Gallbladder Cancer Incidentally Found at Cholecystectomy: Perioperative Risk Factors.

PURPOSE: Risk factors of gallbladder cancer (GBC) are not well-defined resulting in greater than 60% of GBCs being diagnosed incidentally following cholecystectomy performed for presumed benign indications. As most localized GBCs require more extensive oncologic surgery beyond cholecystectomy, this study aims to examine factors associated with incidentally found GBC to improve preoperative and intraoperative diagnoses. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Database from 2007 to 2017 was used to identify cholecystectomies performed with and without a final diagnosis of GBC. Univariate and multivariable logistic regressions were used to compare demographic, intraoperative, and postoperative characteristics among those with and without a diagnosis of GBC. RESULTS: The incidence of GBC was observed to be 0.11% (441/403,443). Preoperative factors associated with risk of GBC included age > 60 (OR 6.51, p < .001), female sex (OR 1.75, p < .001), history of weight loss (2.58, p < .001), and elevated preoperative alkaline phosphatase level (OR 1.67, p = .001). Open approach was associated with 7 times increased risk of GBC compared to laparoscopic approach (OR 7.33, p < .001). In addition to preoperative factors and surgical approach, longer mean operative times (127 min vs 70.7 min, p < .001) were significantly associated with increased risk of GBC compared to benign final pathology. CONCLUSION: This study demonstrates that those with incidentally discovered GBC at cholecystectomy are unique from those undergoing cholecystectomy for benign indications. By identifying predictors of GBC, surgeons can choose high risk individuals for pre-operative oncologic evaluation and consider better tools for identifying GBC such as intraoperative frozen pathology.

Disparities in Surgical Treatment of Resectable Pancreatic Adenocarcinoma at Minority Serving Hospitals.

INTRODUCTION: Minority serving hospitals (MSH) are those serving a disproportionally high number of minority patients. Previous research has demonstrated that treatment at MSH is associated with worse outcomes. We hypothesize that patients treated at MSH are less likely to undergo surgical resection of pancreatic adenocarcinoma compared to patients treated at non-MSH. METHODS: Patients with resectable pancreatic cancer were identified using the National Cancer Database. Institutions treating Black and Hispanic patients in the top decile were categorized as an MSH. Factors associated with the primary outcome of definitive surgical resection were evaluated using multivariable logistic regression. Univariate and multivariable survival analysis was performed. RESULTS: Of the 75,513 patients included in this study, 7.2% were treated at MSH. Patients treated at MSH were younger, more likely to be uninsured, and higher stage compared to those treated at non-MSH (P < 0.001). Patients treated at MSH underwent surgical resection at lower rates (MSH 40% versus non-MSH 44.5%, P < 0.001). On multivariable logistic regression, treatment at MSH was associated with decreased likelihood of undergoing definitive surgery (odds ratio 0.91, P = 0.006). Of those who underwent surgical resection, multivariable survival analysis revealed that treatment at an MSH was associated with increased morality (hazard ratio 1.12, P < 0.001). CONCLUSIONS: Patients with resectable pancreatic adenocarcinoma treated at MSH are less likely to undergo surgical resection compared to those treated at non-MSH. Targeted interventions are needed to address the unique barriers facing MSH facilities in providing care to patients with pancreatic adenocarcinoma.

Outcomes after sublobar resection versus lobectomy in non-small cell carcinoma in situ.

OBJECTIVE: Guidelines for treatment of non-small cell lung cancer identify patients with tumors ≤2 cm and pure carcinoma in situ histology as candidates for sublobar resection. Although the merits of lobectomy, sublobar resection, and lymphoid (LN) sampling, have been investigated in early-stage non-small cell lung cancer, evaluation of these modalities in patients with IS disease can provide meaningful clinical information. This study aims to compare these operations and their relationship with regional LN sampling in this population. METHODS: The National Cancer Database was used to identify patients diagnosed with non-small cell lung cancer clinical Tis N0 M0 with a tumor size ≤2 cm from 2004 to 2017. The χ2 tests were used to examine subgroup differences by type of surgery. Kaplan-Meier method and Cox proportional hazard model were used to compare overall survival. RESULTS: Of 707 patients, 56.7% (401 out of 707) underwent sublobar resection and 43.3% (306 out of 707) underwent lobectomy. There was no difference in 5-year overall survival in the sublobar resection group (85.1%) compared with the lobectomy group (88.9%; P = .341). Multivariable survival analyses showed no difference in overall survival (hazard ratio, 1.044; P = .885) in the treatment groups. LN sampling was performed in 50.9% of patients treated with sublobar resection. In this group, LN sampling was not associated with improved survival (84.9% vs 85.0%; P = .741). CONCLUSIONS: We observed no difference in overall survival between sublobar resection and lobectomy in patients with cTis N0 M0 non-small cell lung cancer with tumors ≤2 cm. Sublobar resection may be an appropriate surgical option for this population. LN sampling was not associated with improved survival in patients treated with sublobar resection.

High-Grade Dysplasia in Inflammatory Bowel Disease: Indication for Colectomy.

BACKGROUND: Patients with inflammatory bowel disease have an increased risk of colorectal cancer and are recommended to undergo increased surveillance compared to the general population. Currently, inadequate evidence exists to guide management of colonic dysplasia discovered during screening of inflammatory bowel disease patients. OBJECTIVE: The goal of this study was to determine the risk of colorectal cancer in patients with ulcerative colitis or Crohn's disease with dysplasia on colonoscopy. DESIGN: This was a retrospective study. SETTING: This study was conducted at a high-volume, quaternary referral center with an inflammatory bowel disease program. PATIENTS: Patients with a diagnosis of inflammatory bowel disease with colonoscopy within 6 months of colectomy were included. MAIN OUTCOME MEASURES: The primary outcome measures included finding of colorectal cancer at time of colectomy. RESULTS: There were 621 patients, 233 with ulcerative colitis and 388 with Crohn's disease. Of ulcerative colitis patients, 25 had low-grade dysplasia on colonoscopy with 1 (4%) found to have colorectal cancer at colectomy. High-grade dysplasia was noted preoperatively in 14 and colorectal cancer was found in 4 (29%) after colectomy. Compared to no dysplasia, low-grade dysplasia did not increase the risk of colorectal cancer (OR 1.98, p = 0.47), but high-grade dysplasia had an increased risk (OR 19.0, p < 0.001) of colorectal cancer. For the 7 patients with Crohn's disease and low-grade dysplasia, colorectal cancer was found in 1 patient (14%) at colectomy. High-grade dysplasia was noted preoperatively in 4 patients with Crohn's Disease, and colorectal cancer was found in 3 patients (75%) after colectomy. Compared to no dysplasia, low-grade dysplasia did not increase the risk of colorectal cancer (OR 12.4, p = 0.88), but high-grade dysplasia did increase the risk of colorectal cancer (OR 223.2, p < 0.001). LIMITATIONS: This study was limited by its retrospective review. CONCLUSION: In both ulcerative colitis and Crohn's disease, low-grade dysplasia was not associated with colorectal cancer. High-grade dysplasia was associated with an increased risk of colorectal cancer at time of colectomy. While continued surveillance may be appropriate for low-grade dysplasia, high-grade dysplasia necessitates surgical resection given the high likelihood of colorectal cancer. See Video Abstract at http://links.lww.com/DCR/B887 . DISPLASIA DE ALTO GRADO EN LA ENFERMEDAD INFLAMATORIA INTESTINAL INDICACIN DE COLECTOMA: ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal tienen un mayor riesgo de cáncer colorrectal y se recomienda someterse a una mayor vigilancia en comparación con la población general. Actualmente, existe evidencia inadecuada para guiar el manejo de la displasia colónica descubierta durante la valoracion de pacientes con enfermedad inflamatoria intestinal.OBJETIVO:Determinar el riesgo de cáncer colorrectal en pacientes con colitis ulcerosa o enfermedad de Crohn con displasia en la colonoscopia.DISEÑO:Este fue un estudio retrospectivo.AJUSTE:Este estudio se llevó a cabo en un centro de referencia cuaternario de alto volumen con un programa de enfermedad inflamatoria intestinal.PACIENTES:Pacientes con diagnóstico de enfermedad inflamatoria intestinal con colonoscopia dentro de los 6 meses posteriores a la colectomía.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado incluyeron el hallazgo de cáncer colorrectal en el momento de la colectomía.RESULTADOS:Hubo 621 pacientes: 233 con colitis ulcerosa y 388 con enfermedad de Crohn. De los pacientes con colitis ulcerosa, 25 tenían displasia de bajo grado en la colonoscopia y 1 (4%) tenía cáncer colorrectal en la colectomía. Se observó displasia de alto grado antes de la operación en 14 y cáncer colorrectal en 4 (29%) después de la colectomía. En comparación con la ausencia de displasia, la displasia de bajo grado no aumentó el riesgo de cáncer colorrectal (Odds Ratio 1,98, p = 0,47), pero la displasia de alto grado tuvo un mayor riesgo (OR 19,0, p <0,001) de cáncer colorrectal. Para los 7 pacientes con enfermedad de Crohn y displasia de bajo grado, se encontró cáncer colorrectal en 1 (14%) en la colectomía. Se observó displasia de alto grado antes de la operación en 4 pacientes con enfermedad de Crohn y cáncer colorrectal en 3 pacientes (75%) después de la colectomía. En comparación con la ausencia de displasia, la displasia de bajo grado no aumentó el riesgo de cáncer colorrectal (Odds Ratio 12.4, p = 0.88), pero la displasia de alto grado sí aumentó el riesgo de cáncer colorrectal (Odds Ratio 223.2, p <.001).LIMITACIONES:Este estudio estuvo limitado por su revisión retrospectiva. CONCLUSIN: Tanto en la colitis ulcerosa como en la enfermedad de Crohn, la displasia de bajo grado no se asoció con el cáncer colorrectal. La displasia de alto grado se asoció con un mayor riesgo de cáncer colorrectal en el momento de la colectomía. Si bien la vigilancia continua puede ser apropiada para la displasia de bajo grado, la displasia de alto grado requiere resección quirúrgica dada la alta probabilidad de cáncer colorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B887 . (Traducción-Dr Yolanda Colorado ).

Carbon Dioxide Embolism Resulting From Liver Laceration During Peritoneal Optical Trocar Entry.

Venous air emboli have been reported to occur in numerous settings, including trauma, various surgical procedures, both laparoscopic and radiologically, and even idiopathically. In this case study, a liver laceration was made during a robot-assisted left colectomy and colostomy in a 69-year-old female resulting in air embolism during insufflation. A drop in end-tidal CO2 was noted and the patient went into immediate cardiac arrest. Adequate pressure was applied and over-suturing of the liver laceration was made with reverse Trendelenburg positioning during the administration of cardiopulmonary resuscitation (CPR) for approximately one minute. The patient completed an open hemicolectomy the following day and made a complete recovery. Preventative and intraoperative measures to prevent further recurrences of venous air emboli are discussed.

Management of Clinical T2N0 Esophageal and Gastroesophageal Junction Adenocarcinoma: What Is the Optimal Treatment?

BACKGROUND: The current standard of care for locally advanced esophageal and gastroesophageal junction (GEJ) adenocarcinoma includes neoadjuvant chemoradiation and surgery. The optimal treatment for clinical T2N0M0 (cT2N0) disease is debated. This study aims to determine the optimal treatment in these patients. METHODS: The National Cancer Database was used to identify patients who underwent surgery for cT2N0 esophageal and GEJ adenocarcinoma from 2004 to 2017. Patients were grouped into surgery-alone, neoadjuvant therapy (NAT), and adjuvant therapy (AT) groups. Subgroups of high-risk patients (tumor ≥ 3 cm, poor differentiation, or lymphovascular invasion) and patients upstaged after upfront surgery were identified. Kaplan-Meier method and Cox proportional hazard ratios were used to compare overall survival. RESULTS: Of 2160 patients included, 957 (44.3%) underwent surgery-alone, 821 (38.0%) underwent NAT and surgery, and 382 (17.7%) underwent surgery and AT. One thousand six hundred nineteen (75.0%) patients had high-risk features. Six hundred fourteen (45.9%) patients were upstaged after upfront surgery. In the overall cohort, AT was associated with improved survival compared to NAT (HR 0.618, p < 0.001) and surgery-alone (HR 0.699, p < 0.001). There was no difference in survival between NAT and surgery-alone (HR 1.132, p = 0.112). Similar results were observed in high-risk patients. Patients upstaged after upfront surgery who received AT had improved survival compared to those initially treated with NAT (HR 0.613, p < 0.001). CONCLUSION: This analysis suggests that cT2N0 esophageal and GEJ adenocarcinomas may not benefit from the intensive multimodality therapy utilized in locally advanced disease. Selective use of AT for patients who are upstaged pathologically, or have high-risk features, is associated with improved outcomes.

Predictors of Conversion During Minimally Invasive Gastrectomy for Malignancy.

INTRODUCTION: Implementation of minimally invasive gastrectomy (MIG) for malignancy is increasing. However, risk factors for conversion to open surgery during laparoscopic and robotic gastrectomy are poorly understood. This study aimed to determine the risk factors for, and impact of, conversion during oncologic resection. METHODS: The National Cancer Database (NCDB) was used to identify patients with clinical stage I-III gastric cancer from 2010 to 2017. Chi-squared test and t-test were used to compare the robotic versus laparoscopic groups. Propensity score weighted multivariable logistic regression was used to evaluate factors associated with conversion to open surgery. RESULTS: Of 6990 patients identified, 5702 (81.6%) underwent a laparoscopic resection and 1288 (18.4%) underwent robotic-assisted resection. Conversion rates were 14.7% and 7.8% for laparoscopic and robotic gastrectomy, respectively. The robotic approach was associated with lower likelihood of conversion compared to laparoscopic approach (odds ratio [OR] = 0.470, P < 0.001). Other factors predictive of conversion included tumor size >5 cm compared to <2 cm (OR 1.714, P = 0.010), total gastrectomy compared to partial gastrectomy (OR 2.019, P < 0.001), antrum/pylorus (OR 2.345, P < 0.001), and body (OR 2.152, P < 0.001) tumors compared to cardia tumors. Compared to those treated with laparoscopic and robotic gastrectomy, patients who underwent conversion experienced significantly longer hospital length of stay and higher rates of positive surgical margins. CONCLUSIONS: Laparoscopic gastrectomy was associated with a higher conversion rate compared to robotic gastrectomy. Conversion to open surgery was associated with a significantly longer length of stay and higher rates of positive margins. Identification of risk factors for conversion can aid in appropriate modality selection.

Pancreatoduodenectomy for monomorphic epitheliotropic intestinal T-cell lymphoma with duodenal obstruction.

We report an unusual case of a woman in her 60s diagnosed with monomorphic epitheliotropic intestinal T-cell lymphoma who required a pancreatoduodenectomy (Whipple procedure) for duodenal obstruction. The patient was initially treated with several cycles of chemotherapy, with persistent disease of the duodenum at D3. She was symptomatic with obstructive symptoms and positron emission tomography (PET)-CT showed disease localised to the duodenum without evidence of active disease elsewhere. The patient underwent pancreatoduodenectomy for both palliation of obstructive symptoms and potential oncological benefit. The patient had mild symptoms of delayed gastric emptying requiring promotility agents postoperatively, but otherwise recovered well after surgery. Unfortunately, surgical pathology revealed diffuse disease through the resected portion of the duodenum and jejunum, with positive proximal and distal margins. We suspect she has diffuse small bowel disease which was occult by CT and PET-CT. Based on this case, we recommend consideration of bypass rather than resection when possible for surgical palliation due to likelihood for extensive bowel involvement.

Is preoperative biliary stenting associated with increased rate of postoperative complications for patients undergoing pancreatoduodenectomy? A review of national surgical quality improvement program data.

BACKGROUND: Jaundice in the setting of periampullary neoplasms is often treated with biliary stenting. Level 1 data demonstrated an increase in perioperative complications after pancreaticoduodenectomy in patients undergoing stent placement. However, the impact of this data on practice patterns in the US remains unknown. METHODS: The National Surgical Quality Improvement Program (NSQIP) Pancreatectomy Targeted Participant Use Data File was used to identify patients from 2014 to 2017 undergoing pancreatoduodenectomy. Chi-square test and multivariable logistic regression were used to compare outcomes between those with biliary stent and those without. RESULTS: Of the 5524 patients, 3321 (60.1%) had biliary stent placement. The stent group was older, had a higher ASA class, and had preoperative weight loss compared to the group without biliary stenting (all p < 0.05). When adjusting for demographic and operative characteristics, the non-stent group had lower associated overall complications and postoperative infections. There was no significant difference in mortality and pancreatic fistula rate between groups. CONCLUSION: Preoperative biliary stenting is still common prior to pancreaticoduodenectomy. With a trend toward increased utilization of neoadjuvant chemotherapy, stenting will likely remain a common practice. Recognition of increased rates of complications associated with stent placement allows for appropriate risk-benefit analysis.

Predictors and Outcomes of Minimally Invasive Surgery for Small Bowel Neuroendocrine Tumors : Minimally Invasive Surgery for SBNETs.

BACKGROUND: Open surgical resection with regional lymphadenectomy is the standard of care for small bowel neuroendocrine tumors (SBNETs). There is no consensus on the role of minimally invasive surgery (MIS). This study aims to evaluate the current national trends for MIS in treating SBNETs and its association with lymph node (LN) yield. METHODS: The National Cancer Database was queried for patients with Stage I-III SBNETs who underwent surgery from 2010-2017. Time trends were examined using the Cochran-Armitage test. Chi-square tests, t test, and multivariable logistic regression assessed associations of surgical approach with patient, clinical, and facility characteristics. Kaplan-Meier curves and propensity score weighted Cox proportional hazards model were used to examine survival. RESULTS: Of the 11,367 patients with Stage I-III SBNETs, 46.5% (N = 5,298) underwent MIS. From 2010-2017, the proportion of MIS increased from 35.6% to 57.7% (P < 0.001). Patients of Stage I disease (OR = 1.23), Caucasian race (OR = 1.18), private insurance (OR = 1.29), and higher volume centers (OR = 1.29) were more likely to undergo MIS (all P < 0.02). The average number of LN harvested in the MIS cohort was greater than in the open surgery cohort (13.3 vs 11.8 LN, P < 0.001). MIS patients had shorter length of stay by 2 days compared to open surgery (5.4 vs 7.6 days, P < 0.001). LN yield ≥ 8 was associated with better survival (HR = 0.77, P < 0.001). CONCLUSION: The utilization of a MIS approach to treat Stage I-III SBNETs has increased, especially at higher volume centers. We did not observe an inferior LN harvest with the MIS cohort compared to the open surgery cohort.

Stoma-less IPAA Is Not Associated With Increased Anastomotic Leak Rate or Long-term Pouch Failure in Patients With Ulcerative Colitis.

BACKGROUND: There is debate regarding the utility of diverting loop ileostomy with IPAA construction in patients requiring colectomy for ulcerative colitis. OBJECTIVE: This study aimed to determine whether the omission of diverting loop ileostomy at the time of IPAA construction increases the risk of complications. DESIGN: This was a retrospective study. SETTINGS: The study was conducted in a high-volume, quaternary referral center with an IBD program. PATIENTS: The patients, who underwent IPAA with or without ileostomy, were diagnosed for ulcerative colitis. MAIN OUTCOME MEASURES: Anastomotic leak rate and pouch failure rates were determined between patients who either had a diverting ileostomy at the time of IPAA creation or had stoma-less IPAA. RESULTS: Of the 414 patients included in this study, 91 had stoma-less IPAA. When compared to IPAA with diverting loop ileostomy, patients with stoma-less IPAA were less likely to be taking prednisone and had decreased blood loss. Short- and long-term outcomes were similar when comparing stoma-less IPAA and IPAA with diverting loop ileostomy, with no significant difference in anastomotic leak rate and long-term pouch failure rates. Diverting loop ileostomy was associated with a 14.6% risk of complication at the time of stoma reversal. LIMITATIONS: The study is limited by its retrospective nature. CONCLUSIONS: The results of this study suggest that the omission of a diverting ileostomy is feasible in select patients undergoing IPAA. Stoma-less IPAA does not have a statistically significant higher risk of anastomotic leak or pouch failure when compared to IPAA with diverting loop ileostomy in properly selected patients. Diverting loop ileostomies have their own risks, which partially offset their perceived safety. See Video Abstract at http://links.lww.com/DCR/B891 .LA ANASTOMÓSIS DE RESERVORIO ILEAL AL ANO SIN ESTOMA NO ESTÁ ASOCIADO CON UN AUMENTO EN LA TASA DE FUGA ANASTOMÓTICA O DISFUNCIÓN DE LA BOLSA A LARGO PLAZO EN PACIENTES CON COLITIS ULCERATIVA. ANTECEDENTES: Existe debate en lo que respecta a la utilidad de efectuar una ileostomía en asa en la construcción de una anastomosis de reservorio ileal al ano en pacientes que requieren colectomía para colitis ulcerativa. OBJETIVO: Determinar si el evitar una ileostomía de derivación en el momento de efectuar una anstomósis de reservorio ileal al ano aumenta el riesgo de complicaciones. DISEO: Estudio retrospectivo. REFERENCIA: Centro de referencia de cuarto nivel de grandes volúmenes con programa de enfermedad inflamatoria intestinal. PACIENTES: Con diagnóstico de colitis ulcerativa sometidos a anastomosis de reservorio ileal al ano con o sin ileostomía derivative. PRINCIPALES MEDIDAS DE RESULTADOS: Tasa de fuga anastomótica y disfunción del reservorio en pacientes sometidos a anastomosis de reservorio ileal al ano con ileostomía derivativa en el mismo evento y aquellos sin derivación de protección. RESULTADOS: De los 414 pacientes incluídos en el estudio, 91 no contaban con ileostomía de protección de la anastomosis del reservorio ileal al ano. Al comprarse con aquellos con ileostomía derivativa, aquellos sin estoma requirieron menor dosis de prednisona y presentaron menor pérdida sanguínea. Los resultados a corto y largo plazo fueron similares al comprar ambos grupos sin haber evidencia significativa de fuga anastomótica o falla del reservorio a largo plazo. La derivación con ileostomía en asa se asoció en un 14.6% de riesgo de complicaciones al efectuar el cierre de la misma. LIMITACIONES: Es una revision retrospectiva. CONCLUSIONES: : Los resultados de este estudio sugieren que la omisión de una ileostomía de protección es posible en pacientes seleccionados sometidos a una anastomosis de reservorio ileoanal. La anastomosis sin derivación de protección no confiere un riesgo estadísticamente significativo de fuga anastomótica o disfunción de la misma al compararse con el procedimiento con estoma derivativo en pacientes seleccionados. Las ileostomías de derivación en asa tienen su propia morbilidad que cuestiona la perfección de su seguridad. Consulte Video Resumen at http://links.lww.com/DCR/B891 . (Traducción- Dr. Miguel Esquivel-Herrera ).

Benefits of Trimodality Therapy Compared with Systemic Therapy Alone in Male Patients with Stage IV Breast Cancer.

BACKGROUND: Male breast cancer (MBC) represents <1% of all breast cancer (BC) diagnoses. Recent publications in female stage IV BC have shown that surgical intervention has a survival benefit. This study aims to determine the impact of surgical intervention in men with stage IV BC and known estrogen (ER) and progesterone receptor (PR) status. METHODS: The National Cancer Database was used to identify 539 stage IV MBC patients with known ER/PR status from 2004 to 2017. Chi-square tests examined subgroup differences between the treatment modalities received. Overall survival (OS) was assessed using the Kaplan-Meier method. Multivariate Cox proportional hazard models examined factors associated with survival. RESULTS: The Kaplan-Meier estimation showed that ER-positive (ER+) and PR-positive (PR+) patients who received surgery, systemic therapy, and radiation (Trimodality) or systemic therapy and surgery (ST+Surg) had improved survival compared with systemic therapy alone (ST) [ER+, p < 0.003; PR+, p < 0.033]. For ER+ patients, the 5-year OS rates by treatment were: Trimodality, 40%; ST+Surg, 27%; and ST, 20%. For PR+ patients, the 5-year OS rates were: Trimodality, 39%; ST+Surg, 24%; and ST, 20%. The Cox proportional hazard model revealed a survival advantage in patients who received Trimodality compared with ST (hazard ratio 0.622; p < 0.002). The timing of systemic therapy in relation to surgery was not found to be significant. CONCLUSIONS: Trimodality therapy has a survival benefit in stage IV MBC patients with known ER+ status than in male patients who receive systemic therapy alone.

Insurance Status and Travel Distance to Single Treatment Facility Predictive of Mastectomy.

BACKGROUND: We evaluated the impact of insurance status and travel distance on the receipt of total mastectomy without reconstruction (TM) compared to breast conserving surgery with radiation (BCT) for early-stage breast cancer (BC) patients who received care at a single facility. We hypothesized that, lack of insurance and increased travel distance would be predictive of TM over BCT and disparities would vary by different races and/or ethnicities. METHODS: Using the National Cancer Database from 2010-2017, we examined surgical patients with stage I or II BC, who received care at one facility. Chi-square tests examined subgroup differences by BCT or TM. Multivariable logistic regressions evaluated patient, facility, and pathologic factors associated with the receipt of TM over BCT for the entire cohort and by races and/or ethnicities. RESULTS: Of the 284,202 patients, 70.1% received BCT while 29.9% received TM. After adjustment travel distance > 60 miles to a treatment facility, and non-insured patients were more likely to receive TM over BCT, when compared to travel distance < 20 miles and private insurance (all P < 0.05). Compared to other races and/or ethnicities, African Americans traveling > 60 miles were 65.4% more likely to receive TM over BCT compared to those traveling < 20 miles (P < .0001). Across all races and/or ethnicities after adjustment, lack of insurance was predictive for receipt of TM over BCT (P < 0.05). CONCLUSIONS: Despite treatment at one facility, increased travel distance and insurance status are independently predictive of the receipt of TM over BCT in patients with early-stage BC. While travel distance is particularly impactful for African Americans, the impact of not having insurance on surgical treatments is universal across all races and/or ethnicities.

Survival Benefit of Guideline-Concordant Postoperative Radiation for Local Merkel Cell Carcinoma.

BACKGROUND: Postoperative radiation therapy (RT) for early-stage Merkel Cell Carcinoma (MCC) decreases the risk of locoregional recurrence and improve overall survival. However, concordance with RT guidelines is unknown. MATERIALS AND METHODS: The National Cancer Database was queried for stage I/II MCC patients receiving surgical intervention from 2006-2017. The cohort was stratified by patients who had and did not have indication(s) for adjuvant RT of the primary tumor site based on National Comprehensive Cancer Network guidelines. We captured the use of RT, patient demographics, socioeconomic characteristics, and clinical characteristics. Logistic regression, Kaplan-Meier method, and propensity score weighted Cox proportional hazards model examined associations and survival benefits of RT. RESULTS: 2,330 stage I/II MCC patients underwent surgical intervention. 1,858 (79.7%) met National Comprehensive Cancer Network criteria for RT of the primary tumor site, of which 1,062 (57.2%) received RT. 472 (20.3%) did not meet criteria for RT, of which 203 (43.0%) received RT. Five-year overall survival advantage was identified for patients who received RT when it was indicated (P < 0.003). There was no evidence of overall survival advantage when patients received guideline-discordant RT (P = 0.478). CONCLUSIONS: Surgical resection with adjuvant RT of the primary tumor site has an overall survival benefit for local MCC when patients meet criteria for RT. This study found a group who received guideline-discordant RT with no survival advantage. Further investigation is warranted to identify the socio-demographic and oncologic reasons for guideline discordance in the treatment of MCC for both under- and over-treatment.

Pathologic upstaging in resected pancreatic adenocarcinoma: Risk factors and impact on survival.

BACKGROUND: Clinical and pathologic staging determine treatment of pancreatic cancer. Clinical stage has been shown to underestimate final pathologic stage in pancreatic cancer, resulting in upstaging. METHODS: National Cancer Database was used to identify clinical stage I pancreatic adenocarcinoma. Univariate, multivariable logistic regression, and Cox proportional hazard ratio were used to determine differences between upstaged and stage concordant patients. RESULTS: Upstaging was seen in 80.2% of patients. Factors found to be significantly associated with upstaging included pancreatic head tumors (OR 2.56), high-grade histology (OR 1.74), elevated Ca 19-9 (OR 2.09), and clinical stage T2 (OR 1.99). Upstaging was associated with a 45% increased risk of mortality compared to stage concordant disease (HR 1.44, p < .001). CONCLUSION: A majority of clinical stage I pancreatic cancer is upstaged after resection. Factors including tumor location, grade, Ca 19-9, and tumor size can help identify those at high risk for upstaging.

Hidradeonoma Papilliferum of the Anus: A Case Report About the Relationship Between Neoplasms of the Mammary-Like-Glands and Hormones.

Hidradenoma papilliferum (HP) is a benign pathologic finding that has been described primarily in the vulvar region. While thought to arise from ectopic tissue along the mammary line, it is now known to also arise from mammary-like anogenital glands (MLG), which are part of the normal anogenital cellular and glandular milieu. Previous work has demonstrated the relationship between HP and hormone receptors, but this has not been documented in a clinical setting. In this case, we present HP in a patient undergoing infertility treatments, presenting with a painful, enlarging anal mass. Upon histopathologic review, the mass was found to be an HP with no malignant changes. This unique case adds to the existing literature on perianal HP. While this case follows the known clinical and histological patterns of HP, the unique temporal relationship to in vitro fertilization (IVF) treatment supports previous in vitrowork on the relationship between HP and hormone receptors.

Adjuvant Chemotherapy After Neoadjuvant Chemotherapy for Pancreatic Cancer is Associated with Improved Survival for Patients with Low-Risk Pathology.

BACKGROUND: With limited evidence, the benefit of adjuvant chemotherapy (AT) after completion of neoadjuvant chemotherapy (NT) and surgical resection for patients with pancreatic adenocarcinoma is debated. Guidelines recommend 6 months of AT for patients receiving NT. However, the patient-derived benefit from additional AT remains unknown. METHODS: The National Cancer Database from 2006 to 2015 was used to identify patients undergoing NT. The chi-square test and multivariable logistic regression were used to identify differences between those receiving only NT and those receiving NT and AT. Survival analysis using the Kaplan-Meier method and the Cox proportional hazard ratio model was applied to the entire cohort and to subgroups with differing lymph node ratios (LNRs), tumor sizes, grades, and surgical margin statuses. RESULTS: Of the 3897 patients who received NT, 36.7 % received additional AT. Analysis of the entire cohort showed that associated survival was significantly improved with NT and AT compared with NT alone (hazard ratio [HR], 0.83; p < 0.001). In the subgroup analysis, the survival benefit of additional AT remained significant for those with negative nodal disease, an LNR lower than 0.15, low-grade histology, and negative margin status. Overall survival did not differ between those receiving NT only and those receiving NT and AT in the group with an LNR of 0.15 or higher, high-grade histology, and positive margins. CONCLUSION: This study identified an increasing trend in the use of AT after NT and showed an associated survival benefit for subgroups with low-risk pathologic features. These results suggest that the addition of AT after NT likely beneficial for these subgroups.

Undertreatment of Pancreatic Cancer: Role of Surgical Pathology.

BACKGROUND: Current guidelines recommend treatment of early-stage pancreatic cancer with surgical resection and chemotherapy. Undertreatment can occur after resection when patients fail to receive adjuvant chemotherapy. Final pathologic results have the potential to bias providers to omit adjuvant chemotherapy, however, the association of surgical pathology and adjuvant chemotherapy is unknown. METHODS: Data from the National Cancer Database identified patients who underwent surgery for stage I or II pancreatic cancer. Chi-square tests and logistic regression were used to determine differences between patients receiving surgery followed by chemotherapy and those who had resection alone. Survival analysis of subgroups with favorable pathology (node-negative disease, tumor size ≤ 2 cm, well-differentiated histology) was performed by the Kaplan-Meier method and the Cox proportional hazards model. RESULTS: Of the 22,131 patients included in this study, 28% were considered undertreated (surgery alone). Favorable pathologic traits of negative lymph nodes, tumor 2 cm in size or smaller, and well-differentiated histology were associated with a 15-35% lower probability that adjuvant chemotherapy would be given than less favorable pathologic results (p < 0.001). Multivariable survival analysis showed significantly lower odds of mortality for patients who received resection and chemotherapy than for those who were undertreated among two subgroups: patients with node-negative disease (hazard ratio [HR] 0.774) and those with a tumor 2 cm in size or smaller (HR 0.771). CONCLUSION: The patients who had early-stage pancreatic cancer with favorable pathology after pancreatectomy were less likely than those with unfavorable pathology to receive adjuvant chemotherapy. This omission had significant survival consequences for subgroups with node-negative disease and tumors 2 cm in size or smaller. Recognition of patients with favorable pathology as an undertreated group is required for efforts to be directed toward encouraging guideline-concordant care and to combat undertreatment of pancreatic cancer.