Impact of pathological response after neoadjuvant chemotherapy on adjuvant therapy decisions and patient outcomes in gastrointestinal cancers.

BACKGROUND: Neoadjuvant chemotherapy (NAC) is frequently used in gastrointestinal cancers (GIC), and pathological, radiological, and tumor marker responses are assessed during and after NAC. AIM: To evaluate the relationship between pathologic, radiologic, tumor marker responses and recurrence-free survival (RFS), overall survival (OS), adjuvant chemotherapy (AC) decisions, and the impact of changing to a different AC regimen after poor response to NAC. METHODS AND RESULTS: Medical records of GIC patients treated with NAC at Mount Sinai between 1/2012 and 12/2018 were reviewed. One hundred fifty-six patients (58.3% male, mean age 63 years) were identified. Primary tumor sites were: 43 (27.7%) pancreas, 62 (39.7%) gastroesophageal, and 51 (32.7%) colorectal. After NAC, 31 (19.9%) patients had favorable pathologic response (FPR; defined as College of American Pathologists [CAP] score 0-1). Of 107 patients with radiological data, 59 (55.1%) had an objective response, and of 113 patients with tumor marker data, 61 (54.0%) had a ≥50% reduction post NAC. FPR, but not radiographic or serological responses, was associated with improved RFS (HR 0.28; 95% CI 0.11-0.72) and OS (HR 0.13; 95% CI 0.2-0.94). Changing to a different AC regimen from initial NAC, among all patients and specifically among those with unfavorable pathological response (UPR; defined as CAP score 2-3) after NAC, was not associated with improved RFS or OS. CONCLUSIONS: GIC patients with FPR after NAC experienced significant improvements in RFS and OS. Patients with UPR did not benefit from changing AC. Prospective studies to better understand the role of pathological response in AC decisions and outcomes in GIC patients are needed.

Implementation and evaluation of a performance improvement intervention to address physician documentation deficiencies in abdominal ultrasound.

PURPOSE: For ultrasound reports to meet criteria for coding as abdomen complete (USABC), 8 elements are required: liver, bile ducts, gallbladder, spleen, kidneys, pancreas, inferior vena cava (IVC), and aorta. Failure to document all 8 results in coding as ultrasound abdomen limited. The purposes of our study were to identify deficiencies in documentation, implement a performance improvement intervention to address deficiencies, and evaluate the intervention. METHODS: In the first phase, 50 consecutive USABC reports performed as part of routine medical care were retrospectively analyzed for the presence or absence of the 8 elements required for USABC coding. Subsequently, education regarding current procedural terminology coding in abdominal ultrasound and standardized macros was provided to radiologists. In the second, postintervention phase, an additional 50 consecutive USABC reports were analyzed for the presence or absence of the 8 elements. RESULTS: In the first phase, none (0%) of 50 reports met criteria for USABC. The most commonly omitted elements were IVC (present in 2% of reports) and aorta (present in 6%). After intervention, there was an increase to 37 reports (74%) meeting criteria for USABC. The most commonly omitted elements were IVC (present in 76%) and aorta (present in 86%). Lack of 100% compliance was secondary to failure to update a macro and inaccurately scheduled studies (focused right lower quadrant/appendicitis study scheduled as USABC). CONCLUSIONS: We improved USABC documentation from 0% to 74%. Our compliance rate after intervention was similar to the 75.1% of previously published larger studies. Our study illustrates the efficacy of simple performance improvement interventions to improve abdominal ultrasound documentation.

Radiographic findings of anastomotic leaks.

Although computed tomography (CT) scans play an important role in the diagnosis and management of anastomotic leaks (AL), there is no consensus on what radiographic findings are associated with AL. The purpose of this study is to identify the most common CT scan findings associated with AL and whether the amount of extraluminal air or the density of extraluminal fluid can be correlated with the presence of an AL. A retrospective chart review of 210 patients with anastomotic leaks from 2003 to 2010 at Mount Sinai Medical Center was performed. Eighty-six patients fit our criteria and were included. All CT scans were reread by an independent radiologist not involved with patient care. Our study included 59 per cent men and 41 per cent women with a mean age of 51 years. Diagnoses included inflammatory bowel disease (53%), malignancy (21%), and diverticulitis (12%). One hundred per cent of the patients had one of three findings: extraluminal air (92%), extraluminal fluid (88%), or extravasation of contrast (32%). Eighty-one per cent (70/86) had both fluid and air simultaneously. Extraluminal air was seen in 79 patients. The estimated amounts of extraluminal air were as follows: 0 to 25 mL (49%), 26 to 500 mL (41%), 500 to 1000 mL (5%), and more than 1000 mL (5%). The Hounsfield unit (HU) measurements of the fluid ranged from 3 to 633 HUs. The most common CT findings associated with AL are pneumoperitoneum and extraluminal fluid, including extravasation of contrast, which can be seen in up to 100 per cent of patients. The amount of estimated extraluminal air and density of fluid collection have no prognostic value in predicting AL.

Intraductal polypoid lipid-rich neuroendocrine tumor of the pancreas with entrapped ductules: case report and review of the literature.

Pancreatic neuroendocrine tumors of the main pancreatic duct are rare and usually small due to symptoms of pancreatic duct obstruction. We present a case of a large (3 cm), well-differentiated (G1) lipid-rich polypoid neuroendocrine tumor of the pancreas completely occluding the main pancreatic duct with non-neoplastic-entrapped ductules and CK19 positivity. Clinical, radiological, gross, microscopic, immunohistochemical, and ultrastructural findings are discussed. The literature pertaining to the unique features of this case is reviewed including clinical and pathologic pitfalls and the possible etiologic and prognostic significance of these findings.

Hepatic imaging in the 21st century.

Imaging of the liver has progressed rapidly during the past decade with continued advancement of current ultrasound, computed tomography, and magnetic resonance imaging (MRI). Each modality not only has seen refinement enabling better anatomic characterization of disease but also has received strength from the addition of new techniques to its resources. New contrast agents have become available for all modalities and some agents, particularly for MRI, have opened the way for better functional assessment. MRI continues to see an elaboration of sequences (including spectroscopy and diffusion) that also open imaging to the microscopic structure of disease and normal function. The further development of workstations have improved both analysis and depiction of disease. In the 21st century imaging will continue to shift from a simple source of anatomic information to a more functional problem-solving tool.