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1.
JAMA Oncol ; 9(2): 234-241, 2023 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-36602807

RESUMEN

Importance: Changes in postsurgical opioid prescribing practices may help reduce chronic opioid use in surgical patients. Objective: To investigate whether postsurgical acute pain across different surgical subspecialties can be managed effectively after hospital discharge with an opioid supply of 3 or fewer days and whether this reduction in prescribed opioids is associated with reduced new, persistent opioid use. Design, Setting, and Participants: In this prospective cohort study with a case-control design, a restrictive opioid prescription protocol (ROPP) specifying an opioid supply of 3 or fewer days after discharge from surgery along with standardized patient education was implemented across all surgical services at a tertiary-care comprehensive cancer center. Participants were all patients who underwent surgery from August 1, 2018, to July 31, 2019. Main Outcomes and Measures: Main outcomes were the rate of compliance with the ROPP in each surgical service, the mean number of prescription days and refill requests, type of opioid prescribed, and rate of conversion to chronic opioid use determined via a state-run opioid prescription program. Postsurgical complications were also measured. Results: A total of 4068 patients (mean [SD] age, 61.0 [13.8] years; 2528 women [62.1%]) were included, with 2017 in the pre-ROPP group (August 1, 2018, to January 31, 2019) and 2051 in the post-ROPP group (February 1, 2019, to July 31, 2019). The rate of compliance with the protocol was 95%. After implementation of the ROPP, mean opioid prescription days decreased from a mean (SD) of 3.9 (4.5) days in the pre-ROPP group to 1.9 (3.6) days in the post-ROPP group (P < .001). The ROPP implementation led to a 45% decrease in prescribed opioids after surgery (mean [SD], 157.22 [338.06] mean morphine milligram equivalents [MME] before ROPP vs 83.54 [395.70] MME after ROPP; P < .001). Patients in the post-ROPP cohort requested fewer refills (367 of 2051 [17.9%] vs 422 of 2017 [20.9%] in the pre-ROPP cohort; P = .02). There was no statistically significant difference in surgical complications. The conversion rate to chronic opioid use decreased following ROPP implementation among both opioid-naive patients with cancer (11.3% [143 of 1267] to 4.5% [118 of 2645]; P < .001) and those without cancer (6.1% [19 of 310] to 2.7% [16 of 600]; P = .02). Conclusions and Relevance: In this cohort study, prescribing an opioid supply of 3 or fewer days to surgical patients after hospital discharge was feasible for most patients, led to a significant decrease in the number of opioids prescribed after surgery, and was associated with a significantly decreased conversion to long-term opioid use without concomitant increases in refill requests or significant compromises in surgical recovery.


Asunto(s)
Analgésicos Opioides , Pautas de la Práctica en Medicina , Humanos , Femenino , Persona de Mediana Edad , Analgésicos Opioides/uso terapéutico , Estudios de Cohortes , Estudios Prospectivos , Dolor Postoperatorio/tratamiento farmacológico , Estudios Retrospectivos
2.
J Natl Compr Canc Netw ; 19(7): 839-868, 2021 07 28.
Artículo en Inglés | MEDLINE | ID: mdl-34340212

RESUMEN

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Neuroendocrine and Adrenal Gland Tumors focus on the diagnosis, treatment, and management of patients with neuroendocrine tumors (NETs), adrenal tumors, pheochromocytomas, paragangliomas, and multiple endocrine neoplasia. NETs are generally subclassified by site of origin, stage, and histologic characteristics. Appropriate diagnosis and treatment of NETs often involves collaboration between specialists in multiple disciplines, using specific biochemical, radiologic, and surgical methods. Specialists include pathologists, endocrinologists, radiologists (including nuclear medicine specialists), and medical, radiation, and surgical oncologists. These guidelines discuss the diagnosis and management of both sporadic and hereditary neuroendocrine and adrenal tumors and are intended to assist with clinical decision-making. This article is focused on the 2021 NCCN Guidelines principles of genetic risk assessment and counseling and recommendations for well-differentiated grade 3 NETs, poorly differentiated neuroendocrine carcinomas, adrenal tumors, pheochromocytomas, and paragangliomas.


Asunto(s)
Neoplasias de las Glándulas Suprarrenales , Tumores Neuroendocrinos , Neoplasias de las Glándulas Suprarrenales/diagnóstico , Neoplasias de las Glándulas Suprarrenales/genética , Neoplasias de las Glándulas Suprarrenales/terapia , Humanos , Oncología Médica , Tumores Neuroendocrinos/diagnóstico , Tumores Neuroendocrinos/genética , Tumores Neuroendocrinos/terapia
3.
Ann Transl Med ; 9(2): 119, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33569421

RESUMEN

BACKGROUND: Immunotherapeutic approaches for pancreatic ductal adenocarcinoma (PDAC) are less successful as compared to many other tumor types. In this study, comprehensive immune profiling was performed in order to identify novel, potentially actionable targets for immunotherapy. METHODS: Formalin-fixed paraffin embedded (FFPE) specimens from 68 patients were evaluated for expression of 395 immune-related markers (RNA-seq), mutational burden by complete exon sequencing of 409 genes, PD-L1 expression by immunohistochemistry (IHC), pattern of tumor infiltrating lymphocytes (TILs) infiltration by CD8 IHC, and PD-L1/L2 copy number by fluorescent in situ hybridization (FISH). RESULTS: The seven classes of actionable genes capturing myeloid immunosuppression, metabolic immunosuppression, alternative checkpoint blockade, CTLA-4 immune checkpoint, immune infiltrate, and programmed cell death 1 (PD-1) axis immune checkpoint, discerned 5 unique clinically relevant immunosuppression expression profiles (from most to least common): (I) combined myeloid and metabolic immunosuppression [affecting 25 of 68 patients (36.8%)], (II) multiple immunosuppressive mechanisms (29.4%), (III) PD-L1 positive (20.6%), (IV) highly inflamed PD-L1 negative (10.3%); and (V) immune desert (2.9%). The Wilcoxon rank-sum test was used to compare the PDAC cohort with a comparison cohort (n=1,416 patients) for the mean expressions of the 409 genes evaluated. Multiple genes including TIM3, VISTA, CCL2, CCR2, TGFB1, CD73, and CD39 had significantly higher mean expression versus the comparison cohort, while three genes (LAG3, GITR, CD38) had significantly lower mean expression. CONCLUSIONS: This study demonstrates that a clinically relevant unique profile of immune markers can be identified in PDAC and be used as a roadmap for personalized immunotherapeutic decision-making strategies.

4.
J Surg Oncol ; 122(2): 195-203, 2020 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-32474957

RESUMEN

BACKGROUND AND OBJECTIVES: Pasireotide was shown in a randomized trial to decrease the rate of postoperative pancreatic fistula (POPF). However, retrospective series from other centers have failed to confirm these results. METHODS: Patients who underwent pancreatoduodenectomy or distal pancreatectomy between January 2014 and February 2019 were included. Patients treated after November 2016 routinely received pasireotide and were compared to a retrospective cohort. Multivariate analysis was performed for the outcome of clinically relevant POPF (CR-POPF), with stratification by fistula risk score (FRS). RESULTS: Ninety-nine of 300 patients received pasireotide. The distribution of high, intermediate, low, and negligible risk patients by FRS was comparable (P = .487). There were similar rates of CR-POPF (19.2% pasireotide vs 14.9% control, P = .347) and percutaneous drainage (12.1% vs 10.0%, P = .567), with greater median number of drain days in the pasireotide group (6 vs 4 days, P < .001). Multivariate modeling for CR-POPF showed no correlation with operation or pasireotide use. Adjustment with propensity weighted models for high (OR, 1.02, 95% CI, 0.45-2.29) and intermediate (OR, 1.02, CI, 0.57-1.81) risk groups showed no correlation of pasireotide with reduction in CR-POPF. CONCLUSIONS: Pasireotide administration after pancreatectomy was not associated with a decrease in CR-POPF, even when patients were stratified by FRS.


Asunto(s)
Pancreatectomía/métodos , Fístula Pancreática/prevención & control , Pancreaticoduodenectomía/métodos , Somatostatina/análogos & derivados , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Pancreatectomía/efectos adversos , Pancreatectomía/estadística & datos numéricos , Fístula Pancreática/epidemiología , Fístula Pancreática/etiología , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/efectos adversos , Pancreaticoduodenectomía/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Lesiones Precancerosas/cirugía , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Retrospectivos , Riesgo , Somatostatina/administración & dosificación
5.
BMC Med Inform Decis Mak ; 19(1): 14, 2019 01 18.
Artículo en Inglés | MEDLINE | ID: mdl-30658646

RESUMEN

BACKGROUND: Regulatory approval of next generation sequencing (NGS) by the FDA is advancing the use of genomic-based precision medicine for the therapeutic management of cancer as standard care. Recent FDA guidance for the classification of genomic variants based on clinical evidence to aid clinicians in understanding the actionability of identified variants provided by comprehensive NGS panels has also been set forth. In this retrospective analysis, we interpreted and applied the FDA variant classification guidance to comprehensive NGS testing performed for advanced cancer patients and assessed oncologist agreement with NGS test treatment recommendations. METHODS: NGS comprehensive genomic profiling was performed in a CLIA certified lab (657 completed tests for 646 patients treated at Roswell Park Comprehensive Cancer Center) between June 2016 and June 2017. Physician treatment recommendations made within 120 days post-test were gathered from tested patients' medical records and classified as targeted therapy, precision medicine clinical trial, immunotherapy, hormonal therapy, chemotherapy/radiation, surgery, transplant, or non-therapeutic (hospice, surveillance, or palliative care). Agreement between NGS test report targeted therapy recommendations based on the FDA variant classification and physician targeted therapy treatment recommendations were evaluated. RESULTS: Excluding variants contraindicating targeted therapy (i.e., KRAS or NRAS mutations), at least one variant with FDA level 1 companion diagnostic supporting evidence as the most actionable was identified in 14% of tests, with physicians most frequently recommending targeted therapy (48%) for patients with these results. This stands in contrast to physicians recommending targeted therapy based on test results with FDA level 2 (practice guideline) or FDA level 3 (clinical trial or off label) evidence as the most actionable result (11 and 4%, respectively). CONCLUSIONS: We found an appropriate "dose-response" relationship between the strength of clinical evidence supporting biomarker-directed targeted therapy based on application of FDA guidance for NGS test variant classification, and subsequent treatment recommendations made by treating physicians. In view of recent changes at FDA, it is paramount to define regulatory grounds and medical policy coverage for NGS testing based on this guidance.


Asunto(s)
Antineoplásicos/uso terapéutico , Secuenciación de Nucleótidos de Alto Rendimiento/normas , Neoplasias/tratamiento farmacológico , Neoplasias/genética , Pruebas de Farmacogenómica/normas , Medicina de Precisión/normas , United States Food and Drug Administration/normas , Perfil Genético , Humanos , Estudios Retrospectivos , Estados Unidos
6.
J Natl Compr Canc Netw ; 16(6): 693-702, 2018 06.
Artículo en Inglés | MEDLINE | ID: mdl-29891520

RESUMEN

The NCCN Guidelines for Neuroendocrine and Adrenal Tumors provide recommendations for the management of adult patients with neuroendocrine tumors (NETs), adrenal gland tumors, pheochromocytomas, and paragangliomas. Management of NETs relies heavily on the site of the primary NET. These NCCN Guidelines Insights summarize the management options and the 2018 updates to the guidelines for locoregional advanced disease, and/or distant metastasis originating from gastrointestinal tract, bronchopulmonary, and thymus primary NETs.


Asunto(s)
Neoplasias de las Glándulas Suprarrenales/terapia , Prestación Integrada de Atención de Salud/normas , Oncología Médica/normas , Tumores Neuroendocrinos/terapia , Neoplasias de las Glándulas Suprarrenales/diagnóstico , Adulto , Humanos , Tumores Neuroendocrinos/diagnóstico , Sociedades Médicas/normas , Estados Unidos
7.
PLoS One ; 13(6): e0198809, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-29889907

RESUMEN

BACKGROUND: There is limited literature about the clinicopathological characteristics and outcomes of rare histologic variants of gallbladder cancer (GBC). METHODS: Using SEER database, surgically managed GBC patients with microscopically confirmed adenocarcinoma, adenosquamous/squamous cell carcinoma and papillary carcinoma were identified from 1988 to 2009. Patients with second primary cancer and distant metastasis at presentation were excluded. The effect of clinicopathological variables on overall survival (OS) and disease specific survival (DSS) were analyzed using univariate and multivariate proportional hazards modeling. All associations were considered statistically significant at an alpha error of 0.01. RESULTS: Out of 4738 cases, 217 adenosquamous/squamous (4.6%), 367 papillary (7.7%), and 4154 adenocarcinomas (87.7%) were identified. Median age was 72 years. Higher tumor grade (grade 2, 3, 4 versus grade 1), higher T stage (T2, T3, T4 versus T1), lymph node positivity (N1 versus N0) and adenosquamous/squamous histology (versus adenocarcinoma) had worse OS and DSS (p < .001). Papillary GBC had better OS and DSS than adenocarcinoma (HR = 0.7; p < .001). Radical surgery (versus simple cholecystectomy) had better OS (HR = 0.83, p = 0.002) in multivariate analysis. OS rates at 3 and 5 years were 0.56 and 0.44 for papillary, 0.3 and 0.22 for adenocarcinoma, and 0.14 and 0.12 for adenosquamous/squamous histology, while DSS rates at 3 and 5 years were 0.67 and 0.61 for papillary, 0.38 and 0.31 for adenocarcinoma, and 0.17 and 0.16 for adenosquamous/squamous subtypes respectively. CONCLUSION: Papillary GBC had better survival outcomes while adenosquamous/squamous GBC had worse survival outcomes compared to gallbladder adenocarcinoma.


Asunto(s)
Neoplasias de la Vesícula Biliar/mortalidad , Neoplasias de la Vesícula Biliar/patología , Adenocarcinoma/patología , Adenocarcinoma Papilar/patología , Anciano , Carcinoma de Células Escamosas/patología , Bases de Datos Factuales , Femenino , Humanos , Estimación de Kaplan-Meier , Metástasis Linfática , Masculino , Análisis Multivariante , Estadificación de Neoplasias , Estudios Retrospectivos
8.
J Gastrointest Oncol ; 9(2): 316-325, 2018 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-29755771

RESUMEN

BACKGROUND: Estimation of preoperative overall survival (OS) of hepatocellular carcinoma (HCC) may guide surgical decision-making. METHODS: OS was analyzed using the National Cancer Data Base from 1998-2012. Patients with HCC who underwent wedge resection, lobectomy or extended lobectomy were selected. Patients who had metastatic disease or previous treatment prior to surgery were excluded. Data was randomly allocated to model building (nb =4,364) and validation cohorts (nv =1,091). Multivariable regression analyses of the nb were used to construct prediction models and optimized using nv. RESULTS: HCC patients (n=5,455) who underwent curative resection had a median OS of 36 months (95% CI, 34-38 months) with 1- and 3-year OS of 73% (95% CI, 72-74%) and 50% (95% CI, 49-51%), respectively. The patient median age was 65, 66% of patients were male, median tumor size was 60 mm; clinical stage 1 =25%, stage 2 =30% and stage 3 =45%. Alpha fetoprotein (AFP) was elevated in 63% of patients. Factors significant in the prediction model included degree of resection, age, race, tumor size, grade, and histologic subtype. CONCLUSIONS: A preoperative OS calculator was developed to assist in the treatment evaluation and OS prediction of HCC patients.

9.
Infect Control Hosp Epidemiol ; 39(5): 555-562, 2018 05.
Artículo en Inglés | MEDLINE | ID: mdl-29553001

RESUMEN

BACKGROUNDSurgical site infections (SSIs) following colorectal surgery (CRS) are among the most common healthcare-associated infections (HAIs). Reduction in colorectal SSI rates is an important goal for surgical quality improvement.OBJECTIVETo examine rates of SSI in patients with and without cancer and to identify potential predictors of SSI risk following CRSDESIGNAmerican College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data files for 2011-2013 from a sample of 12 National Comprehensive Cancer Network (NCCN) member institutions were combined. Pooled SSI rates for colorectal procedures were calculated and risk was evaluated. The independent importance of potential risk factors was assessed using logistic regression.SETTINGMulticenter studyPARTICIPANTSOf 22 invited NCCN centers, 11 participated (50%). Colorectal procedures were selected by principal procedure current procedural technology (CPT) code. Cancer was defined by International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes.MAIN OUTCOMEThe primary outcome of interest was 30-day SSI rate.RESULTSA total of 652 SSIs (11.06%) were reported among 5,893 CRSs. Risk of SSI was similar for patients with and without cancer. Among CRS patients with underlying cancer, disseminated cancer (SSI rate, 17.5%; odds ratio [OR], 1.66; 95% confidence interval [CI], 1.23-2.26; P=.001), ASA score ≥3 (OR, 1.41; 95% CI, 1.09-1.83; P=.001), chronic obstructive pulmonary disease (COPD; OR, 1.6; 95% CI, 1.06-2.53; P=.02), and longer duration of procedure were associated with development of SSI.CONCLUSIONSPatients with disseminated cancer are at a higher risk for developing SSI. ASA score >3, COPD, and longer duration of surgery predict SSI risk. Disseminated cancer should be further evaluated by the Centers for Disease Control and Prevention (CDC) in generating risk-adjusted outcomes.Infect Control Hosp Epidemiol 2018;39:555-562.


Asunto(s)
Neoplasias Colorrectales/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , Adulto , Anciano , Estudios de Cohortes , Neoplasias Colorrectales/epidemiología , Bases de Datos Factuales , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Recto/cirugía , Factores de Riesgo , Estados Unidos/epidemiología
10.
Pancreas ; 47(1): 6-11, 2018 01.
Artículo en Inglés | MEDLINE | ID: mdl-29232340

RESUMEN

The vast majority of patients who present with pancreatic adenocarcinoma have locally advanced or metastatic disease at the time of presentation without possibility of cure. Although in recent years there have been some new promising chemotherapy regimens that improve overall survival by a few months, the prognosis remains dismal. There is, however, a subset of patients who experience durable stable disease or partial responses after initial courses of chemotherapy with locally advanced disease. In these select patients, there remains interest in local ablative therapy with or without resection as a means for local control, palliation of symptoms, and possible improved survival. This review describes the techniques, complications, and expected benefits of several ablative techniques as a treatment modality for locally advanced pancreatic cancer.


Asunto(s)
Técnicas de Ablación/métodos , Adenocarcinoma/cirugía , Páncreas/cirugía , Neoplasias Pancreáticas/cirugía , Ablación por Catéter/métodos , Electroporación/métodos , Humanos , Páncreas/patología , Resultado del Tratamiento
11.
J Gastrointest Oncol ; 8(4): 728-736, 2017 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-28890824

RESUMEN

BACKGROUND: Gemcitabine with capecitabine (gem-cap) is an established regimen for advanced biliary cancer (ABC) supported by our previously reported phase II trial. Here, we provide our updated experience. METHODS: Single institution, retrospective study from 2005 to 2015 of ABC treated with gem-cap. RESULTS: A total of 372 patients with ABC were identified, of whom 227 (61.0%) were treated with chemotherapy. 153 patients (67.4%) received gem-cap, of which 129 (56.8%) received it in the first line. Thirty two point six percent (42/129) were locally advanced, 67.4% (87/129) had metastatic disease, and 18.6% (24/129) received it as adjuvant therapy. Disease sites included 48.8% [63] intrahepatic cholangiocarcinoma (IHCC), 24.0% [31] extrahepatic cholangiocarcinoma (EHCC) and 27.1% [35] gallbladder carcinoma (GBC). Median follow-up was 49.7 months (mo). The median PFS and OS were 8.0 mo [95% confidence intervals (CI): 6.0-9.3] and 13.0 mo (95% CI: 10.7-17.4), respectively. Overall, 53.5% (69/129) experienced a grade 3/4 toxicity. The most common (35.7%) was a hematologic toxicity (neutropenia or thrombocytopenia) followed by infection (25.6%). CONCLUSIONS: Gem-cap provides similar survival outcomes to gemcitabine/cisplatin based on historical comparison to the ABC-2 trial (median PFS =8.0 mo and OS =11.7 mo). Gem-cap may offer the advantage of fewer adverse events compared to the levels reported in ABC-2 (grade 3/4 events 70.7%).

12.
HPB (Oxford) ; 19(7): 587-594, 2017 07.
Artículo en Inglés | MEDLINE | ID: mdl-28433254

RESUMEN

BACKGROUND: Current guidelines recommend adjuvant chemotherapy for resected pancreatic adenocarcinoma (PDAC). However, no studies have addressed its survival benefit for stage I patients as they comprise <10% of PDAC. METHODS: Using the NCDB 2006-2012, resected PDAC patients with stage I disease who received adjuvant therapy (chemotherapy or chemoradiation) were analyzed. Factors associated with overall survival (OS) were identified. RESULTS: 3909 patients with resected stage IA or IB PDAC were identified. Median OS was 60.3 months (mo) for stage IA and 36.9 mo for IB. 45.5% received adjuvant chemotherapy; 19.9% received adjuvant chemoradiation. There was OS benefit for both stage IA/IB patients with adjuvant chemotherapy (HR = 0.73 and 0.76 for IA and IB, respectively, p = 0.002 and <0.001). For patients with Stage IA disease (n = 1,477, 37.8%), age ≥70 (p < 0.001), higher grade (p < 0.001), ≤10 lymph nodes examined (p = 0.008), positive margins (p < 0.001), and receipt of adjuvant chemoradiation (p = 0.002) were associated with worse OS. For stage IB patients (n = 2,432, 62.2%), similar associations were observed with the exception of adjuvant chemoradiation whereby there was no significant association (p = 0.35). CONCLUSION: Adjuvant chemotherapy was associated with an OS benefit for patients with stage I PDAC; adjuvant chemoradiation was either of no benefit or associated with worse OS.


Asunto(s)
Antineoplásicos/uso terapéutico , Carcinoma Ductal Pancreático/tratamiento farmacológico , Neoplasias Pancreáticas/tratamiento farmacológico , Anciano , Antineoplásicos/efectos adversos , Carcinoma Ductal Pancreático/mortalidad , Carcinoma Ductal Pancreático/patología , Carcinoma Ductal Pancreático/cirugía , Quimioradioterapia Adyuvante , Quimioterapia Adyuvante , Distribución de Chi-Cuadrado , Bases de Datos Factuales , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estadificación de Neoplasias , Pancreatectomía , Neoplasias Pancreáticas/mortalidad , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Modelos de Riesgos Proporcionales , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos
13.
Urology ; 97: 124-129, 2016 11.
Artículo en Inglés | MEDLINE | ID: mdl-27491964

RESUMEN

OBJECTIVE: To develop quality assessment tool to evaluate surgical performance for robot-assisted radical cystectomy program. METHODS: A prospectively maintained quality assurance database of 425 consecutive robot-assisted radical cystectomies performed by a single surgeon between 2005 and 2015 was retrospectively reviewed. Potentially modifiable factors, related to the management and perioperative care of patients, were used to evaluate patient care. Criteria included the following: preoperative (administration of neoadjuvant chemotherapy); operative (operative time <6.5 hours and estimated blood loss <500 cc); pathologic (negative soft tissue surgical margins and lymph node yield ≥20); and postoperative (no high-grade complications, readmission, or noncancer-related mortality within 30 days).The Quality Cystectomy Score (QCS) was developed (1 star: achieving ≤2 criteria or mortality within 30 days; 2 stars: 3 or 4 criteria met; 3 stars: 5 or 6 criteria met; and 4 stars: 7 or all criteria met). Univariate and multivariate Cox proportional hazard regression models were fitted to test for the association between QCS and survival outcomes. RESULTS: Most patients (85%) achieved at least 3 stars, and more patients achieved 4 stars with time. High QCS was associated with better recurrence-free, cancer-specific, and overall survival (P values <.05). None of the patients with 1-star were alive at 1 year. Patients with 4 stars achieved the best survival rates (recurrence-free survival [62%], cancer-specific survival [70%], and overall survival [53%] at 5 years) (log rank P < .0001). CONCLUSION: Continuous assessment for quality improvement facilitated implementation and maintenance of robot-assisted program for bladder cancer.


Asunto(s)
Cistectomía/métodos , Recurrencia Local de Neoplasia/patología , Garantía de la Calidad de Atención de Salud , Procedimientos Quirúrgicos Robotizados/métodos , Neoplasias de la Vejiga Urinaria/cirugía , Anciano , Cistectomía/efectos adversos , Bases de Datos Factuales , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Invasividad Neoplásica/patología , Recurrencia Local de Neoplasia/fisiopatología , Recurrencia Local de Neoplasia/cirugía , Estadificación de Neoplasias , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/fisiopatología , Estudios Retrospectivos , Medición de Riesgo , Procedimientos Quirúrgicos Robotizados/efectos adversos , Análisis de Supervivencia , Factores de Tiempo , Resultado del Tratamiento , Neoplasias de la Vejiga Urinaria/mortalidad , Neoplasias de la Vejiga Urinaria/patología
14.
HPB (Oxford) ; 18(6): 523-8, 2016 06.
Artículo en Inglés | MEDLINE | ID: mdl-27317957

RESUMEN

BACKGROUND: The purpose of this study was to determine the association of the extent of metastatic lymph node involvement with survival in pancreatic cancer. METHODS: This is a retrospective review of a prospectively maintained database of patients who underwent resection for pancreatic adenocarcinoma, 1999-2011. RESULTS: 165 patients were identified and divided into 3 groups based on the number of positive lymph nodes - 0 (group A), 1-2 (B), >3 (C). Each group had 55 patients. Those in group C were more likely to have a higher T stage, poorly differentiated grade, lymphovascular invasion (LVI), higher mean intraoperative blood loss, positive margins, tumor location involving the uncinate process, and a higher likelihood of undergoing a pancreaticoduodenectomy. Median overall survival (OS) for group A, B and C was 25.5 months (mo), 21 mo and 12.3 mo, respectively (p < 0.001). No survival difference was noted for survival between groups A and B (p = 0.86). The ratio of involved lymph nodes <0.2 was predictive of improved survival (p < 0.001). CONCLUSIONS: Resected pancreatic cancer patients with only 1-2 positive lymph nodes or less than 20% involvement have a similar prognosis to patients without nodal disease. Current staging should consider stratification based on the extent of nodal involvement.


Asunto(s)
Carcinoma Ductal Pancreático/secundario , Carcinoma Ductal Pancreático/cirugía , Ganglios Linfáticos/patología , Pancreatectomía , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma Ductal Pancreático/mortalidad , Bases de Datos Factuales , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Metástasis Linfática , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Estadificación de Neoplasias , Pancreatectomía/efectos adversos , Pancreatectomía/mortalidad , Neoplasias Pancreáticas/mortalidad , Pancreaticoduodenectomía/efectos adversos , Pancreaticoduodenectomía/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento
15.
J Gastrointest Oncol ; 7(3): 441-8, 2016 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-27284478

RESUMEN

BACKGROUND: Neuroendocrine tumors (NETs) metastatic to the liver are treated with transarterial radioembolization (TARE) using yttrium-90 (Y-90) microspheres or transarterial chemoembolization (TACE). However the criteria for patient selection are not well defined. We sought to determine if Ki67 score could help select patients for one therapy over the other in the management of hepatic neuroendocrine metastases. METHODS: Single institution analysis of patients treated with Y-90 or TACE between 2001 and 2014. Pathologists blinded to clinical information performed Ki67 staining. Data were analyzed using multivariate association for survival outcomes. RESULTS: Amongst 72 patients (male: 39, female: 33, median age: 57 years) with metastatic NET, the most common site of origin was small bowel (n=35, 49%), while pancreas constituted 32% (n=23). Forty-four patients were treated with Y-90 (61%) and 28 patients received TACE (39%). Ki67 score was available in 28 patients (64%) treated with Y-90 and 16 patients (57%) with TACE. Within Y-90 group, there was greater use of Sandostatin (95% vs. 75%, P=0.02) and less number of total treatments completed (89% vs. 46%, P<0.001). There was no significant difference in overall survival (OS) between Y-90 and TACE when used without selection (median, 69 vs. 82 months, P=0.47). When adjusted for Ki67, patients with Ki67 score ≥3% had better OS with Y-90 compared to TACE (HR, 0.1; CI, 0.01-0.9), however for Ki67 <3%, OS was better when treated with TACE compared to Y-90 (HR, 13.5; CI, 1.22-148.87). CONCLUSIONS: There is significant interaction between Ki-67 score and liver-directed treatment benefit in patients with hepatic neuroendocrine metastases. Ki-67 score ≥3% predicts greater benefit with Y-90 and a Ki-67 score <3% predicts greater benefit with TACE.

16.
Oncologist ; 20(7): 742-51, 2015 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-26025932

RESUMEN

UNLABELLED: Biliary tract cancers (BTCs) encompass a group of invasive carcinomas, including cholangiocarcinoma (intrahepatic, perihilar, or extrahepatic), and gallbladder carcinoma. Approximately 90% of patients present with advanced, unresectable disease and have a poor prognosis. The latest recommendation is to treat advanced or metastatic disease with gemcitabine and cisplatin, although chemotherapy has recorded modest survival benefits. Comprehension of the molecular basis of biliary carcinogenesis has resulted in experimental trials of targeted therapies in BTCs, with promising results. This review addresses the emerging role of targeted therapy in the treatment of BTCs. Findings from preclinical studies were reviewed and correlated with the outcomes of clinical trials that were undertaken to translate the laboratory discoveries. IMPLICATIONS FOR PRACTICE: Biliary tract cancers are rare. Approximately 90% of patients present with advanced, unresectable disease and have a poor prognosis. Median overall and progression-free survival are 12 and 8 months, respectively. Because chemotherapy has recorded modest survival benefits, targeted therapies are being explored for personalized treatment of these cancers. A comprehensive review of targeted therapies in biliary tract cancers was undertaken to present emerging evidence from laboratory and/or molecular studies as they translate to clinical trials and outcomes. The latest evidence on this topic is presented to clinicians and practitioners to guide decisions on treatment of this disease.


Asunto(s)
Antineoplásicos/farmacología , Neoplasias del Sistema Biliar/tratamiento farmacológico , Regulación Neoplásica de la Expresión Génica , Terapia Molecular Dirigida/métodos , Neoplasias del Sistema Biliar/genética , Neoplasias del Sistema Biliar/metabolismo , Metilación de ADN , Epigénesis Genética , Receptores ErbB/metabolismo , Humanos , Proteína Oncogénica v-akt/metabolismo , Receptor ErbB-2/metabolismo , Transducción de Señal/efectos de los fármacos , Transducción de Señal/genética , Factor A de Crecimiento Endotelial Vascular/metabolismo
17.
Curr Urol Rep ; 16(6): 41, 2015 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-26003110

RESUMEN

Robot-assisted surgery has changed the landscape of surgery. Implementation of robotics into most surgical specialties has left many educators challenged to develop the tools necessary to train and credential surgeons. Advances in robot-assisted surgery have led to the development of simulators and tools to assess skills that transfer to surgical practice. We report on current trends in robot-assisted surgical training, focus on simulation-based education, and anticipate future developments.


Asunto(s)
Procedimientos Quirúrgicos Robotizados , Animales , Humanos , Neoplasias/cirugía , Prostatectomía/métodos , Procedimientos Quirúrgicos Robotizados/educación , Procedimientos Quirúrgicos Robotizados/métodos
18.
J Natl Compr Canc Netw ; 13(1): 78-108, 2015 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-25583772

RESUMEN

Neuroendocrine tumors (NETs) comprise a broad family of tumors that may or may not be associated with symptoms attributable to hormonal hypersecretion. The NCCN Clinical Practice Guidelines in Oncology for Neuroendocrine Tumors discuss the diagnosis and management of both sporadic and hereditary NETs. This selection from the guidelines focuses on sporadic NETs of the pancreas, gastrointestinal tract, lung, and thymus.


Asunto(s)
Tumores Neuroendocrinos/diagnóstico , Tumores Neuroendocrinos/terapia , Manejo de la Enfermedad , Humanos
19.
Ann Surg Oncol ; 22(5): 1533-9, 2015 May.
Artículo en Inglés | MEDLINE | ID: mdl-25323473

RESUMEN

BACKGROUND: In most jurisdictions, a minority of patients are discussed at multidisciplinary cancer conference (MCC) despite recommendations for such reviews. We assessed the impact of MCC review of gastrointestinal (GI) cancers at a stand-alone cancer center. METHODS: Patient data were prospectively collected on consecutive cases presented at a GI MCC during a 6-month period. Original treatment plans were collected confidentially before presentation and compared to post-MCC treatment plans. We defined changes in management plans as major (change in treatment modality) or minor (testing prior to original plan). RESULTS: A total of 149 cases were evaluated: 115 upper GI (gastric/small bowel-10 %, liver-32 %, pancreaticobiliary-36 %), and 34 lower GI (23 %). Reasons for presentation were: questions regarding progression/metastases (44 %), management (26 %), diagnosis (21 %), pathology (15 %), and resectability (7 %). Physicians were certain of their original plans being the final recommendations in 84 % (n = 125). Change in management was recommended in 36 %; 72 % were major and 28 % were minor. Patients underwent all recommended treatments at our institution in 77 % of cases, a portion in 5 %, and no recommended treatments in 18 %. On multivariate analysis, physician degree of certainty for original management plan was not predictive of a change in management plan (p = 0.61). CONCLUSIONS: Although certainty of prediscussion treatment plan is high, changes in treatment recommendations occurred in more than one-third of patients after GI MCC. This prospective study demonstrates the value of MCC in GI cancer sites, even at a stand-alone cancer center.


Asunto(s)
Neoplasias Gastrointestinales/diagnóstico , Neoplasias Gastrointestinales/terapia , Comunicación Interdisciplinaria , Planificación de Atención al Paciente , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Terapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Grupo de Atención al Paciente , Pronóstico , Estudios Prospectivos , Adulto Joven
20.
Biomed Res Int ; 2014: 230174, 2014.
Artículo en Inglés | MEDLINE | ID: mdl-24877069

RESUMEN

The liver is a common site for both primary and secondary malignancy. Hepatic resection and transplantation are the two treatment modalities that have been shown to achieve complete cure, but only 10 to 20% of patients are candidates for these treatments. For the remaining patients, tumor ablation has emerged as the most promising alternative modality. In addition to providing local control and improving survival outcomes, tumor ablation also helps to down stage patients for potential curative treatments, both alone as well as in combination with other treatments. While tumor ablation can be achieved in multiple ways, the introduction of newer ablative techniques has shifted the focus from palliation to potentially curative treatment. Because the long-term safety and survival benefits are not substantive at present, it is important that we strive to evaluate the results from these studies using appropriate comparative outcome methodologies.


Asunto(s)
Neoplasias Hepáticas/terapia , Supervivencia sin Enfermedad , Humanos , Neoplasias Hepáticas/mortalidad , Tasa de Supervivencia
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