in the lymphadenectomy group (5.5 vs. 0; p < .001). In-hospital mortality (0 vs. 1.3 %; p = .72) and grade 3/4 complication rates (0 vs. 12 %; p = .061) were not significantly different. Patients who underwent lymphadenectomy had improved overall survival (5-year 76 vs. 59 %; p = .041). The benefit of lymphadenectomy on overall survival persisted on multivariate analysis (HR = 0.17; p = .006) controlling for adverse preoperative and intraoperative factors associated with lymphadenectomy, such as tumor size, palpable mass, irregular tumor edges, suspicious nodes on imaging, and multivisceral resection. CONCLUSIONS In this multicenter study of adrenocortical carcinoma patients undergoing R0 resection, the surgeon's effort to dissect peritumoral lymph nodes was independently associated with improved overall survival.
Collapse
Affiliation(s)
- Jon M Gerry
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Thuy B Tran
- Department of Surgery, Stanford University, Stanford, CA, USA
| | | | | | - Jason D Prescott
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jason A Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Ryan C Fields
- Department of Surgery, Washington University, St. Louis, MO, USA
| | - Linda X Jin
- Department of Surgery, Washington University, St. Louis, MO, USA
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Edward A Levine
- Department of Surgery, Wake Forest University, Winston Salem, NC, USA
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | | | | |
Collapse
|
46
|
Kiernan CM, Schlegel C, Kavalukas S, Isom C, Peters MF, Solórzano CC. Does concomitant thyroidectomy increase risks of parathyroidectomy? J Surg Res 2016; 203:34-9. [DOI: 10.1016/j.jss.2016.03.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 03/19/2016] [Accepted: 03/24/2016] [Indexed: 10/22/2022]
|
47
|
Postlewait LM, Ethun CG, Tran TB, Prescott JD, Pawlik TM, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Staley CA, Poultsides GA, Maithel SK. Outcomes of Adjuvant Mitotane after Resection of Adrenocortical Carcinoma: A 13-Institution Study by the US Adrenocortical Carcinoma Group. J Am Coll Surg 2016; 222:480-90. [PMID: 26775162 PMCID: PMC4957938 DOI: 10.1016/j.jamcollsurg.2015.12.013] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 12/11/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Current treatment guidelines recommend adjuvant mitotane after resection of adrenocortical carcinoma with high-risk features (eg, tumor rupture, positive margins, positive lymph nodes, high grade, elevated mitotic index, and advanced stage). Limited data exist on the outcomes associated with these practice guidelines. STUDY DESIGN Patients who underwent resection of adrenocortical carcinoma from 1993 to 2014 at the 13 academic institutions of the US Adrenocortical Carcinoma Group were included. Factors associated with mitotane administration were determined. Primary end points were recurrence-free survival (RFS) and overall survival (OS). RESULTS Of 207 patients, 88 (43%) received adjuvant mitotane. Receipt of mitotane was associated with hormonal secretion (58% vs 32%; p = 0.001), advanced TNM stage (stage IV: 42% vs 23%; p = 0.021), adjuvant chemotherapy (37% vs 5%; p < 0.001), and adjuvant radiation (17% vs 5%; p = 0.01), but was not associated with tumor rupture, margin status, or N-stage. Median follow-up was 44 months. Adjuvant mitotane was associated with decreased RFS (10.0 vs 27.9 months; p = 0.007) and OS (31.7 vs 58.9 months; p = 0.006). On multivariable analysis, mitotane was not independently associated with RFS or OS, and margin status, advanced TNM stage, and receipt of chemotherapy were associated with survival. After excluding all patients who received chemotherapy, adjuvant mitotane remained associated with decreased RFS and similar OS; multivariable analyses again showed no association with recurrence or survival. Stage-specific analyses in both cohorts revealed no association between adjuvant mitotane and improved RFS or OS. CONCLUSIONS When accounting for stage and adverse tumor and treatment-related factors, adjuvant mitotane after resection of adrenocortical carcinoma is not associated with improved RFS or OS. Current guidelines should be revisited and prospective trials are needed.
Collapse
Affiliation(s)
- Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Thuy B Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jason D Prescott
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - 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
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus, OH
| | - 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 General Surgery, 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
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | | | | | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Charles A Staley
- 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.
| |
Collapse
|
48
|
Margonis GA, Kim Y, Tran TB, Postlewait LM, Maithel SK, Wang TS, Glenn JA, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Poultsides GA, Pawlik TM. Outcomes after resection of cortisol-secreting adrenocortical carcinoma. Am J Surg 2015; 211:1106-13. [PMID: 26810939 DOI: 10.1016/j.amjsurg.2015.09.020] [Citation(s) in RCA: 27] [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: 07/26/2015] [Revised: 08/19/2015] [Accepted: 09/01/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND We sought to define the impact of cortisol-secreting status on outcomes after surgical resection of adrenocortical carcinoma (ACC). METHODS The U.S ACC group database was queried to identify patients who underwent ACC resection between 1993 and 2014. The short-term and long-term outcomes were assessed. RESULTS The incidence of all functional and cortisol-secreting tumors was 40.6% and 22.6%, respectively. On multivariable analysis, cortisol secretion remained associated with an increased risk of postoperative complications (odds ratio = 2.25, 95 % confidence interval = 1.04 to 4.88; P = .04). At a median follow-up of 17.6 months, 118 patients (50.4%) had developed a recurrence. On multivariable analysis, after adjusting for patient and disease-related factors cortisol secretion independently predicted shorter recurrence-free survival (Hazard ratio = 2.05, 95% confidence interval = 1.16 to 3.60; P = .01). CONCLUSIONS Cortisol secretion was associated with an increased risk of postoperative morbidity. Recurrence remains high among patients with ACC after surgery; cortisol secretion was independently associated with a shorter recurrence-free survival. Tailoring postoperative surveillance of ACC patients based on their cortisol secreting status may be important.
Collapse
Affiliation(s)
- Georgios Antonios Margonis
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD, 21287, USA
| | - Yuhree Kim
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD, 21287, USA
| | - Thuy B Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jason A Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Linda X Jin
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sharon M Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - George A Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD, 21287, USA.
| |
Collapse
|
49
|
Abstract
This article highlights the epidemiology and pathophysiology of pheochromocytomas and paragangliomas. The current management of pheochromocytoma and paragangliomas, including utilization and interpretation of biochemical testing, preoperative imaging, and genetic screening are discussed. Furthermore, perioperative surgical management, outcomes, and recommended follow-up are reviewed.
Collapse
Affiliation(s)
- Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, 597 Preston Research Building, 2220 Pierce Avenue, Nashville, TN 37232, USA.
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, 597 Preston Research Building, 2220 Pierce Avenue, Nashville, TN 37232, USA
| |
Collapse
|
50
|
Margonis GA, Kim Y, Prescott JD, Tran TB, Postlewait LM, Maithel SK, Wang TS, Evans DB, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Poultsides GA, Pawlik TM. Adrenocortical Carcinoma: Impact of Surgical Margin Status on Long-Term Outcomes. Ann Surg Oncol 2015; 23:134-41. [PMID: 26286195 DOI: 10.1245/s10434-015-4803-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The influence of surgical margin status on long-term outcomes of patients undergoing adrenal resection for ACC remains not well defined. We studied the impact of surgical tumor margin status on recurrence-free survival (RFS) and overall survival (OS) of patients undergoing resection for ACC. METHODS A total of 165 patients who underwent adrenal resection for ACC and met inclusion criteria were identified form a multi-institutional database. Clinicopathological data, pathologic margin status, and long-term outcomes were assessed. Patients were stratified into two groups based on margin status: R0 (margin >1 mm) versus R1. RESULTS R0 resection was achieved in 126 patients (76.4 %), whereas 39 patients (23.6 %) had an R1 resection. Median and 5-year OS for patients undergoing R0 resection were 96.3 months and 64.8 % versus 25.1 months and 33.8 % for patients undergoing an R1 resection (both p < 0.001). On multivariable analysis, surgical margin status was an independent predictor of worse OS (hazard ratio [HR] 2.22, 95 % confidence interval [CI] 1.03-4.77; p = 0.04). The incidence of recurrence also differed between the two groups; 5-year RFS was 30.3 % among patients with an R0 resection versus 13.8 % among patients who had an R1 resection (p = 0.03). Lymph node metastasis (N1) was an independent predictor of RFS (HR 2.70, 95 % CI 1.04-6.99; p = 0.04). CONCLUSIONS A positive margin after ACC resection was associated with worse long-term survival. Patient selection and an emphasis on surgical technique to achieve R0 margins are pivotal to optimizing the best chance for long-term outcome among patients with ACC.
Collapse
Affiliation(s)
| | - Yuhree Kim
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jason D Prescott
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thuy B Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Linda X Jin
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sharon M Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - George A Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|