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Ecker BL, Vollmer CM, Behrman SW, Allegrini V, Aversa J, Ball CG, Barrows CE, Berger AC, Cagigas MN, Christein JD, Dixon E, Fisher WE, Freedman-Weiss M, Guzman-Pruneda F, Hollis RH, House MG, Kent TS, Kowalsky SJ, Malleo G, Salem RR, Salvia R, Schmidt CR, Seykora TF, Zheng R, Zureikat AH, Dickson PV. Role of Adjuvant Multimodality Therapy After Curative-Intent Resection of Ampullary Carcinoma. JAMA Surg 2020; 154:706-714. [PMID: 31141112 DOI: 10.1001/jamasurg.2019.1170] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Ampullary adenocarcinoma is a rare malignant neoplasm that arises within the duodenal ampullary complex. The role of adjuvant therapy (AT) in the treatment of ampullary adenocarcinoma has not been clearly defined. Objective To determine if long-term survival after curative-intent resection of ampullary adenocarcinoma may be improved by selection of patients for AT directed by histologic subtype. Design, Setting, and Participants This multinational, retrospective cohort study was conducted at 12 institutions from April 1, 2000, to July 31, 2017, among 357 patients with resected, nonmetastatic ampullary adenocarcinoma receiving surgery alone or AT. Cox proportional hazards regression was used to identify covariates associated with overall survival. The surgery alone and AT cohorts were matched 1:1 by propensity scores based on the likelihood of receiving AT or by survival hazard from Cox modeling. Overall survival was compared with Kaplan-Meier estimates. Exposures Adjuvant chemotherapy (fluorouracil- or gemcitabine-based) with or without radiotherapy. Main Outcomes and Measures Overall survival. Results A total of 357 patients (156 women and 201 men; median age, 65.8 years [interquartile range, 58-74 years]) underwent curative-intent resection of ampullary adenocarcinoma. Patients with intestinal subtype had a longer median overall survival compared with those with pancreatobiliary subtype (77 vs 54 months; P = .05). Histologic subtype was not associated with AT administration (intestinal, 52.9% [101 of 191]; and pancreatobiliary, 59.5% [78 of 131]; P = .24). Patients with pancreatobiliary histologic subtype most commonly received gemcitabine-based regimens (71.0% [22 of 31]) or combinations of gemcitabine and fluorouracil (12.9% [4 of 31]), whereas treatment of those with intestinal histologic subtype was more varied (fluorouracil, 50.0% [17 of 34]; gemcitabine, 44.1% [15 of 34]; P = .01). In the propensity score-matched cohort, AT was not associated with a survival benefit for either histologic subtype (intestinal: hazard ratio, 1.21; 95% CI, 0.67-2.16; P = .53; pancreatobiliary: hazard ratio, 1.35; 95% CI, 0.66-2.76; P = .41). Conclusions and Relevance Adjuvant therapy was more frequently used in patients with poor prognostic factors but was not associated with demonstrable improvements in survival, regardless of tumor histologic subtype. The value of a multimodality regimen remains poorly defined.
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Affiliation(s)
- Brett L Ecker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Stephen W Behrman
- Department of Surgery, University of Tennessee Health Science Center, Memphis
| | - Valentina Allegrini
- Department of Surgery, University of Verona, Pancreas Institute, Verona, Italy
| | - John Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Courtney E Barrows
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adam C Berger
- Department of Surgery, Jefferson Medical College, Philadelphia, Pennsylvania
| | - Martha N Cagigas
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - John D Christein
- Department of Surgery, University of Alabama School of Medicine, Birmingham
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - William E Fisher
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | | | - Robert H Hollis
- Department of Surgery, University of Alabama School of Medicine, Birmingham
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Tara S Kent
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Stacy J Kowalsky
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Giuseppe Malleo
- Department of Surgery, University of Verona, Pancreas Institute, Verona, Italy
| | - Ronald R Salem
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Roberto Salvia
- Department of Surgery, University of Verona, Pancreas Institute, Verona, Italy
| | - Carl R Schmidt
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Thomas F Seykora
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Richard Zheng
- Department of Surgery, Jefferson Medical College, Philadelphia, Pennsylvania
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paxton V Dickson
- Department of Surgery, University of Tennessee Health Science Center, Memphis
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Barrows CE, Belle JM, Fleishman A, Lubitz CC, James BC. Financial burden of thyroid cancer in the United States: An estimate of economic and psychological hardship among thyroid cancer survivors. Surgery 2019; 167:378-384. [PMID: 31653488 DOI: 10.1016/j.surg.2019.09.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/02/2019] [Accepted: 09/15/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Annual cancer-related healthcare expenditure in the United States is estimated to exceed $150 billion by 2020. As the prevalence of thyroid cancer increases worldwide, thyroid cancer survivorship is associated with increasing personal and cumulative costs. Few studies have examined the psychological and material economic costs experienced by thyroid cancer survivors. We seek to estimate the comparative prevalence of financial and psychological hardship among thyroid cancer and non-thyroid cancer patients in the United States. METHODS The 2011 Medical Expenditure Panel Survey Experiences with Cancer databank was queried to identify thyroid and non-thyroid (colon, breast, lung, prostate) cancer survivors. This survey includes assessments of financial stress, material hardship, and psychological financial hardship. Cancer incidence-based weighted estimates of responses were compared between thyroid and non-thyroid cancer survivors. Independent predictors of material and psychological financial burden were identified through separate multivariate regression models. RESULTS Thyroid cancer survivors more frequently reported psychological financial burden compared to non-thyroid cancer (46.1% vs 24.0%, P = .04). Material financial hardship (28.1% vs 19.9%, P = .37) and concurrent material and psychological hardship (25.1% vs 12.5%, P = .09) were noted at similar frequencies between thyroid and non-thyroid cancer survivors. However, on multivariate analysis, only younger age and lack of health insurance coverage were independently associated with psychological financial hardship. CONCLUSION Thyroid cancer survivors report greater psychological financial hardship than non-thyroid cancer survivors. Because this financial burden may be underrecognized in the medical community, further studies should be conducted to aid physicians in better understanding the impact of a thyroid cancer diagnosis.
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Affiliation(s)
- Courtney E Barrows
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Janeil M Belle
- Department of Surgery, University of Pittsburgh Medical Center, PA
| | - Aaron Fleishman
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Carrie C Lubitz
- Harvard Medical School, Boston, MA; Department of Surgery, Massachusetts General Hospital, Boston, MA; Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Benjamin C James
- Harvard Medical School, Boston, MA; Section of Endocrine Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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Roth EM, Barrows CE, Nishino M, Sacks B, Hasselgren PO, James BC. Papillary thyroid cancer with extrathyroidal extension of desmoid-type fibromatosis. A case report of an aggressive presentation of an uncommon pathologic entity. Int J Surg Case Rep 2019; 63:5-9. [PMID: 31499326 PMCID: PMC6734537 DOI: 10.1016/j.ijscr.2019.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 07/16/2019] [Accepted: 08/02/2019] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Papillary thyroid cancer with desmoid-type fibromatosis (PTC-DTF) is an uncommon tumor characterized by extensive stromal proliferation of fibroblasts and myofibroblasts with a small component of PTC. We report a case of PTC-DTF with infiltration of the mesenchymal component of tumor into perithyroidal muscle and early recurrence of desmoid after thyroidectomy, an outcome previously not reported. PRESENTATION OF CASE A 20-year-old man underwent left hemithyroidectomy for a thyroid nodule. Pathology demonstrated a 4.2 cm tumor with PTC-DTF with the PTC comprising <10% of the tumor. The stromal component extended into adjacent skeletal muscle. After completion thyroidectomy, histopathology of the right thyroid lobe revealed no malignancy or fibromatosis. Neck MRI 16 months after the initial operation revealed a 10.5 cm tumor in the left thyroid bed. Core biopsy and open excisional biopsy showed desmoid-type fibromatosis without PTC. The patient is undergoing chemotherapy of his recurrent desmoid-type fibromatosis. DISCUSSION In patients with PTC-DTF there is a risk of recurrence of the benign component of the tumor. In recent reports, the role of less aggressive surgery, or even non-surgical management, of patients with recurrent DTF has been emphasized, in particular when extensive surgery may be associated with high risk of functional loss. The management of our patient adheres to modern recommendations for the treatment of DTF. CONCLUSION Patients with PTC-DTF should be carefully monitored after thyroidectomy for both recurrent PTC and local recurrence of the fibrous component of the tumor.
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Affiliation(s)
- Eve M Roth
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Courtney E Barrows
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Michiya Nishino
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Barry Sacks
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Per-Olof Hasselgren
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Benjamin C James
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
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Calvillo-Ortiz R, Raven KE, Castillo-Angeles M, Watkins AA, Barrows CE, James BC, Boyd CG, Critchlow JF, Kent TS. Using Individual Clinical Evaluations to Assess Residents' Clinical Judgment; Feasibility and Residents' Perception. J Surg Educ 2018; 75:e31-e37. [PMID: 30292453 DOI: 10.1016/j.jsurg.2018.06.023] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/22/2018] [Accepted: 06/27/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE In surgical training, most assessment tools focus on advanced clinical decision-making or operative skill. Available tools often require significant investment of resources and time. A high stakes oral examination is also required to become board-certified in surgery. We developed Individual Clinical Evaluation (ICE) to evaluate intern-level clinical decision-making in a time- and cost-efficient manner, and to introduce the face-to-face evaluation setting. DESIGN Intern-level ICE consists of 3 clinical scenarios commonly encountered by surgical trainees. Each scenario was developed to be presented in a step-by-step manner to an intern by an attending physician or chief resident. The interns had 17 minutes to complete the face-to-face evaluation and 3 minutes to receive feedback on their performance. The feedback was transcribed and sent to the interns along with incorrect answers. Eighty percent correct was set as a minimum to pass each scenario and continue with the next one. Interns who failed were retested until they passed. Frequency of incorrect response was tracked by question/content area. After passing the 3 scenarios, interns completed a survey about their experience with ICE. SETTING Beth Israel Deaconess Medical Center, an academic tertiary care facility located in Boston, Massachusetts. PARTICIPANTS All first-year surgery residents in our institution (n = 17) were invited to complete a survey. RESULTS All 2016-2017 surgical interns (17) completed the ICEs. A total of $171 (US) was spent conducting the ICEs, and an average of 17 minutes was used to complete each evaluation. In total, 5 different residents failed 1 scenario, with the most common mistake being: failing to stabilize respiration before starting management. After completing the 3 clinical scenarios, more than 90% of respondents agreed or strongly agreed that the evaluations were appropriately challenging for training level, and that the evaluations helped to identify personal strengths and weaknesses in skill and knowledge. The majority believed their knowledge improved as a result of the ICE and felt better prepared to manage these scenarios (88% and 76%, respectively). CONCLUSIONS The ICE is an inexpensive and time efficient way to introduce interns to board type examinations and assess their preparedness for perioperative patient care issues. Common errors were identified which were able to inform educational efforts. ICEs were well accepted by residents. Next steps include extension of the ICE to PGY2 and PGY3 residents.
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Affiliation(s)
| | - Kristin E Raven
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | | | - Ammara A Watkins
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | - Courtney E Barrows
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | - Benjamin C James
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | - Christopher G Boyd
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | - Jonathan F Critchlow
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Tara S Kent
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
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Castillo-Angeles M, Calvillo-Ortiz R, Barrows CE, Chaikof EL, Kent TS. Learning Environment in Surgery Clerkship: What Are Faculty Perceptions? J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.483] [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]
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Barrows CE, Applewhite MK, James BC. Tumor Stage Is Not Associated with 30-Day Complications after Thyroidectomy for Thyroid Cancer. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.335] [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]
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Barrows CE, Ore AS, Critchlow J, Moser AJ. Robot-Assisted Technique for Total Gastrectomy and D2 Lymphadenectomy with Anomalous Vasculature. Ann Surg Oncol 2018; 25:964. [PMID: 29435685 DOI: 10.1245/s10434-017-6304-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Courtney E Barrows
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Ana Sofia Ore
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Jonathan Critchlow
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - A James Moser
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA.
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Ore AS, Barrows CE, Solis-Velasco M, Shaker J, Moser AJ. Robotic enucleation of benign pancreatic tumors. J Vis Surg 2017; 3:151. [PMID: 29302427 DOI: 10.21037/jovs.2017.08.15] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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: 07/26/2017] [Accepted: 08/08/2017] [Indexed: 12/17/2022]
Abstract
Robot-assisted enucleation provides the dual benefits of a minimally-invasive technique and pancreatic parenchymal conservation to selected patients with functional pancreatic neuroendocrine tumors (F-pNETs) and serous cystadenomas. Insulinomas, the most common F-pNETs, are ideal candidates for enucleation when <2 cm given the 80% probability of being benign. Current evidence suggests enucleation for the following: benign, isolated lesions with a distance between tumor and main pancreatic duct ≥3 mm (no focal stricture or dilation), insulinomas, gastrinomas <2 cm, and nonfunctional pancreatic neuroendocrine tumors (NF-pNETs) <1-2 cm and low Ki67 mitotic index. Minimally-invasive enucleation is an imaging-dependent procedure that requires recognizable anatomic landmarks for successful completion, including tumor proximity to the pancreatic duct as well as localization relative to major structures such as the gastroduodenal artery, bile duct, and portal vein. Tumor localization often mandates intraoperative ultrasound aided by duplex studies of intratumoral blood flow and frozen section confirmation. Five patients have undergone robot-assisted enucleation at Beth Israel Deaconess Medical Center between January 2014 and January 2017 with median tumor diameter of 1.3 cm (0.9-1.7 cm) located in the pancreatic head [2] and tail [3]. Surgical indications included insulinoma [2] and NF-pNETs [3]. Median operative time was 204 min (range, 137-347 min) and estimated blood loss of 50 mL. There were no conversions to open or transfusions. Robotic enucleation is a safe and feasible technique that allows parenchymal conservation in a minimally-invasive setting, reducing operative time and length of stay with equivalent pathological outcomes compared to open surgery.
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Affiliation(s)
- Ana Sofia Ore
- The Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Courtney E Barrows
- The Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Monica Solis-Velasco
- The Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jessica Shaker
- The Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - A James Moser
- The Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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