Single-Institution Retrospective Comparison of Preoperative Versus Definitive Chemoradiotherapy for Adenocarcinoma of the Esophagus

Purpose

We sought to determine the impact of esophagectomy on survival in patients with adenocarcinoma of the esophagus cancer after chemoradiotherapy (CRT).

Methods

A database of esophageal cancer was queried for nonmetastatic patients with adenocarcinoma treated between 2000 and 2011 with CRT. Overall survival (OS) and recurrence-free survival (RFS) curves were calculated according to the Kaplan–Meier method and log-rank analysis. Multivariate analysis was performed by the Cox proportional hazard model.

Results

We identified 154 patients (60 without surgery; 94 with surgery) who were included in the analysis. The only differences between the 2 groups were more advanced disease stage, improved performance status, and younger age in the surgery group. Patients undergoing surgery had significantly higher survival. Median and 5-year OS for surgical patients were 4.1 years and 43.6 %, versus 1.9 years and 35.6 % for nonsurgical patients (p = 0.007). Multivariate analysis for OS and RFS revealed that factors associated with increased survival were surgical resection, tumor length < 5 cm, male gender, and lower stage. Age, tumor location, radiation dose/technique, and induction chemotherapy were not prognostic. There was a trend toward improved survival on univariate analysis (p = 0.10) and multivariate analysis (p = 0.063) for surgical patients compared to nonsurgical patients who were healthy enough for surgery before CRT (n = 38), and no difference in OS in nonsurgical patients healthy enough for surgery after CRT (n = 22).

Conclusion

Esophagectomy after CRT is associated with improved survival in patients with adenocarcinoma after CRT. Trimodal therapy should continue to remain the standard of care for esophageal adenocarcinoma.     

Open Versus Minimally Invasive Resection of Gastric GIST: A Multi-Institutional Analysis of Short- and Long-Term Outcomes

Background

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Overall surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of GIST are limited to small, single-institution experiences.

Methods

A total of 397 patients who underwent open surgery (n = 230) or MIS (n = 167) for a gastric GIST between 1998 and 2012 were identified from a multicenter database. The impact of MIS approach on recurrence and survival was analyzed using propensity-score matching by comparing clinicopathologic factors between patients who underwent MIS versus open resection.

Results

There were 19 conversions (10 %) to open; the most common reasons for conversion were tumor more extensive than anticipated (26 %) and unclear anatomy (21 %). On multivariate analysis, smaller tumor size and higher body mass index (BMI) were associated with receipt of MIS. In the propensity-matched cohort (n = 248), MIS resection was associated with decreased length of stay (MIS, 3 days vs open, 8 days) and fewer ≥ grade 3 complications (MIS, 3 % vs open, 14 %) compared with open surgery. High rates of R0 resection and low rates of tumor rupture were seen in both groups. After propensity-score matching, there was no difference in recurrence-free or overall survival comparing the MIS and the open group (both p > 0.05).

Conclusions

An MIS approach for gastric GIST was associated with low morbidity and a high rate of R0 resection. The long-term oncological outcome following MIS was excellent, and therefore the MIS approach should be considered the preferred approach for gastric GIST in well-selected patients.     

Screening Mammography Following Autologous Breast Reconstruction: An Unnecessary Effort

Background

Currently, no standard guidelines exist regarding routine screening imaging in breast cancer patients following autologous reconstruction. Concern over nonpalpable chest wall recurrence has prompted many to pursue screening imaging. We analyzed the pattern of locoregional recurrence (LRR) and yield of screening imaging and exam in these patients.

Methods

We performed a retrospective chart review of all patients who had mastectomy with autologous reconstruction between 2000 and 2009. Presentation of LRR and utility of imaging and breast exam were analyzed. Screening mammography was performed at the discretion of the treating physicians.

Results

A total of 615 patients were identified and follow-up data were available for 541. Median follow-up from time of reconstruction was 7 years. Twenty-seven patients developed a LRR (5.0 %). Among patients screened with mammography (n = 397), an abnormality led to 25 biopsies in 25 patients, and 2 were malignant (8 %). Among patients receiving routine clinical exam (n = 537), an abnormality led to 77 biopsies in 66 patients, and 30 were malignant (39 %). The median time from cancer surgery to LRR was 2.6 years. LRR was detected on clinical exam in 24 of 27 patients (88.9 %). Screening mammography detected two recurrences that were palpable on follow-up exam. One patient had an incidental chest wall recurrence found on PET/CT. In summary, 26 of 27 (96.3 %) patients had a clinically detectable LRR.

Conclusions

Diligent surveillance with clinical breast exam is a reliable method of detecting LRR after autologous reconstruction, identifying 96.3 % of recurrences in our study. Our results do not support routine mammographic screening in this population.     

Differences in Perioperative Care at Low- and High-Mortality Hospitals with Cancer Surgery

Objective

To evaluate adherence to perioperative processes of care associated with major cancer resections.

Background

Mortality rates associated with major cancer resections vary across hospitals. Because mechanisms underlying such variations are not well-established, we studied adherence to perioperative care processes.

Methods

There were 1,279 hospitals participating in the National Cancer DataBase (2005–2006) ranked on a composite measure of mortality for bladder, colon, esophagus, stomach, lung, and pancreas cancer operations. We sampled hospitals from among those with the lowest and highest mortality rates, with 19 low-mortality hospitals [(LMHs), risk-adjusted mortality rate of 2.84 %] and 30 high-mortality hospitals [(HMHs), risk-adjusted mortality rate of 7.37 %]. We then conducted onsite chart reviews. Using logistic regression, we examined differences in perioperative care, adjusting for patient and tumor characteristics.

Results

Compared to LMHs, HMHs were less likely to use prophylaxis against venous thromboembolism, either preoperative or postoperatively [adjusted relative risk (aRR) 0.74, 95 % CI 0.50–0.92 and aRR 0.80, 95 % CI 0.56–0.93, respectively]. The two hospital groups were indistinguishable with respect to processes aimed at preventing surgical site infections, such as the use of antibiotics prior to incision (aRR, 0.99, 95 % CI 0.90–1.04), and processes intended to prevent cardiac events, including the use of β-blockers (1.00, 95 % CI 0.81–1.14). HMHs were significantly less likely to use epidurals (aRR, 0.57, 95 % CI 0.32–0.93).

Conclusions

HMHs and LMHs differ in several aspects of perioperative care. These areas may represent opportunities for improving cancer surgery quality at hospitals with high mortality.     

Efficacy of Adjuvant Radiation Therapy in the Treatment of Soft Tissue Sarcoma of the Extremity: 20-year Follow-Up of a Randomized Prospective Trial

Background

This update of a randomized, prospective study presents the effect of external beam radiation therapy (EBRT) on long-term overall survival, local control, and limb function following limb-sparing surgery (LSS) for the treatment extremity soft tissue sarcoma (STS).

Methods

Following LSS, patients with extremity STS were randomized to receive EBRT or surgery alone. All patients with high-grade STS received adjuvant chemotherapy. Long-term follow-up was obtained through telephone interviews using a questionnaire based on validated methods. Overall survival (OS) was determined by Kaplan–Meier method.

Results

A total of 141 patients with extremity STS were randomized to receive adjuvant EBRT (n = 70) or LSS alone (n = 71). Median follow-up was 17.9 years. The 10- and 20-year survival was 77 % (95 % CI 66–85 %) and 64 % (95 % CI 52–75 %) for patients receiving LSS alone and 82 % (95 % CI 72–90 %) and 71 % (95 % CI 59–81 %) for patients receiving EBRT (p = 0.22). Of the 54 patients who completed telephone interviews, the incidence of local recurrence during the follow-up period was 4 % (1 of 24) in the LSS alone cohort compared with 0 % (0 of 30) in those who received EBRT (p = 0.44). Patients treated with EBRT tended to have more wound complications (17 vs. 12.5 %, p = 0.72), clinically significant edema (25 vs. 12 %, p = 0.31), and functional limb deficits (15 vs. 12 %, p = 0.84).

Conclusions

Adjuvant EBRT following surgery for STS of the extremity provides excellent local control with acceptable treatment-related morbidity and no statistically significant improvement in overall survival.     

Metallic Stent Placement in Patients with Recurrent Malignant Obstruction in the Surgically Altered Stomach

Purpose

The purpose of this study was to assess the technical feasibility and clinical effectiveness of expandable metallic stent placement in 196 patients with recurrent malignant obstruction in their surgically altered stomach.

Methods

The 196 patients were treated using five different types of gastric surgery performed for gastric cancer: total gastrectomy (type 1) in 73 patients; distal gastrectomy with gastroduodenostomy (type 2) in 39 patients; distal gastrectomy with a Roux-en-Y gastrojejunostomy (type 3) in 21 patients; distal gastrectomy with a gastrojejunostomy (type 4) in 49 patients; and palliative gastrojejunostomy for unresectable gastric cancer (type 5) in 14 patients. The technical and clinical success rates, complications, dysphagia score, and influence of chemotherapy were evaluated and the complications compared between the two stent types. The overall survival and stent patency were calculated using the Kaplan–Meier method.

Results

Stent placement was technically successful in 192 of 196 patients (97.9 %), with 184 of the 192 patients (95.8 %) showing symptomatic improvement. The mean dysphagia score improved from 3.24 ± 0.64 to 1.48 ± 0.82 (p < 0.001). The complication rate was 25 %. The incidence of stent migration was significantly higher in fully covered stents and in patients who underwent chemotherapy (p < 0.001 and p = 0.005, respectively). Chemotherapy was significantly associated with an increase of survival (p < 0.001). The median survival and stent patency were 131 and 90 days, respectively.

Conclusion

Placement of expandable metallic stents in patients with recurrent cancer after a surgically altered stomach is technically feasible and clinically effective. Chemotherapy was associated with increased stent migration and prolonged survival.     

Adverse Tumor Biology Associated with Mesenterico-Portal Vein Resection Influences Survival in Patients with Pancreatic Ductal Adenocarcinoma

Background

Although pancreatoduodenectomy (PD) with mesenterico-portal vein resection (VR) can be performed safely in patients with resectable pancreatic ductal adenocarcinoma (PDAC), the impact of this approach on long-term survival is controversial.

Patients and Methods

Analyses of a prospectively collected database revealed 122 consecutive patients with PDAC who underwent PD with (PD+VR) or without (PD?VR) VR between January 2004 and May 2012. Clinical data, operative results, and survival outcomes were analysed.

Results

Sixty-four (53 %) patients underwent PD+VR. The majority (84 %) of the venous reconstructions were performed with a primary end-to-end anastomosis. Demographic and postoperative outcomes were similar between the two groups. American Society of Anesthesiologists (ASA) score, duration of operation, intraoperative blood loss, and blood transfusion requirement were significantly greater in the PD+VR group compared with the PD?VR group. Furthermore, the tumor size was larger, and the rates of periuncinate neural invasion and positive resection margin were higher in the PD+VR group compared with the PD?VR group. Histological venous involvement occurred in 47 of 62 (76 %) patients in the PD+VR group. At a median follow-up of 29 months, the median overall survival (OS) was 18 months for the PD+VR group, and 31 months for the PD?VR group (p = 0.016). ASA score, lymph node metastasis, neurovascular invasion, and tumor differentiation were predictive of survival. The need for VR in itself was not prognostic of survival.

Conclusions

PD with VR has similar morbidity but worse OS compared with a PD?VR. Although VR is not predictive of survival, tumors requiring a PD+VR have more adverse biological features.     

Morbidity and Mortality Associated with Gastrectomy for Gastric Cancer

Background

Surgery alone is often inadequate for advanced-stage gastric cancer. Surgical complications may delay adjuvant therapy. Understanding these complications is needed for multidisciplinary planning.

Material and Methods

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent gastrectomy for malignancy (ICD-9 code 151.x) from 2005 to 2010. Thirty-day mortality and morbidity were evaluated.

Results

Overall, 2,580 patients underwent gastrectomy for malignancy, divided as total gastrectomy 999 (38.7 %) and partial gastrectomy 1,581 (61.3 %). Overall, serious morbidity occurred in 23.6 %, and the 30-day mortality was 4.1 %. Patients receiving a total gastrectomy were younger and healthier than those receiving a partial gastrectomy for the following measured criteria: age, diabetes, chronic obstructive pulmonary disease and hypertension. Serious morbidity and mortality were significantly higher in the total gastrectomy group than the partial gastrectomy group (29.3 vs. 19.9 %, p < 0.001; and 5.4 vs. 3.4 %, p < 0.015, respectively). The inclusion of additional procedures increased the risk of mortality for the following: splenectomy (odds ratio [OR] 2.8; p < 0.001), pancreatectomy (OR 3.5; p = 0.001), colectomy (OR 3.6; p < 0.001), enterectomy (OR 2.7; p = 0.030), esophagectomy (OR 3.5; p = 0.035). Abdominal lymphadenectomy was not associated with increased morbidity (OR 1.1; p = 0.41); rather, it was associated with decreased mortality (OR 0.468; p = 0.028).

Conclusions

Gastrectomy for cancer as currently practiced carries significant morbidity and mortality. Inclusion of additional major procedures increases these risks. The addition of lymphadenectomy was not associated with increased morbidity or mortality. Strategies are needed to optimize surgical outcomes to ensure delivery of multimodality therapy for advanced-stage disease.     

The Effect of Elevated Body Mass Index on Outcomes Following Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

Background

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) can prolong survival in peritoneal-based malignancies. These malignancies harbor in visceral and omental adipose tissue, and as a result, obesity may contribute to greater tumor burden. Obesity also is an independent risk factor for perioperative complications following major surgery. No studies to date have investigated the effect of elevated body mass index (BMI) on disease burden and perioperative outcomes in CRS-HIPEC patients.

Methods

Observational study of consecutive patients taken to the operating suite from 2007 to 2012 for CRS-HIPEC. Data were reviewed retrospectively, and patients for whom complete cytoreduction was not achieved and those with BMI <18.5 were excluded. Various operative data points, including peritoneal cancer index, surgery length, and estimated blood loss, were measured prospectively. Perioperative complications were identified and recorded.

Results

Complete data for review was available for 114 patients. Patients were subdivided based on BMI (group A 18.5–24.9, n = 43; group B 25–29.9, n = 49; group C ≥ 30, n = 22). There was no statistically significant difference in tumor burden, operative length, probability of unresectable disease, operative blood loss, or length of stay between groups. Rates of respiratory, gastrointestinal, infectious, renal, and hematologic complications were not statistically different, with the exception of deep vein thrombosis (A = 0, B = 13.5 %, C = 0; p = 0.026).

Conclusions

CRS-HIPEC can be safely performed in overweight and obese patients without significant increase in perioperative morbidity. Despite the limitations in physical examination and increase in visceral fat, they do not appear to present later than patients with normal BMI, nor do they have higher tumor burden.     

Ovarian Cancer in BRCA Mutation Carriers: Improved Outcome After Intraperitoneal (IP) Cisplatin

Background

Ovarian cancer arising in women with BRCA mutations is known to have a more favorable outcome and to be more responsive to platinum-based regimens than in those without a hereditary background. We analyze our previously published intraperitoneal (IP) studies in relation to BRCA mutation status and update their outcomes.

Methods

Among 62 patients with ovarian cancer enrolled in IP platinum doublet studies in clinical trials (with etoposide (n = 18), with floxuridine (n = 30), and with topotecan (n = 14)), a deleterious BRCA mutation was eventually identified in 10 patients. The outcomes in these BRCA mutation carriers are described and compared with survival of others in respective trials.

Results

Ten patients that were confirmed to have BRCA mutations—all with high-grade and stages IIC to IV disease—survived a median of 10 years (range: 4–18+) after receiving IP cisplatin-based regimens. Two continue with no evidence of disease since their IP treatment, while four others remain alive with recurrences after 8, 9, 10, and 11 years, respectively.

Conclusions

This experience suggests that IP cisplatin leads to favorable long term outcomes in advanced ovarian cancer in women with defective homologous recombination (i.e., with deleterious BRCA mutations). Whether such cisplatin dose-intensification from IP relative to (intravenous) IV drug administration leads to superior results in these mutation carriers requires further study.