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Ammann M, Kinney MAO, Gudmundsdottir H, Santol J, Thiels CA, Warner SG, Truty MJ, Kendrick ML, Smoot RL, Anderson AL, Halfdanarson TR, Nagorney DM, Starlinger PP. Comparison of Octreotide and Vasopressors as First-Line Treatment for Intraoperative Carcinoid Crisis. Ann Surg Oncol 2024; 31:3976-3977. [PMID: 38619707 DOI: 10.1245/s10434-024-15264-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/10/2024] [Indexed: 04/16/2024]
Affiliation(s)
- Markus Ammann
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michelle A O Kinney
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hallbera Gudmundsdottir
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jonas Santol
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Cornelius A Thiels
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Susanne G Warner
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark J Truty
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael L Kendrick
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rory L Smoot
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alexandra L Anderson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - David M Nagorney
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Patrick P Starlinger
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA.
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Gudmundsdottir H, Fogliati A, Grotz TE, Thiels CA, Warner SG, Smoot RL, Truty MJ, Kendrick ML, Nagorney DM, Halfdanarson TR, Cleary SP, Starlinger P. Value of Surgical Cytoreduction in Patients with Small Intestinal Neuroendocrine Tumors Metastatic to the Liver and Peritoneum. Ann Surg Oncol 2024:10.1245/s10434-024-15316-7. [PMID: 38689169 DOI: 10.1245/s10434-024-15316-7] [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: 08/15/2023] [Accepted: 04/01/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Cytoreductive hepatectomy can improve survival and symptoms of hormonal excess in patients with small intestinal neuroendocrine tumor (siNET) liver metastases, but whether to proceed when peritoneal metastases are encountered at the time of planned cytoreductive hepatectomy is controversial. METHODS This was a retrospective review of patients who underwent surgical management of metastatic siNETs at Mayo Clinic between 2000 and 2020. Patients who underwent cytoreductive operation for isolated liver metastases or both liver and peritoneal metastases were compared. RESULTS Of 261 patients who underwent cytoreductive operation for siNETs, 211 had isolated liver metastases and 50 had liver and peritoneal metastases. Complete cytoreduction was achieved in 78% of patients with isolated liver metastases and 56% of those with liver and peritoneal metastases (p = 0.002). After complete cytoreduction, median overall survival (OS) was 11.5 years for isolated liver metastases and 11.2 years for liver and peritoneal metastases (p = 0.10), and relief of carcinoid syndrome was ≥ 97% in both groups. After incomplete cytoreduction with debulking of > 90% of hepatic disease and/or closing Lyon score of 1-2, median OS was 6.4 years for isolated liver metastases and 7.1 years for liver and peritoneal metastases (p = 0.12). CONCLUSIONS Patients with siNETs metastatic to both the liver and peritoneum have favorable outcomes after aggressive surgical cytoreduction, with the best outcomes observed after complete cytoreduction. Therefore, the presence of peritoneal metastases should not by itself preclude surgical cytoreduction in this population.
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Affiliation(s)
| | | | | | | | | | - Rory L Smoot
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Sean P Cleary
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
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3
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Smoot RL, Nagorney DM. The utility of futility. Hepatology 2024; 79:264-266. [PMID: 37768361 DOI: 10.1097/hep.0000000000000614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023]
Affiliation(s)
- Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, Minnesota, USA
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Fiorentini G, Zironda A, Calini G, Abdalla S, Nagorney DM, Warner SG, Smoot RL, Behm KT, Shawki SF, Mathis KL, Vierkant RA, Larson DW, Cleary SP. Minimally invasive vs. open approach to the simultaneous treatment of colorectal tumors with synchronous liver metastasis: a single center, propensity-score matched analysis from Mayo clinic. HPB (Oxford) 2023; 25:1337-1344. [PMID: 37626006 DOI: 10.1016/j.hpb.2023.06.010] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Open combined resections of colorectal primary tumors and synchronous liver metastases have become common in selected cases. However, evidences favoring a minimally invasive (MIS) approach are still limited. The aim of this study is to evaluate the outcomes of MIS vs. open synchronous liver and colorectal resections. METHODS 384 cases of synchronous colorectal and liver resections performed at one institution were identified during the study period. MIS vs open approach were compared after a propensity score matching; surgical outcomes were analyzed. RESULTS MIS cases featured longer operative time (399 vs 300 min, p < 0.001), fewer blood loss (200 vs 500 ml, p = 0.003), and shorter hospitalization (median LOS 4 vs 6 days, p = 0.001). No difference was observed between the two groups for use of Pringle maneuver (p = 0.083), intraoperative blood transfusion (p = 0.061), achievement of negative colorectal (p = 0.176) and liver margins (p = 1.000), postoperative complications (p = 1.000) and significant (Clavien-Dindo ≥ 3a) complications (p = 0.817), delay of adjuvant therapy due to complications (p = 0.555), 30- and 90-day mortality. CONCLUSION Synchronous colorectal and liver metastases resections via a minimally-invasive approach in high-volume centers with appropriate expertise result in significantly lower blood loss and length of stay despite longer operative time in comparison to open, with no oncological inferiority.
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Affiliation(s)
- Guido Fiorentini
- Hepatobiliary and Pancreas Surgery Division, Mayo Clinic, Rochester MN, USA
| | - Andrea Zironda
- Hepatobiliary and Pancreas Surgery Division, Mayo Clinic, Rochester MN, USA
| | - Giacomo Calini
- Colorectal Surgery Division, Mayo Clinic, Rochester MN, USA
| | | | - David M Nagorney
- Hepatobiliary and Pancreas Surgery Division, Mayo Clinic, Rochester MN, USA
| | - Susanne G Warner
- Hepatobiliary and Pancreas Surgery Division, Mayo Clinic, Rochester MN, USA
| | - Rory L Smoot
- Hepatobiliary and Pancreas Surgery Division, Mayo Clinic, Rochester MN, USA
| | - Kevin T Behm
- Colorectal Surgery Division, Mayo Clinic, Rochester MN, USA
| | | | | | - Robert A Vierkant
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - David W Larson
- Colorectal Surgery Division, Mayo Clinic, Rochester MN, USA
| | - Sean P Cleary
- Hepatobiliary and Pancreas Surgery Division, Mayo Clinic, Rochester MN, USA.
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5
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Gudmundsdottir H, Habermann EB, Vierkant RA, Starlinger P, Thiels CA, Warner SG, Smoot RL, Truty MJ, Kendrick ML, Halfdanarson TR, Nagorney DM, Cleary SP. Survival and Symptomatic Relief After Cytoreductive Hepatectomy for Neuroendocrine Tumor Liver Metastases: Long-Term Follow-up Evaluation of More Than 500 Patients. Ann Surg Oncol 2023; 30:4840-4851. [PMID: 37208566 PMCID: PMC10319657 DOI: 10.1245/s10434-023-13372-z] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 02/04/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Distant metastases are the strongest predictor of poor prognosis for patients with neuroendocrine tumors (NETs). Cytoreductive hepatectomy (CRH) can relieve symptoms of hormonal excess and prolong survival for patients with liver metastases (NETLMs), but long-term outcomes are poorly characterized. METHODS This retrospective single-institution analysis analyzed patients who underwent CRH for well-differentiated NETLMs from 2000 to 2020. Kaplan-Meier analysis estimated symptom-free interval and overall and progression-free survival. Multivariable Cox regression analysis evaluated factors associated with survival. RESULTS The inclusion criteria were met by 546 patients. The most common primary sites were the small intestine (n = 279) and the pancreas (n = 194). Simultaneous primary tumor resection was performed for 60 % of the cases. Major hepatectomy comprised 27% of the cases, but this rate decreased during the study period (p < 0.001). Major complications occurred in 20%, and the 90-day mortality rate was 1.6%. Functional disease was present in 37 %, and symptomatic relief was achieved in 96%. The median symptom-free interval was 41 months (62 months after complete cytoreduction and 21 months with gross residual disease) (p = 0.021). The median overall survival was 122 months, and progression-free survival was 17 months. In the multivariable analysis, worse overall survival was associated with age, pancreatic primary tumor, Ki-67, number and size of lesions, and extrahepatic metastases, with Ki-67 as the strongest predictor (odds ratio [OR], 1.90 for Ki-67 [3-20%; p = 0.018] and OR, 4.25 for Ki-67 [>20%; p < 0.001]). CONCLUSION The study showed that CRH for NETLMs is associated with low perioperative morbidity and mortality and excellent overall survival, although the majority will experience recurrence/progression. For patients with functional tumors, CRH can provide durable symptomatic relief.
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Affiliation(s)
- Hallbera Gudmundsdottir
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Robert A Vierkant
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Rory L Smoot
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Sean P Cleary
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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6
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Gudmundsdottir H, Habermann EB, Vierkant RA, Starlinger P, Thiels CA, Warner SG, Smoot RL, Truty MJ, Kendrick ML, Halfdanarson TR, Nagorney DM, Cleary SP. ASO Visual Abstract: Survival and Symptomatic Relief After Cytoreductive Hepatectomy for Neuroendocrine Tumor Liver Metastases-Long-Term Follow-Up of Over 500 Patients. Ann Surg Oncol 2023; 30:4854-4855. [PMID: 37040050 DOI: 10.1245/s10434-023-13424-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Affiliation(s)
- Hallbera Gudmundsdottir
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Robert A Vierkant
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Rory L Smoot
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Sean P Cleary
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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Gudmundsdottir H, Halfdanarson TR, Nagorney DM, Cleary SP. ASO Author Reflections: Long-Term Outcomes after Cytoreductive Hepatectomy for Neuroendocrine Tumor Liver Metastases. Ann Surg Oncol 2023; 30:4852-4853. [PMID: 36940040 DOI: 10.1245/s10434-023-13374-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/21/2023]
Affiliation(s)
| | | | | | - Sean P Cleary
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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Gudmundsdottir H, Yonkus JA, Alva-Ruiz R, Kendrick ML, Smoot RL, Warner SG, Starlinger P, Thiels CA, Nagorney DM, Cleary SP, Grotz TE, Truty MJ. Yield of Staging Laparoscopy for Pancreatic Cancer in the Modern Era: Analysis of More than 1,000 Consecutive Patients. J Am Coll Surg 2023; 237:49-57. [PMID: 37026837 PMCID: PMC10262988 DOI: 10.1097/xcs.0000000000000704] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Accurate staging prior to resection of pancreatic ductal adenocarcinoma (PDAC) is imperative to avoid unnecessary operative morbidity and oncologic futility in patients with occult intra-abdominal distant metastases. We aimed to determine the diagnostic yield of staging laparoscopy (SL) and to identify factors associated with increased risk of positive laparoscopy (PL) in the modern era. STUDY DESIGN Patients with radiographically localized PDAC who underwent SL from 2017 to 2021 were retrospectively reviewed. The yield of SL was defined as the proportion of patients with PL, including gross metastases and/or positive peritoneal cytology. Factors associated with PL were assessed using univariate analysis and multivariable logistic regression. RESULTS Of 1,004 patients who underwent SL, 180 (18%) had PL due to gross metastases (n = 140) and/or positive cytology (n = 96). Patients who had neoadjuvant chemotherapy prior to laparoscopy had lower rates of PL (14% vs 22%, p = 0.002). When the analysis was restricted to chemo-naive patients who had concurrent peritoneal lavage performed, 95 of 419 patients (23%) had PL. In multivariable analysis, PL was associated with younger (<60) age, indeterminate extrapancreatic lesions on preoperative imaging, body/tail tumor location, larger tumor size, and elevated serum CA 19-9 (all p < 0.05). Among patients with no indeterminate extrapancreatic lesions on preoperative imaging, the rate of PL ranged from 1.6% in patients with no risk factors to 42% in young patients with large body/tail tumors and elevated serum CA 19-9. CONCLUSIONS The rate of PL in patients with PDAC remains high in the modern era. SL with peritoneal lavage should be considered for the majority of patients prior to resection, specifically those with high-risk features, and ideally prior to neoadjuvant chemotherapy.
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Affiliation(s)
| | | | | | | | - Rory L Smoot
- From the Department of Surgery, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Sean P Cleary
- From the Department of Surgery, Mayo Clinic, Rochester, MN
| | - Travis E Grotz
- From the Department of Surgery, Mayo Clinic, Rochester, MN
| | - Mark J Truty
- From the Department of Surgery, Mayo Clinic, Rochester, MN
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9
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Alva-Ruiz R, Abdelrahman AM, Starlinger PP, Yonkus JA, Moravec DN, Busch JJ, Fleming CJ, Andrews JC, Mendes BC, Colglazier JJ, Smoot RL, Cleary SP, Nagorney DM, Kendrick ML, Truty MJ. Patency rates of hepatic arterial resection and revascularization in locally advanced pancreatic cancer. HPB (Oxford) 2022; 24:1957-1966. [PMID: 35780039 DOI: 10.1016/j.hpb.2022.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/02/2022] [Accepted: 06/13/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Arterial resection (AR) for pancreatic adenocarcinoma is increasingly considered at specialized centers. We aimed to examine the incidence, risk factors, and outcomes of hepatic artery (HA) occlusion after revascularization. METHODS We included patients undergoing HA resection with interposition graft (IG) or primary end-to-end anastomoses (EE). Complete arterial occlusion (CAO) was defined as "early" (EO) or "late" (LO) before/after 90 days respectively. Kaplan-Meier and change-point analysis for CAO was performed. RESULTS HA resection was performed in 108 patients, IG in 61% (66/108) and EE in 39% (42/108). An equal proportion (50%) underwent HA resection alone or in combination with celiac and/or superior mesenteric artery. CAO was identified in 18% of patients (19/108) with arterial IG least likely to occlude (p=0.019). Hepatic complications occurred in 42% (45/108) and correlated with CAO, symptomatic patients, venous resection, and postoperative portal venous patency. CAO-related operative mortality was 4.6% and significantly higher in EO vs LO (p = 0.046). Median CAO occlusion was 126 days. With change-point analysis, CAO was minimal beyond postoperative day 158. CONCLUSION CAO can occur in up to 18% of patients and the first 5-month post-operative period is critical for surveillance. LO is associated with better outcomes compared to EO unless there is inadequate portal venous inflow.
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Affiliation(s)
- Roberto Alva-Ruiz
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Amro M Abdelrahman
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Patrick P Starlinger
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Jennifer A Yonkus
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - David N Moravec
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Joel J Busch
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Chad J Fleming
- Division of Vascular & Interventional Radiology, Department of Radiology, Mayo Clinic Rochester, MN, USA
| | - James C Andrews
- Division of Vascular & Interventional Radiology, Department of Radiology, Mayo Clinic Rochester, MN, USA
| | - Bernardo C Mendes
- Division of Vascular & Endovascular Surgery, Department of Surgery, Mayo Clinic Rochester MN, USA
| | - Jill J Colglazier
- Division of Vascular & Endovascular Surgery, Department of Surgery, Mayo Clinic Rochester MN, USA
| | - Rory L Smoot
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Sean P Cleary
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - David M Nagorney
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Michael L Kendrick
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Mark J Truty
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA.
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Pery R, Smoot RL, Thiels CA, Cleary SP, Vierkant RA, Ilyas SI, Gores GJ, Nagorney DM. Hepatobiliary and pancreatic resection for cholangiocarcinoma in patients with primary sclerosing cholangitis. Br J Surg 2022; 109:1032-1035. [DOI: 10.1093/bjs/znac229] [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: 02/03/2022] [Revised: 04/09/2022] [Accepted: 06/09/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Ron Pery
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic , Rochester, Minnesota , USA
- Department of Surgery and Transplantation, Sheba Medical Center, Tel Hashomer, affiliated with the Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Rory L Smoot
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic , Rochester, Minnesota , USA
| | - Cornelius A Thiels
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic , Rochester, Minnesota , USA
| | - Sean P Cleary
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic , Rochester, Minnesota , USA
| | - Robert A Vierkant
- Department of Quantitative Health Sciences, Mayo Clinic , Rochester, Minnesota , USA
| | - Sumera I Ilyas
- Division of Gastroenterology and Hepatology, Mayo Clinic , Rochester, Minnesota , USA
| | - Gregory J Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic , Rochester, Minnesota , USA
| | - David M Nagorney
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic , Rochester, Minnesota , USA
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11
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Gudmundsdottir H, Pery R, Graham RP, Thiels CA, Warner SG, Smoot RL, Truty MJ, Kendrick ML, Halfdanarson TR, Habermann EB, Nagorney DM, Cleary SP. ASO Visual Abstract: Safety and Outcomes of Combined Pancreatic and Hepatic Resections for Metastatic Pancreatic Neuroendocrine Tumors. Ann Surg Oncol 2022; 29:6960-6961. [PMID: 35849285 DOI: 10.1245/s10434-022-12092-0] [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: 11/18/2022]
Affiliation(s)
- Hallbera Gudmundsdottir
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Ron Pery
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rondell P Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Rory L Smoot
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | | | - Sean P Cleary
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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De la Cruz Ku G, Aizpuru M, Hackl H, Ubl DS, Habermann EB, Pery R, Driedger M, Assinger A, Nagorney DM, Cleary SP, Smoot RL, Starlinger P. Hepatocellular carcinoma as predominant cancer subgroup accounting for sex differences in post-hepatectomy liver failure, morbidity and mortality. HPB (Oxford) 2022; 24:1453-1463. [PMID: 35293321 DOI: 10.1016/j.hpb.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/11/2022] [Accepted: 02/21/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Experimental evidence suggests sex dependent differences in liver regeneration. Limited evidence is available examining sex differences in post-hepatectomy liver failure (PHLF) and postoperative outcomes. Our aim was to assess the influence of sex on the outcomes after liver resection. METHODS The hepatectomy targeted National Surgical Quality Improvement Program (NSQIP) database was assessed for associations between sex and outcomes. RESULTS A total of 13,401 patients underwent elective hepatic resection between 2014-2017. PHLF was highest among male patients with hepatocellular carcinoma (HCC) (OR = 2.81,95%CI:1.40-5.62). Male sex was independently associated with increased PHLF (OR = 1.47,95%CI:1.15-1.88), major complications (OR = 1.25,95%CI:1.08-1.45), mortality (OR = 1.61,95%CI:1.03-2.50), and if only major resections were assessed (OR = 1.38,95%CI:1.03-1.84). Diagnosis specific subgroup analyses revealed that effects of sex were predominantly HCC associated. CONCLUSIONS This is the largest series investigating the effects of gender on outcomes after hepatic resection. We documented that women undergoing liver resection have significantly lower risk of PHLF. This difference seemed influenced by the striking increase of PHLF in male HCC patients. These hypothesis suggest that sex might play a role in preoperative risk stratification.
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Affiliation(s)
- Gabriel De la Cruz Ku
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA; Universidad Cientifica del Sur, Lima, Peru
| | - Matthew Aizpuru
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hubert Hackl
- Institute of Bioinformatics, Biocenter, Medical University of Innsbruck, Austria
| | - Daniel S Ubl
- Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery and Department of Health Services Research, Mayo Clinic, Rochester, USA
| | - Elizabeth B Habermann
- Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery and Department of Health Services Research, Mayo Clinic, Rochester, USA
| | - Ron Pery
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael Driedger
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alice Assinger
- Center of Physiology and Pharmacology, Institute of Vascular Biology and Thrombosis Research, Austria
| | - David M Nagorney
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sean P Cleary
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rory L Smoot
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Patrick Starlinger
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria.
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Abdelrahman AM, Goenka AH, Alva-Ruiz R, Yonkus JA, Leiting JL, Graham RP, Merrell KW, Thiels CA, Hallemeier CL, Warner SG, Haddock MG, Grotz TE, Tran NH, Smoot RL, Ma WW, Cleary SP, McWilliams RR, Nagorney DM, Halfdanarson TR, Kendrick ML, Truty MJ. FDG-PET Predicts Neoadjuvant Therapy Response and Survival in Borderline Resectable/Locally Advanced Pancreatic Adenocarcinoma. J Natl Compr Canc Netw 2022; 20:1023-1032.e3. [PMID: 36075389 DOI: 10.6004/jnccn.2022.7041] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/03/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) is used in borderline resectable/locally advanced (BR/LA) pancreatic ductal adenocarcinoma (PDAC). Anatomic imaging (CT/MRI) poorly predicts response, and biochemical (CA 19-9) markers are not useful (nonsecretors/nonelevated) in many patients. Pathologic response highly predicts survival post-NAT, but is only known postoperatively. Because metabolic imaging (FDG-PET) reveals primary tumor viability, this study aimed to evaluate our experience with preoperative FDG-PET in patients with BR/LA PDAC in predicting NAT response and survival. METHODS We reviewed all patients with resected BR/LA PDAC who underwent NAT with FDG-PET within 60 days of resection. Pre- and post-NAT metabolic (FDG-PET) and biochemical (CA 19-9) responses were dichotomized in addition to pathologic responses. We compared post-NAT metabolic and biochemical responses as preoperative predictors of pathologic responses and recurrence-free survival (RFS) and overall survival (OS). RESULTS We identified 202 eligible patients. Post-NAT, 58% of patients had optimization of CA 19-9 levels. Major metabolic and pathologic responses were present in 51% and 38% of patients, respectively. Median RFS and OS times were 21 and 48.7 months, respectively. Metabolic response was superior to biochemical response in predicting pathologic response (area under the curve, 0.86 vs 0.75; P<.001). Metabolic response was the only univariate preoperative predictor of OS (odds ratio, 0.25; 95% CI, 0.13-0.40), and was highly correlated (P=.001) with pathologic response as opposed to biochemical response alone. After multivariate adjustment, metabolic response was the single largest independent preoperative predictor (P<.001) for pathologic response (odds ratio, 43.2; 95% CI, 16.9-153.2), RFS (hazard ratio, 0.37; 95% CI, 0.2-0.6), and OS (hazard ratio, 0.21; 95% CI, 0.1-0.4). CONCLUSIONS Among patients with post-NAT resected BR/LA PDAC, FDG-PET highly predicts pathologic response and survival, superior to biochemical responses alone. Given the poor ability of anatomic imaging or biochemical markers to assess NAT responses in these patients, FDG-PET is a preoperative metric of NAT efficacy, thereby allowing potential therapeutic alterations and surgical treatment decisions. We suggest that FDG-PET should be an adjunct and recommended modality during the NAT phase of care for these patients.
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Affiliation(s)
| | - Ajit H Goenka
- Division of Nuclear Medicine Radiology, Department of Radiology
| | - Roberto Alva-Ruiz
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Jennifer A Yonkus
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | | | - Rondell P Graham
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology
| | | | | | | | - Susanne G Warner
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | | | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Nguyen H Tran
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Wen Wee Ma
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Robert R McWilliams
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | | | | | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
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14
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Gudmundsdottir H, Tomlinson JL, Graham RP, Thiels CA, Warner SG, Smoot RL, Kendrick ML, Nagorney DM, Halfdanarson TR, Habermann EB, Truty MJ, Cleary SP. Outcomes of pancreatectomy with portomesenteric venous resection and reconstruction for locally advanced pancreatic neuroendocrine neoplasms. HPB (Oxford) 2022; 24:1186-1193. [PMID: 35078716 DOI: 10.1016/j.hpb.2021.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/15/2021] [Accepted: 12/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND While pancreatectomy with portomesenteric venous resection and reconstruction is commonly performed for locally advanced pancreatic adenocarcinoma, little is known regarding outcomes for pancreatic neuroendocrine neoplasms (panNENs). METHODS Patients who underwent non-parenchyma-sparing pancreatectomy for panNENs at Mayo Clinic from 2000 to 2020 were retrospectively reviewed. Propensity score matching was performed and patient characteristics and outcomes compared. RESULTS Of 867 eligible patients, 41 (4.7%) required vascular resection, including 38 patients who underwent portomesenteric venous resection only. Of these, 23 underwent pancreaticoduodenectomy or total pancreatectomy and 15 distal pancreatectomy. Patients who required portomesenteric venous resection had larger tumors, higher tumor grade, and higher disease stage. After propensity score matching to patients undergoing standard resection, the portomesenteric venous resection group had longer operative times, greater blood loss, and higher transfusion rates. While portomesenteric venous thrombosis was more common after venous resection, major complication rates and perioperative mortality were similar between the two groups, as were 5-year overall and progression-free survival. CONCLUSION For patients with locally advanced panNENs, pancreatectomy with portomesenteric venous resection and reconstruction can be performed in selected patients at high-volume centers with acceptable perioperative morbidity and short- and long-term survival.
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Affiliation(s)
| | | | - Rondell P Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Rory L Smoot
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Elizabeth B Habermann
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sean P Cleary
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
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15
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Gudmundsdottir H, Pery R, Graham RP, Thiels CA, Warner SG, Smoot RL, Truty MJ, Kendrick ML, Halfdanarson TR, Habermann EB, Nagorney DM, Cleary SP. Safety and Outcomes of Combined Pancreatic and Hepatic Resections for Metastatic Pancreatic Neuroendocrine Tumors. Ann Surg Oncol 2022; 29:6949-6957. [PMID: 35731358 PMCID: PMC9492589 DOI: 10.1245/s10434-022-12029-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/02/2022] [Indexed: 11/18/2022]
Abstract
Background Approximately 40–50% of patients with pancreatic neuroendocrine tumors (pNETs) initially present with distant metastases. Little is known about the outcomes of patients undergoing combined pancreatic and hepatic resections for this indication. Methods Patients who underwent hepatectomy for metastatic pNETs at Mayo Clinic Rochester from 2000 to 2020 were retrospectively reviewed. Major pancreatectomy was defined as pancreaticoduodenectomy or total pancreatectomy, and major hepatectomy as right hepatectomy or trisegmentectomy. Characteristics and outcomes of patients who underwent pancreatectomy with simultaneous hepatectomy were compared with those of patients who underwent isolated hepatectomy (with or without prior history of pancreatectomy). Results 205 patients who underwent hepatectomy for metastatic pNETs were identified: 131 underwent pancreatectomy with simultaneous hepatectomy and 74 underwent isolated hepatectomy. Among patients undergoing simultaneous hepatectomy, 89 patients underwent minor pancreatectomy with minor hepatectomy, 11 patients underwent major pancreatectomy with minor hepatectomy, 30 patients underwent minor pancreatectomy with major hepatectomy, and 1 patient underwent major pancreatectomy with major hepatectomy. Patients undergoing simultaneous hepatectomy had more numerous liver lesions (10 or more lesions in 54% vs. 34%, p = 0.008), but the groups were otherwise similar. Rates of any major complications (31% versus 24%, p = 0.43), hepatectomy-specific complications such as bile leak, hemorrhage, and liver failure (0.8–7.6% vs. 1.4–12%, p = 0.30–0.99), and 90-day mortality (1.5% vs. 2.7%, p = 0.62) were similar between the two groups. 5-year overall survival was 64% after combined resections and 65% after isolated hepatectomy (p = 0.93). Conclusion For patients with metastatic pNETs, combined pancreatic and hepatic resections can be performed with acceptable morbidity and mortality in selected patients at high-volume institutions.
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Affiliation(s)
- Hallbera Gudmundsdottir
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ron Pery
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Rondell P Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Rory L Smoot
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Sean P Cleary
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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16
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Alva-Ruiz R, Yohanathan L, Yonkus JA, Abdelrahman AM, Gregory LA, Halfdanarson TR, Mahipal A, McWilliams RR, Ma WW, Hallemeier CL, Graham RP, Grotz TE, Smoot RL, Cleary SP, Nagorney DM, Kendrick ML, Truty MJ. ASO Visual Abstract: Neoadjuvant Chemotherapy Switch in Borderline Resectable/Locally Advanced Pancreatic Cancer. Ann Surg Oncol 2021. [PMID: 34811621 DOI: 10.1245/s10434-021-11076-w] [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: 11/18/2022]
Affiliation(s)
- Roberto Alva-Ruiz
- Division of Hepatobiliary & Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Lavanya Yohanathan
- Division of Hepatobiliary & Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jennifer A Yonkus
- Division of Hepatobiliary & Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amro M Abdelrahman
- Division of Hepatobiliary & Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Lindsey A Gregory
- Division of Hepatobiliary & Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Amit Mahipal
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Wen Wee Ma
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Rondell P Graham
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA
| | - Travis E Grotz
- Division of Hepatobiliary & Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rory L Smoot
- Division of Hepatobiliary & Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sean P Cleary
- Division of Hepatobiliary & Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - David M Nagorney
- Division of Hepatobiliary & Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael L Kendrick
- Division of Hepatobiliary & Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark J Truty
- Division of Hepatobiliary & Pancreas Surgery, Mayo Clinic, Rochester, MN, USA.
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17
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Driedger MR, Cleary SP, Nagorney DM. Synchronous colorectal liver metastases: therapeutic considerations. Hepatobiliary Surg Nutr 2021; 10:711-713. [PMID: 34760982 DOI: 10.21037/hbsn-21-239] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/28/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Michael R Driedger
- Division of Hepatobiliary and Pancreatic Surgery, Atrium Health, Charlotte, NC, USA
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - David M Nagorney
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
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18
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Alva-Ruiz R, Yohanathan L, Yonkus JA, Abdelrahman AM, Gregory LA, Halfdanarson TR, Mahipal A, McWilliams RR, Ma WW, Hallemeier CL, Graham RP, Grotz TE, Smoot RL, Cleary SP, Nagorney DM, Kendrick ML, Truty MJ. Neoadjuvant Chemotherapy Switch in Borderline Resectable/Locally Advanced Pancreatic Cancer. Ann Surg Oncol 2021; 29:1579-1591. [PMID: 34724125 PMCID: PMC8810469 DOI: 10.1245/s10434-021-10991-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/06/2021] [Indexed: 12/31/2022]
Abstract
Background Neoadjuvant chemotherapy (NAC) is an integral part of preoperative treatment for patients with borderline resectable/locally advanced (BR/LA) pancreatic ductal adenocarcinoma (PDAC). The identification of a chemotherapeutic regimen that is both effective and tolerable is critical for NAC to be of oncologic benefit. After initial first-line (FL) NAC, some patients have lack of response or therapeutic toxicities precluding further treatment with the same regimen; optimal decision making regarding this patient population is unclear. Chemotherapy switch (CS) may allow for a larger proportion of patients to undergo curative-intent resection after NAC. Methods We reviewed our surgical database for patients undergoing combinatorial NAC for BR/LA PDAC. Variant histologic exocrine carcinomas, intraductal papillary mucinous neoplasm-associated PDAC, and patients without research consent were excluded. Results Overall, 468 patients with BR/LA PDAC receiving FL chemotherapy were reviewed, of whom 70% (329/468) continued with FL chemotherapy followed by surgical resection. The remaining 30% (139/468) underwent CS, with 72% (100/139) of CS patients going on to curative-intent surgical resection. Recurrence-free survival (RFS) and overall survival (OS) were not significantly different between the resected FL and CS cohorts (30.0 vs. 19.1 months, p = 0.13, and 41.4 vs. 36.4 months, p = 0.94, respectively) and OS was significantly worse in those undergoing CS without subsequent resection (19 months, p < 0.0001). On multivariable analysis, carbohydrate antigen (CA) 19-9 and pathologic treatment responses were predictors of RFS and OS. Conclusion CS in patients undergoing NAC for BR/LA pancreatic cancer does not incur oncologic detriment. The incorporation of CS into NAC treatment sequencing may allow a greater proportion of patients to proceed to curative-intent surgery.
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Affiliation(s)
- Roberto Alva-Ruiz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Lavanya Yohanathan
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jennifer A Yonkus
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amro M Abdelrahman
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Lindsey A Gregory
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Amit Mahipal
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Wen Wee Ma
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Rondell P Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA.
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19
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Mirande MD, Hernandez MC, Nagorney DM. Ingested fishbone causing a hepatic abscess. Br J Surg 2021; 108:e358. [PMID: 34401907 DOI: 10.1093/bjs/znab302] [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: 11/12/2022]
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20
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Sheaffer WW, Davila VJ, Mendes BC, Meltzer AJ, Stone WM, Soh IY, Truty MJ, Nagorney DM, Money SR, Bower TC. Surgical and reconstructive outcomes in primary venous leiomyosarcoma. J Vasc Surg Venous Lymphat Disord 2021; 10:901-907. [PMID: 34352417 DOI: 10.1016/j.jvsv.2021.07.010] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 07/22/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Primary venous leimyosarcomas (PVL) are rare and pose challenges in surgical management. This study evaluates the clinical outcomes and identifies predictors of survival in our surgical series of PVL. METHODS A retrospective review was performed of patients who had resection of PVL at three centers between 1990-2018. Patient demographics, comorbidities, intraoperative data, survival, and graft related outcomes were recorded. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression. RESULTS Seventy patients with a diagnosis of PVL were identified between 1990 and 2018. Fifty-four patients (77%) had PVL of the IVC and 16 (23%) had peripheral PVL. Mean follow up for the series was 55.0 months (range 1-217 months). Fifty one patients (96%) with IVC PVL needed caval reconstruction and 3 (4%) had resection only. There were no deaths within thirty days of surgery. Five patients (9%) required early re-intervention including one (2%) IVC stent. Sixteen peripheral PVL were identified. Eight patients (50%) had venous reconstructions performed and 8 (50%) had the vein resected without reconstruction. There were no deaths within thirty days. Five year survival was 57.5% for IVC PVL and 70.0% for peripheral PVL . Kaplan-Meier survival analysis for IVC and peripheral PVL revealed no difference in overall survival (p = 0.624) at 5 years. CONCLUSIONS PVL is a rare and aggressive disease even with surgical resection. We found no difference in survival between IVC and peripheral lesions suggesting aggressive management is warranted for PVL of any origin. Management of PVL requires a multidisciplinary approach to provide patients with the best long term outcomes.
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Affiliation(s)
- William W Sheaffer
- Mayo Clinic Arizona Division of Vascular Surgery, 5777 E Mayo Boulevard, Phoenix, AZ 85054.
| | - Victor J Davila
- Mayo Clinic Arizona Division of Vascular Surgery, 5777 E Mayo Boulevard, Phoenix, AZ 85054
| | - Bernardo C Mendes
- Mayo Clinic Rochester Division of Vascular Surgery, 200 First St. SW, Rochester, MN 55905
| | - Andrew J Meltzer
- Mayo Clinic Arizona Division of Vascular Surgery, 5777 E Mayo Boulevard, Phoenix, AZ 85054
| | - William M Stone
- Mayo Clinic Arizona Division of Vascular Surgery, 5777 E Mayo Boulevard, Phoenix, AZ 85054
| | - Ina Y Soh
- Mayo Clinic Arizona Division of Vascular Surgery, 5777 E Mayo Boulevard, Phoenix, AZ 85054
| | - Mark J Truty
- Mayo Clinic Rochester Department of General Surgery Subspecialties, 200 First St. SW, Rochester, MN 55905
| | - David M Nagorney
- Mayo Clinic Rochester Department of General Surgery Subspecialties, 200 First St. SW, Rochester, MN 55905
| | - Samuel R Money
- Mayo Clinic Arizona Division of Vascular Surgery, 5777 E Mayo Boulevard, Phoenix, AZ 85054
| | - Thomas C Bower
- Mayo Clinic Rochester Division of Vascular Surgery, 200 First St. SW, Rochester, MN 55905
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21
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Driedger MR, Yamashita TS, Starlinger P, Mathis KL, Smoot RL, Cleary SP, Nagorney DM. Synchronous resection of colorectal cancer primary and liver metastases: an outcomes analysis. HPB (Oxford) 2021; 23:1277-1284. [PMID: 33541806 DOI: 10.1016/j.hpb.2021.01.002] [Citation(s) in RCA: 7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 12/21/2020] [Accepted: 01/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Concurrent resection of the primary cancer and synchronous colorectal cancer liver metastases (CRCLM) was evaluated for differences in outcomes following stratification of both the liver and colorectal resection. METHODS Consecutive cases of synchronous resection of both the CRC primary and CRCLM were reviewed retrospectively at a single, high-volume institution over a 17-year period (2000-2017). RESULTS 273 patients underwent simultaneous resection of CRCLM. The distribution of the primary lesion was similar between the colon (52.4%) and rectum (47.6%), while 46.9% of patients had bilobar liver disease. Major liver/major colorectal resection (n = 24) were significantly more likely to experience colorectal specific morbidity (OR 3.98, 95% CI 1.56-10.15, p = 0.004), liver specific morbidity (OR 7.4, 95% CI 2.22-24.71, p = 0.001), total morbidity (OR 2.91, 95% CI 1.18-7.18, p = 0.020) and 90-day mortality (OR 5.50, 95% CI 1.27-23.81, p = 0.023). Failure to receive adjuvant chemotherapy secondary to postoperative morbidity was associated with significantly worsened survival (HR for death 5.91, 95% CI 1.59-22.01, p = 0.008). CONCLUSIONS Postoperative morbidity precluding the administration of adjuvant chemotherapy is associated with an increase in mortality. Combining a major liver with major colorectal resection is associated with a significant increase in major morbidity and 90-day mortality, and should be avoided.
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Affiliation(s)
- Michael R Driedger
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Thomas S Yamashita
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Patrick Starlinger
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - David M Nagorney
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
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22
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Gudmundsdottir H, Graham RP, Sonbol MB, Smoot RL, Truty MJ, Kendrick ML, Nagorney DM, Habermann EB, Halfdanarson TR, Cleary SP. Multifocality is not associated with worse survival in sporadic pancreatic neuroendocrine tumors. J Surg Oncol 2021; 124:1077-1084. [PMID: 34310723 DOI: 10.1002/jso.26618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/19/2021] [Accepted: 07/11/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Pancreatic neuroendocrine tumors (pNETs) in patients with hereditary cancer syndromes are typically multifocal. In contrast, sporadic pNETs are usually unifocal and the incidence of multifocal sporadic pNETs is unknown. The primary aim of this study was to investigate the incidence of multifocality in sporadic pNETs and any associated effect on recurrence risk and survival. METHODS Patients who underwent resection of pNETs at Mayo Clinic from 2000 to 2019 were identified and clinical data were obtained from medical records. Syndromic disease was defined as pNETs arising in the setting of a hereditary cancer syndrome. Statistical comparisons were made using χ2 , Fisher's exact, and Kruskal-Wallis tests and survival was assessed using the Kaplan-Meier method. RESULTS Six hundred and sixty-one patients with sporadic pNETs and fifty-nine with syndromic pNETs were identified. Multifocal disease was present in 4.8% of sporadic patients and 84.7% of syndromic patients (p < .001). Within patients with sporadic pNETs, clinicopathologic features and recurrence-free and overall survival were similar between patients with unifocal and multifocal disease. CONCLUSIONS Multifocal sporadic pNETs are rare and multifocality is not associated with worse survival or increased recurrence risk. Patients with multifocal sporadic pNETs can likely be safely managed with a combination of resection and observation as indicated for each tumor.
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Affiliation(s)
| | - Rondell P Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad B Sonbol
- Department of Medical Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Rory L Smoot
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Elizabeth B Habermann
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | | | - Sean P Cleary
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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23
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Bergquist JR, Thiels CA, Shubert CR, Ivanics T, Habermann EB, Vege SS, Grotz TE, Cleary SP, Smoot RL, Kendrick ML, Nagorney DM, Truty MJ. Perception versus reality: A National Cohort Analysis of the surgery-first approach for resectable pancreatic cancer. Cancer Med 2021; 10:5925-5935. [PMID: 34289264 PMCID: PMC8419760 DOI: 10.1002/cam4.4144] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/10/2021] [Accepted: 06/25/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Although surgical resection is necessary, it is not sufficient for long‐term survival in pancreatic ductal adenocarcinoma (PDAC). We sought to evaluate survival after up‐front surgery (UFS) in anatomically resectable PDAC in the context of three critical factors: (A) margin status; (B) CA19‐9; and (C) receipt of adjuvant chemotherapy. Methods The National Cancer Data Base (2010–2015) was reviewed for clinically resectable (stage 0/I/II) PDAC patients. Surgical margins, pre‐operative CA19‐9, and receipt of adjuvant chemotherapy were evaluated. Patient overall survival was stratified based on these factors and their respective combinations. Outcomes after UFS were compared to equivalently staged patients after neoadjuvant chemotherapy on an intention‐to‐treat (ITT) basis. Results Twelve thousand and eighty‐nine patients were included (n = 9197 UFS, n = 2892 ITT neoadjuvant). In the UFS cohort, only 20.4% had all three factors (median OS = 31.2 months). Nearly 1/3rd (32.7%) of UFS patients had none or only one factor with concomitant worst survival (median OS = 14.7 months). Survival after UFS decreased with each failing factor (two factors: 23 months, one factor: 15.5 months, no factors: 7.9 months) and this persisted after adjustment. Overall survival was superior in the ITT‐neoadjuvant cohort (27.9 vs. 22 months) to UFS. Conclusion Despite the perceived benefit of UFS, only 1‐in‐5 UFS patients actually realize maximal survival when known factors highly associated with outcomes are assessed. Patients are proportionally more likely to do worst, rather than best after UFS treatment. Similarly staged patients undergoing ITT‐neoadjuvant therapy achieve survival superior to the majority of UFS patients. Patients and providers should be aware of the false perception of ‘optimal’ survival benefit with UFS in anatomically resectable PDAC.
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Affiliation(s)
- John R Bergquist
- Department of Surgery, Division of Surgical Oncology, Stanford University, Stanford, Palo Alto, California, USA.,Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Cornelius A Thiels
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Christopher R Shubert
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA.,Department of Surgery, Division of Hepatopancreatobiliary Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tommy Ivanics
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA.,Department of Surgery, Henry Ford Medical Center, Detroit, Michigan, USA
| | - Elizabeth B Habermann
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Santhi S Vege
- Mayo Clinic Rochester, Department of Medicine, Division of Gastroenterology, Pancreatology Section, Rochester, Minnesota, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
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Yonkus JA, Alva-Ruiz R, Abdelrahman AM, Horsman SE, Cunningham SA, Grotz TE, Smoot RL, Cleary SP, Nagorney DM, Kendrick ML, Truty MJ. Intraoperative bile duct cultures in patients undergoing pancreatic head resection: Prospective comparison of bile duct swab versus bile duct aspiration. Surgery 2021; 170:1794-1798. [PMID: 34226042 DOI: 10.1016/j.surg.2021.06.013] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Postoperative surgical site infection is a major source of morbidity after pancreatic head resections, and data suggest bacterobilia as a leading cause. Some centers use intraoperative bile duct cultures to guide postoperative antimicrobial prophylaxis. This prospective study evaluates culture differences between traditional bile duct swab versus bile duct aspiration intraoperative samples. METHODS Prospective patients undergoing pancreatic head resection with both bile duct swab and bile duct aspiration were included. Cultures were reviewed for organism characteristics. Any growth of organisms was considered a positive culture. Bile duct swab yield and characteristics were compared with bile duct aspiration. Postoperative surgical site infection complications were compared to bile duct culture results. RESULTS Fifty patients were included. Bile duct aspiration resulted in a significantly higher median number of organisms compared to bile duct swab (6 vs 3; P < .001). There were no differences in the number of patients (37 vs 33) having positive bile duct aspiration and bile duct swab cultures (P = .385). Anaerobic cultures (not possible with bile duct swab) were positive in 21 patients with bile duct aspiration. A total of 37 (74%) patients had preoperative biliary stenting, which highly associated (P < .001) with positive cultures. Bile duct culture organisms correlated with postoperative surgical site infection in 12/17 (71%) patients. CONCLUSION Use of bile duct aspiration improves intraoperative bile duct culture organism yield over bile duct swab and may improve tailoring of antibiotics in patients undergoing pancreatic head resection.
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Affiliation(s)
- Jennifer A Yonkus
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Roberto Alva-Ruiz
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Amro M Abdelrahman
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Susan E Horsman
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Scott A Cunningham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.
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25
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Yonkus JA, Alva-Ruiz R, Abdelrahman AM, Leiting JL, Schneider AR, Grotz TE, Cleary SP, Smoot RL, Nagorney DM, Kendrick ML, Kipp BR, Truty MJ. Molecular Peritoneal Staging for Pancreatic Ductal Adenocarcinoma Using Mutant KRAS Droplet-Digital Polymerase Chain Reaction: Results of a Prospective Clinical Trial. J Am Coll Surg 2021; 233:73-80.e1. [PMID: 34022414 DOI: 10.1016/j.jamcollsurg.2021.05.009] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/08/2021] [Accepted: 05/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy with predilection for peritoneal dissemination. Accurate peritoneal staging is imperative for treatment recommendations, as one-third of patients develop peritoneal recurrence after resection. Because >90% of PDAC tumors harbor mutant KRAS (mKRAS), we sought to determine feasibility of mKRAS DNA detection in peritoneal lavage (PL) fluid using droplet-digital polymerase chain reaction (ddPCR) via a prospective trial. STUDY DESIGN Patients with nonmetastatic PDAC undergoing staging laparoscopy with PL were included. PL fluid was sent for cytologic examination, CA19-9/CEA levels, and mKRAS ddPCR assay. Clinically positive laparoscopy was defined as gross metastases or positive cytology. PL mKRAS status was compared with gross findings, cytology, and CA19-9/CEA levels. RESULTS There were 136 patients enrolled; 70 of 136 (51%) patients received neoadjuvant therapy before PL, and 32 of 136 (24%) patients had clinically positive laparoscopy. Cytology was positive in 17 of 136 (13%) patients, and 22 of 136 (16%) patients had gross metastases. Of patients with gross metastases, only 8 of 22 (36%) had positive cytology; 97 of 136 (71%) patients had mKRAS in PL. PL mKRAS was present in 27 of 32 (84%) clinically positive laparoscopies, with higher mean copy number in clinically positive patients (643 vs 10, p = 0.02). Peritoneal mKRAS was positive in an additional 70 clinically negative patients. CONCLUSIONS This prospective study establishes the feasibility of PL mKRAS detection. Clinically positive disease was identified in 1 in 4 staging laparoscopies. Although PL mKRAS was highly associated with clinically positive findings, many clinically negative laparoscopies had detectable PL mKRAS, suggesting that standard staging may be inadequate. Longer follow-up will elucidate utility of this promising molecular assay.
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Affiliation(s)
- Jennifer A Yonkus
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery
| | - Roberto Alva-Ruiz
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery
| | - Amro M Abdelrahman
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery
| | - Jennifer L Leiting
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery
| | - Amber R Schneider
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Travis E Grotz
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery
| | - Sean P Cleary
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery
| | - Rory L Smoot
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery
| | - David M Nagorney
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery
| | - Michael L Kendrick
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery
| | - Benjamin R Kipp
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Mark J Truty
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery.
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26
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Starlinger P, Pereyra D, Hackl H, Ortmayr G, Braunwarth E, Santol J, Najarnia S, Driedger MR, Gregory L, Alva‐Ruiz R, Glasgow A, Assinger A, Nagorney DM, Habermann EB, Staetttner S, Cleary SP, Smoot RL, Gruenberger T. Consequences of Perioperative Serotonin Reuptake Inhibitor Treatment During Hepatic Surgery. Hepatology 2021; 73:1956-1966. [PMID: 33078426 PMCID: PMC8251772 DOI: 10.1002/hep.31601] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/14/2020] [Accepted: 10/01/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Platelet-stored serotonin critically affects liver regeneration in mice and humans. Selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenalin reuptake inhibitors (SNRIs) reduce intraplatelet serotonin. As SSRIs/SNRIs are now one of the most commonly prescribed drugs in the United States and Europe and given serotonin's impact on liver regeneration, we evaluated whether perioperative use of SSRIs/SNRIs affects outcome after hepatic resection. APPROACH AND RESULTS Consecutive patients undergoing hepatic resection (n = 754) were retrospectively included from prospectively maintained databases from two European institutions. Further, an independent cohort of 495 patients from the United States was assessed to validate our exploratory findings. Perioperative intake of SSRIs/SNRIs was recorded, and patients were followed up for postoperative liver dysfunction (LD), morbidity, and mortality. Perioperative intraplatelet serotonin levels were significantly decreased in patients receiving SSRI/SNRI treatment. Patients treated with SSRIs/SNRIs showed a higher incidence of morbidity, severe morbidity, LD, and LD requiring intervention. Associations were confirmed in the independent validation cohort. Combined cohorts documented a significant increase in deleterious postoperative outcome (morbidity odds ratio [OR], 1.56; 95% confidence interval [CI], 1.07-2.31; severe morbidity OR, 1.86; 95% CI, 1.22-2.79; LD OR, 1.96; 95% CI, 1.23-3.06; LD requiring intervention OR, 2.22; 95% CI, 1.03-4.36). Further, multivariable analysis confirmed the independent association of SSRIs/SNRIs with postoperative LD, which was closely associated with postoperative 90-day mortality and 1-year overall survival. CONCLUSIONS We observed a significant association of perioperative SSRI/SNRI intake with adverse postoperative outcome after hepatic resection. This indicates that SSRIs/SNRIs should be avoided perioperatively in patients undergoing hepatic resections.
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Affiliation(s)
- Patrick Starlinger
- Department of SurgeryMedical University of ViennaGeneral HospitalViennaAustria
- Department of SurgeryDivision of Hepatobiliary and Pancreas SurgeryMayo ClinicRochesterMN
| | - David Pereyra
- Department of SurgeryMedical University of ViennaGeneral HospitalViennaAustria
| | - Hubert Hackl
- Institute of BioinformaticsBiocenterMedical University of InnsbruckInnsbruckAustria
| | - Gregor Ortmayr
- Department of SurgeryMedical University of ViennaGeneral HospitalViennaAustria
| | - Eva Braunwarth
- Department of Visceral, Transplantation and Thoracic SurgeryMedical University InnsbruckInnsbruckAustria
| | - Jonas Santol
- Department of SurgeryMedical University of ViennaGeneral HospitalViennaAustria
| | - Sina Najarnia
- Department of SurgeryMedical University of ViennaGeneral HospitalViennaAustria
| | - Michael R. Driedger
- Department of SurgeryDivision of Hepatobiliary and Pancreas SurgeryMayo ClinicRochesterMN
| | - Lindsey Gregory
- Department of SurgeryDivision of Hepatobiliary and Pancreas SurgeryMayo ClinicRochesterMN
| | - Roberto Alva‐Ruiz
- Department of SurgeryDivision of Hepatobiliary and Pancreas SurgeryMayo ClinicRochesterMN
| | - Amy Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care DeliverMayo ClinicRochesterMN
| | - Alice Assinger
- Center of Physiology and PharmacologyMedical University of ViennaViennaAustria
| | - David M. Nagorney
- Department of SurgeryDivision of Hepatobiliary and Pancreas SurgeryMayo ClinicRochesterMN
| | - Elizabeth B. Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care DeliverMayo ClinicRochesterMN
| | - Stefan Staetttner
- Department of Visceral, Transplantation and Thoracic SurgeryMedical University InnsbruckInnsbruckAustria
- Department of General, Visceral and Vascular SurgerySKG KlinikumVöcklabruckAustria
| | - Sean P. Cleary
- Department of SurgeryDivision of Hepatobiliary and Pancreas SurgeryMayo ClinicRochesterMN
| | - Rory L. Smoot
- Department of SurgeryDivision of Hepatobiliary and Pancreas SurgeryMayo ClinicRochesterMN
| | - Thomas Gruenberger
- Department of SurgeryHPB CenterViennese Health NetworkClinic Favoriten and Sigmund Freud Private UniversityViennaAustria
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27
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Driedger MR, Groeschl R, Yohanathan L, Starlinger P, Grotz TE, Smoot RL, Nagorney DM, Cleary SP, Kendrick ML, Truty MJ. Finding the Balance: General Surgery Resident Versus Fellow Training and Exposure in Hepatobiliary and Pancreatic Surgery. J Surg Educ 2021; 78:875-884. [PMID: 33077416 DOI: 10.1016/j.jsurg.2020.09.002] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/27/2020] [Accepted: 09/05/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Institutions training both General Surgery (GS) residents and Hepato-Pancreatico-Biliary (HPB) fellows must strive for adequate case volumes for each trainee cohort. METHODS Six academic years of graduating ACGME Residency and HPB Fellowship Council case logs (July 2011-June 2017) and institutional administrative faculty billing data were examined at a single high-volume center with a formal HPB Surgical Division with both GS Residency and HPB Surgery Fellowship trainees. RESULTS During the 6-year period, 7482 operations were performed by HPB faculty (5.5 total full-time equivalent (FTE)) and included 2419 major liver, 375 major biliary, and 1591 major pancreas cases. Residents/fellows performed 1102 (50%)/1101 (50%) of all major liver operations, 165 (49.7%)/163 (50.3%) major biliary operations, and 843 (59.2%)/581 (40.8%) major pancreas operations, with significantly different case mix of pancreas for resident versus fellow, p < 0.0001. The overall relative proportion of total HPB cases performed by residents versus fellows was 53%/47%, respectively, and this was stable over time, with no significant decrease in resident exposure/cases with dedicated HPB fellowship. CONCLUSIONS Our experience in training both GS residents and HPB fellows with a formal HPB Surgical Division suggests that a high volume HPB Division allows for more than adequate exposure for both groups of trainees.
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Affiliation(s)
- Michael R Driedger
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Ryan Groeschl
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Lavanya Yohanathan
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Patrick Starlinger
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
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Starlinger P, Ubl DS, Hackl H, Starlinger J, Nagorney DM, Smoot RL, Habermann EB, Cleary SP. Combined APRI/ALBI score to predict mortality after hepatic resection. BJS Open 2021; 5:6102898. [PMID: 33609383 PMCID: PMC7893465 DOI: 10.1093/bjsopen/zraa043] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/01/2020] [Accepted: 10/22/2020] [Indexed: 12/31/2022] Open
Abstract
Background Aspartate aminotransferase/platelet ratio index (APRI) and albumin–bilirubin grade (ALBI) are validated prognostic indices implicated as predictors of postoperative liver dysfunction after hepatic resection. The aim of this study was to evaluate the relevance of the combined APRI/ALBI score for postoperative clinically meaningful outcomes. Methods Patients undergoing hepatectomy were included from the American College of Surgeons National Surgical Quality Improvement Program database. The association between APRI/ALBI score and postoperative grade C liver dysfunction, liver dysfunction-associated and overall 30-day mortality was assessed. Results A total of 12 055 patients undergoing hepatic resection from 2014 to 2017 with preoperative blood values and detailed 30-day postoperative outcomes were included (exploration cohort: January 2014 to December 2016; validation cohort: 2017). In the exploration cohort (8538 patients), the combination of both scores (APRI/ALBI) was significantly associated with postoperative grade C liver dysfunction, 30-day mortality, and liver dysfunction-associated 30-day mortality, and was superior to either score alone. The association with postoperative 30-day mortality was confirmed in multivariable analysis. A predictive model was generated using the exploration cohort. The predicted incidence of events closely followed the observed incidence in the validation cohort (3517 patients). Subgroup analyses of tumour types were used to generate disease-specific risk models to assess risk in different clinical scenarios. These findings informed development of a smartphone application (https://tellaprialbi.37binary.com). Conclusion The predictive potential of the combined APRI/ALBI score for clinically relevant outcomes such as mortality was demonstrated. An evidence-based smartphone application will allow clinical translation and facilitation of risk assessment before hepatic resection using routine laboratory parameters.
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Affiliation(s)
- P Starlinger
- Correspondence to: Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, 200 First Street SW Rochester, Minnesota 55905, USA (e-mail: )
| | - D S Ubl
- Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery and Department of Health Services Research, Mayo Clinic, Rochester, Minnesota, USA
| | - H Hackl
- Division of Bioinformatics, Biocenter, Medical University of Innsbruck, Innsbruck, Austria
| | | | - D M Nagorney
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - R L Smoot
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - E B Habermann
- Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery and Department of Health Services Research, Mayo Clinic, Rochester, Minnesota, USA
| | - S P Cleary
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota, USA
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29
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Driedger MR, Puig CA, Thiels CA, Bergquist JR, Ubl DS, Habermann EB, Grotz TE, Smoot RL, Nagorney DM, Cleary SP, Kendrick ML, Truty MJ. Emergent pancreatectomy for neoplastic disease: outcomes analysis of 534 ACS-NSQIP patients. BMC Surg 2020; 20:169. [PMID: 32718311 PMCID: PMC7385869 DOI: 10.1186/s12893-020-00822-8] [Citation(s) in RCA: 5] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 07/10/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND While emergent pancreatic resection for trauma has been previously described, no large contemporary investigations into the frequency, indications, and outcomes of emergent pancreatectomy (EP) secondary to complications of neoplastic disease exist. Modern perioperative outcomes data are currently unknown. METHODS ACS-NSQIP was reviewed for all non-traumatic pancreatic resections (DP - distal pancreatectomy, PD - pancreaticoduodenectomy, or TP- total pancreatectomy) in patients with pancreatico-biliary or duodenal-ampullary neoplasms from 2005 to 2013. Patients treated for complications of pancreatitis were specifically excluded. Emergent operation was defined as NSQIP criteria for emergent case and one of the following: ASA Class 5, preoperative ventilator dependency, preoperative SIRS, sepsis, or septic shock, or requirement of > 4 units RBCs in 72 h prior to resection. Chi-square tests, Fisher's exact tests were performed to compare postoperative outcomes between emergent and elective cases as well as between pancreatectomy types. RESULTS Of 21,452 patients who underwent pancreatectomy for neoplastic indications, we identified 534 (2.5%) patients who underwent emergent resection. Preoperative systemic sepsis (66.3%) and bleeding (17.9%) were most common indications for emergent operation. PD was performed in 409 (77%) patients, DP in 115 (21%), and TP in 10 (2%) patients. Overall major morbidity was significantly higher (46.1% vs. 25.6%, p < 0.001) for emergent vs. elective operations. Emergent operations resulted in increased transfusion rates (47.6% vs. 23.4%, p < 0.001), return to OR (14.0% vs. 5.6%, p < 0.001), organ-space infection (14.6 vs. 10.5, p = 0.002), unplanned intubation (9.% vs. 4.1%, p < 0.001), pneumonia (9.6% vs. 4.2%, p < 0.001), length of stay (14 days vs. 8 days, p < 0.001), and discharge to skilled facility (31.1% vs. 13.9%). These differences persisted when stratified by pancreatic resection type. The 30-day operative mortality was higher in the emergent group (9.4%vs. 2.7%, p < 0.001) and highest for emergent TP (20%). CONCLUSION Emergent pancreatic resection is markedly uncommon in the setting of neoplastic disease. Although these operations result in increased morbidity and mortality compared to elective resections, they can be life-saving in specific circumstances. The results of this large series of modern era national data may assist surgeons as well as patients and their families in making critical decisions in select cases of acutely complicated neoplastic disease.
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Affiliation(s)
- Michael R Driedger
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Carlos A Puig
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Cornelius A Thiels
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - John R Bergquist
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Daniel S Ubl
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Health Care Research and Policy, Mayo Clinic, Rochester, MN, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David M Nagorney
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mark J Truty
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Truty MJ, Colglazier JJ, Mendes BC, Nagorney DM, Bower TC, Smoot RL, DeMartino RR, Cleary SP, Oderich GS, Kendrick ML. En Bloc Celiac Axis Resection for Pancreatic Cancer: Classification of Anatomical Variants Based on Tumor Extent. J Am Coll Surg 2020; 231:8-29. [DOI: 10.1016/j.jamcollsurg.2020.05.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 12/20/2022]
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Buckarma E, Thiels CA, Habermann EB, Glasgow A, Grotz TE, Cleary SP, Smoot RL, Kendrick ML, Nagorney DM, Truty MJ. Preoperative opioid use is associated with increased length of stay after pancreaticoduodenectomy. HPB (Oxford) 2020; 22:1074-1081. [PMID: 31839391 DOI: 10.1016/j.hpb.2019.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 09/19/2019] [Accepted: 11/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative opioid use in patients undergoing low complexity operations has been associated with increased complications, but its relationship to procedures of greater complexity is unclear. We aimed to assess this impact on outcomes following pancreaticoduodenectomy (PD). METHODS A single institution, retrospective cohort of adults undergoing elective PD for cancer (1/2009-9/2015). Preoperative opioid users were defined as patients documented as taking opioids up to 90 days preoperatively. Discharge prescriptions were converted into Oral Morphine Equivalents (OME) and ten-point pain scores were abstracted. Univariate and multivariable analyses compared outcomes of naïve and preoperative opioid users overall and for laparoscopic vs open surgery. RESULTS Of 661 PD patients, 131 (19.8%) were preoperative opioid users. These patients had greater mean pain scores over the first three days after surgery (3.4 ± 1.6, vs 2.8 ± 1.4, p < 0.001), max pain (7.9 ± 1.9 vs 7.2 ± 2.0, p < 0.001), and discharge pain (2.3 ± 1.9 vs 1.8 ± 1.6, p = 0.01) than naïve patients. Preoperative opioid users received more opioids at discharge (mean 496 ± 764 OME) than naïve (320 ± 489 OME, p = 0.03). Thirty-day refill rates were 12.6% (19.1% preoperative vs 10.9% naïve, p = 0.02). After controlling for tumor type, pancreas texture, and duct size, naïve patients had similar odds of clinically significant post-operative pancreatic fistulas (grade B or C) (OR 1.13, p = 0.68) and delayed gastric emptying (OR 1.05, p = 0.87). After controlling for age and complications, preoperative opioid use was associated with increased odds of LOS ≥9 days (OR 1.59, p = 0.04). CONCLUSION Following PD, preoperative opioid users had worse pain scores, received more opioids at discharge, refilled prescriptions more frequently, and were more likely to have prolonged LOS. As most opioid utilization research has been focused on low complexity surgery, additional work aimed at optimizing opioid use in complex oncologic operations is warranted.
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Affiliation(s)
| | | | - Elizabeth B Habermann
- Mayo Clinic Rochester, Department of Surgery, USA; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, USA
| | - Amy Glasgow
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, USA
| | | | | | - Rory L Smoot
- Mayo Clinic Rochester, Department of Surgery, USA
| | | | | | - Mark J Truty
- Mayo Clinic Rochester, Department of Surgery, USA.
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Jin R, Jin Z, Cleary SP, Nagorney DM, Smoot RL, McWilliams RR, Mahipal A. Neoadjuvant chemotherapy followed by liver resection for patients with metastatic colorectal cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
147 Background: Colorectal cancer is one of the leading causes of cancer related deaths with liver being most common site of CRC metastasis. More than 50% of the CRC patients will develop metastatic liver lesion that eventually leads to death in about 70% of them. In this retrospective review we reviewed the outcome of pts who received neoadjuvant chemotherapy followed by resection of liver lesion for metastatic colorectal cancer. Methods: 304 pts who had preoperative chemotherapy were identified from 1045 metastatic colorectal cancer patients who had liver metastasectomy at Mayo Clinic between 1997 and 2018. A retrospective review was conducted by using data from electronic medical records. Statistical analyses utilized Kaplan-Meier method, Log-rank test, and Cox proportional hazards models. Results: There were 113 (37%) female and 191 (63%) male pts. Median age at primary disease diagnosis was 56.5 yrs. Two hundred forty-nine pts presented with stage IV metastatic colorectal cancer. Primary tumor locations were: 53 right-sided, 117 left-sided and 133 rectum. 152 (50%) pts had extrahepatic metastases. Two pts were found to be MSI-H, 113 MSS, 189 unknown. BRAF mutation was found in 6 patients. RAS mutation was present in 84 patients, with 124 unknown. Pts received chemotherapy for median of 2.82 months. Single agent fluoropyrimidine was administered in 38 (12%) pts and rest receiving chemotherapy doublet or triplet with fluropyrimidine plus oxaliplatin being most common regimen. The median overall survival from primary diagnosis for the entire group was 74.5 months. Median overall survival from liver metastasectomy was 60.0 months. In univariate analysis, metachronous disease, age < 60 yrs, and an absence of extrahepatic lesions led to statistically significant improvement of overall survival from primary diagnosis. Metachronous and extrahepatic lesions remained statistically significant in multivariate analysis. Conclusions: Neoadjuvant chemotherapy followed by liver metastasectomy is beneficial for highly-selected metastatic colorectal cancer pts. Compared to a historical control of 30-36 months, our patient population had a median overall survival of about 5 years from resection.
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Maeda S, Moore AM, Yohanathan L, Hata T, Truty MJ, Smoot RL, Cleary SP, Nagorney DM, Grotz TE, Park EJ, Girgis MD, Reber HA, Motoi F, Masuda T, Unno M, Kendrick ML, Donahue TR. Impact of resection margin status on survival in pancreatic cancer patients after neoadjuvant treatment and pancreatoduodenectomy. Surgery 2020; 167:803-811. [PMID: 31992444 DOI: 10.1016/j.surg.2019.12.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 12/03/2019] [Accepted: 12/16/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Resection margin status has been recognized as an independent prognostic factor on overall survival in pancreatic cancer patients undergoing surgical resection. However, its impact after neoadjuvant treatment remains uncertain. METHODS We analyzed 305 patients with resectable or borderline resectable pancreatic cancer treated with neoadjuvant therapy and pancreatoduodenectomy at 3 tertiary referral centers between 2010 and 2017. Positive resection margin was defined as 1 or more cancer cells at any margin. Overall survival was measured from the date of surgery until death or last follow-up. RESULTS One hundred and seventy-eight patients received neoadjuvant chemotherapy and 127 received neoadjuvant chemoradiotherapy. The median overall survival was 29.8 months. The 1-, 3-, and 5-year overall survival rates were 79.2%, 44.0%, and 23.5%, respectively. Negative margin was achieved in 275 (90.2%) patients. Negative margin resection patients had a significantly longer overall survival than positive resection margin patients (31.3 vs 16.3 months, P < .001). In univariate analyses, overall survival was associated with age, margin status, histologic grade, ypT, number of positive lymph nodes, perineural invasion, treatment effect, postoperative carbohydrate antigen 19-9, and adjuvant therapy. Positive margin resection, poorly differentiated carcinoma, treatment effect score of 3, postoperative carbohydrate antigen 19-9 of 37 U/mL or higher, and lack of adjuvant therapy were predictive of poor overall survival in multivariate Cox regression analysis. CONCLUSION Margin status was an independent predictor of overall survival in patients treated with neoadjuvant therapy and pancreatoduodenectomy, supporting the use of a negative margin resection as a surrogate of adequate oncological resection in this setting. Our findings may also have significant implications for patient stratification in future randomized trials.
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Affiliation(s)
- Shimpei Maeda
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA; Department of Surgery, Mayo Clinic, Rochester, MN; Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Alexandra M Moore
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA
| | | | - Tatsuo Hata
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Rory L Smoot
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | | | | | - Eugene J Park
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Mark D Girgis
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Howard A Reber
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Fuyuhiko Motoi
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshiro Masuda
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA; Department of Surgery, Mayo Clinic, Rochester, MN
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Timothy R Donahue
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA.
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Sugimoto M, Takahashi N, Farnell MB, Smyrk TC, Truty MJ, Nagorney DM, Smoot RL, Chari ST, Carter RE, Kendrick ML. Survival benefit of neoadjuvant therapy in patients with non-metastatic pancreatic ductal adenocarcinoma: A propensity matching and intention-to-treat analysis. J Surg Oncol 2019; 120:976-984. [PMID: 31452208 DOI: 10.1002/jso.25681] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 08/12/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Conclusive evidence in favor of neoadjuvant therapy for those with non-metastatic pancreatic ductal adenocarcinoma (PDAC) is still lacking. The objective of this study was to evaluate the survival benefit of neoadjuvant therapy vs upfront surgery for patients with non-metastatic PDAC. METHODS The study involved 565 patients undergoing neoadjuvant therapy or upfront surgery as the primary treatment for PDAC. Propensity score matching was performed between the neoadjuvant therapy group (NAT group) and the upfront surgery group (UFS group) using 20 clinical variables at diagnosis. Overall survival and surgical pathology were compared between the two treatment groups on an intent-to-treat basis. RESULTS In the matched cohort, the NAT group (n = 91) had a longer median overall survival than the UFS group (n = 91) (23.1 months vs 18.5 months, P = .043). The rate of patients undergoing surgical resection was lower in the NAT group (58% vs 80%, P = .001). Regarding surgical pathology, the NAT group had smaller tumor size (2.8 cm vs 4.0 cm, P = .001), lower incidence of positive surgical margins (8% vs 30%, P < .002), and less lymph node metastasis (45% vs 78%, P < .001). CONCLUSIONS The strategy of neoadjuvant therapy before surgical resection appears to offer pathologic effect and survival benefit for the patients presenting with non-metastatic PDAC.
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Affiliation(s)
- Motokazu Sugimoto
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | | | - Michael B Farnell
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Thomas C Smyrk
- Division of Pathology, Mayo Clinic, Rochester, Minnesota
| | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rickey E Carter
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
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Bergquist JR, Leiting JL, Habermann EB, Cleary SP, Kendrick ML, Smoot RL, Nagorney DM, Truty MJ, Grotz TE. Early-onset gastric cancer is a distinct disease with worrisome trends and oncogenic features. Surgery 2019; 166:547-555. [PMID: 31331685 DOI: 10.1016/j.surg.2019.04.036] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/11/2019] [Accepted: 04/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Overall the incidence of gastric cancer is declining in the United States; however, the incidence of early-onset gastric cancer is increasing. We sought to elucidate clinical and genomic characteristics and risk factors for early-onset gastric cancer compared with late-onset gastric cancer. METHODS We utilized the Surveillance, Epidemiology, and End Results database (1973-2015), the Behavioral Risk Factor Surveillance Survey, and The Cancer Genome Atlas to characterize early-onset gastric cancer. RESULTS The incidence of early-onset gastric cancer increased during the study period and now comprises >30% of all gastric cancer in the United States. Early-onset gastric cancer was associated with higher grade (55.2 vs 46.9%), signet-ring cells (19.0 vs 10.4%), diffuse histology (25.7 vs 15.0%), and metastatic disease (49.5 vs 40.9%, all P < .01) compared with late-onset gastric cancer. Early-onset gastric cancer was more likely to be Epstein-Barr virus (7.7 vs 5.1%) or genomically stable (22.5 vs 8.1%) subtype, whereas late-onset gastric cancer was more likely to be microsatellite instability subtype (18.6 vs 5.6%; all P < .01). Risk factors for gastric cancer were less correlated with early-onset gastric cancer compared with late-onset gastric cancer. CONCLUSION The incidence of early-onset gastric cancer has been steadily increasing in the United States, comprising >30% of new gastric cancer cases today. Early-onset gastric cancer is genetically and clinically distinct from traditional gastric cancer. Additional investigations are warranted to better understand this alarming phenomenon.
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Affiliation(s)
- John R Bergquist
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Rochester, MN
| | - Jennifer L Leiting
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Elizabeth B Habermann
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Rochester, MN
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - David M Nagorney
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Mark J Truty
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.
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Martin WP, Vaughan LE, Yoshida K, Takahashi N, Edwards ME, Metzger A, Senum SR, Masyuk TV, LaRusso NF, Griffin MD, El-Zoghby Z, Harris PC, Kremers WK, Nagorney DM, Kamath PS, Torres VE, Hogan MC. Bacterial Cholangitis in Autosomal Dominant Polycystic Kidney and Liver Disease. Mayo Clin Proc Innov Qual Outcomes 2019; 3:149-159. [PMID: 31193902 PMCID: PMC6543502 DOI: 10.1016/j.mayocpiqo.2019.03.004] [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: 11/16/2018] [Revised: 03/12/2019] [Accepted: 03/20/2019] [Indexed: 12/24/2022] Open
Abstract
Objective To describe first episodes of bacterial cholangitis complicating autosomal dominant polycystic kidney disease (ADPKD) and autosomal dominant polycystic liver disease (ADPLD) and to identify risk factors for cholangitis episodes among patients with ADPKD-associated polycystic liver disease (PLD). Patients and Methods We searched the electronic medical records at our tertiary referral center for episodes of cholangitis in patients with ADPKD or ADPLD from January 1, 1996, through June 30, 2017. Cases were categorized as suspected or definite cholangitis by expert review. Clinical, laboratory, and radiologic data were manually abstracted. A nested case-control study was conducted to investigate risk factors for cholangitis in patients with ADPKD. Results We identified 29 cases of definite or suspected cholangitis complicating PLD (24 with ADPKD-associated PLD and 5 with ADPLD). Among patients with definite cholangitis in ADPKD-associated PLD (n=19) vs ADPLD (n=4), the mean ± SD age was 62.4±12.2 vs 55.1±8.6 years, and 9 (47.4%) vs 0 (0%), respectively, were male. The odds of gallstones (odds ratio [OR], 21.6; 95% CI, 3.17-927; P<.001), prior cholecystectomy (OR, 12.2; 95% CI, 1.59-552; P=.008), duodenal diverticulum (OR, 13.5; 95% CI, 2.44 to not estimable; P=.004), type 2 diabetes mellitus (OR, 6.41; 95% CI, 1.01 to not estimable; P=.05), prior endoscopic retrograde cholangiopancreatography (OR, 14.0; 95% CI, 1.80-631; P=.005), and prior kidney transplant (OR, 8.06; 95% CI, 1.72-76.0; P=.004) were higher in patients with ADPKD-associated PLD with definite cholangitis compared to controls. Conclusion Gallstones, prior cholecystectomy, duodenal diverticulosis, type 2 diabetes mellitus, prior endoscopic retrograde cholangiopancreatography, and prior kidney transplant constituted risk factors for cholangitis among patients with ADPKD-associated PLD.
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Key Words
- ADPKD, autosomal dominant polycystic kidney disease
- ADPLD, autosomal dominant polycystic liver disease
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- CT, computed tomography
- ERCP, endoscopic retrograde cholangiopancreatography
- ICD-10, International Classification of Diseases,Tenth Revision
- ICD-9, International Classification of Diseases,Ninth Revision
- MCR, Mayo Clinic, Rochester, MN
- MRI, magnetic resonance imaging
- OR, odds ratio
- PET, positron emission tomography
- PLD, polycystic liver disease
- T2DM, type 2 diabetes mellitus
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Affiliation(s)
- William P Martin
- Diabetes Complications Research Centre, Conway Institute of Biomolecular and Biomedical Research, School of Medicine, University College Dublin, Dublin, Republic of Ireland
| | - Lisa E Vaughan
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | | | - Marie E Edwards
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Andrew Metzger
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Sarah R Senum
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Tetyana V Masyuk
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Matthew D Griffin
- Nephrology Services, Galway University Hospitals, Saolta University Healthcare Group, Galway, Republic of Ireland
| | - Ziad El-Zoghby
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Peter C Harris
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Walter K Kremers
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - David M Nagorney
- Department of Internal Medicine, and Division of Subspecialty General Surgery, Department of General Surgery, Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vicente E Torres
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Marie C Hogan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
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Huffman BM, Jin Z, Yadav S, Patel S, Nagorney DM, Truty MJ, McWilliams RR, Halfdanarson TR, Mahipal A. Novel Prognostic Factors in Resected Small Bowel Adenocarcinoma. Clin Colorectal Cancer 2019; 18:218-225. [PMID: 31178274 DOI: 10.1016/j.clcc.2019.05.002] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 05/08/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Small bowel adenocarcinoma (SBA) is a rare malignancy affecting approximately 3000 patients per year in the United States, and there is limited evidence prognosticating patients with resected SBA. We aimed to evaluate prognostic factors and the role of adjuvant therapy in patients with resected SBA. PATIENTS AND METHODS Two hundred forty-one patients who had resected stage I-III SBA were retrospectively identified at a single tertiary referral institution. Overall survival (OS) analysis was performed by the Kaplan-Meier method, and Wilcoxon tests were used for statistical comparisons. Cox proportional hazards were performed to identify significant variables by univariate and multivariate analysis. RESULTS Median OS for the entire group was 54.5 months (95% confidence interval [CI], 37.2-81.2 months), with 5- and 10-year OS of 48% and 35%. Median follow-up was 113.7 months (95% CI, 97.9-126.6 months). For patients with stage III disease who received adjuvant therapy, the median OS was 33.8 months (95% CI, 27.8-78.8) compared to 24.7 months (95% CI, 11.5-37.8) for patients with no adjuvant therapy (P < .01). Male sex, advanced T stage, advanced N stage, increased positive lymph node ratio, lymphocyte-to-monocyte ratio < 1.56, presence of residual disease, and earlier date of diagnosis predicted worse survival on univariate analysis. Age > 60 years, lymphocyte-to-monocyte ratio < 1.56, and advanced T stage were identified as independent negative predictors of OS for all patients by multivariate analysis. CONCLUSION Advanced age, advanced T stage, and lymphocyte-to-monocyte ratio < 1.56 independently predicted survival in resected SBA. Adjuvant therapy is associated with improved survival in patients with resected stage III SBA.
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Affiliation(s)
| | - Zhaohui Jin
- Division of Medical Oncology, Mayo Clinic, Rochester, MN
| | | | - Shruti Patel
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | | | | | - Amit Mahipal
- Division of Medical Oncology, Mayo Clinic, Rochester, MN.
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Hernandez MC, Bergquist JR, Leiting JL, Ivanics T, Yang L, Smoot RL, Nagorney DM, Truty MJ. Patient-Derived Xenografts Can Be Reliably Generated from Patient Clinical Biopsy Specimens. J Gastrointest Surg 2019; 23:818-824. [PMID: 30756315 DOI: 10.1007/s11605-019-04109-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/17/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patient-derived xenografts (PDX) are clinically relevant human cancer models that can be used to guide individualized medicine. We aimed to generate PDX models from clinically obtained biopsy specimens (surgical or image-guided) hypothesizing that low volume biopsy specimens could provide sufficient viable tissue to successfully engraft PDX models from patients with unresectable or metastatic disease. MATERIALS AND METHODS We maintain a prospective high volume gastrointestinal malignancy PDX program. With informed consent and institutional approval, biopsy specimens (surgical or image-guided) were obtained from patients with unresectable or metastatic tumors: pancreatic adenocarcinoma (PDAC), cholangiocarcinoma, gastric and gallbladder carcinoma. Biopsies were implanted into immunodeficient mice. Tumor growth was monitored, viable tumor was passed into subsequent generations, and histopathology was confirmed. RESULTS In this study, biopsy specimens from 29 patients were used for PDX engraftment. Successful PDX engraftment was variable with highest engraftment rates in gastric and gallbladder carcinoma specimens (100%) compared to engraftment rates of 33% and 29% in PDAC and cholangiocarcinoma respectively. PDX models created from metastasis biopsies compared to unresectable primary tumor tissue demonstrated higher engraftment rates (69% versus 15.4%, p = 0.001). PDX models demonstrated higher engraftment rates when biopsies were obtained during surgical operations (n = 15) compared to image-guided (n = 14) (73% versus 14%, p = 0.003). Patient age, pretreatment status, or ischemic time was not different between biopsy methods. CONCLUSIONS PDX models can be successfully created from clinical biopsy specimens in patients with metastatic or unresectable GI cancers. The use of clinical biopsy specimens for PDX engraftment can expand the repertoire of stage-specific PDX models for downstream basic/translational research.
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Affiliation(s)
- Matthew C Hernandez
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - John R Bergquist
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Jennifer L Leiting
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Tommy Ivanics
- Department of Surgery, Henry Ford Medical Center, Detroit, MI, USA
| | - Lin Yang
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rory L Smoot
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - David M Nagorney
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Mark J Truty
- Section of Hepatobiliary and Pancreatic Surgery, Division of Subspecialty General Surgery, Department of Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA.
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Hernandez MC, Panchamia J, Finnesgard EJ, Leiting JL, Franssen B, Saleem H, Kendrick ML, Nagorney DM, Truty MJ, Smoot RL. Transversus abdominis plane blocks with liposomal bupivacaine after open major hepatectomy is associated with reduced early patient-reported pain scores and opioid administration. Surgery 2018; 164:1251-1258. [PMID: 30201232 DOI: 10.1016/j.surg.2018.07.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/05/2018] [Accepted: 07/11/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Opioid overprescription can contribute to suboptimal patient outcomes. Surgeon-performed transversus abdominis plane blocks appear to be associated with pain reduction. We compared the analgesic efficacy of surgeon-performed transversus abdominis plane blocks for major hepatectomy with or without concurrent neuraxial analgesia. METHODS We performed a single-institution review, assessing surgeon-performed transversus abdominis plane blocks for major hepatectomy during 2013-2016. The primary outcome was patient-reported pain (11-point numeric pain-rating scale) and the secondary outcome was opioid consumption. Independent factors predictive of pain control were identified using logistic regression and reported as odds ratios with 95% confidence intervals. RESULTS A total of 232 patients with a mean (± SD) age of 56.5 (±13.9) years; 51.7% were female. Operative duration, incision type, and American Society of Anesthesiologists score were similar between groups. The 24-hour pain score was decreased substantially in patients who received a transversus abdominis plane block compared with those who did not (3 [2-4] versus 5 [4-6], P = .001) and this decrease in pain sscore persisted at 48 hours (2 [1-2] versus 4 [4-5], P = .001). In patients who received a transversus abdominis plane block, there were decreasess in consumption of oral morphine equivalents at 24 hours (322 [± 18] versus 183 [± 15], P = .0001) and 48 hours (100 [± 11] versus 33 [± 9.4], P = .03) compared with those without transversus abdominis plane block respectively. CONCLUSION In patients receiving a transversus abdominis plane block, early patient opioid consumption was decreased and utilization was predictive for improved pain control. Routine transversus abdominis plane block administration should be considered during major hepatectomy as a step toward curbing systematic reliance on opioids for pain management. A prospective study on the utility of transversus abdominis plane block in hepatectomy is warranted.
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Affiliation(s)
- Matthew C Hernandez
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jason Panchamia
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Eric J Finnesgard
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jennifer L Leiting
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Bernardo Franssen
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Humza Saleem
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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Mudireddy M, Gangat N, Lasho TL, Finke C, Hanson CA, Ketterling RP, Ashrani AA, Pardanani A, Nagorney DM, Tefferi A. Early thrombotic events and preemptive systemic anticoagulation following splenectomy for myelofibrosis. Am J Hematol 2018; 93:E235-E238. [PMID: 29981287 DOI: 10.1002/ajh.25203] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/18/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Mythri Mudireddy
- Division of Hematology, Department of Internal Medicine; Mayo Clinic; Rochester Minnesota
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine; Mayo Clinic; Rochester Minnesota
| | - Terra L. Lasho
- Division of Hematology, Department of Internal Medicine; Mayo Clinic; Rochester Minnesota
| | - Christy Finke
- Division of Hematology, Department of Internal Medicine; Mayo Clinic; Rochester Minnesota
| | - Curtis A. Hanson
- Department of Laboratory Medicine; Mayo Clinic; Rochester Minnesota
| | | | - Aneel A. Ashrani
- Division of Hematology, Department of Internal Medicine; Mayo Clinic; Rochester Minnesota
| | - Animesh Pardanani
- Division of Hematology, Department of Internal Medicine; Mayo Clinic; Rochester Minnesota
| | | | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine; Mayo Clinic; Rochester Minnesota
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Kinney MAO, Nagorney DM, Clark DF, O'Brien TD, Turner JD, Marienau ME, Schroeder DR, Martin DP. Partial hepatic resections for metastatic neuroendocrine tumors: perioperative outcomes. J Clin Anesth 2018; 51:93-96. [PMID: 30098573 DOI: 10.1016/j.jclinane.2018.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/23/2018] [Accepted: 08/03/2018] [Indexed: 10/28/2022]
Abstract
STUDY OBJECTIVE Partial hepatic resection reduces tumor burden in patients with metastatic neuroendocrine tumors, thereby improving quality and length of life. These procedures can be challenging as well as life-threatening. Our aim was to evaluate our patients' perioperative outcomes and propose a definition for an intraoperative carcinoid crisis relevant to this surgery, given its unique surgical considerations. DESIGN Retrospective study. SETTING Mayo Clinic, Rochester, Minnesota. PATIENTS One hundred sixty-nine patients undergoing partial hepatic resection for metastatic neuroendocrine tumors between 1997 and 2015 were identified retrospectively from a surgical database at Mayo Clinic Rochester. INTERVENTIONS None. MEASUREMENTS Intraoperative carcinoid crisis for patients undergoing hepatic resection of neuroendocrine tumors was defined. Patients' medical records were reviewed and data were abstracted describing patient and procedural characteristics and perioperative outcomes. MAIN RESULTS There were no documented cases of carcinoid crisis (0.0%, 95% C.I. 0.0% to 2.2%). One patient developed clinical findings of an emerging carcinoid crisis, but was successfully treated with doses of octreotide and findings resolved in <10 min. Prophylactically 500 μg octreotide was given subcutaneously in 77% (130/169) of patients preoperatively. CONCLUSIONS There were no documented cases of carcinoid crisis (0.0%, 95% C.I. 0.0% to 2.2%). Adverse events were infrequent.
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Johnson B, Jin Z, Haddock MG, Hallemeier CL, Martenson JA, Smoot RL, Larson DW, Dozois EJ, Nagorney DM, Grothey A. A Curative-Intent Trimodality Approach for Isolated Abdominal Nodal Metastases in Metastatic Colorectal Cancer: Update of a Single-Institutional Experience. Oncologist 2018; 23:679-685. [PMID: 29445027 PMCID: PMC6067943 DOI: 10.1634/theoncologist.2017-0456] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 12/21/2017] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The purpose of this study was to define survival rates in patients with isolated advanced abdominal nodal metastases secondary to colorectal cancer (CRC), treated with curative-intent trimodality therapy. MATERIALS AND METHODS Sixty-five patients received trimodality therapy, defined as chemotherapy delivered with external beam radiotherapy (EBRT) followed by lymphadenectomy and intraoperative radiotherapy (IORT). Infusional 5-fluorouracil was the most common radiosensitizer used (63%, 41 patients). The median dose of EBRT was 50 Gy, and the median dose of IORT was 12.5 Gy. We evaluated time to distant metastasis, toxicities, local failure within the EBRT field, recurrence within the IORT field, and survival. RESULTS Fifty-two percent of patients were male; patients' median age was 50.5 years. All patients had an Eastern Cooperative Oncology Group score ≤1. Twenty-nine patients had right-sided colon cancer, 22 had left-sided colon cancer, and 14 had rectal primaries. The median time from initial CRC diagnosis to development of abdominal nodal metastatic disease was 20.6 months (95% confidence interval [CI], 21.2-40.8 months). Seventy-eight percent (51 patients) had para-aortic nodal metastases, 15% (10 patients) had mesenteric nodal metastases, and 6% (4 patients) had both. With a median follow-up of 77.6 months, the median overall survival and 5-year estimated survival rate were 55.4 months (95% CI, 47.2-80.9 months) and 45%, respectively. The median progression-free survival was 19.3 months (95% CI, 16.5-32.8 months). Twenty-six (40%) patients never developed distant disease. The outcome was not affected by disease sidedness or rectal primary. Treatment was well tolerated without grade 3 or 4 toxicities. CONCLUSION Trimodality therapy produces sustainable long-term survival in selected patients with metastatic CRC presenting with isolated retroperitoneal or mesenteric nodal relapse. IMPLICATIONS FOR PRACTICE This article reports a unique trimodality approach incorporating external beam radiotherapy with radiosensitizing chemotherapy, surgical resection, and intraoperative radiotherapy provides durable survival benefit with significant curative potential for patients with metastatic colorectal cancer who present with isolated abdominal nodal (mesenteric and/or retroperitoneal) recurrence.
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Affiliation(s)
- Benny Johnson
- Department of Medical Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - Zhaohui Jin
- Department of Medical Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | | | - James A Martenson
- Department of Radiation Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - Rory L Smoot
- Department of Surgical Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - David W Larson
- Department of Surgical Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - Eric J Dozois
- Department of Surgical Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - David M Nagorney
- Department of Surgical Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - Axel Grothey
- Department of Medical Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
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Abstract
Hepatocellular carcinoma (HCC) is a major cause of cancer-related death worldwide. In select patients, surgical treatment in the form of either resection or transplantation offers a curative option. The aims of this review are to (1) review the current American Association for the Study of Liver Diseases/European Association for the Study of the Liver guidelines on the surgical management of HCC and (2) review the proposed changes to these guidelines and analyze the strength of evidence underlying these proposals. Three authors identified the most relevant publications in the literature on liver resection and transplantation for HCC and analyzed the strength of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification. In the United States, the liver allocation system provides priority for liver transplantation to patients with HCC within the Milan criteria. Current evidence suggests that liver transplantation may also be indicated in certain patient groups beyond Milan criteria, such as pediatric patients with large tumor burden or adult patients who are successfully downstaged. Patients with no underlying liver disease may also benefit from liver transplantation if the HCC is unresectable. In patients with no or minimal (compensated) liver disease and solitary HCC ≥2 cm, liver resection is warranted. If liver transplantation is not available or contraindicated, liver resection can be offered to patients with multinodular HCC, provided that the underlying liver disease is not decompensated. Many patients may benefit from surgical strategies adapted to local resources and policies (hepatitis B prevalence, organ availability, etc). Although current low-quality evidence shows better overall survival with aggressive surgical strategies, this approach is limited to select patients. Larger and well-designed prospective studies are needed to better define the benefits and limits of such approach.
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Affiliation(s)
- Daniel Zamora-Valdes
- 1 Divisions of Transplantation Surgery, William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, USA
| | - Timucin Taner
- 1 Divisions of Transplantation Surgery, William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, USA
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Tee MC, Krajewski AC, Groeschl RT, Farnell MB, Nagorney DM, Kendrick ML, Cleary SP, Smoot RL, Croome KP, Truty MJ. Indications and Perioperative Outcomes for Pancreatectomy with Arterial Resection. J Am Coll Surg 2018; 227:255-269. [PMID: 29752997 DOI: 10.1016/j.jamcollsurg.2018.05.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/04/2018] [Accepted: 05/03/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pancreatectomy with arterial resection (AR) is performed infrequently. As indications evolve, we evaluated indications, outcomes, and predictors of mortality, morbidity, and survival after AR. STUDY DESIGN We performed a single-institution review of elective pancreatectomies with AR (from July1990 to July 2017). Univariate and multivariate analyses were performed for predictors of outcomes and survival. RESULTS A total of 111 patients underwent pancreatectomy with AR including any hepatic (54%), any celiac (44%), any superior mesenteric (14%), or multiple ARs (14%), with revascularization in 55%. The majority of cases were planned (77%) and performed post-2010 (78%). Overall 90-day major morbidity (≥grade III) and mortality were 54% and 13%, respectively, due to post-pancreatectomy hemorrhage (PPH), postoperative pancreatic fistula (POPF), or ischemia in the majority of cases. There was a significant decrease in mortality post-2010 (9% vs 29%, p = 0.02), and this was protective on multivariate analysis (odds ratio [OR] 0.1, p = 0.004); PPH increased mortality (OR 6.1, p < 0.001). Post-pancreatectomy hemorrhage was associated with major morbidity (OR 5.1, p = 0.005), reoperation (OR = 23.0, p = 0.004), ICU (OR 5.5, p < 0.001), and readmission (OR 2.6, p = 0.004). Other morbidity predictors were AR with graft (OR 4.0, p = 0.031) and POPF (OR 3.1, p = 0.003). Median survival was 28.5 months and improved for ductal adenocarcinoma after neoadjuvant chemotherapy (p = 0.038). There were no differences in survival based on AR type. CONCLUSIONS Regardless of indication or type, pancreatectomy with AR is associated with risks greater than standard resections. Mortality has decreased in the modern era; however, morbidity remains high from hemorrhagic, fistula, or ischemia-related complications. Mitigation measures are needed if advanced resections are considered with increasing frequency given the potential oncologic benefit of AR in selected cases after modern chemotherapy.
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Affiliation(s)
- May C Tee
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | - Rory L Smoot
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, MN.
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Jin Z, Sanhueza CT, Johnson B, Nagorney DM, Larson DW, Mara KC, Harmsen WC, Smyrk TC, Grothey A, Hubbard JM. Outcome of Mismatch Repair-Deficient Metastatic Colorectal Cancer: The Mayo Clinic Experience. Oncologist 2018; 23:1083-1091. [PMID: 29674439 DOI: 10.1634/theoncologist.2017-0289] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 02/12/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Deficiencies in the DNA mismatch repair system cause errors during DNA replication, which in turn give rise to microsatellite instability (MSI). The impact of MSI on survival in metastatic colorectal cancer (mCRC) is unclear. This cohort study aims to investigate the prognostic and predictive value of MSI in mCRC prior to the immune therapy era. MATERIALS AND METHODS A total of 75 MSI-high (MSI-H) mCRC patients (pts) and 75 matched (age, gender, disease sidedness, metachronous/synchronous) microsatellite-stable (MSS) mCRC pts were identified from 1,268 mCRC pts who had MSI/mismatch repair test results at Mayo Clinic Rochester between January 1992 and July 2016. A retrospective review was conducted by using data from electronic medical records. Statistical analyses utilized the Kaplan-Meier method, log-rank test, and Cox proportional hazards models. RESULTS The MSS group was well matched to the MSI-H group based on age, gender, location, and chronicity of metastatic disease. MSI-H mCRC pts had earlier disease recurrence (median time from initial diagnosis to metastatic disease diagnosis, MSI-H group 12.9 vs. MSS group 20.9 months, p = .034). Median overall survival (OS) was 28.1 and 37.4 months for MSI-H and MSS pts, respectively (p = .99). In total, 94.7% of MSI-H pts and 98.7% of MSS pts had fluoropyrimidine-based chemotherapy for metastatic disease, and there was no difference in OS between these two groups (32.3 vs. 37.4 months, p = .91). Forty-three MSI-H and thirty-nine MSS pts had metastasectomy and/or ablation of metastases (p = .51) with longer median OS compared with pts without metastasectomy (MSI-H: 82.0 vs. 13.9, p < .001; MSS: 69.9 vs. 19.7, p < .001). Age <65 years, BRAF wild type, and metastasectomy were associated with better OS in univariate analysis. Only metastasectomy remained statistically significant in multivariate analysis (p < .001). CONCLUSION In mCRC, patients with MSI-H tumors have similar, but numerically shorter, median overall survival compared with those with MSS tumors. In both groups, metastasectomy and ablation of metastatic disease should be considered to optimize OS. IMPLICATIONS FOR PRACTICE This study clearly demonstrated the survival benefits that aggressive metastasectomy provides in selected microsatellite instability-high metastatic colorectal cancer patients. This could be meaningful practice-changing information that has been long awaited.
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Affiliation(s)
- Zhaohui Jin
- Department of Medical Oncology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
| | - Cristobal T Sanhueza
- Department of Medical Oncology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
| | - Benny Johnson
- Department of Medical Oncology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
| | - David M Nagorney
- Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
| | - David W Larson
- Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
| | - Kristin C Mara
- Department of Statistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
| | - William C Harmsen
- Department of Statistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
| | - Thomas C Smyrk
- Department of Pathology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
| | - Axel Grothey
- Department of Medical Oncology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
| | - Joleen M Hubbard
- Department of Medical Oncology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
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Johnson B, Jin Z, Truty MJ, Smoot RL, Nagorney DM, Kendrick ML, Kipp BR, Grothey A. Impact of Metastasectomy in the Multimodality Approach for BRAF V600E Metastatic Colorectal Cancer: The Mayo Clinic Experience. Oncologist 2018; 23:128-134. [PMID: 28904173 PMCID: PMC5759813 DOI: 10.1634/theoncologist.2017-0230] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/03/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND BRAF V600E mutations are present in 8%-10% of patients with metastatic colorectal cancer (mCRC) and portend poor prognosis. This study investigated the impact of metastasectomy for patients with BRAF V600E mCRC. SUBJECTS, MATERIALS, AND METHODS Using prospective clinical and molecular data, patients with BRAF V600E mCRC were analyzed for clinical characteristics and survival. Statistical analyses utilized the Kaplan-Meier method, log-rank test, and Cox proportional hazard models. RESULTS Fifty-two patients were identified between July 1, 2008, and January 4, 2016. Patient characteristics included median age 65 years, 61% female, Eastern Cooperative Oncology Group performance status ≤1, 71% with right-sided tumors, and 28% with liver-limited metastasis. In the first-line setting, 7% (4/52) received fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFOXIRI)/bevacizumab (BEV) and 81% were treated with doublet chemotherapy consisting of fluoropyrimidine, oxaliplatin, and BEV. Median overall survival (OS) for all 52 patients was 25 months with median progression-free survival (PFS) of 9.3 months. With median follow-up of 18.3 months, 21 patients underwent metastasectomy with longer OS (29.1 months vs. 22.7 months, hazard ratio [HR] = 0.33; confidence interval [CI], 0.12-0.78; p = .01) and PFS (13.6 months vs. 6.2 months, HR = 0.53, CI, 0.28-0.97; p = .03) compared with the non-metastasectomy cohort. In multivariate analysis, metastasectomy remained significant for improved survival outcomes (HR = 0.52; 95% CI, 0.07-1.02; p = .02). Median disease-free survival after metastasectomy was 9.7 months (95% CI, 5.5-19.5). Two patients remain disease-free at the time of last follow-up, with one patient without relapse for greater than 2 years (28.9 months). CONCLUSION Multimodality therapy incorporating metastasectomy for BRAF V600E mCRC should be considered and might be associated with improved overall survival in select patients. IMPLICATIONS FOR PRACTICE BRAF V600E metastatic colorectal cancer (mCRC) represents an extremely difficult molecular subset of colorectal cancer to treat. To date, this subset remains refractory to standard chemotherapies, prompting extensive clinical investigation regarding novel treatment approaches and targeted modalities. While the use of metastasectomy for expanded RAS wild-type and RAS mutated mCRC has resulted in improved overall survival for select patients, utilization of metastasectomy in patients with BRAF V600E mCRC remains controversial. This article explores the authors' experience with BRAF V600E mCRC to ascertain whether a multidisciplinary approach incorporating metastasectomy for well-selected patients improves overall survival.
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Affiliation(s)
- Benny Johnson
- Department of Medical Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - Zhaohui Jin
- Department of Medical Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - Mark J Truty
- Department of Surgical Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - Rory L Smoot
- Department of Surgical Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - David M Nagorney
- Department of Surgical Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - Michael L Kendrick
- Department of Surgical Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - Benjamin R Kipp
- Department of Anatomic Pathology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - Axel Grothey
- Department of Medical Oncology, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
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Tefferi A, Mudireddy M, Gangat N, Hanson CA, Ketterling RP, Pardanani A, Nagorney DM. Risk factors and a prognostic model for postsplenectomy survival in myelofibrosis. Am J Hematol 2017; 92:1187-1192. [PMID: 28782256 DOI: 10.1002/ajh.24881] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 08/02/2017] [Indexed: 01/04/2023]
Abstract
Palliative treatment in myelofibrosis (MF) includes transfusion support, JAK2 inhibitors, involved field radiotherapy and splenectomy. To assist in selecting patients who are likely to benefit from splenectomy, we looked into risk factors for postsplenectomy survival, in 120 consecutive cases (median age 66 years); at the time of splenectomy, 61% displayed red cell transfusion need, 49% platelet count <100 × 10(9)/L, 25% leukocyte count >25 × 10(9)/L, 60% constitutional symptoms and 13% circulating blasts ≥5%; dynamic international prognostic scoring system risk categories were 21% high, 55% intermediate-2, 21% intermediate-1 and 3% low. Among informative cases, karyotype was abnormal in 60% and driver mutational status was JAK2 75%, CALR 15%, MPL 4% and triple-negative 6%. At median follow-up of 1.3 years, from time of splenectomy, 95 (79%) deaths and 30 (25%) leukemic transformations were recorded. Median postsplenectomy survival was 1.5 years; in multivariable analysis, survival was adversely affected by age >65 years, transfusion need, leukocyte count >25 × 10(9)/L and circulating blasts ≥5%; these variables were subsequently used to devise an HR-weighted scoring system with high (3-4 risk factors), intermediate (2 risk factors) and low (0-1 risk factors) risk categories; the corresponding postsplenectomy median survivals were 0.3 (HR 5.9, 95% CI 3.2-11.0), 1.3 (HR 2.9, 95% CI 1.8-4.6) and 2.9 years. Postsplenectomy survival was not affected by driver mutational status or occurrence of leukemic transformation. Leukemia-free survival was predicted by very high risk karyotype. The observations from the current study might help identify appropriate candidates for splenectomy in MF.
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Zaydfudim VM, Chapman WC, Nagorney DM. Challenges in patient selection for liver resection or transplantation in patients with hepatocellular carcinoma beyond Milan criteria. Hepatobiliary Surg Nutr 2017; 6:287-289. [PMID: 28848757 DOI: 10.21037/hbsn.2017.07.04] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Victor M Zaydfudim
- Division of Surgical Oncology, Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, USA
| | - William C Chapman
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO, USA
| | - David M Nagorney
- Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA
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Jin Z, Sanhueza CT, Johnson B, Smyrk TC, Larson DW, Nagorney DM, Hubbard JM, Grothey A. Outcome of mismatch repair deficient metastatic colorectal cancer (CRC): The Mayo Clinic Experience. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e15030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e15030 Background: Deficiencies in the DNA mismatch repair (dMMR) system cause errors during DNA replication, which in turn give rise to microsatellite instability (MSI-H). MSI-H in mCRC is rare and its prognostic and predictive impact on outcome is unclear. This cohort study aims to investigate the prognostic and predictive value of MSI-H in metastatic CRC prior to the immune therapy era. Methods: 75 MSI-H mCRC patients (pts) and 75 matched (age, gender, disease sidedness, metachronous) MSS mCRC pts were identified from 1268 mCRC who had MSI/MMR test results at Mayo Clinic Rochester between 1/1992 and 7/2016. A retrospective review was conducted by using data from electronic medical records (EMR). Statistical analyses utilized Kaplan-Meier method, Log-rank test, and Cox proportional hazards models. Results: In the MSI-H group, there were 39 male (52%) and 36 female (48%) pts. Median age at metastatic disease diagnosis was 54.7 years. 35 patients presented with stage IV CRC. Primary tumors location: 38 right side, 11 transverse colon, 15 left side, 11 rectum. The MSS group was well matched (3 mismatches for gender and 1 mismatch for metachronous metastatic disease). Median overall survivals (OS) were 28.1 and 37.4 months for MSI-H and MSS pts, respectively ( p= 0.098). 98.7% MSS pts and 94.7% MSI-H pts had Fluoropyrimidine-based chemotherapy for metastatic disease and there was no median OS difference between these two groups (37.4 vs. 32.3 months p= 0.91). 43 MSI-H and 39 MSS pts had metastasectomy including ablation ( p= 0.51) with longer median OS (82.0 and 69.9 months, p= 0.90) compared to pts without metastasectomy (13.9 and 19.7 months, p= 0.15). Age < 65, metastasectomy, asymptomatic metastatic lesions, BRAF wild type, and multiple metastasectomy were associated with better survival in univariate analysis. Only metastasectomy remained statistically significant in multivariate analysis ( p< 0.0001). Conclusions: MSI-H mCRC do not appear to have improved prognosis compared with MSS cancers, in fact, there is a trend toward inferior outcome. In both groups, metastasectomy including multiple metastasectomy should be considered to optimize OS.
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Johnson B, Jin Z, Haddock MG, Hallemeier CL, Martenson JA, Smoot RL, Larson DW, Dozois EJ, Nagorney DM, Grothey A. A curative intent trimodality approach for advanced isolated abdominal nodal metastasis in metastatic colorectal cancer: Update of a single-institutional experience. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.3556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
3556 Background: To define and update survival rates and relapse patterns in patients (pts) with isolated advanced abdominal nodal metastasis secondary to colorectal cancer (CRC), treated with curative intent using aggressive trimodality therapy. Methods: Fifty-seven pts with isolated advanced abdominal lymph node metastasis (retroperitoneal and mesenteric) secondary to colorectal cancer received trimodality therapy defined as chemotherapy delivered in conjunction with external beam radiotherapy (EBRT) followed by lymphadenectomy and intraoperative radiotherapy (IORT). Infusional 5-FU was the most common radiosensitizer used (66%, 38 pts). The median dose of EBRT was 50 Gy & the median dose of intraoperative radiotherapy was 12.5 Gy. End points included distant metastasis, toxicities, local failure within EBRT field, recurrence within the intraoperative radiotherapy field, and survival. Results: 49% of pts were male, median age 50.5 yrs. All patients had ECOG ≤ 1. 27 pts had primary right sided colon cancer, 16 left sided colon cancer and 14 rectal primaries. Median time from initial CRC diagnosis to development of abdominal lymph node metastatic disease was 24 months (95% CI, 23.5-45.1 months). 84% (48 pts) had paraaortic nodal metastases, 12% (7 pts) had mesenteric nodal metastases, and 3% (2 pts) had both. With a median follow up of 89.4 months, the median overall survival and 5-year estimated survival rate were 53.2 months (95% CI, 46.4-78.8 months) and 42%, respectively. Median progression free survival was 19.3 months (95% CI, 15.6-32.8 months). 21 (37%) pts never developed distant disease. Outcome was not affected by disease sidedness, rectal primary, or mutational profile. Treatment was well tolerated without any grade 3/4 toxicities. Conclusions: The use of trimodality therapy including EBRT with radiosensitizing chemotherapy, lymphadenectomy and IORT produces sustainable long-term survival in selected metastatic CRC pts presenting with isolated retroperitoneal/mesenteric nodal relapse.
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