Pathologic Complete Response, Total Neoadjuvant Therapy and the Survival Paradox in Locally Advanced Rectal Cancer.

BACKGROUND: Pathologic complete response (pCR) after preoperative chemoradiation (nCRT) correlates with improved overall survival for patients with locally advanced rectal cancers (LARCs). Escalation protocols including total neoadjuvant therapy (TNT), which delivers multi-agent chemotherapy and chemoradiation before surgery, are associated with increased complete response rates. However, TNT is not associated with improved overall survival. The authors hypothesized that the route to pCR may be an important predictor of oncologic outcome. METHODS: Adults with LARC between 2006 and 2017 were identified in the National Cancer Database. The cohort was limited to those who received neoadjuvant radiation (45-70 Gy) and underwent proctectomy. RESULTS: Of 25,880 patients, 16 % received TNT and 84 % had nCRT followed by either multi-agent (27 %), single-agent (14 %), or no adjuvant chemotherapy (44 %). Overall, 18 % achieved pCR, with higher rates in the TNT cohort than in the nCRT (18 %) or multi-agent (14 %) chemotherapy cohorts. With control for covariates, the OS in the pCR cohort was similar for the patients that received single-agent therapy and those that received multi-agent adjuvant therapy, and superior to the TNT and no adjuvant therapy cohorts. Conversely, among the patients who did not achieve pCR, those who received single-agent chemotherapy had OS comparable with those who had multi-agent adjuvant therapy and TNT, which was better than no adjuvant therapy. CONCLUSION: Patients achieving pCR after TNT had worse OS than those who had CRT alone, suggesting that the neoadjuvant route by which pCR is achieved is prognostically relevant. Therefore, in the era of neoadjuvant therapy escalation, pCR does not necessarily portend a uniformly favorable prognosis.

Admission Lymphopenia is Associated With Discharge Disposition in Blunt Chest Wall Trauma Patients.

BACKGROUND: Lymphopenia contributes to the immune suppression observed in critical illness. However, its role in the immunologic response to trauma remains unclear. Herein, we assessed whether admission lymphopenia is associated with poor outcomes in patients with blunt chest wall trauma (BCWT). METHODS: All adult patients with a Chest Abbreviated Injury Score (CAIS) ≥2 admitted to our Level I Trauma center between May 2009 and December 2018 were identified in our institution Trauma Registry. Patients with absolute lymphocyte counts (ALC) collected within 24 H of admission were included. Patients who died within 24 H of admission, had bowel perforation on admission, penetrating trauma, and burns were excluded. Demographics, injury characteristics, comorbidities, ALC, complications, and outcomes were collected. Lymphopenia was defined as an ALC ≤1000/µL. Association between lymphopenia and clinical outcomes of BCWT was assessed using multivariate analyses. P < 0.05 was considered significant. RESULTS: A total of 1394 patients were included; 69.7% were male; 44.3% were lymphopenic. On univariate analysis, lymphopenia was associated with longer in-hospital stay (11.6±10.2 versus 10.1±11.4, P = 0.009), in-hospital death (9.7% versus 5.8%, P = 0.006), and discharge to a healthcare facility (60.9% versus 46.4%, P < 0.001). Controlling for Injury Severity Score, age, gender, and comorbidities, the association between lymphopenia and discharge to another facility (SNF/rehabilitation facility/ACH) (OR = 1.380 [1.041-1.830], P = 0.025) remained significant. CONCLUSIONS: Lymphopenia on admission is associated with discharge requiring increased healthcare support. Routine lymphocyte count monitoring on admission may provide important prognostic information for BCWT patients.

Contemporary management of rectal cancer.

The management of rectal cancer has undergone significant changes over the past 50 years, and this has been associated with major improvements in overall outcomes and quality of life. From standardization of total mesorectal excision to refinements in radiation delivery and shifting of chemoradiotherapy treatment to favor a neoadjuvant approach, as well as the development of targeted chemotherapeutics, these management strategies have continually aimed to achieve locoregional and systemic control while limiting adverse effects and enhance overall survival. This article highlights evolving aspects of rectal cancer therapy including improved staging modalities, total neoadjuvant therapy, the role of short-course and more selective radiotherapy strategies, as well as organ preservation. We also discuss the evolving role of minimally invasive surgery and comment on lateral pelvic lymph node dissection. Key message: Rectal cancer management is constantly evolving through refinements in radiation timing and delivery, modification of chemoradiotherapy treatment schedules, and increasing utilization of minimally invasive surgical techniques and organ preservation strategies. This manuscript aims to provide a synopsis of recent changes in the management of rectal cancer, highlighting contemporary modifications in neoadjuvant approaches and surgical management to enhance the knowledge of surgeons who care for this challenging population.

Pediatric Appendectomy: an Analysis of 22,334 Cases from the Pediatric National Surgical Quality Improvement Program Data.

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Radiographic Enchondroma Surveillance: Assessing Clinical Outcomes and Costs Effectiveness.

Background: Enchondromas are a common long bone benign tumor often discovered incidentally on imaging for adjacent pathology. These benign cartilaginous tumors can be difficult to differentiate from low-grade chondrosarcomas on imaging and histology. Multiple advanced imaging studies and clinic visits are required to confirm stability. Surveillance for these lesions can lead to significant patient costs without a clear oncologic or functional benefit. There is a lack of evidence-based consensus guidelines for the surveillance of enchondromas. The purposes of our study are: 1) to determine the number and proportion of low-grade cartilaginous tumors that demonstrate growth or require treatment and 2) to optimize the efficacy and cost-effectiveness of surveillance strategies for detecting biologically active lesions. Methods: A retrospective single-institution study was performed on 55 subjects, 18 years or older, with long bone enchondromas without concerning radiographic characteristics that were referred to our institution's orthopaedic oncology clinic from July 1, 2009 to November 30, 2016. All subjects had at least 12 months of radiographic follow-up. We performed a chart and imaging review to assess for growth of the lesion over time. The number of pre-referral imaging and the number of follow-up imaging studies were recorded. The costs of plain radiographs and advanced imaging were estimated using our institution's global charge list in 2016. Results: For stable enchondromas, 35 out of 52 lesions (67.3%) presented in the lower extremities compared to three out of three (100%) growing cartilaginous tumors. Three out of 55 (5.45%) long bone cartilaginous lesions exhibited growth at a median of 23 (range 21-25 months) follow-up. There was no apparent difference in median presenting age for stable versus growing lesions (58.5 versus 55.0 years old, p =0.5673) or median lesion size at presentation (4.1 cm versus 3.6 cm, p = 0.2923). None of these lesions presented with pain attributable to the lesion. One out of seven biopsied cartilaginous lesions (four stable and three growing) had a histology diagnosis of grade 1 chondrosarcoma. There was no significant difference in the median number of total clinical visits for stable (four) and growing (five) enchondromas (p = 0.0807). The median pre-referral costs per patient were: plain radiographs ($383.00), CT scans ($0.00), and MRI imaging ($3,969.00). The median post-referral costs for plain radiographs and MRI per patient were $1,326.00 and $4,668.00, respectively. The annual median costs for plain radiographs and MRI were $609.23 and $2,240.64, respectively. Discussion: In conclusion, enchondroma growth was a rare event and typically occurred at two years follow-up in our series. Given the low risk for malignant transformation, we propose surveillance with plain radiographic follow-up for stable enchondromas every 3-6 months for the first year and then annually for at least three years of total follow-up. The most significant costs savings can be made by limiting MRI imaging in the absence of clinical or radiographic concern. Additional studies are needed to determine the long-term risk of growth or declaration of chondrosarcoma.Level of Evidence: IV.

Overlapping Surgery in Primary Total Knee Arthroplasty: Are 6-Week Complications Worse than Single Operating Room Scheduling?

Background: Overlapping surgery is common in high-volume total knee arthroplasty (TKA) practices and has come under recent scrutiny in the press. The aim of this study was to evaluate differences in 6-week clinical and radiographic outcomes for primary TKA patients between single and overlapping operating room (OR) days. Methods: We retrospectively reviewed individual patient records of a consecutive series of primary TKAs with complete 6-week follow-up performed by a single academic surgeon between 2008-2016 (N= 452). Patients were stratified by single vs. overlapping OR days. 177 patients (39%) had an overlapping surgery. Age, body mass index (BMI), Charlson Comorbidity Index (CCI) and American Society of Anesthesiologists (ASA) class were recorded to assess for confounding variables. Outcomes included anesthesia time, 6-week readmission, unplanned return to OR, medical and surgical complication, and 6-week radiographic alignment. Results: There were no significant differences in anesthesiology time (165.5 vs 164.5 min, p=0.85), medical or surgical complication rates (10.5% vs 6.2%, p=0.11), 6-week readmissions (4.4% vs 1.7%, p=0.12), or return to OR (1.8% vs 1.7%, p=1.00) before or after adjusting for age, BMI, gender, ASA and CCI. There was no difference between overlapping and single OR cohorts in rate of neutral coronal alignment (2°-8° valgus) (98.3% vs 98.9%, respectively, p=0.68) or presence of periprosthetic lucency (p=0.43). Conclusions: This study demonstrates no differences in 6-week clinical or radiographic outcomes between patients undergoing primary TKA on single versus overlapping OR days. These results support the safe practice of overlapping surgical scheduling in high-volume primary TKA centers.Level of Evidence: III.