International assessment and validation of the prognostic role of lymph node ratio in patients with resected pancreatic head ductal adenocarcinoma

Background

Lymph node ratio (LNR; positive/harvested lymph nodes) was identified as overall survival predictor in several cancers, including pancreatic adenocarcinoma. It remains unclear if LNR is predictive of overall survival in pancreatic adenocarcinoma patients staged pN2. This study assessed the prognostic overall survival role of LNR in pancreatic adenocarcinoma patients in relation with lymph node involvement.

Methods

A retrospective international study in six different centers (Europe and United States) was performed. Pancreatic adenocarcinoma patients who underwent pancreatoduodenectomy from 2000 to 2017 were included. Patients with neoadjuvant treatment, metastases, R2 resections, or missing data regarding nodal status were excluded. Survival curves were calculated using Kaplan-Meier method and compared using log-rank test. Multivariable Cox regressions were performed to find independent overall survival predictors adjusted for potential confounders.

Results

A total of 1,327 patients were included. Lymph node involvement (pN+) was found in 1,026 patients (77%), 561 pN1 (55%) and 465 pN2 (45%). Median LNR in pN+ patients was 0.214 [interquartile range (IQR): 0.105-0.364]. On multivariable analysis, LNR was the strongest overall survival predictor in the entire cohort [hazard ratio (HR) =5.5; 95% confidence interval (CI): 3.1-9.9; P<0.001] and pN+ patients (HR =3.8; 95% CI: 2.2-6.6; P<0.001). Median overall survival was better in patients with LNR <0.225 compared to patients with LNR ≥0.225 in the entire cohort and pN+ patients. Similar results were found in pN2 patients (worse overall survival when LNR ≥0.225).

Conclusions

LNR appeared as an important prognostic factor in patients undergoing surgery for pancreatic adenocarcinoma and permitted to stratify overall survival in pN2 patients. LNR should be routinely used in complement to tumor-node-metastasis (TNM) stage to better predict patient prognosis.

P077 LONG-TERM CLINICAL OUTCOMES OF AN ANTIBIOTIC-COATED NON-CROSSLINKED PORCINE ACELLULAR DERMAL GRAFT IN HIGH-RISK ABDOMINAL WALL RECONSTRUCTION

Aim

Abdominal wall reconstruction in high-risk and contaminated cases remains a challenging surgical dilemma. We report long-term clinical outcomes for a rifampin/minocycline-coated acellular dermal graft (XenMatrix™ AB) in complex abdominal wall reconstruction for patients with a prior open abdomen or contaminated wounds.

Material and Methods

Patients undergoing abdominal wall reconstruction at our institution at high risk for surgical site occurrence and reconstructed with XenMatrix™ AB with intent-to-treat between 2014 through 2017 were included. Demographics, operative characteristics, and outcomes were collected. Primary outcome was hernia recurrence. Secondary outcomes included length of stay, surgical site occurrence, readmission, morbidity, and mortality.

Results

Twenty-two patients underwent abdominal wall reconstruction using XenMatrix™ AB during the study period. Two patients died while inpatient from progression of their comorbid diseases and were excluded. Sixty percent of patients had an open abdomen at time of repair. All patients were Modified VHWG class 2 or 3.

There was a total of four 30-day infectious complications including superficial cellulitis/fat necrosis (15%) and one intraperitoneal abscess (5%). No patients required re-operation or graft excision.

Median clinical follow-up was 35.1 months with a mean of 32.2 +/- 16.5 months. Two asymptomatic recurrences and one symptomatic recurrence were noted during this period. Follow-up was extended by phone interview which identified no additional recurrences at a median of 45.5 and mean of 50.5 +/-12.7 months.

Conclusions

We present long-term outcomes for patients with high-risk and contaminated wounds who underwent abdominal wall reconstruction reinforced with XenMatrix™ AB to achieve early, permanent abdominal closure. Acceptable outcomes were noted.

Prognostic value of positive histological margins in patients with pancreatic head ductal adenocarcinoma and lymph node involvement: an international multicentric study

BACKGROUND

Resection margin status and lymph node (LN) involvement are known prognostic factors for patients who undergo pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC). This study aimed to compare overall survival (OS) and disease-free survival (DFS) by resection margin status in patients with PDAC and LN involvement.

METHODS

A retrospective international multicentric study was performed including four Western centers. Multivariable Cox analysis was performed to identify prognostic factors of OS and DFS. Median OS and DFS were calculated using Kaplan-Meier curves and compared using log-rank tests.

RESULTS

A cohort of 814 PDAC patients with pancreatoduodenectomy were analyzed. A total of 651 patients had LN involvement (80%). On multivariable analysis R1 resection was not an independent factor of worse OS and DFS in patients with LN involvement (HR 1.1, p = 0.565; HR 1.2, p = 0.174). Only tumor size, grade, and adjuvant chemotherapy were associated with OS and DFS. Median OS and DFS were similar between patients with R0 and R1 resections (23 vs. 20 months, p = 0.196; 15 vs. 14 months, p = 0.080).

CONCLUSION

Resection status was not identified as predictor of OS or DFS in PDAC patients with LN involvement. Extensive surgery to achieve R0 resection in such patients might not influence the disease course.

Current trends in vena cava reconstructive techniques with major liver resection: a systematic review

PURPOSE

Historically, invasion of the inferior vena cava (IVC) represented advanced and often unresectable hepatic disease. With surgical and anesthetic innovations, IVC resection and reconstruction have become feasible in selected patients. This review assesses technical variations in reconstructive techniques and post-operative management.

METHODS

A comprehensive literature search was performed according to PRISMA. Inclusion criteria were (i) peer-reviewed articles in English; (ii) at least three cases; (iii) hepatic IVC resection and reconstruction (January 2015-March 2020). Primary outcomes were reconstructive technique, anti-thrombotic regimen, post-operative IVC patency, and infection. Secondary outcomes included post-operative complications and malignant disease survival.

RESULTS

Fourteen articles were included allowing for investigation of 351 individual patients. Analysis demonstrated significant heterogeneity in surgical reconstructive technique, anti-thrombotic management, and post-operative monitoring of patency. There was increased utilization of ex vivo approaches and decreased use of venovenous bypass compared with previously published reviews.

CONCLUSION

This review of literature published between 2015 and 2020 reveals persistent heterogeneity of hepatic IVC reconstructive techniques and peri-operative management. Increased utilization of ex vivo approaches and decreased use of venovenous bypass point towards improved operative techniques, peri-operative management, and anesthesia. In order to gain evidence for consensus on management, a registry would be beneficial.

Faster Return to Intended Oncologic Treatment (RIOT) After Trisectionectomy Does Not Translate to Better Outcomes

BACKGROUND

Resection with trisectionectomy may necessitate liver molding for adequate future liver remnant (FLR), and subsequent complications can impact return to intended oncologic therapy (RIOT). This study evaluated whether a difference in RIOT exists with the use of molding and between liver molding techniques (associating liver partition and portal vein ligation for staged hepatectomy [ALPPS] and portal vein embolization [PVE]) with trisectionectomy.

METHODS

A retrospective review evaluated trisectionectomies for malignancy. Outcomes were compared with and without molding, and RIOT was determined.

RESULTS

Fifty-one patients underwent trisectionectomy: 11 ALPPS, 14 PVE, 26 without molding. 73% of ALPPS, 64% of PVE, and 58% without molding achieved RIOT (P = .971). There were no differences found in baseline characteristics, R0 rate, length of stay, readmission, complications, or mortality. Time to RIOT was significantly different (ALPPS: 3.3 months; PVE: 5.2 months; none: 2.4 months, P = .0203). There were no differences in recurrence or survival.

CONCLUSIONS

Liver molding should not cause apprehension as there are no differences in achieving RIOT. Although technique alters time to RIOT, this does not translate into improved outcomes, implicating disease biology, and regeneration stimulus.

Pathologic response translates to improved patient survival after locoregional treatment for hepatocellular carcinoma: the importance of minimally invasive microwave ablation

BACKGROUND

Hepatectomy or transplantation can serve as curative treatment for early-stage hepatocellular carcinoma (HCC). Unfortunately, as progression remains a reality, locoregional therapies (LRT) for curative or bridging intent have become common. Efficacy on viability, outcomes, and accuracy of imaging should be defined to guide treatment.

METHODS

Patients with HCC who underwent minimally invasive (MIS) microwave ablation (MWA), transarterial chemoembolization (TACE), or both (MIS-MWA-TACE) prior to hepatectomy or transplantation were identified. Tumor response and preoperative computed tomography (CT) accuracy were assessed and compared to pathology. Clinical and oncologic outcomes were compared between MIS-MWA, TACE, and MIS-MWA-TACE.

RESULTS

Ninety-one patients, with tumors from all stages of the Barcelona Clinic Liver Cancer (BCLC) staging, were identified who underwent LRT prior to resection or transplant. Fourteen patients underwent MIS-MWA, 46 underwent TACE, and 31 underwent both neoadjuvantly. TACE population was older; otherwise, there were no differences in demographics. Fifty-seven percent of MIS-MWA patients had no viable tumor on pathology whereas only 13% of TACE patients and 29% of MIS-MWA-TACE patients had complete destruction (p = 0.004). The amount of remaining viable tumor in the explant was also significantly different between groups (MIS-MWA: 17.2%, TACE: 48.7%, MIS-MWA-TACE: 18.6%; p ≤ 0.0001). Compared with TACE, the MIS-MWA and MIS-MWA-TACE groups had significantly improved overall survival (MIS-MWA: 99.94 months, TACE: 75.35 months, MIS-MWA-TACE: 140 months; p = 0.017). This survival remained significant with stratification by tumor size. CT accuracy was found to be 50% sensitive and 86% specific for MIS-MWA. For TACE, CT had an 82% sensitivity and 33% specificity and for MIS-MWA-TACE, there was a 42% sensitivity and 78% specificity.

CONCLUSION

The impact of locoregional treatments on tumor viability is distinct and superior with MIS-MWA alone and MIS-MWA-TACE offering significant advantage over TACE alone. The extent of this effect may be implicated in the improved overall survival.

Advances in borderline resectable pancreatic adenocarcinoma

Pancreatic adenocarcinoma is one of the most lethal cancers in oncology. Pancreatic cancer is the third most common cause of cancer-related mortality in the United States. As the years have progressed, the importance of a multidisciplinary and multimodal approach to pancreatic cancer care has been recognized and is now recommended in all major society guidelines. A subset of pancreatic cancer, borderline resectable pancreatic cancer (BRPC), has emerged as a distinct clinical entity for which specialized treatment plans are now being developed. The medical oncologist, surgical oncologist, and radiation oncologist must work jointly to help deliver the best clinical outcome for the patient with pancreatic cancer. In this discussion, we describe the current state of surgical, locoregional therapies and systemic therapy in BRPC.

Health Care Disparities Knowledge, Attitudes, and Behaviors in Resident Physicians

PURPOSE

Health care disparities are an important but sometimes underrepresented topic in graduate medical education. In this study we measured the impact of educational and behavioral interventions on resident knowledge about and attitudes toward health care disparities.

METHODS

Faculty from 6 residency programs designed and presented an hour-long educational intervention to emphasize the importance of and increase resident knowledge about health care disparities. Selected residents then helped design a month-long behavioral intervention to engage their peers in conversations about disparities with patients. Surveys were administered pre- and post-educational intervention as well as post-behavioral intervention in order to measure the impact each intervention had on resident knowledge and attitudes.

RESULTS

Paired-samples t-tests showed that residents were more knowledgeable about health care disparities issues following didactic teaching (P<0.001) and felt such issues were more important (P<0.001). Furthermore, presence of these feelings significantly predicted the frequency of engaging in the behavioral intervention (r=0.44, P<0.01).

CONCLUSIONS

Two brief, simple interventions produced significant changes in resident knowledge, attitudes and behaviors regarding health care disparities. The educational intervention was most effective at increasing knowledge of disparities in general and encouraging participation in the behavioral intervention, while the behavioral intervention was useful in increasing knowledge of specific patients' barriers to care.

Real-time fMRI neurofeedback: progress and challenges

In February of 2012, the first international conference on real time functional magnetic resonance imaging (rtfMRI) neurofeedback was held at the Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland. This review summarizes progress in the field, introduces current debates, elucidates open questions, and offers viewpoints derived from the conference. The review offers perspectives on study design, scientific and clinical applications, rtfMRI learning mechanisms and future outlook.

Sympathetic modulation of the host defense response to infectious challenge during recovery from hemorrhage

BACKGROUND

Trauma/hemorrhage (TxHem) is associated with an immediate pro-inflammatory response that, if exaggerated or prolonged, is thought to contribute to the subsequent immunosuppression that characterizes the period after injury. Previously we have demonstrated that chemical sympathectomy (SNSx) accentuates this immediate pro-inflammatory response to TxHem. These findings suggest that the noradrenergic system plays a critical role in limiting the magnitude of the inflammatory response during TxHem and preserving the integrity of the host defense response to a subsequent infectious challenge during the period after TxHem.

OBJECTIVE

To examine the contribution of tissue norepinephrine to the host defense response to an infectious challenge during recovery from TxHem.

METHODS

Male Sprague-Dawley rats underwent SNSx (6-hydroxydopamine, i.p. daily for 3 days) prior to vascular catheter implantation. Conscious, unrestrained rats were subjected to traumatic injury (muscle crush) prior to a fixed-pressure hemorrhage (40 mm Hg for 60 min) and fluid resuscitation followed 24 h later by cecal ligation and puncture (CLP).

RESULTS

SNSx impaired the hemodynamic and thermoregulatory response to hemorrhage as indicated by decreased basal blood pressure, impaired blood pressure recovery during fluid resuscitation, and greater hypothermia after CLP. Furthermore, SNSx accentuated the TNF-alpha, IL-1, IL-6, and IL-10 response to TxHem + infection in plasma 6 h after CLP and in peritoneal lavage fluid 24 h after CLP.

CONCLUSION

These results indicate that the integrity of the noradrenergic system is necessary for adequate hemodynamic, thermoregulatory, and inflammatory responses to infection during the period following TxHem.

[Windmill principle versus clockwork principle--tradition and interaction in academic lectures. A. N. S. A. Radiologica]

In reply to depersonalization of teaching, students hiding behind anonymity and their decreasing effective presence in campus life, academic teaching has to become practice-oriented, attractive and at least more effective. The traditional teacher-based lecture competes with student-centered and issue-related academic events like problem-based learning, thus, concerning student-teacher interaction. The model of a clockwork represents the components of a traditional lecture. The model of a windmill is suitable for explaining synergistic effects in scope and experience during an interaction concerned lecture. An example of student-teacher interaction and students' activation even in a preclinical course of lectures on anatomy and radiology is given. A high response and acceptance of the lecture is assured by structure-and process-oriented features.

Oto-spondylo-megaepiphyseal dysplasia (OSMED)

Four personal longitudinal observations and two cases from the literature are used to introduce the concept of oto-spondylo-megaepiphyseal dysplasia (OSMED). The condition may be recognized at birth. The main clinical findings are sensoneurinal deafness, enlarged 1st interphalangeal joints of the hands, relative short extremities with abnormally large knees and elbows but still normal total body length. In the second decade of life, backpain and decreased mobility of the joints may follow. 4/6 patients had a cleft palate. The diagnostic radiological findings are the big epiphyses combined with a moderate platyspondyly, most marked in the lower thoracic region. The occurrence of OSMED in two sisters suggests an autosomal-recessive transmission. No biochemical anomaly could be detected.

Placebo attribution in methadone patients

The effect of external cues on the attributed effectiveness of a placebo was evaluated with methadone patients and a nonaddict control group. Two sources of external feedback, implicit dosage strength (liquid drug color) and explicit performance information (pursuit rotor feedback), were varied along with drug usage. The results indicated that the methadone patients made significantly greater placebo attributions and relied more upon the external cues in making those attributions than did the nonaddict control group. Implications for drug therapy are presented.