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Makris EA, Tran TB, Delitto DJ, Lee B, Ethun CG, Grignol V, Harrison Howard J, Bedi M, Clark Gamblin T, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Cullinan D, Fields RC, Cardona K, Poultsides G, Kirane A. Natural history of undifferentiated pleomorphic sarcoma: Experience from the US Sarcoma Collaborative. J Surg Oncol 2024. [PMID: 38562002 DOI: 10.1002/jso.27620] [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: 01/10/2024] [Accepted: 02/13/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Undifferentiated pleomorphic sarcoma (UPS) is a relatively rare but aggressive neoplasm. We sought to utilize a multi-institutional US cohort of sarcoma patients to examine predictors of survival and recurrence patterns after resection of UPS. METHODS From 2000 to 2016, patients with primary UPS undergoing curative-intent surgical resection at seven academic institutions were retrospectively reviewed. Epidemiologic and clinicopathologic factors were reviewed by site of origin. Overall survival (OS), recurrence-free survival (RFS), time-to-locoregional (TTLR), time-to-distant recurrence (TTDR), and patterns of recurrence were analyzed. RESULTS Of the 534 UPS patients identified, 53% were female, with a median age of 60 and median tumor size of 8.5 cm. The median OS, RFS, TTLR, and TTDR for the entire cohort were 109, 49, 86, and 46 months, respectively. There were no differences in these survival outcomes between extremity and truncal UPS. Compared with truncal, extremity UPS were more commonly amenable to R0 resection (87% vs. 75%, p = 0.017) and less commonly associated with lymph node metastasis (1% vs. 6%, p = 0.031). R0 resection and radiation treatment, but not site of origin (extremity vs. trunk) were independent predictors of OS and RFS. TTLR recurrence was shorter for UPS resected with a positive margin and for tumors not treated with radiation. CONCLUSION For patients with resected extremity and truncal UPS, tumor size >5 cm and positive resection margin are associated with worse survival OS and RFS, irrespectively the site of origin. R0 surgical resection and radiation treatment may help improve these survival outcomes.
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Affiliation(s)
| | - Thuy B Tran
- Surgical Oncology, Stanford University, Stanford, California, USA
| | - Daniel J Delitto
- Surgical Oncology, Stanford University, Stanford, California, USA
| | - Byrne Lee
- Surgical Oncology, Stanford University, Stanford, California, USA
| | - Cecilia G Ethun
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Valerie Grignol
- Surgical Oncology, The Ohio State University, Columbus, Ohio, USA
| | | | - Meena Bedi
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Jennifer Tseng
- Surgical Oncology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Kevin K Roggin
- Surgical Oncology, University of Chicago Medicine, Chicago, Illinois, USA
| | | | | | - Darren Cullinan
- Surgical Oncology, Washington University, St. Louis, Missouri, USA
| | - Ryan C Fields
- Surgical Oncology, Washington University, St. Louis, Missouri, USA
| | - Kenneth Cardona
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | | | - Amanda Kirane
- Surgical Oncology, Stanford University, Stanford, California, USA
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Tran TB, Downing L, Elmes JB, Arnall JR, Moore DC. Avatrombopag for the Treatment of Immune Thrombocytopenia and Periprocedural Thrombocytopenia Associated With Chronic Liver Disease. J Pharm Pract 2024; 37:184-189. [PMID: 36113085 DOI: 10.1177/08971900221125827] [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: 11/17/2022]
Abstract
Objective: To review the pharmacology, pharmacokinetics, clinical efficacy, safety, dosing and administration, and place in therapy of avatrombopag for the treatment of immune thrombocytopenia and chronic liver disease-associated thrombocytopenia. Summary: Avatrombopag is an orally administered thrombopoietin receptor agonist approved for the treatment of immune thrombocytopenia and is the first oral thrombopoietin receptor agonist approved for the treatment of perioperative thrombocytopenia associated with chronic liver disease in adults. The efficacy and safety of avatrombopag has been demonstrated in a multicenter, randomized, double blind, placebo-controlled phase III study in the setting of immune thrombocytopenia and in 2 identically designed, multicenter, randomized, double blind, placebo-controlled phase III trials in the setting of thrombocytopenia associated with chronic liver disease. The most common adverse events reported in the clinical trials were headache, fatigue, and gastrointestinal toxicities. The incidence of bleeding events was comparable between the avatrombopag and placebo treatment groups in each study. Avatrombopag has not been shown to be associated with hepatoxicity and does not require food restriction like the other oral thrombopoietin receptor agonist for immune thrombocytopenia, eltrombopag. Also, unlike eltrombopag for immune thrombocytopenia, it can be dosed less frequently than once daily. Conclusion: Avatrombopag offers another safe and effective oral option for the treatment of immune thrombocytopenia without food restrictions and an alternative, transfusion-sparing option for thrombocytopenia associated with chronic liver disease patients undergoing surgery.
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Affiliation(s)
- Thuy B Tran
- Specialty Pharmacy Service, Atrium Health, Charlotte, NC, USA
| | - Lauren Downing
- Specialty Pharmacy Service, Atrium Health, Charlotte, NC, USA
| | - Joseph B Elmes
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Concord, NC, USA
| | - Justin R Arnall
- Specialty Pharmacy Service, Atrium Health, Charlotte, NC, USA
| | - Donald C Moore
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Concord, NC, USA
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3
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Finney N, Tran T, Hasjim BJ, Jakowatz J, Chiao E, Eng O, Wolf R, Jutric Z, Yamamoto M, Tran TB. Primary sarcoma of the liver: A nationwide analysis of a rare mesenchymal tumor. J Surg Oncol 2024; 129:358-364. [PMID: 37796036 DOI: 10.1002/jso.27477] [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: 08/06/2023] [Revised: 09/10/2023] [Accepted: 09/23/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Primary liver sarcomas are rare malignancies. Prognostic factors associated with long-term survival remain poorly understood. The objective of this study is to determine factors associated with long-term survival. METHODS The Surveillance, Epidemiology, and End Results (SEER) database was queried to identify patients with visceral sarcoma arising from the liver. Demographic factors, tumor characteristics, resection status, and survival were evaluated. Multivariate Cox regression analysis was performed to determine predictors of survival. RESULTS A total of 743 patients with primary hepatic sarcoma were identified. The median tumor size was 10 cm. Only 30% (n = 221) of patients in the cohort underwent surgery. The 5-year overall survival rates were 47.9% for localized disease, 29.5% for regional disease, and 16.5% for distant disease, p < 0.001. Among patients who underwent surgical resection, patients with embryonal sarcoma had better 5-year survival compared with angiosarcoma and other histologic subtypes. On multivariate analysis, surgery was associated with improved survival, while older age, higher stage, and angiosarcoma histology were the strongest independent predictors of poor survival. CONCLUSIONS Surgery remains the mainstay of treatment for this rare malignancy but is performed in less than one-third of patients. Angiosarcoma histology is associated with worse overall survival, while surgical resection remains the strongest predictor of improved overall survival.
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Affiliation(s)
- Nicole Finney
- Department of Surgery, Division of Surgical Oncology, University of California Irvine, Orange, California, USA
| | - Tu Tran
- Department of Surgery, Division of Surgical Oncology, University of California Irvine, Orange, California, USA
| | - Bima J Hasjim
- Department of Surgery, Division of Surgical Oncology, University of California Irvine, Orange, California, USA
| | - James Jakowatz
- Department of Surgery, Division of Surgical Oncology, University of California Irvine, Orange, California, USA
| | - Elaine Chiao
- Department of Surgery, Division of Surgical Oncology, University of California Irvine, Orange, California, USA
| | - Oliver Eng
- Department of Surgery, Division of Surgical Oncology, University of California Irvine, Orange, California, USA
| | - Ronald Wolf
- Department of Surgery, Division of Surgical Oncology, University of California Irvine, Orange, California, USA
| | - Zeljika Jutric
- Department of Surgery, Division of Surgical Oncology, University of California Irvine, Orange, California, USA
| | - Maki Yamamoto
- Department of Surgery, Division of Surgical Oncology, University of California Irvine, Orange, California, USA
| | - Thuy B Tran
- Department of Surgery, Division of Surgical Oncology, University of California Irvine, Orange, California, USA
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4
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Tran TB, Boyce J, Mitchell H, Speaks J, Arnall JR. Real-world Experience of Caplacizumab for Adolescents in the First-line Setting: Case Reports. J Pediatr Hematol Oncol 2023; 45:e1031-e1034. [PMID: 37526365 DOI: 10.1097/mph.0000000000002716] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/05/2023] [Indexed: 08/02/2023]
Abstract
Acquired thrombotic thrombocytopenic purpura (aTTP) is a thrombotic microangiopathy resulting in high mortality. Caplacizumab is approved for treatment of adults with acquired thrombotic thrombocytopenic purpura that has shown faster platelet normalization, clinical improvement, and reduced risk of recurrent/refractory disease. We report 2 cases of adolescents treated off-label with caplacizumab who were able to stop before 30 days from end of plasma exchange after platelets normalized and ADAMTS13 activity recovered to >20% to 30%. Our results show similar efficacy to other reports of patients under 18 receiving caplacizumab in first line, regardless of plasma exchange strategy, and may offer insight into early cessation criteria.
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Affiliation(s)
- Thuy B Tran
- Department of Pharmacy, Specialty Pharmacy Services, Atrium Health, Charlotte, NC
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5
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Tran TB, Arnall JR, Kleiboer B, Hinson A. Recombinant von Willebrand factor for perioperative bleeding management in pediatric patient with allergy to plasma-derived von Willebrand factor. Pediatr Blood Cancer 2023; 70:e29918. [PMID: 35925936 DOI: 10.1002/pbc.29918] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/07/2022] [Accepted: 07/20/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Thuy B Tran
- Specialty Pharmacy Service, Department of Pharmacy, Atrium Health, Charlotte, North Carolina, USA
| | - Justin R Arnall
- Specialty Pharmacy Service, Department of Pharmacy, Atrium Health, Charlotte, North Carolina, USA
| | - Brendan Kleiboer
- Levine Children's Cancer and Blood Disorder, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Ashley Hinson
- Levine Children's Cancer and Blood Disorder, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
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Grant C, Hagopian G, Tran TB, Nagaraj G, Moyers JT. Correspondence on 'Outcomes of stage IV melanoma in the era of immunotherapy: a National Cancer Database (NCDB) analysis from 2014 to 2016' by Sussman et al. J Immunother Cancer 2022; 10:jitc-2022-006187. [PMID: 36600605 PMCID: PMC9743369 DOI: 10.1136/jitc-2022-006187] [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] [Accepted: 11/09/2022] [Indexed: 12/13/2022] Open
Affiliation(s)
- Christopher Grant
- Department of Medicine, University of California Irvine, Irvine, California, USA
| | - Garo Hagopian
- Department of Medicine, University of California Irvine, Irvine, California, USA
| | - Thuy B Tran
- Division of Surgical Oncology, Department of Surgery, University of California Irvine, Irvine, California, USA
| | - Gayathri Nagaraj
- Division of Medical Oncology and Hematology, Loma Linda University, Loma Linda, California, USA
| | - Justin T Moyers
- Division of Hematology and Oncology, Department of Medicine, University of California Irvine, Irvine, California, USA
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7
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Gusho CA, King D, Ethun CG, Cardona K, Harrison Howard J, Tran TB, Poultsides G, Tseng J, Roggin KK, Fields RC, Cullinan DR, Chouliaras K, Votanopoulos K, Grignol VP, Bedi M. Extraskeletal myxoid chondrosarcoma: Clinicopathological features and outcomes from the United States sarcoma collaborative database. J Surg Oncol 2022; 126:1533-1542. [PMID: 35962783 DOI: 10.1002/jso.27062] [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: 05/16/2022] [Revised: 07/25/2022] [Accepted: 08/04/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUNDS AND OBJECTIVES This investigation described clinicopathological features and outcomes of extraskeletal myxoid chondrosarcoma (EMC) patients. METHODS EMC patients were identified from the United States Sarcoma Collaborative database between 2000 and 2016. Overall survival (OS) and recurrence-free survival (RFS) were calculated, and prognostic factors were analyzed. RESULTS Sixty individuals with a mean age of 55 years were included, and 65.0% (n = 39) were male. 73.3% (n = 44) had a primary tumor. A total of 41.6% (n = 25) developed tumor relapse following resection. The locoregional recurrence rate was 30.0% (n = 18/60), and mean follow-up was 42.7 months. The 5-year OS was 71.0%, while the 5-year RFS was 41.4%. On multivariate analysis for all EMC, chemotherapy (hazard ratio [HR], 6.054; 95% confidence interval [CI], 1.33-27.7; p = 0.020) and radiation (HR, 5.07, 95% CI, 1.3-20.1; p = 0.021) were independently predictive of a worse RFS. Among patients with primary EMC only, the 5-year OS was 85.3%, with a 30.0% (n = 12) locoregional recurrence rate, though no significant prognostic factors were identified. CONCLUSIONS Long-term survival with EMC is probable, however there exists a high incidence of locoregional recurrence. While chemotherapy and radiation were associated with a worse RFS, these findings were likely confounded by recurrent disease as significance was lost in the primary EMC-only subset.
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Affiliation(s)
| | - David King
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - J Harrison Howard
- Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Thuy B Tran
- Department of Surgery, Stanford University, Palo Alto, CA, USA
| | | | | | | | - Ryan C Fields
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | | | - Valerie P Grignol
- Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Meena Bedi
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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8
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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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9
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Squires MH, Ethun CG, Donahue EE, Benbow JH, Anderson CJ, Jagosky MH, Manandhar M, Patt JC, Kneisl JS, Salo JC, Hill JS, Ahrens W, Prabhu RS, Livingston MB, Gower NL, Needham M, Trufan SJ, Fields RC, Krasnick BA, Bedi M, Votanopoulos K, Chouliaras K, Grignol V, Roggin KK, Tseng J, Poultsides G, Tran TB, Cardona K, Howard JH. ASO Visual Abstract: Extremity Soft Tissue Sarcoma-A Multi-institutional Validation of Prognostic Nomograms. Ann Surg Oncol 2022. [PMID: 35088171 DOI: 10.1245/s10434-021-11263-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | | | - Erin E Donahue
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | - Colin J Anderson
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | | | | | - Joshua C Patt
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | - Jeffrey S Kneisl
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | | | - Joshua S Hill
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - William Ahrens
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | | | - Nicole L Gower
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | - Sally J Trufan
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Ryan C Fields
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Meena Bedi
- Medical College of Wisconsin, Milwaukee, WI, USA
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10
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Squires MH, Ethun CG, Donahue EE, Benbow JH, Anderson CJ, Jagosky MH, Manandhar M, Patt JC, Kneisl JS, Salo JC, Hill JS, Ahrens W, Prabhu RS, Livingston MB, Gower NL, Needham M, Trufan SJ, Fields RC, Krasnick BA, Bedi M, Votanopoulos K, Chouliaras K, Grignol V, Roggin KK, Tseng J, Poultsides G, Tran TB, Cardona K, Howard JH. Extremity Soft Tissue Sarcoma: A Multi-Institutional Validation of Prognostic Nomograms. Ann Surg Oncol 2022; 29:3291-3301. [PMID: 35015183 DOI: 10.1245/s10434-021-11205-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 11/15/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prognostic nomograms for patients with resected extremity soft tissue sarcoma (STS) include the Sarculator and Memorial Sloan Kettering (MSKCC) nomograms. We sought to validate these two nomograms within a large, modern, multi-institutional cohort of resected primary extremity STS patients. METHODS Resected primary extremity STS patients from 2000 to 2017 were identified across nine high-volume U.S. institutions. Predicted 5- and 10-year overall survival (OS) and distant metastases cumulative incidence (DMCI), and 4-, 8-, and 12-year disease-specific survival (DSS) were calculated with Sarculator and MSKCC nomograms, respectively. Predicted survival probabilities stratified in quintiles were compared in calibration plots to observed survival assessed by Kaplan-Meier estimates. Cumulative incidence was estimated for DMCI. Harrell's concordance index (C-index) assessed discriminative ability of nomograms. RESULTS A total of 1326 patients underwent resection of primary extremity STS. Common histologies included: undifferentiated pleomorphic sarcoma (35%), fibrosarcoma (13%), and leiomyosarcoma (9%). Median tumor size was 8.0 cm (IQR 4.5-13.0). Tumor grade distribution was: Grade 1 (13%), Grade 2 (9%), Grade 3 (78%). Median OS was 172 months, with estimated 5- and 10-year OS of 70% and 58%. C-indices for 5- and 10-year OS (Sarculator) were 0.72 (95% CI 0.70-0.75) and 0.73 (95% CI 0.70-0.75), and 0.72 (95% CI 0.69-0.75) for 5- and 10-year DMCI. C-indices for 4-, 8-, and 12-year DSS (MSKCC) were 0.71 (95% CI 0.68-0.75). Calibration plots showed good prognostication across all outcomes. CONCLUSIONS Sarculator and MSKCC nomograms demonstrated good prognostic ability for survival and recurrence outcomes in a modern, multi-institutional validation cohort of resected primary extremity STS patients. External validation of these nomograms supports their ongoing incorporation into clinical practice.
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Affiliation(s)
| | | | - Erin E Donahue
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | - Colin J Anderson
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | | | | | - Joshua C Patt
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | - Jeffrey S Kneisl
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | | | - Joshua S Hill
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - William Ahrens
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | | | - Nicole L Gower
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | - Sally J Trufan
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Ryan C Fields
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Meena Bedi
- Medical College of Wisconsin, Milwaukee, WI, USA
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Olson CR, Suarez-Kelly LP, Ethun CG, Shelby RD, Yu PY, Hughes TM, Palettas M, Tran TB, Poultsides G, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Krasnick BA, Fields RC, King DM, Bedi M, Pollock RE, Grignol VP, Cardona K, Howard JH. Resection Status Does Not Impact Recurrence in Well-Differentiated Liposarcoma of the Extremity. Am Surg 2021; 87:1752-1759. [PMID: 34758653 DOI: 10.1177/00031348211054536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Well-differentiated liposarcoma (WDLPS) is a low-grade soft tissue sarcoma with a propensity for local recurrence. The necessity of obtaining microscopically free surgical margins (R0) to minimize local recurrence is not clear. This study evaluates recurrence-free survival (RFS) of extremity WDLPS in relation to resection margin status. METHODS A retrospective review of adult patients with primary extremity WDLPS at seven US institutions from 2000 to 2016 was performed. Patients with recurrent tumors or incomplete resection (R2) were excluded. Clinicopathologic factors were analyzed to assess impact on local RFS. RESULTS 97 patients with primary extremity WDLPS were identified. The majority of patients had deep, lower extremity tumors. Mean tumor size was 18.2±8.9cm. Patients were treated with either radical (76.3%) or excisional (23.7%) resections; 64% had R0 and 36% had microscopically positive (R1) resection margins. Ten patients received radiation therapy with no difference in receipt of radiation between R0 vs R1 groups. Thirteen patients (13%) developed a local recurrence with no difference in RFS between R0 vs R1 resection. Five-year RFS was 59.5% for R0 vs 85.2% for R1. Only one patient died of disease after developing dedifferentiation and distant metastasis despite originally having an R0 resection. DISCUSSION In this large multi-institutional study of surgical resection of extremity WDLPS, microscopically positive margins were not associated with an increased risk of recurrence. Positive microscopic margin resection for extremity WDLPS may yield similar rates of local control while avoiding a radical approach to obtain microscopically negative margins.
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Affiliation(s)
- Chelsea R Olson
- Department of Surgery, 5557University of South Alabama, Mobile, AL, USA
| | | | - Cecilia G Ethun
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Rita D Shelby
- Department of Surgery, 10624Stanford University, Palo Alto, CA, USA
| | - Peter Y Yu
- Department of Surgery, 10624Stanford University, Palo Alto, CA, USA
| | - Tasha M Hughes
- Department of Surgery, 10624Stanford University, Palo Alto, CA, USA
| | - Marilly Palettas
- Department of Surgery, 10624Stanford University, Palo Alto, CA, USA
| | - Thuy B Tran
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - George Poultsides
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Jennifer Tseng
- Department of Surgery, 12275Washington University School of Medicine, St. Louis, MO, USA
| | - Kevin K Roggin
- Department of Surgery, 12275Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Bradley A Krasnick
- Department of Surgery, 12306The Ohio State University, Columbus, OH, USA
| | - Ryan C Fields
- Department of Surgery, 12306The Ohio State University, Columbus, OH, USA
| | - David M King
- Department of Surgery, 23034Emory University, Atlanta, GA, USA
| | - Meena Bedi
- Department of Surgery, 23034Emory University, Atlanta, GA, USA
| | - Raphael E Pollock
- Department of Surgery, 12306The Ohio State University, Columbus, OH, USA
| | | | - Kenneth Cardona
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - J Harrison Howard
- Department of Surgery, 5557University of South Alabama, Mobile, AL, USA.,Department of Surgery, 10624Stanford University, Palo Alto, CA, USA
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12
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Stewart CL, Tran TB, Nguyen A, Zain J, Lai L, Fong Y, Woo Y. Cholecystectomy in patients with hematologic malignancies. Am J Surg 2021; 223:1157-1161. [PMID: 34711411 DOI: 10.1016/j.amjsurg.2021.10.037] [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: 07/28/2021] [Revised: 10/01/2021] [Accepted: 10/21/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cholecystectomy in patients with hematologic malignancies remains poorly understood. METHODS We retrospectively evaluated patients with hematologic malignancies who underwent cholecystectomy at a single institution. RESULTS Of 313 patients who presented for evaluation of abdominal pain, 64 underwent cholecystectomy for acute cholecystitis (34.4%), gangrenous cholecystitis (21.9%), chronic cholecystitis (23.4%), and cholelithiasis (20%). Most had a history of hematopoietic cell transplantation (62.5%) and/or immunosuppressive medication within 30 days of consultation (82.8%). Ultrasound had a 39% false-negative rate for acute nongangrenous cholecystitis. Operative time was 92 ± 39 min, 7 were performed open, 10 had intraoperative transfusions, and 4 had grade 3+ complications. Intraoperative transfusion was associated with increased postoperative length of stay (p = 0.03). Open procedure, operative time, estimated blood loss, intraoperative transfusion, and complications were not associated with timing of surgery. CONCLUSIONS Patients with hematologic malignancies can safely undergo cholecystectomy. Length of postoperative stay for inpatients is associated with intraoperative blood transfusion.
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Affiliation(s)
| | - Thuy B Tran
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Andrew Nguyen
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Jasmine Zain
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Lily Lai
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Yuman Fong
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Yanghee Woo
- Department of Surgery, City of Hope, Duarte, CA, USA.
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13
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Tran TB, Raoof M, Melstrom L, Kyulo N, Shaikh Z, Jones VC, Erhunmwunsee L, Fong Y, Warner SG. Racial and Ethnic Bias Impact Perceptions of Surgeon Communication. Ann Surg 2021; 274:597-604. [PMID: 34506314 DOI: 10.1097/sla.0000000000005060] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate patient satisfaction scores as a function of physician and patient race and sex. BACKGROUND Patient satisfaction is increasingly used as a surrogate for physician performance. How patient and surgeon race and ethnicity affect perceptions of surgeon communication and care is not widely explored. METHODS Press Ganey patient satisfaction surveys collected from January 2019 to September 2020 were studied. Multivariate logistic regressions were used to identify factors associated with favorable surgeon performance as a function of patient and surgeon demographics. RESULTS A total of 4732 unique outpatient satisfaction survey responses were analyzed. The majority of patients were White (60.5%), followed by Asian (8.6%), Black (4.2%), and Hispanic (4.3%). URM accounted for 8.9% of the 79 surgeons evaluated, and 34% were female. Black, Hispanic, and Asian patients were more likely to report unfavorable experiences than their White counterparts (P < 0.01). Spanish-speaking patients were most likely to perceive that surgeon show less respect for patient concerns (13.9% vs 9.3%, P = 0.004) and inadequate time spent explaining health concerns (12.6% vs 9.2%, P < 0.001). Female surgeons were more likely to achieve the highest overall ratings for effective communication, whereas Asian surgeons received lower scores. Asian surgeons were more likely than non-Asian surgeons to receive lower scores in explanation (37.3% vs 44.1%, P = 0.003). After adjusting for confounding factors, Asian surgeons had 26% lower odds of receiving favorable scores for overall communication (odds ratio: 0.736, 95% confidence interval: 0.619-0.877, P = 0.001). CONCLUSIONS Both patient and surgeon race and sex drive negative perceptions of patient-physician communication. As URM report more negative experiences, further studies should focus on effects of surgeon cultural awareness on underrepresented patient satisfaction.
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Affiliation(s)
- Thuy B Tran
- Department of Surgery, Division of Surgical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Mustafa Raoof
- Department of Surgery, Division of Surgical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Laleh Melstrom
- Department of Surgery, Division of Surgical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Namgyal Kyulo
- Department of Patient Experience, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Zameer Shaikh
- Department of Patient Experience, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Veronica C Jones
- Department of Surgery, Division of Breast Surgery, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Loretta Erhunmwunsee
- Department of Surgery, Division of Thoracic Surgery, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Yuman Fong
- Department of Surgery, Division of Surgical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Susanne G Warner
- Department of Surgery, Division of Surgical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
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14
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Squires MH, Ethun CG, Donahue EE, Benbow JH, Anderson CJ, Jagosky MH, Salo JC, Hill JS, Ahrens W, Prabhu RS, Livingston MB, Gower NL, Needham M, Trufan SJ, Fields RC, Krasnick BA, Bedi M, Abbott DE, Schwartz P, Votanopoulos K, Chouliaras K, Grignol V, Roggin KK, Tseng J, Poultsides G, Tran TB, Cardona K, Howard JH. A multi-institutional validation study of prognostic nomograms for retroperitoneal sarcoma. J Surg Oncol 2021; 124:829-837. [PMID: 34254691 DOI: 10.1002/jso.26586] [Citation(s) in RCA: 3] [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: 05/31/2021] [Accepted: 06/12/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Prognostic nomograms for patients undergoing resection of retroperitoneal sarcoma (RPS) include the Sarculator and Memorial Sloan Kettering (MSK) sarcoma nomograms. We sought to validate the Sarculator and MSK nomograms within a large, modern multi-institutional cohort of patients with primary RPS undergoing resection. METHODS Patients who underwent resection of primary RPS between 2000 and 2017 across nine high-volume US institutions were identified. Predicted 7-year disease-free (DFS) and overall survival (OS) and 4-, 8-, and 12-year disease-specific survival (DSS) were calculated from the Sarculator and MSK nomograms, respectively. Nomogram-predicted survival probabilities were stratified in quintiles and compared in calibration plots to observed survival outcomes assessed by Kaplan-Meier estimates. Discriminative ability of nomograms was quantified by Harrell's concordance index (C-index). RESULTS Five hundred and two patients underwent resection of primary RPS. Histologies included leiomyosarcoma (30%), dedifferentiated liposarcoma (23%), and well-differentiated liposarcoma (15%). Median tumor size was 14.0 cm (interquartile range [IQR], 8.5-21.0 cm). Tumor grade distribution was: Grade 1 (27%), Grade 2 (17%), and Grade 3 (56%). Median DFS was 31.5 months; 7-year DFS was 29%. Median OS was 93.8 months; 7-year OS was 51%. C-indices for 7-year DFS, and OS by the Sarculator nomogram were 0.65 (95% confidence interval [CI]: 0.62-0.69) and 0.69 (95%CI: 0.65-0.73); plots demonstrated good calibration for predicting 7-year outcomes. The C-index for 4-, 8-, and 12-year DSS by the MSK nomogram was 0.71 (95%CI: 0.67-0.75); plots demonstrated similarly good calibration ability. CONCLUSIONS In a diverse, modern validation cohort of patients with resected primary RPS, both Sarculator and MSK nomograms demonstrated good prognostic ability, supporting their ongoing adoption into clinical practice.
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Affiliation(s)
- Malcolm H Squires
- Division of Surgical Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Emory University, Atlanta, Georgia, USA
| | - Erin E Donahue
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Jennifer H Benbow
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Colin J Anderson
- Department of Orthopedic Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Megan H Jagosky
- Department of Medical Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Jonathan C Salo
- Division of Surgical Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Joshua S Hill
- Division of Surgical Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - William Ahrens
- Department of Pathology, Atrium Health, Charlotte, North Carolina, USA
| | - Roshan S Prabhu
- Department of Radiation Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Michael B Livingston
- Department of Medical Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Nicole L Gower
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Mckenzie Needham
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Sally J Trufan
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Bradley A Krasnick
- Department of Surgery, School of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Meena Bedi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Patrick Schwartz
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | | | | | - Valerie Grignol
- Division of Surgical Oncology, The Ohio State University, Columbus, OH, USA
| | - Kevin K Roggin
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Jennifer Tseng
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - George Poultsides
- Department of Surgery, Stanford University, Palo Alto, California, USA
| | - Thuy B Tran
- Department of Surgery, Stanford University, Palo Alto, California, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Emory University, Atlanta, Georgia, USA
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15
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Baechle JJ, Marincola Smith P, Solórzano CC, Tran TB, Postlewait LM, Maithel SK, Prescott J, Pawlik T, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Shirley LA, Fields RC, Jin L, Abbott DE, Ronnekleiv-Kelly S, Sicklick JK, Yopp A, Mansour J, Duh QY, Seiser N, Votanopoulos K, Levine EA, Poultsides G, Kiernan CM. Cumulative GRAS Score as a Predictor of Survival After Resection for Adrenocortical Carcinoma: Analysis From the U.S. Adrenocortical Carcinoma Database. Ann Surg Oncol 2021; 28:6551-6561. [PMID: 33586069 DOI: 10.1245/s10434-020-09562-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 12/21/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare but aggressive malignancy, and many prognostic factors that influence survival remain undefined. Individually, the GRAS (Grade, Resection status, Age, and Symptoms of hormone hypersecretion) parameters have demonstrated their prognostic value in ACC. This study aimed to assess the value of a cumulative GRAS score as a prognostic indicator after ACC resection. METHODS A retrospective cohort study of adult patients who underwent surgical resection for ACC between 1993 and 2014 was performed using the United States Adrenocortical Carcinoma Group (US-ACCG) database. A sum GRAS score was calculated for each patient by adding one point each when the criteria were met for tumor grade (Weiss criteria ≥ 3 or Ki67 ≥ 20%), resection status (micro- or macroscopically positive margin), age (≥ 50 years), and preoperative symptoms of hormone hypersecretion (present). Overall survival (OS) and disease-free survival (DFS) by cumulative GRAS score were analyzed by the Kaplan-Meier method and log-rank test. RESULTS Of the 265 patients in the US-ACCG database, 243 (92%) had sufficient data available to calculate a cumulative GRAS score and were included in this analysis. The 265 patients comprised 23 patients (10%) with a GRAS of 0, 52 patients (21%) with a GRAS of 1, 92 patients (38%) with a GRAS of 2, 63 patients (26%) with a GRAS of 3, and 13 patients (5%) with a GRAS of 4. An increasing GRAS score was associated with shortened OS (p < 0.01) and DFS (p < 0.01) after index resection. CONCLUSION In this retrospective analysis, the cumulative GRAS score effectively stratified OS and DFS after index resection for ACC. Further prospective analysis is required to validate the cumulative GRAS score as a prognostic indicator for clinical use.
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Affiliation(s)
- Jordan J Baechle
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,School of Medicine, Meharry Medical College, Nashville, TN, USA
| | | | - Carmen C Solórzano
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thuy B Tran
- Department of Surgery, Stanford Medical Center, Stanford, CA, USA
| | - Lauren M Postlewait
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jason Prescott
- Department of Surgery, The Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Timothy Pawlik
- Department of Surgery, The Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ioannis Hatzaras
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Rivfka Shenoy
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | | | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Linda Jin
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Daniel E Abbott
- Department of General Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sean Ronnekleiv-Kelly
- Department of General Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Adam Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Colleen M Kiernan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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16
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Stahl CC, Schwartz PB, Ethun CG, Marka N, Krasnick BA, Tran TB, Poultsides GA, Roggin KK, Fields RC, Clarke CN, Votanopoulos KI, Cardona K, Abbott DE. Renal Function After Retroperitoneal Sarcoma Resection with Nephrectomy: A Matched Analysis of the United States Sarcoma Collaborative Database. Ann Surg Oncol 2020; 28:1690-1696. [PMID: 33146839 DOI: 10.1245/s10434-020-09290-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/14/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Nephrectomy often is required during en bloc resection of a retroperitoneal sarcoma (RPS) to achieve an R0 or R1 resection. The impact of nephrectomy on postoperative renal function in this patient population, who also may benefit from subsequent nephrotoxic systemic therapy, is not well described. METHODS The United States Sarcoma Collaborative (USSC) database was queried for patients undergoing RPS resection between 2000 and 2016. Patients with missing pre- or postoperative measures of renal function were excluded. A matched cohort was created using coarsened exact matching. Weighted logistic regression was used to control further for differences between the nephrectomy and non-nephrectomy cohorts. The primary outcomes were postoperative acute kidney injury (AKI), acute renal failure (ARF), and dialysis. RESULTS The initial cohort consisted of 858 patients, 3 (0.3%) of whom required postoperative dialysis. The matched cohort consisted of 411 patients, 108 (26%) of whom underwent nephrectomy. The patients who underwent nephrectomy had higher rates of postoperative AKI (14.8% vs 4.3%; p < 0.01) and ARF (4.6% vs 1.3%; p = 0.04), but no patients required dialysis postoperatively. Logistic regression modeling showed that the risk of AKI (odds ratio [OR], 5.16; p < 0.01) and ARF (OR 5.04; p < 0.01) after nephrectomy persisted despite controlling for age and preoperative renal function. CONCLUSIONS Nephrectomy is associated with an increased risk of postoperative AKI and ARF after RPS resection. This study was unable to statistically assess the impact of nephrectomy on postoperative dialysis, but the risk of postoperative dialysis is 0.5% or less regardless of nephrectomy status.
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Affiliation(s)
| | | | - Cecilia G Ethun
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Nicholas Marka
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | | | | | | | | | - Ryan C Fields
- Siteman Cancer Center, Washington University, St. Louis, MO, USA
| | | | | | - Kenneth Cardona
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin, Madison, WI, USA
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17
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Kone LB, Kunda NM, Tran TB, Maker AV. Surgeon-Placed Continuous Wound Infusion Pain Catheters Markedly Decrease Narcotic Use and Improve Outcomes After Pancreatic Tumor Resection. Ann Surg Oncol 2020; 28:2287-2295. [PMID: 32880771 DOI: 10.1245/s10434-020-09067-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/09/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pancreatectomy results in significant postoperative pain and typically requires opioid analgesia for adequate pain control. Local anesthetics may decrease postoperative pain and opioid requirements but can be limited by onset of action, duration of effect, and inability to titrate dosing after administration. This can be overcome by surgeon placement of tunneled peri-incisional catheters with continuous wound infusion (CWI). METHODS This retrospective cohort study analyzed patients undergoing open pancreatic tumor resection. All the patients received patient-controlled analgesia (PCA), enabling an objective comparison of opioid requirements, and underwent the same recovery pathway. The patients received CWI (n = 45), PCA alone (n = 11), or epidural analgesia (EA) (n = 9). The primary outcome was total opioid use in terms of intravenous morphine milligram equivalents (MMEs) and patient-reported pain scores on a numeric rating scale (NRS) of 0 to 10. RESULTS No differences in baseline patient or tumor characteristics were observed. In both the uni- and multivariate analyses, CWI was associated with lower opioid use than PCA (MME, 83 vs 207 mg; p = 0.004) or EA (MME, 83 vs 156 mg; p < 0.001) without having a negative impact on pain scores. Furthermore, CWI was associated with a greater percentage of time that patients experienced optimal pain control (NRS, ≤ 4: 63% vs 50%; p = 0.033) and a shorter time to PCA independence (4.0 vs 4.9 days; p = 0.004) than PCA alone. In addition, CWI was associated with earlier ambulation [EA vs CWI: odds ratio (OR), 0.05; p = 0.021], improved spirometry performance (CWI vs PCA: regression coefficient (coef), 267; p = 0.013), and earlier urinary catheter removal (EA vs CWI: coef, 1.30; p = 0.013). The findings showed no differences in time to return of bowel function, antiemetic use, or hospital length of stay. CONCLUSIONS After open pancreatic tumor resection, CWI is safe and associated with decreased opioid requirements and improved functional outcomes without a negative impact on pain scores, supporting its potential for preferred use over PCA or EA alone.
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Affiliation(s)
- Lyonell B Kone
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, IL, USA.,Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Nicholas M Kunda
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, IL, USA.,Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Thuy B Tran
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, IL, USA.,Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Ajay V Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, IL, USA. .,Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
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18
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Strong EA, Park SH, Ethun CG, Chow B, King D, Bedi M, Charlson J, Mogal H, Tsai S, Christians K, Tran TB, Poultsides G, Grignol V, Howard JH, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Cullinan D, Fields RC, Gamblin TC, Cardona K, Clarke CN. High neutrophil-lymphocyte ratio is not independently associated with worse survival or recurrence in patients with extremity soft tissue sarcoma. Surgery 2020; 168:760-767. [PMID: 32736869 DOI: 10.1016/j.surg.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 05/21/2020] [Accepted: 06/10/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Soft tissue sarcomas are a heterogenous group of neoplasms without well-validated biomarkers. Cancer-related inflammation is a known driver of tumor growth and progression. Recent studies have implicated a high circulating neutrophil-lymphocyte ratio as a surrogate marker for the inflammatory tumor microenvironment and a poor prognosticator in multiple solid tumors, including colorectal and pancreatic cancers. The impact of circulating neutrophil-lymphocyte ratio in soft tissue sarcomas has yet to be elucidated. METHODS We performed a retrospective analysis of patients undergoing curative resection for primary or recurrent extremity soft tissue sarcomas at academic centers within the US Sarcoma Collaborative. Neutrophil-lymphocyte ratio was calculated retrospectively in treatment-naïve patients using blood counts at or near diagnosis. RESULTS A high neutrophil-lymphocyte ratio (≥4.5) was associated with worse survival on univariable analysis in patients with extremity soft tissue sarcomas (hazard ratio 2.07; 95% confidence interval, 1.54-2.8; P < .001). On multivariable analysis, increasing age (hazard ratio 1.03; 95% confidence interval, 1.02-1.04; P < .001), American Joint Committee on Cancer T3 (hazard ratio 1.89; 95% confidence interval, 1.16-3.09; P = .011), American Joint Committee on Cancer T4 (hazard ratio 2.36; 95% confidence interval, 1.42-3.92; P = .001), high tumor grade (hazard ratio 4.56; 95% confidence interval, 2.2-9.45; P < .001), and radiotherapy (hazard ratio 0.58; 95% confidence interval, 0.41-0.82; P = .002) were independently predictive of overall survival, but a high neutrophil-lymphocyte ratio was not predictive of survival (hazard ratio 1.26; 95% confidence interval, 0.87-1.82; P = .22). CONCLUSION Tumor inflammation as measured by high pretreatment neutrophil-lymphocyte ratio was not independently associated with overall survival in patients undergoing resection for extremity soft tissue sarcomas.
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Affiliation(s)
- Erin A Strong
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Cecilia G Ethun
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Bonnie Chow
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - David King
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Meena Bedi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - John Charlson
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Harveshp Mogal
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Susan Tsai
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Thuy B Tran
- Department of Surgery, Stanford University, Palo Alto, CA
| | | | - Valerie Grignol
- Department of Surgery, The Ohio State University, Columbus, OH
| | | | - Jennifer Tseng
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | | | | | | | - Ryan C Fields
- Department of Surgery, Washington University, St. Louis, MO
| | - T Clark Gamblin
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Kenneth Cardona
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
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19
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Lee RM, Ethun CG, Zaidi MY, Tran TB, Poultsides GA, Grignol VP, Howard JH, Bedi M, Gamblin TC, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Krasnick BA, Fields RC, Oskouei SV, Monson DK, Reimer NB, Maithel SK, Cardona K. A closer look at the natural history and recurrence patterns of high-grade truncal/extremity leiomyosarcomas: A multi-institutional analysis from the US Sarcoma Collaborative. Surg Oncol 2020; 34:292-297. [PMID: 32891345 DOI: 10.1016/j.suronc.2020.06.003] [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: 12/16/2019] [Revised: 04/27/2020] [Accepted: 06/18/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND/OBJECTIVE Natural history and outcomes for truncal/extremity (TE) soft tissue sarcoma (STS) is derived primarily from studies investigating all histiotypes as one homogenous cohort. We aimed to define the recurrence rate (RR), recurrence patterns, and response to radiation of TE leiomyosarcomas (LMS). METHODS Patients from the US Sarcoma Collaborative database with primary, high-grade TE STS were identified. Patients were grouped into LMS or other histology (non-LMS). Primary endpoints were locoregional recurrence-free survival (LR-RFS), distant-RFS (D-RFS), and disease specific survival (DSS). RESULTS Of 1215 patients, 93 had LMS and 1122 non-LMS. In LMS patients, median age was 63 and median tumor size was 6 cm. In non-LMS patients, median age was 58 and median tumor size was 8 cm. In LMS patients, overall RR was 42% with 15% LR-RR and 29% D-RR. The 3yr LR-RFS, D-RFS, and DSS were 84%, 65%, and 76%, respectively. When considering high-risk (>5 cm and high-grade, n = 49) LMS patients, the overall RR was 45% with 12% LR-RR and 35% D-RR. 61% received radiation. The 3yr LR-RFS (78vs93%, p = 0.39), D-RFS (53vs63%, p = 0.27), and DSS (67vs91%, p = 0.17) were similar in those who did and did not receive radiation. High-risk, non-LMS patients had a similar overall RR of 42% with 15% LR-RR and 30% D-RR. 60% of non-LMS patients received radiation. There was an improved 3yr LR-RFS (82vs75%, p = 0.030) and DSS (77vs65%,p = 0.007) in non-LMS patients who received radiation. CONCLUSIONS In our cohort, patients with LMS have a low local recurrence rate (12-15%) and modest distant recurrence rate (29-35%). However, LMS patients had no improvement in local control or long-term outcomes with radiation. The value of radiation in these patients merits further investigation.
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Affiliation(s)
- Rachel M Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Mohammad Y Zaidi
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Thuy B Tran
- Department of Surgery, Stanford University Medical Center, Palo Alto, CA, USA
| | - George A Poultsides
- Department of Surgery, Stanford University Medical Center, Palo Alto, CA, USA
| | - Valerie P Grignol
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - John H Howard
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Meena Bedi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - T Clark Gamblin
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jennifer Tseng
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | | | | | - Bradley A Krasnick
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Shervin V Oskouei
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - David K Monson
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Nickolas B Reimer
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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20
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Abstract
Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with a dismal prognosis. When diagnosed in advanced stages of the disease, the outcomes of surgical resection are not well understood. The objective of this study is to determine the impact of surgery in patients with advanced ACC. Using the Surveillance, Epidemiology and End Results database, we identified patients diagnosed with Stage III and IVACC between 1988 and 2009. A total of 320 patients with Stage III and IV disease were included in our analysis. In patients treated with surgical resection, the Stage III 1- and 5-year survival rates were 77 and 40 per cent, respectively, whereas the Stage IV 1- and 5-year survival rates were 54 and 27.6 per cent, respectively. Patients treated without surgery had poor survival at 1 year for both Stage III (13%) and Stage IV (16%) ( P < 0.01 compared with the surgical groups). Lymph node dissection was performed in 26 per cent of the patients with advanced ACC and was associated with improved survival in univariate analysis of Stage IV patients. Overall, our results indicate that favorable survival outcomes can be achieved even in patients with Stage III and IV disease and surgery should be considered in patients with advanced ACC.
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Affiliation(s)
- Thuy B. Tran
- From Hepatobiliary Surgery and Liver Transplantation, Cedars-Sinai Medical Center, Los Angeles, California
| | - Douglas Liou
- From Hepatobiliary Surgery and Liver Transplantation, Cedars-Sinai Medical Center, Los Angeles, California
| | - Vijay G. Menon
- From Hepatobiliary Surgery and Liver Transplantation, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nicholas N. Nissen
- From Hepatobiliary Surgery and Liver Transplantation, Cedars-Sinai Medical Center, Los Angeles, California
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21
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Barr JT, Tran TB, Rock BM, Wahlstrom JL, Dahal UP. Strain-Dependent Variability of Early Discovery Small Molecule Pharmacokinetics in Mice: Does Strain Matter? Drug Metab Dispos 2020; 48:613-621. [PMID: 32474442 DOI: 10.1124/dmd.120.090621] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 05/19/2020] [Indexed: 12/21/2022] Open
Abstract
Drug discovery programs routinely perform pharmacokinetic (PK) studies in mice to prioritize lead compounds based on anticipated exposure-efficacy and exposure-toxicity relationships. Because of logistical and/or technical issues, the strain of mouse in early discovery PK studies may not always match the strain in toxicity or efficacy studies. This elicits the question do appreciable strain-dependent differences in PK parameters exist to an extent that would warrant conducting PK studies in a strain that matches efficacy and toxicity models? To understand the impact that strain may have on PK parameters, we selected eight marketed drugs with well characterized absorption, distribution, metabolism, and excretion properties and diverse structures to perform PK studies in three common mouse strains (Bagg Albino c, C57BL/6, and CD-1). Some statistical strain-dependent differences were observed; however, we found good general agreement of PK parameters between strains: 88%, 100%, 75%, 76%, 94%, and 88% of compounds were within twofold across strains for clearance, volume of distribution at steady state, t 1/2, C max, T max, and oral bioavailability, respectively. Overall, we recommend that an approach using a single strain of mouse is appropriate for discovery screening PK studies, provided that proper caution is exercised. SIGNIFICANCE STATEMENT: The mouse strain in discovery pharmacokinetic (PK) studies may not match the strain in efficacy and toxicology studies. Currently, there is a gap in the literature addressing whether differences in PK parameters across mouse strains exist such that multiple PK studies are warranted. The results from this study indicated that the PK properties of clinically used drugs between mouse strains are within an acceptable range such that single strain PK is appropriate.
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Affiliation(s)
- John T Barr
- Pharmacokinetics and Drug Metabolism, Amgen Inc., South San Francisco, California
| | - Thuy B Tran
- Pharmacokinetics and Drug Metabolism, Amgen Inc., South San Francisco, California
| | - Brooke M Rock
- Pharmacokinetics and Drug Metabolism, Amgen Inc., South San Francisco, California
| | - Jan L Wahlstrom
- Pharmacokinetics and Drug Metabolism, Amgen Inc., South San Francisco, California
| | - Upendra P Dahal
- Pharmacokinetics and Drug Metabolism, Amgen Inc., South San Francisco, California
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22
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Shelby RD, Suarez-Kelly LP, Yu PY, Hughes TM, Ethun CG, Tran TB, Poultsides G, King DM, Bedi M, Mogal H, Clarke C, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Krasnick BA, Fields RC, Pollock RE, Howard JH, Cardona K, Grignol V. Neoadjuvant radiation improves margin-negative resection rates in extremity sarcoma but not survival. J Surg Oncol 2020; 121:1249-1258. [PMID: 32232871 DOI: 10.1002/jso.25905] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 02/16/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Radiation improves limb salvage in extremity sarcomas. Timing of radiation therapy remains under investigation. We sought to evaluate the effects of neoadjuvant radiation (NAR) on surgery and survival of patients with extremity sarcomas. MATERIALS AND METHODS A multi-institutional database was used to identify patients with extremity sarcomas undergoing surgical resection from 2000-2016. Patients were categorized by treatment strategy: surgery alone, adjuvant radiation (AR), or NAR. Survival, recurrence, limb salvage, and surgical margin status was analyzed. RESULTS A total of 1483 patients were identified. Most patients receiving radiotherapy had high-grade tumors (82% NAR vs 81% AR vs 60% surgery; P < .001). The radiotherapy groups had more limb-sparing operations (98% AR vs 94% NAR vs 87% surgery; P < .001). NAR resulted in negative margin resections (90% NAR vs 79% surgery vs 75% AR; P < .0001). There were fewer local recurrences in the radiation groups (14% NAR vs 17% AR vs 27% surgery; P = .001). There was no difference in overall or recurrence-free survival between the three groups (OS, P = .132; RFS, P = .227). CONCLUSION In this large study, radiotherapy improved limb salvage rates and decreased local recurrences. Receipt of NAR achieves more margin-negative resections however this did not improve local recurrence or survival rates over.
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Affiliation(s)
- Rita D Shelby
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | | | - Peter Y Yu
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Tasha M Hughes
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Cecilia G Ethun
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Thuy B Tran
- Department of Surgery, Stanford University, Palo Alto, California
| | | | - David M King
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Meena Bedi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Harveshp Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Callisia Clarke
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer Tseng
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | | | | | - Bradley A Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Kenneth Cardona
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Valerie Grignol
- Department of Surgery, The Ohio State University, Columbus, Ohio
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23
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Bedi M, Ethun CG, Charlson J, Tran TB, Poultsides G, Grignol V, Howard JH, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Cullinan D, Fields RC, Cardona K, King DM. Is a Nomogram Able to Predict Postoperative Wound Complications in Localized Soft-tissue Sarcomas of the Extremity? Clin Orthop Relat Res 2020; 478:550-559. [PMID: 32168066 PMCID: PMC7145071 DOI: 10.1097/corr.0000000000000959] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative wound complications are challenging in patients with localized extremity soft-tissue sarcomas. Various factors have been associated with wound complications, but there is no individualized predictive model to allow providers to counsel their patients and thus offer methods to mitigate the risk of complications and implement appropriate measures. QUESTIONS/PURPOSES We used data from multiple centers to ask: (1) What risk factors are associated with postoperative wound complications in patients with localized soft-tissue sarcomas of the extremity? (2) Can we create a predictive nomogram that will assess the risk of wound complications in individual patients after resection for soft-tissue sarcoma? METHODS From 2000 to 2016, 1669 patients undergoing limb-salvage resection for a localized primary or recurrent extremity soft-tissue sarcoma with at least 120 days of follow-up at eight participating United States Sarcoma Collaborative institutions were identified. Wound complications included superficial wounds with or without drainage, deep wounds with drainage because of dehiscence, and intentional opening of the wound within 120 days postoperatively. Sixteen variables were selected a priori by clinicians and statisticians as potential risk factors for wound complications. A univariate analysis was performed using Fisher's exact tests for categorical predictors, and Wilcoxon's rank-sum tests were used for continuous predictors. A multiple logistic regression analysis was used to train the prediction model that was used to create the nomogram. The prediction performance of the datasets was evaluated using a receiver operating curve, area under the curve, and calibration plot. RESULTS After controlling for potential confounding factors such as comorbidities, functional status, albumin level, and chemotherapy use, we found that increasing age (odds ratio 1.02; 95% confidence interval, 1.00-1.03; p = 0.008), BMI (OR 1.05; 95% CI, 1.02-1.09; p = 0.004), lower-extremity location (OR 6; 95% CI, 2.87-12.69; p < 0.001), and neoadjuvant radiation (OR 2; 95% CI, 1.47-3.16; p < 0.001) were associated with postoperative wound complications (area under the curve 69.2% [range 62.8%-75.6%]). CONCLUSIONS We found that age, BMI, tumor location, and timing of radiation are associated with the risk of wound complications. Based on these factors, a validated nomogram has been established that can provide an individualized prediction of wound complications in patients with a resected soft-tissue sarcoma of the extremity. This may allow for proactive management with nutrition and surgical techniques, and help determine the delivery of radiation in patients with a high risk of having these complications. LEVEL OF EVIDENCE Level III, therapeutic study.
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24
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Squires MH, Ethun CG, Suarez-Kelly LP, Yu PY, Hughes TM, Shelby RD, Tran TB, Poultsides G, Charlson J, Gamblin TC, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Krasnick BA, Fields RC, Pollock RE, Grignol V, Cardona K, Howard JH. Trends in the Use of Adjuvant Chemotherapy for High-Grade Truncal and Extremity Soft Tissue Sarcomas. J Surg Res 2019; 245:577-586. [PMID: 31494391 DOI: 10.1016/j.jss.2019.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 03/01/2019] [Revised: 07/12/2019] [Accepted: 08/05/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND In the randomized controlled trial (RCT) EORTC 62931, adjuvant chemotherapy failed to show improvement in relapse-free survival (RFS) or overall survival (OS) for patients with resected high-grade soft tissue sarcoma (STS). We evaluated whether the negative results of this 2012 RCT have influenced multidisciplinary treatment patterns for patients with high-grade STS undergoing resection at seven academic referral centers. METHODS The U.S. Sarcoma Collaborative database was queried to identify patients who underwent curative-intent resection of primary high-grade truncal or extremity STS from 2000 to 2016. Patients with recurrent tumors, metastatic disease, and those receiving neoadjuvant chemotherapy were excluded. Patients were divided by treatment era into early (2000-2011, pre-European Organisation for Research and Treatment of Cancer [EORTC] trial) and late (2012-2016, post-EORTC trial) cohorts for analysis. Rates of adjuvant chemotherapy and clinicopathologic variables were compared between the two cohorts. Univariate and multivariate regression analyses were used to determine factors associated with OS and RFS. RESULTS 949 patients who met inclusion criteria were identified, with 730 patients in the early cohort and 219 in the late cohort. Adjuvant chemotherapy rates were similar between the early and late cohorts (15.6% versus 14.6%; P = 0.73). Patients within the early and late cohorts demonstrated similar median OS (128 months versus median not reached, P = 0.84) and RFS (107 months versus median not reached, P = 0.94). Receipt of adjuvant chemotherapy was associated with larger tumor size (13.6 versus 8.9 cm, P < 0.001), younger age (53.3 versus 63.7 years, P < 0.001), and receipt of adjuvant radiation (P < 0.001). On multivariate regression analysis, risk factors associated with decreased OS were increasing American Society of Anesthesiologists class (P = 0.02), increasing tumor size (P < 0.001), and margin-positive resection (P = 0.01). Adjuvant chemotherapy was not associated with OS (P = 0.88). Risk factors associated with decreased RFS included increasing tumor size (P < 0.001) and margin-positive resection (P = 0.03); adjuvant chemotherapy was not associated with RFS (P = 0.23). CONCLUSIONS Rates of adjuvant chemotherapy for resected high-grade truncal or extremity STS have not decreased over time within the U.S. Sarcoma Collaborative, despite RCT data suggesting a lack of efficacy. In this retrospective multi-institutional analysis, adjuvant chemotherapy was not associated with RFS or OS on multivariate analysis, consistent with the results from EORTC 62931. Rates of adjuvant chemotherapy for high-grade STS were low in both cohorts but may be influenced more by selection bias based on clinicopathologic variables such as tumor size, margin status, and patient age than by prospective, randomized data.
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Affiliation(s)
- Malcolm H Squires
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
| | - Lorena P Suarez-Kelly
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Peter Y Yu
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Tasha M Hughes
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Rita D Shelby
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Thuy B Tran
- Department of Surgery, Stanford University Medical Center, Palo Alto, California
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Palo Alto, California
| | - John Charlson
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - T Clark Gamblin
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer Tseng
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | | | | | - Bradley A Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Raphael E Pollock
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Valerie Grignol
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
| | - J Harrison Howard
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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25
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Zaidi MY, Ethun CG, Tran TB, Poultsides G, Grignol VP, Howard JH, Bedi M, Mogal H, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Krasnick B, Fields RC, Oskouei S, Reimer N, Monson D, Maithel SK, Cardona K. Assessing the Role of Neoadjuvant Chemotherapy in Primary High-Risk Truncal/Extremity Soft Tissue Sarcomas: An Analysis of the Multi-institutional U.S. Sarcoma Collaborative. Ann Surg Oncol 2019; 26:3542-3549. [PMID: 31342400 DOI: 10.1245/s10434-019-07639-7] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The role of neoadjuvant chemotherapy (NCT) for high-risk soft tissue sarcoma (STS) is questioned. This study aimed to define which patients may experience a survival advantage with NCT. METHODS All the patients from the U.S. Sarcoma Collaborative database (2000-2016) who underwent curative-intent resection of high-grade, primary truncal/extremity STS size 5 cm or larger were included in this study. The primary end points were recurrence-free survival (RFS) and overall survival (OS). RESULTS Of the 4153 patients, 770 were included in the study. The median tumor size was 10 cm, and 669 of the patients (87%) had extremity tumors. The most common histology was undifferentiated pleomorphic sarcoma (UPS), found in 42% of the patients. Of the 770 patients, 216 (28%) received NCT. The patients who received NCT had deeper, larger tumors (p < 0.001). Of the patients with tumors 5 cm or larger and 8 cm or larger, NCT was not associated with improved RFS or OS. However for the patients with tumors 10 cm or larger, NCT was associated with improved 5-year RFS (51% vs 40%; p = 0.053) and 5-year OS (58% vs 47%; p = 0.043). By location, the patients with extremity tumors 10 cm or larger but not truncal tumors had improved 5-yearr RFS (54% vs 42%; p = 0.042) and 5-year OS (61% vs 47%; p = 0.015) with NCT. According to histology, no subtype had improved RFS or OS with NCT, although the patients with UPS had a trend toward improved 5-year RFS (56% vs 42%; p = 0.092) and 5-year OS (66% vs 52%; p = 0.103) with NCT. CONCLUSION For the patients with high-grade STS, NCT was associated with improved RFS and OS when tumors were 10 cm or larger and located in the extremity. However, no histiotype-specific advantage was identified. Future studies assessing the efficacy of NCT may consider focusing on these patients, with added focus on histology-specific strategies.
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Affiliation(s)
- Mohammad Y Zaidi
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Thuy B Tran
- Department of Surgery, Stanford University Medical Center, Palo Alto, CA, USA
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Palo Alto, CA, USA
| | - Valerie P Grignol
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - J Harrison Howard
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Meena Bedi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Harveshp Mogal
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jennifer Tseng
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | | | | | - Brad Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Shervin Oskouei
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Nickolas Reimer
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - David Monson
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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26
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Prendergast KM, Smith PM, Tran TB, Postlewait LM, Maithel SK, Prescott JD, Pawlik TM, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Shirley LA, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Votanopoulos KI, Levine EA, Poultsides GA, Solórzano CC, Kiernan CM. Features of synchronous versus metachronous metastasectomy in adrenal cortical carcinoma: Analysis from the US adrenocortical carcinoma database. Surgery 2019; 167:352-357. [PMID: 31272813 DOI: 10.1016/j.surg.2019.05.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/09/2019] [Accepted: 05/19/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Adrenocortical carcinoma is a rare, aggressive cancer. We compared features of patients who underwent synchronous versus metachronous metastasectomy. METHODS Adult patients who underwent resection for metastatic adrenocortical carcinoma from 1993 to 2014 at 13 institutions of the US adrenocortical carcinoma group were analyzed retrospectively. Patients were categorized as synchronous if they underwent metastasectomy at the index adrenalectomy or metachronous if they underwent resection after recurrence of the disease. Factors associated with overall survival were assessed by univariate analysis. RESULTS In the study, 84 patients with adrenocortical carcinoma underwent metastasectomy; 26 (31%) were synchronous and 58 (69%) were metachronous. Demographics were similar between groups. The synchronous group had more T4 tumors at the index resection (42 vs 3%, P < .001). The metachronous group had prolonged median survival after the index resection (86.3 vs 17.3 months, P < .001) and metastasectomy (36.9 vs 17.3 months, P = .007). Synchronous patients with R0 resections had improved survival compared to patients with R1/2 resections (P = .008). Margin status at metachronous metastasectomy was not associated with survival (P = .452). CONCLUSION Select patients with metastatic adrenocortical carcinoma may benefit from metastasectomy. Patients with metachronous metastasectomy have a more durable survival benefit than those undergoing synchronous metastasectomy. This study highlights need for future studies examining differences in tumor biology that could explain outcome disparities in these distinct patient populations.
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Affiliation(s)
| | | | - Thuy B Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Jason D Prescott
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, NY
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, NY
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH
| | | | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Linda X Jin
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Sharon M Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
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27
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Gannon NP, King DM, Ethun CG, Charlson J, Tran TB, Poultsides G, Grignol V, Howard JH, Tseng J, Roggin KK, Votanopoulos K, Krasnick B, Fields RC, Cardona K, Bedi M. The role of radiation therapy and margin width in localized soft-tissue sarcoma: Analysis from the US Sarcoma Collaborative. J Surg Oncol 2019; 120:325-331. [PMID: 31172531 DOI: 10.1002/jso.25522] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 04/15/2019] [Revised: 05/12/2019] [Accepted: 05/13/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND OBJECTIVES Soft-tissue sarcomas (STSs) are often treated with resection and radiation (RT)±chemotherapy. The role of RT in decreasing resection width to achieve local control is unclear. We evaluated RT on margin width to achieve local control and local recurrence (LR). METHODS From 2000 to 2016, 514 patients with localized STS were identified from the US Sarcoma Collaborative database. Patients were stratified by a margin and local control was compared amongst treatment groups. RESULTS LR was 9% with positive, 4.2% with ≤1 mm, and 9.3% with >1 mm margins (P = .315). In the ≤1 mm group, LR was 5.7% without RT, 0% with preoperative RT, and 0% with postoperative RT (P < .0001). In the >1 mm group, LR was 10.2%, 0%, and 3.7% in the no preoperative and postoperative RT groups, respectively (P = .005). RT did not influence LR in patients with positive margins. In stage I-III and II-III patients, local recurrence-free survival was higher following RT (P = .008 and P = .05, respectively). CONCLUSIONS RT may play a larger role in minimizing LR than margin status. In patients with positive margins, RT may decrease LR to similar rates as a negative margin without RT and may be considered to decrease the risk of LR with anticipated close/positive margins.
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Affiliation(s)
- Nicholas P Gannon
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David M King
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - John Charlson
- Division of Hematology and Oncology, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Thuy B Tran
- Department of Surgery, Stanford University, Palo Alto, California
| | | | - Valerie Grignol
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, Ohio
| | - J Harrison Howard
- Division of Surgical Oncology, Department of Surgery, University of South Alabama, Mobile, Alabama
| | - Jennifer Tseng
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Kevin K Roggin
- Department of Surgery, University of Chicago, Chicago, Illinois
| | | | - Bradley Krasnick
- Department of Surgery, Washington University, St. Louis, Missouri
| | - Ryan C Fields
- Department of Surgery, Washington University, St. Louis, Missouri
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Meena Bedi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
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28
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Maker AV, Tran TB, Coburn N, Fong ZV, Cardona K, Newell P, Morris-Stiff G, Chavin K, Mansour J. Does attending a Delphi consensus conference impact surgeon attitudes? Survey results from the Americas HepatoPancreatoBiliary Association consensus conference on small asymptomatic pancreatic neuroendocrine tumors. HPB (Oxford) 2019; 21:524-530. [PMID: 30442562 DOI: 10.1016/j.hpb.2018.10.001] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/02/2018] [Accepted: 10/05/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Management of asymptomatic small well-differentiated (panNET) <2 cm remains controversial. A consensus conference was held on this topic. The impact of attending the conference and participating in the audience response survey on surgeon's clinical approach to pancreatic neuroendocrine tumors was assessed. METHODS Audience members were surveyed using a smartphone real-time response system at the beginning and end of the conference. RESULTS The majority of 75 attendees underwent fellowship training, and 30% had >10 years experience as attending surgeons. Previously published consensus statements on the topic were considered insufficient to guide surgical practice by 82% of attendees, and over 96% desired additional data. After review of the data, consensus statements, and decision-making process, a significant number of participants changed their opinions regarding indications for tissue biopsy (p = 0.001), size thresholds for excision (p = 0.002), and regional lymph node dissection (p = 0.002) independent of whether a consensus was reached by the content-expert panel. CONCLUSIONS This represented the first Delphi process consensus on the topic, and the survey confirmed the topic as well-chosen and timely. Attendees changed opinions on management of panNET regardless of whether formal consensus was reached. Therefore, statements of consensus combined with presentation of literature and live discussion served to impact attendees' approach to this disease.
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Affiliation(s)
- Ajay V Maker
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA.
| | - Thuy B Tran
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Natalie Coburn
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, USA
| | - Zhi V Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Philippa Newell
- Department of Surgery, Providence Portland Medical Center, Portland, OR, USA
| | | | - Kenneth Chavin
- Department of Surgery, University Hospitals, Cleveland, OH, USA
| | - John Mansour
- Department of Surgery, UT Southwestern, Dallas, TX, USA
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Abstract
BACKGROUND Adjuvant immunotherapy has improved outcomes in patients with advanced melanoma; however, the potential benefit for patients with pancreatic ductal adenocarcinoma (PDAC) remains unknown. The aim of this study was to determine the impact of adjuvant chemotherapy and immunotherapy (CTx-IT) compared with CTx alone on patient survival after resection of PDAC. STUDY DESIGN Patients who underwent resection of PDAC from 2004 to 2015 were identified from the National Cancer Database. Univariate and multivariate Cox proportional hazards models were used to determine predictors of overall survival (OS) based on the type of adjuvant therapy received. Patients who received adjuvant immunotherapy were compared with those who received adjuvant CTx alone by propensity score matching. RESULTS Of 21,313 patients who received curative-intent resection for PDAC followed by adjuvant systemic therapy, 269 (1.3%) patients were treated with adjuvant CTx-IT. Propensity score matching resulted in a cohort of 477 patients: (229 CTx only and 248 CTx-IT). The 5-year OS was higher in the CTx-IT group compared with CTx alone (29.2% vs 18.3%; p = 0.0045). On multivariate analysis, the addition of adjuvant immunotherapy was associated was improved overall survival (hazard ratio 0.74; p = 0.007). CONCLUSIONS The addition of adjuvant immunotherapy to chemotherapy is associated with improved survival compared with chemotherapy alone after curative-intent resection of pancreatic adenocarcinoma. Future research is warranted to match specific immunotherapy agents with susceptible patient populations to improve outcomes for this aggressive disease.
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Affiliation(s)
- Thuy B Tran
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, and the Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL
| | - Vijay K Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, and the Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL
| | - Ajay V Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, and the Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL.
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Barr JT, Lade JM, Tran TB, Dahal UP. Fraction Unbound for Liver Microsome and Hepatocyte Incubations for All Major Species Can Be Approximated Using a Single-Species Surrogate. Drug Metab Dispos 2019; 47:419-423. [DOI: 10.1124/dmd.118.085936] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 02/05/2019] [Indexed: 11/22/2022] Open
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Tran TB, Ethun CG, Pawlik TM, Schmidt C, Beal EW, Fields RC, Krasnick B, Weber SM, Salem A, Martin RCG, Scoggins CR, Shen P, Mogal HD, Idrees K, Isom CA, Hatzaras I, Shenoy R, Maithel SK, Poultsides GA. Actual 5-Year Survivors After Surgical Resection of Hilar Cholangiocarcinoma. Ann Surg Oncol 2018; 26:611-618. [PMID: 30539494 DOI: 10.1245/s10434-018-7075-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The prevalence and characteristics of actual 5-year survivors after surgical treatment of hilar cholangiocarcinoma (HC) have not been described previously. METHODS Patients who underwent resection for HC from 2000 to 2015 were analyzed through a multi-institutional registry from 10 U.S. academic medical centers. The clinicopathologic characteristics and both the perioperative and long-term outcomes for actual 5-year survivors were compared with those for non-survivors (patients who died within 5 years after surgery). Patients alive at last encounter who had a follow-up period shorter than 5 years were excluded from the study. RESULTS The study identified 257 patients with HC who underwent curative-intent resection with an actuarial 5-year survival of 19%. Of 194 patients with a follow-up period longer than 5 years, 23 (12%) were 5-year survivors. Compared with non-survivors, the 5-year survivors had a lower median pretreatment CA 19-9 level (116 vs. 34 U/L; P = 0.008) and a lower rate of lymph node involvement (42% vs. 15%; P = 0.027) and R1 margins (39% vs. 17%; P = 0.042). However, the sole presence of these factors did not preclude a 5-year survival after surgery. The frequencies of bile duct resection alone, major hepatectomy, caudate lobe resection, portal vein or hepatic artery resection, preoperative biliary sepsis, intraoperative blood transfusion, serious postoperative complications, and receipt of adjuvant chemotherapy were comparable between the two groups. CONCLUSIONS One in eight patients with HC reaches the 5-year survival milestone after resection. A 5-year survival can be achieved even in the presence of traditionally unfavorable clinicopathologic factors (elevated CA 19-9, nodal metastasis, and R1 margins).
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Affiliation(s)
- Thuy B Tran
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Cecilia G Ethun
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.,Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Carl Schmidt
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Eliza W Beal
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Robert C G Martin
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | | | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Harveshp D Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Kamran Idrees
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chelsea A Isom
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY, USA
| | - Shishir K Maithel
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
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Yu PY, Beal EW, Hughes TM, Suarez-Kelly LP, Shelby RD, Ethun CG, Tran TB, Poultsides G, Charlson J, Gamblin TC, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Krasnick BA, Fields RC, Pollock RE, Grignol V, Cardona K, Howard JH. Perioperative chemotherapy is not associated with improved survival in high-grade truncal sarcoma. J Surg Res 2018; 231:248-256. [PMID: 30278937 DOI: 10.1016/j.jss.2018.05.030] [Citation(s) in RCA: 2] [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: 12/01/2017] [Revised: 04/30/2018] [Accepted: 05/18/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The treatment benefit of perioperative chemotherapy (CTX) for truncal soft tissue sarcoma (STS) is not well established. This study evaluates the association of CTX with survival for patients with resected primary high-grade truncal STS. MATERIALS AND METHODS Adult patients with high-grade truncal STS who had curative-intent resection from 2000 to 2016 at seven U.S. institutions were evaluated retrospectively. Patients were stratified by receipt of CTX. Kaplan-Meier curves with log-rank tests were used to compare overall survival (OS) and recurrence-free survival. Logistic regression models were used to evaluate characteristics associated with OS. RESULTS Of patients with primary high-grade truncal STS, 235 underwent curative-intent resections. The most common histology was undifferentiated pleomorphic sarcoma and mean tumor size was 7.8 cm. Thirty percent of the patients received CTX (n = 70). Among patients receiving CTX, 34% (n = 24) had neoadjuvant CTX, 44% (n = 31) adjuvant CTX, and 21% (n = 15) had neoadjuvant and adjuvant CTX. Patients receiving CTX were more likely to receive radiation (51% versus 34%, P = 0.01), have deep tumors (86% versus 73%, P = 0.037) and solid organ invasion (14% versus 3%, P = 0.001). On univariate analysis, patients who received CTX had worse OS (P < 0.01) and a trend toward worse recurrence-free survival (P = 0.08). Margin status was the only variable associated with improved OS on multivariate analysis (odds ratio 4.36, 95% confidence interval 1.56, 12.13, P < 0.01). CONCLUSIONS In this multi-institutional retrospective analysis of resected high-grade truncal STS, receipt of perioperative CTX was not associated with improved OS, which may be related to selection bias. Microscopically negative margin status was the only independent factor associated with OS.
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Affiliation(s)
- Peter Y Yu
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Eliza W Beal
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Tasha M Hughes
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | | | - Rita D Shelby
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | | | - Thuy B Tran
- Department of Surgery, Stanford University, Palo Alto, California
| | | | - John Charlson
- Department of Surgery and Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - T Clark Gamblin
- Department of Surgery and Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer Tseng
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | | | | | - Bradley A Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Valerie Grignol
- Department of Surgery, The Ohio State University, Columbus, Ohio
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Ethun CG, Poorman CE, Postlewait LM, Tran TB, Prescott JD, Pawlik TM, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solórzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Staley CA, Poultsides GA, Maithel SK. A Novel T-Stage Classification System for Adrenocortical Carcinoma: Proposal from the U.S. Adrenocortical Carcinoma Study Group. VideoEndocrinology 2018. [DOI: 10.1089/ve.2017.0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Cecilia G. Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Caroline E. Poorman
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Lauren M. Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Thuy B. Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Jason D. Prescott
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M. Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tracy S. Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, New York
| | - John E. Phay
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Linda X. Jin
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Sharon M. Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jason K. Sicklick
- Department of Surgery, University of California San Diego, San Diego, California
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, California
| | - Adam C. Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John C. Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, California
| | | | | | | | - Edward A. Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Charles A. Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - George A. Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Johnson AC, Ethun CG, Liu Y, Lopez-Aguiar AG, Tran TB, Poultsides G, Grignol V, Howard JH, Bedi M, Gamblin TC, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Cullinan D, Fields RC, Delman KA, Wood WC, Cardona K, Maithel SK. Studying a Rare Disease Using Multi-Institutional Research Collaborations vs Big Data: Where Lies the Truth? J Am Coll Surg 2018; 227:357-366.e3. [PMID: 29906615 DOI: 10.1016/j.jamcollsurg.2018.05.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/31/2018] [Accepted: 05/31/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Multi-institutional collaborations provide granularity lacking in epidemiologic data sets to enable in-depth study of rare diseases. For patients with superficial, high-grade soft tissue sarcomas of the trunk and extremity, the value of radiation therapy (RT) is not clear. We aimed to use the 7-institution US Sarcoma Collaborative (USSC) and the National Cancer Database (NCDB) to investigate this issue. STUDY DESIGN All adult patients with superficial truncal and extremity high-grade soft tissue sarcomas who underwent primary curative-intent resection from 2000 to 2016 at USSC institutions or were included in the NCDB from 2004 to 2013 were analyzed. Propensity score matching was performed. End points were locoregional recurrence-free survival (LRFS), overall survival (OS), and disease-specific survival (DSS). RESULTS Of 4,153 patients in the USSC, 169 patients with superficial high-grade tumors underwent primary curative-intent resection, 38% of which received RT. On multivariable Cox-regression analysis, RT was not associated with improved LRFS (p = 0.56), OS (p = 0.31), or DSS (p = 0.20). On analysis of 51 propensity score-matched pairs, RT was still not associated with increased LRFS, OS, or DSS. Analysis of 631 propensity score-matched pairs in the NCDB demonstrated improved 5-year OS rate associated with RT (80% vs 70%; p = 0.02). The LRFS and DSS rates were not evaluable. CONCLUSIONS Granular data afforded by collaborative research enables in-depth analysis of patient outcomes. The NCDB, although powered with large numbers, cannot assess many relevant outcomes (eg recurrence, DSS, or complications). In this study, the approaches yielded conflicting results. The USSC data suggested no value of radiation and the NCDB demonstrated improved OS, contradicting all randomized controlled trials in sarcoma. The pros and cons of either approach must be considered when applying results to clinical practice, and underscore the importance of randomized controlled trials.
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Affiliation(s)
- Aileen C Johnson
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Yuan Liu
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Alexandra G Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Thuy B Tran
- Department of Surgery, Stanford University Medical Center, Palo Alto, CA
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Valerie Grignol
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - J Harrison Howard
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Meena Bedi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - T Clark Gamblin
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Jennifer Tseng
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | | | | | - Darren Cullinan
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Keith A Delman
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - William C Wood
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA.
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Marincola Smith P, Kiernan CM, Tran TB, Postlewait LM, Maithel SK, Prescott J, Pawlik T, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay J, Shirley LA, Fields RC, Jin L, Weber S, Salem A, Sicklick J, Gad S, Yopp A, Mansour J, Duh QY, Seiser N, Votanopoulos K, Levine EA, Poultsides G, Solórzano CC. Role of Additional Organ Resection in Adrenocortical Carcinoma: Analysis of 167 Patients from the U.S. Adrenocortical Carcinoma Database. Ann Surg Oncol 2018; 25:2308-2315. [PMID: 29868977 DOI: 10.1245/s10434-018-6546-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare and aggressive cancer. This report describes factors and outcomes associated with resection of extra-adrenal organs en bloc during index adrenalectomy. METHODS Patients who underwent ACC resection for non-metastatic disease from 1993 to 2014 at 13 participating institutions of the US-ACC Group were included in the study. Factors associated with en bloc resection were assessed by uni- and multivariate analysis. The primary end point was overall survival. RESULTS In this study, 167 patients were included and categorized as adrenalectomy with en bloc resection (AdEBR) if they had extra-adrenal organs removed or adrenalectomy (Ad) if they did not. The demographics were similar between the AdEBR (n = 68, 40.7%) and Ad groups, including age, gender, race, American Society of Anesthesiology (ASA) class, and body mass index (BMI). The AdEBR group had larger tumors (13 vs. 10 cm), more open operations (97.1 vs. 63.6%), and more lymph node dissections (LNDs) (36.8 vs. 12.1%). The most common organs removed were kidney (55.9%), liver (27.9%), and spleen (23.5%). Multiple organs were removed in 38.2% (n = 26) of the patients. Margin-negative resections were similar between the two groups. In the multivariate Cox regression adjusted for T and N stages, LND, margin, size, and hormone hypersecretion, en bloc resection was not associated with improved survival (hazard ratio [HR], 1.42; p = 0.323). CONCLUSION The study findings validated current practice by showing that en bloc resection should occur at index adrenalectomy for ACC when a T4 lesion is suspected pre- or intraoperatively, or when it is necessary to avoid tumor rupture. However, in this study, when a negative margin resection was otherwise achieved, removal of extra-adrenal organs en bloc was not associated with additional survival benefit.
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Affiliation(s)
- Paula Marincola Smith
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building 2220 Pierce Ave, Nashville, TN, 37232, USA
| | - Colleen M Kiernan
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building 2220 Pierce Ave, Nashville, TN, 37232, USA
| | - Thuy B Tran
- Stanford University School of Medicine, Stanford, CA, USA
| | - Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jason Prescott
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy Pawlik
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tracy S Wang
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jason Glenn
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Rivka Shenoy
- New York University School of Medicine, New York, NY, USA
| | - John Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | | | - Ryan C Fields
- Barnes-Jewish Hospital and the Alvin J. Siteman Comprehensive Cancer Center, Washington University School of Medicine, St Louis, MO, USA
| | - Linda Jin
- Barnes-Jewish Hospital and the Alvin J. Siteman Comprehensive Cancer Center, Washington University School of Medicine, St Louis, MO, USA
| | - Sharon Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jason Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Adam Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Carmen C Solórzano
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building 2220 Pierce Ave, Nashville, TN, 37232, USA.
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Beal EW, Lyon E, Kearney J, Wei L, Ethun CG, Black SM, Dillhoff M, Salem A, Weber SM, Tran TB, Poultsides G, Shenoy R, Hatzaras I, Krasnick B, Fields RC, Buttner S, Scoggins CR, Martin RC, Isom CA, Idrees K, Mogal HD, Shen P, Maithel SK, Pawlik TM, Schmidt CR. Evaluating the American College of Surgeons National Surgical Quality Improvement project risk calculator: results from the U.S. Extrahepatic Biliary Malignancy Consortium. HPB (Oxford) 2017; 19:1104-1111. [PMID: 28890310 PMCID: PMC5915623 DOI: 10.1016/j.hpb.2017.08.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 08/01/2017] [Accepted: 08/12/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The objective of this study is to evaluate use of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) online risk calculator for estimating common outcomes after operations for gallbladder cancer and extrahepatic cholangiocarcinoma. METHODS Subjects from the United States Extrahepatic Biliary Malignancy Consortium (USE-BMC) who underwent operation between January 1, 2000 and December 31, 2014 at 10 academic medical centers were included in this study. Calculator estimates of risk were compared to actual outcomes. RESULTS The majority of patients underwent partial or major hepatectomy, Whipple procedures or extrahepatic bile duct resection. For the entire cohort, c-statistics for surgical site infection (0.635), reoperation (0.680) and readmission (0.565) were less than 0.7. The c-statistic for death was 0.740. For all outcomes the actual proportion of patients experiencing an event was much higher than the median predicted risk of that event. Similarly, the group of patients who experienced an outcome did have higher median predicted risk than those who did not. CONCLUSIONS The ACS NSQIP risk calculator is easy to use but requires further modifications to more accurately estimate outcomes for some patient populations and operations for which validation studies show suboptimal performance.
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Affiliation(s)
- Eliza W. Beal
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and the James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Ezra Lyon
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and the James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Joe Kearney
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and the James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Lai Wei
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and the James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Cecilia G. Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Sylvester M. Black
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and the James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Mary Dillhoff
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and the James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Thuy B. Tran
- Department of Surgery, Stanford University Medical Center, Stanford
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY
| | | | | | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Stefan Buttner
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Charles R. Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY
| | - Robert C.G. Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY
| | - Chelsea A. Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Kamron Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Timothy M. Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and the James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Carl R. Schmidt
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and the James Cancer Hospital and Solove Research Institute, Columbus, OH
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Poorman CE, Ethun CG, Postlewait LM, Tran TB, Prescott JD, Pawlik TM, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solórzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Staley CA, Poultsides GA, Maithel SK. A Novel T-Stage Classification System for Adrenocortical Carcinoma: Proposal from the US Adrenocortical Carcinoma Study Group. Ann Surg Oncol 2017; 25:520-527. [PMID: 29164414 DOI: 10.1245/s10434-017-6236-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND The 7th AJCC T-stage system for adrenocortical carcinoma (ACC), based on size and extra-adrenal invasion, does not adequately stratify patients by survival. Lymphovascular invasion (LVI) is a known poor prognostic factor. We propose a novel T-stage system that incorporates LVI to better risk-stratify patients undergoing resection for ACC. METHOD Patients undergoing curative-intent resections for ACC from 1993 to 2014 at 13 institutions comprising the US ACC Group were included. Primary outcome was disease-specific survival (DSS). RESULTS Of the 265 patients with ACC, 149 were included for analysis. The current T-stage system failed to differentiate patients with T2 versus T3 disease (p = 0.10). Presence of LVI was associated with worse DSS versus no LVI (36 mo vs. 168 mo; p = 0.001). After accounting for the individual components of the current T-stage system (size, extra-adrenal invasion), LVI remained a poor prognostic factor on multivariable analysis (hazard ratio 2.14, 95% confidence interval 1.05-4.38, p = 0.04). LVI positivity further stratified patients with T2 and T3 disease (T2: 37 mo vs. median not reached; T3: 36 mo vs. 96 mo; p = 0.03) but did not influence survival in patients with T1 or T4 disease. By incorporating LVI, a new T-stage classification system was created: [T1: ≤ 5 cm, (-)local invasion, (+/-)LVI; T2: > 5 cm, (-)local invasion, (-)LVI OR any size, (+)local invasion, (-)LVI; T3: > 5 cm, (-)local invasion, (+)LVI OR any size, (+)local invasion, (+)LVI; T4: any size, (+)adjacent organ invasion, (+/-)LVI]. Each progressive new T-stage group was associated with worse median DSS (T1: 167 mo; T2: 96 mo; T3: 37 mo; T4: 15 mo; p < 0.001). CONCLUSIONS Compared with the current T-stage system, the proposed T-stage system, which incorporates LVI, better differentiates T2 and T3 disease and accurately stratifies patients by disease-specific survival. If externally validated, this T-stage classification should be considered for future AJCC staging systems.
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Affiliation(s)
- Caroline E Poorman
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Thuy B Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jason D Prescott
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Linda X Jin
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sharon M Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Charles A Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - George A Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA. .,Division of Surgical Oncology, Winship Cancer Institute, 1365C Clifton Road NE, 2nd Floor, Atlanta, GA, 30322, USA.
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38
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Poorman CE, Postlewait LM, Ethun CG, Tran TB, Prescott JD, Pawlik TM, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Staley CA, Poultsides GA, Maithel SK. Blood Transfusion and Survival for Resected Adrenocortical Carcinoma: A Study from the United States Adrenocortical Carcinoma Group. Am Surg 2017. [DOI: 10.1177/000313481708300735] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Perioperative blood transfusion is associated with decreased survival in pancreatic, gastric, and liver cancer. The effect of transfusion in adrenocortical carcinoma (ACC) has not been studied. Patients with available transfusion data undergoing curative-intent resection of ACC from 1993 to 2014 at 13 institutions comprising the United States Adrenocortical Carcinoma Group were included. Factors associated with blood transfusion were determined. Primary and secondary end points were recurrence-free survival (RFS) and overall survival (OS), respectively. Out of 265 patients, 149 were included for analysis. Out of these, 57 patients (38.3%) received perioperative transfusions. Compared to nontransfused patients, transfused patients more commonly had stage 4 disease (46% vs 24%, P = 0.01), larger tumors (15.8 vs 10.2 cm, P < 0.001), inferior vena cava involvement (24.6% vs 5.4%, P = 0.002), additional organ resection (78.9% vs 36.3%, P < 0.001), and major complications (29% vs 2%, P < 0.001). Transfusion was associated with decreased RFS (8.9 vs 24.7 months, P = 0.006) and OS (22.8 vs 91.0 months, P < 0.001). On univariate Cox regression, transfusion, stage IV, hormonal hypersecretion, and adjuvant therapy were associated with decreased RFS. On multivariable analysis, only transfusion [hazard ratio (HR) = 1.7, 95% confidence interval (CI) 51.0–2.9, P = 0.04], stage IV (HR = 3.2, 95% CI = 1.7–5.9, P < 0.001), and hormonal hypersecretion (HR = 2.6, 95% CI = 1.5–4.2, P < 0.001) were associated with worse RFS. When applying this model to OS, similar associations were seen (transfusion HR = 2.0, 95% CI = 1.1–3.8, P = 0.02; stage 4 HR = 6.2, 95% CI = 3.1–12.4, P < 0.001; hormonal hypersecretion HR = 3.5, 95% CI = 1.9–6.4, P < 0.001). There was no difference in outcomes between patients who received 1 to 2 units versus >2 units of packed red blood cells in median RFS (8.9 vs 8.4 months, P = 0.95) or OS (26.5 vs 18.6 months, P = 0.63). Peri-operative transfusion is associated with earlier recurrence and decreased survival after curative-intent resection of ACC. Strategies and protocols to minimize blood transfusion should be developed and followed.
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Affiliation(s)
- Caroline E. Poorman
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Lauren M. Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Cecilia G. Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Thuy B. Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Jason D. Prescott
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M. Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tracy S. Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, New York
| | - John E. Phay
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Ryan C. Fields
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Linda X. Jin
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Sharon M. Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jason K. Sicklick
- Department of Surgery, University of California San Diego, San Diego, California
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, California
| | - Adam C. Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John C. Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, California
| | | | | | | | - Edward A. Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Charles A. Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - George A. Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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39
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Poorman CE, Postlewait LM, Ethun CG, Tran TB, Prescott JD, Pawlik TM, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Staley CA, Poultsides GA, Maithel SK. Blood Transfusion and Survival for Resected Adrenocortical Carcinoma: A Study from the United States Adrenocortical Carcinoma Group. Am Surg 2017; 83:761-768. [PMID: 28738949 PMCID: PMC6054878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Perioperative blood transfusion is associated with decreased survival in pancreatic, gastric, and liver cancer. The effect of transfusion in adrenocortical carcinoma (ACC) has not been studied. Patients with available transfusion data undergoing curative-intent resection of ACC from 1993 to 2014 at 13 institutions comprising the United States Adrenocortical Carcinoma Group were included. Factors associated with blood transfusion were determined. Primary and secondary end points were recurrence-free survival (RFS) and overall survival (OS), respectively. Out of 265 patients, 149 were included for analysis. Out of these, 57 patients (38.3%) received perioperative transfusions. Compared to nontransfused patients, transfused patients more commonly had stage 4 disease (46% vs 24%, P = 0.01), larger tumors (15.8 vs 10.2 cm, P < 0.001), inferior vena cava involvement (24.6% vs 5.4%, P = 0.002), additional organ resection (78.9% vs 36.3%, P < 0.001), and major complications (29% vs 2%, P < 0.001). Transfusion was associated with decreased RFS (8.9 vs 24.7 months, P = 0.006) and OS (22.8 vs 91.0 months, P < 0.001). On univariate Cox regression, transfusion, stage IV, hormonal hypersecretion, and adjuvant therapy were associated with decreased RFS. On multivariable analysis, only transfusion [hazard ratio (HR) = 1.7, 95% confidence interval (CI) =1.0-2.9, P = 0.04], stage IV (HR = 3.2, 95% CI = 1.7-5.9, P < 0.001), and hormonal hypersecretion (HR = 2.6, 95% CI = 1.5-4.2, P < 0.001) were associated with worse RFS. When applying this model to OS, similar associations were seen (transfusion HR = 2.0, 95% CI = 1.1-3.8, P = 0.02; stage 4 HR = 6.2, 95% CI = 3.1-12.4, P < 0.001; hormonal hypersecretion HR = 3.5, 95% CI = 1.9-6.4, P < 0.001). There was no difference in outcomes between patients who received 1 to 2 units versus >2 units of packed red blood cells in median RFS (8.9 vs 8.4 months, P = 0.95) or OS (26.5 vs 18.6 months, P = 0.63). Perioperative transfusion is associated with earlier recurrence and decreased survival after curative-intent resection of ACC. Strategies and protocols to minimize blood transfusion should be developed and followed.
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40
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Lee CW, Salem AI, Schneider DF, Leverson GE, Tran TB, Poultsides GA, Postlewait LM, Maithel SK, Wang TS, Hatzaras I, Shenoy R, Phay JE, Shirley L, Fields RC, Jin LX, Pawlik TM, Prescott JD, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Weber SM. Minimally Invasive Resection of Adrenocortical Carcinoma: a Multi-Institutional Study of 201 Patients. J Gastrointest Surg 2017; 21:352-362. [PMID: 27770290 PMCID: PMC5263186 DOI: 10.1007/s11605-016-3262-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 08/24/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVES Minimally invasive surgery for adrenocortical carcinoma (ACC) is controversial. We sought to evaluate the perioperative and long-term outcomes following minimally invasive (MIS) and open resection (OA) of ACC in patients treated with curative intent surgery. METHODS Retrospective data from patients who underwent adrenalectomy for primary ACC at 13 tertiary care cancer centers were analyzed, including demographics, clinicopathological, and operative outcomes. Outcomes following MIS were compared to OA. RESULTS A total of 201 patients were evaluated including 47 MIS and 154 OA. There was no difference in utilization of MIS approach among institutions (p = 0.24) or 30-day morbidity (29.3 %, MIS, vs. 30.9 %, OA; p = 0.839). The only preoperatively determined predictor for MIS was smaller tumor size (p < 0.001). There was no difference in rates of intraoperative tumor rupture (p = 0.612) or R0 resection (p = 0.953). Only EBL (p = 0.038) and T stage (p = 0.045) were independent prognostic indicators of overall survival after adjusting for significant factors. The surgical approach was not associated with overall or disease-free survival. CONCLUSION MIS adrenalectomy may be utilized for preoperatively determined ACC ≤ 10.0 cm; however, OA should be utilized for adrenal masses with either preoperative or intraoperative evidence of local invasion or enlarged lymph nodes, regardless of size.
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Affiliation(s)
- Christina W. Lee
- Department of Surgery, University Of Wisconsin School Of Medicine and Public Health - Madison, WI USA
| | - Ahmed I. Salem
- Department of Surgery, University Of Wisconsin School Of Medicine and Public Health - Madison, WI USA
| | - David F. Schneider
- Department of Surgery, University Of Wisconsin School Of Medicine and Public Health - Madison, WI USA
| | - Glen E. Leverson
- Department of Surgery, University Of Wisconsin School Of Medicine and Public Health - Madison, WI USA
| | - Thuy B. Tran
- Department of Surgery, Stanford University - Palo Alto, CA USA
| | | | | | - Shishir K. Maithel
- Department of Surgery, Emory University School of Medicine - Atlanta, GA USA
| | - Tracy S. Wang
- Department of Surgery, Medical College Of Wisconsin - Milwaukee, WI USA
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine - New York, NY USA
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine - New York, NY USA
| | - John E. Phay
- Department of Surgery, Ohio State University - Columbus, OH USA
| | | | - Ryan C. Fields
- Department of Surgery, Washington University - St. Louis, MO USA
| | - Linda X. Jin
- Department of Surgery, Washington University - St. Louis, MO USA
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine - Baltimore, MD USA
| | - Jason D. Prescott
- Department of Surgery, Johns Hopkins University School of Medicine - Baltimore, MD USA
| | - Jason K. Sicklick
- Department of Surgery, University Of California - San Diego - San Diego, CA USA
| | - Shady Gad
- Department of Surgery, University Of California - San Diego - San Diego, CA USA
| | - Adam C. Yopp
- Department of Surgery, University Of Texas Southwestern Medical Center - Dallas, TX USA
| | - John C. Mansour
- Department of Surgery, University Of Texas Southwestern Medical Center - Dallas, TX USA
| | - Quan-Yang Duh
- Department of Surgery, University Of California - San Francisco - San Francisco, CA USA
| | - Natalie Seiser
- Department of Surgery, University Of California - San Francisco - San Francisco, CA USA
| | - Carmen C. Solorzano
- Department of Surgery, Vanderbilt University Medical Center - Nashville, TN USA
| | - Colleen M. Kiernan
- Department of Surgery, Vanderbilt University Medical Center - Nashville, TN USA
| | | | - Edward A. Levine
- Department of Surgery, Wake Forest University School of Medicine - Winston-Salem, NC USA
| | - Sharon M. Weber
- Department of Surgery, University Of Wisconsin School Of Medicine and Public Health - Madison, WI USA
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41
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Tran TB, Postlewait LM, Maithel SK, Prescott JD, Wang TS, Glenn J, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Hatzaras I, Shenoy R, Pawlik TM, Norton JA, Poultsides GA. Actual 10-year survivors following resection of adrenocortical carcinoma. J Surg Oncol 2016; 114:971-976. [PMID: 27633419 PMCID: PMC5278771 DOI: 10.1002/jso.24439] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 08/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy with limited therapeutic options beyond surgical resection. The characteristics of actual long-term survivors following surgical resection for ACC have not been previously reported. METHOD Patients who underwent resection for ACC at one of 13 academic institutions participating in the US Adrenocortical Carcinoma Group from 1993 to 2014 were analyzed. Patients were stratified into four groups: early mortality (died within 2 years), late mortality (died within 2-5 years), actual 5-year survivor (survived at least 5 years), and actual 10-year survivor (survived at least 10 years). Patients with less than 5 years of follow-up were excluded. RESULTS Among the 180 patients available for analysis, there were 49 actual 5-year survivors (27%) and 12 actual 10-year survivors (7%). Patients who experienced early mortality had higher rates of cortisol-secreting tumors, nodal metastasis, synchronous distant metastasis, and R1 or R2 resections (all P < 0.05). The need for multi-visceral resection, perioperative blood transfusion, and adjuvant therapy correlated with early mortality. However, nodal involvement, distant metastasis, and R1 resection did not preclude patients from becoming actual 10-year survivors. Ten of twelve actual 10-year survivors were women, and of the seven 10-year survivors who experienced disease recurrence, five had undergone repeat surgery to resect the recurrence. CONCLUSION Surgery for ACC can offer a 1 in 4 chance of actual 5-year survival and a 1 in 15 chance of actual 10-year survival. Long-term survival was often achieved with repeat resection for local or distant recurrence, further underscoring the important role of surgery in managing patients with ACC. J. Surg. Oncol. 2016;114:971-976. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Thuy B. Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | | | | | - Jason D. Prescott
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tracy S. Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John E. Phay
- Department of Surgery, Ohio State University, Columbus, Ohio
| | - Kara Keplinger
- Department of Surgery, Ohio State University, Columbus, Ohio
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Linda X. Jin
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jason K. Sicklick
- Department of Surgery, University of California San Diego, San Diego, California
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, California
| | - Adam C. Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John C. Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, California
| | | | | | | | - Edward A. Levine
- Department of Surgery, Wake Forest Baptist Medical Center, Winston Salem, North Carolina
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Ohio State University, Columbus, Ohio
| | - Jeffrey A. Norton
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - George A. Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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42
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Margonis GA, Amini N, Kim Y, Tran TB, Postlewait LM, Maithel SK, Wang TS, Evans DB, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Moses LE, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Poultsides GA, Pawlik TM. Incidence of Perioperative Complications Following Resection of Adrenocortical Carcinoma and Its Association with Long-Term Survival. World J Surg 2016; 40:706-714. [PMID: 26546184 DOI: 10.1007/s00268-015-3307-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The association of postoperative complications with long-term oncologic outcomes remains unclear. We sought to determine the incidence of complications among patients who underwent surgery for adrenocortical carcinoma (ACC) and define the relationship of morbidity with long-term survival. METHODS Patients who underwent surgery for ACC between 1993 and 2014 were identified from 13 academic institutions participating in the US ACC group study. The incidence and type of the postoperative complications, the factors associated with them as well their association with long-term survival were analyzed. RESULTS A total of 265 patients with median age of 52 years (IQR 44-63) were identified; at surgery, the majority of patients underwent an open abdominal procedure (n = 169, 66.8%). A postoperative complication occurred in 99 patients for a morbidity of 37.4%; five patients (1.9%) died in hospital. Factors associated with morbidity included a thoraco-abdominal operative approach (reference: open abdominal; OR 2.85, 95% CI 1.00-8.18), and a hormonally functional tumor (OR 3.56, 95% CI 1.65-7.69) (all P < 0.05). Presence of any complication was associated with a worse long-term outcome (median survival: no complication, 58.9 months vs. any complication, 25.1 months; P = 0.009). In multivariate analysis, after adjusting for patient- and disease-related factors postoperative infectious complications independently predicted shorter overall survival (hazard ratio (HR) 5.56, 95% CI 2.24-13.80; P < 0.001). CONCLUSION Postoperative complications were independently associated with decreased long-term survival after resection for ACC. The prevention of complications may be important from an oncologic perspective.
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Affiliation(s)
- Georgios Antonios Margonis
- Department of Surgery, Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Neda Amini
- Department of Surgery, Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Yuhree Kim
- Department of Surgery, Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Thuy B Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Lindsey E Moses
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sharon M Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - George A Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Timothy M Pawlik
- Department of Surgery, Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
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Kim Y, Margonis GA, Prescott JD, Tran TB, Postlewait LM, Maithel SK, Wang TS, Evans DB, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem AI, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Poultsides GA, Pawlik TM. Nomograms to Predict Recurrence-Free and Overall Survival After Curative Resection of Adrenocortical Carcinoma. JAMA Surg 2016; 151:365-73. [PMID: 26676603 DOI: 10.1001/jamasurg.2015.4516] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Adrenocortical carcinoma (ACC) is a rare but aggressive endocrine tumor, and the prognostic factors associated with long-term outcomes after surgical resection remain poorly defined. OBJECTIVES To define clinicopathological variables associated with recurrence-free survival (RFS) and overall survival (OS) after curative surgical resection of ACC and to propose nomograms for individual risk prediction. DESIGN, SETTING, AND PARTICIPANTS Nomograms to predict RFS and OS after surgical resection of ACC were proposed using a multi-institutional cohort of patients who underwent curative-intent surgery for ACC at 13 major institutions in the United States between March 17, 1994, and December 22, 2014. The dates of our study analysis were April 15, 2015, to May 12, 2015. MAIN OUTCOMES AND MEASURES The discriminative ability and calibration of the nomograms to predict RFS and OS were tested using C statistics, calibration plots, and Kaplan-Meier curves. RESULTS In total, 148 patients who underwent surgery for ACC were included in the study. The median patient age was 53 years, and 65.5% (97 of 148) of the patients were female. One-third of the patients (35.1% [52 of 148]) had a functional tumor, and the median tumor size was 11.2 cm. Most patients (77.7% [115 of 148]) underwent R0 resection, and 8.8% (13 of 148) of the patients had N1 disease. Using backward stepwise selection of clinically important variables with the Akaike information criterion, the following variables were incorporated in the prediction of RFS: tumor size of at least 12 cm (hazard ratio [HR], 3.00; 95% CI, 1.63-5.70; P < .001), positive nodal status (HR, 4.78; 95% CI, 1.47-15.50; P = .01), stage III/IV (HR, 1.80; 95% CI, 0.95-3.39; P = .07), cortisol-secreting tumor (HR, 2.38; 95% CI, 1.27-4.48; P = .01), and capsular invasion (HR, 1.96; 95% CI, 1.02-3.74; P = .04). Factors selected as predicting OS were tumor size of at least 12 cm (HR, 1.78; 95% CI, 1.00-3.17; P = .05), positive nodal status (HR, 5.89; 95% CI, 2.05-16.87; P = .001), and R1 margin (HR, 2.83; 95% CI, 1.51-5.30; P = .001). The discriminative ability and calibration of the nomograms revealed good predictive ability as indicated by the C statistics (0.74 for RFS and 0.70 for OS). CONCLUSIONS AND RELEVANCE Independent predictors of survival and recurrence risk after curative-intent surgery for ACC were selected to create nomograms predicting RFS and OS. The nomograms were able to stratify patients into prognostic groups and performed well on internal validation.
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Affiliation(s)
- Yuhree Kim
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Georgios A Margonis
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jason D Prescott
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thuy B Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | | | | | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine in St Louis, Missouri
| | - Linda X Jin
- Department of Surgery, Washington University School of Medicine in St Louis, Missouri
| | - Sharon M Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Ahmed I Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Shady Gad
- Department of Surgery, University of California, San Diego
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco
| | - Natalie Seiser
- Department of Surgery, University of California, San Francisco
| | | | | | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - George A Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Tran TB, Maithel SK, Pawlik TM, Wang TS, Hatzaras I, Phay JE, Fields RC, Weber SM, Sicklick JK, Yopp AC, Duh QY, Solorzano CC, Votanopoulos KI, Poultsides GA. Clinical Score Predicting Long-Term Survival after Repeat Resection for Recurrent Adrenocortical Carcinoma. J Am Coll Surg 2016; 223:794-803. [PMID: 27618748 DOI: 10.1016/j.jamcollsurg.2016.08.568] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/28/2016] [Accepted: 08/29/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is an aggressive malignancy typically resistant to chemotherapy and radiation. Surgery, even in the setting of locally recurrent or metastatic disease, remains the only potentially curative option. However, the subset of patients who will benefit from repeat resection in this setting remains ill defined. The objective of this study was to propose a prognostic clinical score that facilitates selection of patients for repeat resection of recurrent ACC. STUDY DESIGN Patients who underwent curative-intent repeat resection for recurrent ACC at 1 of 13 academic medical centers participating in the US ACC Study Group were identified. End points included morbidity, mortality, and overall survival. RESULTS Fifty-six patients underwent repeat curative-intent resection for recurrent ACC (representing 21% of 265 patients who underwent resection for primary ACC) from 1997 to 2014. Median age was 52 years. Sites of resected recurrence included locoregional only (54%), lung only (14%), liver only (12%), combined locoregional and lung (4%), combined liver and lung (4%), and other distant sites (12%). Thirty-day morbidity and mortality rates were 40% and 5.4%, respectively. Cox regression analysis revealed that the presence of multifocal recurrence, disease-free interval <12 months, and extrapulmonary distant metastases were independent predictors of poor survival. A clinical score consisting of 1-point each for the 3 variables demonstrated good discrimination in predicting survival after repeat resection (5-year: 72% for 0 points, 32% for 1 point, 0% for 2 or 3 points; p = 0.0006, area under the curve = 0.78). CONCLUSIONS Long-term survival after repeat resection for recurrent ACC is feasible when 2 of the following factors are present: solitary tumor, disease-free interval >12 months, and locoregional or pulmonary recurrence.
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Affiliation(s)
- Thuy B Tran
- Department of Surgery, Stanford University, Stanford, CA
| | | | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University, Baltimore, MD
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH
| | - Ryan C Fields
- Department of Surgery, Washington University, St Louis, MO
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern, Dallas, TX
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA
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Gerry JM, Tran TB, Postlewait LM, Maithel SK, Prescott JD, Wang TS, Glenn JA, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Hatzaras I, Shenoy R, Pawlik TM, Norton JA, Poultsides GA. Lymphadenectomy for Adrenocortical Carcinoma: Is There a Therapeutic Benefit? Ann Surg Oncol 2016; 23:708-713. [PMID: 27590329 DOI: 10.1245/s10434-016-5536-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Lymph node metastasis is an established predictor of poor outcome for adrenocortical carcinoma (ACC); however, routine lymphadenectomy during surgical resection of ACC is not widely performed and its therapeutic role remains unclear. METHODS Patients undergoing margin-negative resection for localized ACC were identified from a multi-institutional database. Patients were stratified into 2 groups based on the surgeon's effort or not to perform a lymphadenectomy as documented in the operative note. Clinical, pathologic, and outcome data were compared between the 2 groups. RESULTS Of 120 patients who met inclusion criteria from 1993 to 2014, 32 (27 %) underwent lymphadenectomy. Factors associated with lymphadenectomy were tumor size (12 vs. 9.5 cm; p = .007), palpable mass at presentation (26 vs. 12 %; p = .07), suspicious lymph nodes on preoperative imaging (44 vs. 7 %; p < .001), and need for multivisceral resection (78 vs. 36 %; p < .001). Median number of lymph nodes harvested was higher in the lymphadenectomy group (5.5 vs. 0; p < .001). In-hospital mortality (0 vs. 1.3 %; p = .72) and grade 3/4 complication rates (0 vs. 12 %; p = .061) were not significantly different. Patients who underwent lymphadenectomy had improved overall survival (5-year 76 vs. 59 %; p = .041). The benefit of lymphadenectomy on overall survival persisted on multivariate analysis (HR = 0.17; p = .006) controlling for adverse preoperative and intraoperative factors associated with lymphadenectomy, such as tumor size, palpable mass, irregular tumor edges, suspicious nodes on imaging, and multivisceral resection. CONCLUSIONS In this multicenter study of adrenocortical carcinoma patients undergoing R0 resection, the surgeon's effort to dissect peritumoral lymph nodes was independently associated with improved overall survival.
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Affiliation(s)
- Jon M Gerry
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Thuy B Tran
- Department of Surgery, Stanford University, Stanford, CA, USA
| | | | | | - Jason D Prescott
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jason A Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Ryan C Fields
- Department of Surgery, Washington University, St. Louis, MO, USA
| | - Linda X Jin
- Department of Surgery, Washington University, St. Louis, MO, USA
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Edward A Levine
- Department of Surgery, Wake Forest University, Winston Salem, NC, USA
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA
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Tran TB, Worhunsky DJ, Squires MH, Jin LX, Spolverato G, Votanopoulos KI, Cho CS, Weber SM, Schmidt C, Levine EA, Bloomston M, Fields RC, Pawlik TM, Maithel SK, Norton JA, Poultsides GA. To Roux or not to Roux: a comparison between Roux-en-Y and Billroth II reconstruction following partial gastrectomy for gastric cancer. Gastric Cancer 2016; 19:994-1001. [PMID: 26400843 DOI: 10.1007/s10120-015-0547-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 09/09/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the extent of resection frequently dictates the method of reconstruction following distal subtotal gastrectomy, it is unclear whether Roux-en-Y gastrojejunostomy compared with Billroth II gastrojejunostomy is associated with superior perioperative outcomes. METHODS Patients who underwent resection for gastric cancer with Roux-en-Y or Billroth II reconstruction between 2000 and 2012 in seven academic institutions (US Gastric Cancer Collaborative) were identified. Patients who underwent total gastrectomy, gastric wedge, or palliative resections (metastatic disease or R2 resections) were excluded. RESULTS Of a total of 965 patients, 447 met the inclusion criteria. A comparison between the Roux-en-Y (n = 257) and Billroth II (n = 190) groups demonstrated no differences in patient and tumor characteristics, except for Billroth II patients having a higher proportion of antral tumors (71 % vs. 50 %, p < 0.001). Roux-en-Y operations were slightly longer (244 min vs. 212 min, p < 0.001) and associated with somewhat higher blood loss (243 ml vs. 205 ml, p = 0.033). However, there were no significant differences in the length of hospital stay (8 days vs. 7 days), readmission rate (17 % vs. 18 %), 90-day mortality (5.1 % vs. 4.7 %), incidence (39 % vs. 41 %) and severity of complications, dependency on jejunostomy tube feeding at discharge (13 % vs. 12 %), same-patient decrease in serum albumin level from the preoperative to the postoperative value at 30, 60, and 90 days, receipt of adjuvant therapy (50 % vs. 53 %), or 5-year survival (44 % vs. 41 %). CONCLUSIONS Although long-term quality-of-life parameters were not compared, this study did not show an advantage of Roux-en-Y gastrojejunostomy over Billroth II gastrojejunostomy in short-term perioperative outcomes. Both techniques should be regarded as equally acceptable reconstructive options following partial gastrectomy for gastric cancer.
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Affiliation(s)
- Thuy B Tran
- Department of Surgery, Stanford Cancer Institute, Stanford University, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA
| | - David J Worhunsky
- Department of Surgery, Stanford Cancer Institute, Stanford University, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA
| | - Malcolm H Squires
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Linda X Jin
- Department of Surgery, Barnes-Jewish Hospital and Alvin J. Siteman Cancer Center, Washington University, St Louis, MO, USA
| | - Gaya Spolverato
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | | | - Clifford S Cho
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Carl Schmidt
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | - Edward A Levine
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Mark Bloomston
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | - Ryan C Fields
- Department of Surgery, Barnes-Jewish Hospital and Alvin J. Siteman Cancer Center, Washington University, St Louis, MO, USA
| | - Timothy M Pawlik
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Shishir K Maithel
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jeffrey A Norton
- Department of Surgery, Stanford Cancer Institute, Stanford University, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA
| | - George A Poultsides
- Department of Surgery, Stanford Cancer Institute, Stanford University, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA.
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Dua MM, Gerry J, Salles A, Tran TB, Triadafilopoulos G, Visser BC. Biliary Cystadenoma: A Suggested "Cystamatic" Approach? Dig Dis Sci 2016; 61:1835-8. [PMID: 26514678 DOI: 10.1007/s10620-015-3943-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 10/22/2015] [Indexed: 01/29/2023]
Affiliation(s)
- Monica M Dua
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3691, Stanford, CA, 94305, USA.
| | - Jon Gerry
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3691, Stanford, CA, 94305, USA
| | - Arghavan Salles
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3691, Stanford, CA, 94305, USA
| | - Thuy B Tran
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3691, Stanford, CA, 94305, USA
| | | | - Brendan C Visser
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3691, Stanford, CA, 94305, USA
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48
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Postlewait LM, Ethun CG, Tran TB, Prescott JD, Pawlik TM, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Staley CA, Poultsides GA, Maithel SK. Outcomes of Adjuvant Mitotane after Resection of Adrenocortical Carcinoma: A 13-Institution Study by the US Adrenocortical Carcinoma Group. J Am Coll Surg 2016; 222:480-90. [PMID: 26775162 PMCID: PMC4957938 DOI: 10.1016/j.jamcollsurg.2015.12.013] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 12/11/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Current treatment guidelines recommend adjuvant mitotane after resection of adrenocortical carcinoma with high-risk features (eg, tumor rupture, positive margins, positive lymph nodes, high grade, elevated mitotic index, and advanced stage). Limited data exist on the outcomes associated with these practice guidelines. STUDY DESIGN Patients who underwent resection of adrenocortical carcinoma from 1993 to 2014 at the 13 academic institutions of the US Adrenocortical Carcinoma Group were included. Factors associated with mitotane administration were determined. Primary end points were recurrence-free survival (RFS) and overall survival (OS). RESULTS Of 207 patients, 88 (43%) received adjuvant mitotane. Receipt of mitotane was associated with hormonal secretion (58% vs 32%; p = 0.001), advanced TNM stage (stage IV: 42% vs 23%; p = 0.021), adjuvant chemotherapy (37% vs 5%; p < 0.001), and adjuvant radiation (17% vs 5%; p = 0.01), but was not associated with tumor rupture, margin status, or N-stage. Median follow-up was 44 months. Adjuvant mitotane was associated with decreased RFS (10.0 vs 27.9 months; p = 0.007) and OS (31.7 vs 58.9 months; p = 0.006). On multivariable analysis, mitotane was not independently associated with RFS or OS, and margin status, advanced TNM stage, and receipt of chemotherapy were associated with survival. After excluding all patients who received chemotherapy, adjuvant mitotane remained associated with decreased RFS and similar OS; multivariable analyses again showed no association with recurrence or survival. Stage-specific analyses in both cohorts revealed no association between adjuvant mitotane and improved RFS or OS. CONCLUSIONS When accounting for stage and adverse tumor and treatment-related factors, adjuvant mitotane after resection of adrenocortical carcinoma is not associated with improved RFS or OS. Current guidelines should be revisited and prospective trials are needed.
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Affiliation(s)
- Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Thuy B Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jason D Prescott
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, NY
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, NY
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH
| | - Kara Keplinger
- Department of Surgery, The Ohio State University, Columbus, OH
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Linda X Jin
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Sharon M Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | | | | | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Charles A Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | | | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA.
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Worhunsky DJ, Dua MM, Tran TB, Siu B, Poultsides GA, Norton JA, Visser BC. Laparoscopic hepatectomy in cirrhotics: safe if you adjust technique. Surg Endosc 2016; 30:4307-14. [PMID: 26895906 DOI: 10.1007/s00464-016-4748-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 01/11/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Minimally invasive liver surgery is a growing field, and a small number of recent reports have suggested that laparoscopic liver resection (LLR) is feasible even in patients with cirrhosis. However, parenchymal transection of the cirrhotic liver is challenging due to fibrosis and portal hypertension. There is a paucity of data regarding the technical modifications necessary to safely transect the diseased parenchyma. METHODS Patients undergoing LLR by a single surgeon between 2008 and 2015 were reviewed. Patients with cirrhosis were compared to those without cirrhosis to examine differences in surgical technique, intraoperative characteristics, and outcomes (including liver-related morbidity and general postoperative complication rates). RESULTS A total of 167 patients underwent LLR during the study period. Forty-eight (29 %) had cirrhosis, of which 43 (90 %) had hepatitis C. Most had Child-Pugh class A disease (85 %). Compared to noncirrhotics, patients with cirrhosis were older, had more comorbidities, and were more likely to have hepatocellular carcinoma. Precoagulation before parenchymal transection was used more frequently in cirrhotics (65 vs. 15 %, P < 0.001), and mean portal triad clamping time was longer (32 vs. 22 min, P = 0.002). There were few conversions to open surgery, though hand-assisted laparoscopy was used as an alternative to converting to open in three patients with cirrhosis. Blood loss was relatively low for both groups. Although there were more postoperative complications among cirrhotics (38 vs. 13 %, P = 0.001), this was almost entirely due to a higher rate of minor (Clavien-Dindo I or II) complications. Liver-related morbidity, major complications, and mortality rates were similar. CONCLUSIONS LLR is safe for selected patients with cirrhosis. The added complexity associated with the division of diseased liver parenchyma may be overcome with some form of technique modification, including more liberal use of precoagulation, portal triad clamping, or a hand-assist port.
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Affiliation(s)
- David J Worhunsky
- Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA, 94305, USA
| | - Monica M Dua
- Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA, 94305, USA
| | - Thuy B Tran
- Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA, 94305, USA
| | - Bernard Siu
- Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA, 94305, USA
| | - George A Poultsides
- Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA, 94305, USA
| | - Jeffrey A Norton
- Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA, 94305, USA
| | - Brendan C Visser
- Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA, 94305, USA.
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Tran TB, Dua MM, Worhunsky DJ, Poultsides GA, Norton JA, Visser BC. An economic analysis of pancreaticoduodenectomy: should costs drive consumer decisions? Am J Surg 2016; 211:991-997.e1. [PMID: 26902956 DOI: 10.1016/j.amjsurg.2015.10.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 05/28/2015] [Revised: 10/10/2015] [Accepted: 10/28/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Consumer groups campaign for cost transparency believing that patients will select hospitals accordingly. We sought to determine whether the cost of pancreaticoduodenectomy (PD) should be considered in choosing a hospital. METHODS Using the Nationwide Inpatient Sample database, we analyzed charges for patients who underwent PD from 2000 to 2010. Outcomes were stratified by hospital volume. RESULTS A total of 15,599 PDs were performed in 1,186 hospitals. The median cost was $87,444 (interquartile range $16,015 to $144,869). High volume hospitals (HVH) had shorter hospital stay (11 vs 15 days, P < .001) and mortality (3% vs 7.6%, P < .001). PD performed at low volume hospitals had higher charges compared with HVH ($97,923 vs $81,581, P < .001). On multivariate analysis, HVH was associated with a lower risk of mortality, while extremes in hospital costs, cardiac comorbidity, and any complication were significant predictors of mortality. CONCLUSION Although PDs performed at HVH are associated with better outcomes and lower hospital charges, costs should not be the primary determinant when selecting a hospital.
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Affiliation(s)
- Thuy B Tran
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA 94305, USA
| | - Monica M Dua
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA 94305, USA
| | - David J Worhunsky
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA 94305, USA
| | - George A Poultsides
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA 94305, USA
| | - Jeffrey A Norton
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA 94305, USA
| | - Brendan C Visser
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA 94305, USA.
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