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Bou-Samra P, Singhal S. Precision Oncology in Lung Cancer Surgery. Surg Oncol Clin N Am 2024; 33:311-320. [PMID: 38401912 DOI: 10.1016/j.soc.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2024]
Abstract
Precision in lung cancer surgery is our ability to use the most cutting edge and up to date information to provide personalized and targeted surgical care to our patients. It aims to tailor patient care to patient and tumor characteristics and susceptibilities as well as to optimize the ways treatments are administered. This may include specific perioperative medical treatment, changing operative techniques to more minimally invasive ones if the situation permits, performing sub-anatomical surgeries when possible, and using innovative tumor visualization methods to enhance detection of previously occult disease to ultimately decrease the extent of the planned resection.
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Affiliation(s)
- Patrick Bou-Samra
- The University of Pennsylvania - Stemmler Hall, 3450 Hamilton Walk, Philadelphia, PA 19104, USA
| | - Sunil Singhal
- Department of Thoracic Surgery, Perelman School of Medicine, University of Pennsylvania, 14th Floor PCAM South Tower, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Bou-Samra P, Kneuertz PJ. Advances in the clinical use of patient-reported outcomes in thoracic surgery. Curr Opin Anaesthesiol 2024; 37:75-78. [PMID: 38085875 DOI: 10.1097/aco.0000000000001326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
PURPOSE OF REVIEW Patient-reported outcomes (PROs) are increasingly recognized as a clinical tool for measuring and improving patient-centric care. This review provides a summary on recent advances in the use of PROs in the field of thoracic surgery. RECENT FINDINGS PROs have been used as primary endpoints in clinical trials and observational studies evaluating clinical care pathways and quantifying the benefits of minimally invasive surgical techniques for patients undergoing lung surgery. Qualitative and quantitative research has yielded fundamental insights into which PRO domains are meaningful and valued by patients after lung surgery. Patient experience and recovery after esophagectomy have been further characterized by using PROs. New disease-specific survey tools for patients have been developed to track long-term symptoms after esophageal reconstruction. Patient satisfaction has emerged as the key metric used to gauge the patient centeredness of hospital systems. SUMMARY Advances have been made in the application of PROs in multiple areas of thoracic surgery, which include lung and esophageal surgery. The growing focus on the use of PROs in clinical pathways has led to a better understanding on how to optimize patient experience.
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Affiliation(s)
- Patrick Bou-Samra
- Division of Thoracic Surgery, The Ohio State University Wexner Medical Center
| | - Peter J Kneuertz
- Division of Thoracic Surgery, The Ohio State University Wexner Medical Center
- Ohio State University Comprehensive Cancer Center- James and Solove Research Institute, Columbus, Ohio, USA
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Bou-Samra P, Joffe J, Chang A, Guo E, Segil A, Azari F, Kennedy G, Din A, Hwang WT, Singhal S. Preoperative predictors of successful tumour localization by intraoperative molecular imaging with pafolacianine in lung cancer to create predictive nomogram. Eur J Cardiothorac Surg 2024; 65:ezad392. [PMID: 38191994 DOI: 10.1093/ejcts/ezad392] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/17/2023] [Accepted: 01/05/2024] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVES Intraoperative molecular imaging (IMI) uses cancer-targeted fluorescent probe to locate nodules. Pafolacianine is a Food and Drug Administration-approved fluorescent probe for lung cancer. However, it has a 8-12% false negative rate for localization. Our goal is to define preoperative predictors of tumour localization by IMI. METHODS We performed a retrospective review of patients who underwent IMI using pafolacianine for lung lesions from June 2015 to August 2019. Candidate predictors including sex, age, body mass index, smoking history, tumour size, distance of tumour from surface, use of neoadjuvant therapy and positron emission tomography avidity were included. The outcome was fluorescence in vivo and comprehensively included those who were true or false positives negatives. Multiple imputation was used to handle the missing data. The final model was evaluated using the area under the receiver operating characteristic curve. RESULTS Three hundred nine patients were included in our study. The mean age was 64 (standard deviation 13) and 68% had a smoking history. The mean distance of the tumours from the pleural surface was 0.4 cm (standard deviation 0.6). Smoking in pack-years and distance from pleura had an odds ratio of 0.99 [95% confidence interval: 0.98-0.99; P = 0.03] and 0.46 [95% confidence interval: 0.27-0.78; P = 0.004], respectively. The final model had an area under the receiver operating characteristic curve of 0.68 and was used to create a nomogram that gives a probability of fluorescence in vivo. CONCLUSIONS Primary tumours that are deeper from the pleural surface, especially in patients with a higher pack-years, are associated with a decreased likelihood of intraoperative localization. We identified a nomogram to predict the likelihood of tumour localization with IMI with pafolacianine.
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Affiliation(s)
- Patrick Bou-Samra
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jonah Joffe
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics (DBEI), The University of Pennsylvania, Philadelphia, PA, USA
| | - Austin Chang
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Emily Guo
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alix Segil
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Feredun Azari
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gregory Kennedy
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Azra Din
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Wei-Ting Hwang
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics (DBEI), The University of Pennsylvania, Philadelphia, PA, USA
| | - Sunil Singhal
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Bou-Samra P, Chang A, Guo E, Azari F, Kennedy G, Santini JT, Bensen ES, Jarrar D, Singhal S. Cathepsin detection to identify malignant cells during robotic pulmonary resection. Transl Lung Cancer Res 2023; 12:2370-2380. [PMID: 38205214 PMCID: PMC10775009 DOI: 10.21037/tlcr-23-370] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/25/2023] [Indexed: 01/12/2024]
Abstract
Background Intraoperative molecular imaging (IMI) uses a fluorescent probe to identify occult cancers. VGT-309 is a quenched activity-based probe that is activated in the presence of cathepsins, enzymes overexpressed in cancer cells, and detected by near-infrared (NIR) light. This study aims to evaluate the sensitivity and the positive predictive value (PPV) of robotic-assisted thoracic surgery (RATS) with intraoperative molecular imaging (RIMI) using VGT-309 to localize tumors using NIR light to detect areas with increased cathepsin activity. Our secondary outcome was to compare RIMI to video-assisted thoracic surgery (VATS) with intraoperative molecular imaging (VIMI). Methods In a phase 2 clinical trial at the University of Pennsylvania, patients (n=10) with suspicious pulmonary lesions underwent RATS. First, white light was used followed by RIMI to identify tissues with increased cathepsin activity. Then, VIMI was performed to compare the sensitivity and PPV in identifying the cathepsin activity. The resected specimens were then evaluated for fluorescence and underwent histopathological analysis for cathepsin expression. Image analysis was performed using ImageJ software. Statistical analysis was conducted using IBM SPSS Statistics software. A P value of 0.05 or less was considered significant. Results RATS with white light identified 6 out of the 10 pulmonary nodules, whereas adding RIMI identified an additional 4 more pulmonary nodules. RIMI and VIMI were able to detect the same 8/10 (80%) nodules. The addition of VIMI did not identify any lesions that RIMI may have missed. The mean fluorescence intensity of tumors visualized by RIMI was 115.81 A.U. [standard deviation (SD) =58.57] compared to 95.6 A.U. (SD =14.81) by VIMI (P=0.41). The mean tumor-to-background ratios (TBR) of tumors visualized by RIMI was 9.20 (SD =9.12) compared to 2.29 A.U. (SD =1.11) using VIMI (P=0.1). The sensitivity of RIMI and VIMI was 88.9% which was superior to that of RATS (55.6%). The PPV of RATS was 83.3% compared to 100% in RIMI and VIMI. Conclusions RIMI is a valuable option for visualization of occult disease using VGT-309-guided IMI through identifying areas of increased cathepsin activity. In this small series, RIMI and VIMI showed clinical equivalence in sensitivity and PPV of detecting cathepsin activity.
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Affiliation(s)
- Patrick Bou-Samra
- Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
| | - Austin Chang
- Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
| | - Emily Guo
- Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
| | - Feredun Azari
- Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
| | - Gregory Kennedy
- Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
| | | | | | - Doraid Jarrar
- Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
| | - Sunil Singhal
- Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
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Kennedy GT, Azari FS, Chang A, Chang A, Bou-Samra P, Desphande C, Delikatny EJ, Eruslanov E, Kucharczuk JC, Rice DC, Singhal S. A pH-Activatable Nanoprobe Labels Diverse Histologic Subtypes of Human Lung Cancer During Resection. Mol Imaging Biol 2023; 25:824-832. [PMID: 37697109 DOI: 10.1007/s11307-023-01853-2] [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: 05/01/2023] [Revised: 08/02/2023] [Accepted: 08/15/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Intraoperative molecular imaging (IMI) uses tumor-targeted optical contrast agents to improve identification and clearance of cancer during surgery. Recently, pH-activatable contrast agents have been developed but none has been tested in lung cancer. Here, we report the successful clinical translation of pegsitacianine (ONM-100), a pH-activatable nanoprobe, for fluorescence-guided lung cancer resection. METHODS We first characterized the pH setpoint for pegsitacianine fluorescence activation in vitro. We then optimized the specificity, dosing, and timing of pegsitacianine in murine flank xenograft models of lung adenocarcinoma and squamous cell carcinoma. Finally, we tested pegsitacianine in humans undergoing lung cancer surgery as part of an ongoing phase 2 trial. RESULTS We found that the fluorescence activation of pegsitacianine occurred below physiologic pH in vitro. Using preclinical models of lung cancer, we found that the probe selectively labeled both adenocarcinoma and squamous cell carcinoma xenografts (mean tumor-to-background ratio [TBR] > 2.0 for all cell lines). In the human pilot study, we report cases in which pegsitacianine localized pulmonary adenocarcinoma and pulmonary squamous cell carcinoma (TBRs= 2.7 and 2.4) in real time to illustrate its successful clinical translation and potential to improve surgical management. CONCLUSIONS This translational study demonstrates the feasibility of pegsitacianine as an IMI probe to label the two most common histologic subtypes of human lung cancer.
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Affiliation(s)
- Gregory Thomas Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Civic Center Boulevard, 14th Floor, South Pavilion, Philadelphia, PA, 19104, USA
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Civic Center Boulevard, 14th Floor, South Pavilion, Philadelphia, PA, 19104, USA
| | - Ashley Chang
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Civic Center Boulevard, 14th Floor, South Pavilion, Philadelphia, PA, 19104, USA
| | - Austin Chang
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Civic Center Boulevard, 14th Floor, South Pavilion, Philadelphia, PA, 19104, USA
| | - Patrick Bou-Samra
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Civic Center Boulevard, 14th Floor, South Pavilion, Philadelphia, PA, 19104, USA
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Edward J Delikatny
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Evgeniy Eruslanov
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Civic Center Boulevard, 14th Floor, South Pavilion, Philadelphia, PA, 19104, USA
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Civic Center Boulevard, 14th Floor, South Pavilion, Philadelphia, PA, 19104, USA
| | - David C Rice
- Department of Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Civic Center Boulevard, 14th Floor, South Pavilion, Philadelphia, PA, 19104, USA.
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Bou-Samra P, Chang A, Singhal S, Itkin M. Fluorescence-guided surgery with indocyanine green to identify an idiopathic chyle leak-case report. AME Case Rep 2023; 7:41. [PMID: 37942032 PMCID: PMC10628415 DOI: 10.21037/acr-23-53] [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] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/18/2023] [Indexed: 11/10/2023]
Abstract
Background Chylothorax is the leakage of chyle into the pleural space and is associated with up to 50% morbidity. Although, the identification of traumatic chylothoraces is well described, non-traumatic chylothoraxes, mostly idiopathic, present therapeutic challenges as they are difficult to localize. We describe an attempt at localizing and treating an idiopathic chylothorax refractory to conservative and minimally invasive techniques. This was done using indocyanine green (ICG) and was a joint case between a thoracic surgeon and an interventional radiologist. Case Description A 50-year-old female with a recent history of coronavirus disease (COVID)-19 presented with shortness of breath. She was found to have a right pleural effusion and was admitted to the hospital, where a chest tube was inserted and pleural fluid analysis confirmed the diagnosis of a chylothorax. Conservative management was attempted but with little success. Initial magnetic resonance lymphangiogram (MRL) revealed abnormal enhancing lymphatic masses in the right paraspinal thoracic space as well as lympho-venous junction obstruction with large neck collaterals. She then underwent percutaneous lympho-venous junction angioplasty followed by multiple rounds of glue embolization without clinical improvement. The decision was then made to proceed with a thoracotomy, identification of the site of thoracic duct (TD) leakage, and a mechanical pleurodesis assisted by intraoperative imaging. Ten mg of ICG was injected into the inguinal lymph nodes. Using a camera capable of detection of near-infrared (NIR) light, we were able to visualize the site from which the ICG was extravasating in the chest. Glue was then injected in that area to further help in reducing the leak. After keeping her nil per os (NPO) and requiring one more ligation, a repeat MRL showed a markedly decreased leak into the right pleural space. Two weeks later, she was seen in clinic and reported significant improvement in her symptoms. Conclusions This is the case of a 50-year-old female who was found to have a significant right chylothorax. She underwent conservative management, followed by tube thoracostomy, and TD ligation but was refractory to treatment. Fluorescence-guided surgery was pivotal to localize the leakage site and help seal it intraoperatively.
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Affiliation(s)
- Patrick Bou-Samra
- Department of Thoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Austin Chang
- Department of Thoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Thoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Maxim Itkin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
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Bou-Samra P, Chang A, Kelly N, Yudien M, Galandarova A, Ibrahimli A, Kennedy GT, Azari F. Ground-glass opacities: a problem bound to get more challenging. Quant Imaging Med Surg 2023; 13:5447-5450. [PMID: 37581032 PMCID: PMC10423360 DOI: 10.21037/qims-23-797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 06/12/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Patrick Bou-Samra
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Surgery, Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Austin Chang
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nicholas Kelly
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mikhal Yudien
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Aysuna Galandarova
- Department of Surgery, Ankara Yildirim Beyazit Faculty of Medicine, Ankara, Turkey
| | - Arturan Ibrahimli
- Department of Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gregory T. Kennedy
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Feredun Azari
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Azari F, Zhang K, Kennedy G, Bou-Samra P, Chang A, Nadeem B, Chang A, Galandarova A, Ibrahimli A, Karimov Z, Din A, Kucharczuk J, Doraid J, Pechet T, Delikatny E, Singhal S. Prospective validation of tumor folate receptor expression density with the association of pafolacianine fluorescence during intraoperative molecular imaging-guided lung cancer resections. Eur J Nucl Med Mol Imaging 2023; 50:2453-2465. [PMID: 36905412 PMCID: PMC10314365 DOI: 10.1007/s00259-023-06141-3] [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: 10/08/2022] [Accepted: 02/08/2023] [Indexed: 03/12/2023]
Abstract
PURPOSE Pafolacianine, a folate receptor alpha-targeted NIR tracer, has demonstrated clear efficacy in intraoperative molecular imaging-guided (IMI) lung cancer surgery. However, the selection of patients who would benefit from IMI remains challenging given the variability of fluorescence with patient-associated and histopathologic factors. Our goal in this study was to prospectively evaluate whether preoperative FRα/FRβ staining can predict pafolacianine-based fluorescence during real-time lung cancer resections. METHODS This was a prospective study conducted between 2018 and 2022 that reviewed core biopsy and intraoperative data from patients with suspected lung cancer. A total of 196 patients were deemed eligible, of whom core biopsies were taken from 38 patients and assessed for FRα and FRβ expression by immunohistochemistry (IHC). All patients underwent infusion of pafolacianine 24 h prior to surgery. Intraoperative fluorescence images were captured with the VisionSense bandpass filter-enabled camera. All histopathologic assessments were performed by a board-certified thoracic pathologist. RESULTS Of the 38 patients, 5 (13.1%) were found to have benign lesions (necrotizing granulomatous inflammation, lymphoid aggregates) and 1 had metastatic non-lung nodule. Thirty (81.5%) had malignant lesions, with the vast majority (23, 77.4%) being lung adenocarcinoma (7 (22.5%) SCC). None of the benign tumors (0/5, 0%) exhibited in vivo fluorescence (mean TBR of 1.72), while 95% of the malignant tumors fluoresced (mean TBR of 3.11 ± 0.31) compared to squamous cell carcinoma (1.89 ± 0.29) of the lung and sarcomatous lung metastasis (2.32 ± 0.09) (p < 0.01). The TBR was significantly higher in the malignant tumors (p = 0.009). The median FRα and FRβ staining intensities were both 1.5 for benign tumors, while the FRα and FRβ staining intensities were 3 and 2 for malignant tumors, respectively. Increased FRα expression was significantly associated with the presence of fluorescence (p = 0.01), CONCLUSION: This prospective study sought to determine whether preoperative FRα and FRβ expression on core biopsy IHC correlates with intraoperative fluorescence during pafolacianine-guided surgery. These results, although of small sample size, including limited non-adenocarcinoma cohort, suggest that performing FRα IHC on preoperative core biopsies of adenocarcinomas as compared to squamous cell carcinomas could provide low-cost, clinically useful information for optimal patient selection which should be further explored in advanced clinical trials.
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Affiliation(s)
- Feredun Azari
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Kevin Zhang
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gregory Kennedy
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Patrick Bou-Samra
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
- Ohio State University School of Medicine, Ohio, Columbus, USA
| | - Ashley Chang
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Bilal Nadeem
- Ankara Yildirim Beyazit Faculty of Medicine, Ankara, Turkey
| | - Austin Chang
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | | | | | - Ziya Karimov
- Faculty of Medicine, Ege University, Izimir, Turkey
| | - Azra Din
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - John Kucharczuk
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Jarrar Doraid
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Taine Pechet
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Edward Delikatny
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA.
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Bou-Samra P, Chang A, Arambepola S, Guo E, Azari F, Kennedy G, Segil A, Singhal S. Preclinical Lymph Node Model for Intraoperative Molecular Imaging of Cancer. Res Sq 2023:rs.3.rs-2953015. [PMID: 37398120 PMCID: PMC10312951 DOI: 10.21203/rs.3.rs-2953015/v1] [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] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Purpose Lymph node(LN) dissection is part of most oncologic resections. Intraoperatively identifying a positive LN(+ LN), that harbors malignant cells, can be challenging. We hypothesized that intraoperative molecular imaging(IMI) using a cancer-targeted fluorescent prober can identify + LNs. This study aimed to develop a preclinical model of a + LN and test it using an activatable cathepsin-based enzymatic probe, VGT-309. Procedures In the first model, we used peripheral blood mononuclear cells (PBMC), representing the lymphocytic composition of the LN, mixed with different concentrations of human lung adenocarcinoma cell line A549. Then, they were embedded in a Matrigel® matrix. A black dye was added to mimic LN anthracosis. Model two was created using a murine spleen, the largest lymphoid organ, injected with various concentrations of A549. To test these models, we co-cultured A549 cells with VGT-309. Mean fluorescence intensity(MFI) was. An independent sample t-test was used to compare the average MFI of each A549:negative control ratio. Results A significant difference in MFI from our PBMC control was noted when A549 cells were 25% of the LN (p = 0.046) in both 3D cell aggregate models-where the LNs native parenchyma is replaced and the one where the tumor grows over the native parenchyma. For the anthracitic equivalents of these models, the first significant MFI compared to the control was when A549 cells were 9% of the LN (p = 0.002) in the former model, and 16.7% of the LN (p = 0.033) in the latter. In our spleen model, we first noted significance in MFI when A549 cells were 16.67% of the cellular composition.(p = 0.02). Conclusions A + LN model allows for a granular evaluation of different cellular burdens in + LN that can be assessed using IMI. This first exvivo + LN model can be used in preclinical testing of several existing dyes and in creating more sensitive cameras for IMI-guided LN detection.
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Affiliation(s)
| | - Austin Chang
- University of Pennsylvania Perelman School of Medicine
| | | | - Emily Guo
- University of Pennsylvania Perelman School of Medicine
| | - Feredun Azari
- University of Pennsylvania Perelman School of Medicine
| | | | - Alix Segil
- University of Pennsylvania Perelman School of Medicine
| | - Sunil Singhal
- University of Pennsylvania Perelman School of Medicine
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Bou-Samra P, Muhammad N, Chang A, Karsalia R, Azari F, Kennedy G, Stummer W, Tanyi J, Martin L, Vahrmeijer A, Smith B, Rosenthal E, Wagner P, Rice D, Lee A, Abdelhafeez A, Malek MM, Kohanbash G, Barry Edwards W, Henderson E, Skjøth-Rasmussen J, Orosco R, Gibbs S, Farnam RW, Shankar L, Sumer B, Kumar ATN, Marcu L, Li L, Greuv V, Delikatny EJ, Lee JYK, Singhal S. Intraoperative molecular imaging: 3rd biennial clinical trials update. J Biomed Opt 2023; 28:050901. [PMID: 37193364 PMCID: PMC10182831 DOI: 10.1117/1.jbo.28.5.050901] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/18/2023]
Abstract
Significance This third biennial intraoperative molecular imaging (IMI) conference shows how optical contrast agents have been applied to develop clinically significant endpoints that improve precision cancer surgery. Aim National and international experts on IMI presented ongoing clinical trials in cancer surgery and preclinical work. Previously known dyes (with broader applications), new dyes, novel nonfluorescence-based imaging techniques, pediatric dyes, and normal tissue dyes were discussed. Approach Principal investigators presenting at the Perelman School of Medicine Abramson Cancer Center's third clinical trials update on IMI were selected to discuss their clinical trials and endpoints. Results Dyes that are FDA-approved or currently under clinical investigation in phase 1, 2, and 3 trials were discussed. Sections on how to move benchwork research to the bedside were also included. There was also a dedicated section for pediatric dyes and nonfluorescence-based dyes that have been newly developed. Conclusions IMI is a valuable adjunct in precision cancer surgery and has broad applications in multiple subspecialties. It has been reliably used to alter the surgical course of patients and in clinical decision making. There remain gaps in the utilization of IMI in certain subspecialties and potential for developing newer and improved dyes and imaging techniques.
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Affiliation(s)
- Patrick Bou-Samra
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Najib Muhammad
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Austin Chang
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Ritesh Karsalia
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Feredun Azari
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Gregory Kennedy
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Walter Stummer
- University of Muenster, Department of Neurosurgery, Muenster, Germany
| | - Janos Tanyi
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Linda Martin
- University of Virginia, School of Medicine, Charlottesville, Virginia, United States
| | | | - Barbara Smith
- Harvard University, School of Medicine, Boston, Massachusetts, United States
| | - Eben Rosenthal
- Stanford University, School of Medicine, Stanford, California, United States
| | - Patrick Wagner
- Allegheny Health Network, Pittsburgh, Pennsylvania, United States
| | - David Rice
- University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Amy Lee
- Seattle’s Children’s Hospital, Seattle, Washington, United States
| | | | - Marcus M. Malek
- Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Gary Kohanbash
- The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | | | - Eric Henderson
- Dartmouth College, Geisel School of Medicine, Hanover, New Hampshire, United States
| | | | - Ryan Orosco
- The University of New Mexico Medical Center, Albuquerque, New Mexico
| | - Summer Gibbs
- Oregon Health & Science University, Knight Cancer Institute, School of Medicine, Portland, Oregon, United States
| | | | - Lalitha Shankar
- National Institute of Health, Bethesda, Maryland, United States
| | - Baran Sumer
- University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Anand T. N. Kumar
- Harvard University, School of Medicine, Boston, Massachusetts, United States
| | - Laura Marcu
- University of California Davis, School of Medicine, Sacramento, California, United States
| | - Lei Li
- California Institute of Technology, Pasadena, California, United States
| | - Victor Greuv
- University of Illinois at Urbana-Champaign, Urbana-Champaign, United States
| | - Edward J. Delikatny
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - John Y. K. Lee
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Sunil Singhal
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
- Address all correspondence to Sunil Singhal,
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Bou-Samra P, Chang A, Azari F, Kennedy G, Segil A, Guo E, Marmarelis M, Langer C, Singhal S. Epidemiological, therapeutic, and survival trends in malignant pleural mesothelioma: A review of the National Cancer Database. Cancer Med 2023. [PMID: 37062067 DOI: 10.1002/cam4.5915] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/09/2023] [Accepted: 03/27/2023] [Indexed: 04/17/2023] Open
Abstract
BACKGROUND Malignant pleural mesothelioma (MPM) is an aggressive cancer of the cells lining the pleural cavity with a low overall incidence. The National Cancer Database (NCDB) released in August 2022 updated data that reflect the newest trends in MPM. METHODS The NCDB was queried for patients diagnosed with MPM between 2004 and 2020. Variables collected included demographics, tumor characteristics, and treatment. Student's t-test and independent-samples proportions test were used for means analysis. Survival was assessed by the Kaplan-Meier method using SPSS version 28. RESULTS A total of 41,074 patients were diagnosed with mesothelioma, with a steady incidence (0.25%) between 2004 and 2017. The mean age of diagnosis was 70 (SD 13). 73.2% of the patients were males, 69% had no comorbidities, and 93.3% were white. More patients were diagnosed at Stage 1 after 2008 (p < 0.001). Since 2010, there has been a significant increase in patients offered treatment with 73.9% receiving some therapy (p < 0.01): 50.5% received chemotherapy, 27.6% surgery, 8.6% radiation, and 5.4% immunotherapy. The median overall survival was 10.3 months from diagnosis [95% CI: 10.2-10.5]. Risk factors associated with 30-day mortality from surgical intervention included age (OR = 1.02, p < 0.001), male gender (OR = 1.3, p = 0.03), poorly differentiated grade (OR = 2.1, p < 0.001), Stage 4 (OR = 1.4, p = 0014), and epithelioid histology (OR = 0.51, p = 0.03). CONCLUSION The current management of MPM is based on stage and histologic subtype. Due to the small numbers of patients at most academic centers, the NCDB provides a robust dataset to draw upon broad data points in treatment discussions with patients.
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Affiliation(s)
- Patrick Bou-Samra
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Austin Chang
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Feredun Azari
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Gregory Kennedy
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Alix Segil
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Emily Guo
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Melina Marmarelis
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Division of Hematology & Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Corey Langer
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Division of Hematology & Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Sunil Singhal
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
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12
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Habib JR, Kinny-Köster B, Bou-Samra P, Alsaad R, Sereni E, Javed AA, Ding D, Cameron JL, Lafaro KJ, Burns WR, He J, Yu J, Wolfgang CL, Burkhart RA. Surgical Decision-Making in Pancreatic Ductal Adenocarcinoma: Modeling Prognosis Following Pancreatectomy in the Era of Induction and Neoadjuvant Chemotherapy. Ann Surg 2023; 277:151-158. [PMID: 33843794 DOI: 10.1097/sla.0000000000004915] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop a predictive model of oncologic outcomes for patients with pancreatic ductal adenocarcinoma (PDAC) undergoing resection after neoadjuvant or induction chemotherapy use. BACKGROUND Early recurrence following surgical resection for PDAC is common. The use of neoadjuvant chemotherapy prior to resection may increase the likelihood of long-term systemic disease control. Accurately characterizing an individual's likely oncologic outcome in the perioperative setting remains challenging. METHODS Data from patients with PDAC who received chemotherapy prior to pancreatectomy at a single high-volume institution between 2007 and 2018 were captured in a prospectively collected database. Core clinicopathologic data were reviewed for accuracy and survival data were abstracted from the electronic medical record and national databases. Cox-proportional regressions were used to model outcomes and develop an interactive prognostic tool for clinical decision-making. RESULTS A total of 581 patients were included with a median overall survival (OS) and recurrence-free survival (RFS) of 29.5 (26.5-32.5) and 16.6 (15.8-17.5) months, respectively. Multivariable analysis demonstrates OS and RFS were associated with type of chemotherapeutic used andthe number of chemotherapy cycles received preoperatively. Additional factors contributing to survival models included: tumor grade, histopathologic response to therapy, nodal status, and administration of adjuvant chemotherapy. The models were validated using an iterative bootstrap method and with randomized cohort splitting. The models were well calibrated with concordance indices of 0.68 and 0.65 for the final OS and RFS models, respectively. CONCLUSION We developed an intuitive and dynamic decision-making tool that can be useful in estimating OS, RFS, and location-specific disease recurrence rates. This prognostic tool may add value to patient care in discussing the benefits associated with surgical resection for PDAC.
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Affiliation(s)
- Joseph R Habib
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Patrick Bou-Samra
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ranim Alsaad
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elisabetta Sereni
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ammar A Javed
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ding Ding
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kelly J Lafaro
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William R Burns
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jun Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher L Wolfgang
- Department of Surgery, New York University School of Medicine and NYU-Langone Medical Center, New York, NY
| | - Richard A Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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13
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Azari F, Kennedy GT, Chang A, Nadeem B, Bou-Samra P, Chang A, Segil A, Bernstein E, Sullivan NT, Eruslanov E, Delikatny J, Singhal S. Sodium Multivitamin Transporter-Targeted Fluorochrome Facilitates Enhanced Metabolic Evaluation of Tumors Through Coenzyme-R Dependent Intracellular Signaling Pathways. Mol Imaging Biol 2022; 25:569-585. [PMID: 36534331 DOI: 10.1007/s11307-022-01792-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Intraoperative molecular imaging (IMI)-guided resections have been shown to improve oncologic outcomes for patients undergoing surgery for solid malignancies. The technology utilizes fluorescent tracers targeting cancer cells without the use of any ionizing radiation. However, currently available targeted IMI tracers are effective only for tumors with a highly specific receptor expression profile, and there is an unmet need for IMI tracers to label a broader range of tumor types. Here, we describe the development and testing of a novel tracer (CR)-S0456) targeted to the sodium multivitamin transporter (SMVT). METHODS Preclinical models of fibrosarcoma (HT-1080), lung (A549), breast (4T1), and renal cancers (HEK-293 T) in vitro and in vivo were used for assessment of (CR)-S0456 specific tumor labeling via sodium-mediated SMVT uptake in dipotassium phosphate or choline chloride-containing media buffer. Additionally, pharmacologic inhibition of multiple intracellular coenzyme-R obligate signaling pathways, including holocarboxylase synthetase (sulconazole nitrate), PI3K/AKT/mTOR (omipalisib), and calmodulin-dependent phosphatase (calmidazolium), were investigated to assess (CR)-S0456 uptake kinetics. Human fibrosarcoma-bearing xenografts in athymic nude mice were used for tumor and metabolic-specific labeling. Novel NIR needle confocal laser endomicroscopic (nCLE) intratumoral sampling was performed to demonstrate single-cell specific labeling by CR-S0456. RESULTS CR-S0456 localization in vitro correlated with highly proliferative cell lines (MTT) and doubling time (p < 0.05) with the highest microscopic fluorescence detected in aggressive human fibrosarcomas (HT-1080). Coenzyme-R-specific localization was demonstrated to be SMVT-specific after competitive inhibition of internal localization with excess administration of pantothenic acid. Inhibiting the activity of SMVT by affecting sodium ion hemostasis prevented the complete uptake of CR-S0456. In vivo validation demonstrated (CR)-S0456 localization to xenograft models with accurate identification of primary tumors as well as margin assessment down to 1 mm3 tumor volume. Systemic treatment of xenograft-bearing mice with a dual PI3K/mTOR inhibitor suppressed intratumoral cell signaling and (CR)-S0456 uptake via a reduction in SMVT expression. Novel analysis of in vivo intratumoral cytologic fluorescence using near-infrared confocal laser endomicroscopy demonstrated the absence of coenzyme-R-mediated NIR fluorescence but not fibroblast activation protein (FAP)-conjugated fluorochrome, indicating specific intracellular inhibition of coenzyme-R obligate pathways. CONCLUSION These findings suggest that a SMVT-targeted NIR contrast agent can be a suitable tracer for imaging a wide range of malignancies as well as evaluating metabolic response to systemic therapies, similar to PET imaging with immune checkpoint inhibitors.
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Affiliation(s)
- Feredun Azari
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Department of Thoracic Surgery, Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, 14th floor, South Pavilion, Philadelphia, PA, 19104, USA.
| | - Gregory T Kennedy
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ashley Chang
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Bilal Nadeem
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Patrick Bou-Samra
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Austin Chang
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alix Segil
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Elizabeth Bernstein
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Neil T Sullivan
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Evgeniy Eruslanov
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - James Delikatny
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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14
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Azari F, Kennedy GT, Bou-Samra P, Singhal S. Intraoperative molecular imaging in thoracic oncology: pushing the boundaries of precision resection for occult non-small cell lung cancer in the era of minimally invasive surgery. J Thorac Dis 2022; 14:3688-3691. [PMID: 36389330 PMCID: PMC9641340 DOI: 10.21037/jtd-22-1100] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/02/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Feredun Azari
- Department of Thoracic Surgery, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory T. Kennedy
- Department of Thoracic Surgery, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick Bou-Samra
- Department of Thoracic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Thoracic Surgery, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Dadashzadeh ER, Huckaby LV, Handzel R, Hossain MS, Sanin GD, Anto VP, Bou-Samra P, Moses JB, Cai S, Phelos HM, Simmons RL, Rosengart MR, van der Windt DJ. The Risk of Incarceration During Nonoperative Management of Incisional Hernias: A Population-based Analysis of 30,998 Patients. Ann Surg 2022; 275:e488-e495. [PMID: 32773624 PMCID: PMC8917417 DOI: 10.1097/sla.0000000000003916] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of the study was to quantify the risk of incarceration of incisional hernias. BACKGROUND Operative repair is the definitive treatment for incisional ventral hernias but is often deferred if the perceived risk of elective operation is elevated secondary to comorbid conditions. The risk of incarceration during nonoperative management (NOM) factors into shared decision making by patient and surgeon; however, the incidence of acute incarceration remains largely unknown. METHODS A retrospective analysis of adult patients with an International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis of incisional hernia was conducted from 2010 to 2017 in 15 hospitals of a single healthcare system. The primary outcome was incarceration necessitating emergent operation. The secondary outcome was 30-, 90-, and 365-day mortality. Univariate and multivariate analyses were used to determine independent predictors of incarceration. RESULTS Among 30,998 patients with an incisional hernia (mean age 58.1 ± 15.9 years; 52.7% female), 23,022 (78.1%) underwent NOM of whom 540 (2.3%) experienced incarceration, yielding a 1- and 5-year cumulative incidence of 1.24% and 2.59%, respectively. Independent variables associated with incarceration included: age older than 40 years, female sex, current smoker, body mass index 30 or greater, and a hernia-related inpatient admission. All-cause mortality rates at 30, 90, and 365 days were significantly higher in the incarceration group at 7.2%, 10%, and 14% versus 1.1%, 2.3%, and 5.3% in patients undergoing successful NOM, respectively. CONCLUSIONS Incarceration is an uncommon complication of NOM but is associated with a significant risk of death. Tailored decision making for elective repair and considering the aforementioned risk factors for incarceration provides an initial step toward mitigating the excess morbidity and mortality of an incarceration event.
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Affiliation(s)
- Esmaeel R. Dadashzadeh
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA
- Pittsburgh Surgical Outcomes Research Center (Pitt-SORCe), University of Pittsburgh, Pittsburgh, PA
| | - Lauren V. Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
- Pittsburgh Surgical Outcomes Research Center (Pitt-SORCe), University of Pittsburgh, Pittsburgh, PA
| | - Robert Handzel
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA
- Pittsburgh Surgical Outcomes Research Center (Pitt-SORCe), University of Pittsburgh, Pittsburgh, PA
| | - M. Shanaz Hossain
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gloria D. Sanin
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Vincent P. Anto
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick Bou-Samra
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - J. B. Moses
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Stephen Cai
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Heather M. Phelos
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
- Pittsburgh Surgical Outcomes Research Center (Pitt-SORCe), University of Pittsburgh, Pittsburgh, PA
| | - Richard L. Simmons
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Matthew R. Rosengart
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
- Pittsburgh Surgical Outcomes Research Center (Pitt-SORCe), University of Pittsburgh, Pittsburgh, PA
| | - Dirk J. van der Windt
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
- Pittsburgh Surgical Outcomes Research Center (Pitt-SORCe), University of Pittsburgh, Pittsburgh, PA
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16
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Bou-Samra P, Scott P, Cheng H, Kallem C, Pathak R, Geller DA, Marsh W, Wang Y, Antoni M, Penedo F, Tsung A, Steel JL. Social Support is Associated with Survival in Patients Diagnosed with Gastrointestinal Cancer. J Gastrointest Cancer 2021; 53:854-861. [PMID: 34806126 DOI: 10.1007/s12029-021-00741-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of this study was to examine the link between psychological, behavioral, and social factors and survival in patients diagnosed with gastrointestinal cancer. METHODS A cohort of gastrointestinal cancer patients were administered a battery of questionnaires that assessed trauma, depression, social support, sleep, diet, exercise, quality of life, tobacco and alcohol use, pain, and fatigue. Analyses included Pearson's correlations, analyses of variance, Kaplan Meier survival, and Cox regression analyses. RESULTS Of the 568 patients, the majority were male (57.9%) and Caucasian (91.9%), with a mean age of 61 (S.D. = 10.7). The level of perceived social support was comparable to patients with other medical conditions. Sociodemographic predictors of social support included the number of years of education (r = 0.109, p = 0.05), marital status (F(6,387) = 5.465, p ≤ 0.001), and whether the patients' income met the family's basic needs (F(1,377) = 25.531, p < 0.001). Univariate analyses revealed that older age (p < 0.001), male gender (p = 0.007), being black (p = 0.005), diagnosis of hepatocellular carcinoma (p = 0.046), higher body mass index (p = 0.022), larger tumor size (p = 0.032), initial treatment including chemotherapy rather than surgery (p < 0.001), and lower level of perceived social support (p = 0.037) were associated with poorer survival. Using multivariate Cox regression and adjusting for all factors found to be significant in univariate survival analyses, older age (p = 0.024) and lower perceived social support (HR = 0.441, 95% CI = 0.233, 0.833; p = 0.012) were the factors that remained significantly associated with poorer survival. CONCLUSION There are several biological and psychosocial factors that predict cancer mortality. Social support appears to be a robust factor affecting mortality in gastrointestinal cancer patients.
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Affiliation(s)
- Patrick Bou-Samra
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paul Scott
- Department of Psychology, School of Education, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hannah Cheng
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Cramer Kallem
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ritambhara Pathak
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David A Geller
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Wallis Marsh
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yisi Wang
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael Antoni
- Department of Psychology, University of Miami, Miami, FL, USA
| | - Frank Penedo
- Department of Psychology, University of Miami, Miami, FL, USA
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jennifer L Steel
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. .,Department of Psychiatry, University of Pittsburgh, 3459 Fifth Avenue; Montefiore 7S, Pittsburgh, PA, 15213, USA. .,Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA.
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17
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Dadashzadeh ER, Bou-Samra P, Huckaby LV, Nebbia G, Handzel RM, Varley PR, Wu S, Tsung A. Leveraging Decision Curve Analysis to Improve Clinical Application of Surgical Risk Calculators. J Surg Res 2021; 261:58-66. [PMID: 33418322 DOI: 10.1016/j.jss.2020.11.059] [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: 06/05/2020] [Revised: 09/23/2020] [Accepted: 11/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Surgical risk calculators (SRCs) have been developed for estimation of postoperative complications but do not directly inform decision-making. Decision curve analysis (DCA) is a method for evaluating prediction models, measuring their utility in guiding decisions. We aimed to analyze the utility of SRCs to guide both preoperative and postoperative management of patients undergoing hepatopancreaticobiliary surgery by using DCA. METHODS A single-institution, retrospective review of patients undergoing hepatopancreaticobiliary operations between 2015 and 2017 was performed. Estimation of postoperative complications was conducted using the American College of Surgeons SRC [ACS-SRC] and the Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) calculator; risks were compared with observed outcomes. DCA was used to model optimal patient selection for risk prevention strategies and to compare the relative performance of the ACS-SRC and POTTER calculators. RESULTS A total of 994 patients were included in the analysis. C-statistics for the ACS-SRC prediction of 12 postoperative complications ranged from 0.546 to 0.782. DCA revealed that an ACS-SRC-guided readmission prevention intervention, when compared with an all-or-none approach, yielded a superior net benefit for patients with estimated risk between 5% and 20%. Comparison of SRCs for venous thromboembolism intervention demonstrated superiority of the ACS-SRC for thresholds for intervention between 2% and 4% with the POTTER calculator performing superiorly between 4% and 8% estimated risk. CONCLUSIONS SRCs can be used not only to predict complication risk but also to guide risk prevention strategies. This methodology should be incorporated into external validations of future risk calculators and can be applied for institution-specific quality improvement initiatives to improve patient outcomes.
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Affiliation(s)
| | - Patrick Bou-Samra
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Lauren V Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Giacomo Nebbia
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Biomedical Informatics, Intelligent Systems Program, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert M Handzel
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Patrick R Varley
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Shandong Wu
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Biomedical Informatics, Intelligent Systems Program, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Medical Center, Columbus, Ohio.
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18
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van der Windt DJ, Bou-Samra P, Dadashzadeh ER, Chen X, Varley PR, Tsung A. Preoperative risk analysis index for frailty predicts short-term outcomes after hepatopancreatobiliary surgery. HPB (Oxford) 2018; 20:1181-1188. [PMID: 30005992 DOI: 10.1016/j.hpb.2018.05.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/10/2018] [Accepted: 05/19/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Risk Analysis Index (RAI) for frailty is a rapid survey for comorbidities and performance status, which predicts mortality after general surgery. We aimed to validate the RAI in predicting outcomes after hepatopancreatobiliary surgery. METHODS Associations of RAI, determined in 162 patients prior to undergoing hepatopancreatobiliary surgery, with prospectively collected 30-day post-operative outcomes were analyzed with multivariate logistic and linear regression. RESULTS Patients (age 62 ± 14, 51% female) had a median RAI of 7, range 0-25. With every unit increase in RAI, length of stay increased by 5% (95% CI: 2-7%), odds of ICU admission increased by 10% (0-20%), ICU length of stay increased by 21% (9-34%), and odds of discharge to a nursing facility increased by 8% (0-17%) (all P < 0.05). Particularly in patients who suffered a first post-operative complication, RAI was associated with additional complications (1.6 unit increase in Comprehensive Complication Index per unit increase in RAI, P = 0.002). In a direct comparison in a subset of 74 patients, RAI and the ACS-NSQIP Risk Calculator performed comparably in predicting outcomes. CONCLUSION While RAI and ACS-NSQIP Risk Calculator comparatively predicted short-term outcomes after HPB surgery, RAI has been specifically designed to identify frail patients who can potentially benefit from preoperative prehabilitation interventions.
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Affiliation(s)
- Dirk J van der Windt
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Patrick Bou-Samra
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Xilin Chen
- Pittsburgh Surgical Outcomes Research Center (PittSORCe), University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick R Varley
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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19
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Tohme S, Kaltenmeier C, Bou-Samra P, Varley PR, Tsung A. Race and Health Disparities in Patient Refusal of Surgery for Early-Stage Pancreatic Cancer: An NCDB Cohort Study. Ann Surg Oncol 2018; 25:3427-3435. [PMID: 30043318 DOI: 10.1245/s10434-018-6680-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Indexed: 01/05/2023]
Abstract
AIM To identify factors associated with refusal of surgery in patients with early-stage pancreatic cancer and estimate the impact of this decision on survival. METHODS Using the National Cancer Data Base, 26,358 patients were identified with potentially resectable tumors (pretreatment clinical stage I: T1 or T2 N0M0). Multivariate models were employed to identify factors predicting failure to undergo surgery and assess the impact on survival. RESULTS Of early-stage patients who were recommended surgery, 7.8% (N = 992) refused surgery for resectable early-stage pancreatic cancer. On multivariable analysis, patients were more likely to refuse surgery if they were older [odds ratio (OR) = 1.18; 95% confidence interval (CI) 1.16-1.19], female (OR = 1.52; 95% CI 1.33-1.73), African American (vs White, OR = 1.79; 95% CI 1.37-2.34), on Medicare/Medicaid (vs private, OR = 2.75; 95% CI 1.54-4.92) or had higher Charlson-Deyo score (2 vs 0, OR = 1.33; 95% CI 1.03-1.72). Patients were also significantly more likely to refuse surgery if they were seen at a center that is not an academic/research program (OR 1.9; 95% CI 1.6-2.27). Patients who were recommended surgery but refused had significantly worse survival than those with stage I who received surgery [median survival 6.8 vs 24 months, Cox hazard ratio (HR) 3.41; 95% CI 3.12-3.60]. CONCLUSIONS The percentage of patients refusing surgery for operable early-stage pancreatic cancer has been decreasing in the last decade but remains a significant issue that affects survival. Disparities in refusal of surgery are independently associated with several variables including gender, race, and insurance. To mitigate national disparities in surgical care, future studies should focus on exploring potential reasons for refusal and developing communication interventions.
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Affiliation(s)
- Samer Tohme
- Department of General Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
| | | | - Patrick Bou-Samra
- Department of General Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick R Varley
- Department of General Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Allan Tsung
- Department of General Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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