Pediatric Homicides: Not Just a Teenage Problem.

INTRODUCTION: Homicide is a leading cause of death for American children. We hypothesized demographics and homicide circumstances would differ by victim age. METHODS: We performed a retrospective analysis of the 2003-2020 National Violent Death Reporting System. The National Violent Death Reporting System collects data from nearly all 50 states, the District of Columbia, and Puerto Rico. Demographics (age, sex, race, and ethnicity), homicide year, and weapon type were abstracted. Inclusion criteria were pediatric victims (age < 18). Two groups: 0-4 y old (young cohort [YC]) and 13-17 y old (teen cohort [TC]) were compared. Chi-squared tests, p-test, and t-tests with significance P < 0.05 were used to determine the association between victim demographics, cohort, and homicide mechanism. RESULTS: 10,569 pediatric (male: 70.2% [n = 7424], median age: 12 y old [interquartile range 1-16], black: 52.7% [n = 5573]) homicides met inclusion. Homicides demonstrated a bimodal age distribution (YC: 40.9% [n = 4320] versus TC: 48.9% [n = 5164]). Gender and race were both associated with homicide victimhood (P < 0.001). TC homicides were more likely to be male (YC: 57.8% [n = 2496] versus TC: 83.7% [n = 4320], P < 0.001) and black (YC: 40.1% [n = 1730] versus TC: 65.0% [n = 3357], P < 0.001). Pediatric homicides increased from 2018 (n = 1049) to 2020 (n = 1597), with only TC demonstrating a significant increase (2018: n = 522 versus 2020: n = 971, P < 0.001). Homicide mechanism was significantly associated with age (Blunt: YC: 57.5% [n = 2484] versus TC: 2.9% [n = 148], P < 0.001; Penetrating: YC: 7.9% [n = 340] versus TC: 92.8% [n = 4794], P < 0.001). CONCLUSIONS: Pediatric homicides demonstrate distinct demographic characteristics and homicide mechanisms between two at risk age cohorts. Age-based education and intervention strategies may increase injury prevention programs' efficacy.

The role of endoscopic resection in early-stage esophageal adenocarcinoma: Esophagectomy is associated with improved survival in patients presenting with clinical stage T1bN0 disease.

BACKGROUND: Studies evaluating endoscopic resection for early-stage (cT1N0M0) esophageal adenocarcinoma include small numbers of patients with T1b tumors. The role of endoscopic resection in esophageal adenocarcinoma remains incompletely defined. METHODS: We queried the National Cancer Database to identify patients presenting with esophageal adenocarcinoma between 2010 and 2017. Those treated with neoadjuvant chemoradiotherapy and endoscopic ablation were excluded. Patients undergoing endoscopic resection for cT1a and cT1b tumors were separately 1:1 propensity matched for relevant demographic and tumor factors to those undergoing esophagectomy for disease of like clinical stage. The Kaplan-Meier method was used to compare 5-year overall survival for matched cohorts. RESULTS: A total of 3,157 patients met the inclusion criteria. Of these patients, 2,024 (64.1%) had cT1a and 1133 (35.9%) had cT1b disease. Among those with cT1a tumors, 461 (22.8%) underwent esophagectomy, 1,357 (67.0%) endoscopic resection, and 206 (10.2%) treatment with chemoradiotherapy alone. Among those with cT1b tumors, 649 (57.3%) underwent esophagectomy, 293 (25.9%) endoscopic resection, and 191 (16.8%) chemoradiotherapy. On unadjusted comparison, patients treated for esophageal adenocarcinoma with chemoradiotherapy had a lower rate of overall survival than those treated with endoscopic resection or esophagectomy (26.1% vs 73.1% vs 75.5%, P < .001). On comparison of matched cohorts, patients undergoing endoscopic resection for cT1b tumors demonstrated lower rates of overall survival than those undergoing esophagectomy (60.6% vs 74.1%, P = .0013), whereas those undergoing endoscopic resection for cT1a tumors demonstrated rates of overall survival statistically similar to those undergoing esophagectomy (77.8% vs 80.2%, P = .75). CONCLUSION: Esophagectomy is associated with improved overall survival relative to endoscopic resection in patients presenting with cT1bN0M0 but not in those with cT1a esophageal adenocarcinoma.

Early-Stage Ampullary Cancer: Is Local Excision an Effective Alternative to Radical Resection?

BACKGROUND: The efficacy of local excision (transduodenal or endoscopic ampullectomy) in treating early-stage ampullary cancer has not been well defined. STUDY DESIGN: We queried the National Cancer Database to identify patients undergoing either local tumor excision or radical resection for early-stage (cTis-T2, N0, M0) ampullary adenocarcinoma between 2004 and 2018. Cox modeling was used to identify factors associated with overall survival. Patients undergoing local excision were then 1:1 propensity score-matched for demographics, hospital level, and histopathological factors to those undergoing radical resection. The Kaplan-Meier method was used to compare overall survival (OS) profiles for matched cohorts. RESULTS: A total of 1,544 patients met inclusion criteria. A total of 218 (14%) underwent local tumor excision, and 1,326 (86%) radical resection. On propensity score matching, 218 patients undergoing local excision were successfully matched to 218 patients undergoing radical resection. On comparison of matched cohorts, those undergoing local excision had lower rate of margin-negative (R0) resection (85.1% vs 99%, p < 0.001) and lower median lymph node count (0 vs 13, p < 0.001) but had significantly shorter length of initial hospitalization (median days: 1 vs 10 days, p < 0.001), lower rate of 30-day readmission (3.3% vs 12.0%, p = 0.001), and lower rate of 30-day mortality (1.8% vs 6.5%, p = 0.016) than patients undergoing radical resection. There was no statistically significant difference in OS between the matched cohorts (46.9% vs 52.0%, p = 0.46). CONCLUSIONS: In patients presenting with early-stage ampullary adenocarcinoma, local tumor excision is associated with higher rate of R1 resection but accelerated postprocedure recovery and patterns of OS comparable with those after radical resection.

A matched cohort comparison of endoscopic resection, chemoradiation and esophagectomy in the treatment of early-stage esophageal squamous cell carcinoma.

BACKGROUND: The efficacy of endoscopic resection in early-stage esophageal squamous cell carcinoma has not been defined. METHODS: We queried the National Cancer Database to identify patients presenting with cT1N0M0 esophageal squamous cell cancer between 2004 and 2017. Transitive match methods were used to 1:1:1 propensity match patients undergoing endoscopic resection to patients undergoing esophagectomy and those undergoing definitive chemoradiotherapy. Kaplan Meier method was used to compare 5-year overall survival profiles for matched cohorts. RESULTS: 301 patients (19%) underwent endoscopic resection; 497 (32%) esophagectomy; 767 (49%) chemoradiation. On comparison of matched cohorts, patients undergoing chemoradiation demonstrated lower rates of survival than those undergoing esophagectomy (32% vs. 59%, p < 0.0001) while those undergoing endoscopic resection demonstrated rates comparable to patients undergoing esophagectomy (53% vs. 59%, p = 0.77). CONCLUSIONS: For cT1N0M0 esophageal squamous cell cancer, endoscopic resection is associated with rates of survival similar to those following esophagectomy and better than those following definitive chemoradiation.

Comparative effectiveness of stereotactic body radiation therapy versus surgery for stage I lung cancer in otherwise healthy patients: An instrumental variable analysis.

Objectives: Stereotactic body radiation therapy (SBRT) is an established primary treatment modality in patients with lung cancer who have multiple comorbidities and/or advanced-stage disease. However, its role in otherwise healthy patients with stage I lung cancer is unclear. In this context, we compared the effectiveness of SBRT versus surgery on overall survival using a national database. Methods: We identified all patient with clinical stage I non-small cell lung cancer from the National Cancer Database from 2004 to 2016. We defined otherwise healthy patients as those with a Charlson-Deyo comorbidity index of 0 and whose treatment plan included options for either SBRT or surgery. We further excluded patients who received SBRT due to a contraindication to surgery. We first used propensity score matching and Cox proportional hazard models to identify associations. Next, we fit 2-stage residual inclusion models using an instrumental variables approach to estimate the effects of SBRT versus surgery on long-term survival. We used the hospital SBRT utilization rate as the instrument. Results: Of 25,963 patients meeting all inclusion/exclusion criteria, 5465 (21%) were treated with SBRT. On both Cox proportional hazards modeling and propensity-score matched Kaplan-Meier analysis, surgical resection was associated with improved survival relative to SBRT. In the instrumental-variable-adjusted model, SBRT remained associated with decreased survival (hazard ratio, 2.64; P < .001). Both lobectomy (hazard ratio, 0.17) and sublobar resections (hazard ratio, 0.28) were associated with improved overall survival compared with SBRT (P < .001). Conclusions: In otherwise healthy patients with stage I NSCLC, surgical resection is associated with a survival benefit compared with SBRT. This is true for both lobar and sublobar resections.

The benefit of liver transplant beyond Milan criteria: An analysis using the National Cancer Database.

BACKGROUND: Published studies examining the efficacy of liver transplantation in patients presenting with hepatocellular cancer beyond the traditional Milan criteria for liver transplantation have primarily been single institution series with limited ability to compare outcomes to alternative methods of management. METHODS: We queried the National Cancer Database to identify patients presenting between 2004 and 2016 with histologically confirmed clinical stage III and IVA hepatocellular cancer. Multivariable regression was used to identify factors associated with liver transplantation. Patients undergoing liver transplantation were 1:1 propensity score-matched for age, demographics, comorbid disease, clinical stage, and histologic resection margin to those undergoing surgical resection. The Kaplan-Meier method was used to compare overall survival profiles for matched cohorts. RESULTS: Seven hundred and ninety-two patients met inclusion criteria-590 (74.5%) underwent surgical resection and 202 (25.5%) liver transplantation. On adjusted analysis, patients undergoing liver transplantation were less likely to have advanced age (>60 years; odds ratio 0.39, 95% confidence interval [0.21-0.71]) and to be of Black race (odds ratio 0.42, 95% confidence interval [0.23-0.73]) or Asian (odds ratio 0.25, 95% confidence interval [0.11-0.53]) ethnicity but were more likely to have advanced (Charlson score >2) comorbidity scores, (odds ratio 2.48, 95% confidence interval [1.58-3.90]) and more likely to have private health insurance (odds ratio 4.17, 95% confidence interval [1.31-18.66]) than those undergoing surgical resection. On Kaplan-Meier analysis of matched cohorts, patients undergoing liver transplantation demonstrated significantly better rates of 5-year overall survival (65.3% vs 26.3%, P < .0001) and longer median overall survival times than those undergoing resection (53.1 ± 2.78 vs 26.9 ± 1.20 months, P < .0001). CONCLUSION: Liver transplantation offers the potential to be an effective treatment modality in select patients presenting with stage III and IVA hepatocellular cancer.

Small-sized gastrointestinal stromal tumors: Is there an association between expectant management and overall survival?

BACKGROUND: Small-sized gastrointestinal stromal tumors (GISTs) have limited malignant potential. Few studies evaluate the safety and efficacy of expectant management (EM) for patients presenting with small GIST. METHODS: We queried the National Cancer Database to identify patients ≤65 years presenting with GISTs smaller than 3 cm in size between 2004 and 2015. Patients undergoing EM were 1:3 propensity score matched for relevant covariates to patients undergoing resection. Kaplan-Meier (KM) analysis of matched cohorts was used to evaluate the association between EM and overall survival (OS). RESULTS: 1330 patients met inclusion criteria; 966 (72.6%) had gastric GISTs. 1196 (89.9%) underwent resection; 134 (10.1%) EM. 117 patients undergoing EM were propensity-matched to 356 patients undergoing resection. There was no difference in 5-year OS between patients undergoing EM and those undergoing resection (95.7% vs 92.6%, p = 0.4882). CONCLUSIONS: Survival for small GISTs is similar with expectant management or resection.

Resectable intrahepatic and hilar cholangiocarcinoma: Is margin status associated with survival?

BACKGROUND: Prior studies evaluating the effect of margin status on clinical outcome in patients undergoing resection for intrahepatic and extrahepatic hilar cholangiocarcinoma include small numbers of patients with histologically positive margins. The value of margin negative resection in these cases remains unclear. METHODS: We queried the National Cancer Database to identify patients undergoing resection for clinical stage I to III intrahepatic and extrahepatic hilar between 2004 and 2015. Patients receiving neoadjuvant therapy and those having <3 lymph nodes examined were excluded. Patients undergoing positive resection were 1:1 propensity matched to those undergoing negative resection. Kaplan-Meier methods were used to compare overall survival for the matched cohorts. RESULTS: In the study, 3,618 patients met the inclusion criteria, and 3,018 (83.4%) underwent negative resection; 600 (16.6%) positive resection. Patients undergoing negative resection had smaller tumors (2.97 ± 0.07 cm vs 3.49 ± 0.15 cm), were less likely to have stage 3 disease (16.7% vs 25.7%) and to receive adjuvant radiation (27.1% vs 45.7%) and chemotherapy (49.4% vs 61.0%) than those undergoing positive resection (all P < .05). On comparison of matched cohorts, patients undergoing negative resection had longer median overall survival (24.5 ± 0.02 vs 19.1 ± 0.02 months) and higher rates of 5-year overall survival (24.5% vs 16.7%) than those undergoing positive resection (P < .01). CONCLUSION: In patients presenting with resectable intrahepatic and extrahepatic hilar, negative resection is associated with improved overall survival. Extended resections performed in an effort to clear surgical margins are warranted in patients fit for such procedures.

Low and moderate grade retroperitoneal liposarcoma: Is adjuvant radiotherapy associated with improved survival in patients undergoing R1 resection?

BACKGROUND: Few studies evaluate the efficacy of adjuvant radiotherapy (aXRT) in patients with retroperitoneal liposarcoma undergoing resection to histologically positive (R1) margins. METHODS: We queried the National Cancer Database to identify patients undergoing R1 resection for localized, large (>5 cm) low and moderate grade retroperitoneal liposarcoma between 2004 and 2016. Kaplan Meier method was used to compare overall survival (OS) for patients receiving aXRT to a 1:2 propensity-matched cohort of patients undergoing resection alone. RESULTS: A total of 322 (76.5%) patients underwent R1 resection alone, while 99 (23.5%) underwent resection followed by aXRT. The 99 receiving aXRT were successfully 1:2 propensity-score matched to 198 undergoing resection alone. There was no difference in 5-year OS between matched cohorts (69.7% vs 76.2%, p = 0.40). CONCLUSIONS: In patients undergoing R1 resection of moderate- and well-differentiated retroperitoneal liposarcoma, use of aXRT is not associated with an improvement in OS.

Intrahepatic cholangiocarcinoma: Is there a role for liver transplantation?

BACKGROUND: Liver transplantation offers a potential for curative-intent treatment in patients presenting with non-metastatic intrahepatic cholangiocarcinoma that is not amenable to partial hepatectomy. There is little empiric evidence evaluating the efficacy of liver transplantation in patients with intrahepatic cholangiocarcinoma. METHODS: We queried the National Cancer Database to identify patients presenting with histologically confirmed clinical stage I to III intrahepatic cholangiocarcinoma between 2004 and 2016. Propensity scoring was used to develop matched cohorts of patients undergoing treatment with liver transplantation, surgical resection, or chemotherapy alone. Kaplan Meier methods were used to compare rates of overall survival. RESULTS: One thousand four hundred and eleven patients met inclusion criteria. Of these, 66 (4.7%) underwent liver transplantation, 461 (32.7%) underwent surgical resection, and 884 (62.6%) were treated with chemotherapy alone. On adjusted analysis, patients undergoing liver transplantation were more likely to be male (odds ratio 4.35, 95% confidence interval [0.12, 0.42]), have a Charlson Comorbidity Score ≥2 (odds ratio 3.11, 95% confidence interval [1.44, 6.57]), and to receive both neoadjuvant (odds ratio 2.78, 95% confidence interval [1.36,5.75], and adjuvant (odds ratio 1.94, 95% confidence interval [0.97, 3.87]) systemic therapy than those undergoing resection. On Kaplan Meier analysis, patients undergoing liver transplantation demonstrated rates of 5-year overall survival (36.1% vs 34.7%, P = .53) that were statistically identical to those for stage-matched and margin-matched patients undergoing resection but significantly better than those for stage-matched patients treated with systemic therapy alone (36.1% vs 5.3%, P < .0001). CONCLUSION: Patients undergoing liver transplantation for intrahepatic cholangiocarcinoma demonstrate overall survival profiles similar to stage-matched and margin-matched patients undergoing surgical resection. Liver transplantation is an effective treatment modality in select patients presenting with localized intrahepatic cholangiocarcinoma.

Octogenarians undergoing pancreaticoduodenectomy: Assessing outcomes, disposition, and timing of chemotherapy.

BACKGROUND: Inclusion of pancreaticoduodenectomy has demonstrated higher rates of curative treatment in pancreatic cancer, yet prior research has suggested increased postoperative complications in octogenarians (patients older than 80 years). This study aimed to understand the impact of age on patients undergoing a pancreaticoduodenectomy, focusing on postoperative outcomes and return to intended oncologic treatment. MATERIALS AND METHODS: We conducted a single-institution retrospective cohort study for patients undergoing pancreaticoduodenectomy from 2007 to 2018. Collected data included demographics, preoperative comorbidities, and postoperative data (length of stay, 30-day mortality, 1-year mortality, infection, discharge location). Data were separated into 2 cohorts: octogenarians (≥ 80 years) and nonoctogenarians (< 80). χ2 and independent-sample t tests were used for analysis. RESULTS: A total of 649 patients underwent pancreaticoduodenectomy from 2007 to 2018; 63 (9.7%) were octogenarians. No differences were found in infectious complications (P = .607), 30-day mortality (P = .363), or 1-year mortality (P = .895). Octogenarians had a longer length of stay (P = .003) and were more likely to be discharged to skilled nursing facilities (P < .001). There was no significant difference in neoadjuvant chemotherapy administration, although octogenarians were less likely to receive adjuvant chemotherapy (P = .048) and declined adjuvant therapy at a higher rate (P = .003). CONCLUSION: Performing a pancreaticoduodenectomy in octogenarians can be safe and effective in a properly selected cohort. Although postoperative morbidity and mortality are similar to younger patients, elderly patients are more likely to be discharged to nursing facilities and less likely to receive adjuvant chemotherapy. This study suggests that age alone should not be a discriminating factor when discussing surgical therapy for pancreatic cancer treatment in octogenarians.

Is positive histologic surgical margin associated with overall survival in patients with resectable gallbladder cancer?

BACKGROUND: Achieving microscopically negative (R0) surgical margins in gallbladder cancer often requires a partial hepatectomy with associated risk of morbidity and potential to delay adjuvant therapy. Prior studies on the importance of margin status in resectable gall bladder cancer include small numbers of patients with positive (R1) resection margins and are underpowered. METHODS: We queried the National Cancer Database to identify patients undergoing resection of gallbladder adenocarcinoma between 2004 and 2015. Patients presenting with metastatic disease, those who received neoadjuvant therapy, and those with fewer than 3 lymph nodes assessed were excluded. 1:1 propensity score matching was used to develop cohorts undergoing either R0 or R1 resection, matched for demographic, pathologic, and facility characteristics. Kaplan-Meier analysis was used to assess the association between margin status and overall survival. RESULTS: A total of 1,439 patients met inclusion criteria; 1,285 underwent R0 and 154 underwent R1 resection. On Kaplan-Meier analysis of propensity-matched cohorts, patients undergoing R0 resection had a median overall survival that was 18 months longer than those undergoing R1 resection (34.6 ±â€¯2.0 months vs 16.3 ±â€¯1.7 months, P < .001). CONCLUSION: In patients presenting with resectable gallbladder adenocarcinoma, margin-negative resection is associated with significant improvement in overall survival.

Positive microscopic surgical margins: Is there an association with survival in resected small gastrointestinal stromal tumors?

BACKGROUND: Few studies evaluate the relationships between surgical approach, histologic margin, and overall survival in gastrointestinal stromal tumor. We test the hypothesis that margin positive resection is associated with compromised overall survival. METHODS: We queried the National Cancer Data Base to identify patients undergoing resections for gastrointestinal stromal tumors ≤3 cm in size between 2010 and 2015. Multivariable logistic regression was used to identify factors associated with positive microscopic margins on final pathology. Cox proportional hazard methods were used to evaluate factors associated with overall survival. RESULTS: 2064 patients met inclusion criteria; 135 (6.5%) had a microscopically positive surgical margin. On multivariable regression, minimally invasive approach was not associated with risk of a positive margin (OR 1.06 95% CI [0.71, 1.59]). On Cox analysis, positive margin status was not associated with OS (R1: 1.03, CI [0.46-2.31], reference R0). CONCLUSIONS: Positive microscopic surgical margins are not associated with compromised overall survival in patients undergoing resection of small gastrointestinal stromal tumors. Minimally invasive surgical approaches do not compromise oncologic outcomes in these cases.

The importance of the margin of resection and radiotherapy in retroperitoneal liposarcoma.

BACKGROUND: Prior studies evaluating the impact of adjuvant or neoadjuvant radiotherapy on clinical outcomes in retroperitoneal liposarcoma have been underpowered. METHODS: We queried the National Cancer Database for patients undergoing resection of retroperitoneal liposarcoma from 2004 to 2016. Cox proportional hazards modeling stratified by tumor size was used to identify factors associated with overall survival. RESULTS: 4018 patients met inclusion criteria. 251 had small (<5 cm), 574 intermediate (5-10 cm), and 3193 large (>10 cm) tumors. Positive surgical margins were correlated with risk of death across all tumor size categories (<5 cm HR 2.33, CI [1.20, 4.55]; 5-10 cm HR 1.49, CI [1.03, 2.14]; >10 cm HR 1.30, CI [1.12, 1.51]). Adjuvant radiotherapy was associated with improved survival for patients with large tumors only (HR 0.75, CI [0.64, 0.89]). CONCLUSIONS: In retroperitoneal liposarcoma, adjuvant radiation is associated with improved survival only for patients with tumors larger than 10 cm. Radiation should be used sparingly in patients with smaller tumors. SUMMARY: The use of radiotherapy in the management of retroperitoneal sarcoma remains controversial. We isolated retroperitoneal liposarcomas only and identified a survival benefit from radiotherapy treatment only in tumors larger than 10 cm and only in the adjuvant setting.

The importance of the margin of resection and external radiation in non-lipomatous retroperitoneal sarcoma.

BACKGROUND: Prior studies evaluating the impact of adjuvant or neoadjuvant radiation on clinical outcomes of patients with non-lipomatous retroperitoneal sarcoma have been underpowered. METHODS: We queried the National Cancer Database to identify patients undergoing surgical resection of retroperitoneal sarcoma with non-lipomatous histology from 2004 to 2016. Multivariable logistic regression and Cox proportional hazards modelling with patients stratified by tumor size were used to identify factors associated with overall survival. RESULTS: 3,394 patients met inclusion criteria. 592 had small (<5 cm), 1,186 had intermediate (5-10 cm), and 1,616 had large (>10 cm) tumors. Use of either neoadjuvant or adjuvant radiotherapy was associated with improved survival for patients with intermediate (neoadjuvant HR 0.67, CI [0.46, 0.98]; adjuvant HR 0.61, CI [0.50, 0.76]) and large (neoadjuvant HR 0.50, CI [0.37, 0.68]; adjuvant HR 0.56, CI [0.47, 0.69]) tumors, while adjuvant radiation therapy was associated with a survival benefit for small-sized tumors (HR 0.67, CI [0.46, 0.99]). CONCLUSIONS: Radiation therapy is associated with an overall survival benefit in patients presenting undergoing resection of non-lipomatous retroperitoneal sarcoma.