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Chen KA, Pak J, Agala CB, Stem JM, Guillem JG, Barnes EL, Herfarth HH, Kapadia MR. Factors Associated With Performing IPAA After Total Colectomy for Ulcerative Colitis. Dis Colon Rectum 2024; 67:674-680. [PMID: 38276963 DOI: 10.1097/dcr.0000000000003130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
BACKGROUND IPAA is considered the procedure of choice for restorative surgery after total colectomy for ulcerative colitis. Previous studies have examined the rate of IPAA within individual states but not at the national level in the United States. OBJECTIVE This study aimed to assess the rate of IPAA after total colectomy for ulcerative colitis in a national population and identify factors associated with IPAA. DESIGN This was a retrospective cohort study. SETTINGS This study was performed in the United States. PATIENTS Patients who were aged 18 years or older and who underwent total colectomy between 2009 and 2019 for a diagnosis of ulcerative colitis were identified within a commercial database. This database excluded patients with public insurance, including all patients older than 65 years with Medicare. MAIN OUTCOME MEASURES The primary outcome was IPAA. Multivariable logistic regression was used to assess the association between covariates and the likelihood of undergoing IPAA. RESULTS In total, 2816 patients were included, of whom 1414 (50.2%) underwent IPAA, 928 (33.0%) underwent no further surgery, and 474 (16.8%) underwent proctectomy with end ileostomy. Younger age, lower comorbidities, elective case, and laparoscopic approach in the initial colectomy were significantly associated with IPAA but socioeconomic status was not. LIMITATIONS This retrospective study included only patients with commercial insurance. CONCLUSIONS A total of 50.2% of patients who had total colectomy for ulcerative colitis underwent IPAA, and younger age, lower comorbidities, and elective cases are associated with a higher rate of IPAA placement. This study emphasizes the importance of ensuring follow-up with colorectal surgeons to provide the option of restorative surgery, especially for patients undergoing urgent or emergent colectomies. See Video Abstract . FACTORES ASOCIADOS CON LA REALIZACIN DE ANASTOMOSIS ANALBOLSA ILEAL DESPUS DE UNA COLECTOMA TOTAL POR COLITIS ULCEROSA ANTECEDENTES:La anastomosis ileo-anal se considera el procedimiento de elección para la cirugía reparadora tras la colectomía total por colitis ulcerosa. Estudios previos han examinado la tasa de anastomosis ileo-anal dentro de los estados individuales, pero no a nivel nacional en los Estados Unidos.OBJETIVO:Evaluar la tasa de anastomosis bolsa ileal-anal después de la colectomía total para la colitis ulcerosa en una población nacional e identificar los factores asociados con la anastomosis bolsa ileal-anal.DISEÑO:Se trata de un estudio de cohortes retrospectivo.LUGAR:Este estudio se realizó en los Estados Unidos.PACIENTES:Los pacientes que tenían ≥18 años de edad que se sometieron a colectomía total entre 2009 y 2019 para un diagnóstico de colitis ulcerosa fueron identificados dentro de una base de datos comercial. Esta base de datos excluyó a los pacientes con seguro público, incluidos todos los pacientes >65 años con Medicare.MEDIDAS DE RESULTADO PRINCIPALES:El resultado primario fue la anastomosis ileal bolsa-anal. Se utilizó una regresión logística multivariable para evaluar la asociación entre las covariables y la probabilidad de someterse a una anastomosis ileal.RESULTADOS:En total, se incluyeron 2.816 pacientes, de los cuales 1.414 (50,2%) se sometieron a anastomosis ileo-anal, 928 (33,0%) no se sometieron a ninguna otra intervención quirúrgica y 474 (16,8%) se sometieron a proctectomía con ileostomía terminal. La edad más joven, las comorbilidades más bajas, el caso electivo, y el abordaje laparoscópico en la colectomía inicial se asociaron significativamente con la anastomosis ileal bolsa-anal, pero no el estatus socioeconómico.LIMITACIONES:Este estudio retrospectivo incluyó sólo pacientes con seguro comercial.CONCLUSIONES:Un 50,2% de los pacientes se someten a anastomosis ileo-anal y la edad más joven, las comorbilidades más bajas y los casos electivos se asocian con una mayor tasa de colocación de anastomosis ileo-anal. Esto subraya la importancia de asegurar el seguimiento con cirujanos colorrectales para ofrecer la opción de cirugía reparadora, especialmente en pacientes sometidos a colectomías urgentes o emergentes. (Traducción-Dr. Yolanda Colorado ).
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Affiliation(s)
- Kevin A Chen
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joyce Pak
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Chris B Agala
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jonathan M Stem
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jose G Guillem
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Muneera R Kapadia
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Chen KA, Goffredo P, Butler LR, Joisa CU, Guillem JG, Gomez SM, Kapadia MR. Prediction of Pathologic Complete Response for Rectal Cancer Based on Pretreatment Factors Using Machine Learning. Dis Colon Rectum 2024; 67:387-397. [PMID: 37994445 DOI: 10.1097/dcr.0000000000003038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
BACKGROUND Pathologic complete response after neoadjuvant therapy is an important prognostic indicator for locally advanced rectal cancer and may give insights into which patients might be treated nonoperatively in the future. Existing models for predicting pathologic complete response in the pretreatment setting are limited by small data sets and low accuracy. OBJECTIVE We sought to use machine learning to develop a more generalizable predictive model for pathologic complete response for locally advanced rectal cancer. DESIGN Patients with locally advanced rectal cancer who underwent neoadjuvant therapy followed by surgical resection were identified in the National Cancer Database from years 2010 to 2019 and were split into training, validation, and test sets. Machine learning techniques included random forest, gradient boosting, and artificial neural network. A logistic regression model was also created. Model performance was assessed using an area under the receiver operating characteristic curve. SETTINGS This study used a national, multicenter data set. PATIENTS Patients with locally advanced rectal cancer who underwent neoadjuvant therapy and proctectomy. MAIN OUTCOME MEASURES Pathologic complete response defined as T0/xN0/x. RESULTS The data set included 53,684 patients. Pathologic complete response was experienced by 22.9% of patients. Gradient boosting showed the best performance with an area under the receiver operating characteristic curve of 0.777 (95% CI, 0.773-0.781), compared with 0.684 (95% CI, 0.68-0.688) for logistic regression. The strongest predictors of pathologic complete response were no lymphovascular invasion, no perineural invasion, lower CEA, smaller size of tumor, and microsatellite stability. A concise model including the top 5 variables showed preserved performance. LIMITATIONS The models were not externally validated. CONCLUSIONS Machine learning techniques can be used to accurately predict pathologic complete response for locally advanced rectal cancer in the pretreatment setting. After fine-tuning a data set including patients treated nonoperatively, these models could help clinicians identify the appropriate candidates for a watch-and-wait strategy. See Video Abstract . EL CNCER DE RECTO BASADA EN FACTORES PREVIOS AL TRATAMIENTO MEDIANTE EL APRENDIZAJE AUTOMTICO ANTECEDENTES:La respuesta patológica completa después de la terapia neoadyuvante es un indicador pronóstico importante para el cáncer de recto localmente avanzado y puede dar información sobre qué pacientes podrían ser tratados de forma no quirúrgica en el futuro. Los modelos existentes para predecir la respuesta patológica completa en el entorno previo al tratamiento están limitados por conjuntos de datos pequeños y baja precisión.OBJETIVO:Intentamos utilizar el aprendizaje automático para desarrollar un modelo predictivo más generalizable para la respuesta patológica completa para el cáncer de recto localmente avanzado.DISEÑO:Los pacientes con cáncer de recto localmente avanzado que se sometieron a terapia neoadyuvante seguida de resección quirúrgica se identificaron en la Base de Datos Nacional del Cáncer de los años 2010 a 2019 y se dividieron en conjuntos de capacitación, validación y prueba. Las técnicas de aprendizaje automático incluyeron bosque aleatorio, aumento de gradiente y red neuronal artificial. También se creó un modelo de regresión logística. El rendimiento del modelo se evaluó utilizando el área bajo la curva característica operativa del receptor.ÁMBITO:Este estudio utilizó un conjunto de datos nacional multicéntrico.PACIENTES:Pacientes con cáncer de recto localmente avanzado sometidos a terapia neoadyuvante y proctectomía.PRINCIPALES MEDIDAS DE VALORACIÓN:Respuesta patológica completa definida como T0/xN0/x.RESULTADOS:El conjunto de datos incluyó 53.684 pacientes. El 22,9% de los pacientes experimentaron una respuesta patológica completa. El refuerzo de gradiente mostró el mejor rendimiento con un área bajo la curva característica operativa del receptor de 0,777 (IC del 95%: 0,773 - 0,781), en comparación con 0,684 (IC del 95%: 0,68 - 0,688) para la regresión logística. Los predictores más fuertes de respuesta patológica completa fueron la ausencia de invasión linfovascular, la ausencia de invasión perineural, un CEA más bajo, un tamaño más pequeño del tumor y la estabilidad de los microsatélites. Un modelo conciso que incluye las cinco variables principales mostró un rendimiento preservado.LIMITACIONES:Los modelos no fueron validados externamente.CONCLUSIONES:Las técnicas de aprendizaje automático se pueden utilizar para predecir con precisión la respuesta patológica completa para el cáncer de recto localmente avanzado en el entorno previo al tratamiento. Después de realizar ajustes en un conjunto de datos que incluye pacientes tratados de forma no quirúrgica, estos modelos podrían ayudar a los médicos a identificar a los candidatos adecuados para una estrategia de observar y esperar. (Traducción-Dr. Ingrid Melo ).
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Affiliation(s)
- Kevin A Chen
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paolo Goffredo
- Division of Colorectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Logan R Butler
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Chinmaya U Joisa
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jose G Guillem
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Shawn M Gomez
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Muneera R Kapadia
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Chen KA, Joisa CU, Stem JM, Guillem JG, Gomez SM, Kapadia MR. Prediction of Ureteral Injury During Colorectal Surgery Using Machine Learning. Am Surg 2023; 89:5702-5710. [PMID: 37133432 PMCID: PMC10622328 DOI: 10.1177/00031348231173981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND Ureteral injury (UI) is a rare but devastating complication during colorectal surgery. Ureteral stents may reduce UI but carry risks themselves. Risk predictors for UI could help target the use of stents, but previous efforts have relied on logistic regression (LR), shown moderate accuracy, and used intraoperative variables. We sought to use an emerging approach in predictive analytics, machine learning, to create a model for UI. METHODS Patients who underwent colorectal surgery were identified in the National Surgical Quality Improvement Program (NSQIP) database. Patients were split into training, validation, and test sets. The primary outcome was UI. Three machine learning approaches were tested including random forest (RF), gradient boosting (XGB), and neural networks (NN), and compared with traditional LR. Model performance was assessed using area under the curve (AUROC). RESULTS The data set included 262,923 patients, of whom 1519 (.578%) experienced UI. Of the modeling techniques, XGB performed the best, with an AUROC score of .774 (95% CI .742-.807) compared with .698 (95% CI .664-.733) for LR. Random forest and NN performed similarly with scores of .738 and .763, respectively. Type of procedure, work RVUs, indication for surgery, and mechanical bowel prep showed the strongest influence on model predictions. CONCLUSIONS Machine learning-based models significantly outperformed LR and previous models and showed high accuracy in predicting UI during colorectal surgery. With proper validation, they could be used to support decision making regarding the placement of ureteral stents preoperatively.
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Affiliation(s)
- Kevin A. Chen
- Department of Surgery, University of North Carolina at Chapel Hill, NC, USA
| | - Chinmaya U. Joisa
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, NC, USA
| | - Jonathan M. Stem
- Department of Surgery, University of North Carolina at Chapel Hill, NC, USA
| | - Jose G. Guillem
- Department of Surgery, University of North Carolina at Chapel Hill, NC, USA
| | - Shawn M. Gomez
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, NC, USA
| | - Muneera R. Kapadia
- Department of Surgery, University of North Carolina at Chapel Hill, NC, USA
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Rodgers-Fouche L, Arora S, Ricker C, Li D, Farooqi M, Balaguer F, Dominguez-Valentin M, Guillem JG, Kanth P, Liska D, Melson J, Mraz KA, Shirts BH, Vilar E, Katona BW, Hodan R. Exploring Stakeholders' Perspectives on Implementing Universal Germline Testing for Colorectal Cancer: Findings From a Clinical Practice Survey. JCO Precis Oncol 2023; 7:e2300440. [PMID: 37897815 PMCID: PMC10860957 DOI: 10.1200/po.23.00440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 08/24/2023] [Accepted: 09/13/2023] [Indexed: 10/30/2023] Open
Abstract
PURPOSE New guidelines recommend considering germline genetic testing for all patients with colorectal cancer (CRC). However, there is a lack of data on stakeholders' perspectives on the advantages and barriers of implementing universal germline testing (UGT). This study assessed the perspectives of members of the Collaborative Group of the Americas on Inherited Gastrointestinal Cancer (CGA-IGC) regarding the implementation of UGT for patients with CRC, including readiness, logistics, and barriers. METHODS A cross-sectional survey was sent to 317 active members of CGA-IGC. The survey included sections on demographics, clinical practice specialty, established institutional practices for testing, and questions pertaining to support of and barriers to implementing UGT for patients with CRC. RESULTS Eighty CGA-IGC members (25%) participated, including 42 genetic counselors (53%) and 14 gastroenterologists (18%). Forty-seven (59%) reported an academic medical center as their primary work setting, and most participants (56%) had more than 10 years of clinical practice. Although most participants (73%) supported UGT, 54% indicated that changes in practice would be required before adopting UGT, and 39% indicated that these changes would be challenging to implement. There was support for both genetics and nongenetics providers to order genetic testing, and a majority (57%) supported a standardized multigene panel rather than a customized gene panel. Key barriers to UGT implementation included limited genetics knowledge among nongenetics providers, time-consuming processes for obtaining consent, ordering tests, disclosing results, and lack of insurance coverage. CONCLUSION This study demonstrates wide support among hereditary GI cancer experts for implementation of UGT for patients with CRC. However, alternative service delivery models using nongenetics providers should be considered to address the logistical barriers to UGT implementation, particularly the growing demand for genetic testing.
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Affiliation(s)
| | - Sanjeevani Arora
- Cancer Prevention and Control Program, Fox Chase Cancer Center, Philadelphia, PA
| | - Charité Ricker
- Division of Medical Oncology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Dan Li
- Department of Gastroenterology, Kaiser Permanente Medical Center, Santa Clara, CA
| | - Maheen Farooqi
- Division of Medical Oncology, University of Southern California, Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Francesc Balaguer
- Department of Gastroenterology, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
| | - Mev Dominguez-Valentin
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, Oslo, Norway
| | - Jose G. Guillem
- Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Priyanka Kanth
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Joshua Melson
- Division of Gastroenterology, University of Arizona Cancer Center, Tucson, AZ
| | | | - Brian H. Shirts
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
| | - Eduardo Vilar
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bryson W. Katona
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Rachel Hodan
- Cancer Genetics, Stanford Health Care, Palo Alto, CA
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Chen KA, Goffredo P, Hu D, Joisa CU, Guillem JG, Gomez SM, Kapadia MR. Estimating Risk of Locoregional Failure and Overall Survival in Anal Cancer Following Chemoradiation: A Machine Learning Approach. J Gastrointest Surg 2023; 27:1925-1935. [PMID: 37407899 PMCID: PMC10528925 DOI: 10.1007/s11605-023-05755-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/03/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Optimal treatment of anal squamous cell carcinoma (ASCC) is definitive chemoradiation. Patients with persistent or recurrent disease require abdominoperineal resection (APR). Current models for predicting need for APR and overall survival are limited by low accuracy or small datasets. This study sought to use machine learning (ML) to develop more accurate models for locoregional failure and overall survival for ASCC. METHODS This study used the National Cancer Database from 2004-2018, divided into training, validation, and test sets. We included patients with stage I-III ASCC who underwent chemoradiation. Our primary outcomes were need for APR and 3-year overall survival. Random forest (RF), gradient boosting (XGB), and neural network (NN) ML-based models were developed and compared with logistic regression (LR). Accuracy was assessed using area under the receiver operating characteristic curve (AUROC). RESULTS APR was required in 5.3% (1,015/18,978) of patients. XGB performed best with AUROC of 0.813, compared with 0.691 for LR. Tumor size, lymphovascular invasion, and tumor grade showed the strongest influence on model predictions. Mortality was 23.6% (7,988/33,834). AUROC for XGB and LR were similar at 0.766 and 0.748, respectively. For this model, age, radiation dose, sex, and insurance status were the most influential variables. CONCLUSIONS We developed and internally validated machine learning-based models for predicting outcomes in ASCC and showed higher accuracy versus LR for locoregional failure, but not overall survival. After external validation, these models may assist clinicians with identifying patients with ASCC at high risk of treatment failure.
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Affiliation(s)
- Kevin A Chen
- Divison of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 100 Manning Drive, 4038 Burnett Womack Building, CB #7050, Chapel Hill, NC, 27599, USA
| | - Paolo Goffredo
- Division of Colon & Rectal Surgery, Department of Surgery, University of Minnesota, 420 Delaware St SE, MN, 55455, Minneapolis, USA
| | - David Hu
- Department of Biostatistics, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 3101 McGavran-Greenberg Hall, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - Chinmaya U Joisa
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, 10202C Mary Ellen Jones Building, Chapel Hill, NC, 27599, USA
| | - Jose G Guillem
- Divison of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 100 Manning Drive, 4038 Burnett Womack Building, CB #7050, Chapel Hill, NC, 27599, USA
| | - Shawn M Gomez
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, 10202C Mary Ellen Jones Building, Chapel Hill, NC, 27599, USA
| | - Muneera R Kapadia
- Divison of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 100 Manning Drive, 4038 Burnett Womack Building, CB #7050, Chapel Hill, NC, 27599, USA.
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Couwenberg AM, Varvoglis DN, Grieb BC, Marijnen CA, Ciombor KK, Guillem JG. New Opportunities for Minimizing Toxicity in Rectal Cancer Management. Am Soc Clin Oncol Educ Book 2023; 43:e389558. [PMID: 37307515 PMCID: PMC10450577 DOI: 10.1200/edbk_389558] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Advances in multimodal management of locally advanced rectal cancer (LARC), consisting of preoperative chemotherapy and/or radiotherapy followed by surgery with or without adjuvant chemotherapy, have improved local disease control and patient survival but are associated with significant risk for acute and long-term morbidity. Recently published trials, evaluating treatment dose intensification via the addition of preoperative induction or consolidation chemotherapy (total neoadjuvant therapy [TNT]), have demonstrated improved tumor response rates while maintaining acceptable toxicity. In addition, TNT has led to an increased number of patients achieving a clinical complete response and thus eligible to pursue a nonoperative, organ-preserving, watch and wait approach, thereby avoiding toxicities associated with surgery, such as bowel dysfunction and stoma-related complications. Ongoing trials using immune checkpoint inhibitors in patients with mismatch repair-deficient tumors suggest that this subgroup of patients with LARC could potentially be treated with immunotherapy alone, sparing them the toxicity associated with preoperative treatment and surgery. However, the majority of rectal cancers are mismatch repair-proficient and less responsive to immune checkpoint inhibitors and require multimodal management. The synergy noted in preclinical studies between immunotherapy and radiotherapy on immunogenic tumor cell death has led to the design of ongoing clinical trials that explore the benefit of combining radiotherapy, chemotherapy, and immunotherapy (mainly of immune checkpoint inhibitors) and aim to increase the number of patients eligible for organ preservation.
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Affiliation(s)
- Alice M. Couwenberg
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Brian C. Grieb
- Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Corrie A.M. Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kristen K. Ciombor
- Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Jose G. Guillem
- Department of Surgery, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill, Chapel Hill, NC
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Mraz KA, Hodan R, Rodgers-Fouche L, Arora S, Balaguer F, Guillem JG, Jeter JM, Kanth P, Li D, Liska D, Melson J, Perez K, Ricker C, Shirts BH, Vilar E, Katona BW, Dominguez-Valentin M. Current chemoprevention approaches in Lynch syndrome and Familial adenomatous polyposis: a global clinical practice survey. Front Oncol 2023; 13:1141810. [PMID: 37293588 PMCID: PMC10247284 DOI: 10.3389/fonc.2023.1141810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/02/2023] [Indexed: 06/10/2023] Open
Abstract
Background International chemoprevention preferences and approaches in Lynch syndrome (LS) and APC-associated polyposis, including Familial adenomatous polyposis (FAP) and attenuated FAP (AFAP) have not been previously explored. Aim To describe current chemoprevention strategies for patients with LS or FAP/AFAP (referred to collectively as FAP) practiced by members of four international hereditary cancer societies through administration of a survey. Results Ninety-six participants across four hereditary gastrointestinal cancer societies responded to the survey. Most respondents (91%, 87/96) completed information regarding their demographics and practice characteristics relating to hereditary gastrointestinal cancer and chemoprevention clinical practices. Sixty-nine percent (60/87) of respondents offer chemoprevention for FAP and/or LS as a part of their practice. Of the 75% (72/96) of survey respondents who were eligible to answer practice-based clinical vignettes based off of their responses to ten barrier questions regarding chemoprevention, 88% (63/72) of those participants completed at least one case vignette question to further characterize chemoprevention practices in FAP and/or LS. In FAP, 51% (32/63) would offer chemoprevention for rectal polyposis, with sulindac - 300 mg (18%, 10/56) and aspirin (16%, 9/56) being the most frequently selected options. In LS, 93% (55/59) of professionals discuss chemoprevention and 59% (35/59) frequently recommend chemoprevention. Close to half of the respondents (47%, 26/55) would recommend beginning aspirin at time of commencement of the patient's first screening colonoscopy (usually at age 25yrs). Ninety-four percent (47/50) of respondents would consider a patient's diagnosis of LS as an influential factor for aspirin use. There was no consensus on the dose of aspirin (≤100 mg, >100 mg - 325 mg or 600 mg) to offer patients with LS and there was no agreement on how other factors, such as BMI, hypertension, family history of colorectal cancer, and family history of heart disease, would affect the recommendation for aspirin use. Possible harm among older patients (>70 years) was identified as the most common reason to discourage aspirin use. Conclusion Although chemoprevention is widely discussed and offered to patients with FAP and LS by an international group of hereditary gastrointestinal cancer experts, there is significant heterogeneity in how it is applied in clinical practice.
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Affiliation(s)
- Kathryn A. Mraz
- Department of Genetics, Grey Genetics, Brooklyn, NY, United States
- Research Department, Center for Genomic Interpretation, Sandy, UT, United States
| | - Rachel Hodan
- Cancer Genetics, Stanford Health Care, Palo Alto, CA, United States
| | - Linda Rodgers-Fouche
- Center for Cancer Risk Assessment, Massachusetts General Hospital, Boston, MA, United States
| | - Sanjeevani Arora
- Cancer Prevention and Control Program, Fox Chase Cancer Center, Philadelphia, PA, United States
| | - Francesc Balaguer
- Department of Gastroenterology, Hospital Clínic de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
| | - Jose G. Guillem
- Division of Gastrointestinal Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC, United States
| | - Joanne M. Jeter
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, United States
| | - Priyanka Kanth
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Dan Li
- Department of Gastroenterology, Kaiser Permanente Medical Center, Santa Clara, CA, United States
| | - David Liska
- Department of Colorectal Surgery and Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Joshua Melson
- Division of Gastroenterology, University of Arizona Cancer Center, Tucson, AZ, United States
| | - Kimberly Perez
- Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, MA, United States
| | - Charite Ricker
- Division of Medical Oncology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Brian H. Shirts
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, United States
| | - Eduardo Vilar
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Bryson W. Katona
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Mev Dominguez-Valentin
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, Oslo, Norway
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8
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Chen KA, Joisa CU, Stem J, Guillem JG, Eng SMG, Kapadia MR. Improved Prediction of Surgical-Site Infection After Colorectal Surgery Using Machine Learning. Dis Colon Rectum 2023; 66:458-466. [PMID: 36538699 PMCID: PMC10069984 DOI: 10.1097/dcr.0000000000002559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Surgical-site infection is a source of significant morbidity after colorectal surgery. Previous efforts to develop models that predict surgical-site infection have had limited accuracy. Machine learning has shown promise in predicting postoperative outcomes by identifying nonlinear patterns within large data sets. OBJECTIVE This study aimed to seek usage of machine learning to develop a more accurate predictive model for colorectal surgical-site infections. DESIGN Patients who underwent colorectal surgery were identified in the American College of Surgeons National Quality Improvement Program database from years 2012 to 2019 and were split into training, validation, and test sets. Machine-learning techniques included random forest, gradient boosting, and artificial neural network. A logistic regression model was also created. Model performance was assessed using area under the receiver operating characteristic curve. SETTINGS A national, multicenter data set. PATIENTS Patients who underwent colorectal surgery. MAIN OUTCOME MEASURES The primary outcome (surgical-site infection) included patients who experienced superficial, deep, or organ-space surgical-site infections. RESULTS The data set included 275,152 patients after the application of exclusion criteria. Of all patients, 10.7% experienced a surgical-site infection. Artificial neural network showed the best performance with area under the receiver operating characteristic curve of 0.769 (95% CI, 0.762-0.777), compared with 0.766 (95% CI, 0.759-0.774) for gradient boosting, 0.764 (95% CI, 0.756-0.772) for random forest, and 0.677 (95% CI, 0.669-0.685) for logistic regression. For the artificial neural network model, the strongest predictors of surgical-site infection were organ-space surgical-site infection present at time of surgery, operative time, oral antibiotic bowel preparation, and surgical approach. LIMITATIONS Local institutional validation was not performed. CONCLUSIONS Machine-learning techniques predict colorectal surgical-site infections with higher accuracy than logistic regression. These techniques may be used to identify patients at increased risk and to target preventive interventions for surgical-site infection. See Video Abstract at http://links.lww.com/DCR/C88 . PREDICCIN MEJORADA DE LA INFECCIN DEL SITIO QUIRRGICO DESPUS DE LA CIRUGA COLORRECTAL MEDIANTE EL APRENDIZAJE AUTOMTICO ANTECEDENTES:La infección del sitio quirúrgico es una fuente de morbilidad significativa después de la cirugía colorrectal. Los esfuerzos anteriores para desarrollar modelos que predijeran la infección del sitio quirúrgico han tenido una precisión limitada. El aprendizaje automático se ha mostrado prometedor en la predicción de los resultados posoperatorios mediante la identificación de patrones no lineales dentro de grandes conjuntos de datos.OBJETIVO:Intentamos utilizar el aprendizaje automático para desarrollar un modelo predictivo más preciso para las infecciones del sitio quirúrgico colorrectal.DISEÑO:Los pacientes que se sometieron a cirugía colorrectal se identificaron en la base de datos del Programa Nacional de Mejoramiento de la Calidad del Colegio Estadounidense de Cirujanos de los años 2012 a 2019 y se dividieron en conjuntos de capacitación, validación y prueba. Las técnicas de aprendizaje automático incluyeron conjunto aleatorio, aumento de gradiente y red neuronal artificial. También se creó un modelo de regresión logística. El rendimiento del modelo se evaluó utilizando el área bajo la curva característica operativa del receptor.CONFIGURACIÓN:Un conjunto de datos multicéntrico nacional.PACIENTES:Pacientes intervenidos de cirugía colorrectal.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario (infección del sitio quirúrgico) incluyó pacientes que experimentaron infecciones superficiales, profundas o del espacio de órganos del sitio quirúrgico.RESULTADOS:El conjunto de datos incluyó 275.152 pacientes después de la aplicación de los criterios de exclusión. El 10,7% de los pacientes presentó infección del sitio quirúrgico. La red neuronal artificial mostró el mejor rendimiento con el área bajo la curva característica operativa del receptor de 0,769 (IC del 95 %: 0,762 - 0,777), en comparación con 0,766 (IC del 95 %: 0,759 - 0,774) para el aumento de gradiente, 0,764 (IC del 95 %: 0,756 - 0,772) para conjunto aleatorio y 0,677 (IC 95% 0,669 - 0,685) para regresión logística. Para el modelo de red neuronal artificial, los predictores más fuertes de infección del sitio quirúrgico fueron la infección del sitio quirúrgico del espacio del órgano presente en el momento de la cirugía, el tiempo operatorio, la preparación intestinal con antibióticos orales y el abordaje quirúrgico.LIMITACIONES:No se realizó validación institucional local.CONCLUSIONES:Las técnicas de aprendizaje automático predicen infecciones del sitio quirúrgico colorrectal con mayor precisión que la regresión logística. Estas técnicas se pueden usar para identificar a los pacientes con mayor riesgo y para orientar las intervenciones preventivas para la infección del sitio quirúrgico. Consulte Video Resumen en http://links.lww.com/DCR/C88 . (Traducción-Dr Yolanda Colorado ).
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Affiliation(s)
- Kevin A Chen
- Department of Surgery, University of North Carolina, Chapel Hill, NC 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC 27599
| | - Chinmaya U Joisa
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill, NC 10202C Mary Ellen Jones Building, Chapel Hill, NC, 27599
| | - Jonathan Stem
- Department of Surgery, University of North Carolina, Chapel Hill, NC 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC 27599
| | - Jose G Guillem
- Department of Surgery, University of North Carolina, Chapel Hill, NC 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC 27599
| | - Shawn M Gomez Eng
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill, NC 10202C Mary Ellen Jones Building, Chapel Hill, NC, 27599
| | - Muneera R Kapadia
- Department of Surgery, University of North Carolina, Chapel Hill, NC 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC 27599
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Nash GM, Garcia-Aguilar J, Paty P, Gonen M, Foote MB, Chung S, Mohamed M, Aguirre N, Weiser MR, Rassam R, Guillem JG, Smith JJ, Pappou E, Wei IH, Momtaz P, Gollub MJ, Vakiani E, Shia J, Saltz LB, Cercek A. Colorectal cohort analysis from the Intraperitoneal Chemotherapy After Cytoreductive Surgery for Peritoneal Metastasis (ICARuS) clinical trial. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.4_suppl.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
160 Background: ICARuS is a randomized phase II, multicenter trial to evaluate the relative efficacy of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) with mitomycin C vs. Early Postoperative Intraperitoneal Chemotherapy (EPIC) with floxuridine (FUDR), after cytoreductive surgery (CRS), for the treatment of peritoneal metastases (PM) from colorectal (CRC) or appendiceal cancer (AC). PRODIGE7 results failed to demonstrate benefit of HIPEC therapy after complete gross resection of CRC PM, prompting termination of CRC accrual and early cohort analysis. Methods: Patients with isolated, confirmed PM were eligible for 1:1 randomization to CRS plus HIPEC with mitomycin C or CRS plus EPIC with FUDR. Patients were stratified by recent systemic chemotherapy and disease (AC vs. CRC). The trial was originally powered to evaluate 212 patients for a 20% gain in a primary endpoint of 3-year progression free survival (PFS: HR = 1.75). Results: Seventy-five CRC patients were included between 4/2013 and 12/2018 for HIPEC (N = 40) or EPIC (N = 35) treatment. Baseline characteristics were well balanced. After a median follow up of 36 months, the median PFS was 7.7 months (95% CI: 6.3-11.1) in the HIPEC arm and 8.8 months (95% CI: 7.1-21.9) in the EPIC arm, HR = 0.69 (95% CI: 0.42-1.14) p = 0.14. In the 42 left-sided primary cancers, the median PFS was 8.4 months (95% CI: 6.4-17.7) in the HIPEC arm and 12.5 months (95% CI: 8.1-NR) in the EPIC arm, HR = 0.60 (95% CI: 0.29-1.22) p = 0.14. In the 33 right-sided primary cancers, the median PFS was 6.5 months (95% CI: 5.5-14.1) in the HIPEC arm and 8 months (95% CI: 5.8-24.1) in the EPIC arm, HR = 0.80 (95% CI: 0.39-1.64) p = 0.53. PFS was significantly better in the EPIC arm among patients with BRAF wildtype (WT) tumors and patients with higher PM burden (PCI > 7). There was no difference between HIPEC and EPIC in the primary toxicity endpoint of complications grade 3 or above (23 vs. 34%, p = 0.3). Conclusions: Three-year PFS did not significantly differ between treatment arms. The lack of survival benefit of HIPEC in the entire cohort and in subset analysis is consistent with the findings of PRODIGE7. ICARuS remains open to accrual for AC. These data support further investigation of the potential benefit of EPIC with CRS in carefully selected patients with CRC PM. Clinical trial information: NCT01815359 .
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Affiliation(s)
| | | | - Philip Paty
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mithat Gonen
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | | | - Jose G. Guillem
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | - Iris H Wei
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Parisa Momtaz
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marc J Gollub
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Jinru Shia
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Andrea Cercek
- Memorial Sloan Kettering Cancer Center, New York, NY
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Luo WY, Agala CB, Shetty P, Kapadia MR, Stem JM, Guillem JG. Racial and regional disparities in the management of locally advanced rectal cancer. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.4_suppl.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
14 Background: Surgical margins following rectal cancer resection impact oncologic outcomes and may reflect adequacy of care. We examined the relationship between race, ethnicity, or region of care with margin positivity following rectal cancer resection. Methods: We queried the National Cancer Database (NCDB) for patients diagnosed with stage II-IV rectal cancer between 2004-2018 who underwent surgical resection and excluded patients with missing data for race/ethnicity and radiation therapy/surgery status, and/or who had local excision only. We performed a propensity-score analysis via inverse probability of treatment weighting (IPTW) of margin positivity rate as outcome and race/ethnicity and region as predictors of interest. We controlled for age, sex, Charlson-Deyo Score, pathologic stage, pathologic grade, time from diagnosis to surgical resection, surgery type, sequence of radiation and surgery, facility type, insurance type, level of education, distance between patient and facility, and region of the United States. Results: Our query yielded 73,269 patients. Median patient age was 63 (IQR: 54-72) years and 40% were female. 81%,8%, 6%, and 5% were non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic Other, respectively. After IPTW adjustment, non-Hispanic Black patients had 19% higher odds of margin positivity relative to non-Hispanic White patients (OR: 1.185, 95% CI: 1.094-1.284; p<.0001) Patients in the Northeast United States had a 10% lower odds of margin positivity compared to those in the South (OR: 0.900, 95% CI: 0.842-0.962; p=0.0019). Conclusions: Being non-Hispanic Black was significantly associated with a higher likelihood of positive margin following rectal cancer resection when compared to their non-Hispanic White counterparts. Patients in the South also experienced significantly higher rates of positive margin when compared to Northeast patients. Further investigation into potential interactions between racial and regional disparities and other contributors is warranted.[Table: see text]
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Affiliation(s)
- William Yu Luo
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Chris B Agala
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Pragna Shetty
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | - Jose G. Guillem
- University of North Carolina at Chapel Hill, Chapel Hill, NC
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11
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Chen KA, Joisa CU, Stitzenberg KB, Stem J, Guillem JG, Gomez SM, Kapadia MR. Development and Validation of Machine Learning Models to Predict Readmission After Colorectal Surgery. J Gastrointest Surg 2022; 26:2342-2350. [PMID: 36070116 PMCID: PMC10081888 DOI: 10.1007/s11605-022-05443-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/18/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Readmission after colorectal surgery is common and often implies complications for patients and costs for hospitals. Previous works have created predictive models using logistic regression for this outcome but have shown limited accuracy. Machine learning has shown promise in improving predictions by identifying non-linear patterns in data. We sought to create a more accurate predictive model for readmission after colorectal surgery using machine learning. METHODS Patients who underwent colorectal surgery were identified in the National Quality Improvement Program (NSQIP) database including years 2012-2019 and split into training, validation, and test sets. The primary outcome was readmission within 30 days of surgery. Three types of machine learning models were created, including random forest (RF), gradient boosting (XGB), and neural network (NN). A logistic regression (LR) model was also created for comparison. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC). RESULTS The dataset included 213,827 patients after application of exclusion criteria. A total of 23,083 (10.8%) of patients experienced readmission. NN obtained an AUROC of 0.751 (95% CI 0.743-0.759), compared with 0.684 (95% CI 0.676-0.693) for LR. RF and XGB performed similarly with AUROCs of 0.749 (95% CI 0.741-0.757) and 0.745 (95% CI 0.737-0.753) respectively. Ileus, index admission length of stay, organ-space surgical site infection present at time of surgery, and ostomy placement were identified as the most contributory variables. CONCLUSIONS Machine learning approaches outperformed traditional statistical methods in the prediction of readmission after colorectal surgery. After external validation, this improved prediction model could be used to target interventions to reduce readmission rate.
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Affiliation(s)
- Kevin A Chen
- Department of Surgery, University of North Carolina, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC, 27599, USA
| | - Chinmaya U Joisa
- Joint Department of Biomedical Engineering, University of North Carolina, 10202C Mary Ellen Jones Building, Chapel Hill, NC, 27599, USA
| | - Karyn B Stitzenberg
- Department of Surgery, University of North Carolina, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC, 27599, USA
| | - Jonathan Stem
- Department of Surgery, University of North Carolina, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC, 27599, USA
| | - Jose G Guillem
- Department of Surgery, University of North Carolina, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC, 27599, USA
| | - Shawn M Gomez
- Joint Department of Biomedical Engineering, University of North Carolina, 10202C Mary Ellen Jones Building, Chapel Hill, NC, 27599, USA
| | - Muneera R Kapadia
- Department of Surgery, University of North Carolina, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC, 27599, USA.
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12
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Yuval JB, Thompson HM, Fiasconaro M, Patil S, Wei IH, Pappou EP, Smith JJ, Guillem JG, Nash GM, Weiser MR, Paty PB, Garcia-Aguilar J, Widmar M. Predictors of operative difficulty in robotic low anterior resection for rectal cancer. Colorectal Dis 2022; 24:1318-1324. [PMID: 35656853 PMCID: PMC9701150 DOI: 10.1111/codi.16212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/12/2022] [Accepted: 05/24/2022] [Indexed: 02/08/2023]
Abstract
AIM This study evaluates the relationship of tumour and anatomical features with operative difficulty in robotic low anterior resection performed by four experienced surgeons in a high-volume colorectal cancer practice. METHODS Data from 382 patients who underwent robotic low anterior resection by four expert surgeons between January 2016 and June 2019 were included in the analysis. Operating time was used as a measure of operative difficulty. Univariate and multivariate mixed models were used to identify associations between baseline characteristics and operating time, with surgeon as a random effect, thereby controlling for variability in surgeon speed and proficiency. In an exploratory analysis, operative difficulty was defined as conversion to laparotomy, a positive margin or an incomplete mesorectum. RESULTS Median operating time was 4.28 h (range 1.95-11.33 h) but varied by surgeon from 3.45 h (1.95-6.10 h) to 5.93 h (3.33-11.33 h) (P < 0.001). Predictors of longer operating time in multivariate analysis were male sex, higher body mass index, neoadjuvant radiotherapy, low tumour height, greater sacral height and larger mesorectal area at the S5 vertebral level. Conversion occurred in two cases (0.5%), and incomplete mesorectum and positive margins were found in nine (2.4%) and 19 (5.0%) patients, respectively. Neoadjuvant radiotherapy and larger pelvic outlet were the only characteristics associated with the exploratory measure of difficulty. CONCLUSION Predicting operative difficulty based on easy to identify, preoperative radiological and clinical variables is feasible in robotic anterior resection.
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Affiliation(s)
- Jonathan B. Yuval
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hannah M. Thompson
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Megan Fiasconaro
- Departments of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Departments of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Iris H. Wei
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emmanouil P. Pappou
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J. Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jose G. Guillem
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Garrett M. Nash
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin R. Weiser
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip B. Paty
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria Widmar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Møller P, Seppälä T, Dowty JG, Haupt S, Dominguez-Valentin M, Sunde L, Bernstein I, Engel C, Aretz S, Nielsen M, Capella G, Evans DG, Burn J, Holinski-Feder E, Bertario L, Bonanni B, Lindblom A, Levi Z, Macrae F, Winship I, Plazzer JP, Sijmons R, Laghi L, Valle AD, Heinimann K, Half E, Lopez-Koestner F, Alvarez-Valenzuela K, Scott RJ, Katz L, Laish I, Vainer E, Vaccaro CA, Carraro DM, Gluck N, Abu-Freha N, Stakelum A, Kennelly R, Winter D, Rossi BM, Greenblatt M, Bohorquez M, Sheth H, Tibiletti MG, Lino-Silva LS, Horisberger K, Portenkirchner C, Nascimento I, Rossi NT, da Silva LA, Thomas H, Zaránd A, Mecklin JP, Pylvänäinen K, Renkonen-Sinisalo L, Lepisto A, Peltomäki P, Therkildsen C, Lindberg LJ, Thorlacius-Ussing O, von Knebel Doeberitz M, Loeffler M, Rahner N, Steinke-Lange V, Schmiegel W, Vangala D, Perne C, Hüneburg R, de Vargas AF, Latchford A, Gerdes AM, Backman AS, Guillén-Ponce C, Snyder C, Lautrup CK, Amor D, Palmero E, Stoffel E, Duijkers F, Hall MJ, Hampel H, Williams H, Okkels H, Lubiński J, Reece J, Ngeow J, Guillem JG, Arnold J, Wadt K, Monahan K, Senter L, Rasmussen LJ, van Hest LP, Ricciardiello L, Kohonen-Corish MRJ, Ligtenberg MJL, Southey M, Aronson M, Zahary MN, Samadder NJ, Poplawski N, Hoogerbrugge N, Morrison PJ, James P, Lee G, Chen-Shtoyerman R, Ankathil R, Pai R, Ward R, Parry S, Dębniak T, John T, van Overeem Hansen T, Caldés T, Yamaguchi T, Barca-Tierno V, Garre P, Cavestro GM, Weitz J, Redler S, Büttner R, Heuveline V, Hopper JL, Win AK, Lindor N, Gallinger S, Le Marchand L, Newcomb PA, Figueiredo J, Buchanan DD, Thibodeau SN, ten Broeke SW, Hovig E, Nakken S, Pineda M, Dueñas N, Brunet J, Green K, Lalloo F, Newton K, Crosbie EJ, Mints M, Tjandra D, Neffa F, Esperon P, Kariv R, Rosner G, Pavicic WH, Kalfayan P, Torrezan GT, Bassaneze T, Martin C, Moslein G, Ahadova A, Kloor M, Sampson JR, Jenkins MA. Colorectal cancer incidences in Lynch syndrome: a comparison of results from the prospective lynch syndrome database and the international mismatch repair consortium. Hered Cancer Clin Pract 2022; 20:36. [PMID: 36182917 PMCID: PMC9526951 DOI: 10.1186/s13053-022-00241-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 08/31/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To compare colorectal cancer (CRC) incidences in carriers of pathogenic variants of the MMR genes in the PLSD and IMRC cohorts, of which only the former included mandatory colonoscopy surveillance for all participants. METHODS CRC incidences were calculated in an intervention group comprising a cohort of confirmed carriers of pathogenic or likely pathogenic variants in mismatch repair genes (path_MMR) followed prospectively by the Prospective Lynch Syndrome Database (PLSD). All had colonoscopy surveillance, with polypectomy when polyps were identified. Comparison was made with a retrospective cohort reported by the International Mismatch Repair Consortium (IMRC). This comprised confirmed and inferred path_MMR carriers who were first- or second-degree relatives of Lynch syndrome probands. RESULTS In the PLSD, 8,153 subjects had follow-up colonoscopy surveillance for a total of 67,604 years and 578 carriers had CRC diagnosed. Average cumulative incidences of CRC in path_MLH1 carriers at 70 years of age were 52% in males and 41% in females; for path_MSH2 50% and 39%; for path_MSH6 13% and 17% and for path_PMS2 11% and 8%. In contrast, in the IMRC cohort, corresponding cumulative incidences were 40% and 27%; 34% and 23%; 16% and 8% and 7% and 6%. Comparing just the European carriers in the two series gave similar findings. Numbers in the PLSD series did not allow comparisons of carriers from other continents separately. Cumulative incidences at 25 years were < 1% in all retrospective groups. CONCLUSIONS Prospectively observed CRC incidences (PLSD) in path_MLH1 and path_MSH2 carriers undergoing colonoscopy surveillance and polypectomy were higher than in the retrospective (IMRC) series, and were not reduced in path_MSH6 carriers. These findings were the opposite to those expected. CRC point incidence before 50 years of age was reduced in path_PMS2 carriers subjected to colonoscopy, but not significantly so.
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Affiliation(s)
- Pål Møller
- grid.55325.340000 0004 0389 8485Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, 0379 Oslo, Norway
| | - Toni Seppälä
- grid.15485.3d0000 0000 9950 5666Department of Gastrointestinal Surgery, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Applied Tumour Genomics Research Program, University of Helsinki, Helsinki, Finland ,grid.412330.70000 0004 0628 2985Faculty of Medicine and Health Technology, Tampere University and Tays Cancer Center, Tampere University Hospital, Tampere, Finland
| | - James G. Dowty
- grid.1008.90000 0001 2179 088XCentre of Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria 3010 Australia
| | - Saskia Haupt
- grid.7700.00000 0001 2190 4373Engineering Mathematics and Computing Lab (EMCL), Interdisciplinary Center for Scientific Computing (IWR), Heidelberg University, Heidelberg, Germany ,grid.424699.40000 0001 2275 2842Data Mining and Uncertainty Quantification (DMQ), Heidelberg Institute for Theoretical Studies (HITS), Heidelberg, Germany
| | - Mev Dominguez-Valentin
- grid.55325.340000 0004 0389 8485Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, 0379 Oslo, Norway
| | - Lone Sunde
- grid.27530.330000 0004 0646 7349Department of Clinical Genetics, Aalborg University Hospital, 9000 Aalborg, Denmark ,grid.7048.b0000 0001 1956 2722Department of Biomedicine, Aarhus University, DK-8000 Aarhus, Denmark
| | - Inge Bernstein
- grid.5117.20000 0001 0742 471XDepartment of Surgical Gastroenterology, Aalborg University Hospital, Aalborg University, 9100 Aalborg, Denmark ,grid.5117.20000 0001 0742 471XInstitute of Clinical Medicine, Aalborg University Hospital, Aalborg University, 9100 Aalborg, Denmark
| | - Christoph Engel
- grid.9647.c0000 0004 7669 9786Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, 04107 Leipzig, Germany
| | - Stefan Aretz
- grid.10388.320000 0001 2240 3300Institute of Human Genetics, National Center for Hereditary Tumor Syndromes, Medical Faculty, University of Bonn, 53127 Bonn, Germany
| | - Maartje Nielsen
- grid.10419.3d0000000089452978Department of Clinical Genetics, Leids Universitair Medisch Centrum, 2300RC, Leiden, The Netherlands
| | - Gabriel Capella
- grid.417656.7Hereditary Cancer Program, Institut Català d’Oncologia-IDIBELL, L; Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Dafydd Gareth Evans
- grid.5379.80000000121662407Division of Evolution and Genomic Sciences, Manchester Centre for Genomic Medicine, University of Manchester, Manchester University NHS Foundation Trust, Manchester, M13 9WL UK
| | - John Burn
- grid.1006.70000 0001 0462 7212Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE1 3BZ UK
| | - Elke Holinski-Feder
- grid.411095.80000 0004 0477 2585Campus Innenstadt, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, 80336 Munich, Germany ,grid.491982.f0000 0000 9738 9673MGZ – Center of Medical Genetics, 80335 Munich, Germany
| | - Lucio Bertario
- grid.15667.330000 0004 1757 0843Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Bernardo Bonanni
- grid.15667.330000 0004 1757 0843Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Annika Lindblom
- grid.4714.60000 0004 1937 0626Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Zohar Levi
- grid.413156.40000 0004 0575 344XDepartment Rabin Medical Center, Service High Risk GI Cancer Gastroenterology, Petach Tikva, Israel
| | - Finlay Macrae
- grid.416153.40000 0004 0624 1200Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Australia ,grid.1008.90000 0001 2179 088XDepartment of Medicine, Melbourne University, Melbourne, Australia
| | - Ingrid Winship
- grid.416153.40000 0004 0624 1200Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Australia ,grid.1008.90000 0001 2179 088XDepartment of Medicine, Melbourne University, Melbourne, Australia
| | - John-Paul Plazzer
- grid.416153.40000 0004 0624 1200The Royal Melbourne Hospital, Melbourne, Australia
| | - Rolf Sijmons
- grid.4494.d0000 0000 9558 4598Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Luigi Laghi
- grid.10383.390000 0004 1758 0937Department of Medicine and Surgery, Laboratory of Molecular Gastroenterology, IRCCS Humanitas Research Hospital, University of Parma, Parma, Italy
| | - Adriana Della Valle
- Hospital Fuerzas Armadas, Grupo Colaborativo Uruguayo, Investigación de Afecciones Oncológicas Hereditarias (GCU), Montevideo, Uruguay
| | - Karl Heinimann
- grid.410567.1Medical Genetics, Institute for Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Elizabeth Half
- grid.413731.30000 0000 9950 8111Gastrointestinal Cancer Prevention Unit, Gastroenterology Department, Rambam Health Care Campus, Haifa, Israel
| | | | | | - Rodney J. Scott
- grid.413648.cUniversity of Newcastle and the Hunter Medical Research Institute, Callaghan, Australia
| | - Lior Katz
- grid.9619.70000 0004 1937 0538Department of Gastroenterology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ido Laish
- grid.413795.d0000 0001 2107 2845The Department of Gastroenterology, High Risk and GI Cancer Prevention Clinic, Gastro-Oncology Unit, Sheba Medical Center, Ramat Gan, Israel
| | - Elez Vainer
- grid.9619.70000 0004 1937 0538Department of Gastroenterology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Carlos Alberto Vaccaro
- grid.414775.40000 0001 2319 4408Hereditary Cancer Program (PROCANHE), Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
| | - Dirce Maria Carraro
- grid.413320.70000 0004 0437 1183Genomic and Molecular Biology Group, A.C.Camargo Cancer Center, Sao Paulo, Brazil
| | - Nathan Gluck
- grid.12136.370000 0004 1937 0546Department of Gastroenterology, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Naim Abu-Freha
- grid.7489.20000 0004 1937 0511The Institute of Gastroenterology and Hepatology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Aine Stakelum
- grid.412751.40000 0001 0315 8143St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland
| | - Rory Kennelly
- grid.412751.40000 0001 0315 8143St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland
| | - Des Winter
- grid.412751.40000 0001 0315 8143St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland
| | | | - Marc Greenblatt
- grid.59062.380000 0004 1936 7689University of Vermont, Larner College of Medicine, Burlington, VT 05405 USA
| | - Mabel Bohorquez
- grid.412192.d0000 0001 2168 0760University of Tolima, Tolima, Colombia
| | - Harsh Sheth
- Foundation for Research in Genetics and Endocrinology, FRIGE House, Jodhpur Village Road, Satellite Ahmedabad, Ahmedabad, 380015 India
| | - Maria Grazia Tibiletti
- grid.18147.3b0000000121724807Ospedale di Circolo ASST Settelaghi, Centro di Ricerca Tumori Eredo-Familiari, Università dell’Insubria, Varese, Italy
| | | | - Karoline Horisberger
- grid.412004.30000 0004 0478 9977Department of Abdominal and Transplantation Surgery, Universitätsspital Zürich, Rämistrasse 100, CH-8091 Zürich, Switzerland
| | - Carmen Portenkirchner
- grid.412004.30000 0004 0478 9977Department of Abdominal and Transplantation Surgery, Universitätsspital Zürich, Rämistrasse 100, CH-8091 Zürich, Switzerland
| | - Ivana Nascimento
- Laboratório de Imonologia, ICS/UFBA, Núcleo de Oncologia da Bahia/Oncoclinicas, Salvador, Brazil
| | - Norma Teresa Rossi
- grid.413199.70000 0001 0368 1276Hospital Privado Universitario de Córdoba, Cordoba, Argentina
| | - Leandro Apolinário da Silva
- Hospital Universitario Oswaldo Cruz, Universidade de Pernambuco, Hospital de Câncer de Pernambuco, IPON - Instituto de Pesquisas Oncológicas do Nordeste, Salvador, Brazil
| | - Huw Thomas
- grid.7445.20000 0001 2113 8111Department of Surgery and Cancer, St Mark’s Hospital, Imperial College London, London, UK
| | - Attila Zaránd
- grid.11804.3c0000 0001 0942 9821Department of Transplantation and Surgery, Semmelweis University Budapest, Budapest, Hungary
| | - Jukka-Pekka Mecklin
- grid.9681.60000 0001 1013 7965Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland ,grid.460356.20000 0004 0449 0385Department of Surgery, Central Finland Health Care District, Jyväskylä, Finland
| | - Kirsi Pylvänäinen
- grid.460356.20000 0004 0449 0385Department of Education and Science, Central Finland Health Care District, Jyväskylä, Finland
| | - Laura Renkonen-Sinisalo
- grid.15485.3d0000 0000 9950 5666Department of Gastrointestinal Surgery, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Applied Tumour Genomics Research Program, University of Helsinki, Helsinki, Finland
| | - Anna Lepisto
- grid.15485.3d0000 0000 9950 5666Department of Gastrointestinal Surgery, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Applied Tumour Genomics Research Program, University of Helsinki, Helsinki, Finland
| | - Päivi Peltomäki
- grid.7737.40000 0004 0410 2071Department of Medical and Clinical Genetics, University of Helsinki, Helsinki, Finland
| | - Christina Therkildsen
- grid.413660.60000 0004 0646 7437The Danish HNPCC Register, Gastro Unit, Copenhagen University Hospital – Amager and Hvidovre, Copenhagen, Denmark
| | - Lars Joachim Lindberg
- grid.413660.60000 0004 0646 7437The Danish HNPCC Register, Gastro Unit, Copenhagen University Hospital – Amager and Hvidovre, Copenhagen, Denmark
| | - Ole Thorlacius-Ussing
- grid.5117.20000 0001 0742 471XDepartment of Surgical Gastroenterology, Aalborg University Hospital, Aalborg University, 9100 Aalborg, Denmark ,grid.5117.20000 0001 0742 471XInstitute of Clinical Medicine, Aalborg University Hospital, Aalborg University, 9100 Aalborg, Denmark
| | - Magnus von Knebel Doeberitz
- grid.5253.10000 0001 0328 4908Department of Applied Tumour Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany ,grid.7497.d0000 0004 0492 0584Clinical Cooperation Unit Applied Tumour Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Markus Loeffler
- grid.9647.c0000 0004 7669 9786Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Nils Rahner
- grid.14778.3d0000 0000 8922 7789Institute of Human Genetics, University Clinic Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Verena Steinke-Lange
- grid.411095.80000 0004 0477 2585Campus Innenstadt, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, 80336 Munich, Germany ,grid.491982.f0000 0000 9738 9673MGZ – Center of Medical Genetics, 80335 Munich, Germany
| | - Wolff Schmiegel
- grid.5570.70000 0004 0490 981XDepartment of Medicine, Knappschaftskrankenhaus, Ruhr-University Bochum, Bochum, Germany
| | - Deepak Vangala
- grid.5570.70000 0004 0490 981XDepartment of Medicine, Knappschaftskrankenhaus, Ruhr-University Bochum, Bochum, Germany
| | - Claudia Perne
- grid.10388.320000 0001 2240 3300Institute of Human Genetics, National Center for Hereditary Tumor Syndromes, Medical Faculty, University of Bonn, 53127 Bonn, Germany
| | - Robert Hüneburg
- grid.15090.3d0000 0000 8786 803XDepartment of Internal Medicine, University Hospital Bonn, Bonn, Germany
| | - Aída Falcón de Vargas
- grid.413504.70000 0004 1761 9942Genetics Unit, Hospital Vargas de Caracas, Caracas, Venezuela ,grid.8171.f0000 0001 2155 0982Escuela de Medicina Jose Maria Vargas, Universidad, Central de Venezuela, UCV, Caracas, Venezuela
| | | | - Anne-Marie Gerdes
- grid.4973.90000 0004 0646 7373Department of Clinical Genetics, Rigshospitalet, Copenhagen University Hospital, DK-2100 Copenhagen, Denmark
| | - Ann-Sofie Backman
- grid.4714.60000 0004 1937 0626Department of Medicine Solna, Unit of Internal medicine, Karolinska Institutet, Stockholm, Sweden
| | - Carmen Guillén-Ponce
- grid.411347.40000 0000 9248 5770Medical Oncology Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Carrie Snyder
- grid.254748.80000 0004 1936 8876Hereditary Cancer Center, Department of Preventive Medicine, Creighton University, Omaha, NE 68178 USA
| | - Charlotte K. Lautrup
- grid.27530.330000 0004 0646 7349Department of Clinical Genetics, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - David Amor
- grid.416107.50000 0004 0614 0346Murdoch Children’s Research Institute and University of Melbourne Department of Paediatrics, Royal Children’s Hospital, Parkville, VIC 3052 Australia
| | - Edenir Palmero
- grid.419166.dDepartment of Genetics, Brazilian National Cancer Institute, Rio de Janeiro, Brazil ,grid.427783.d0000 0004 0615 7498Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Elena Stoffel
- grid.214458.e0000000086837370Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
| | - Floor Duijkers
- grid.7177.60000000084992262Department of Clinical Genetics, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Michael J. Hall
- grid.249335.a0000 0001 2218 7820Department of Clinical Genetics, Fox Chase Cancer Center, Philadelphia, PA USA
| | - Heather Hampel
- grid.261331.40000 0001 2285 7943Division of Human Genetics, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210 USA
| | - Heinric Williams
- grid.415341.60000 0004 0433 4040Department of Urology, Geisinger Medical Center, Danville, PA 17822 USA
| | - Henrik Okkels
- grid.5117.20000 0001 0742 471XDepartment of Molecular Diagnostics, Aalborg University, Aalborg, Denmark
| | - Jan Lubiński
- grid.107950.a0000 0001 1411 4349Department of Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Jeanette Reece
- grid.1008.90000 0001 2179 088XCentre of Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria 3010 Australia
| | - Joanne Ngeow
- grid.59025.3b0000 0001 2224 0361Lee Kong Chian School of Medicine, Nanyang Technological University Singapore and Cancer Genetics Service National Cancer Centre Singapore, Singapore, Singapore
| | - Jose G. Guillem
- grid.410711.20000 0001 1034 1720Gastrointestinal Surgery, University of North Carolina, Chapel Hill, NC USA
| | - Julie Arnold
- New Zealand Familial Gastrointestinal Cancer Service, Auckland, New Zealand
| | - Karin Wadt
- grid.4973.90000 0004 0646 7373Department of Clinical Genetics, Rigshospitalet, Copenhagen University Hospital, DK-2100 Copenhagen, Denmark
| | - Kevin Monahan
- grid.416510.7St Mark’s Hospital & Imperial College, London, UK
| | - Leigha Senter
- grid.261331.40000 0001 2285 7943Ohio State University Comprehensive Cancer Center, Columbus, OH 43210 USA
| | - Lene J. Rasmussen
- grid.5254.60000 0001 0674 042XDepartment of Cellular and Molecular Medicine, Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Liselotte P. van Hest
- grid.12380.380000 0004 1754 9227Department of Clinical Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Luigi Ricciardiello
- grid.6292.f0000 0004 1757 1758IRCCS AOU di Bologna, and Department of Medical and Surgical Sciences - University of Bologna, Bologna, Italy
| | - Maija R. J. Kohonen-Corish
- grid.417229.b0000 0000 8945 8472Woolcock Institute of Medical Research, Glebe, Sydney, NSW 2037 Australia
| | - Marjolijn J. L. Ligtenberg
- grid.10417.330000 0004 0444 9382Department of Human Genetics and Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Melissa Southey
- grid.1002.30000 0004 1936 7857Monash Health Translation Precinct, Monash University, Clayton South, VIC 3169 Australia
| | - Melyssa Aronson
- grid.492573.e0000 0004 6477 6457Zane Cohen Centre, Sinai Health System, Toronto, Ontario Canada
| | - Mohd N. Zahary
- grid.449643.80000 0000 9358 3479Faculty of Health Sciences, University Sultan Zainal Abidin, Kuala Terengganu, Terengganu Malaysia
| | - N. Jewel Samadder
- grid.470142.40000 0004 0443 9766Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ 85054 USA
| | - Nicola Poplawski
- grid.1010.00000 0004 1936 7304Adelaide Medical School, University of Adelaide, Adelaide, SA 5000 Australia ,grid.416075.10000 0004 0367 1221Adult Genetics Unit, Royal Adelaide Hospital, Adelaide, SA 5000 Australia
| | - Nicoline Hoogerbrugge
- grid.10417.330000 0004 0444 9382Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Patrick J. Morrison
- grid.4777.30000 0004 0374 7521Regional Medical Genetics Centre, Belfast HSC Trust, City Hospital Campus, Queen’s University Belfast, Belfast, Northern Ireland UK
| | - Paul James
- grid.1008.90000 0001 2179 088XPeter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010 Australia
| | - Grant Lee
- grid.1008.90000 0001 2179 088XGenomics Platform Group, Centre for Cancer Research, University of Melbourne, Parkville, VIC Australia
| | - Rakefet Chen-Shtoyerman
- The Biology Department, Ariel University, Ariel and the Oncogenetic Clinic, The Clinical Genetics Institute, Kaplan Medical Center, Rehovot, Israel
| | - Ravindran Ankathil
- grid.11875.3a0000 0001 2294 3534Human Genome Centre, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan Malaysia
| | - Rish Pai
- grid.417468.80000 0000 8875 6339Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, AZ 85259 USA
| | - Robyn Ward
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, University of Sydney, Sydney, NSW 2006 Australia
| | - Susan Parry
- New Zealand Familial Gastrointestinal Cancer Service, Auckland, New Zealand
| | - Tadeusz Dębniak
- grid.107950.a0000 0001 1411 4349Department of Genetics and Pathology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Thomas John
- grid.1055.10000000403978434Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria Australia
| | - Thomas van Overeem Hansen
- grid.4973.90000 0004 0646 7373Department of Clinical Genetics, Rigshospitalet, Copenhagen University Hospital, DK-2100 Copenhagen, Denmark
| | - Trinidad Caldés
- grid.411068.a0000 0001 0671 5785Molecular Oncology Laboratory, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Tatsuro Yamaguchi
- grid.415479.aDepartment of Clinical Genetics, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Verónica Barca-Tierno
- grid.411347.40000 0000 9248 5770Department of Genetics, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Pilar Garre
- grid.411068.a0000 0001 0671 5785Molecular Oncology Laboratory, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Giulia Martina Cavestro
- grid.15496.3f0000 0001 0439 0892Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan, Italy
| | - Jürgen Weitz
- grid.4488.00000 0001 2111 7257Technische Universität Dresden, Dresden, Germany
| | - Silke Redler
- grid.14778.3d0000 0000 8922 7789Institute of Human Genetics, University Clinic Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Reinhard Büttner
- grid.411097.a0000 0000 8852 305XDepartment of Pathology, University Hospital of Cologne, Cologne, Germany
| | - Vincent Heuveline
- grid.7700.00000 0001 2190 4373Engineering Mathematics and Computing Lab (EMCL), Interdisciplinary Center for Scientific Computing (IWR), Heidelberg University, Heidelberg, Germany
| | - John L. Hopper
- grid.1008.90000 0001 2179 088XCentre of Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria 3010 Australia
| | - Aung Ko Win
- grid.1008.90000 0001 2179 088XCentre of Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria 3010 Australia
| | - Noralane Lindor
- grid.417468.80000 0000 8875 6339Department of Health Science Research, Mayo Clinic Arizona, Phoenix, USA
| | - Steven Gallinger
- grid.17063.330000 0001 2157 2938Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Loïc Le Marchand
- grid.410445.00000 0001 2188 0957University of Hawaii Cancer Center, Honolulu, USA
| | - Polly A. Newcomb
- grid.270240.30000 0001 2180 1622Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024 USA
| | - Jane Figueiredo
- grid.270240.30000 0001 2180 1622Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024 USA
| | - Daniel D. Buchanan
- grid.1008.90000 0001 2179 088XColorectal Oncogenomics Group, Department of Clinical Pathology, The University of Melbourne, Parkville, Victoria Australia ,grid.1008.90000 0001 2179 088XUniversity of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria Australia ,grid.416153.40000 0004 0624 1200Genomic Medicine and Family Cancer Clinic, Royal Melbourne Hospital, Parkville, Victoria Australia
| | - Stephen N. Thibodeau
- grid.66875.3a0000 0004 0459 167XDepartment of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905 USA
| | - Sanne W. ten Broeke
- grid.10419.3d0000000089452978Leids Universitair Medisch Centrum, Leiden, Netherlands
| | - Eivind Hovig
- grid.55325.340000 0004 0389 8485Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, 0379 Oslo, Norway ,grid.5510.10000 0004 1936 8921Department of Informatics, Centre for Bioinformatics, University of Oslo, Oslo, Norway
| | - Sigve Nakken
- grid.55325.340000 0004 0389 8485Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, 0379 Oslo, Norway ,grid.5510.10000 0004 1936 8921Centre for Cancer Cell Reprogramming (CanCell), Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Marta Pineda
- grid.417656.7Hereditary Cancer Program, Institut Català d’Oncologia-IDIBELL, L; Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Nuria Dueñas
- grid.417656.7Hereditary Cancer Program, Institut Català d’Oncologia-IDIBELL, L; Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Joan Brunet
- grid.417656.7Hereditary Cancer Program, Institut Català d’Oncologia-IDIBELL, L; Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Kate Green
- grid.5379.80000000121662407Division of Evolution and Genomic Sciences, Manchester Centre for Genomic Medicine, University of Manchester, Manchester University NHS Foundation Trust, Manchester, M13 9WL UK
| | - Fiona Lalloo
- grid.5379.80000000121662407Division of Evolution and Genomic Sciences, Manchester Centre for Genomic Medicine, University of Manchester, Manchester University NHS Foundation Trust, Manchester, M13 9WL UK
| | - Katie Newton
- grid.498924.a0000 0004 0430 9101Department of Surgery, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Emma J. Crosbie
- grid.498924.a0000 0004 0430 9101Gynaecological Oncology Research Group, Manchester University NHS Foundation Trust, Manchester, UK ,grid.5379.80000000121662407Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Miriam Mints
- grid.24381.3c0000 0000 9241 5705Division of Obstetrics and Gyneacology, Department of Women’s and Children’s Health, Karolinska Institutet, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Douglas Tjandra
- grid.416153.40000 0004 0624 1200Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Australia ,grid.1008.90000 0001 2179 088XDepartment of Medicine, Melbourne University, Melbourne, Australia
| | - Florencia Neffa
- Hospital Fuerzas Armadas, Grupo Colaborativo Uruguayo, Investigación de Afecciones Oncológicas Hereditarias (GCU), Montevideo, Uruguay
| | - Patricia Esperon
- Hospital Fuerzas Armadas, Grupo Colaborativo Uruguayo, Investigación de Afecciones Oncológicas Hereditarias (GCU), Montevideo, Uruguay
| | - Revital Kariv
- grid.12136.370000 0004 1937 0546Department of Gastroenterology, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Guy Rosner
- grid.12136.370000 0004 1937 0546Department of Gastroenterology, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Walter Hernán Pavicic
- grid.414775.40000 0001 2319 4408Hereditary Cancer Program (PROCANHE), Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina ,grid.414775.40000 0001 2319 4408Instituto de Medicina Traslacional e Ingeniería Biomédica (IMTIB), Hospital Italiano de Buenos Aires-IUHI-CONICET, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
| | - Pablo Kalfayan
- grid.414775.40000 0001 2319 4408Hereditary Cancer Program (PROCANHE), Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
| | - Giovana Tardin Torrezan
- grid.413320.70000 0004 0437 1183Genomic and Molecular Biology Group, A.C.Camargo Cancer Center, Sao Paulo, Brazil
| | - Thiago Bassaneze
- grid.413471.40000 0000 9080 8521Hospital Sirio Libanes, Sao Paulo, Brazil
| | - Claudia Martin
- Hospital Universitario Oswaldo Cruz, Universidade de Pernambuco, Hospital de Câncer de Pernambuco, IPON - Instituto de Pesquisas Oncológicas do Nordeste, Salvador, Brazil
| | - Gabriela Moslein
- grid.412581.b0000 0000 9024 6397Surgical Center for Hereditary Tumors, Ev. Bethesda Khs Duisburg, University Witten-Herdecke, Herdecke, Germany
| | - Aysel Ahadova
- grid.5253.10000 0001 0328 4908Department of Applied Tumour Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Kloor
- grid.5253.10000 0001 0328 4908Department of Applied Tumour Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Julian R. Sampson
- grid.5600.30000 0001 0807 5670Division of Cancer and Genetics, Institute of Medical Genetics, Cardiff University School of Medicine, Heath Park, Cardiff, CF14 4XN UK
| | - Mark A. Jenkins
- grid.1008.90000 0001 2179 088XCentre of Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria 3010 Australia
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Chen KA, Berginski ME, Desai CS, Guillem JG, Stem J, Gomez Eng SM, Kapadia MR. Differential Performance of Machine Learning Models in Prediction of Procedure-Specific Outcomes. J Gastrointest Surg 2022; 26:1732-1742. [PMID: 35508684 PMCID: PMC9444966 DOI: 10.1007/s11605-022-05332-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/02/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Procedure-specific complications can have devastating consequences. Machine learning-based tools have the potential to outperform traditional statistical modeling in predicting their risk and guiding decision-making. We sought to develop and compare deep neural network (NN) models, a type of machine learning, to logistic regression (LR) for predicting anastomotic leak after colectomy, bile leak after hepatectomy, and pancreatic fistula after pancreaticoduodenectomy (PD). METHODS The colectomy, hepatectomy, and PD National Surgical Quality Improvement Program (NSQIP) databases were analyzed. Each dataset was split into training, validation, and testing sets in a 60/20/20 ratio, with fivefold cross-validation. Models were created using NN and LR for each outcome. Models were evaluated primarily with area under the receiver operating characteristic curve (AUROC). RESULTS A total of 197,488 patients were included for colectomy, 25,403 for hepatectomy, and 23,333 for PD. For anastomotic leak, AUROC for NN was 0.676 (95% 0.666-0.687), compared with 0.633 (95% CI 0.620-0.647) for LR. For bile leak, AUROC for NN was 0.750 (95% CI 0.739-0.761), compared with 0.722 (95% CI 0.698-0.746) for LR. For pancreatic fistula, AUROC for NN was 0.746 (95% CI 0.733-0.760), compared with 0.713 (95% CI 0.703-0.723) for LR. Variables related to intra-operative information, such as surgical approach, biliary reconstruction, and pancreatic gland texture were highly important for model predictions. DISCUSSION Machine learning showed a marginal advantage over traditional statistical techniques in predicting procedure-specific outcomes. However, models that included intra-operative information performed better than those that did not, suggesting that NSQIP procedure-targeted datasets may be strengthened by including relevant intra-operative information.
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Affiliation(s)
- Kevin A Chen
- Department of Surgery, University of North Carolina, Chapel Hill, NC, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC 27599
| | - Matthew E Berginski
- Department of Pharmacology, University of North Carolina, Chapel Hill, NC, 120 Mason Farm Rd, Genetic Medicine Building, Chapel Hill, NC 27599
| | - Chirag S Desai
- Department of Surgery, University of North Carolina, Chapel Hill, NC, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC 27599
| | - Jose G Guillem
- Department of Surgery, University of North Carolina, Chapel Hill, NC, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC 27599
| | - Jonathan Stem
- Department of Surgery, University of North Carolina, Chapel Hill, NC, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC 27599
| | - Shawn M Gomez Eng
- Department of Pharmacology, University of North Carolina, Chapel Hill, NC, 120 Mason Farm Rd, Genetic Medicine Building, Chapel Hill, NC 27599,Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill, NC, 10202C Mary Ellen Jones Building, Chapel Hill, NC, 27599
| | - Muneera R Kapadia
- Department of Surgery, University of North Carolina, Chapel Hill, NC, 100 Manning Drive, Burnett Womack Building, Suite 4038, Chapel Hill, NC 27599
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15
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Kim JK, Marco MR, Roxburgh CSD, Chen CT, Cercek A, Strombom P, Temple LKF, Nash GM, Guillem JG, Paty PB, Yaeger R, Stadler ZK, Gonen M, Segal NH, Reidy DL, Varghese A, Shia J, Vakiani E, Wu AJ, Romesser PB, Crane CH, Gollub MJ, Saltz L, Smith JJ, Weiser MR, Patil S, Garcia-Aguilar J. Survival After Induction Chemotherapy and Chemoradiation Versus Chemoradiation and Adjuvant Chemotherapy for Locally Advanced Rectal Cancer. Oncologist 2022; 27:380-388. [PMID: 35278070 PMCID: PMC9074984 DOI: 10.1093/oncolo/oyac025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 12/07/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Total neoadjuvant therapy (TNT) improves tumor response in locally advanced rectal cancer (LARC) patients compared to neoadjuvant chemoradiotherapy alone. The effect of TNT on patient survival has not been fully investigated. MATERIALS AND METHODS This was a retrospective case series of patients with LARC at a comprehensive cancer center. Three hundred and eleven patients received chemoradiotherapy (chemoRT) as the sole neoadjuvant treatment and planned adjuvant chemotherapy, and 313 received TNT (induction fluorouracil and oxaliplatin-based chemotherapy followed by chemoradiotherapy in the neoadjuvant setting). These patients then underwent total mesorectal excision or were entered in a watch-and-wait protocol. The proportion of patients with complete response (CR) after neoadjuvant therapy (defined as pathological CR or clinical CR sustained for 2 years) was compared by the χ2 test. Disease-free survival (DFS), local recurrence-free survival, distant metastasis-free survival, and overall survival were assessed by Kaplan-Meier analysis and log-rank test. Cox regression models were used to further evaluate DFS. RESULTS The rate of CR was 20% for chemoRT and 27% for TNT (P=.05). DFS, local recurrence-free survival, metastasis-free survival, and overall survival were no different. Disease-free survival was not associated with the type of neoadjuvant treatment (hazard ratio [HR] 1.3; 95% confidence interval [CI] 0.93-1.80; P = .12). CONCLUSIONS Although TNT does not prolong survival than neoadjuvant chemoradiotherapy plus intended postoperative chemotherapy, the higher response rate associated with TNT may create opportunities to preserve the rectum in more patients with LARC.
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Affiliation(s)
- Jin K Kim
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael R Marco
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Chin-Tung Chen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul Strombom
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Larissa K F Temple
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Garrett M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jose G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip B Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rona Yaeger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zsofia K Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neil H Segal
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Diane L Reidy
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anna Varghese
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jinru Shia
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Efsevia Vakiani
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul B Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Leonard Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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16
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Kim JK, Thompson H, Jimenez-Rodriguez RM, Wu F, Sanchez-Vega F, Nash GM, Guillem JG, Paty PB, Wei IH, Pappou EP, Widmar M, Weiser MR, Smith JJ, Garcia-Aguilar J. Adoption of Organ Preservation and Surgeon Variability for Patients with Rectal Cancer Does Not Correlate with Worse Survival. Ann Surg Oncol 2022; 29:1172-1179. [PMID: 34601641 PMCID: PMC8727510 DOI: 10.1245/s10434-021-10877-3] [Citation(s) in RCA: 2] [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: 05/05/2021] [Accepted: 09/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Watch-and-wait is variably adopted by surgeons and the impact of this on outcomes is unknown. We compared the disease-free survival and organ preservation rates of locally advanced rectal cancer patients treated by expert colorectal surgeons at a comprehensive cancer center. METHODS This study included retrospective data on patients diagnosed with stage II/III rectal adenocarcinoma from January 2013 to June 2017 who initiated neoadjuvant therapy (either with chemoradiation, chemotherapy, or a combination of both) and were treated by an expert colorectal surgeon. RESULTS Overall, 444 locally advanced rectal cancer patients managed by five surgeons were included. Tumor distance from the anal verge, type of neoadjuvant therapy, and organ preservation rates varied by treating surgeon. There was no difference in disease-free survival after stratifying by the treating surgeon (p = 0.2). On multivariable analysis, neither the type of neoadjuvant therapy nor the treating surgeon was associated with disease-free survival. CONCLUSIONS While neoadjuvant therapy type and organ preservation rates varied among surgeons, there were no meaningful differences in disease-free survival. These data suggest that among expert colorectal surgeons, differing thresholds for selecting patients for watch-and-wait do not affect survival.
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Affiliation(s)
- Jin K. Kim
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Hannah Thompson
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Fan Wu
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Francisco Sanchez-Vega
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Garrett M. Nash
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Jose G. Guillem
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Philip B. Paty
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Iris H. Wei
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Emmanouil P. Pappou
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Maria Widmar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Martin R. Weiser
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - J. Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
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17
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Jimenez-Rodriguez RM, Flynn J, Patil S, Widmar M, Quezada-Diaz F, Lynn P, Strombom P, Temple L, Smith JJ, Wei IH, Pappou EP, Guillem JG, Paty PB, Nash GM, Weiser MR, Garcia-Aguilar J. Erratum to: Comparing outcomes of robotic versus open mesorectal excision for rectal cancer. BJS Open 2022; 6:6526453. [PMID: 35143633 PMCID: PMC8830748 DOI: 10.1093/bjsopen/zrac021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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18
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Jimenez-Rodriguez RM, Flynn J, Patil S, Widmar M, Quezada-Diaz F, Lynn P, Strombom P, Temple L, Smith JJ, Wei IH, Pappou EP, Guillem JG, Paty PP, Nash GM, Weiser MR, Garcia-Aguilar J. Comparing outcomes of robotic versus open mesorectal excision for rectal cancer. BJS Open 2021; 5:6510901. [PMID: 35040943 PMCID: PMC8765333 DOI: 10.1093/bjsopen/zrab135] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/23/2021] [Indexed: 12/17/2022] Open
Abstract
Background The outcomes of robot-assisted mesorectal excision for rectal cancer, compared with open resection, have not been fully characterized. Methods A retrospective analysis of pathologic, short-term, and long-term outcomes in patients with rectal adenocarcinoma who underwent total or tumour-specific mesorectal excision at a high-volume cancer centre between 2008 and 2017 was conducted. Outcomes after robotic and open surgery were compared on an intention-to-treat basis. Results Out of 1048 resections performed, 1018 patients were reviewed, with 638 who underwent robotic surgery and 380 open surgery. Robotic surgery was converted to the open approach in 17 (2.7 per cent) patients. Patients who underwent robotic surgery were younger (median 54 (range 22–91) years versus median 58 (range 18–97) years; P < 0.001), had higher tumours (median 80 (range 0–150) mm from the anal verge versus median 70 (0–150) mm; P = 0.001), and were less likely to have received neoadjuvant therapy (64 per cent versus 73 per cent; P = 0.003). For patients who underwent a robotic total mesorectal excision, the operating time was longer (median 283.5 (range 117–712) min versus median 249 (range 70–661) min; P < 0.001). However, the rate of complications was lower (29 per cent versus 45 per cent; P < 0.001) and length of hospital stay was shorter (median 5 (range 1–32) days versus median 7 (range 0–137) days; P < 0.001). Median follow-up of survivors was 2.9 years. The proportion of patients with a positive circumferential resection margin did not differ between the groups, nor did the rate of local recurrence (robotic versus open: 3.7 per cent, 95 per cent c.i. 1.9 to 5.6 versus 2.8 per cent, 95 per cent c.i. 1.0 to 4.6; P = 0.400), systemic recurrence (robotic versus open: 11.7 per cent, 95 per cent c.i. 8.5 to 14.8 versus 13.0 per cent, 95 per cent c.i. 9.2 to 16.5; P = 0.300), or overall survival (robotic versus open: 97.8 per cent, 95 per cent c.i. 96.3 to 99.3 versus 93.5 per cent, 95 per cent c.i. 90.8 to 96.2; P = 0.050). The same results were documented in a subanalysis of 370 matched patients, including 185 who underwent robotic surgery and 185 open surgery, for the overall incidence of any postoperative complications, overall survival, disease-free survival, local recurrence, and systemic recurrence. Conclusion In patients with rectal cancer who are candidates for curative resection, robotic mesorectal excision is associated with lower complication rates, shorter length of stay, and equivalent oncologic outcomes, compared with open mesorectal excision.
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Affiliation(s)
| | - Jessica Flynn
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sujata Patil
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Maria Widmar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Felipe Quezada-Diaz
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Patricio Lynn
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Paul Strombom
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Larissa Temple
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joshua J Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Iris H Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Emmanouil P Pappou
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jose G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Philip P Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Garrett M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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19
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Kim JK, Thompson H, Jimenez-Rodriguez RM, Wu F, Sanchez-Vega F, Nash GM, Guillem JG, Paty PB, Wei IH, Pappou EP, Widmar M, Weiser MR, Smith JJ, Garcia-Aguilar J. ASO Visual Abstract: Adoption of Organ Preservation and Surgeon Variability for Patients with Rectal Cancer Does Not Correlate with Worse Survival. Ann Surg Oncol 2021. [PMID: 34716517 DOI: 10.1245/s10434-021-10940-z] [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)
- Jin K Kim
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Colorectal Service, New York, USA
| | - Hannah Thompson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Colorectal Service, New York, USA
| | - Rosa M Jimenez-Rodriguez
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Colorectal Service, New York, USA
| | - Fan Wu
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Colorectal Service, New York, USA
| | - Francisco Sanchez-Vega
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Colorectal Service, New York, USA.,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Garrett M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Colorectal Service, New York, USA
| | - Jose G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Colorectal Service, New York, USA
| | - Philip B Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Colorectal Service, New York, USA
| | - Iris H Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Colorectal Service, New York, USA
| | - Emmanouil P Pappou
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Colorectal Service, New York, USA
| | - Maria Widmar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Colorectal Service, New York, USA
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Colorectal Service, New York, USA
| | - J Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Colorectal Service, New York, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Colorectal Service, New York, USA.
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20
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Tan WJ, Patil S, Guillem JG, Paty PB, Weiser MR, Nash GM, Smith JJ, Pappou EP, Wei IH, Garcia-Aguilar J. Primary Tumor-Related Complications and Salvage Outcomes in Patients with Metastatic Rectal Cancer and an Untreated Primary Tumor. Dis Colon Rectum 2021; 64:45-52. [PMID: 33306531 PMCID: PMC7931667 DOI: 10.1097/dcr.0000000000001803] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND For rectal cancer with unresectable metastases, current practice favors omitting interventions directed at the primary tumor in asymptomatic patients. OBJECTIVE This study aimed to determine the proportion of patients with primary tumor-related complications, characterize salvage outcomes, and measure survival in patients with metastatic rectal cancer who did not undergo upfront intervention for their primary tumor. DESIGN This is a retrospective analysis. SETTING This study was conducted at a comprehensive cancer center. PATIENTS Patients who presented between January 1, 2008, and December 31, 2015, with synchronous stage IV rectal cancer, an unresected primary tumor, and no prior primary tumor-directed intervention were selected. MAIN OUTCOME MEASURES The main outcome measured was the rate of primary tumor-related complications in the cohort that did not receive any primary tumor-directed intervention. The Kaplan-Meier method and Cox regression analysis were used to determine whether complications are associated with survival. RESULTS The cohort comprised 358 patients with a median age of 56 years (22-92). Median follow-up was 26 months (range, 1-93 months). Among the 168 patients (46.9%) who eventually underwent elective resection of the primary tumor, the surgery was performed with curative intent in 66 patients (18.4%) and preemptive intent in 102 patients (28.5%). Of the 190 patients who did not undergo an upfront or elective intervention for the primary tumor, 68 (35.8%) experienced complications. Nonsurgical intervention for complications was attempted in 34 patients with an overall success rate of 61.8% (21/34). Surgical intervention was performed in 47 patients (including 13 patients for whom nonsurgical intervention failed): diversion in 26 patients and resection in 21 patients. Of those 47 patients, 42 (89.4%) ended up with a colostomy or ileostomy. LIMITATIONS This study was conducted at a single center. CONCLUSION A significant proportion of patients with metastatic rectal cancer and untreated primary tumor experience primary tumor-related complications. These patients should be followed closely, and preemptive intervention (resection, diversion, or radiation) should be considered if the primary tumor progresses despite systemic therapy. See Video Abstract at http://links.lww.com/DCR/B400. COMPLICACIONES RELACIONADAS CON EL TUMOR PRIMARIO Y RESULTADOS DE RESCATE EN PACIENTES CON CÁNCER DE RECTO METASTÁSICO Y UN TUMOR PRIMARIO NO TRATADO: Para el cáncer de recto con metástasis no resecables, la práctica actual favorece la omisión de las intervenciones dirigidas al tumor primario en pacientes asintomáticos.Determinar la proporción de pacientes con complicaciones relacionadas con el tumor primario, caracterizar los resultados de rescate y medir la supervivencia en pacientes con cáncer rectal metastásico que no se sometieron a una intervención inicial para su tumor primario.Análisis retrospectivo.Centro oncológico integral.Pacientes que se presentaron entre el 1 de enero de 2008 y el 31 de diciembre de 2015 con cáncer de recto en estadio IV sincrónico, un tumor primario no resecado y sin intervención previa dirigida al tumor primario.Tasa de complicaciones relacionadas con el tumor primario en la cohorte que no recibió ninguna intervención dirigida al tumor primario. Se utilizó el método de Kaplan-Meier y el análisis de regresión de Cox para determinar si las complicaciones están asociadas con la supervivencia.La cohorte estuvo compuesta por 358 pacientes con una mediana de edad de 56 años (22-92). La mediana de seguimiento fue de 26 meses (rango, 1 a 93 meses). Entre los 168 pacientes (46,9%) que finalmente se sometieron a resección electiva del tumor primario, la cirugía se realizó con intención curativa en 66 pacientes (18,4%) y con intención preventiva en 102 pacientes (28,5%). De los 190 pacientes que no se sometieron a una intervención inicial o electiva para el tumor primario, 68 (35,8%) experimentaron complicaciones. Se intentó una intervención no quirúrgica para las complicaciones en 34 pacientes con una tasa de éxito global del 61,8% (21 de 34). La intervención quirúrgica se realizó en 47 pacientes (incluidos 13 pacientes en los que falló la intervención no quirúrgica): derivación en 26 pacientes y resección en 21 pacientes. De esos 47 pacientes, 42 (89,4%) terminaron con una colostomía o ileostomía.Único centro.Una proporción significativa de pacientes con cáncer de recto metastásico y primario no tratado experimentan complicaciones relacionadas con el tumor primario. Se debe hacer un seguimiento estrecho de estos pacientes y considerar la posibilidad de una intervención preventiva (resección, derivación o radiación) si el tumor primario progresa a pesar de la terapia sistémica. Consulte Video Resumen en http://links.lww.com/DCR/B400.
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Affiliation(s)
- Winson J. Tan
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of General Surgery, Sengkang General Hospital, Singapore
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jose G. Guillem
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Philip B. Paty
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Martin R. Weiser
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Garrett M. Nash
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - J. Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emmanouil P. Pappou
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Iris H. Wei
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
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21
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Affiliation(s)
- Jose G. Guillem
- Department of Surgery, UNC School of Medicine, Chapel Hill, North Carolina
| | - Raul Cutait
- Department of Surgery, University of São Paulo, São Paulo, Brazil
| | - Fehza Remzi
- Department of Surgery, NYU Grossman School of Medicine, New York, New York
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22
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Wei IH, Pappou EP, Smith JJ, Widmar M, Nash GM, Weiser MR, Paty PB, Guillem JG, Afonso A, Garcia-Aguilar J. Monitoring an Ongoing Enhanced Recovery After Surgery (ERAS) Program: Adherence Improves Clinical Outcomes in a Comparison of Three Thousand Colorectal Cases. Clin Surg 2020; 5:2909. [PMID: 33163851 PMCID: PMC7643765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
AIM In 2014, Memorial Sloan Kettering Cancer Center was identified as an outlier for increased length of stay (LOS) after colorectal surgery. We subsequently implemented a comprehensive Enhanced Recovery After Surgery (ERAS) program in January 2016, which is continually monitored to target areas for improvement. The primary aim of this study was to evaluate the impact of a newly established ERAS program in a high-volume colorectal center over time. METHOD This was a retrospective cohort study, comparing 3000 sequential cancer patients who underwent elective colorectal surgery before and after ERAS implementation. Patients were divided into three groups (Pre-, Early, and Late ERAS). Adherence to ERAS process measures and outcomes (LOS, complications, and 30-day readmission) were compared among the three time periods. RESULTS Adherence to ERAS metrics significantly increased over time, from a median of 25% Pre-ERAS to 67% Early and 75% Late ERAS (p < 0.0001). Mean LOS decreased from 5.2 days Pre-ERAS to 4.5 Early and 4.0 Late ERAS (p < 0.0001). There were no differences in rates of complications or readmissions, and patients with shorter LOS had lower readmission rates. With ERAS, the readmission rate was 4.4% for patients discharged within 3 days, versus >10% for LOS ≥5 days (p < 0.0001). CONCLUSION Initiation of an ERAS program at a high-volume colorectal center was associated with decreased LOS, without increasing morbidity. Increased ERAS adherence was associated with a further decrease in LOS. Multidisciplinary monitoring to promote protocol adherence is necessary for maintaining a safe and effective ERAS program.
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Affiliation(s)
- Iris H. Wei
- Department of Surgery, Memorial Sloan Kettering Cancer
Center, New York, NY
| | | | - J. Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer
Center, New York, NY
| | - Maria Widmar
- Department of Surgery, Memorial Sloan Kettering Cancer
Center, New York, NY
| | - Garrett M. Nash
- Department of Surgery, Memorial Sloan Kettering Cancer
Center, New York, NY
| | - Martin R. Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer
Center, New York, NY
| | - Philip B. Paty
- Department of Surgery, Memorial Sloan Kettering Cancer
Center, New York, NY
| | - Jose G. Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer
Center, New York, NY
| | - Anoushka Afonso
- Department of Anesthesiology, Memorial Sloan
Kettering Cancer Center, New York, NY
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23
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Quezada-Diaz FF, Hameed I, von Mueffling A, Salo-Mullen EE, Catalano JD, Smith JJ, Weiser MR, Garcia-Aguilar J, Stadler ZK, Guillem JG. Risk of Metachronous Colorectal Neoplasm after a Segmental Colectomy in Lynch Syndrome Patients According to Mismatch Repair Gene Status. J Am Coll Surg 2020; 230:669-675. [PMID: 32007537 DOI: 10.1016/j.jamcollsurg.2020.01.005] [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: 12/16/2019] [Accepted: 01/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Because of increased risk of metachronous colorectal cancer (CRC), all patients with Lynch syndrome (LS) are offered a total colectomy. However, because metachronous CRC rate by mismatch repair (MMR) gene is uncertain, and total colectomy negatively impacts quality of life, it remains unclear whether segmental resection is indicated for lower penetrance MMR genes. We evaluated metachronous CRC incidence according to MMR gene in LS patients who underwent a segmental colectomy. STUDY DESIGN Single-center, retrospective cohort study in patients with an earlier colectomy for CRC and an MMR germline mutation in MLH1, MSH2, MSH6, or PMS2 followed prospectively in a hereditary CRC family registry. All patients underwent surveillance colonoscopy. Metachronous CRC was defined as one detected more than 1 year after index resection. Primary end point was cumulative incidence of metachronous CRC overall and by MMR gene. RESULTS One hundred and ten patients were included: 35 with MLH1 likely pathogenic/pathogenic (LP/P) variants (32%), 42 MSH2 (38%), 20 MSH6 (18%), and 13 PMS2 (12%). Median follow-up 4.26 years (range 0.53 to 19.92 years). Overall, metachronous CRC developed in 22 patients (20%). At 10-year follow-up, incidence was 12% (95% CI 6% to 23%), with no metachronous CRC detected in patients with a PMS2 or MSH6 LP/P variant. CONCLUSIONS After index segmental resection, metachronous CRC is less likely to develop in LS patients with MSH6 or PMS2 LP/P variant than in MLH1 or MSH2 carriers. Our data support segmental resection and long-term colonoscopic surveillance rather than total colectomy in carefully selected, well-informed LS patients with MSH6 or PMS2 LP/P variant.
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Affiliation(s)
- Felipe F Quezada-Diaz
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Irbaz Hameed
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexa von Mueffling
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Erin E Salo-Mullen
- Clinical Genetics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John D Catalano
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Martin R Weiser
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zsofia K Stadler
- Clinical Genetics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jose G Guillem
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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24
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Ganesh K, Wu C, O'Rourke KP, Szeglin BC, Zheng Y, Sauvé CEG, Adileh M, Wasserman I, Marco MR, Kim AS, Shady M, Sanchez-Vega F, Karthaus WR, Won HH, Choi SH, Pelossof R, Barlas A, Ntiamoah P, Pappou E, Elghouayel A, Strong JS, Chen CT, Harris JW, Weiser MR, Nash GM, Guillem JG, Wei IH, Kolesnick RN, Veeraraghavan H, Ortiz EJ, Petkovska I, Cercek A, Manova-Todorova KO, Saltz LB, Lavery JA, DeMatteo RP, Massagué J, Paty PB, Yaeger R, Chen X, Patil S, Clevers H, Berger MF, Lowe SW, Shia J, Romesser PB, Dow LE, Garcia-Aguilar J, Sawyers CL, Smith JJ. A rectal cancer organoid platform to study individual responses to chemoradiation. Nat Med 2019; 25:1607-1614. [PMID: 31591597 PMCID: PMC7385919 DOI: 10.1038/s41591-019-0584-2] [Citation(s) in RCA: 278] [Impact Index Per Article: 55.6] [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: 12/03/2018] [Accepted: 08/15/2019] [Indexed: 12/22/2022]
Abstract
Rectal cancer (RC) is a challenging disease to treat that requires chemotherapy, radiation and surgery to optimize outcomes for individual patients. No accurate model of RC exists to answer fundamental research questions relevant to patients. We established a biorepository of 65 patient-derived RC organoid cultures (tumoroids) from patients with primary, metastatic or recurrent disease. RC tumoroids retained molecular features of the tumors from which they were derived, and their ex vivo responses to clinically relevant chemotherapy and radiation treatment correlated with the clinical responses noted in individual patients' tumors. Upon engraftment into murine rectal mucosa, human RC tumoroids gave rise to invasive RC followed by metastasis to lung and liver. Importantly, engrafted tumors displayed the heterogenous sensitivity to chemotherapy observed clinically. Thus, the biology and drug sensitivity of RC clinical isolates can be efficiently interrogated using an organoid-based, ex vivo platform coupled with in vivo endoluminal propagation in animals.
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Affiliation(s)
- Karuna Ganesh
- Molecular Pharmacology Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Chao Wu
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kevin P O'Rourke
- Cancer Biology and Genetics Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine/Rockefeller University/Sloan Kettering Tri-Institutional MD-PhD Program, New York, NY, USA
| | - Bryan C Szeglin
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Youyun Zheng
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Mohammad Adileh
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Isaac Wasserman
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael R Marco
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amanda S Kim
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maha Shady
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Francisco Sanchez-Vega
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Computational Oncology Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Wouter R Karthaus
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Helen H Won
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Seo-Hyun Choi
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Raphael Pelossof
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Afsar Barlas
- Molecular Cytology Core Facility, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter Ntiamoah
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emmanouil Pappou
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Arthur Elghouayel
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James S Strong
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Chin-Tung Chen
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jennifer W Harris
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin R Weiser
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Garrett M Nash
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jose G Guillem
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Iris H Wei
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard N Kolesnick
- Molecular Pharmacology Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Harini Veeraraghavan
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eduardo J Ortiz
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Iva Petkovska
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea Cercek
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Leonard B Saltz
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jessica A Lavery
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ronald P DeMatteo
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joan Massagué
- Cancer Biology and Genetics Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip B Paty
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rona Yaeger
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Xi Chen
- Department of Public Health Sciences, Sylvestor Comprehensive Cancer Center, Miami, FL, USA
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hans Clevers
- Hubrecht Institute, Royal Netherlands Academy of Arts and Sciences, University of Medical Center, Utrecht, The Netherlands
| | - Michael F Berger
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Scott W Lowe
- Cancer Biology and Genetics Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jinru Shia
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Gastrointestinal Pathology, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul B Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lukas E Dow
- Sandra and Edward Meyer Cancer Center, Departments of Medicine and Biochemistry, Weill Cornell Medicine, Weill Cornell Graduate School of Medical Sciences, New York, NY, USA
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles L Sawyers
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - J Joshua Smith
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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25
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Roxburgh CSD, Strombom P, Lynn P, Cercek A, Gonen M, Smith JJ, Temple LKF, Nash GM, Guillem JG, Paty PB, Shia J, Vakiani E, Yaeger R, Stadler ZK, Segal NH, Reidy D, Varghese A, Wu AJ, Crane CH, Gollub MJ, Saltz LB, Garcia-Aguilar J, Weiser MR. Changes in the multidisciplinary management of rectal cancer from 2009 to 2015 and associated improvements in short-term outcomes. Colorectal Dis 2019; 21:1140-1150. [PMID: 31108012 PMCID: PMC6773478 DOI: 10.1111/codi.14713] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/16/2019] [Indexed: 12/13/2022]
Abstract
AIM Significant recent changes in management of locally advanced rectal cancer (LARC) include preoperative staging, use of extended neoadjuvant therapies and minimally invasive surgery (MIS). This study was aimed at characterizing these changes and associated short-term outcomes. METHOD We retrospectively analysed treatment and outcome data from patients with T3/4 or N+ LARC ≤ 15 cm from the anal verge who were evaluated at a comprehensive cancer centre in 2009-2015. RESULTS In total, 798 patients were identified and grouped into five cohorts based on treatment year: 2009-2010, 2011, 2012, 2013 and 2014-2015. Temporal changes included increased reliance on MRI staging, from 57% in 2009-2010 to 98% in 2014-2015 (P < 0.001); increased use of total neoadjuvant therapy, from 17% to 76% (P < 0.001); and increased use of MIS, from 33% to 70% (P < 0.001). Concurrently, median hospital stay decreased (from 7 to 5 days; P < 0.001), as did the rates of Grade III-V complications (from 13% to 7%; P < 0.05), surgical site infections (from 24% to 8%; P < 0.001), anastomotic leak (from 11% to 3%; P < 0.05) and positive circumferential resection margin (from 9% to 4%; P < 0.05). TNM downstaging increased from 62% to 74% (P = 0.002). CONCLUSION Shifts toward MRI-based staging, total neoadjuvant therapy and MIS occurred between 2009 and 2015. Over the same period, treatment responses improved, and lengths of stay and the incidence of complications decreased.
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Affiliation(s)
- C S D Roxburgh
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
- Institute of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - P Strombom
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - P Lynn
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - A Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - M Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - J J Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - L K F Temple
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - G M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - J G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - P B Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - J Shia
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - E Vakiani
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - R Yaeger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Z K Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - N H Segal
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - D Reidy
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - A Varghese
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - A J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - C H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - M J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - L B Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - J Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - M R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
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26
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Strombom P, Widmar M, Keskin M, Gennarelli RL, Lynn P, Smith JJ, Guillem JG, Paty PB, Nash GM, Weiser MR, Garcia-Aguilar J. Assessment of the Value of Comorbidity Indices for Risk Adjustment in Colorectal Surgery Patients. Ann Surg Oncol 2019; 26:2797-2804. [PMID: 31209671 DOI: 10.1245/s10434-019-07502-9] [Citation(s) in RCA: 8] [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] [Received: 09/10/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE Comorbidity indices (CIs) are widely used in retrospective studies. We investigated the value of commonly used CIs in risk adjustment for postoperative complications after colorectal surgery. METHODS Patients undergoing colectomy without stoma for colonic neoplasia at a single institution from 2009 to 2014 were included. Four CIs were calculated or obtained for each patient, using administrative data: Charlson-Deyo (CCI-D), Charlson-Romano (CCI-R), Elixhauser Comorbidity Score, and American Society of Anesthesiologists classification. Outcomes of interest in the 90-day postoperative period were any surgical complication, surgical site infection (SSI), Clavien-Dindo (CD) grade 3 or higher complication, anastomotic leak or abscess, and nonroutine discharge. Base models were created for each outcome based on significant bivariate associations. Logistic regression models were constructed for each outcome using base models alone, and each index as an additional covariate. Models were also compared using the DeLong and Clarke-Pearson method for receiver operating characteristic (ROC) curves, with the CCI-D as the reference. RESULTS Overall, 1813 patients were included. Postoperative complications were reported in 756 (42%) patients. Only 9% of patients had a CD grade 3 or higher complication, and 22.8% of patients developed an SSI. Multivariable modeling showed equivalent performance of the base model and the base model augmented by the CIs for all outcomes. The ROC curves for the four indices were also similar. CONCLUSIONS The inclusion of CIs added little to the base models, and all CIs performed similarly well. Our study suggests that CIs do not adequately risk-adjust for complications after colorectal surgery.
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Affiliation(s)
- Paul Strombom
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria Widmar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Metin Keskin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Renee L Gennarelli
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Patricio Lynn
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jose G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip B Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Garrett M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Smith JJ, Strombom P, Chow OS, Roxburgh CS, Lynn P, Eaton A, Widmar M, Ganesh K, Yaeger R, Cercek A, Weiser MR, Nash GM, Guillem JG, Temple LKF, Chalasani SB, Fuqua JL, Petkovska I, Wu AJ, Reyngold M, Vakiani E, Shia J, Segal NH, Smith JD, Crane C, Gollub MJ, Gonen M, Saltz LB, Garcia-Aguilar J, Paty PB. Assessment of a Watch-and-Wait Strategy for Rectal Cancer in Patients With a Complete Response After Neoadjuvant Therapy. JAMA Oncol 2019; 5:e185896. [PMID: 30629084 DOI: 10.1001/jamaoncol.2018.5896] [Citation(s) in RCA: 300] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance The watch-and-wait (WW) strategy aims to spare patients with rectal cancer unnecessary resection. Objective To analyze the outcomes of WW among patients with rectal cancer who had a clinical complete response to neoadjuvant therapy. Design, Setting, and Participants This retrospective case series analysis conducted at a comprehensive cancer center in New York included patients who received a diagnosis of rectal adenocarcinoma between January 1, 2006, and January 31, 2015. The median follow-up was 43 months. Data analyses were conducted from June 1, 2016, to October 1, 2018. Exposures Patients had a clinical complete response after completing neoadjuvant therapy and agreed to a WW strategy of active surveillance and possible salvage surgery (n = 113), or patients underwent total mesorectal excision and were found to have a pathologic complete response (pCR) at resection (n = 136). Main Outcomes and Measures Kaplan-Meier estimates were used for analyses of local regrowth and 5-year rates of overall survival, disease-free survival, and disease-specific survival. Results Compared with the 136 patients in the pCR group, the 113 patients in the WW group were older (median [range], 67.2 [32.1-90.9] vs 57.3 [25.0-87.9] years, P < .001) with cancers closer to the anal verge (median [range] height from anal verge, 5.5 [0.0-15.0] vs 7.0 [0.0-13.0] cm). All 22 local regrowths in the WW group were detected on routine surveillance and treated by salvage surgery (20 total mesorectal excisions plus 2 transanal excisions). Pelvic control after salvage surgery was maintained in 20 of 22 patients (91%). No pelvic recurrences occurred in the pCR group. Rectal preservation was achieved in 93 of 113 patients (82%) in the WW group (91 patients with no local regrowths plus 2 patients with local regrowths salvaged with transanal excision). At 5 years, overall survival was 73% (95% CI, 60%-89%) in the WW group and 94% (95% CI, 90%-99%) in the pCR group; disease-free survival was 75% (95% CI, 62%-90%) in the WW group and 92% (95% CI, 87%-98%) in the pCR group; and disease-specific survival was 90% (95% CI, 81%-99%) in the WW group and 98% (95% CI, 95%-100%) in the pCR group. A higher rate of distant metastasis was observed among patients in the WW group who had local regrowth vs those who did not have local regrowth (36% vs 1%, P < .001). Conclusions and Relevance A WW strategy for select rectal cancer patients who had a clinical complete response after neoadjuvant therapy resulted in excellent rectal preservation and pelvic tumor control; however, in the WW group, worse survival was noted along with a higher incidence of distant progression in patients with local regrowth vs those without local regrowth.
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Affiliation(s)
- J Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul Strombom
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Oliver S Chow
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Campbell S Roxburgh
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Patricio Lynn
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne Eaton
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria Widmar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karuna Ganesh
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rona Yaeger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Garrett M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jose G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Larissa K F Temple
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sree B Chalasani
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James L Fuqua
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Iva Petkovska
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marsha Reyngold
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Efsevia Vakiani
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jinru Shia
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Neil H Segal
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James D Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mithat Gonen
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Leonard B Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Philip B Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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28
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Roxburgh CSD, Strombom P, Lynn P, Gonen M, Paty PB, Guillem JG, Nash GM, Smith JJ, Wei I, Pappou E, Garcia-Aguilar J, Weiser MR. Role of the Interval from Completion of Neoadjuvant Therapy to Surgery in Postoperative Morbidity in Patients with Locally Advanced Rectal Cancer. Ann Surg Oncol 2019; 26:2019-2027. [PMID: 30963399 DOI: 10.1245/s10434-019-07340-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Increasing the interval from completion of neoadjuvant therapy to surgery beyond 8 weeks is associated with increased response of rectal cancer to neoadjuvant therapy. However, reports are conflicting on whether extending the time to surgery is associated with increased perioperative morbidity. METHODS Patients who presented with a tumor within 15 cm of the anal verge in 2009-2015 were grouped according to the interval between completion of neoadjuvant therapy and surgery: < 8 weeks, 8-12 weeks, and 12-16 weeks. RESULTS Among 607 patients, the surgery was performed at < 8 weeks in 317 patients, 8-12 weeks in 229 patients, and 12-16 weeks in 61 patients. Patients who underwent surgery at 8-12 weeks and patients who underwent surgery at < 8 weeks had comparable rates of complications (37% and 44%, respectively). Univariable analysis identified male sex, earlier date of diagnosis, tumor location within 5 cm of the anal verge, open operative approach, abdominoperineal resection, and use of neoadjuvant chemoradiotherapy alone to be associated with higher rates of complications. In multivariable analysis, male sex, tumor location within 5 cm of the anal verge, open operative approach, and neoadjuvant chemoradiotherapy administered alone were independently associated with the presence of a complication. The interval between neoadjuvant therapy and surgery was not an independent predictor of postoperative complications. CONCLUSIONS Delaying surgery beyond 8 weeks from completion of neoadjuvant therapy does not appear to increase surgical morbidity in rectal cancer patients.
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Affiliation(s)
- Campbell S D Roxburgh
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Institute of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Paul Strombom
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Patricio Lynn
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip B Paty
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jose G Guillem
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Garrett M Nash
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Iris Wei
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emmanouil Pappou
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin R Weiser
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Quezada-Diaz F, Jimenez-Rodriguez RM, Pappou EP, Joshua Smith J, Patil S, Wei I, Guillem JG, Paty PB, Nash GM, Weiser MR, Garcia-Aguilar J. Effect of Neoadjuvant Systemic Chemotherapy With or Without Chemoradiation on Bowel Function in Rectal Cancer Patients Treated With Total Mesorectal Excision. J Gastrointest Surg 2019; 23:800-807. [PMID: 30350191 PMCID: PMC6430650 DOI: 10.1007/s11605-018-4003-7] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 10/05/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiation (CRT) impairs bowel function in patients with rectal cancer treated with total mesorectal excision (TME). The impact of other forms of neoadjuvant therapy such as neoadjuvant chemotherapy alone (NC) and induction chemotherapy followed by CRT (total neoadjuvant therapy or TNT) on postoperative bowel function has not been investigated. METHODS We conducted a retrospective review of 176 rectal cancer patients treated between November 1, 2011, and August 31, 2017. All patients completed the MSKCC Bowel Function Instrument (BFI), a validated bowel function questionnaire, at least 6 months after TME and/or ileostomy reversal. Differences in BFI scores were compared across four groups (surgery alone, CRT, NC, and TNT) and also according to exposure to neoadjuvant RT and neoadjuvant chemotherapy. A multivariable linear regression model was used to evaluate the independent relationship between exposure to neoadjuvant RT or chemotherapy and BFI. RESULTS BFI total scores were significantly different between the four groups (p = 0.008). Exposure to RT correlated with worse BFI total scores (p = 0.002), and no differences were found in BFI total score after exposure to neoadjuvant chemotherapy (p = 0.92). In a linear regression model, only exposure to RT (β = - 5.1; 95% CI - 8.9 to - 1.3; p = 0.008) and tumor distance from the anal verge (β = 1.23; 95% CI 0.48 to 1.97; p = 0.001) were significantly correlated with BFI total score. CONCLUSION NC, whether administered alone or added to CRT, does not seem to impair bowel function. These data should be used to counsel rectal cancer patients when discussing neoadjuvant therapy options.
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Affiliation(s)
- Felipe Quezada-Diaz
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Rosa M. Jimenez-Rodriguez
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Emmanouil P. Pappou
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - J. Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Iris Wei
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Jose G. Guillem
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Philip B. Paty
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Garrett M. Nash
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Martin R. Weiser
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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30
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Tufts LS, Jarnagin ED, Flynn JR, Gonen M, Guillem JG, Paty PB, Nash GM, Smith JJ, Wei IH, Pappou E, D’Angelica MI, Allen PJ, Kingham TP, Balachandran VP, Drebin JA, Garcia-Aguilar J, Jarnagin WR, Weiser MR. A perioperative multidisciplinary care bundle reduces surgical site infections in patients undergoing synchronous colorectal and liver resection. HPB (Oxford) 2019; 21:181-186. [PMID: 30077525 PMCID: PMC6358518 DOI: 10.1016/j.hpb.2018.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/21/2018] [Accepted: 07/04/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) are a major cause of morbidity, mortality, and healthcare costs, and patients undergoing simultaneous colorectal/liver resections are at an especially high SSI risk. METHODS Data were collected on all patients undergoing synchronous colorectal/liver resection from 2011 to 2016 (n = 424). The intervention, implemented in 2013, included 13 multidisciplinary perioperative components. The primary endpoints were superficial/deep and organ space SSIs. Secondary endpoints were hospital length of stay (LOS) and 30-day readmission rate. To control for changes in SSI rates independent of the intervention, interrupted time series analysis was conducted. RESULTS Overall, superficial/deep, and organ space SSIs decreased by 60.5% (p < 0.001), 80.6% (p < 0.001), and 47.6% (p = 0.008), respectively. In the pre-intervention cohort (n = 231), there were 79 (34.2%), 31 (13.4%), and 48 (20.8%) total, superficial/deep, and organs space SSIs, respectively. In the post-intervention cohort (n = 193), there were 26 (13.5%), 5 (2.6%), and 21 (10.9%) total, superficial/deep, and organs space SSIs, respectively. Median LOS decreased from 9 to 8 days (p < 0.001). Readmission rates did not change (p = 0.6). Interrupted time series analysis found no significant trends in SSI rate within the pre-intervention (p = 0.35) and post-intervention (p = 0.55) periods. CONCLUSION In combined colorectal/liver resection patients, implementation of a multidisciplinary care bundle was associated with a 61% reduction in SSIs, with the greatest impact on superficial/deep SSI, and modest reduction in LOS. The absence of trends within each time period indicated that the intervention was likely responsible for SSI reduction. Future efforts should target further reduction in organ space SSI.
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Wasserman I, Lee LH, Ogino S, Marco MR, Wu C, Chen X, Datta J, Sadot E, Szeglin B, Guillem JG, Paty PB, Weiser MR, Nash GM, Saltz L, Barlas A, Manova-Todorova K, Uppada SPB, Elghouayel AE, Ntiamoah P, Glickman JN, Hamada T, Kosumi K, Inamura K, Chan AT, Nishihara R, Cercek A, Ganesh K, Kemeny NE, Dhawan P, Yaeger R, Sawyers CL, Garcia-Aguilar J, Giannakis M, Shia J, Smith JJ. SMAD4 Loss in Colorectal Cancer Patients Correlates with Recurrence, Loss of Immune Infiltrate, and Chemoresistance. Clin Cancer Res 2018; 25:1948-1956. [PMID: 30587545 DOI: 10.1158/1078-0432.ccr-18-1726] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 09/21/2018] [Accepted: 12/18/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE SMAD4 has shown promise in identifying patients with colorectal cancer at high risk of recurrence or death.Experimental Design: A discovery cohort and independent validation cohort were classified by SMAD4 status. SMAD4 status and immune infiltrate measurements were tested for association with recurrence-free survival (RFS). Patient-derived xenografts from SMAD4-deficient and SMAD4-retained tumors were used to examine chemoresistance. RESULTS The discovery cohort consisted of 364 patients with stage I-IV colorectal cancer. Median age at diagnosis was 53 years. The cohort consisted of 61% left-sided tumors and 62% stage II/III patients. Median follow-up was 5.4 years (interquartile range, 2.3-8.2). SMAD4 loss, noted in 13% of tumors, was associated with higher tumor and nodal stage, adjuvant therapy use, fewer tumor-infiltrating lymphocytes (TIL), and lower peritumoral lymphocyte aggregate (PLA) scores (all P < 0.04). SMAD4 loss was associated with worse RFS (P = 0.02). When stratified by SMAD4 and immune infiltrate status, patients with SMAD4 loss and low TIL or PLA had worse RFS (P = 0.002 and P = 0.006, respectively). Among patients receiving 5-fluorouracil (5-FU)-based systemic chemotherapy, those with SMAD4 loss had a median RFS of 3.8 years compared with 13 years for patients with SMAD4 retained. In xenografted mice, the SMAD4-lost tumors displayed resistance to 5-FU. An independent cohort replicated our findings, in particular, the association of SMAD4 loss with decreased immune infiltrate, as well as worse disease-specific survival. CONCLUSIONS Our data show SMAD4 loss correlates with worse clinical outcome, resistance to chemotherapy, and decreased immune infiltrate, supporting its use as a prognostic marker in patients with colorectal cancer.
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Affiliation(s)
- Isaac Wasserman
- Icahn School of Medicine at Mount Sinai, New York, New York.,Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lik Hang Lee
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shuji Ogino
- Department of Oncologic Pathology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts.,Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Michael R Marco
- Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chao Wu
- Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Xi Chen
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Jashodeep Datta
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eran Sadot
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bryan Szeglin
- Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Albert Einstein College of Medicine, New York, New York
| | - Jose G Guillem
- Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Philip B Paty
- Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Martin R Weiser
- Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Garrett M Nash
- Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Leonard Saltz
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Afsar Barlas
- Molecular Cytology Core Facility, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katia Manova-Todorova
- Molecular Cytology Core Facility, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Srijaya Prakash Babu Uppada
- Department of Biochemistry and Molecular Biology, Buffet Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska
| | - Arthur E Elghouayel
- Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York.,College of William and Mary, Williamsburg, Virginia
| | - Peter Ntiamoah
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan N Glickman
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Tsuyoshi Hamada
- Department of Oncologic Pathology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Keisuke Kosumi
- Department of Oncologic Pathology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Kentaro Inamura
- Division of Pathology, The Cancer Institute, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Andrew T Chan
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts.,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Reiko Nishihara
- Department of Oncologic Pathology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts.,Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Andrea Cercek
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karuna Ganesh
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy E Kemeny
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Punita Dhawan
- Department of Biochemistry and Molecular Biology, Buffet Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska
| | - Rona Yaeger
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles L Sawyers
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julio Garcia-Aguilar
- Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marios Giannakis
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jinru Shia
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - J Joshua Smith
- Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York. .,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
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Jimenez-Rodriguez RM, Quezada-Diaz F, Tchack M, Pappou E, Wei IH, Smith JJ, Nash GM, Guillem JG, Paty PB, Weiser MR, Garcia-Aguilar J. Use of the Xi robotic platform for total abdominal colectomy: a step forward in minimally invasive colorectal surgery. Surg Endosc 2018; 33:966-971. [PMID: 30350106 DOI: 10.1007/s00464-018-6529-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 10/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of the da Vinci robotic platform for total colectomy has been limited by the need to reposition the patient-side surgical cart from one side of the patient to the other, which increases operative time. In this study, we examined the feasibility of robotic total colectomy using the da Vinci Xi model, which offers a rotating boom-mounted system and laser-targeted trocar positioning. METHODS The study cohort consisted of 23 patients who underwent minimally invasive total colectomy for cancer or polyposis syndromes at a comprehensive cancer center between 2015 and 2017. Of the 23 colectomies, 15 were robotic and eight were laparoscopic. For the robotic colectomies, trocars were placed in the supraumbilical region and all four quadrants. The da Vinci Xi robot was placed between the patient's legs, and the boom was rotated from left to right and then to the middle in order to work sequentially on the right colon, the left colon, and the pelvis. Operating time and short-term outcomes were compared between the patients who underwent robotic surgery and the patients who underwent laparoscopic surgery. RESULTS The two groups of patients were comparable in age, gender, BMI, physical status, and disease types. In the robotic group, median length of stay (4 vs. 6 days, p = 0.047) was significantly shorter and median operative time (243 vs. 263 min, p = 0.97) and median estimated blood loss (50 vs. 100 ml; p = 0.08) were similar between the groups. CONCLUSIONS With the da Vinci Xi boom-mounted system, total abdominal colectomy can be performed without the need to move the patient-side surgical cart and is associated with shorter length of stay and similar operative time compared to the laparoscopic approach.
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Affiliation(s)
- Rosa M Jimenez-Rodriguez
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Felipe Quezada-Diaz
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Madeline Tchack
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Emmanouil Pappou
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Iris H Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - J Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Garrett M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Jose G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Philip B Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA.
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Weiser MR, Gonen M, Usiak S, Pottinger T, Samedy P, Patel D, Seo S, Smith JJ, Guillem JG, Temple L, Nash GM, Paty PB, Baldwin-Medsker A, Cheavers CE, Eagan J, Garcia-Aguilar J. Effectiveness of a multidisciplinary patient care bundle for reducing surgical-site infections. Br J Surg 2018; 105:1680-1687. [PMID: 29974946 DOI: 10.1002/bjs.10896] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 04/16/2018] [Accepted: 05/03/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Surgical-site infection (SSI) is associated with significant healthcare costs. To reduce the high rate of SSI among patients undergoing colorectal surgery at a cancer centre, a comprehensive care bundle was implemented and its efficacy tested. METHODS A pragmatic study involving three phases (baseline, implementation and sustainability) was conducted on patients treated consecutively between 2013 and 2016. The intervention included 13 components related to: bowel preparation; oral and intravenous antibiotic selection and administration; skin preparation, disinfection and hygiene; maintenance of normothermia during surgery; and use of clean instruments for closure. SSI risk was evaluated by means of a preoperative calculator, and effectiveness was assessed using interrupted time-series regression. RESULTS In a population with a mean BMI of 30 kg/m2 , diabetes mellitus in 17·5 per cent, and smoking history in 49·3 per cent, SSI rates declined from 11·0 to 4·1 per cent following implementation of the intervention bundle (P = 0·001). The greatest reductions in SSI rates occurred in patients at intermediate or high risk of SSI: from 10·3 to 4·7 per cent (P = 0·006) and from 19 to 2 per cent (P < 0·001) respectively. Wound care modifications were very different in the implementation phase (43·2 versus 24·9 per cent baseline), including use of an overlying surface vacuum dressing (17·2 from 1·4 per cent baseline) or leaving wounds partially open (13·2 from 6·7 per cent baseline). As a result, the biggest difference was in wound-related rather than organ-space SSI. The median length of hospital stay decreased from 7 (i.q.r. 5-10) to 6 (5-9) days (P = 0·002). The greatest reduction in hospital stay was seen in patients at high risk of SSI: from 8 to 6 days (P < 0·001). SSI rates remained low (4·5 per cent) in the sustainability phase. CONCLUSION Meaningful reductions in SSI can be achieved by implementing a multidisciplinary care bundle at a hospital-wide level.
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Affiliation(s)
- M R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - S Usiak
- Infection Control Program, Memorial Sloan Kettering Cancer Center, New York, USA
| | - T Pottinger
- Division of Quality and Safety, Memorial Sloan Kettering Cancer Center, New York, USA
| | - P Samedy
- Division of Quality and Safety, Memorial Sloan Kettering Cancer Center, New York, USA
| | - D Patel
- Division of Quality and Safety, Memorial Sloan Kettering Cancer Center, New York, USA
| | - S Seo
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - J J Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - J G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - L Temple
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - G M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - P B Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - A Baldwin-Medsker
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, USA
| | - C E Cheavers
- Division of Quality and Safety, Memorial Sloan Kettering Cancer Center, New York, USA
| | - J Eagan
- Infection Control Program, Memorial Sloan Kettering Cancer Center, New York, USA
| | - J Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
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Cercek A, Roxburgh CSD, Strombom P, Smith JJ, Temple LKF, Nash GM, Guillem JG, Paty PB, Yaeger R, Stadler ZK, Seier K, Gonen M, Segal NH, Reidy DL, Varghese A, Shia J, Vakiani E, Wu AJ, Crane CH, Gollub MJ, Garcia-Aguilar J, Saltz LB, Weiser MR. Adoption of Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer. JAMA Oncol 2018; 4:e180071. [PMID: 29566109 DOI: 10.1001/jamaoncol.2018.0071] [Citation(s) in RCA: 349] [Impact Index Per Article: 58.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Treatment of locally advanced rectal (LARC) cancer involves chemoradiation, surgery, and chemotherapy. The concept of total neoadjuvant therapy (TNT), in which chemoradiation and chemotherapy are administered prior to surgery, has been developed to optimize delivery of effective systemic therapy aimed at micrometastases. Objective To compare the traditional approach of preoperative chemoradiation (chemoRT) followed by postoperative adjuvant chemotherapy with the more recent TNT approach for LARC. Design, Setting, and Participants A retrospective cohort analysis using Memorial Sloan Kettering Cancer Center (MSK) records from 2009 to 2015 was carried out. A total of 811 patients who presented with LARC (T3/4 or node-positive) were identified. Exposures Of the 811 patients, 320 received chemoRT with planned adjuvant chemotherapy and 308 received TNT (induction fluorouracil- and oxaliplatin-based chemotherapy followed by chemoRT). Main Outcomes and Measures Treatment and outcome data for the 2 cohorts were compared. Dosing and completion of prescribed chemotherapy were assessed on the subset of patients who received all therapy at MSK. Results Of the 628 patients overall, 373 (59%) were men and 255 (41%) were women, with a mean (SD) age of 56.7 (12.9) years. Of the 308 patients in the TNT cohort, 181 (49%) were men and 127 (49%) were women. Of the 320 patients in the chemoRT with planned adjuvant chemotherapy cohort, 192 (60%) were men and 128 (40%) were women. Patients in the TNT cohort received greater percentages of the planned oxaliplatin and fluorouracil prescribed dose than those in the chemoRT with planned adjuvant chemotherapy cohort. The complete response (CR) rate, including both pathologic CR (pCR) in those who underwent surgery and sustained clinical CR (cCR) for at least 12 months posttreatment in those who did not undergo surgery, was 36% in the TNT cohort compared with 21% in the chemoRT with planned adjuvant chemotherapy cohort. Conclusions and Relevance Our findings provide additional support for the National Comprehensive Cancer Network (NCCN) guidelines that categorize TNT as a viable treatment strategy for rectal cancer. Our data suggest that TNT facilitates delivery of planned systemic therapy. Long-term follow-up will determine if this finding translates into improved survival. In addition, given its high CR rate, TNT may facilitate nonoperative treatment strategies aimed at organ preservation.
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Affiliation(s)
- Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Campbell S D Roxburgh
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Institute of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, England
| | - Paul Strombom
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - J Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Larissa K F Temple
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Garrett M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jose G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Philip B Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rona Yaeger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zsofia K Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kenneth Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Neil H Segal
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Diane L Reidy
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anna Varghese
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jinru Shia
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York
| | - Efsevia Vakiani
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Leonard B Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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35
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Roxburgh CSD, Strombom P, Lynn PB, Paty P, Guillem JG, Nash GM, Smith JJ, Wei IH, Garcia-Aguilar J, Weiser MR. Influence of timing of surgery on perioperative morbidity after neoadjuvant therapy for locally advanced rectal cancer. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.4_suppl.754] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
754 Background: Timing of surgery following completion of neoadjuvant therapy (NT) for locally advanced rectal cancer (LARC) has important implications for treatment response. However, it was recently reported in the GRECCAR 6 trial that delayed surgery beyond 8 weeks from completion of NT is associated with increased complications. Within a cohort of LARC patients treated with NT (CRT alone, Total NT (TNT) and chemotherapy alone) we examine perioperative complications based on time from NT to surgery. Methods: Patients with Stage II/III LARC ≤15cm from the anal verge who received NT from 06/01/09 – 03/01/15 were identified and preoperative morbidity collected on those undergoing rectal resection. Patients were grouped according to time of surgery from completion of NT (5-8 weeks – early surgery / 8-12 weeks – late surgery). Results: 798 patients were identified and 547 underwent rectal resection within 12 weeks of completing NT (440 LAR and 107 APR). Surgery was performed 5-8 following NT in 252 pts and 8-12 weeks following NT in 246 pts. 204 patients (41%) had a post-op complication: 53 (10%) Grade 3-5 complication and 83 (17%) SSI. There were no statistically significant differences in rates of all complications (44% vs 38%), grade 3-5 complications (9% vs 11%), SSI (17% vs 17%), and LOS (median 6 days vs 6 days) between the early and late surgery groups. Similar results were obtained when evaluating the subgroups by type of NT (CRT alone, chemo alone or TNT), surgical approach (open vs minimally invasive and sphincter preservation vs colostomy), post-treatment TNM stage and year of treatment (all NS). In addition, we did not observe differences in rates of downstaging responses: T downstaging (63% vs 64%), N downstaging (61% vs 54%), > 95% regression (34% vs 34%) or pCR rates (18% vs 18%) between the early and later surgery groups. Conclusions: In patients undergoing radical surgery for LARC post NT, we do not observe an effect of timing of surgery on surgical complications. Although timing of surgery is reported to influence response rates, we did not reproduce these findings, likely as a consequence of the high rate of deferral of surgery/ non-operative management in this cohort.
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Affiliation(s)
| | - Paul Strombom
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Philip Paty
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Iris H Wei
- Memorial Sloan Kettering Cancer Center, New York, NY
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36
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Cavnar MJ, Wang L, Balachandran VP, Antonescu CR, Tap WD, Keohan M, Singer S, Temple L, Nash GM, Weiser MR, Guillem JG, Aguilar JG, DeMatteo RP, Paty PB. Rectal Gastrointestinal Stromal Tumor (GIST) in the Era of Imatinib: Organ Preservation and Improved Oncologic Outcome. Ann Surg Oncol 2017; 24:3972-3980. [PMID: 29058144 DOI: 10.1245/s10434-017-6087-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Approximately 5% of gastrointestinal stromal tumors (GISTs) originate in the rectum, and historically, radical resection was commonly performed. Little is known about the outcome for rectal GIST in the era of imatinib. METHODS Using a prospectively maintained database, this study retrospectively analyzed 47 localized primary rectal GISTs treated at our center from 1982 to 2016, stratified by when imatinib became available in 2000. Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were analyzed by the Kaplan-Meier method. RESULTS Rectal GISTs represented 7.1% of 663 primary GISTs. The findings showed 17 patients in the pre-imatinib era and 30 patients in the imatinib era. The two groups had similar follow-up evaluation, age, gender, Miettinen risk, and distance to the anal verge. In the imatinib era, tumors were smaller at diagnosis (median 4 vs. 5 cm; p = 0.029), and 24 of the 30 patients received perioperative imatinib. In the high-risk patients, organ preservation and negative margins were more common among the 13 patients treated with neoadjuvant imatinib than among the 21 patients treated directly with surgery. High-risk patients who received perioperative imatinib (n = 15) had greater (or nearly significantly greater) 5-year OS, DSS, local RFS, and distant RFS than those who did not (n = 19) (91, 100, 100, and 71% vs. 47, 65, 74, and 41%; p = 0.049, 0.052, 0.077, 0.051, respectively). In the imatinib era, no patient has had a local recurrence or death due to GIST. CONCLUSIONS The use of imatinib is associated with organ preservation and improved oncologic outcome for patients with rectal GIST.
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Affiliation(s)
- Michael J Cavnar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Lin Wang
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing, China
| | - Vinod P Balachandran
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cristina R Antonescu
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William D Tap
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary Keohan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sam Singer
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Larissa Temple
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Garrett M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jose G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julio Garcia Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ronald P DeMatteo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip B Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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37
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Cercek A, Roxburgh CSD, Strombom P, Smith JJ, Temple LKF, Nash GM, Guillem JG, Paty P, Yaeger R, Stadler ZK, Segal NH, Reidy DL, Shia J, Vakiani E, Wu AJC, Crane CH, Gollub MJ, Garcia-Aguilar J, Saltz L, Weiser MR. Total neoadjuvant chemotherapy to facilitate delivery and tolerance of systemic chemotherapy and response in locally advanced rectal cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.3519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
3519 Background: The most common therapy for locally advanced (T3/4 or N+) rectal cancer (LARC) consists of preoperative chemoradiotherapy (chemoRT) followed by surgery and adjuvant chemotherapy. Recently, use of total neoadjuvant therapy (TNT) with preoperative chemotherapy in addition to chemoRT prior to resection has been accepted as an alternative. Methods: Of 811 consecutive patients (pts) who presented with LARC at our cancer center in 2009-2015, 320 received chemoRT with planned adjuvant chemotherapy, and 308 received TNT (induction FOLFOX/CAPOX chemotherapy followed by chemoRT). Treatment and outcome data for those two cohorts were compared. Results: Pts in the TNT cohort received greater percentages of the planned oxaliplatin and fluorouracil prescribed dose than those in the chemoRT with planned adjuvant chemotherapy cohort (p < 0·005 and p < 0·001, respectively). The complete response (CR) rate, which includes pathological CR (pCR) and clinical CR (cCR) at 6 months post-treatment, was 21% in the chemoRT with planned adjuvant chemotherapy cohort and 36% in the TNT cohort. The median follow-up was 40 months in the chemoRT with planned adjuvant chemotherapy cohort and 23 months in the TNT cohort. Fewer distant recurrences were seen in patients who had T downstaging (p < 0·001), N downstaging (p < 0·005), a cCR (p = 0·005), or a pCR (p < 0·005). There was no statistically significant difference in distant-recurrence-free survival between the two cohorts. Conclusions: Our findings provide additional support for the National Comprehensive Cancer Network (NCCN) guidelines for rectal cancer treatment, which categorizes TNT as a viable treatment strategy that facilitates superior compliance and delivery of systemic therapy. Given its high CR rate, TNT may be beneficial as part of a nonoperative treatment strategy aimed at organ preservation.
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Affiliation(s)
- Andrea Cercek
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Campbell SD Roxburgh
- Memorial Sloan-Kettering Cancer Center Section of Colorectal Surgery, New York, NY
| | - Paul Strombom
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jesse Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | | | | | - Philip Paty
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Rona Yaeger
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zsofia Kinga Stadler
- Clinical Genetics Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Neil Howard Segal
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Jinru Shia
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Efsevia Vakiani
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | | | | | | | - Leonard Saltz
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Martin R. Weiser
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
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Affiliation(s)
- Campbell S Roxburgh
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jose G Guillem
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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39
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Cercek A, Roxburgh CSD, Strombom P, Smith JJ, Temple LKF, Nash GM, Guillem JG, Paty P, Garcia-Aguilar J, Yaeger RD, Stadler ZK, Segal NH, Reidy DL, Shia J, Vakiani E, Wu AJC, Crane CH, Gollub MJ, Saltz L, Weiser MR. Total neoadjuvant therapy for locally advanced rectal cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.4_suppl.662] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
662 Background: Current therapy for locally advanced rectal cancer (LARC) consists of 6 months of perioperative therapy, either with pre-operative chemo-radiotherapy (CRT) and post operative adjuvant chemotherapy (PAC) or total neoadjuvant therapy (TNT) with induction chemotherapy (ICT) followed by CRT then surgery. The aim of our study was to report on the safety, efficacy and complete response rates comparing TNT to PAC in a larger series of LARC patients (pts) at Memorial Sloan Kettering Cancer Center (MSKCC). Methods: Pts treated at MSKCC (2009-15) were analyzed based on the intended treatment schedule (TNT or PAC). 730 LARC pts were treated with CRT, of these 320 received neoadjuvant CRT and 308 received TNT. Results: In the TNT group 205 pts (73%) underwent surgery within 26 weeks of completion of treatment, of which 38 (19%) had a pCR. Of the 78 pts who did not undergo surgery within 26 weeks, 68 (87%) had a complete clinical response (cCR). In the PAC group 293 pts (92%) underwent surgery within 26 weeks and 45 (15%) had a pCR. Of the 27 pts who did not undergo surgery within 26 weeks 22 (81%) had a cCR. The median follow up was 25 mo in the TNT group and 29 mo in the PAC group. There was no statistically significant difference in the distant metastasis free survival between the treatment regimens, despite a higher number of cT4 and cN + tumors in the TNT group. Fewer distant recurrences were seen in pts who had evidence of T downstaging (P < 0.001), N downstaging (P < 0.005), the presence of a cCR (P = 0.005) or a pCR (P < 0.005). Of the pts who received all treatment at MSKCC, comparison of dose of 5-FU and oxaliplatin between the preoperative (N = 249) and postoperative regimens (N = 101) was notable for a higher average dose received of both 5FU and oxaliplatin (p < 0.005 and p < 0.001) in the ICT group. Conclusions: These data add weight to the evidence already included in the NCCN guidelines that pre-operative chemotherapy as part of TNT is a viable treatment strategy with superior compliance and delivery of systemic therapy. Given the high complete response rate, TNT may be used as part of an organ preservation treatment strategy.
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Affiliation(s)
- Andrea Cercek
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Campbell SD Roxburgh
- Memorial Sloan Kettering Cancer Center Section of Colorectal Surgery, New York, NY
| | - Paul Strombom
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | - Philip Paty
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | | | - Zsofia Kinga Stadler
- Clinical Genetics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Diane Lauren Reidy
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Jinru Shia
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Efsevia Vakiani
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | | | | | - Leonard Saltz
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Martin R. Weiser
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
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Konishi T, Shimada Y, Lee LH, Cavalcanti MS, Morris M, Hsu M, Gonen M, Smith JJ, Nash GM, Temple LKF, Guillem JG, Paty P, Garcia-Aguilar J, Vakiani E, Shia J, Weiser MR. Poorly differentiated clusters as a prognostic marker at the invasive front of colon cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.4_suppl.621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
621 Background: Histology at the invasive front of colon cancer can predict malignant potential. However, the optimal histological marker is yet to be established. This study compares the various invasive front histologic markers. Methods: A single-institution prospective database was queried for consecutive patients who underwent curative resection for Stage I-III colon adenocarcinoma from 2007-14. Histologic features were reviewed by a pathologist, including poorly differentiated clusters (PDC), tumor budding (BD), perineural invasion (PN), desmoplastic reaction (DR) and Crohn’s like reaction (CLR) at the invasive front, and WHO grade of the whole tumor. PDC was defined as cancer clusters of ≥ 5 cancer cells that lack a gland-like structure, and was graded into G1 ( < 5), G2 (5-9) and G3 ( ≥ 10) by the highest number of the clusters /HPF. Clinical outcome included recurrence free survival (RFS) and peak hazard function of recurrence and death identified using the kernel-smoothing method. Predictive accuracy was measured with concordance probability estimate (CPE) for proportional hazards regression. Inter-observer agreement was assessed by weighted kappa values on diagnoses rendered by 3 pathologists on 50 randomly selected cases. Results: The study cohort consisted of 851 patients with a median follow up of 36 months. PDC, BD, PN, DR and CLR at the invasive front were significantly associated with RFS. When analyzed by stage, PDC, BD and PN were associated with RFS both in Stage II and Stage III, while the others were prognostic only in Stage III. CPE was the highest in PDC (0.642), indicating the best predictive accuracy, while it was the lowest in WHO grade (0.526). Weighted kappa was also the highest for PDC, indicating the best inter-observer agreement (PDC: 0.824, WHO grade: 0.568). The smoothed graph of the hazard function showed that the risk of recurrence was not only the highest but peaked earlier for PDC G3 (between0 and 12 months) than PDC G2 (between12 and 24 months) and G1 (no evident peak). Conclusions: Of the commonly evaluated histologic markers at the invasive front, PDC grade is the most predictive and reproducible. Further confirmatory investigations are warranted to determine if PDC can replace WHO grade.
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Affiliation(s)
- Tsuyoshi Konishi
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Yoshifumi Shimada
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Lik Hang Lee
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Martin Morris
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Meier Hsu
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Mithat Gonen
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | - Philip Paty
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Efsevia Vakiani
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jinru Shia
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Martin R. Weiser
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
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Roxburgh CSD, Strombom P, Lynn PB, Cercek A, Saltz L, Gollub MJ, Crane CH, Wu AJC, Shia J, Vakiani E, Smith JJ, Temple LKF, Nash GM, Guillem JG, Paty P, Garcia-Aguilar J, Weiser MR. Evolution in multimodality management of locally advanced rectal cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.4_suppl.684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
684 Background: This study reports the evolving multimodality management of locally advanced rectal cancer (LARC) and associated outcomes at a high volume center. Methods: Patients with Stage II/III LARC <15cm from the anal verge evaluated by the colorectal surgery service were identified from a prospective database. Clinical management including neoadjuvant therapy (NT) and surgical treatment along with pathologic and perioperative outcomes were collected. Results: Between June 2009 and March 2015, 798 patients were evaluated and received NT for LARC. Majority were staged cT3/T4 (84%) or cN+ (78%), and 635 had surgery within 26wks following NT. Reliance on MRI staging increased from 57% to 98% during the study period (P < 0.001). There was increased usage of total NT (NEO) with pre-op chemotherapy (CT) and chemoradiotherapy (CRT) (17% to 76%, p < 0.001) with a concomitant decrease in use of CRT alone (77% to 16%, p < 0.001) and post-op CT (70% to 15%, p < 0.001). The proportion undergoing surgery beyond 8wks after NT rose from 41% to 62% (P < 0.001) and beyond 8 wks after CRT rose from 45% to 72% (p < 0.001). The percentage of patients not undergoing resection by 26wks (nonoperative management) rose from 12% to 27%, P < 0.001). Minimally invasive surgery (MIS) increased from 33% to 71% (P < 0.001); in 2014-15 98% of MIS was robot-assisted. Over the study period there was a decrease in LOS (mean 8.1 to 6.5 days, p < 0.001), grade III-V complications (13% to 7%, p < 0.05), surgical site infections (25% to 8%, p < 0.001), and anastomotic leak (11% to 3%, p < 0.05). The proportion undergoing ileostomy closure within 15 wks rose from 7% to 73% (P < 0.001). Involved CRM rates decreased from 9% to 3% (P < 0.01). TNM downstaging increased from 62% to 74% (p = 0.002). Complete response rates (clinical and pathologic) at 26wks was 26% in 2009-10 and 32% in 2014/5 (p = 0.067). Conclusions: Over the past decade, there has been a shift to MRI staging, total NT (NEO), and MIS rectal resection at 8-12 weeks. This has been associated with higher response rates, shorter LOS, and fewer complications.
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Affiliation(s)
- Campbell SD Roxburgh
- Memorial Sloan Kettering Cancer Center Section of Colorectal Surgery, New York, NY
| | - Paul Strombom
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Andrea Cercek
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Leonard Saltz
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Jinru Shia
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Efsevia Vakiani
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | | | | | | | - Philip Paty
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Martin R. Weiser
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
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Wasserman I, Lee LH, Shia J, Wu C, Chen X, Guillem JG, Paty P, Weiser MR, Nash GM, Temple LKF, Saltz L, Yaeger RD, Barlas A, Manova-Todorova KO, Vakiani E, Elghouayel AE, Kemeny NE, Garcia-Aguilar J, Sawyers CL, Smith JJ. SMAD4 loss in colorectal cancer: Correlation with recurrence, chemoresistance, and immune infiltrate. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.4_suppl.587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
587 Background: Few markers reliably identify colorectal cancer (CRC) patients at risk of recurrence and death. SMAD4 loss occurs in 10-20% of cases and has shown promise in identifying high-risk stage II/III patients. We examined SMAD4 status and association with clinical/pathologic features in 446 stage I-IV CRC patients at Memorial Sloan Kettering (MSK). Methods: Patients undergoing curative resection were included (1981-2010). Familial polyposis syndrome patients and those with inadequate tissue were excluded. Tissue microarrays were constructed (n=364). Immunohistochemistry for SMAD4 and mismatch repair (MMR) proteins was completed. SMAD4 nuclear stain intensity was scored (scale=0-3; 0=loss). On whole sections, MMR proteins (present or absent), tumor-infiltrating lymphocytes (TILs) and peritumoral lymphocyte aggregates (PLAs) were scored (scale=0-3). Associations between clinical/pathologic features and SMAD4 loss vs. retention were analyzed. Kaplan-Meier estimates and log-rank test were used for recurrence-free and overall survival analyses (RFS and OS). Results: SMAD4 loss was noted in 13%. Median age at diagnosis was 53 years, and 51% were male. The cohort consisted of 61% hindgut tumors and 62% stage II/III patients. With up to 33 years of follow-up, the mean was 6 years. SMAD4 loss correlated with higher tumor and nodal stage, adjuvant therapy use, and lower TIL and PLA scores (p<0.04 for all). Unlike prior studies, no significant differences in OS based on SMAD4 status across the entire cohort were noted; however, older patients (>median) were noted to have worse OS with SMAD4 loss (p<0.01). SMAD4 loss did correlate with worse RFS (p=0.02), persisting even when excluding MMR-deficient patients. Additionally, SMAD4 loss was associated with worse RFS in both the adjuvant chemotherapy group (median RFS=3.8 vs. 13 years; p=0.06) and the resection-only group (median RFS=4.2 years vs. not yet reached; p< 0.01). Conclusions: SMAD4 loss correlates with worse RFS and resistance to adjuvant therapy. SMAD4 loss also correlates with lower TIL and PLA scores. Future work will address chemoresistance mechanisms, relevance to adjuvant therapy use, and loss of immune infiltrate in SMAD4-null tumors.
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Affiliation(s)
| | - Lik Hang Lee
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jinru Shia
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Chao Wu
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Xi Chen
- University of Miami Miller School of Medicine, Miami, FL
| | | | - Philip Paty
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Martin R. Weiser
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | | | - Leonard Saltz
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Afsar Barlas
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Efsevia Vakiani
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
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Widmar M, Keskin M, Beltran P, Nash GM, Guillem JG, Temple LK, Paty PB, Weiser MR, Garcia-Aguilar J. Incisional hernias after laparoscopic and robotic right colectomy. Hernia 2016; 20:723-8. [PMID: 27469592 DOI: 10.1007/s10029-016-1518-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 07/17/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Incisional hernia (IH) is a common complication after colectomy, with impacts on both health care utilization and quality of life. The true incidence of IH after minimally invasive colectomy is not well described. The purpose of this study was to examine IH incidence after minimally invasive right colectomies (RC) and to compare the IH rates after laparoscopic (L-RC) and robotic (R-RC) colectomies. METHODS This is a retrospective review of patients undergoing minimally invasive RC at a single institution from 2009 to 2014. Only patients undergoing RC for colonic neoplasia were included. Patients with previous colectomy or intraperitoneal chemotherapy were excluded. Three L-RC patients were included for each R-RC patient. The primary outcome was IH rate based on clinical examination or computed tomography (CT). Univariate and multivariate time-to-event analyses were used to assess predictors of IH. RESULTS 276 patients where included, of which 69 had undergone R-RC and 207 L-RC. Patient and tumor characteristics were similar between the groups, except for higher tumor stage in L-RC patients. Both the median time to diagnosis (9.2 months) and the overall IH rate were similar between the groups (17.4 % for R-RC and 22.2 % for L-RC), as were all other postoperative complications. In multivariable analyses, the only significant predictor of IH was former or current tobacco use (hazard raio 3.0, p = 0.03). CONCLUSIONS This study suggests that the incidence of IH is high after minimally invasive colectomy and that this rate is equivalent after R-RC and L-RC. Reducing the IH rate represents an important opportunity for improving quality of life and reducing health care utilization after minimally invasive colectomy.
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Affiliation(s)
- M Widmar
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - M Keskin
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - P Beltran
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - G M Nash
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - J G Guillem
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - L K Temple
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - P B Paty
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - M R Weiser
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - J Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA.
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Smith JJ, Lee LH, Chen X, Wu C, Pelossof R, Nash GM, Temple LR, Guillem JG, Weiser MR, Paty PB, Shia J, Garcia-Aguilar J, Sawyers CL. Abstract LB-A24: Molecular alteration of SMAD4 in hindgut-derived colorectal tumors identifies a distinct subset of patients and is associated with worse recurrence-free survival. Mol Cancer Ther 2015. [DOI: 10.1158/1535-7163.targ-15-lb-a24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
This abstract has been withheld from publication due to its inclusion in the AACR-NCI-EORTC Molecular Targets Conference 2015 Official Press Program. It will be posted online at the time of its presentation in a press conference or in a session: 10:00 AM ET Friday, November 6.
Citation Format: Jesse Joshua Smith, Lik Hang Lee, Xi Chen, Chao Wu, Raphael Pelossof, Garrett M. Nash, Larissa R. Temple, Jose G. Guillem, Martin R. Weiser, Philip B. Paty, Jinru Shia, Julio Garcia-Aguilar, Charles L. Sawyers. Molecular alteration of SMAD4 in hindgut-derived colorectal tumors identifies a distinct subset of patients and is associated with worse recurrence-free survival. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr LB-A24.
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Affiliation(s)
| | | | - Xi Chen
- 2University of Miami Miller School of Medicine, Miami, FL
| | - Chao Wu
- 1Memorial Sloan Kettering, New York, NY
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Salo-Mullen EE, Shia J, Brownell I, Allen P, Girotra M, Robson ME, Offit K, Guillem JG, Markowitz AJ, Stadler ZK. Mosaic partial deletion of the PTEN gene in a patient with Cowden syndrome. Fam Cancer 2015; 13:459-67. [PMID: 24609522 DOI: 10.1007/s10689-014-9709-4] [Citation(s) in RCA: 12] [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: 12/17/2022]
Abstract
Cowden syndrome is an autosomal dominant condition caused by pathogenic mutations in the phosphatase and tensin homolog (PTEN) gene. Only a small proportion of identified pathogenic mutations have been reported to be large deletions and rearrangements. We report on a female patient with a previous history of breast ductal carcinoma in situ who presented to our institution for management of gastrointestinal hamartomatous polyposis. Although several neoplastic predisposition syndromes were considered, genetic evaluation determined that the patient met clinical diagnostic criteria for Cowden syndrome. Array-based comparative genomic hybridization was performed and revealed a mosaic partial deletion of the PTEN gene. Follow-up clinical history including bilateral thyroid nodules, dermatological findings, and a new primary "triple-negative" adenocarcinoma of the contralateral breast are discussed. We highlight the need for recognition and awareness of mosaicism as it may provide an explanation for variable phenotypic presentations and may alter the genetic counseling risk assessment of affected individuals and family members.
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Affiliation(s)
- Erin E Salo-Mullen
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, Box 295, New York, NY, 10065, USA
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Guillem JG, Bertelsen C. Total proctocolectomy for rectal cancer in Lynch syndrome: indications and considerations. Colorectal Cancer 2015. [DOI: 10.2217/crc.15.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY Patients with Lynch syndrome and rectal cancer present a unique clinical challenge. Management of the primary rectal cancer and prophylactic removal of the colon should be considered. In patients requiring a mesorectal excision, a combined prophylactic colon removal can be considered. Although surveillance of the colon with frequent colonoscopies is an alternative, concerns of metachronous colon cancer development support prophylactic removal of the colon as an alternative. Since data are not available to confirm superiority of either approach, the final decision is greatly dependent upon a patient's wishes and preferences. Patients interested in pursuing simultaneous prophylactic colon removal can be offered total proctocolectomy with either ileal pouch anal-anastomosis as a sphincter-preserving alternative or a total proctocolectomy with end ileostomy.
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Affiliation(s)
- Jose G Guillem
- Memorial Sloan Kettering Cancer Center, Department of Surgery, Colorectal Service, 1275 York Avenue, C1077, New York, NY 10065, USA
| | - Corinna Bertelsen
- Memorial Sloan Kettering Cancer Center, Department of Surgery, Colorectal Service, 633 3rd Avenue, 1584A, New York, NY 10017, USA
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Smith JJ, Chow OS, Eaton A, Widmar M, Nash GM, Temple LKF, Guillem JG, Weiser MR, Goodman KA, Cercek A, Saltz L, Gollub MJ, Gonen M, Garcia-Aguilar J, Paty P. Organ preservation in patients with rectal cancer with clinical complete response after neoadjuvant therapy. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.3_suppl.509] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
509 Background: Nonoperative management (NOM) of rectal cancer following a clinical complete response (cCR) to neoadjuvant therapy is a non-standard approach. We review our experience with NOM to evaluate safety and efficacy. Methods: A retrospective review of prospectively collected data between 2006 and 2014 was conducted. We compared patients completing neoadjuvant therapy for stage I to III rectal cancers who: a) achieved cCR and were treated with NOM, or b) underwent standard total mesorectal excision (TME) and achieved a pathologic complete response (pCR). Kaplan-Meier estimates and the log-rank test were used. Results: Seventy-three patients underwent NOM after cCR. From 369 rectal resections performed, 72 (20%) achieved pCR and form the comparison group. Median follow-up across both groups was 3.3 years. Rectal preservation was achieved in 56 (77%) of the patients treated with NOM. Of the 19 NOM patients with local regrowth, 18 were salvaged successfully with standard TME (n=16) or local excision (n=2), with one patient pending a salvage operation (n=1). No significant differences were noted in the number of distant recurrences between the NOM and pCR groups. Four-year disease-specific survival and overall survival between the two groups were not significantly different. Conclusions: In this highly selected group of patients with cCR to neoadjuvant treatment, NOM with surgical salvage of local tumor regrowth achieved local control in all patients. The oncologic outcome for NOM patients at 4 years was comparable to patients with pCR after rectal resection. These data continue to suggest that NOM does not compromise oncologic outcome, and that preservation of the rectum is achieved in a majority of patients. [Table: see text]
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Affiliation(s)
| | | | - Anne Eaton
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | | | - Andrea Cercek
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Leonard Saltz
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | | | - Mithat Gonen
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Philip Paty
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
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Cercek A, Goodman KA, Hajj C, Weisberger E, Segal NH, Reidy-Lagunes DL, Stadler ZK, Wu AJ, Weiser MR, Paty PB, Guillem JG, Nash GM, Temple LK, Garcia-Aguilar J, Saltz LB. Neoadjuvant chemotherapy first, followed by chemoradiation and then surgery, in the management of locally advanced rectal cancer. J Natl Compr Canc Netw 2014; 12:513-9. [PMID: 24717570 DOI: 10.6004/jnccn.2014.0056] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Standard therapy for locally advanced rectal cancer (LARC) is preoperative chemoradiotherapy and postoperative chemotherapy. At Memorial Sloan-Kettering Cancer Center (MSKCC) the authors began offering FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) as initial treatment for patients with high-risk LARC to target micrometastases while treating the primary tumor. The purpose of this study is to report the safety and efficacy of initial FOLFOX given before chemoradiotherapy on tumor downsizing and pathologic complete response (pathCR) in LARC. The records of patients with stage II/III rectal cancer treated at MSKCC between 2007 and 2012 were reviewed. Of approximately 300 patients with LARC treated at MSKCC, 61 received FOLFOX as initial therapy. Of these 61 patients, 57 received induction FOLFOX (median 7 cycles) followed by chemoradiation, and 4 experienced an excellent response, declined chemoradiation, and underwent total mesorectal excision (TME). Twelve of the 61 patients did not undergo TME: 9 had a complete clinical response (CCR), 1 declined despite persistent tumor, 1 declined because of comorbidities, and 1 developed metastatic disease. Among the 61 patients receiving initial FOLFOX, 22 (36%) had either a pathCR (n=13) or a CCR (n=9). Of the 49 patients who underwent TME, all had R0 resections and 23 (47%) had tumor response greater than 90%, including 13 (27%) who experienced a pathCR. Of the 28 patients who received all 8 cycles of FOLFOX, 8 experienced a pathCR (29%) and 3 a CCR (11%). No serious adverse events occurred that required a delay in treatment during FOLFOX or chemoradiation. FOLFOX and chemoradiation before planned TME results in tumor regression, a high rate of delivery of planned therapy, and a substantial rate of pathCRs, and offers a good platform for nonoperative management in select patients.
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Affiliation(s)
- Andrea Cercek
- From the aGastrointestinal Oncology Service, Department of Medicine, bDepartment of Radiation Therapy, and cColorectal Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
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Lim SB, Guillem JG. Nonoperative strategies for rectal cancer following a complete clinical response to preoperative chemoradiation: a few considerations. Oncology (Williston Park) 2014; 28:620-621. [PMID: 25144284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Schrag D, Weiser MR, Goodman KA, Gonen M, Hollywood E, Cercek A, Reidy-Lagunes DL, Gollub MJ, Shia J, Guillem JG, Temple LKF, Paty PB, Saltz LB. Neoadjuvant chemotherapy without routine use of radiation therapy for patients with locally advanced rectal cancer: a pilot trial. J Clin Oncol 2014; 32:513-8. [PMID: 24419115 PMCID: PMC5795691 DOI: 10.1200/jco.2013.51.7904] [Citation(s) in RCA: 322] [Impact Index Per Article: 32.2] [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] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Although neoadjuvant chemoradiotherapy achieves low local recurrence rates in clinical stages II to III rectal cancer, it delays administration of optimal chemotherapy. We evaluated preoperative infusional fluorouracil, leucovorin, and oxaliplatin (FOLFOX)/bevacizumab with selective rather than consistent use of chemoradiotherapy. PATIENTS AND METHODS Thirty-two patients with clinical stages II to III rectal cancer participated in this single-center phase II trial. All were candidates for low anterior resection with total mesorectal excision (TME). Patients were to receive six cycles of FOLFOX, with bevacizumab included for cycles 1 to 4. Patients with stable/progressive disease were to have radiation before TME, whereas responders were to have immediate TME. Postoperative radiation was planned if R0 resection was not achieved. Postoperative FOLFOX × 6 was recommended, but adjuvant regimens were left to clinician discretion. The primary outcome was R0 resection rate. RESULTS Between April 2007 and December 2008, 32 (100%) of 32 study participants had R0 resections. Two did not complete preoperative chemotherapy secondary to cardiovascular toxicity. Both had preoperative chemoradiotherapy and then R0 resections. Of 30 patients completing preoperative chemotherapy, all had tumor regression and TME without preoperative chemoradiotherapy. The pathologic complete response rate to chemotherapy alone was 8 of 32 (25%; 95% CI, 11% to 43%). The 4-year local recurrence rate was 0% (95% CI, 0% to 11%); the 4-year disease-free survival was 84% (95% CI, 67% to 94%). CONCLUSION For selected patients with clinical stages II to III rectal cancer, neoadjuvant chemotherapy and selective radiation does not seem to compromise outcomes. Preoperative Radiation or Selective Preoperative Radiation and Evaluation Before Chemotherapy and TME (PROSPECT), a randomized phase III trial to validate this experience, is now open in the US cooperative group network.
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Affiliation(s)
- Deborah Schrag
- All authors: Memorial Sloan-Kettering Cancer Center, New York, NY
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