Neoadjuvant Stereotactic MR-Guided Ablative Radiation Therapy (SMART) and Surgical Outcomes in Patients with Pancreatic Cancer

PURPOSE/OBJECTIVE(S)

The benefit of neoadjuvant radiation therapy for patients undergoing surgery for pancreatic ductal adenocarcinoma (PDAC) remains unclear. Stereotactic MR-guided adaptive radiation therapy (SMART) treatment to ablative doses is a newer technique that is well tolerated and has increased local control in unresectable pancreatic cancer. For resectable pancreatic cancer, neoadjuvant SMART has the potential to decrease local recurrence risk and positive margin rates. However, there is concern for perioperative risks associated with ablative dose treatments. We report the efficacy and safety of surgical resection in patients who have received neoadjuvant SMART at our institution.

MATERIALS/METHODS

We conducted a retrospective analysis of all consecutive patients diagnosed with PDAC who had noted vascular involvement of the celiac axis, superior mesenteric, and/or portal vessels between January 2016 and December 2022 at a single, high-volume, academic institution. Perioperative events were defined according to the Clavien-Dindo classification. The Kaplan Meier method was applied to estimate disease free survival (DFS) and overall survival (OS).

RESULTS

Seventeen patients with PDAC and vessel involvement at time of diagnosis who received SMART were included. Median follow-up time was 14.3 months; all patients underwent surgery, at a median time after radiation of 28 days (range: 15 - 90). Median length of postoperative stay was 7 days (range: 3 - 15). Five patients (29%) underwent vascular resection. Fifteen patients (88%) achieved R0 resection, with two R1 resections noted at the SMA and pancreatic neck respectively. Seven patients (41%) had adverse events attributable to surgery, with the majority being defined as abscess or infection (n = 5; 29%). One (6%) Clavien-Dindo grade III or higher toxicity was observed - a cortical cerebrovascular event following surgery. No major bleeding events requiring surgical intervention were noted. At time of event censorship, there were no observable locoregional failures. The median DFS and OS were not reached; however, 1-year DFS and OS were 62% and 87%, respectively.

CONCLUSION

Neoadjuvant SMART appears to be safe, with low rates of surgical complications and promising outcomes. Further identification of patients for this approach requires additional investigation.

First Constraints on Heavy QCD Axions with a Liquid Argon Time Projection Chamber Using the ArgoNeuT Experiment

We present the results of a search for heavy QCD axions performed by the ArgoNeuT experiment at Fermilab. We search for heavy axions produced in the NuMI neutrino beam target and absorber decaying into dimuon pairs, which can be identified using the unique capabilities of ArgoNeuT and the MINOS near detector. This decay channel is motivated by a broad class of heavy QCD axion models that address the strong CP and axion quality problems with axion masses above the dimuon threshold. We obtain new constraints at a 95% confidence level for heavy axions in the previously unexplored mass range of 0.2-0.9 GeV, for axion decay constants around tens of TeV.

Neuroimaging of brain connectivity related to reading outcomes in children born preterm: A critical narrative review

Premature children are at high risk for delays in language and reading, which can lead to poor school achievement. Neuroimaging studies have assessed structural and functional connectivity by diffusion MRI, functional MRI, and magnetoencephalography, in order to better define the "reading network" in children born preterm. Findings point to differences in structural and functional connectivity compared to children born at term. It is not entirely clear whether this discrepancy is due to delayed development or alternative mechanisms for reading, which may have developed to compensate for brain injury in the perinatal period. This narrative review critically appraises the existing literature evaluating the neural basis of reading in preterm children, summarizes the current findings, and suggests future directions in the field.

Cardiac effects of renal ischemia

Mortality in acute kidney injury (AKI) remains very high, yet the cause of death is often failure of extrarenal organs. We and others have demonstrated remote organ dysfunction after renal ischemia. The term "cardiorenal syndrome" was first applied to the "cross talk" between the organs by the National Heart, Lung, and Blood Institute of the National Institutes of Health, and the clinical importance is being increasingly appreciated. Nevertheless, more information is needed to effectively address the consequences of renal injury on the heart. Since AKI often occurs in patients with comorbidities, we investigated the effect of renal ischemia in the setting of existing cardiac failure. We hypothesized that the cardiac effects of renal ischemia would be significantly amplified in experimental cardiomyopathy. Male Sprague-Dawley rats with preexisting cardiac and renal injury due to low-dose doxorubicin were subjected to bilateral renal artery occlusion. Cardiac structure and function were examined 2 days after reperfusion. Loss of functional myocardial tissue with decreases in left ventricular pressure, increases in apoptotic cell death, inflammation, and collagen, and greater disruption in ultrastructure with mitochondrial fragmentation were seen in the doxorubicin/ischemia group compared with animals in the groups treated with doxorubicin alone or following ischemia alone. Systemic inflammation and cardiac abnormalities persisted for at least 21 wk. These results suggest that preexisting comorbidities can result in much more severe distant organ effects of acute renal injury. The results of this study are relevant to human AKI.NEW & NOTEWORTHY Acute kidney injury is common, expensive, and deadly, yet morbidity and mortality are often secondary to remote organ dysfunction. We hypothesized that the effects of renal ischemia would be amplified in the setting of comorbidities. Sustained systemic inflammation and loss of functional myocardium with significantly decreased systolic and diastolic function, apoptotic cell death, and increased collagen and inflammatory cells were found in the heart after renal ischemia in the doxorubicin cardiomyopathy model (vs. renal ischemia alone). Understanding the remote effects of renal ischemia has the potential to improve outcomes in acute kidney injury.

Leveraging the Multidisciplinary Tumor Board for Dissemination of Evidence-Based Recommendations on the Staging and Treatment of Gastric Cancer: A Pilot Study

BACKGROUND

Compliance with evidence-based treatment guidelines for gastric cancer across the United States is poor. This pilot study aimed to create and evaluate a change package for disseminating information on the staging and treatment of gastric cancer during multidisciplinary tumor boards and for identifying barriers to implementation.

METHODS

The change package included a 10-min video, a brief knowledge assessment, and a discussion guide. Commission on Cancer-accredited sites that perform gastrectomy were invited to participate. Participants completed the Organizational Readiness for Implementing Change (ORIC) scale (range, 12-60) and scales to measure the feasibility, acceptability, and appropriateness (score range, 4-20). Semi-structured interviews were conducted to further define inner and outer setting barriers.

RESULTS

Seven centers participated in the study. A total of 74 participants completed the pre-video knowledge assessment, and 55 participants completed the post-video assessment. The recommendations found to be most controversial were separate staging laparoscopy and modified D2 lymphadenectomy. Sum scores were calculated for acceptability (mean, 17.43 ± 2.51) appropriateness (mean, 16.86 ± 3.24), and feasibility (mean, 16.14 ± 3.07) of the change package. The ORIC scores (mean, 46.57 ± 8.22) correlated with responses to the open-ended questions. The key barriers identified were patient volume, skills in the procedures, and attitudes and beliefs.

CONCLUSIONS

The change package was moderately to highly feasible, appropriate, and acceptable. The activity identified specific recommendations for gastric cancer care that are considered controversial and local barriers to implementation. Future efforts could focus on building skills and knowledge as well as the more difficult issue of attitudes and beliefs.

MicroBooNE and the ν_{e} Interpretation of the MiniBooNE Low-Energy Excess

A new generation of neutrino experiments is testing the 4.7σ anomalous excess of electronlike events observed in MiniBooNE. This is of huge importance for particle physics, astrophysics, and cosmology, not only because of the potential discovery of physics beyond the standard model, but also because the lessons we will learn about neutrino-nucleus interactions will be crucial for the worldwide neutrino program. MicroBooNE has recently released results that appear to disfavor several explanations of the MiniBooNE anomaly. Here, we show quantitatively that MicroBooNE results, while a promising start, unquestionably do not probe the full parameter space of sterile neutrino models hinted at by MiniBooNE and other data, nor do they probe the ν_{e} interpretation of the MiniBooNE excess in a model-independent way.

New Constraints on Tau-Coupled Heavy Neutral Leptons with Masses m_{N}=280-970 MeV

A search for heavy neutral leptons has been performed with the ArgoNeuT detector exposed to the NuMI neutrino beam at Fermilab. We search for the decay signature N→νμ^{+}μ^{-}, considering decays occurring both inside ArgoNeuT and in the upstream cavern. In the data, corresponding to an exposure to 1.25×10^{20}  POT, zero passing events are observed consistent with the expected background. This measurement leads to a new constraint at 90% confidence level on the mixing angle |U_{τN}|^{2} of tau-coupled Dirac heavy neutral leptons with masses m_{N}=280-970  MeV, assuming |U_{eN}|^{2}=|U_{μN}|^{2}=0.

Ki67 does not predict recurrence for low-grade appendiceal mucinous neoplasms with peritoneal dissemination after cytoreductive surgery and HIPEC

Low-grade appendiceal mucinous neoplasms (LAMN) can disseminate to become low-grade mucinous carcinoma peritonei (LGMCP), which is optimally treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). Approximately half of the patients with LGMCP recur despite complete cytoreduction, and risk factors for recurrence are poorly understood. We sought to evaluate if Ki67 predicts progression of LGMCP after CRS/HIPEC. A retrospective review of a prospectively maintained database was performed to identify patients treated with complete CRS/HIPEC for LGMCP from 2008 to 2019 with Ki67 assessed. Patient characteristics, histologic data, average and focally high "hotspot") Ki67 index, progression-free survival (PFS), and overall survival (OS) were analyzed. Ki-67 immunostain was performed on the histologic section with the highest cellularity and architectural complexity. Forty-four patients with LGMCP (55% male, median age 61) were identified. The median Ki67 score and hotspot Ki67 score was 15% (1-70) and 50% (1-90), respectively. On univariate analysis, average Ki67 and hotspot Ki67 were not predictive of PFS when analyzed as continuous normalized values (HR 1.0, p = 0.79 and HR 1.1, p = 0.38, respectively) or as categorical values when stratified by the median (HR 0.9, p = 0.67 and HR 1.0, p = 0.93). This remained true on multivariate analysis when stratified for peritoneal cancer index, CEA, and completeness of cytoreduction score for both normalized Ki67 and hotspot Ki67 (HR 0.9 [95% CI 0.8-1.3], p = 0.94 and HR 1.04 [95% CI 0.8-1.3], p = 0.73, respectively). Ki67 failed to predict disease recurrence for patients with LGMCP in this cohort.

Predictors and significance of histologic response to neoadjuvant therapy for gastric cancer

BACKGROUND

Perioperative therapy is the standard-of-care for locally-advanced gastric cancer but many patients do not respond. There are currently no known factors that predict response to therapy.

METHODS

This was a retrospective study aimed to evaluate treatment effect grade (TEG) in patients with locally advanced gastric cancer treated with neoadjuvant therapy and surgery at a single center. Ordinal logistic regression was performed to identify predictors of TEG, scaled from 0 to 3.

RESULTS

Fifty patients were identified. The majority were male (n = 33) and 50% were Hispanic. The most common regimens given were: 5-fluorouracil/leucovorin, oxaliplatin, and docetaxel (n = 23, 46%), epirubicin, cis- or oxaliplatin, and 5-fluorouracil/leucovorin or Xeloda (n = 8, 16%), and 5-fluorouracil/leucovorin and oxaliplatin (n = 9, 18%). Twenty-seven patients (55%) had complete or partial response to therapy (TEG 0-2), and 23 patients (46%) had no response (TEG 3). Of numerous variables analyzed, only race and SRC histology were associated with TEG. TEG was associated with disease free, but not disease specific survival.

CONCLUSIONS

In this cohort, 46% of patients had no histologic response to therapy. SRC histology, and possibly race, should be considered in determination of optimal multidisciplinary regimens and in amount of therapy to be given upfront, as patients with SRC histology and those of non-Asian race are less likely to respond to standard regimens.

A Multi-institutional Study of Peritoneal Recurrence Following Resection of Low-grade Appendiceal Mucinous Neoplasms

BACKGROUND

Peritoneal dissemination of low-grade appendiceal mucinous neoplasms (LAMNs), sometimes referred to as pseudomyxoma peritonei, can result in significant morbidity and mortality. Little is known about the natural history of localized (non-disseminated) LAMNs.

OBJECTIVE

The goal of this study was to evaluate the risk of peritoneal recurrence in patients with localized LAMNs.

METHODS

We performed a multi-institutional retrospective review of patients with pathologically confirmed localized LAMNs. Baseline characteristics, pathology, and follow-up data were collected. The primary endpoint was the rate of peritoneal recurrence.

RESULTS

We identified 217 patients with localized LAMNs. Median age was 59 years (11-95) and 131 (60%) patients were female. Surgical management included appendectomy for 124 (57.1%) patients, appendectomy with partial cecectomy for 26 (12.0%) patients, and colectomy for 67 (30.9%) patients. Pathology revealed perforation in 46 patients (37.7% of 122 patients with perforation status mentioned in the report), extra-appendiceal acellular mucin (EAM) in 49 (22.6%) patients, and extra-appendiceal neoplastic cells (EAC) in 13 (6.0%) patients. Median follow-up was 51.1 months (0-271). Seven (3.2%) patients developed a peritoneal recurrence, with a median time to recurrence of 14.4 months (2.5-47.0). Seven (15.2%) patients with histologic evidence of perforation had recurrence, versus no patients (0%) without perforation (p < 0.001); five (10.2%) patients with EAM versus two (1.2%) patients without EAM (p = 0.007), and one (7.7%) patient with EAC versus six (2.9%) patients without EAC (p = 0.355) had recurrence.

CONCLUSIONS

This multi-institutional study represents the largest reported series of patients with localized LAMNs. In the absence of perforation or extra-appendiceal mucin or cells, recurrence was extremely rare; however, patients with any of these pathologic findings require careful follow-up.

Commission on Cancer Facility Type is Associated with Overall Survival in Patients with Gastric Adenocarcinoma in the United States

BACKGROUND

In the United States, "high-volume" centers for gastric cancer treat significantly fewer cases per year compared with centers in Asia. Factors associated with oncologic outcomes, aside from volume, are poorly understood.

METHODS

Patients with gastric adenocarcinoma between 2004 and 2015 were analyzed in the NCDB cohort. Commission on Cancer facility types were classified as either Academic/Research Programs (ARP) or Non-Academic Programs (NAP). Factors associated with treatment at facility type were assessed by logistic regression. Overall survival was compared between facility types by Cox proportional hazard models.

RESULTS

Thirty-nine percent of patients were treated at ARPs. In multivariable analysis, patients treated at ARPs were younger, healthier (Charlson-Deyo score), and had lower AJCC stage. Treatment at an ARP was associated with superior median OS compared with treatment at a NAP (17.3 months vs. 11.1 months, respectively, P < 0.001,) and in each stage of disease. Treatment of stages II and III patients at ARPs increased over time. Among patients with stages II and III disease, adherence to therapy guidelines was higher and postoperative mortality was lower at ARPs.

CONCLUSION

Although patients at ARPs tend to have favorable characteristics, superior overall survival may also be due to better adherence to therapy guidelines and capacity to rescue after surgical complications.

Prognostic Utility of Pre- and Postoperative Circulating Tumor DNA Liquid Biopsies in Patients with Peritoneal Metastases

BACKGROUND

Circulating tumor DNA (ctDNA) is a promising technology for treatment selection, prognostication, and surveillance after definitive therapy. Its use in the perioperative setting for patients with metastatic disease has not been well studied. We characterize perioperative plasma ctDNA and its association with progression-free survival (PFS) in patients undergoing surgery for peritoneal metastases.

PATIENTS AND METHODS

We recruited 71 patients undergoing surgery for peritoneal metastases and evaluated their plasma with a targeted 73-gene ctDNA next-generation sequencing test before and after surgery. The association between perioperative ctDNA, as well as other patient factors, and PFS was evaluated by Cox regression.

RESULTS

ctDNA was detectable in 28 patients (39.4%) preoperatively and in 37 patients (52.1%) postoperatively. Patients with high ctDNA [maximum somatic variant allele fraction (MSVAF) > 0.25%] had worse PFS than those with low MSVAF (< 0.25%) in both the pre- and postoperative settings (median 4.8 vs. 19.3 months, p < 0.001, and 9.2 vs.15.0 months, p = 0.049, respectively; log-rank test). On multivariate analysis, high-grade histology [hazard ratio (HR) 3.42, p = 0.001], incomplete resection (HR 2.35, p = 0.010), and high preoperative MSVAF (HR 3.04, p = 0.001) were associated with worse PFS. Patients with new postoperative alterations in the context of preoperative alteration(s) also had a significantly shorter PFS compared with other groups (HR 4.28, p < 0.001).

CONCLUSIONS

High levels of perioperative ctDNA and new postoperative ctDNA alterations in the context of preoperative alterations predict worse outcomes in patients undergoing resection for peritoneal metastases. This may highlight a role for longitudinal ctDNA surveillance in this population.

Oncolytic Herpes Simplex Virus Prevents Premalignant Lesions from Progressing to Cancer

Early detection and timely treatment of precancerous lesions are hallmarks of successful strategies to prevent deaths due to cancer. Oncolytic viruses are a group of promising anti-cancer agents with wide-ranging experimental and clinical efficacy against solid tumors. Previously, we have shown that NV1066, an oncolytic herpes simplex-1 virus encoding enhanced green fluorescent protein, selectively infects, replicates in, and kills various cancer types. In this study, we sought to determine whether this oncolytic agent can treat precancerous lesions to prevent cancer formation. Using an oral chemical carcinogenesis model in hamsters, we assessed the ability of NV1066 to infect precancerous and cancerous lesions. NV1066 consistently infected dysplastic cells, carcinoma in situ, and squamous cell carcinoma. Animals receiving an intramucosal injection of NV1066 for 7 weeks showed significantly fewer (3-fold) and smaller (4-fold) lesions compared to animals that did not receive viral treatment. Results indicate that infectivity might be dependent on the herpes simplex virus 1 receptor, nectin-1. This study demonstrates that not only can NV1066 treat oral squamous cell carcinoma, but it can also infect and treat premalignant lesions, thus delaying cancer progression. Overall, our study shows the potential of the oncolytic virus NV1066 as a cancer prevention tool.

Preoperative Risk Score for Predicting Incomplete Cytoreduction: A 12-Institution Study from the US HIPEC Collaborative

BACKGROUND

For patients with peritoneal carcinomatosis undergoing cytoreductive surgery with heated intraperitoneal chemotherapy (CRS/HIPEC), incomplete cytoreduction (CCR2/3) confers morbidity without survival benefit. The aim of this study is to identify preoperative factors which predict CCR2/3.

METHODS

All patients who underwent curative-intent CRS/HIPEC of low/high-grade appendiceal, colorectal, or peritoneal mesothelioma cancers in the 12-institution US HIPEC Collaborative from 2000 to 2017 were included (n = 2027). The primary aim is to create an incomplete-cytoreduction risk score (ICRS) to predict CCR2/3 CRS utilizing preoperative data. ICRS was created from a randomly selected cohort of 50% of patients (derivation cohort) and verified on the remaining patients (validation cohort).

RESULTS

Within our derivation cohort (n = 998), histology was low-grade appendiceal neoplasms in 30%, high-grade appendiceal tumor in 41%, colorectal tumor in 22%, and peritoneal mesothelioma in 8%. CCR0/1 was achieved in 816 patients and CCR 2/3 in 116 patients. On multivariable analysis, preoperative factors associated with incomplete cytoreduction were male gender [odds ratio (OR) 3.4, p = 0.007], presence of ascites (OR 2.8, p = 0.028), cancer antigen (CA)-125 ≥ 40 U/mL (OR 3.4, p = 0.012), and carcinoembryonic antigen (CEA) ≥ 4.2 ng/mL (OR 3.2, p = 0.029). Each preoperative factor was assigned a score of 0 or 1 to form an ICRS from 0 to 4. Scores were grouped as zero (0), low (1-2), or high (3-4). Incidence of CCR2/3 progressively increased by risk group from 1.6% in zero to 13% in low and 39% in high. When ICRS was applied to the validation cohort (n = 1029), this relationship was maintained.

CONCLUSION

The incomplete cytoreduction risk score incorporates preoperative factors to accurately stratify the risk of CCR2/3 resection in CRS/HIPEC. This score should not be used in isolation, however, to exclude patients from surgery.

Obstruction-Free Survival Following Operative Intervention for Malignant Bowel Obstruction in Appendiceal Cancer

BACKGROUND

Patients with peritoneal metastases from appendiceal cancer are at high risk of malignant bowel obstruction (MBO), which is associated with significant morbidity and mortality. There are no definitive treatment guidelines regarding operative intervention for MBO. We sought to evaluate the efficacy and safety of operative intervention in this population.

METHODS

We identified patients with peritoneal metastases from appendiceal cancer who underwent surgery for MBO at our institution between 2011 and 2018. Baseline characteristics, postoperative complications, and follow-up data were collected. The primary endpoint was obstruction-free survival (OFS). Other endpoints were postoperative recovery of bowel function, 60-day Clavien-Dindo (CD) morbidity, and overall survival (OS).

RESULTS

Twenty-six patients underwent operative treatment for MBO, of whom 14 had high-grade (HG) histology and 12 had low-grade (LG) histology. Seven (25.9%) patients had severe (CD grade 3 or higher) 60-day complications, including one (3.8%) postoperative death. All remaining patients had return of bowel function and resumed oral intake during hospitalization. Six (23.1%) patients had repeat admissions for MBO after surgery. Median OFS was 17.0 months (95% confidence interval [CI] 2.3-31.8), and median OS was 18.5 months (95% CI 3.6-33.3) following surgery.

CONCLUSION

In this carefully selected group of patients with peritoneal metastases from appendiceal cancer, surgery for MBO provided durable palliation with acceptable morbidity.

Exploring the roles, functions, and background of patient navigators and case managers: A scoping review

BACKGROUND

Patient navigators and case managers are health care workers who aim to provide individualized assistance to patients facing significant health concerns. Although these roles emerged from distinct historical need, the terms are often used interchangeably in the literature and are described to have overlapping functions. Differences in the way that these roles are conceptualized across countries has led to a lack of clarity regarding the exact functions that each offer to patients, caregivers, and the health care system.

OBJECTIVES

To differentiate the functions and backgrounds of patient navigators and case managers across settings and disease contexts.

DESIGN

This review was guided based on the PRISMA extension for scoping reviews using a five-step review process: identify the research questions; search and identify relevant studies; select studies based on a priori criterion; chart the data; and collate, summarize and report the results.

DATA SOURCES

A search of the literature was undertaken in peer-reviewed databases (Medline, CINAHL, and PubMed) and the grey literature (Google and unpublished articles in online repositories).

REVIEW METHODS

Extracted data included information on patient navigators and/or case managers related to their reported background, training, and/or knowledge; roles and/or specific functions; clinical setting; and targeted condition or disease type.

RESULTS

The search strategy resulted in 10,523 articles. After applying the eligibility criteria during title and abstract evaluation, 468 full-text articles were reviewed, resulting in a total of 160 articles. Functions of patient navigators and case managers were organized into nine emerging categories: (1) advocacy; (2) care coordination; (3) case monitoring and patient needs assessment; (4) community engagement; (5) education; (6) administration and research activities; (7) psychosocial support; (8) navigation of services; and (9) reduction of barriers. The background and knowledge areas of each role were compared and contrasted, and three categories related to the practice context of each role were identified: (1) typical setting and care trajectory; (2) target patient population; and (3) mode of service delivery.

CONCLUSIONS

The current study identified important differences in the functions between patient navigators and case managers. However, there remains significant ambiguity between the functions of these two roles. Standardized definitions detailing scope of practice, and allowing for inherent flexibility across different settings, are needed to improve service delivery.

Primary Tumor Sidedness is Predictive of Survival in Colon Cancer Patients Treated with Cytoreductive Surgery With or Without Hyperthermic Intraperitoneal Chemotherapy: A US HIPEC Collaborative Study

INTRODUCTION

The clinical relevance of primary tumor sidedness is not fully understood in colon cancer patients with peritoneal metastasis treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

This was a retrospective cohort study of a multi-institutional database of patients with peritoneal surface malignancy at 12 participating high-volume academic centers from the US HIPEC Collaborative.

RESULTS

Overall, 336 patients with colon primary tumors who underwent curative-intent CRS with or without HIPEC were identified; 179 (53.3%) patients had right-sided primary tumors and 157 (46.7%) had left-sided primary tumors. Patients with right-sided tumors were more likely to be older, male, have higher Peritoneal Cancer Index (PCI), and have a perforated primary tumor, but were less likely to have extraperitoneal disease. Patients with complete cytoreduction (CC-0/1) had a median disease-free survival (DFS) of 11.5 months (95% confidence interval [CI] 7.6-15.3) versus 13.1 months (95% CI 9.5-16.8) [p = 0.158] and median overall survival (OS) of 30 months (95% CI 23.5-36.6) versus 45.4 months (95% CI 35.9-54.8) [p = 0.028] for right- and left-sided tumors; respectively. Multivariate analysis revealed that right-sided primary tumor was an independent predictor of worse DFS (hazard ratio [HR] 1.75, 95% CI 1.19-2.56; p =0.004) and OS (HR 1.72, 95% CI 1.09-2.73; p = 0.020).

CONCLUSION

Right-sided primary tumor was an independent predictor of worse DFS and OS. Relevant clinicopathologic criteria, such as tumor sidedness and PCI, should be considered in patient selection for CRS with or without HIPEC, and guide stratification for clinical trials.

Does Primary Tumor Side Matter in Patients with Metastatic Colon Cancer Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy?

BACKGROUND

Primary tumor location has been shown to be prognostic of overall survival (OS) in patients with both locally advanced and metastatic colorectal cancer. The impact of sidedness on prognosis has not been evaluated in the setting of peritoneal-only metastases treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

A retrospective review of prospectively maintained databases of patients with peritoneal surface malignancy undergoing CRS/HIPEC from three high-volume centers was performed.

RESULTS

A total of 115 patients with metastatic colon cancer to the peritoneum who underwent CRS/HIPEC with mitomycin C were identified. Fifty-one patients (45%) had left-sided primary tumors, and 64 (55%) had right-sided primary tumors. Patients with right-sided tumors were more likely to be older (median age 56 vs. 49 years, p = 0.007) and to have signet ring cell histology (17% vs. 4%, p = 0.026). Patients with right-sided tumors had median disease-free survival (DFS) and OS of 14 months (95% confidence interval [CI] 10.5-17.5) and 36 months (95% CI 27.4-44.6), respectively, versus 16 months (95% CI 11.0-21.0) and 69 months (95% CI 24.3-113.7) for those patients with left-sided tumors. On multivariate analysis, primary tumor side was an independent predictor of both DFS and OS.

CONCLUSIONS

In this study, there was a dramatic, clinically significant difference in OS between patients with right- and left-sided tumors, and primary tumor side was an independent predictor of DFS and OS. Primary tumor side should be considered in patient selection for CRS with or without HIPEC.

Preequilibrium Asymmetries in the ^{239}Pu(n,f) Prompt Fission Neutron Spectrum

The physical properties of neutrons emitted from neutron-induced fission are fundamental to our understanding of nuclear fission. However, while state-of-the-art fission models still incorporate isotropic fission neutron spectra, it is believed that the preequilibrium prefission component of these spectra is strongly anisotropic. The lack of experimental guidance on this feature has not motivated incorporation of anisotropic neutron spectra in fission models, though any significant anisotropy would impact descriptions of a fissioning system. In the present work, an excess of counts at high energies in the fission neutron spectrum of ^{239}Pu is clearly observed and identified as an excess of the preequilibrium prefission distribution above the postfission neutron spectrum. This excess is separated from the underlying postfission neutron spectrum, and its angular distribution is determined as a function in incident neutron energy and outgoing neutron detection angle. Comparison with neutron scattering models provides the first experimental evidence that the preequilibrium angular distribution is uncorrelated with the fission axis. The results presented here also impact the interpretation of several influential prompt fission neutron spectrum measurements.

Development of a variable-energy, high-intensity, pulsed-mode ion source for low-energy nuclear astrophysics studies

The primary challenge in directly measuring nuclear reaction rates near stellar energies is their small cross sections. The signal-to-background ratio in these complex experiments can be significantly improved by employing high-current (mA-range) beams and novel detection techniques. Therefore, the electron cyclotron resonance ion source at the Laboratory for Experimental Nuclear Astrophysics underwent a complete upgrade of its acceleration column and microwave system to obtain high-intensity, pulsed proton beams. The new column uses a compression design with O-ring seals for vacuum integrity. Its voltage gradient between electrode sections is produced by the parallel resistance of channels of chilled, deionized water. It also incorporates alternating, transverse magnetic fields for electron suppression and an axially adjustable beam extraction system. Following this upgrade, the operational bremsstrahlung radiation levels and high-voltage stability of the source were vastly improved, over 3.5 mA of target beam current was achieved, and an order-of-magnitude increase in normalized brightness was measured. Beam optics calculations, structural design, and further performance results for this source are presented.

Preoperative Circulating Tumor DNA in Patients with Peritoneal Carcinomatosis is an Independent Predictor of Progression-Free Survival

BACKGROUND

Next-generation sequencing (NGS) is a useful tool for detecting genomic alterations in circulating tumor DNA (ctDNA). To date, most ctDNA tests have been performed on patients with widely metastatic disease. Patients with peritoneal carcinomatosis (metastases) present unique prognostic and therapeutic challenges. We therefore explored preoperative ctDNA in patients with peritoneal metastases undergoing surgery.

METHODS

Patients referred for surgical resection of peritoneal metastases underwent preoperative blood-derived ctDNA analysis (clinical-grade NGS [68-73 genes]). ctDNA was quantified as the percentage of altered circulating cell-free DNA (% cfDNA).

RESULTS

Eighty patients had ctDNA testing: 46 (57.5%) women; median age 55.5 years. The following diagnoses were included: 59 patients (73.8%), appendix cancer; 11 (13.8%), colorectal; five (6.3%), peritoneal mesothelioma; two (2.5%), small bowel; one (1.3%) each of cholangiocarcinoma, ovarian, and testicular cancer. Thirty-one patients (38.8%) had detectable preoperative ctDNA alterations, most frequently in the following genes: TP53 (25.8% of all alterations detected) and KRAS (11.3%). Among 15 patients with tissue DNA NGS, 33.3% also had ctDNA alterations (overall concordance = 96.7%). Patients with high ctDNA quantities (≥ 0.25% cfDNA, n = 25) had a shorter progression-free survival (PFS) than those with lower ctDNA quantities (n = 55; 7.8 vs. 15.0 months; hazard ratio 3.23, 95% confidence interval 1.43-7.28, p = 0.005 univariate, p = 0.044 multivariate).

CONCLUSIONS

A significant proportion of patients with peritoneal metastases referred for surgical intervention have detectable ctDNA alterations preoperatively. Patients with high levels of ctDNA have a worse prognosis independent of histologic grade.

Cirrhosis is not a contraindication to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in highly selected patients

BACKGROUND

Patient selection for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is critically important to optimizing outcomes. There is currently no literature regarding the safety of CRS/HIPEC in patients with cirrhosis. The aim of this case series is to report the outcomes of three patients with well-compensated cirrhosis who underwent CRS/HIPEC.

METHODS

Patients were identified from a prospectively maintained peritoneal surface malignancy database. Patient, tumor, and operative-related details were recorded as short-term postoperative outcomes. Results were analyzed using descriptive statistics.

RESULTS

All patients had well-compensated (Child-Pugh Class A) cirrhosis and Eastern Cooperative Oncology Group (ECOG) performance status of 0. One patient had preoperative evidence of portal hypertension. All safely underwent CRS/HIPEC with completeness of cytoreduction (CC) scores of 0. The postoperative morbidity profile was unique, but all complications were manageable and resulted in full recovery to preoperative baseline status.

CONCLUSIONS

Patient selection for CRS/HIPEC is critical for optimization of short- and long-term outcomes. This small series suggests that well-compensated cirrhosis should not be an absolute contraindication to CRS/HIPEC.

Circulating tumor DNA (ctDNA) landscape and prognostic implications in advanced gastroesophageal adenocarcinoma (GEC)

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Background: Esophagogastric junction (EGJ) and gastric (GC) cancer, together GEA, have a poor prognosis, high molecular heterogeneity, and few targeted therapeutic options. Guardant360 is a clinical gene panel test for next generation sequencing (NGS) of plasma circulating tumor (ct) DNA. Methods: We evaluated a large cohort of ctDNA-derived genomic results (Guardant Health, Inc.), including a subset of pts from the University of Chicago (UC) with clinical data. GEA pts in these 2 cohorts were assessed for genomic alteration (GA) distribution: mutations (mt), indels, amplifications (amp) and fusions. UC survival analyses were performed using log-rank test and select gene-by-gene alteration frequency by pt with chi-square comparisons. Results: The overall ctDNA cohort comprised 1128 pts with median age 64 yrs (range 19-98) and 73% males. At least 1 detectable GA (median 4, range 0-102) was observed in 870 pts (77%). The UC subset of pts (n=171), median age 63 yrs (range 19-87), included 2/10/27/61% stage I/II/III/IV, 77/13/5/5% Caucasian/African American/Asian/Hispanic, 74% male and 63% EGJ. At least 1 detectable GA (median 4, range 1-102) was observed in 157 pts; median GAs per test by stage I vs II/III vs IV was 1.5/3.5/4.5. GA distributions were similar to the larger cohort (Table 1). Stage IV pts tested within 6 weeks of diagnosis/recurrence (n=34) had a median survival of 8.7 months. In these pts, BRAF/ FGFR2 amps and ARAF mts were each prognostic for worse survival ( p<0.05), and MET and KRAS amps trended towards significance. Mt allele frequency (MAF) ctDNA burden inversely correlated with survival ( p=0.01) . In 138 pts with ≥2 serial tests, non-synonymous GAs in MET, PIK3CA, and FGFR1 were more commonly late events (all p<0.05 ). Conclusions: GAs in plasma ctDNA were detected in 77% of GEA pts including numerous actionable targets. ctDNA analysis merits further evaluation as a prognostic biomarker assessing specific genes, overall ctDNA burden, and molecular heterogeneity at baseline and serially. [Table: see text]

Indocyanine green fluorescence-guided parathyroidectomy for primary hyperparathyroidism

BACKGROUND

Our aim was to evaluate the ease and utility of using indocyanine green fluorescence angiography for intraoperative localization of the parathyroid glands.

METHODS

Indocyanine green fluorescence angiography was performed during 60 parathyroidectomies for primary hyperparathyroidism during a 22-month period. Indocyanine green was administered intravenously to guide operative navigation using a commercially available fluorescence imaging system. Video files were graded by 3 independent surgeons for strength of enhancement using an adapted numeric scoring system.

RESULTS

There were 46 (77%) female patients and 14 (23%) male patients whose ages ranged from 17 to 87 (average 60) years old. Of the 60 patients, 43 (71.6%) showed strong enhancement, 13 (21.7%) demonstrated mild to moderate vascular enhancement, and 4 (6.7%) exhibited little or no vascular enhancement. Of the 54 patients who had a preoperative sestamibi scan, a parathyroid adenoma was identified in 36, while 18 failed to localize. Of the 18 patients who failed to localize, all 18 patients (100%) had an adenoma that fluoresced on indocyanine green imaging. The operations were performed safely with minimal blood loss and short operative times.

CONCLUSION

Indocyanine green angiography has the potential to assist surgeons in identifying parathyroid glands rapidly with minimal risk.

Factors Associated with 60-Day Readmission Following Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy

INTRODUCTION

Readmission rates following surgery are subject to scrutiny in efforts to control health care costs. This study was designed to define the 60-day readmission rate following cytoreduction and HIPEC at a high-volume center and to identify factors associated with readmission.

METHODS

Patients who underwent complete cytoreduction and HIPEC at a single institution from August 2007 through June 2014 were identified from a prospectively maintained database. Multiple preoperative and operative factors were analyzed for their ability to predict 60-day readmission following surgery.

RESULTS

A total of 250 patients were identified. Forty patients (17%) experienced readmission within 60 days of surgery. The most common reasons for readmission were ileus/dehydration (12, 31%), deep space infection (8, 21%), and DVT/PE (6, 15%). Initial postoperative length of stay was longer for patients readmitted within 60 days (median 12 vs. 9 days, p = 0.013). Of categorical variables analyzed, including gender, histology, HIPEC agent, intraoperative transfusion, and individual procedures performed during cytoreduction, adjuvant systemic therapy, and postoperative morbidity, only Charlson comorbidity index CCI (odds ratio (OR) = 3.80 [1.68-8.60]) and stoma creation (OR = 6.04 [1.56-12.14]) were associated with 60-day readmission.

CONCLUSIONS

Few measurable variables are associated with readmission following cytoreduction and HIPEC. Patients with high CCI and those with stomas created at the time of CRS/HIPEC may be at increased risk of readmission within 60 days. Earlier or more frequent follow-up for high-risk patients should be considered as a strategy to reduce readmissions.

Renal Tubular Cell-Derived Extracellular Vesicles Accelerate the Recovery of Established Renal Ischemia Reperfusion Injury

Ischemic renal injury is a complex syndrome; multiple cellular abnormalities cause accelerating cycles of inflammation, cellular damage, and sustained local ischemia. There is no single therapy that effectively resolves the renal damage after ischemia. However, infusions of normal adult rat renal cells have been a successful therapy in several rat renal failure models. The sustained broad renal benefit achieved by relatively few donor cells led to the hypothesis that extracellular vesicles (EV, largely exosomes) derived from these cells are the therapeutic effector in situ We now show that EV from adult rat renal tubular cells significantly improved renal function when administered intravenously 24 and 48 hours after renal ischemia in rats. Additionally, EV treatment significantly improved renal tubular damage, 4-hydroxynanoneal adduct formation, neutrophil infiltration, fibrosis, and microvascular pruning. EV therapy also markedly reduced the large renal transcriptome drift observed after ischemia. These data show the potential utility of EV to limit severe renal ischemic injury after the occurrence.

Overinterpretation is common in pathological diagnosis of appendix cancer during patient referral for oncologic care

CONTEXT

Low-grade appendiceal mucinous neoplasm (LAMN) and appendiceal adenocarcinoma are known to cause the majority of pseudomyxoma peritonei (PMP, i.e. mucinous ascites); however, recognition and proper classification of these neoplasms can be difficult despite established diagnostic criteria.

OBJECTIVE

To determine the pathological diagnostic concordance for appendix neoplasia and related lesions during patient referral to an academic medical center specialized in treating patients with PMP.

DESIGN

The anatomic pathology laboratory information system was searched to identify cases over a two-year period containing appendix specimens with mucinous neoplasia evaluated by an outside pathology group and by in-house slide review at a single large academic medical center during patient referral.

RESULTS

161 cases containing appendix specimens were identified over this period. Forty-six of 161 cases (28.6%) contained appendiceal primary neoplasia or lesions. Of these, the originating pathologist diagnosed 23 cases (50%) as adenocarcinoma and 23 cases (50%) as LAMN; however, the reference pathologist diagnosed 29 cases (63.0%) as LAMN, 13 cases (28.3%) as adenocarcinoma, and 4 cases (8.7%) as ruptured simple mucocele. Importantly, for cases in which the originating pathologist rendered a diagnosis of adenocarcinoma, the reference pathologist rendered a diagnosis of adenocarcinoma (56.5%, 13 of 23), LAMN (39.1%, 9 of 23), or simple mucocele (4.3%, 1 of 23). The overall diagnostic concordance rate for these major classifications was 71.7% (33 of 46) with an unweighted observed kappa value of 0.48 (95% CI, 0.27-0.69), consistent with moderate interobserver agreement. All of the observed discordance (28.3%) for major classifications could be attributed to over-interpretation. In addition, the majority of LAMN cases (65.5%) had potential diagnostic deficiencies including over-interpretation as adenocarcinoma and lacking or discordant risk stratification (i.e. documentation of extra-appendiceal neoplastic epithelium).

CONCLUSIONS

Appendiceal mucinous lesions remain a difficult area for appropriate pathological classification with substantial discordance due to over-interpretation in this study. The findings highlight the critical need for recognition and application of diagnostic criteria regarding these tumors. Recently published consensus guidelines and a checklist provided herein may help facilitate improvement of diagnostic concordance and thereby reduce over-interpretation and potential overtreatment. Further studies are needed to determine the extent of this phenomenon and its potential clinical impact.

The benefits and limitations of robotic assisted transhiatal esophagectomy for esophageal cancer

Robotic-assisted transhiatal esophagectomy (RATE) is a minimally invasive approach to total esophagectomy with less morbidity but equivalent efficacy when compared with the traditional open approach. The robotic platform offers numerous technical advantages that assist with the esophageal dissection, which allows the procedure to be completed without entry into the thoracic cavity. The major criticism of the transhiatal approach is that it forfeits the ability of the surgeon to perform a formal lymphadenectomy, but this does not appear to affect long-term survival.

Human Trial of a Genetically Modified Herpes Simplex Virus for Rapid Detection of Positive Peritoneal Cytology in the Staging of Pancreatic Cancer

Introduction

Patients with peritoneal dissemination of pancreatic adenocarcinoma do not benefit from surgical resection, but radiologic and cytologic detection of peritoneal cancer lack sensitivity. This trial sought to determine if an oncolytic virus may be used as a diagnostic agent to detect peritoneal cancer.

Methods

Peritoneal washings from patients with pancreatic adenocarcinoma were incubated with the enhanced green fluorescent protein (eGFP)-expressing oncolytic herpes simplex virus (HSV) NV1066. eGFP-positive or negative status was recorded for each specimen and compared to results obtained by conventional cytologic evaluation. These results were correlated with recurrence and survival for patients who underwent R0 resection.

Results

Of 82 patients entered in this trial, 12 (15%) had positive cytology and 50 (61%) had virally-mediated eGFP positive cells in peritoneal washings. All cytology-positive patients were also eGFP positive. HSV-mediated fluorescence detection had sensitivities of 94% and 100% for detection of any and peritoneal metastatic disease; respectively. Median recurrence free and disease specific survival were 6.5 and 18.3 months for eGFP positive patients, versus 12.2 and 36.2 months for eGFP negative patients (P = 0.01 and 0.19); respectively.

Conclusions

A genetically modified HSV can be used as a highly sensitive diagnostic agent for detection of micro-metastatic disease in patients with pancreatic adenocarcinoma and may improve patient selection for surgery.

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Oncolytic virus-mediated fluorescence is a sensitive assay for detection of cancer cells in peritoneal fluid.

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Pancreatic cancer patients with eGFP-positive cells in peritoneal washings had a poor prognosis following surgery.

Pancreatic cancer is an aggressive disease. Even with complete surgical removal of a pancreatic tumor, recurrence is common. Patients with microscopic spread of cancer cells into the abdomen, or peritoneum, do not benefit from surgery. Current methods of detection of this kind of spread are not very sensitive. This study utilized a virus that specifically infects cancer cells and expresses a green fluorescent protein within them to detect peritoneal disease. Viral fluorescence was more sensitive than standard methods for detecting peritoneal disease and may help to identify which patients with pancreas cancer will benefit from surgery.

A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has an emerging role in the treatment of peritoneal malignancies. The CRS-HIPEC approach has known treatment-related toxicities. This study sought to determine the predictors of major postoperative complications after CRS-HIPEC in a high-volume center.

METHODS

From a single-institution database, this study investigated complications experienced by patients undergoing CRS-HIPEC. Multiple preoperative and operative factors were analyzed for their ability to predict 60-day Clavien grade 3 and greater (major) complications by logistic regression. A predictive model was created from preoperative factors using multivariate logistic regression. The model was tested by Akaike's information criterion, the Hosmer and Lemeshow Goodness-of-Fit Test, the receiver operating characteristic, and the Youden Index.

RESULTS

The study evaluated 247 patients undergoing CRS-HIPEC. The primary tumor site was the appendix in 166 cases (67.2 %), the colorectal area in 51 cases (20.6 %), the peritoneum (mesothelioma) in 22 cases (8.9 %), the ovary in 5 cases (2 %), and the small bowel in 3 cases (1.2 %). The median peritoneal cancer index was 14 (range 0-29), and 235 patients (95.1 %) had a complete (CC-0/1) cytoreduction. Major complications occurred for 41 patients (16.6 %), classified as grade 3 in 33 cases (13.4 %), grade 4 in 5 cases (2 %), and grade 5 (deaths) in 3 cases (1.2 %). The factors predictive of major complications in the multivariate analysis were a Charlson Comorbidity Index (CCI) score higher than 0 [odds ratio (OR), 2.505; p = 0.035], presence of preoperative symptoms (OR 1.951; p = 0.064), and prior resection status [no resection or prior CRS-HIPEC (OR 2.087) vs. prior resection without CRS-HIPEC (OR 3.209); p = 0.046]. These variables were used to create a tool predictive of postoperative complications.

CONCLUSION

Presence of symptoms, CCI, and prior resection status predict major complications and define a low-risk population after CRS-HIPEC.

Management of Appendix Cancer

Primary cancers of the appendix are rare and are frequently diagnosed after surgery for appendicitis, presumed ovarian primary malignancy, or other indications. Primary appendix cancers are histologically diverse, and classification of these tumors has historically been confusing because of the nonstandardized nomenclature that is used. This review aimed to describe the epidemiology, presentation, workup, staging, and management of primary appendix cancers using current, recommended nomenclature. For this purpose, tumors were broadly classified as colonic-type or mucinous adenocarcinoma, goblet cell adenocarcinoma, or neuroendocrine carcinoma. Signet ring cell carcinoma was not regarded as an individual entity. The presence of signet ring cells is a histologic feature that may or may not be present in colonic-type or mucinous adenocarcinoma. The management of primary appendix cancer is complex and is dependent on the histologic subtype and extent of disease. Randomized, prospective trials do not exist for these rare tumors and management is largely guided by retrospective data expert consensus guidelines, which are summarized here.

Laparoscopy is Safe and Accurate to Evaluate Peritoneal Surface Metastasis Prior to Cytoreductive Surgery

BACKGROUND

Completeness of cytoreduction is a significant predictor of long-term outcome after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Imaging has limited sensitivity to identify peritoneal metastases and therefore predict whether complete cytoreduction is possible. We reviewed our experience using laparoscopy to determine candidates for complete cytoreduction and HIPEC.

METHODS

This single-center, retrospective study examined patients from 2007 to 2014 who underwent laparoscopy to determine complete cytoreduction (CC-0/1)/HIPEC candidacy. Preoperative, intraoperative, and postoperative data were collected.

RESULTS

A total of 145 laparoscopies were performed on 141 patients, 72 (51.1 %) of whom were female, with a median age of 53 years (range 20-79). The primary site was appendiceal in 67 (47.5 %) patients, colorectal in 43 (30.5 %), mesothelioma in 17 (12.1 %), unknown in 9 (6.4 %), small bowel in 3 (2.1 %), gastric in 1, and ovarian in 1 (0.7 % each). Overall, 115 (81.6 %) patients had prior abdominal surgery, 111 (76.6 %) had evidence of disease on imaging, and 117 (80.7 %) underwent prior chemotherapy, with a median of 5.9 weeks between the last treatment and laparoscopy (0.9-498.9 weeks). Four (2.8 %) intraoperative complications were observed (one liver laceration, two enterotomies, and one air embolus), and nine (6.2 %) postoperative complications [four (2.8 %) Clavien grade (CG) I, three (2.8 %) CG II, one (0.7 %) CG III (return to operating room) and one (0.7 %) CG IV (transient ischemic attack)]. Forty-eight patients deemed candidates by laparoscopy underwent CRS/HIPEC (positive predictive value 82.8 %).

CONCLUSION

Diagnostic laparoscopy is a safe, feasible, and accurate staging tool in patients with suspected peritoneal metastases being considered for CRS.

Laparoscopic Versus Open Gastrectomy for Gastric Adenocarcinoma in the West: A Case-Control Study

INTRODUCTION

Data on laparoscopic gastrectomy in patients with gastric cancer in the Western hemisphere are lacking. This study aimed to compare outcomes following laparoscopic versus open gastrectomy for gastric adenocarcinoma at a Western center.

METHODS

Eighty-seven consecutive patients who underwent laparoscopic gastrectomy from November 2005 to April 2013 were compared with 87 patients undergoing open resection during the same time period. Patients were matched for age, stage, body mass index, and procedure (distal subtotal vs. total gastrectomy). Endpoints were short- and long-term perioperative outcomes.

RESULTS

Overall, 65 patients (37 %) had locally advanced disease, and 40 (23 %) had proximal tumors. The laparoscopic approach was associated with longer operative time (median 240 vs.165 min; p < 0.01), less blood loss (100 vs.150 mL; p < 0.01), higher rate of microscopic margin positivity (9 vs.1 %; p = 0.04), decreased duration of narcotic and epidural use (2 vs. 4 days, p = 0.04, and 3 vs. 4 days, p = 0.02, respectively), decreased minor complications in the early (27 vs. 16 %) and late (17 vs. 7 %) postoperative periods (p < 0.01), decreased length of stay (5 vs. 7 days; p = 0.01), and increased likelihood of receiving adjuvant therapy (82 vs. 51 %; p < 0.01). There was no difference in the number of lymph nodes retrieved (median 20 in both groups), major morbidity, or 30-day mortality.

CONCLUSIONS

Laparoscopic gastrectomy for gastric adenocarcinoma is safe and effective for select patients in the West.

Laparoscopic evacuation of mucinous ascites for palliation of pseudomyxoma peritonei

INTRODUCTION

Accumulation of mucinous ascites causes significant morbidity for patients with unresectable pseudomyxoma peritonei (PMP). The success of paracentesis for mucin evacuation is limited due to the presence of adhesions, disease burden, and the viscous nature of mucinous ascites. We sought to review our experience with laparoscopic evacuation of mucinous ascites for palliation of PMP.

METHODS

Records were reviewed for patients who underwent laparoscopy for carcinomatosis secondary to appendix or colon cancer from July 2007 to January 2014. Of 123 patients, 10 were identified who underwent 17 laparoscopic procedures for palliative evacuation of mucinous ascites.

RESULTS

All patients had primary appendiceal cancers and all presented with symptomatic ascites causing abdominal distension and bloating. Pneumoperitoneum was established with a Veress needle or 5-mm optical viewing trocar in the majority of cases (n = 11). In the remaining six cases, an open technique was used and a 10-mm Hasson trocar was placed. There were no trocar-related complications. The median volume of mucin evacuated was 2.0 liters (range 1.7-8.0). All procedures were done as same-day surgeries; no patients required hospitalization. All patients reported symptomatic improvement following the procedure. One patient experienced a grade 1 complication of persistent drainage from one incision, which was managed in the outpatient setting. The median follow-up for all pts was 9.1 months. The median time to recurrent symptoms requiring repeat intervention was 5.3 months.

CONCLUSIONS

Laparoscopic evacuation of mucinous ascites for select patients with PMP is feasible and results in significant, durable symptom control with minimal morbidity.

Predictors of progression in high-grade appendiceal or colorectal peritoneal carcinomatosis after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Long-term survival of patients with appendiceal or colorectal peritoneal carcinomatosis (PC) may be achieved by combining cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). Unfortunately, such favorable outcomes are realized in a minority of patients. Given the morbidity of the CRS/HIPEC and the uncertain role of postresection systemic therapy, it is important that prognostic factors in high-grade PC be clearly defined.

METHODS

This single center, retrospective, cohort study examined the outcomes of CRS/HIPEC performed on patients with high-grade PC secondary to appendiceal or colorectal adenocarcinoma between 2007 and 2013. Cox regression analysis was utilized to evaluate the association between potential prognostic factors [age, sex, primary site, lymph node (LN) status, peritoneal cancer index (PCI) score, completeness of cytoreduction score (CC score), number of visceral resections, and systemic chemotherapy] and progression-free survival (PFS).

RESULTS

A total of 70 patients with high-grade appendiceal or colorectal PC underwent CRS/HIPEC during the study period; 82.9 % underwent complete (CC-0) cytoreduction with a median PFS of 9.7 months. Positive LNs at the time of CRS/HIPEC were predictors of worse PFS on univariate and multivariate analysis. No association was demonstrated between pre- or post-HIPEC systemic chemotherapy and PFS.

CONCLUSIONS

High-grade PC secondary to appendiceal or colorectal adenocarcinoma can be managed with CRS/HIPEC. The number of LN metastases at the time of CRS/HIPEC is the strongest predictor of progression and must be considered when determining patient eligibility for this aggressive treatment.

Impact of cardiac comorbidity on early outcomes after pancreatic resection

BACKGROUND

In patients undergoing pancreatic resection (PR), identification of subgroups at increased risk for postoperative complications can allow focused interventions that may improve outcomes.

STUDY DESIGN

Patients undergoing PR from 2005-2010 were selected from the American College of Surgeons National Surgical Quality Improvement Program database and categorized as having any history of cardiac disease (angina, congestive heart failure (CHF), myocardial infarction (MI), cardiac stent, or bypass) or as having acute cardiac disease (symptoms of CHF or angina within 30 days or MI within 6 months). These variables were utilized to examine the relationship between cardiac disease and outcomes after PR.

RESULTS

The rate of serious complications and perioperative mortality in patients with any history of cardiac disease vs. those without was 34 vs. 24 % (p < 0.001) and 4.5 vs. 2.0 % (p < 0.001), respectively, and in patients with acute cardiac disease compared to patients without was 37 vs. 25 % (p < 0.001) and 8.6 vs. 2.2 % (p < 0.001), respectively. In multivariate analysis, the two cardiac disease variables remained associated with mortality.

CONCLUSIONS

In patients undergoing PR, cardiac disease is a significant risk factor for adverse outcomes. These observations are critical for meaningful informed consent in patients considering pancreatectomy.

Prognostic significance of the highest peripancreatic lymph node in biliary tract adenocarcinoma

BACKGROUND

Patients with biliary tract adenocarcinoma with nodal involvement have a poor prognosis. There is currently no standardized method for intraoperative lymph node assessment. The current study aimed to determine the prognostic significance of the highest peripancreatic lymph node (HPLN) in biliary tract malignancy.

METHODS

This was a retrospective study of patients undergoing potential curative resection of biliary tract adenocarcinoma from January 1995 through December 2010 who prospectively had intraoperative sampling of the HPLN. The median follow-up was 72.8 months. The primary end points were recurrence-free survival (RFS) and disease-specific survival (DSS).

RESULTS

The rate of HPLN positivity in 110 patients undergoing exploration for potential curative resection was 30 % and did not vary with histologic subtype (gallbladder vs. cholangiocarcinoma). Eighty-five patients underwent complete gross resection. In this subset, median RFS and DSS were 34.3 months (95 % confidence interval [CI] 23.6-not reached [NR]) and 62.4 months (95 % CI 40.8-NR) for HPLN-negative patients, and 9.6 months (95 % CI 4.76-NR) and 20.5 months (95 % CI 7.4-NR) for HPLN-positive patients (p < 0.01), respectively. Median DSS was 14.6 months (95 % CI 9.6-25.4) for patients with unresectable disease. On multivariate analysis, HPLN status was an independent predictor of RFS (hazard ratio 3.73, 95 % CI 1.86-7.45; p < 0.01) and DSS (hazard ratio 3.98, 95 % CI 1.89-8.38; p < 0.01).

CONCLUSIONS

HPLN status is prognostic of RFS and DSS in biliary tract adenocarcinoma. Intraoperative nodal staging by HPLN sampling warrants further investigation in a prospective trial.

Peritoneal debulking/intraperitoneal chemotherapy-non-sarcoma

The combination of cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) is widely practiced for appendiceal, colorectal, gastric, and ovarian cancers with isolated peritoneal metastasis as well as for primary peritoneal cancer. The aim of this report is to explain the rationale and available techniques for CRS and IPC, and to highlight disease-specific considerations that should be taken into account when evaluating potential candidates for CRS and IPC.

Internal hernia after gastrectomy for cancer with Roux-Y reconstruction

BACKGROUND

The incidence of internal hernia (IH) after gastrectomy for cancer with Roux-Y reconstruction has not been well-defined. This study aimed to define the true incidence of IH after gastrectomy for cancer with Roux-Y reconstruction; to describe the presentation, timing, and management of this complication; and to identify factors associated with IH.

METHODS

Clinical and follow-up information were reviewed for all patients who underwent open or laparoscopic gastrectomy with Roux-Y reconstruction for cancer at a single institution from January 2005 through April 2012.

RESULTS

A total of 298 patients underwent gastrectomy for cancer with Roux-Y reconstruction. At a median follow-up of 22.4 months, we identified 16 patients (5%) who underwent subsequent reoperation for IH. No patient who had closure of mesenteric defects developed IH. IH occurred in 1 of 99 patients after open subtotal gastrectomy (1%), 10 of 165 after open total gastrectomy (6%), 1 of 16 after laparoscopic subtotal gastrectomy (6%), and 4 of 18 after laparoscopic total gastrectomy (22%; P < .03). On univariate analysis, younger age, lower body mass index, no previous abdominal surgery, laparoscopic approach, and total gastrectomy were associated with IH. IH tended to occur early after laparoscopic gastrectomy (median, 7 months) and late after open gastrectomy (median, 24 months).

CONCLUSION

IH after gastrectomy with Roux-Y reconstruction is likely underreported. A high degree of suspicion for IH should be maintained in patients presenting with emesis or abdominal pain after gastrectomy with Roux-Y reconstruction, especially after laparoscopic or total gastrectomy. Closure of mesenteric defects after laparoscopic and total gastrectomy should be considered when technically feasible.

Vein involvement during pancreaticoduodenectomy: is there a need for redefinition of "borderline resectable disease"?

INTRODUCTION

Current National Comprehensive Cancer Network guidelines recommend neoadjuvant therapy for borderline resectable pancreatic adenocarcinoma to increase the likelihood of achieving R0 resection. A consensus has not been reached on the degree of venous involvement that constitutes borderline resectability. This study compares the outcome of patients who underwent pancreaticoduodenectomy with or without vein resection without neoadjuvant therapy.

METHODS

A multi-institutional database of patients who underwent pancreaticoduodenectomy was reviewed. Patients who required vein resection due to gross vein involvement by tumor were compared to those without evidence of vein involvement.

RESULTS

Of 492 patients undergoing pancreaticoduodenectomy, 70 (14 %) had vein resection and 422 (86 %) did not. There was no difference in R0 resection (66 vs. 75 %, p = NS). On multivariate analysis, vein involvement was not predictive of disease-free or overall survival.

CONCLUSION

This is the largest modern series examining patients with or without isolated vein involvement by pancreas cancer, none of whom received neoadjuvant therapy. Oncological outcome was not different between the two groups. These data suggest that up-front surgical resection is an appropriate option and call into question the inclusion of isolated vein involvement in the definition of "borderline resectable disease."