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Hernandez MC, Fan D, Sandhu J, Mahuron K, Kessler J, Raoof M, Fakih M, Singh G, Fong Y, Melstrom LG. Recurrence patterns after complex multimodality therapy and hepatic arterial infusion for colorectal liver metastases: A reflection of biology and technique. J Surg Oncol 2024. [PMID: 38505908 DOI: 10.1002/jso.27622] [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: 01/08/2024] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND AND METHODS We characterized colorectal liver metastasis recurrence and survival patterns after surgical resection and intraoperative ablation ± hepatic arterial infusion pump (HAIP) placement. We estimated patterns of recurrence and survival in patients undergoing contemporary multimodal treatments. Between 2017 and 2021, patient, tumor characteristics, and recurrence data were collected. Primary outcomes included recurrence patterns and survival data based on operative intervention. RESULTS There were 184 patients who underwent hepatectomy and intraoperative ablation. Sixty patients (32.6%) underwent HAIP placement. A total of 513 metastases were ablated, median total of 2 ablations per patient. Median time to recurrence was 31 [22-40] months. Recurrence patterns included tumor at ablative margin on first scheduled postoperative imaging (8, 4.3%), local tumor recurrence at ablative site (69, 37.5%), and non-ablated liver tumor recurrence (38, 20.6%). In patients who underwent HAIP placement, the rate of liver recurrence was reduced (45% vs 70.9%, p = 0.0001). Median overall survival was 64 [41-58] months and prolonged survival was associated with HAIP treatment (85 [66-109] vs 60 [51-70] months. CONCLUSIONS AND DISCUSSION Hepatic recurrence is common and combination of intraoperative ablation and HAIP treatments were associated with prolonged survival. These data may reflect patient selection however, future work will clarify preoperative tumor and patient characteristics that may better predict recurrence expectations.
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Affiliation(s)
- Matthew C Hernandez
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Darrell Fan
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Jaideep Sandhu
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Kelly Mahuron
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Jonathan Kessler
- Department of Radiology, City of Hope National Medical Center, Duarte, California, USA
| | - Mustafa Raoof
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Marwan Fakih
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Gagandeep Singh
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Yuman Fong
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Laleh G Melstrom
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, California, USA
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Melstrom LG, Mahuron K, Sun V. What to Expect…When You Are Having Surgery. JAMA Surg 2024:2816277. [PMID: 38477896 DOI: 10.1001/jamasurg.2024.0142] [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: 03/14/2024]
Affiliation(s)
- Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Kelly Mahuron
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Virginia Sun
- Department of Surgery, City of Hope National Medical Center, Duarte, California
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Dominguez DA, Melstrom LG. ASO Author Reflections: Adjuvant Chemoradiation in Resected Biliary Cancers-Insights and Implications. Ann Surg Oncol 2024:10.1245/s10434-024-15172-5. [PMID: 38472671 DOI: 10.1245/s10434-024-15172-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 02/25/2024] [Indexed: 03/14/2024]
Affiliation(s)
- Dana A Dominguez
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA.
| | - Laleh G Melstrom
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA
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Dominguez DA, Wong P, Chen YJ, Singh GP, Fong Y, Li D, Ituarte PHG, Melstrom LG. Adjuvant Chemoradiation in Resected Biliary Adenocarcinoma: Evaluation of SWOG S0809 with a Large National Database. Ann Surg Oncol 2024:10.1245/s10434-024-15117-y. [PMID: 38443700 DOI: 10.1245/s10434-024-15117-y] [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: 12/22/2023] [Accepted: 02/14/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND There is a paucity of evidence supporting the use of adjuvant radiation therapy in resected biliary cancer. Supporting evidence for use comes mainly from the small SWOG S0809 trial, which demonstrated an overall median survival of 35 months. We aimed to use a large national database to evaluate the use of adjuvant chemoradiation in resected extrahepatic bile duct and gallbladder cancer. METHODS Using the National Cancer Database, we selected patients from 2004 to 2017 with pT2-4, pN0-1, M0 extrahepatic bile duct or gallbladder adenocarcinoma with either R0 or R1 resection margins, and examined factors associated with overall survival (OS). We examined OS in a cohort of patients mimicking the SWOG S0809 protocol as a large validation cohort. Lastly, we compared patients who received chemotherapy only with patients who received adjuvant chemotherapy and radiation using entropy balancing propensity score matching. RESULTS Overall, 4997 patients with gallbladder or extrahepatic bile duct adenocarcinoma with available survival information meeting the SWOG S0809 criteria were selected, 469 of whom received both adjuvant chemotherapy and radiotherapy. Median OS in patients undergoing chemoradiation was 36.9 months, and was not different between primary sites (p = 0.841). In a propensity score matched cohort, receipt of adjuvant chemoradiation had a survival benefit compared with adjuvant chemotherapy only (hazard ratio 0.86, 95% confidence interval 0.77-0.95; p = 0.004). CONCLUSION Using a large national database, we support the findings of SWOG S0809 with a similar median OS in patients receiving chemoradiation. These data further support the consideration of adjuvant multimodal therapy in resected biliary cancers.
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Affiliation(s)
- Dana A Dominguez
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Paul Wong
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Yi-Jen Chen
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Gagandeep P Singh
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Yuman Fong
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Daneng Li
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Philip H G Ituarte
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Laleh G Melstrom
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA.
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Dominguez DA, Wong P, Melstrom LG. Existing and emerging biomarkers in hepatocellular carcinoma: relevance in staging, determination of minimal residual disease, and monitoring treatment response: a narrative review. Hepatobiliary Surg Nutr 2024; 13:39-55. [PMID: 38322200 PMCID: PMC10839735 DOI: 10.21037/hbsn-22-526] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 03/15/2023] [Indexed: 02/08/2024]
Abstract
Background and Objective With the development of novel active systemic therapies, the landscape of hepatocellular carcinoma (HCC) management is rapidly changing. However, HCC lacks sensitive and specific biomarkers to predict prognosis, monitor for minimal residual disease after locoregional therapy, and predict treatment response. In this review, we aim to summarize the best supporting evidence for refining existing, and development of novel biomarkers for staging, prognosis, determination of minimal residual disease and monitoring treatment response in HCC, focusing on those with evidence in clinical trials. Methods PubMed and Embase databases were searched using the keywords; hepatocellular carcinoma, biomarker, minimal residual disease, surveillance, prognosis, staging, alpha-fetoprotein (AFP), liquid biopsy, treatment response, adjuvant, immunotherapy. Relevant clinical studies were included. Key Content and Findings AFP remains the major workhorse as the most widely used biomarker in HCC, however, its lack of wide applicability due to the high proportion of patients with HCC who are AFP negative, limits its value throughout all stages of HCC management. Significant work has been done to combine AFP with other clinical and serologic factors to increase its accuracy and utility as a biomarkers. However, it is likely that other more novel biomarkers such as those obtained through liquid biopsy will provide the prognostic power necessary for applications such as detecting recurrence and predicting treatment response. Liquid biopsy provides not only a wealth of potential biomarkers including circulating tumor cells and cell-free RNA/DNA, but also the ability to examine the mutational characteristics of the tumor with next generation sequencing. While early evidence supports the potential impact of many new biomarkers, validation in large clinical trials is lacking. Conclusions This review highlights the paucity of sensitive and specific, widely applicable biomarkers, throughout all phases of management of HCC and summarizes evidence on biomarkers currently in use, as well as those in development and validation. Inclusion of biomarker analysis through clinical trials in HCC is critical to development of optimal therapeutic regimens, and improve patient outcomes.
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Affiliation(s)
- Dana A. Dominguez
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Paul Wong
- University of California, San Francisco, San Francisco, CA, USA
| | - Laleh G. Melstrom
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA
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Limbach K, Esslin P, Sun V, Fan D, Kaiser AM, Paz IB, Raoof M, Lewis A, Melstrom KA, Lai L, Woo Y, Singh G, Fong Y, Melstrom LG. Randomized Controlled Trial of Perioperative Telemonitoring of Patient Generated Health Data in Gastrointestinal Oncologic Surgery: Assessing Overall Feasibility and Acceptability. World J Surg 2023; 47:3131-3137. [PMID: 37728775 PMCID: PMC10694107 DOI: 10.1007/s00268-023-07179-y] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2023] [Indexed: 09/21/2023]
Affiliation(s)
- Kristen Limbach
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Rd, Duarte, CA, 91010, USA
| | - Patricia Esslin
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Rd, Duarte, CA, 91010, USA
| | - Virginia Sun
- Department of Nursing Research, City of Hope National Medical Center, Duarte, CA, USA
| | - Darrell Fan
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Rd, Duarte, CA, 91010, USA
| | - Andreas M Kaiser
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Rd, Duarte, CA, 91010, USA
| | - I Benjamin Paz
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Rd, Duarte, CA, 91010, USA
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Rd, Duarte, CA, 91010, USA
| | - Aaron Lewis
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Rd, Duarte, CA, 91010, USA
| | - Kurt A Melstrom
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Rd, Duarte, CA, 91010, USA
| | - Lily Lai
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Rd, Duarte, CA, 91010, USA
| | - Yanghee Woo
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Rd, Duarte, CA, 91010, USA
| | - Gagandeep Singh
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Rd, Duarte, CA, 91010, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Rd, Duarte, CA, 91010, USA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Rd, Duarte, CA, 91010, USA.
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Labadie KP, Melstrom LG, Lewis AG. Safe implementation of a minimally invasive hepatopancreatobiliary program, a narrative review and institutional experience. J Surg Oncol 2023; 128:1347-1352. [PMID: 37781938 DOI: 10.1002/jso.27455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/17/2023] [Indexed: 10/03/2023]
Abstract
Laparoscopic and robotic-assisted approaches to hepatopancreatobiliary (HPB) operations have expanded worldwide. As surgeons and medical centers contemplate initiating and expanding minimally invasive surgical (MIS) programs for complex HPB surgical operations, there are many factors to consider. This review highlights the key components of developing an MIS HPB program and shares our recent institutional experience with the adoption and expansion of an MIS approach to pancreaticoduodenectomy.
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Affiliation(s)
- Kevin P Labadie
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
| | - Aaron G Lewis
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
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8
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Ausania F, Landi F, González-Abós C, Martinie JB, Vrochides D, Walsh M, Hossain SM, White S, Prabakaran V, Melstrom LG, Fong Y, Valle V, Bing Y, Xiu D, Di Franco G, De' Angelis N, Laurent A, Giuliani G, Pernazza G, Memeo R, Rios J, Coratti A, Morelli L, Giulianotti PC. Robotic versus laparoscopic distal pancreatectomy for pancreatic adenocarcinoma in obese patients. Int J Med Robot 2023:e2596. [PMID: 37937476 DOI: 10.1002/rcs.2596] [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: 08/24/2023] [Revised: 10/08/2023] [Accepted: 10/26/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Robotic distal pancreatectomy (RDP) is associated with a lower conversion rate and less blood loss than laparoscopic distal pancreatectomy (LDP). LDP has similar oncological outcomes as open surgery in PDAC. The aim of this study was to compare perioperative and oncological outcomes in obese patients with RDP versus LDP for PDAC. MATERIALS AND METHODS Retrospectively, all obese patients who underwent RDP or LDP for PDAC between 2012 and 2022 at 12 international expert centres were included. RESULTS out of 372, 81 patients were included. All baseline features were comparable between the two groups. RDP was associated with decreased blood loss (495mlLDP vs. 188mlRDP; p = 0.003), lower conversion rate (13.5%RDP vs. 36.4%LDP; p = 0.019) and lower rate of Clavien-Dindo ≥3 complications (13.5%RDP vs. 36.4%LDP; p = 0.019). Overall and disease-free survival were comparable. CONCLUSIONS In obese patients with left-sided PDAC, the robotic approach was associated with improved intraoperative outcomes and fewer severe complications.
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Affiliation(s)
- Fabio Ausania
- Department of HBP Surgery and Transplantation, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
| | - Filippo Landi
- Department of HBP Surgery and Transplantation, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
| | - Carolina González-Abós
- Department of HBP Surgery and Transplantation, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
| | - John B Martinie
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Matthew Walsh
- HPB Surgery Department, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shanaz M Hossain
- HPB Surgery Department, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Laleh G Melstrom
- Division of Surgical Oncology, Gastrointestinal Disease Team, City of Hope Medical Center, Duarte, California, USA
| | - Yuman Fong
- Division of Surgical Oncology, Gastrointestinal Disease Team, City of Hope Medical Center, Duarte, California, USA
| | - Valentina Valle
- Department of Surgery, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Yuntao Bing
- Department of General Surgery, Beijing Third Hospital, Beijing, China
| | - Dianrong Xiu
- Department of General Surgery, Beijing Third Hospital, Beijing, China
| | - Gregorio Di Franco
- Division of Translational and New Technologies in Medicine and Surgery, General Surgery Department, University of Pisa, Pisa, Italy
| | - Nicola De' Angelis
- Department of Digestive, HBP Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, Creteil, France
| | - Alexis Laurent
- Department of Digestive, HBP Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, Creteil, France
| | - Giuseppe Giuliani
- Division of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Graziano Pernazza
- General and Robotic Surgery Department, San Giovanni Hospital, Rome, Italy
| | - Riccardo Memeo
- Department of Surgery, Acquaviva delle Fonti Hospital, Bari, Italy
| | - José Rios
- Department of Clinical Pharmacology, Hospital Clinic and Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Andrea Coratti
- Division of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Luca Morelli
- Division of Translational and New Technologies in Medicine and Surgery, General Surgery Department, University of Pisa, Pisa, Italy
| | - Pier C Giulianotti
- Department of Surgery, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Ausania F, Landi F, Martinie JB, Vrochides D, Walsh M, Hossain SM, White S, Prabakaran V, Melstrom LG, Fong Y, Butturini G, Bignotto L, Valle V, Bing Y, Xiu D, Di Franco G, Sanchez-Bueno F, de'Angelis N, Laurent A, Giuliani G, Pernazza G, Esposito A, Salvia R, Bazzocchi F, Esposito L, Pietrabissa A, Pugliese L, Memeo R, Uyama I, Uchida Y, Rios J, Coratti A, Morelli L, Giulianotti PC. Robotic versus laparoscopic distal pancreatectomy in obese patients. Surg Endosc 2023; 37:8384-8393. [PMID: 37715084 PMCID: PMC10615948 DOI: 10.1007/s00464-023-10361-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/30/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Although robotic distal pancreatectomy (RDP) has a lower conversion rate to open surgery and causes less blood loss than laparoscopic distal pancreatectomy (LDP), clear evidence on the impact of the surgical approach on morbidity is lacking. Prior studies have shown a higher rate of complications among obese patients undergoing pancreatectomy. The primary aim of this study is to compare short-term outcomes of RDP vs. LDP in patients with a BMI ≥ 30. METHODS In this multicenter study, all obese patients who underwent RDP or LDP for any indication between 2012 and 2022 at 18 international expert centers were included. The baseline characteristics underwent inverse probability treatment weighting to minimize allocation bias. RESULTS Of 446 patients, 219 (50.2%) patients underwent RDP. The median age was 60 years, the median BMI was 33 (31-36), and the preoperative diagnosis was ductal adenocarcinoma in 21% of cases. The conversion rate was 19.9%, the overall complication rate was 57.8%, and the 90-day mortality rate was 0.7% (3 patients). RDP was associated with a lower complication rate (OR 0.68, 95% CI 0.52-0.89; p = 0.005), less blood loss (150 vs. 200 ml; p < 0.001), fewer blood transfusion requirements (OR 0.28, 95% CI 0.15-0.50; p < 0.001) and a lower Comprehensive Complications Index (8.7 vs. 8.9, p < 0.001) than LPD. RPD had a lower conversion rate (OR 0.27, 95% CI 0.19-0.39; p < 0.001) and achieved better spleen preservation rate (OR 1.96, 95% CI 1.13-3.39; p = 0.016) than LPD. CONCLUSIONS In obese patients, RDP is associated with a lower conversion rate, fewer complications and better short-term outcomes than LPD.
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Affiliation(s)
- Fabio Ausania
- Department of HBP Surgery and Transplantation, General and Digestive Surgery, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), C. Villarroel, 170, 08036, Barcelona, Spain
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain
| | - Filippo Landi
- Department of HBP Surgery and Transplantation, General and Digestive Surgery, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), C. Villarroel, 170, 08036, Barcelona, Spain.
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain.
| | - John B Martinie
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Matthew Walsh
- HPB Surgery Department, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Shanaz M Hossain
- HPB Surgery Department, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Laleh G Melstrom
- Division of Surgical Oncology, Gastrointestinal Disease Team, City of Hope Medical Center, Duarte, CA, USA
| | - Yuman Fong
- Division of Surgical Oncology, Gastrointestinal Disease Team, City of Hope Medical Center, Duarte, CA, USA
| | - Giovanni Butturini
- Department of HBP Surgery, P. Pederzoli Hospital, Peschiera del Garda, Italy
| | - Laura Bignotto
- Department of HBP Surgery, P. Pederzoli Hospital, Peschiera del Garda, Italy
| | - Valentina Valle
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Yuntao Bing
- Department of General Surgery, Beijing Third Hospital, Beijing, China
| | - Dianrong Xiu
- Department of General Surgery, Beijing Third Hospital, Beijing, China
| | - Gregorio Di Franco
- Division of Translational and New Technologies in Medicine and Surgery, General Surgery Department, University of Pisa, Pisa, Italy
| | | | - Nicola de'Angelis
- Department of Digestive, HBP Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, Creteil, France
| | - Alexis Laurent
- Department of Digestive, HBP Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, Creteil, France
| | - Giuseppe Giuliani
- Division of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Graziano Pernazza
- General and Robotic Surgery Department, San Giovanni Hospital, Rome, Italy
| | | | - Roberto Salvia
- HBP Surgery Department, Policlinico G.B. Rossi Hospital, Verona, Italy
| | - Francesca Bazzocchi
- Department of HBP Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy
| | - Ludovica Esposito
- Department of HBP Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy
| | | | - Luigi Pugliese
- Department of HBP Surgery, Policlinico S. Matteo Hospital, Pavia, Italy
| | - Riccardo Memeo
- Department of Surgery, Acquaviva delle Fonti Hospital, Bari, Italy
| | - Ichiro Uyama
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yuichiro Uchida
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - José Rios
- Department of Clinical Pharmacology, Hospital Clinic and Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Andrea Coratti
- Division of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Luca Morelli
- Division of Translational and New Technologies in Medicine and Surgery, General Surgery Department, University of Pisa, Pisa, Italy
| | - Pier C Giulianotti
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
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Melstrom LG, Kaiser A, Lau C, Chan K, Raoof M, Singh G, Fong Y, Sun V. Characteristics of Proactive Triage Nursing Telephone Encounters in a Pilot of Perioperative Telemonitoring in Surgical Oncology. Am Surg 2023; 89:5027-5029. [PMID: 37503832 DOI: 10.1177/00031348231191217] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Affiliation(s)
- Laleh G Melstrom
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Andreas Kaiser
- Division of Colorectal Surgery, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Clayton Lau
- Division of Urologic Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Kevin Chan
- Division of Urologic Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Mustafa Raoof
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Gagandeep Singh
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Yuman Fong
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Virginia Sun
- Division of Colorectal Surgery, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
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Phan T, Zhang XH, Rosen S, Melstrom LG. P38 kinase in gastrointestinal cancers. Cancer Gene Ther 2023; 30:1181-1189. [PMID: 37248432 PMCID: PMC10501902 DOI: 10.1038/s41417-023-00622-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 04/09/2023] [Accepted: 05/04/2023] [Indexed: 05/31/2023]
Abstract
Gastrointestinal cancers are a leading cause of cancer morbidity and mortality worldwide with 4.2 million new cases and 3.2 million deaths estimated in 2020. Despite the advances in primary and adjuvant therapies, patients still develop distant metastases and require novel therapies. Mitogen‑activated protein kinase (MAPK) cascades are crucial signaling pathways that regulate many cellular processes, including proliferation, differentiation, apoptosis, stress responses and cancer development. p38 Mitogen Activated Protein Kinases (p38 MAPKs) includes four isoforms: p38α (MAPK14), p38β (MAPK11), p38γ (MAPK12), and p38δ (MAPK13). p38 MAPK was first identified as a stress response protein kinase that phosphorylates different transcriptional factors. Dysregulation of p38 pathways, in particular p38γ, are associated with cancer development, metastasis, autophagy and tumor microenvironment. In this article, we provide an overview of p38 and p38γ with respect to gastrointestinal cancers. Furthermore, targeting p38γ is also discussed as a potential therapy for gastrointestinal cancers.
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Affiliation(s)
- Thuy Phan
- Department of Surgery, City of Hope Medical Center, Duarte, CA, USA
| | - Xu Hannah Zhang
- Department of Hematology, City of Hope Medical Center, Duarte, CA, USA
| | - Steven Rosen
- Department of Hematology, City of Hope Medical Center, Duarte, CA, USA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope Medical Center, Duarte, CA, USA.
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12
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Dominguez DA, Sampath S, Agulnik M, Liang Y, Nguyen B, Trisal V, Melstrom LG, Lewis AG, Paz IB, Roberts RF, Tseng WW. Surgical Management of Retroperitoneal Sarcoma. Curr Oncol 2023; 30:4618-4631. [PMID: 37232807 DOI: 10.3390/curroncol30050349] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/26/2023] [Accepted: 04/26/2023] [Indexed: 05/27/2023] Open
Abstract
Surgery is the cornerstone of treatment for retroperitoneal sarcoma (RPS). Surgery should be performed by a surgical oncologist with sub-specialization in this disease and in the context of a multidisciplinary team of sarcoma specialists. For primary RPS, the goal of surgery is to achieve the complete en bloc resection of the tumor along with involved organs and structures to maximize the clearance of the disease. The extent of resection also needs to consider the risk of complications. Unfortunately, the overarching challenge in primary RPS treatment is that even with optimal surgery, tumor recurrence occurs frequently. The pattern of recurrence after surgery (e.g., local versus distant) is strongly associated with the specific histologic type of RPS. Radiation and systemic therapy may improve outcomes in RPS and there is emerging data studying the benefit of non-surgical treatments in primary disease. Topics in need of further investigation include criteria for unresectability and management of locally recurrent disease. Moving forward, global collaboration among RPS specialists will be key for continuing to advance our understanding of this disease and find more effective treatments.
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Affiliation(s)
- Dana A Dominguez
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Sagus Sampath
- Department of Radiation Oncology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Mark Agulnik
- Department of Medical Oncology and Therapeutics Research, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Yu Liang
- Department of Pathology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Bao Nguyen
- Department of Diagnostic Radiology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Vijay Trisal
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Laleh G Melstrom
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Aaron G Lewis
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Isaac Benjamin Paz
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Randall F Roberts
- Division of Thoracic Surgery (Vascular Surgery Section), City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - William W Tseng
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
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13
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Choong K, Wong P, Thornblade L, Melstrom K, Lai L, Kaiser A, Singh G, Warner SG, Fakih M, Fong Y, Melstrom LG. Combined Liver and Colon Resection of Synchronous Colorectal Liver Metastases at a Quaternary Center. J Surg Res 2023; 288:252-260. [PMID: 37030183 DOI: 10.1016/j.jss.2023.03.008] [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: 09/23/2022] [Revised: 02/23/2023] [Accepted: 03/09/2023] [Indexed: 04/10/2023]
Abstract
INTRODUCTION Existing literature on the safety of combined liver and colorectal resections for synchronous colorectal liver metastases is mixed. Using a retrospective review of our institutional data, we aimed to show that combined colorectal and liver resections for synchronous metastases is both feasible and safe in a quaternary center. METHODS A retrospective review of combined resections for synchronous colorectal liver metastases at a quaternary referral center from 2015 to 2020 was completed. Clinicopathologic and perioperative data was collected. Univariate and multivariable analyses were performed to identify risk factors for major postoperative complications. RESULTS One hundred one patients were identified, with 35 undergoing major liver resections ( ≥ 3 segments) and 66 undergoing minor liver resections. The vast majority of patients (94%) received neoadjuvant therapy. There was no difference in postoperative major complications (Clavien-Dindo grade 3+) between major and minor liver resections (23.9% versus 12.1%, P = 0.16). On univariate analysis, Albumin-Bilirubin (ALBI) score >1 (P < 0.05) was predictive of major complication. However, on multivariable regression analysis, no factor was associated with significantly increased odds of major complication. CONCLUSIONS This work demonstrates that with thoughtful patient selection, combined resection for synchronous colorectal liver metastases can be safely performed at a quaternary referral center.
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Affiliation(s)
- Kevin Choong
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Paul Wong
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Lucas Thornblade
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Kurt Melstrom
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Lily Lai
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Andreas Kaiser
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Gagandeep Singh
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Susanne G Warner
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Marwan Fakih
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Yuman Fong
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Laleh G Melstrom
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California.
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14
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Hogg ME, Melstrom LG. Top Pancreatic Tumor Articles from 2021 to Inform Your Cancer Patients. Ann Surg Oncol 2023; 30:3437-3443. [PMID: 36917337 DOI: 10.1245/s10434-023-13277-x] [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: 11/07/2022] [Accepted: 02/12/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND More than 10,000 publications about pancreatic cancer were found on PubMed during the past year. METHODS To best inform patients with pancreatic cancer, the obvious, frequent questions asked during patient counseling when dealing with resectable pancreatic cancer, borderline resectable pancreatic cancer, and unresectable pancreatic cancer were considered. RESULTS The publications highlighted are comprehensive on the current management of neoadjuvant therapy for resectable pancreatic cancer, the addition of radiation to neoadjuvant therapy for borderline resectable pancreatic cancer, the utility of arterial resections in unresectable pancreatic cancer, and the role of minimally invasive approach to pancreatic cancer surgical therapy. CONCLUSION These articles are high yield and comprehensive review on key issues facing surgical oncologists who operate on pancreatic cancer.
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Affiliation(s)
- Melissa E Hogg
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
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15
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Scott A, Wong P, Melstrom LG. Surgery and hepatic artery infusion therapy for intrahepatic cholangiocarcinoma. Surgery 2023:S0039-6060(23)00045-4. [PMID: 36906437 DOI: 10.1016/j.surg.2023.01.019] [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: 12/15/2022] [Revised: 01/22/2023] [Accepted: 01/28/2023] [Indexed: 03/13/2023]
Abstract
Intrahepatic cholangiocarcinoma is an aggressive tumor that commonly presents at an advanced stage requiring multimodal treatment. Surgical resection remains the only curative option; however, only 20% to 30% of patients present with resectable disease as these tumors remain asymptomatic at an early stage. Diagnostic workup for intrahepatic cholangiocarcinoma includes contrast-enhanced cross-sectional imaging (eg, computed tomography, magnetic resonance imaging) to determine resectability and percutaneous biopsy for patients receiving neoadjuvant therapy or with unresectable disease. Surgical treatment of resectable intrahepatic cholangiocarcinoma is centered on complete resection of the mass with negative (R0) margins while preserving sufficient future liver remnant. Intraoperative measures that aid in ensuring resectability include diagnostic laparoscopy to rule out peritoneal disease or distant metastases and ultrasound to evaluate for vascular invasion or intrahepatic metastases. Predictors of survival after surgery for intrahepatic cholangiocarcinoma include margin status, vascular invasion, nodal disease, and tumor size and multifocality. Patients with resectable intrahepatic cholangiocarcinoma may also benefit from systemic chemotherapy in either the neoadjuvant or adjuvant setting; however, guidelines do not presently support the use of neoadjuvant chemotherapy outside of ongoing clinical trials. For unresectable intrahepatic cholangiocarcinoma, the combination of gemcitabine and cisplatin has been the first-line chemotherapeutic option, but recent advancements in triplet regimens and immunotherapies may offer novel strategies. Hepatic artery infusion presents an efficacious adjunct to systemic chemotherapy as it takes advantage of the hepatic arterial blood supply that feeds intrahepatic cholangiocarcinomas to deliver high-dose chemotherapy to the liver through a subcutaneous pump. Thus, hepatic artery infusion takes advantage of first-pass hepatic metabolism and provides liver-directed therapy while minimizing systemic exposure. In unresectable intrahepatic cholangiocarcinoma, using hepatic artery infusion therapy in conjunction with systemic chemotherapy has been associated with better overall survival and response rates when compared to systemic chemotherapy alone or other liver-directed therapies, such as transarterial chemoembolization and transarterial radioembolization. This review focuses on surgical intervention for resectable intrahepatic cholangiocarcinoma and the utility of hepatic artery infusion for patients with unresectable disease.
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Affiliation(s)
- Aaron Scott
- City of Hope National Medical Center, Duarte, CA
| | - Paul Wong
- City of Hope National Medical Center, Duarte, CA
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16
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Phan T, Nguyen VH, Su R, Li Y, Qing Y, Qin H, Cho H, Jiang L, Wu X, Chen J, Fakih M, Diamond DJ, Goel A, Melstrom LG. Targeting fat mass and obesity-associated protein mitigates human colorectal cancer growth in vitro and in a murine model. Front Oncol 2023; 13:1087644. [PMID: 36874096 PMCID: PMC9981948 DOI: 10.3389/fonc.2023.1087644] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/27/2023] [Indexed: 02/19/2023] Open
Abstract
Introduction Colorectal cancer (CRC) remains a significant cause of cancer related mortality. Fat mass and obesity-associated protein (FTO) is a m6A mRNA demethylase that plays an oncogenic role in various malignancies. In this study we evaluated the role of FTO in CRC tumorigenesis. Methods Cell proliferation assays were conducted in 6 CRC cell lines with the FTO inhibitor CS1 (50-3200 nM) (± 5-FU 5-80 mM) and after lentivirus mediated FTO knockdown. Cell cycle and apoptosis assays were conducted in HCT116 cells (24 h and 48 h, 290 nM CS1). Western blot and m6A dot plot assays were performed to assess CS1 inhibition of cell cycle proteins and FTO demethylase activity. Migration and invasion assays of shFTO cells and CS1 treated cells were performed. An in vivo heterotopic model of HCT116 cells treated with CS1 or with FTO knockdown cells was performed. RNA-seq was performed on shFTO cells to assess which molecular and metabolic pathways were impacted. RT-PCR was conducted on select genes down-regulated by FTO knockdown. Results We found that the FTO inhibitor, CS1 suppressed CRC cell proliferation in 6 colorectal cancer cell lines and in the 5-Fluorouracil resistant cell line (HCT116-5FUR). CS1 induced cell cycle arrest in the G2/M phase by down regulation of CDC25C and promoted apoptosis of HCT116 cells. CS1 suppressed in vivo tumor growth in the HCT116 heterotopic model (p< 0.05). Lentivirus knockdown of FTO in HCT116 cells (shFTO) mitigated in vivo tumor proliferation and in vitro demethylase activity, cell growth, migration and invasion compared to shScr controls (p< 0.01). RNA-seq of shFTO cells compared to shScr demonstrated down-regulation of pathways related to oxidative phosphorylation, MYC and Akt/ mTOR signaling pathways. Discussion Further work exploring the targeted pathways will elucidate precise downstream mechanisms that can potentially translate these findings to clinical trials.
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Affiliation(s)
- Thuy Phan
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, United States
| | - Vu H Nguyen
- Department of Hematology, City of Hope National Medical Center, Duarte, CA, United States
| | - Rui Su
- Beckman Research Institute, Department of Systems Biology, City of Hope National Medical Center, Monrovia, CA, United States
| | - Yangchan Li
- Beckman Research Institute, Department of Systems Biology, City of Hope National Medical Center, Monrovia, CA, United States
| | - Ying Qing
- Beckman Research Institute, Department of Systems Biology, City of Hope National Medical Center, Monrovia, CA, United States
| | - Hanjun Qin
- Beckman Research Institute, The Integrative Genomics Core, City of Hope National Medical Center, Duarte, CA, United States
| | - Hyejin Cho
- Beckman Research Institute, The Integrative Genomics Core, City of Hope National Medical Center, Duarte, CA, United States
| | - Lei Jiang
- Department of Molecular and Cellular Endocrinology, City of Hope National Medical Center, Duarte, CA, United States
| | - Xiwei Wu
- Beckman Research Institute, The Integrative Genomics Core, City of Hope National Medical Center, Duarte, CA, United States
| | - Jianjun Chen
- Beckman Research Institute, Department of Systems Biology, City of Hope National Medical Center, Monrovia, CA, United States
| | - Marwan Fakih
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, United States
| | - Don J Diamond
- Department of Hematology, City of Hope National Medical Center, Duarte, CA, United States
| | - Ajay Goel
- Department of Molecular Diagnostics and Experimental Therapeutics, City of Hope National Medical Center, Monrovia, CA, United States
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, United States
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17
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Melstrom LG, Zhou X, Kaiser A, Chan K, Lau C, Raoof M, Warner SG, Zhumkhawala A, Yuh B, Singh G, Fong Y, Sun V. Feasibility of perioperative remote monitoring of patient-generated health data in complex surgical oncology. J Surg Oncol 2022; 127:192-202. [PMID: 36169200 PMCID: PMC10087541 DOI: 10.1002/jso.27106] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/12/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND The feasibility of remote perioperative telemonitoring of patient-generated physiologic health data and patient-reported outcomes in a high risk complex general and urologic oncology surgery population is evaluated. METHODS Complex general surgical/urologic oncology patients wore a pedometer, completed ePROs (electronic patient-reported outcome surveys) and record their vitals (weight, pulse, pulse oximetry, blood pressure, and temperature) via a telehealth app platform. Feasibility (% adherence) was assessed as the primary outcome measure. RESULTS Twenty-one patients with a median age 58 (32-82) years were included. The readmission rate was 33% and the incidence of ≥Grade 3a morbidity was 24%. Adherence to vital sign and ePRO measurements was 95% before surgery, 91% at discharge, and 82%, 68%, and 64% at postdischarge d2, 7, 14, and 30, respectively. There was significant worsening of mobility, self-care and usual daily activity at postdischarge d2 compared to preoperative baseline (p < 0.05). Median daily preoperative steps taken by patients with <Grade 3a versus ≥Grade 3a postoperative morbidity was 6062 versus 4166 (p < 0.05). Of those interviewed, 87% (13/15) viewed vital sign devices as helpful in recovery. CONCLUSIONS Telemonitoring is feasible in a general surgical and urologic oncology setting. Future studies will ascertain optimal patient selection, duration, and extent of perioperative monitoring.
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Affiliation(s)
- Laleh G Melstrom
- Department of Surgery City of Hope, Division of Surgical Oncology, Duarte, California, USA
| | - Xiaoke Zhou
- Department of Population Sciences, City of Hope, Duarte, California, USA
| | - Andreas Kaiser
- Department of Surgery City of Hope, Division of Colorectal Surgery, Duarte, California, USA
| | - Kevin Chan
- Department of Surgery City of Hope, Division of Urologic Oncology, Duarte, California, USA
| | - Clayton Lau
- Department of Surgery City of Hope, Division of Urologic Oncology, Duarte, California, USA
| | - Mustafa Raoof
- Department of Surgery City of Hope, Division of Surgical Oncology, Duarte, California, USA
| | | | - Ali Zhumkhawala
- Department of Surgery City of Hope, Division of Urologic Oncology, Duarte, California, USA
| | - Bertram Yuh
- Department of Surgery City of Hope, Division of Urologic Oncology, Duarte, California, USA
| | - Gagandeep Singh
- Department of Surgery City of Hope, Division of Surgical Oncology, Duarte, California, USA
| | - Yuman Fong
- Department of Surgery City of Hope, Division of Surgical Oncology, Duarte, California, USA
| | - Virginia Sun
- Department of Surgery City of Hope, Division of Surgical Oncology, Duarte, California, USA.,Department of Population Sciences, City of Hope, Duarte, California, USA
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18
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Tran TB, Wong P, Raoof M, Melstrom K, Fong Y, Melstrom LG. The evolving gender distribution in authorship over time in American surgery. Am J Surg 2022; 224:1217-1221. [DOI: 10.1016/j.amjsurg.2022.05.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 05/06/2022] [Accepted: 05/23/2022] [Indexed: 11/01/2022]
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19
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Nguyen AH, O'Leary MP, De Andrade JP, Ituarte PG, Warner SG, Melstrom LG, Kessler J, Fong Y, Li D, Singh G. Presentation and survival of gastro-entero-pancreatic neuroendocrine tumors in young adults versus older patients. Am J Surg 2021; 223:939-944. [PMID: 34474917 DOI: 10.1016/j.amjsurg.2021.08.030] [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: 06/08/2021] [Revised: 08/02/2021] [Accepted: 08/16/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND A minority of patients with gastro-entero-pancreatic neuroendocrine tumors (GEP-NETs) is diagnosed at younger age. This population-based study explores the broad clinical and pathologic features of the youngest 5% of adult patients with GEP-NETs. METHODS A retrospective study of the National Cancer Database (NCDB) of patients with a primary GEP-NET was performed. Patients were stratified by age. Kaplan-Meier and multivariate Cox proportional hazards analyses were performed. RESULTS We identified 31,983 patients with a diagnosis of a GEP-NET and only 5% of patients were under the age of 35. Young patients were found to have greater proportions of localized, well differentiated disease. On multivariate analysis, young age, well differentiated histology, early stage, and surgical intervention were associated with lower risk of mortality. CONCLUSIONS Young patients with GEP-NETs tend to have earlier stage of presentation and well differentiated tumors, which may be most amenable to surgical intervention.
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Affiliation(s)
- Andrew H Nguyen
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Michael P O'Leary
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - James P De Andrade
- Department of Surgery, University of Iowa Health Care, 200 Hawkins Drive, Iowa City, IA, USA
| | - Philip G Ituarte
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Susanne G Warner
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Jonathan Kessler
- Department of Radiology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Daneng Li
- Department of Medical Oncology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Gagandeep Singh
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA.
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20
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Thornblade LW, Wong P, Li D, Warner SG, Chang S, Raoof M, Kessler J, Amini A, Lin J, Chung V, Singh G, Fong Y, Melstrom LG. Patterns of Whole Exome Sequencing in Resected Cholangiocarcinoma. Cancers (Basel) 2021; 13:cancers13164062. [PMID: 34439216 PMCID: PMC8394619 DOI: 10.3390/cancers13164062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Cholangiocarcinomas are rare cancers that harbor a significant number of potentially targetable mutations. In this study, we assessed the frequency of genomic profiling for resected cholangiocarcinomas. We found that, over the past decade, a third of patients underwent tumor genomic profiling, among whom 89% harbored a targetable mutation. Mutations were associated with a median of one approved drug. A quarter of eligible sequenced patients were treated with therapy targeting tumor-specific mutations. Abstract Background: With minimally effective chemotherapy options, cholangiocarcinoma patients have 5 year survival rate of 10%. Tumor genetic profiling (TGP) can identify mutations susceptible to targeted therapies. We sought to describe the use of TGP and frequency of actionable results in resected cholangiocarcinoma. Methods: A retrospective review of patients undergoing curative intent resection at a comprehensive cancer center (2010–2020). Clinicopathologic and partial or whole exome sequencing data were reviewed. Results: 114 patients (mean age 65 ± 11 years, 45% female) underwent resection of cholangiocarcinoma (46% poorly differentiated, 54% intrahepatic, 36% node positive, 75% margin negative). Additionally, 32% of patients underwent TGP, yielding a mean of 3.1 actionable mutations per patient (range 0–14). Mutations aligned with a median of one drug per patient (range 0–11). Common mutations included TP53 (33%), KRAS (31%), IDH1/2 (14%), FGFR (14%), and BRAF (8%). Targeted therapies were administered in only 4% of patients (23% of eligible sequenced patients). After a median 22 months, 23% had recurrence and 29% were deceased. Discussion: TGP for cholangiocarcinoma has increased over the last decade with targeted therapies identified in most sequenced tumors, impacting treatment in a quarter of eligible patients. Precision medicine will play a central role in the future care of cholangiocarcinoma.
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Affiliation(s)
- Lucas W. Thornblade
- Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010, USA; (L.W.T.); (P.W.); (S.G.W.); (M.R.); (G.S.); (Y.F.)
| | - Paul Wong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010, USA; (L.W.T.); (P.W.); (S.G.W.); (M.R.); (G.S.); (Y.F.)
| | - Daneng Li
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA 91010, USA; (D.L.); (V.C.)
| | - Susanne G. Warner
- Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010, USA; (L.W.T.); (P.W.); (S.G.W.); (M.R.); (G.S.); (Y.F.)
| | - Sue Chang
- Department of Pathology, City of Hope National Medical Center, Duarte, CA 91010, USA;
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010, USA; (L.W.T.); (P.W.); (S.G.W.); (M.R.); (G.S.); (Y.F.)
| | - Jonathan Kessler
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, USA; (J.K.); (A.A.)
| | - Arya Amini
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, USA; (J.K.); (A.A.)
| | - James Lin
- Division of Gastroenterology, City of Hope National Medical Center, Duarte, CA 91010, USA;
| | - Vincent Chung
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA 91010, USA; (D.L.); (V.C.)
| | - Gagandeep Singh
- Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010, USA; (L.W.T.); (P.W.); (S.G.W.); (M.R.); (G.S.); (Y.F.)
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010, USA; (L.W.T.); (P.W.); (S.G.W.); (M.R.); (G.S.); (Y.F.)
| | - Laleh G. Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010, USA; (L.W.T.); (P.W.); (S.G.W.); (M.R.); (G.S.); (Y.F.)
- Correspondence: ; Tel.: +1-626-218-0282
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21
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Attiyeh MA, Amini A, Chung V, Melstrom LG. Multidisciplinary management of locally advanced pancreatic adenocarcinoma: Biology is King. J Surg Oncol 2021; 123:1395-1404. [PMID: 33831247 DOI: 10.1002/jso.26415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/18/2021] [Accepted: 01/27/2021] [Indexed: 12/21/2022]
Abstract
The annual incidence of pancreatic cancer is nearly 50,000 patients. The 5-year overall survival is only 9%, and there remains a great need for better therapy. A subset of these patients presents with locally advanced disease. Multidisciplinary therapy has evolved to include some combination of systemic chemotherapy, locoregional radiation, and surgery in select patients with excellent biology. This review will address the thoughtful evidence-based and individualized approach to these patients.
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Affiliation(s)
- Marc A Attiyeh
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Arya Amini
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Vincent Chung
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Laleh G Melstrom
- Department of Surgical Oncology, City of Hope National Medical Center, Duarte, California, USA
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22
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Melstrom LG, Warner SG, Wong P, Sun V, Raoof M, Singh G, Chavin KD, Fong Y, Adam R, Hugh TJ. Management of disappearing colorectal liver metastases: an international survey. HPB (Oxford) 2021; 23:506-511. [PMID: 33144051 DOI: 10.1016/j.hpb.2020.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 05/03/2020] [Revised: 08/13/2020] [Accepted: 10/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Improved chemotherapy response rates have lead to "disappearing" colorectal liver metastases (dCRLM). We aim to assess management patterns of dCRLM from an international body of hepatobiliary surgeons. METHODS A survey was designed, tested for item relevance, readability and content validity, and distributed to the AHPBA, IHPBA and ANZHPBA. RESULTS The majority of 226 respondents were <15 years from training (69%), practiced in academia (82%) and devoted >50% of their practice to hepatobiliary (75%). Surgeons utilize CT(45%) or MRI(47%) for preoperative planning with a preferred imaging interval of <6 weeks. Nearly all have experienced dCRLM (99%) and 63% of surgeons have waited a few months to assess for durability of response prior to definitive surgical/ablative therapy. Only 24% place fiducial markers for lesions <1-cm prior to neoadjuvant chemotherapy. Intra-operatively, 97% of surgeons perform ultrasound, and 71% ablation. When a tumor has "disappeared," 49% elect for observation and 31% resect if the dCRLM is superficial. Of those electing observation, 87% believe there is effective treatment with progression on surveillance imaging. CONCLUSIONS Nearly all surgeons have experienced dCRLM with half choosing observation over intervention due to the belief that these lesions may be re-addressed in the future.
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Affiliation(s)
- Laleh G Melstrom
- City of Hope Comprehensive Cancer Center Department of Surgery, USA.
| | - Susanne G Warner
- City of Hope Comprehensive Cancer Center Department of Surgery, USA
| | - Paul Wong
- City of Hope Comprehensive Cancer Center Department of Surgery, USA
| | - Virginia Sun
- City of Hope Comprehensive Cancer Center Department of Population Sciences, USA
| | - Mustafa Raoof
- City of Hope Comprehensive Cancer Center Department of Surgery, USA
| | - Gagandeep Singh
- City of Hope Comprehensive Cancer Center Department of Surgery, USA
| | | | - Yuman Fong
- City of Hope Comprehensive Cancer Center Department of Surgery, USA
| | - Rene Adam
- Paul-Brousse Hospital, Assistance Publique Hopitaux de Paris Department of Surgery, France
| | - Thomas J Hugh
- University of Sydney, Department of Surgery, Australia
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23
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Rossi LA, Melstrom LG, Fong Y, Sun V. Predicting post-discharge cancer surgery complications via telemonitoring of patient-reported outcomes and patient-generated health data. J Surg Oncol 2021; 123:1345-1352. [PMID: 33621378 PMCID: PMC8764868 DOI: 10.1002/jso.26413] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/22/2021] [Accepted: 01/24/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Post-discharge oncologic surgical complications are costly for patients, families, and healthcare systems. The capacity to predict complications and early intervention can improve postoperative outcomes. In this proof-of-concept study, we used a machine learning approach to explore the potential added value of patient-reported outcomes (PROs) and patient-generated health data (PGHD) in predicting post-discharge complications for gastrointestinal (GI) and lung cancer surgery patients. METHODS We formulated post-discharge complication prediction as a binary classification task. Features were extracted from clinical variables, PROs (MD Anderson Symptom Inventory [MDASI]), and PGHD (VivoFit) from a cohort of 52 patients with 134 temporal observation points pre- and post-discharge that were collected from two pilot studies. We trained and evaluated supervised learning classifiers via nested cross-validation. RESULTS A logistic regression model with L2 regularization trained with clinical data, PROs and PGHD from wearable pedometers achieved an area under the receiver operating characteristic of 0.74. CONCLUSIONS PROs and PGHDs captured through remote patient telemonitoring approaches have the potential to improve prediction performance for postoperative complications.
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Affiliation(s)
- Lorenzo A. Rossi
- Department of Applied AI & Data Science, City of Hope
National Medical Center, Duarte, CA, USA
| | - Laleh G. Melstrom
- Department of Surgery, City of Hope National Medical
Center, Duarte, CA, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical
Center, Duarte, CA, USA
| | - Virginia Sun
- Department of Surgery, City of Hope National Medical
Center, Duarte, CA, USA
- Department of Population Sciences, City of Hope National
Medical Center, Duarte, CA, USA
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24
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Phan T, Nguyen VH, Buettner R, Morales C, Yang L, Wong P, Tsai W, Salazar MD, Gil Z, Diamond DJ, Rabinowitz JD, Rosen S, Melstrom LG. Inhibition of de novo pyrimidine synthesis augments Gemcitabine induced growth inhibition in an immunocompetent model of pancreatic cancer. Int J Biol Sci 2021; 17:2240-2251. [PMID: 34239352 PMCID: PMC8241727 DOI: 10.7150/ijbs.60473] [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] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 05/18/2021] [Indexed: 12/13/2022] Open
Abstract
Leflunomide (Lef) is an agent used in autoimmune disorders that interferes with DNA synthesis. De Novo pyrimidine synthesis is a mechanism of Gemcitabine (Gem) resistance in pancreatic cancer. This study aims to assess the efficacy and changes in the tumor microenvironment of Lef monotherapy and in combination with Gem, in a syngeneic mouse model of pancreatic cancer. Methods: MTS proliferation assays were conducted to assess growth inhibition by Gem (0-20 nM), Lef (0-40 uM) and Gem+Lef in KPC (KrasLSL.G12D/+;p53R172H/+; PdxCretg/+) cells in vitro. An in vivo heterotopic KPC model was used and cohorts were treated with: PBS (control), Gem (75 mg/kg/q3d), Lef (40 mg/kg/d), or Gem+Lef. At d28 post-treatment, tumor burden, proliferation index (Ki67), and vascularity (CD31) were measured. Changes in the frequency of peripheral and intratumoral immune cell subsets were evaluated via FACS. Liquid chromatography-mass spectrometry was used for metabolomics profiling. Results: Lef inhibits KPC cell growth and synergizes with Gem in vitro (P<0.05; Combination Index 0.44 (<1 indicates synergy). In vivo, Lef alone and in combination with Gem delays KPC tumor progression (P<0.001). CTLA-4+T cells are also significantly decreased in tumors treated with Lef, Gem or in combination (Gem+Lef) compared to controls (P<0.05). Combination therapy also decreased the Ki67 and vascularity (P<0.01). Leflunomide inhibits de novo pyrimidine synthesis both in vitro (p<0.0001) and in vivo (p<0.05). Conclusions: In this study, we demonstrated that Gem+Lef inhibits pancreatic cancer growth, decrease T cell exhaustion, vascularity and as proof of principle inhibits de novo pyrimidine synthesis. Further characterization of changes in adaptive immunity are necessary to characterize the mechanism of tumor growth inhibition and facilitate translation to a clinical trial.
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Affiliation(s)
- Thuy Phan
- Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010
| | - Vu H. Nguyen
- Department of Hematology, City of Hope National Medical Center, Duarte, CA 91010
| | - Ralf Buettner
- Department of Hematology, City of Hope National Medical Center, Duarte, CA 91010
| | - Corey Morales
- Department of Hematology, City of Hope National Medical Center, Duarte, CA 91010
| | - Lifeng Yang
- Lewis Sigler Institute for Integrative Genomics and Department of Chemistry, Princeton University, Princeton, NJ 08544
| | - Paul Wong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010
| | - Weiman Tsai
- Department of Hematology, City of Hope National Medical Center, Duarte, CA 91010
| | | | - Ziv Gil
- Rambam Medical Center, Israel
| | - Don J Diamond
- Department of Hematology, City of Hope National Medical Center, Duarte, CA 91010
| | - Joshua D. Rabinowitz
- Lewis Sigler Institute for Integrative Genomics and Department of Chemistry, Princeton University, Princeton, NJ 08544
| | - Steven Rosen
- Department of Hematology, City of Hope National Medical Center, Duarte, CA 91010
| | - Laleh G. Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010
- ✉ Corresponding author: Laleh Melstrom MD, City of Hope National Medical Center, Department of Surgery and Immuno-oncology, 1500 E Duarte Road, Duarte, CA 91010. E-mail: ; Phone: 626 218 0282; Fax: 626 218 1113
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25
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Lafaro KJ, Khithani AS, Wong P, LaRocca CJ, Warner SG, Fong Y, Melstrom LG. Academic Productivity in Hepatopancreatobiliary Surgeons: Identifying Benchmarks Associated With Rank in North America. Am Surg 2020; 87:1474-1479. [PMID: 33356426 DOI: 10.1177/0003134820966282] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Academic achievement is an integral part of the promotion process; however, there are no standardized metrics for faculty or leadership to reference in assessing this potential for promotion. The aim of this study was to identify metrics that correlate with academic rank in hepatopancreaticobiliary (HPB) surgeons. MATERIALS AND METHODS Faculty was identified from 17 fellowship council accredited HPB surgery fellowships in the United States and Canada. The number of publications, citations, h-index values, and National Institutes of Health (NIH) funding for each faculty member was captured. RESULTS Of 111 surgeons identified, there were 31 (27%) assistant, 39 (35%) associate, and 41 (36%) full professors. On univariate analysis, years in practice, h-index, and a history of NIH funding were significantly associated with a surgeon's academic rank (P < .05). Years in practice and h-index remained significant on multivariate analysis (P < .001). DISCUSSION Academic productivity metrics including h-index and NIH funding are associated with promotion to the next academic rank.
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Affiliation(s)
- Kelly J Lafaro
- Department of Surgery, 1500Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Surgery, 20220City of Hope National Medical Center, Duarte, CA, USA
| | - Amit S Khithani
- Department of Surgery, 20220City of Hope National Medical Center, Duarte, CA, USA.,Miami Dade Surgical Group, Miami, FL, USA
| | - Paul Wong
- Department of Surgery, 20220City of Hope National Medical Center, Duarte, CA, USA
| | - Christopher J LaRocca
- Department of Surgery, 20220City of Hope National Medical Center, Duarte, CA, USA.,Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Susanne G Warner
- Department of Surgery, 20220City of Hope National Medical Center, Duarte, CA, USA
| | - Yuman Fong
- Department of Surgery, 20220City of Hope National Medical Center, Duarte, CA, USA
| | - Laleh G Melstrom
- Department of Surgery, 20220City of Hope National Medical Center, Duarte, CA, USA
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26
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Abstract
Importance In the past few decades, there has been rapid advancements in imaging technologies that have become irreplaceable in the pre-operative assessment of patients with pancreatic tumors. Modern imaging modalities, including computed tomography (CT) and endoscopic ultrasound (EUS), can provide critical information of the absence or presence of metastatic disease in pancreatic cancer, as well as details on the local extent and resectability, allowing for the selection of stage appropriate treatments and pre-operatively determined surgical approach. Objective The aim of this review is to discuss staging, resectability, and imaging for patients with pancreatic tumors. Evidence Review A literature review was performed of articles relevant to the topics of staging, resectability, and imaging of pancreatic tumors. Imaging modalities included CT, EUS, magnetic resonance imaging (MRI), positron emission tomography (PET), antibody-based and narrow band imaging. Findings CT pancreas protocol combined with EUS serve as the primary modalities in diagnosis, staging, and surgical planning in patients with pancreatic tumors. MRI is an alternative to CT with near equivalent utility in the pre-operative setting. In some circumstances, PET-CT may be a cost-effective initial study to detect distant disease. Conclusions and Relevance Current imaging technologies play a critical role in the evaluation of patients with pancreatic tumors. Advances in the past 3 decades in imaging technologies have revolutionized the process of assessment of stage and resectability in patients with pancreatic tumors. Future imaging technologies will address current limitation in the evaluation of occult metastatic disease.
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27
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Melstrom LG, Rodin AS, Rossi LA, Fu P, Fong Y, Sun V. Patient generated health data and electronic health record integration in oncologic surgery: A call for artificial intelligence and machine learning. J Surg Oncol 2020; 123:52-60. [PMID: 32974930 DOI: 10.1002/jso.26232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 12/16/2022]
Abstract
In this review, we aim to assess the current state of science in relation to the integration of patient-generated health data (PGHD) and patient-reported outcomes (PROs) into routine clinical care with a focus on surgical oncology populations. We will also describe the critical role of artificial intelligence and machine-learning methodology in the efficient translation of PGHD, PROs, and traditional outcome measures into meaningful patient care models.
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Affiliation(s)
- Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California, USA
| | - Andrei S Rodin
- Department of Computational and Quantitative Medicine, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, USA
| | - Lorenzo A Rossi
- Applied AI and Data Science Department, City of Hope National Medical Center, Duarte, California, USA
| | - Paul Fu
- Department of Pediatrics, City of Hope National Medical Center, Duarte, California, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, California, USA
| | - Virginia Sun
- Department of Surgery, City of Hope National Medical Center, Duarte, California, USA.,Department of Population Sciences, City of Hope National Medical Center, Duarte, California, USA
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28
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Le VH, O'Connor VV, Li D, Melstrom LG, Fong Y, DiFronzo AL. Outcomes of neoadjuvant therapy for cholangiocarcinoma: A review of existing evidence assessing treatment response and R0 resection rate. J Surg Oncol 2020; 123:164-171. [PMID: 32974932 DOI: 10.1002/jso.26230] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/03/2020] [Accepted: 09/05/2020] [Indexed: 12/15/2022]
Abstract
Adjuvant chemotherapy for cholangiocarcinoma (CCA) has not been shown to gain significant improvements in survival. Factors contributing to suboptimal treatment response include aggressive disease biology and late clinical presentation. When feasible, surgical resection is the first line of treatment. Yet, recurrence remains high and long-term survival is rare. Neoadjuvant therapy is an appealing approach, with oncologic advantages in allowing the treatment of occult systemic disease and selection of patients most likely to benefit from radical surgery. However, given the surgery-first treatment paradigm for CCA, there is a paucity of data supporting neoadjuvant therapy. This review summarizes the current evidence on treatment response and margin-negative (R0) resection rate associated with neoadjuvant therapy for CCA.
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Affiliation(s)
- Viet H Le
- Department of Surgery, City of Hope National Medical Center, Duarte, California, USA
| | - Victoria V O'Connor
- Department of Surgery, Kaiser Permanente - Los Angeles Medical Center, Los Angeles, California, USA
| | - Daneng Li
- Department of Medical Oncology and Therapeutic Research, City of Hope National Medical Center, Duarte, California, USA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, California, USA
| | - Andrew L DiFronzo
- Department of Surgery, Kaiser Permanente - Los Angeles Medical Center, Los Angeles, California, USA
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29
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De Andrade JP, Wong P, O'Leary MP, Parekh V, Amini A, Schoellhammer HF, Margolin KA, Afkhami M, Melstrom LG. Multidisciplinary Care for Melanoma of Unknown Primary: Experience in the Era of Molecular Profiling. Ann Surg Oncol 2020; 27:5240-5247. [PMID: 32909128 DOI: 10.1245/s10434-020-09112-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/14/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Melanoma of unknown primary (MUP) accounts for approximately 3% of melanoma diagnoses. This study sought to evaluate treatment and outcomes for a modern MUP cohort. METHODS A retrospective review of MUP was performed at a tertiary referral cancer center. RESULTS Of 815 melanoma patients, 67 (8.2%) had MUP. Men were more likely to have MUP than women (67% vs. 55%; p = 0.04). The most common sites of MUP were lymph nodes (28%), visceral solid organs (25%), brain (16%), and skin/subcutaneous tissues (10%). Of the patients who underwent tumor genomic profiling, 52% harbored pathogenic BRAF mutations. Of the 24 patients who underwent multi-gene panel testing, all had pathogenic mutations and 21 (88%) had mutations in addition to or exclusive of BRAF, including 11 patients (46%) with telomerase reverse transcriptase promoter mutations. Checkpoint inhibitors (39%) and BRAF-MEK inhibitors (7%) were the most common first-line treatments. Upfront surgical resection was used for 25% of the MUP patients, and 12 of these resections were for curative intent. During a median follow-up period of 22.1 months, the median overall survival (OS) was not met for the patients with MUP isolated to lymph nodes. At 56.8 months, 75% of these patients were alive. The median OS was 37.4 months for skin/soft tissue MUP, 33.3 months for single solid organ viscera MUP, and 29.8 months for metastatic brain MUP. CONCLUSION Multigene panel testing identified pathogenic mutations in all tested MUP patients and frequently identified targets outside BRAF. Despite advanced stage, aggressive multimodal therapy for MUP can be associated with 5-year OS and should be pursued for appropriate candidates.
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Affiliation(s)
- James P De Andrade
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Paul Wong
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Michael P O'Leary
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Vishwas Parekh
- Department of Pathology, City of Hope National Medical Center, Duarte, CA, USA
| | - Arya Amini
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Hans F Schoellhammer
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Kim A Margolin
- Division of Medical Oncology, Department of Medicine, City of Hope National Medical Center, Duarte, CA, USA
| | - Michelle Afkhami
- Department of Pathology, City of Hope National Medical Center, Duarte, CA, USA
| | - Laleh G Melstrom
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA.
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30
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Abstract
: There is a long history of personal protective equipment (PPE) used by the surgeon to minimize the transmission of various pathogens. In the context of the present coronavirus disease 2019 pandemic there is significant controversy as to what forms of PPE are appropriate or adequate. This review aims to describe the pathogenic mechanism and route of spread of the causative virus, severe acute respiratory syndrome coronavirus, as it pertains to accumulated published data from experienced centers globally. The various forms of PPE that are both available and appropriate are addressed. There are options in the form of eyewear, gloves, masks, respirators, and gowns. The logical and practical utilization of these should be data driven and evolve based on both experience and data. Last, situations specific to surgical populations are addressed. We aim to provide granular collective data that has thus far been published and that can be used as a reference for optimal PPE choices in the perioperative setting for surgical teams.
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Affiliation(s)
- Camille L Stewart
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | | | - Don J Diamond
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
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31
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Stewart CL, De Andrade JP, Duma N, Ralph OK, Choong K, Gonzalez L, McClintock NC, Sandoval E, Melstrom LG, Warner SG. Unconscious Bias in Speaker Introductions at a Surgical Oncology Meeting: Hierarchy Reigns Over Gender. Ann Surg Oncol 2020; 27:3754-3761. [PMID: 32712891 DOI: 10.1245/s10434-020-08906-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/08/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Recent reviews of medical conferences have shown that women were less likely to receive a formal introduction compared with men. We examined speaker introductions at the Society of Surgical Oncology (SSO) annual meeting to determine whether similar biases exist within our organization. METHODS An observational study of video-archived speaker introductions at the 2018 and 2019 SSO annual meetings was conducted. Professional address was defined as professional title followed by full name or last name. Multivariable logistic regression was used to identify factors associated with form of address. RESULTS There were 499 speaker introductions reviewed. Speakers included 290 (58%) men and 238 (49%) post-graduate trainees (residents and fellows). A non-professional form of address was used to introduce 148 (30%) speakers and was most often used for post-graduate trainees (33%). Full professors were more likely than junior faculty to introduce speakers with a non-professional form of address (37% of full professors vs 18% of assistant professors, p < 0.001). In multivariable regression analysis these findings persisted. Trainees were 2.8 times more likely to receive a non-professional form of address (p = 0.003). Use of a non-professional introduction did not significantly vary by the speaker's nor the introducer's gender. CONCLUSIONS Residents and fellows were more likely to receive a non-professional form of address, and the likelihood of this increased with rising seniority of the introducer. The manner of speaker introduction did not vary by gender in our organization. More research is needed to explore the influence of these disparities on academic advancement for the next generation of surgical oncologists.
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Affiliation(s)
- Camille L Stewart
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA.
| | - James P De Andrade
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Narjust Duma
- Department of Medicine, Division of Hematology, Medical Oncology and Palliative Care, University of Wisconsin, Madison, WI, USA
| | - Oliver K Ralph
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Kevin Choong
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Lorena Gonzalez
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | | | - Ethan Sandoval
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Laleh G Melstrom
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Susanne G Warner
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
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32
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Lafaro K, Blakely AM, Melstrom LG, Warner SG, Lee B, Singh G, Fong Y, Raoof M. Prognostic impact of tumor location in resected gallbladder cancer: A national cohort analysis. J Surg Oncol 2020; 122:1084-1093. [PMID: 32652555 DOI: 10.1002/jso.26107] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/07/2020] [Accepted: 06/15/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Tumor location (peritoneal vs hepatic) has been incorporated in the 8th edition of the American Joint Committee on Cancer Staging system for gallbladder cancer. However, larger studies are needed to confirm the prognostic impact of tumor location. METHODS Patients with pathologically-confirmed gallbladder cancer with information on primary tumor location were included from the National Cancer Database (2009-2012). We compared patients with hepatic-side tumors to those on the peritoneal side. Survival data were plotted using the Kaplan-Meier method. Prognostic factors were modeled with a multivariate Cox Proportional Hazards Model. Primary outcome was overall survival (OS). RESULTS A total of 1251 patients were included. In comparison to patients with peritoneal-sided tumors, patients with hepatic-sided tumors were more likely to: be of higher pT stage (pT3: 49% vs 24%; P < .001); node positive (31% vs 24%; P = .016); undergo liver resection (53% vs 25%; P < .001); or have positive margins (29% vs 16%; P < .001). However, on multivariate analysis, there was no difference in OS between the groups (HR, 0.97; 95% CI, 0.79-1.18; P = .753). Liver resection was associated with improved survival regardless of tumor location in pT2 tumors (peritoneal: HR, 0.57; P = .034; hepatic: HR, 0.67; P < .001). CONCLUSIONS This study failed to demonstrate the independent prognostic value of primary tumor location in patients with gallbladder cancer.
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Affiliation(s)
- Kelly Lafaro
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew M Blakely
- Department of Surgery, National Institute of Health, Bethesda, Maryland
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Susanne G Warner
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Byrne Lee
- Department of Surgery, Stanford Medicine, Stanford, California
| | - Gagandeep Singh
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, California
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33
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De Andrade JP, Blakely AM, Nguyen AH, Ituarte PHG, Warner SG, Melstrom LG, Lee B, Singh G. Neuroendocrine Tumors of Meckel's Diverticula: Rare but Fare Well. Am Surg 2020. [DOI: 10.1177/000313481908501010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Neuroendocrine tumors (NETs) are the most common malignancy arising in Meckel's diverticula (MDs). To date, there are no large series characterizing these tumors. The National Cancer Database was queried for patients with MD NETs (n = 162) from 2004 to 2014. Patient and tumor characteristics as well as outcomes were analyzed. MD NETs were more common in men (72.8%) at a median age of 62 years; 95.1 per cent of patients were white. All patients underwent surgery. Clinical M0 disease was present in 97.4 per cent of patients, and 88.2 per cent of tumors were well differentiated. Lymphovascular invasion was present in 13.2 per cent. Most (60.4%) tumors were less than 10 mm. Lymphadenectomy was performed in 32.9 per cent of patients, with 52.1 per cent of these found to have metastatic lymph node disease. Although most MD NETs are well differentiated, smaller than 10 mm, and do not have lymphovascular invasion, lymph node metastases are commonly found, suggesting that mesenteric lymphadenectomy with adequate resection of the small bowel may be necessary for adequate staging and disease clearance.
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Affiliation(s)
- James P. De Andrade
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Andrew M. Blakely
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Andrew H. Nguyen
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Philip H. G. Ituarte
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Susanne G. Warner
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Laleh G. Melstrom
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Byrne Lee
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Gagandeep Singh
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
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Che M, Kweon SM, Teo JL, Yuan YC, Melstrom LG, Waldron RT, Lugea A, Urrutia RA, Pandol SJ, Lai KKY. Targeting the CBP/β-Catenin Interaction to Suppress Activation of Cancer-Promoting Pancreatic Stellate Cells. Cancers (Basel) 2020; 12:cancers12061476. [PMID: 32516943 PMCID: PMC7352534 DOI: 10.3390/cancers12061476] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/27/2020] [Accepted: 06/04/2020] [Indexed: 02/06/2023] Open
Abstract
Background: Although cyclic AMP-response element binding protein-binding protein (CBP)/β-catenin signaling is known to promote proliferation and fibrosis in various organ systems, its role in the activation of pancreatic stellate cells (PSCs), the key effector cells of desmoplasia in pancreatic cancer and fibrosis in chronic pancreatitis, is largely unknown. Methods: To investigate the role of the CBP/β-catenin signaling pathway in the activation of PSCs, we have treated mouse and human PSCs with the small molecule specific CBP/β-catenin antagonist ICG-001 and examined the effects of treatment on parameters of activation. Results: We report for the first time that CBP/β-catenin antagonism suppresses activation of PSCs as evidenced by their decreased proliferation, down-regulation of “activation” markers, e.g., α-smooth muscle actin (α-SMA/Acta2), collagen type I alpha 1 (Col1a1), Prolyl 4-hydroxylase, and Survivin, up-regulation of peroxisome proliferator activated receptor gamma (Ppar-γ) which is associated with quiescence, and reduced migration; additionally, CBP/β-catenin antagonism also suppresses PSC-induced migration of cancer cells. Conclusion: CBP/β-catenin antagonism represents a novel therapeutic strategy for suppressing PSC activation and may be effective at countering PSC promotion of pancreatic cancer.
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Affiliation(s)
- Mingtian Che
- Department of Molecular Medicine, Beckman Research Institute of City of Hope, Duarte, CA 91010, USA; (M.C.); (S.-M.K.); (J.-L.T.)
| | - Soo-Mi Kweon
- Department of Molecular Medicine, Beckman Research Institute of City of Hope, Duarte, CA 91010, USA; (M.C.); (S.-M.K.); (J.-L.T.)
| | - Jia-Ling Teo
- Department of Molecular Medicine, Beckman Research Institute of City of Hope, Duarte, CA 91010, USA; (M.C.); (S.-M.K.); (J.-L.T.)
| | - Yate-Ching Yuan
- Department of Computational and Quantitative Medicine, Beckman Research Institute of City of Hope, Duarte, CA 91010, USA;
| | - Laleh G. Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010, USA;
| | - Richard T. Waldron
- Pancreatic Research Program, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (R.T.W.); (A.L.); (S.J.P.)
- Department of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA
| | - Aurelia Lugea
- Pancreatic Research Program, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (R.T.W.); (A.L.); (S.J.P.)
- Department of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA
| | - Raul A. Urrutia
- Department of Surgery and the Genomic Sciences and Precision Medicine Center (GSPMC), Medical College of Wisconsin, Milwaukee, WI 53226, USA;
| | - Stephen J. Pandol
- Pancreatic Research Program, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (R.T.W.); (A.L.); (S.J.P.)
- Department of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA
| | - Keane K. Y. Lai
- Department of Pathology, City of Hope National Medical Center, and Department of Molecular Medicine, Beckman Research Institute of City of Hope, Duarte, CA 91010, USA
- City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA
- Correspondence:
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Lafaro KJ, Li A, Rodriguez J, Clark K, Loscalzo M, Wong FL, Melstrom LG, Warner SG. Surgeon and patient perceptions of cure in advanced gastrointestinal malignancies: Are we on the same page? J Surg Oncol 2020; 122:489-494. [PMID: 32441359 DOI: 10.1002/jso.25986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/09/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Effective communication is essential to complex shared decision making and is associated with improved recovery and pain control. However, patients and surgeons often have disparate expectations of treatment efficacy and perceptions of cure for advanced malignancies. This study measures correlation of patient and surgeon expectations with perceptions of cure. METHODS Our prospective study surveying surgeon-patient dyads before and after surgical consultation was performed for advanced abdominal malignancy between July and November 2017 at a single NCI designated cancer center using electronic questionnaires. RESULTS Patients and surgeons' own opinions regarding surgical candidacy (Q1), chance at cure (Q2), and life expectancy (Q3) did not measurably change from pre- to postvisit survey as evidenced by unchanged response concordance (patients Q1 P = .82; Q2 P = .81; and Q3 P = .53; surgeon responses Q1: P = .17; Q2: P = .32; and Q3: P = .50). Patient and surgeon perception of likelihood of cure and of estimated life expectancy remained discordant in pre- and postvisit surveys (Q2: P = .006 and Q3: P = .03). CONCLUSIONS These data highlight the stark differences between patient and surgeon perceptions of cure and prognosis of gastrointestinal cancers. These results prove that a larger scale study using this electronic questionnaire is feasible and important to better understand these differences and enhance shared decision making.
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Affiliation(s)
- Kelly J Lafaro
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Arthur Li
- Department of Population Sciences, City of Hope National Medical Center, Duarte, California
| | - Jenny Rodriguez
- Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, California
| | - Karen Clark
- Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, California
| | - Matthew Loscalzo
- Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, California
| | - F Lennie Wong
- Department of Population Sciences, City of Hope National Medical Center, Duarte, California
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Susanne G Warner
- Department of Surgery, City of Hope National Medical Center, Duarte, California
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LaRocca CJ, Li A, Lafaro K, Clark K, Loscalzo M, Melstrom LG, Warner SG. The impact of financial toxicity in gastrointestinal cancer patients. Surgery 2020; 168:167-172. [PMID: 32197785 DOI: 10.1016/j.surg.2020.02.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 02/04/2020] [Accepted: 02/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Biopsychosocial distress screening is a critical component of comprehensive cancer care. Financial issues are a common source of distress in this patient population. This study uses a biopsychosocial distress screening tool to determine the factors associated with financial toxicity and the impact of these stressors on gastrointestinal cancer patients. METHODS A 48-question, proprietary distress screening tool was administered to patients with gastrointestinal malignancies from 2009 to 2015. This validated, electronically-administered tool is given to all new patients. Responses were recorded on a 5-point Likert scale from 1 (not a problem) to 5 (very severe problem), with responses rated at ≥3 indicative of distress. Univariate and multivariate logistic regressions were used to analyze the data. RESULTS Most of the 1,027 patients had colorectal (50%) or hepatobiliary (31%) malignancies. Additionally, 34% of all patients expressed a high level of financial toxicity. Age greater than 65 (odds ratio: 0.63, 95% confidence interval: 0.47-0.86, P < .01), college education (odds ratio: 0.53, 95% confidence interval: 0.38-0.73, P < .0001), being partnered (odds ratio: 0.61, 95% confidence interval: 0.44-0.84, P < .01), and annual income greater than $40,000 (odds ratio: 0.27, 95% confidence interval: 0.19-0.38, P < .0001) were all protective against financial toxicity on univariate analysis. Also, heavy tobacco use was associated significantly with increased distress on univariate analysis (odds ratio: 2.79, 95% confidence interval: 1.38-5.78, P < .01). With the exception of partnered status (odds ratio: 1.18, 95% confidence interval: 0.76-1.85, P = .46), all these variables retained their significant association with financial toxicity in the multivariate model. CONCLUSION Financial toxicity impacts a large number of cancer patients. Further study of at-risk populations may identify patients who would benefit from pre-emptive education and counseling interventions as part of their routine cancer care.
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Affiliation(s)
- Christopher J LaRocca
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Arthur Li
- Department of Information Sciences, City of Hope National Medical Center, Duarte, CA
| | - Kelly Lafaro
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Karen Clark
- Department of Supportive Medicine, City of Hope National Medical Center, Duarte, CA
| | - Matthew Loscalzo
- Department of Supportive Medicine, City of Hope National Medical Center, Duarte, CA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Susanne G Warner
- Department of Surgery, City of Hope National Medical Center, Duarte, CA.
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Stewart CL, Wong P, Selby L, Warner SG, Raoof M, Singh G, Fong Y, Melstrom LG. Minimally invasive distal pancreatectomy and the cost of conversion. J Surg Oncol 2020; 121:670-675. [PMID: 31967336 DOI: 10.1002/jso.25852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 12/26/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) is preferred for distal pancreatectomy but is not always attempted due to the risk of conversion to open. We hypothesized that the total cost for MIS converted to open procedures would be comparable to those that started open. METHODS A prospectively collected institutional registry (2011-2017) was reviewed for demographic, clinical, and perioperative cost data for patients undergoing distal pancreatectomy. RESULTS There were 80 patients who underwent distal pancreatectomy: 41 open, 39 MIS (11 laparoscopic and 28 robotic). Conversion to open occurred in 14 of 39 (36%, 3 laparoscopic and 11 robotic). Length of stay was shorter for the MIS completed (6 days; range, 3-8), and MIS converted to open (7 days; range, 4-10) groups, compared with open (10 days; range, 5-36; P = .003). Laparoscopic cases were the least expensive (P = .02). Robotic converted to open procedures had the highest operating room cost. However, the total cost for robotic converted to open cohort was similar to the open cohort due to cost savings associated with a shorter length of stay. CONCLUSIONS Despite the higher intraoperative costs of robotic surgery, there is no significant overall financial penalty for conversion to open. Financial considerations should not play a role in selecting a robotic or open approach.
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Affiliation(s)
| | - Paul Wong
- Department of Surgery, City of Hope, Duarte, California
| | - Luke Selby
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Mustafa Raoof
- Department of Surgery, City of Hope, Duarte, California
| | | | - Yuman Fong
- Department of Surgery, City of Hope, Duarte, California
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Konstantinidis IT, Ituarte P, Woo Y, Warner SG, Melstrom K, Kim J, Singh G, Lee B, Fong Y, Melstrom LG. Trends and outcomes of robotic surgery for gastrointestinal (GI) cancers in the USA: maintaining perioperative and oncologic safety. Surg Endosc 2019; 34:4932-4942. [PMID: 31820161 DOI: 10.1007/s00464-019-07284-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 11/28/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Minimally invasive surgery (MIS) continues to gain traction as a feasible approach for the operative management of gastrointestinal (GI) malignancies. The aim of this study is to quantify national trends, perioperative and oncologic outcomes of MIS for the most common GI malignancies including the esophagus, stomach, pancreas, colon, and rectum. We hypothesize that with more widespread use of MIS techniques, perioperative outcomes and oncologic resection quality will remain preserved. METHODS The National Cancer Database (2010-2014) was utilized to assess perioperative outcomes and pathologic quality of MIS (robotic and laparoscopic) compared to open, in patients who underwent resection for cancers of the esophagus, stomach, pancreas, colon, and rectum. Multilevel logistic regression models were constructed to identify independent factors associated with postoperative and long-term outcomes. RESULTS Data from 11,023 esophageal, 30,664 gastric, 30,689 pancreas, 260,669 colon, and 52,239 rectal resections were analyzed. Although laparoscopy is the most prevalent MIS approach, the number of robotic resections increased nearly fourfold from 2010 to 2014 in all organ sites (increase by factor: esophagus: 3.8, stomach: 4.4, pancreas: 4.4, colon: 3.8 and rectum: 4). The number of laparoscopic resections increased at a slower rate (factor: 1.3-1.9), whereas the number of open resections decreased (factor: 0.67-0.77). Patients who underwent robotic-assisted resections were younger for stomach and colorectal resections and with lower Charlson Comorbidity Index across all sites. Patients who underwent robotic or laparoscopic resections had shorter hospitalizations, fewer readmissions (with the exception of rectal resections) and lower postoperative mortality at 90 days. Robotic-assisted resections had comparable negative margin resections and number of lymph nodes to laparoscopic and open resections across all sites. CONCLUSION The utilization of robotic-assisted resections of GI cancers is rapidly increasing with more frequent use in younger and healthier patients. This study demonstrates that with the rising utilization of robotic-assisted resections, perioperative outcomes and oncologic safety have not been compromised.
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Affiliation(s)
| | - Philip Ituarte
- Department of Surgery, City of Hope National Medical Center, Medical Office Bldg., 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Yanghee Woo
- Department of Surgery, City of Hope National Medical Center, Medical Office Bldg., 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Susanne G Warner
- Department of Surgery, City of Hope National Medical Center, Medical Office Bldg., 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Kurt Melstrom
- Department of Surgery, City of Hope National Medical Center, Medical Office Bldg., 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Jae Kim
- Department of Surgery, City of Hope National Medical Center, Medical Office Bldg., 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Gagandeep Singh
- Department of Surgery, City of Hope National Medical Center, Medical Office Bldg., 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Byrne Lee
- Department of Surgery, City of Hope National Medical Center, Medical Office Bldg., 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Medical Office Bldg., 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Medical Office Bldg., 1500 East Duarte Road, Duarte, CA, 91010, USA.
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Melstrom LG, Eng OS, Raoof M, Singh G, Fong Y, Latorre K, Choi GH, Salem R, Bentrem DJ, Lewandowski R, Makris E, Poultsides G, Dhar VK, Chadalavada S, Shah SA, Johnson AC, Sekhar A, Kies D, Maithel SK, Rocha F, Alseidi A, Hagendoorn J, Borel Rinkes IHM, Fisher AV, Ronnekleiv-Kelly S, Weber SM, Winslow ER, Abbott DE. Is hepatectomy safe following Yttrium-90 therapy? A multi-institutional international experience. HPB (Oxford) 2019; 21:1520-1526. [PMID: 31005493 DOI: 10.1016/j.hpb.2019.03.366] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 01/22/2019] [Accepted: 03/14/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Single institution reports demonstrate variable safety profiles when liver-directed therapy with Yttrium-90 (Y-90) is followed by hepatectomy. We hypothesized that in well-selected patients, hepatectomy after Y90 is feasible and safe. METHODS Nine institutions contributed data for patients undergoing Y90 followed by hepatectomy (2008-2017). Clinicopathologic and perioperative data were analyzed, with 90-day morbidity and mortality as primary endpoints. RESULTS Forty-seven patients were included. Median age was 59 (20-75) and 62% were male. Malignancies treated included hepatocellular cancer (n = 14; 30%), colorectal cancer (n = 11; 23%), cholangiocarcinoma (n = 8; 17%), neuroendocrine (n = 8; 17%) and other tumors (n = 6). The distribution of Y-90 treatment was: right (n = 30; 64%), bilobar (n = 14; 30%), and left (n = 3; 6%). Median future liver remnant (FLR) following Y90 was 44% (30-78). Resections were primarily right (n = 16; 34%) and extended right (n = 14; 30%) hepatectomies. The median time to resection from Y90 was 196 days (13-947). The 90-day complication rate was 43% and mortality was 2%. Risk factors for Clavien-Dindo Grade>3 complications included: number of Y-90-treated lobes (OR 4.5; 95% CI1.14-17.7; p = 0.03), extent of surgery (p = 0.04) and operative time (p = 0.009). CONCLUSIONS These data demonstrate that hepatectomy following Y-90 is safe in well-selected populations. This multi-disciplinary treatment paradigm should be more widely studied, and potentially adopted, for patients with inadequate FLR.
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Lafaro KJ, Melstrom LG. The Paradoxical Web of Pancreatic Cancer Tumor Microenvironment. Am J Pathol 2019; 189:44-57. [PMID: 30558722 DOI: 10.1016/j.ajpath.2018.09.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 08/28/2018] [Accepted: 09/25/2018] [Indexed: 02/07/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is increasing in incidence and is projected to become the second leading cause of cancer death in the United States. Despite significant advances in understanding the disease, there has been minimal increase in PDAC patient survival. PDAC tumors are unique in the fact that there is significant desmoplasia. This generates a large stromal compartment composed of immune cells, inflammatory cells, growth factors, extracellular matrix, and fibroblasts, comprising the tumor microenvironment (TME), which may represent anywhere from 15% to 85% of the tumor. It has become evident that the TME, including both the stroma and extracellular component, plays an important role in tumor progression and chemoresistance of PDAC. This review will discuss the multiple components of the TME, their specific impact on tumorigenesis, and the multiple therapeutic targets.
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Affiliation(s)
- Kelly J Lafaro
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California.
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De Andrade JP, Blakely AM, Nguyen AH, Ituarte PHG, Warner SG, Melstrom LG, Lee B, Singh G. Neuroendocrine Tumors of Meckel's Diverticula: Rare but Fare Well. Am Surg 2019; 85:1125-1128. [PMID: 31657307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Neuroendocrine tumors (NETs) are the most common malignancy arising in Meckel's diverticula (MDs). To date, there are no large series characterizing these tumors. The National Cancer Database was queried for patients with MD NETs (n = 162) from 2004 to 2014. Patient and tumor characteristics as well as outcomes were analyzed. MD NETs were more common in men (72.8%) at a median age of 62 years; 95.1 per cent of patients were white. All patients underwent surgery. Clinical M0 disease was present in 97.4 per cent of patients, and 88.2 per cent of tumors were well differentiated. Lymphovascular invasion was present in 13.2 per cent. Most (60.4%) tumors were less than 10 mm. Lymphadenectomy was performed in 32.9 per cent of patients, with 52.1 per cent of these found to have metastatic lymph node disease. Although most MD NETs are well differentiated, smaller than 10 mm, and do not have lymphovascular invasion, lymph node metastases are commonly found, suggesting that mesenteric lymphadenectomy with adequate resection of the small bowel may be necessary for adequate staging and disease clearance.
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Phan T, Nguyen V, Buettner R, Morales C, D’Alincourt MS, Rosen ST, Melstrom LG. Leflunomide Changes the Tumor Immune Microenvironment and Mitigates Pancreatic Cancer Growth in an Immunocompetent Mouse Model. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Raoof M, Blakely AM, Melstrom LG, Lee B, Warner SG, Chung V, Singh G, Chen Y, Fong Y. Adjuvant chemotherapy versus chemoradiation in high-risk pancreatic adenocarcinoma: A propensity score-matched analysis. Cancer Med 2019; 8:5881-5890. [PMID: 31414566 PMCID: PMC6792522 DOI: 10.1002/cam4.2491] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 12/26/2022] Open
Abstract
PURPOSE The American Society of Clinical Oncology guidelines recommend adjuvant chemoradiation (ACR) for margin-positive (R1) and/or node-positive (N+) pancreatic cancers. Our goal was to investigate if there is evidence of superiority of adjuvant chemoradiation (ACR) over adjuvant chemotherapy (AC). METHODS We utilized data from the National Cancer Database (NCDB) for N+ and/or R1 pancreatic adenocarcinoma patients diagnosed from 2004 to 2012 who underwent ACR or AC. Patients who received neoadjuvant radiation, no adjuvant treatment, or adjuvant radiation alone were excluded. Propensity score nearest-neighbor 1:1 matching (PSM) was performed between ACR and AC groups based on age, sex, race, insurance, year of diagnosis, comorbidities, tumor site and size, T-stage, nodal status, margin status, grade, and treatment facility. Primary outcome was overall survival (OS). RESULTS A total of 8297 patients were eligible. After PSM, two well-balanced groups of 3244 patients each were analyzed. ACR resulted in superior OS compared with AC alone (Hazard ratio [HR] 0.83, 95% CI 0.79-0.87; median OS 22 vs 19 months, P < .0001). Subset analyses demonstrated OS benefit of ACR compared with AC in N+, R0 patients (HR: 0.82, 95% CI 0.77-0.88; Median OS 24 vs 20 months, P < .001) as well as N+, R1 patients (HR: 0.77, 95% CI 0.68-0.87; Median OS 17 vs 15 months, P < .001); but not in node-negative, R1 patients (HR: 1.12, 95% CI 0.84-1.48; Median OS 18 vs 22 months, P = .63). CONCLUSION The addition of radiation to AC was associated with a clinically small but meaningful increase in survival of patients undergoing curative-intent pancreatic resections. This association was not evident in patients with microscopically positive margins but node-negative disease and larger studies will be needed.
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Affiliation(s)
- Mustafa Raoof
- Department of SurgeryCity of Hope National Medical CenterDuarteCalifornia
| | - Andrew M. Blakely
- Department of SurgeryCity of Hope National Medical CenterDuarteCalifornia
| | - Laleh G. Melstrom
- Department of SurgeryCity of Hope National Medical CenterDuarteCalifornia
| | - Byrne Lee
- Department of SurgeryCity of Hope National Medical CenterDuarteCalifornia
| | - Susanne G. Warner
- Department of SurgeryCity of Hope National Medical CenterDuarteCalifornia
| | - Vincent Chung
- Department of Medical OncologyCity of Hope National Medical CenterDuarteCalifornia
| | - Gagandeep Singh
- Department of SurgeryCity of Hope National Medical CenterDuarteCalifornia
| | - Yi‐Jen Chen
- Department of Radiation OncologyCity of Hope National Medical CenterDuarteCalifornia
| | - Yuman Fong
- Department of SurgeryCity of Hope National Medical CenterDuarteCalifornia
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Lafaro KJ, Eng OS, Raoof M, Ituarte P, Warner SG, Singh G, Fong Y, Melstrom LG. A prognostic nomogram for patients with resected fibrolamellar hepatocellular carcinoma. Hepatobiliary Surg Nutr 2019; 8:338-344. [PMID: 31489303 DOI: 10.21037/hbsn.2019.05.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Fibrolamellar hepatocellular carcinoma (FLHC) is a unique entity compared to conventional hepatocellular carcinoma. The aim of this study was to examine post-resection outcomes and prognostic indicators for survival in this group of FLHC patients. Methods A retrospective analysis of the National Cancer Database (NCDB) for patients with FLHC who underwent resection from 2004 to 2014 was performed. Univariate and multivariate Cox proportional hazard models were used to identify factors associated with overall survival, and a prognostic nomogram was generated. Results There were 197 patients identified, 171 (86.8%) of whom had long-term follow-up data. Univariate and multivariate analyses were performed using patient and tumor demographics with the outcome variable of overall survival. On multivariate analysis, age [hazard ratio (HR) 1.03, P=0.003], vascular invasion (HR 1.75, P=0.05), tumor size >7 cm (HR 2.18, P=0.044), multifocal disease (HR 3.34, P=0.002), and node positive (pN+) disease (HR 2.75, P=0.003) were all negative predictors of overall survival. A prognostic nomogram was generated using these factors with a c-statistic superior to that of American Joint Committee on Cancer (AJCC) staging (0.710 vs. 0.654). Conclusions Independent predictors of decreased overall survival in patients with FLHC include age, vascular invasion, tumor size >7 cm, multifocal disease, and pN+ disease. This is the first study to develop a nomogram exclusively for FLHC that may predict survival in future studies.
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Affiliation(s)
- Kelly J Lafaro
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Oliver S Eng
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Philip Ituarte
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Susanne G Warner
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Gagandeep Singh
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
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Blakely AM, Wong P, Chu P, Warner SG, Raoof M, Singh G, Fong Y, Melstrom LG. Intraoperative bile spillage is associated with worse survival in gallbladder adenocarcinoma. J Surg Oncol 2019; 120:603-610. [PMID: 31292970 DOI: 10.1002/jso.25617] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/21/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Gallbladder adenocarcinoma is often incidentally identified following cholecystectomy. We hypothesized that intraoperative bile spillage would be a negative prognostic factor. METHODS A retrospective review of patients treated at a cancer center with histologically confirmed gallbladder adenocarcinoma, 2009-2017, was performed. Patient, disease, and treatment factors were analyzed in terms of progression-free survival (PFS) and overall survival (OS). RESULTS Sixty-six patients were identified. Tumor stage was T1 (n = 8, 12%), T2 (n = 23, 35%), T3 (n = 35, 53%). Node stage was N0 (n = 22, 33%), N1+ (n = 26, 39%), Nx (n = 18, 27%). Operations included cholecystectomy alone (n = 27, 36%), cholecystectomy and partial hepatectomy (n = 30, 45%), or hepaticojejunostomy (n = 9, 14%). Median PFS was 7 months (interquartile range [IQR], 2-19); median OS was 16 months (IQR, 10-31). Subset multivariate proportional hazards regression of 41 patients who underwent initial cholecystectomy showed decreased PFS was associated with intraoperative spillage (n = 12, 29%; hazard ratio [HR], 5.5; P = .0014); decreased OS was associated with drain placement (n = 21, 51%; HR, 8.1; P = .006). CONCLUSIONS Intraoperative bile spillage and surgical drain placement at initial cholecystectomy are negatively associated with PFS and OS in gallbladder adenocarcinoma. Explicit documentation of spillage and drain placement rationale is critical, possibly indicating locally advanced disease and prompting stronger consideration of systemic therapy before definitive resection.
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Affiliation(s)
- Andrew M Blakely
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Paul Wong
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Peiguo Chu
- Department of Pathology, City of Hope National Medical Center, Duarte, California
| | - Susanne G Warner
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Gagandeep Singh
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California
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Buettner R, Morales C, Wu X, Sanchez JF, Li H, Melstrom LG, Rosen ST. Leflunomide Synergizes with Gemcitabine in Growth Inhibition of PC Cells and Impairs c-Myc Signaling through PIM Kinase Targeting. Mol Ther Oncolytics 2019; 14:149-158. [PMID: 31211245 PMCID: PMC6562366 DOI: 10.1016/j.omto.2019.04.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/30/2019] [Indexed: 02/07/2023]
Abstract
The immunosuppressive agent leflunomide has been used in the treatment of over 300,000 patients with rheumatoid arthritis. Its active metabolite, teriflunomide (Ter), directly inhibits dihydroorotate dehydrogenase (DHODH), an enzyme involved in nucleoside synthesis. We report that Ter not only shows in vitro anti-proliferative activity in pancreatic cancer (PC) cells as a single agent but also synergizes with the chemotherapeutic gemcitabine (Gem) in growth inhibition of PC cells. The growth-inhibitory effects of Ter are not solely caused by inhibition of DHODH. Through a kinase screening approach, we identified the PIM-3 serine-threonine kinase as a novel direct target. Subsequent dose-response kinase assays showed that Ter directly inhibited all three PIM family members, with the highest activities against PIM-3 and -1. The PIM-3 kinase was the PIM family member most often associated with PC oncogenesis and was also the kinase inhibited the most by Ter among more than 600 kinases investigated. Ter in PC cells induced changes in phosphorylation and expression of PIM downstream targets, consistent with the effects achieved by overexpression or downregulation of PIM-3. Finally, pharmacological inhibition of PIM proteins not only diminished PC cell proliferation, but also small-molecule pan-PIM and PIM-3 inhibitors synergized with Gem in growth inhibition of PC cells.
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Affiliation(s)
- Ralf Buettner
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Corey Morales
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Xiwei Wu
- Integrative Genomics Core, Department of Molecular Medicine, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - James F Sanchez
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Hongzhi Li
- Department of Computational Therapeutics, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Steven T Rosen
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA 91010, USA
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Phan T, Nguyen VH, D'Alincourt MS, Manuel ER, Kaltcheva T, Tsai W, Blazar BR, Diamond DJ, Melstrom LG. Salmonella-mediated therapy targeting indoleamine 2, 3-dioxygenase 1 (IDO) activates innate immunity and mitigates colorectal cancer growth. Cancer Gene Ther 2019; 27:235-245. [PMID: 30824815 PMCID: PMC8177749 DOI: 10.1038/s41417-019-0089-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [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: 12/18/2018] [Revised: 01/30/2019] [Accepted: 02/10/2019] [Indexed: 12/19/2022]
Abstract
Patients with colon cancer remain largely refractory to current immunotherapeutic strategies. This is, in part, due to the overexpression of the immune checkpoint protein indoleamine 2,3-dioxygenase 1 (IDO). IDO is an important enzyme contributing to tumor-mediated immunosuppression and also correlates with poor prognosis in colon cancer patients. The aim of this study was to assess the therapeutic efficacy of attenuated Salmonella typhimurium delivering an shRNA plasmid targeting IDO (shIDO-ST) in two mouse models of colorectal cancer. In vitro, the CT26 and MC38 murine colon cancer cell lines were shown to upregulate IDO expression following stimulation with interferon-γ (IFN-γ) and tumor necrosis factor-α (TNF-α). Transfection of both cell lines with shIDO plasmid reduced IDO protein expression and function. In vivo, shIDO-ST treatment significantly delayed CT26 and MC38 tumor progression compared to mice treated with scrambled shRNA control (shScr-ST) or the clinically-tested IDO inhibitor epacadostat. Increased tumor infiltration of neutrophils was found to be the primary immune cell population associated with shIDO-ST treatment, suggesting robust activation of innate immunity. Although increased tumor expression of IDO is associated with resistance to antibody therapy against programed cell death-1 (anti-PD1), co-administration of anti-PD1 with shIDO-ST did not provide additional tumor growth control in either model of colorectal cancer. Altogether, we demonstrate that treatment with shIDO-ST markedly delays tumor growth in two immunocompetent colorectal mouse models and this appears to be a superior therapeutic strategy compared to epacadostat or blocking anti-PD1 antibody therapy in colon cancer.
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Affiliation(s)
- Thuy Phan
- Department of Immuno-Oncology, Beckman Research Institute of the City of Hope, Duarte, CA, USA
| | - Vu H Nguyen
- Department of Hematology, City of Hope National Medical Center, Duarte, CA, USA
| | | | - Edwin R Manuel
- Department of Immuno-Oncology, Beckman Research Institute of the City of Hope, Duarte, CA, USA
| | - Teodora Kaltcheva
- Department of Hematology, City of Hope National Medical Center, Duarte, CA, USA
| | - Weimin Tsai
- Department of Hematology, City of Hope National Medical Center, Duarte, CA, USA
| | - Bruce R Blazar
- Department of Pediatrics, Division of Blood and Marrow Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Don J Diamond
- Department of Hematology, City of Hope National Medical Center, Duarte, CA, USA
| | - Laleh G Melstrom
- Department of Immuno-Oncology, Beckman Research Institute of the City of Hope, Duarte, CA, USA. .,Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA.
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Melstrom LG, Tzeng CWD. Metastatic colorectal cancer: The reality of the present and the optimism of the future. J Surg Oncol 2019; 119:547-548. [PMID: 30806484 DOI: 10.1002/jso.25427] [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: 02/11/2019] [Accepted: 02/11/2019] [Indexed: 11/08/2022]
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Raoof M, Jutric Z, Melstrom LG, Lee B, Li D, Warner SG, Fong Y, Singh G. Prognostic significance of Chromogranin A in small pancreatic neuroendocrine tumors. Surgery 2018; 165:760-766. [PMID: 30447803 DOI: 10.1016/j.surg.2018.10.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 07/26/2018] [Revised: 10/03/2018] [Accepted: 10/15/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The incidence of nonfunctional pancreatic neuroendocrine tumors ≤2cm is rising. The biologic behavior of these tumors is variable; thus, their management remains controversial. Chromogranin A upregulation is a useful diagnostic biomarker of neuroendocrine tumors; however, the prognostic significance of Chromogranin A is unclear. The objective of this study was to determine whether Chromogranin A levels have prognostic value in pancreatic neuroendocrine tumor patients and may help guide management. METHODS We evaluated the National Cancer Database over a 10-year period (2004-2013). Patients with pancreatic neuroendocrine tumors measuring ≤2cm, without distant metastases, were identified and categorized as Chromogranin A high (>420ng/mL) or Chromogranin A low (≤420ng/mL), and those lacking data on Chromogranin A levels were excluded from the study. Univariate and multivariate analyses were performed using Cox proportional hazards model. Cut-point determination was performed using the Contal and O'Quigley method. RESULTS Of the 445 eligible patients, 352 (79%) were Chromogranin A low and 93 (21%) were Chromogranin A high. Median Chromogranin A level was 71ng/mL (interquartile range, 24-294ng/mL). Chromogranin levels were associated with clinical nodal status and grade. Furthermore, on multivariate analysis, Chromogranin A levels (Chromogranin A high versus Chromogranin A low) independently predicted overall survival after controlling for tumor size, grade, clinical nodal status, and academic status of the facility (hazard ratio: 7.90, 95%CI: 2.34-26.69, P = .001). The greatest benefit of surgical resection was noted in patients in the Chromogranin A high subgroup (log-rank P <.001). CONCLUSION Serum Chromogranin A levels can be incorporated in surgical decision-making for patients with small pancreatic neuroendocrine tumors. Patients in the Chromogranin A low group can be considered for observation, whereas patients in the Chromogranin A high group should be strongly considered for resection.
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Affiliation(s)
- Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Zeljka Jutric
- Department of Surgery, University of California, Irvine, CA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Byrne Lee
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Daneng Li
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA
| | - Susanne G Warner
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Gagandeep Singh
- Department of Surgery, City of Hope National Medical Center, Duarte, CA.
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LaRocca CJ, Wong P, Eng OS, Raoof M, Warner SG, Melstrom LG. Academic productivity in surgical oncology: Where is the bar set for those training the next generation? J Surg Oncol 2018; 118:397-402. [PMID: 30125359 DOI: 10.1002/jso.25143] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 05/31/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Promotion and tenure are important milestones for academic surgical oncologists. The aim of this study was to quantify academic metrics associated with rank in surgical oncologists training the next generation. METHODS Faculty were identified from accredited surgical oncology fellowships in the United States. Scopus was used to obtain the number of publications/citations and h-index values. The National Institutes of Health (NIH) RePORT website was used to identify funding history. RESULTS Of the 319 surgeons identified, complete rank information was obtained for 308. The majority of faculty were men (70%) and only 11% of full professors were women. The median h-index values were 7, 17, and 39 for assistant, associate, and full professors, respectively. While 50% of full professors had a history of NIH funding, only 26% had RO1s and 20% had current NIH funding. Using multivariate analysis, years in practice, h-index, and a history of NIH funding were associated with academic rank (P < .05). CONCLUSION Objective benchmarks, such as the median h-index and NIH funding, provide additional insights for both junior faculty and leadership into the productivity needed to attain promotion to the next academic rank for surgical oncologists.
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Affiliation(s)
- Christopher J LaRocca
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Paul Wong
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Oliver S Eng
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Mustafa Raoof
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Susanne G Warner
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Laleh G Melstrom
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
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