Further Distance From Treating Facility is Associated With Advanced Colon Cancer at Presentation and Increased Mortality.

BACKGROUND: Colon cancer outcomes in the United States have improved over the last thirty years. However, there remain significant outcome disparities, especially in rural regions. It is unclear if distance to the treating facility has an independent effect on colon cancer mortality and outcomes. We sought to evaluate whether distance from a treating facility impacts stage at diagnosis and mortality. METHODS: The National Cancer Database (NCDB) was utilized to identify a cohort of adult patients with colon cancer between the years 2013 and 2017 in all regions of the United States. Outcomes measured included colon cancer TNM stage, time to surgery, time to chemotherapy, and overall survival. RESULTS: A total of n = 356,189 patients met inclusion criteria. When controlling for race, education status, insurance status, comorbidities, and income, distance from the treating facility was a significant predictor of stage at presentation with more advanced clinical TNM stage as distance increased (AORs 1.12-1.62, P < .001 for all groups). Longer distance significantly increased the time to surgery (between 5.06 and 14.46 days, P < .001) and overall mortality (HR 1.11-1.28, P < .001). Median survival was 82.4 months for the closest group, versus 75.1 months for the farthest group (P < .001). CONCLUSIONS: Increased distance from the treating facility resulted in a significantly higher stage at presentation, increased time to surgery, and increased mortality. These results suggest that there are significant disparities in access to cancer care for patients who live in rural areas. Targeted interventions by treating facilities are needed to improve screening and timely treatment for rural colon cancer patients.

Merkel Cell Polyomavirus Antibody Titer Predicts Recurrence-Free Survival.

BACKGROUND: Merkel cell polyomavirus (MCPyV) is associated with the development of Merkel cell carcinoma (MCC). Antibody (MCPyV-Ab) titers may have prognostic implications. This study evaluated the impact of the presence or absence of MCPyV-Ab on the 2-year overall survival (OS) and disease-free survival (DFS) of MCC patients. METHODS: This single-center, IRB-approved, retrospective cohort study evaluated 51 adult patients with MCC from 2014 to 2021 using a prospectively maintained database. Patients were compared by MCPyV-Ab status, and Kaplan-Meier analysis was used to evaluate 2-year OS and DFS. RESULTS: Of the 51 patients, 13 (25.4%) were seropositive, 41 (80.4%) underwent wide excision, 40 (80.0%) received radiotherapy, and 43 (84.3%) received multimodal therapy. The median follow-up period was 15.5 months (range 1-69.5 months). The median 2-year OS of the entire cohort was not reached. The median 2-year OS was not reached for either the seronegative or the seropositive patients. The difference in 2-year OS between the groups was not statistically significant (p = 0.37). Eight patients, all seronegative, were never rendered disease-free and were removed from recurrence analysis. The seropositive patients experienced no recurrences. Of the 30 seronegative patients, 9 (30.0%) experienced recurrence. The median 2-year DFS of the entire cohort was not reached. The median 2-year DFS of the seronegative group was 22.2 months. The 2-year DFS was not reached for the seropositive cohort. Seropositivity conferred a significantly better 2-year DFS than seronegativity (p = 0.04). CONCLUSION: The MCPyV-Ab seropositive patients demonstrated improved 2-year DFS. The seropositive patients showed a strong trend toward improved 2-year OS, although the difference not statistically significant. This study substantiated the value of MCPyV-Ab assessment for MCC.

Biliary Drainage Before and After Liver Resection for Perihilar Cholangiocarcinoma.

Perihilar cholangiocarcinoma (PHC) is a rare tumor that requires surgical resection for a potential cure. The role of preoperative biliary drainage has long been debated, given its treatment of biliary sepsis and decompression of the future liver remnant (FLR), but high procedure-specific morbidity. The indications, methods, and outcomes for preoperative biliary drainage are discussed to serve as a guide for perioperative management of patients with resectable PHC. Multiple studies from the literature related to perihilar cholangiocarcinoma, biliary drainage, and management of the FLR were reviewed. Commonly employed preoperative biliary drainage includes endoscopic biliary stenting and percutaneous transhepatic biliary drainage. Drainage of the FLR remains controversial, with most experts recommending drainage of the only in patients with an FLR <50%. Biliary drainage for resectable PHC requires a patient-specific approach with careful determination of the FLR and balancing of potential morbidity with the benefits of drainage.

Outcomes After Adjuvant Hyperthermic Intraperitoneal Chemotherapy for High-Risk Primary Appendiceal Neoplasms After Complete Resection.

INTRODUCTION: Appendiceal neoplasms are uncommon tumors. Optimal treatment for patients with perforation or high-grade pathology after initial resection is unknown. This study evaluated patients with increased risk for peritoneal dissemination after primary resection, but no evidence of peritoneal disease, who underwent adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: This multi-institutional cohort study evaluated 56 patients with high-risk (HR) appendiceal neoplasms with a peritoneal carcinomatosis index of 0 who underwent HIPEC. The patients were divided into two groups: perforated low-grade appendiceal (LGA) carcinoma and HR neoplasms, which included perforated high-grade appendiceal carcinoma, positive margins after initial resection, minimal macroscopic peritoneal disease that was previously resected or completely responded to systemic chemotherapy prior to HIPEC, goblet cell carcinoma, and adenocarcinoma with signet ring cell features. Overall survival (OS) and recurrence-free survival (RFS) were estimated by Kaplan-Meier analysis. RESULTS: Thirty-eight percent of patients had perforated LGA and 68% had HR features. Five-year OS probability was 82.1% for the entire cohort, and 100% and 70.1% for patients with perforated LGA and HR features, respectively (p = 0.024). Five-year RFS probability was 79.3% for the entire cohort, and 90.0% and 72.4% for patients with perforated LGA and HR features, respectively (p = 0.025). Eight patients recurred after HIPEC and their OS was significantly worse (p < 0.001). CONCLUSION: While adjuvant HIPEC is both safe and feasible, there appears to be little benefit over close surveillance when outcomes are compared with historical and prospective studies, especially for perforated LGA carcinoma.

Role of Surgery for Metastatic Melanoma.

Complete surgical resection of metastatic melanoma has a known survival benefit. Treatment of metastatic melanoma, however, has become increasingly complex with the introduction of targeted treatments and immune checkpoint inhibitors. Integration of systemic medical therapy and surgical resection has shown promising results, with significantly improved long-term survivals. Results from current clinical trials are awaited to help further delineate the sequence and combination of systemic therapy and surgery.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal mesothelioma: patient selection and special considerations.

Malignant peritoneal mesothelioma (MPM) is a rare, aggressive malignancy that typically presents with vague symptoms, ascites, and/or diffuse peritoneal studding. Despite findings of advanced disease within the peritoneal cavity, spread beyond the abdomen is uncommon. Although advances in systemic chemotherapy have been made, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remain the mainstay of treatment. Median overall survival of approximately 50 months with CRS/HIPEC has been demonstrated, with age, gender, histologic subtype, peritoneal carcinomatosis index, comorbidities, nodal and extra-abdominal metastases, and completeness of cytoreduction all playing a role in prognosis. In patients with refractory malignant ascites and unresectable disease, complete resolution of ascites and improvement in quality of life have been demonstrated with palliative HIPEC. In appropriately selected patients, CRS/HIPEC plays a critical role in the treatment and palliation of MPM.

Minimally Invasive Surgical Approaches for Peritoneal Surface Malignancy.

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an evolving strategy in the locoregional management of peritoneal surface malignancies, and the role of laparoscopy is expanding. Staging laparoscopy is routinely used to obtain tissue for diagnosis and assess extent of tumor burden. Laparoscopic CRS and HIPEC with curative intent is safe and effective in patients with a low disease burden. In patients with refractory malignant ascites, complete resolution of ascites and improvement in quality of life have been demonstrated with palliative laparoscopic HIPEC. Laparoscopic CRS and HIPEC has an expanding role in the treatment of peritoneal surface disease.

Oncology Navigation Decreases Time to Treatment in Patients with Pancreatic Malignancy.

BACKGROUND: Care of pancreatic cancer patients has become increasingly complex, which has led to delays in the initiation of therapy. Nurse navigators have been added to care teams, in part, to ameliorate this delay. This study investigated the difference in time from first oncology visit to first treatment date in patients with any pancreatic malignancy before and after the addition of an Oncology Navigator. METHODS: A single-institution database of patients with any pancreatic neoplasm evaluated by a provider in radiation, medical, or surgical oncology between 1 October 2015 and 30 September 2017 was analyzed. After 1 October 2016, an Oncology Navigator met patients at their initial visit and coordinated care throughout treatment. The cohort was divided into two groups: patients evaluated prior to the implementation of an Oncology Navigator and patients evaluated after implementation. Patient demographics and time from first visit to first intervention were compared. RESULTS: Overall, 147 patients with a new diagnosis of pancreatic neoplasm were evaluated; 57 patients were seen prior to the start of the Oncology Navigator program and 79 were evaluated after the navigation program was implemented. On univariate analysis, time from first contact by any provider to intervention was 46 days prior to oncology navigation and 26 days after implementation of oncology navigation (p = 0.005). While controlling for other covariates, employment of the Oncology Navigator decreased the time from first contact by any provider to intervention by almost 16 days (p = 0.009). CONCLUSIONS: Implementing an oncology navigation program significantly decreased time to treatment in patients with pancreatic malignancy.

Ratio of intra-operative fluid to anesthesia time and its impact on short term perioperative outcomes following gastrectomy for cancer: A retrospective cohort study.

BACKGROUND: This study evaluates the short-term impact of fluid administration during gastrectomy for cancer. METHODS: A multi-institutional database of patients undergoing gastrectomy for cancer from three tertiary centers was reviewed. Logistic and linear regression analyses were performed. RESULTS: 205 patients were included. The majority of patients (n = 116, 57%) underwent proximal or total gastrectomy. Median anesthesia time was 280 min (range 95-691 min). Median intraoperative crystalloid administration was 2901 ml (range 500-10,700 ml). Median colloid administration was 0 (range 0-3835 ml), although only 66 patients (32%) received colloid. On multivariate analysis, patients who received <10.0 ml total fluid per minute of anesthesia had a significantly higher risk of complications (OR 4.12, p = 0.010). Crystalloid and total fluid administration ratios did not significantly affect LOS or discharge disposition. CONCLUSIONS: Restricting intra-operative fluid resuscitation to <10 ml total fluid per minute anesthesia is associated with an increased risk of complications in patients undergoing gastrectomy for cancer.

Trends in the Incidence of Oropharyngeal Cancers in the United States.

OBJECTIVE: The incidence of oropharyngeal squamous cell carcinoma (SCCa) has increased in the United States despite a decrease in tobacco usage, and it may be driven by an increase in oral human papilloma virus (HPV) infection. We studied the incidence of tongue base and tonsillar SCCa over time to understand the changing epidemiology of oropharyngeal SCCa. SETTING: Large national tumor registry. SUBJECTS AND METHODS: We studied patients diagnosed with oropharyngeal SCCa in SEER data (Surveillance, Epidemiology, and End Results) from 1973 to 2009. Age-adjusted incidence rates standardized to the 2000 US population were computed, with stratifications for age, sex, race, and stage. RESULTS: The sample included 10,061 tongue base and 11,515 tonsillar oropharyngeal cancers. When stratified by age, the incidence of oropharyngeal SCCa in patients ≤55 years of age more than doubled over 30 years. While the incidence rate in females remained stable, the rate in males more than doubled, from 2 per 100,000 persons in 1973 to >4 per 100,000 persons in 2009. The age-adjusted incidence of oropharyngeal SCCa in patients of black race/ethnicity remained consistently elevated, but the incidence in patients of white race/ethnicity rose from 1.3 per 100,000 persons to >2.5 per 100,000 persons, surpassing the incidence in black patients starting in 2002. CONCLUSION: The observation that the incidence of oropharyngeal SCCa is increasing among younger white males, despite a reduction in tobacco usage in the United States, is consistent with HPV as the source. Primary and secondary prevention strategies may be warranted in this population.

Frozen Section Interpretation of Pancreatic Margins: Subspecialized Gastrointestinal Pathologists Versus General Pathologists.

Intraoperative assessment of pancreatic parenchymal margin during pancreatectomies is challenging and misinterpretation by the pathologist is a cause of incorrect frozen section (FS) diagnosis. Although the current literature supports that pancreatic margin FS diagnosis and its accuracy has no impact on the patient outcome for pancreatic ductal adenocarcinoma (PDAC) patients and reexcision in an attempt to achieve a negative intraoperative pancreatic margin after positive FS is not associated with increased overall survival; still it remains a routine practice in many institutions. To this end, we sought to assess the interobserver variation and accuracy of FS diagnosis between subspecialized gastrointestinal/pancreatobiliary (GI) and general pathologists. Seventy seven consecutive pancreatic parenchymal margin FSs performed on pancreatectomies for PDAC from 2010 to 2013 were retrieved at our institution. These were retrospectively evaluated by 2 GI and 2 general pathologists independently without knowledge of the original FS diagnosis or the final diagnosis. The specificity, sensitivity, positive predictive value, negative predictive value, and accuracy of GI versus general pathologist was 97.8% versus 87.5%, 61.1% versus 66.7%, 78.6% versus 41.4%, 95% versus 95.2%, and 93.5% versus 85.1%, respectively. The interobserver agreement between GI and general pathologists was fair (κ = .337, P < .001). The interobserver agreement between 2 GI pathologists was fair (κ = .373, P = .0005) and between 2 general pathologists was slight (κ = .195, P = .042). Although overall accuracy of subspecialized GI pathologists was higher than that of general pathologists, none had an accuracy of 100%. Our study reaffirms the challenging nature of these FSs.

Marginal zinc intake reduces the protective effect of lactation on mammary gland carcinogenesis in a DMBA-induced tumor model in mice.

Breastfeeding can reduce breast cancer risk; however, unknown factors modify this protective effect. Zinc (Zn) modulates an array of cellular functions including oxidative stress, cell proliferation, motility and apoptosis. Marginal Zn intake is common in women and is associated with breast cancer. We reported that marginal Zn intake in mice leads to mammary gland hypoplasia and hallmarks of pre-neoplastic lesions. In the present study, we tested the hypothesis that marginal Zn intake confounds the protective effect of lactation on breast cancer. Nulliparous mice fed control (ZA, 30 mg Zn/kg) or a marginal Zn diet (ZD, 15 mg Zn/kg), were bred and offspring were weaned naturally. Post-involution, mice were gavaged with corn oil or 7,12-dimethylbenz(a)anthracene (DMBA, 1 mg/wk for 4 weeks) and tumor development was monitored. A ZD diet led to insufficient involution, increased fibrosis and oxidative stress. Following DMBA treatment, mice fed ZD had higher oxidative stress in mammary tissue that correlated with reduced levels of peroxiredoxin-1 and p53 and tended to have shorter tumor latency and greater incidence of non-palpable tumors. In summary, marginal Zn intake creates a toxic mammary gland microenvironment and abrogates the protective effect of lactation on carcinogenesis.

The Cost of Hospice Services in Terminally Ill Patients With Head and Neck Cancer.

IMPORTANCE: Hospice care has been suggested as a way to preserve dignity and to lower costs at the end of life, which may be particularly important for patients with head and neck cancer because this disease is associated with considerable morbidity and a high mortality risk. OBJECTIVES: To use data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to estimate monthly costs of all services used during the last months of life by patients with oral cavity and pharyngeal cancers and to determine whether those who used hospice services had lower costs. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort analysis of SEER-Medicare data (January 1, 1995, to December 31, 2007). The setting was all participating SEER hospitals that treated patients with oral cavity or pharyngeal cancer. Participants were 65 years and older who were diagnosed as having oral cavity (n = 4205) or pharyngeal (n = 3178) cancer between January 1, 1995, and December 31, 2005, who subsequently died between January 1, 1995, and December 31, 2007. EXPOSURE: Use of hospice services before death. MAIN OUTCOMES AND MEASURES: Hospice use was identified through Medicare claims. The primary outcome was all-cause Medicare expenditures, inflated to 2009 US dollars. We used a propensity score analysis to estimate the difference in the mean costs to Medicare in the last month of life between patients who used hospice services and patients who did not use hospice services. RESULTS: Most patients (63.4% [1018 of 1605] with oral cavity cancer and 57.8% [644 of 1114] with pharyngeal cancer) who enrolled in hospice did so within 30 days of death. Patients who received hospice care had $7035 (95% CI, $6040-$8160) lower costs in the last month of life for oral cavity cancer and $7430 (95% CI, $6340-$9100) lower costs in the last month of life for pharyngeal cancer. These cost savings were greater in the last month of life when patients enrolled in hospice more than 30 days before death. CONCLUSIONS AND RELEVANCE: Encouraging hospice admissions for patients with oral cavity and pharyngeal cancers provides not only compassionate, dignified care at the end of life but also an opportunity for substantial savings in health care costs.

Emphysematous gastritis and gastric emphysema: similar radiographic findings, distinct clinical entities.

INTRODUCTION: Despite similar appearances on imaging studies, emphysematous gastritis (EG) and gastric emphysema (GE) are rare clinical entities encountered in surgical practices. The purpose of this review is to clarify the presentation, natural history, and optimal treatment strategies for these two disorders. METHODS: We conducted a comprehensive literature review for reported adult cases of EG and GE in MEDLINE. Two cases from our institution were also included. Patient with demographics, diagnostic and therapeutic data, and outcomes were compared between patients with EG and GE. RESULTS: A total of 75 cases were included for our review. The finding of intramural air in the stomach was often associated with portal vein gas, pneumatosis intestinalis, or pneumoperitoneum in both groups. Surgical removal of the stomach was performed in 23.1% of EG patients, but only one patient in the GE group. In the EG group, overall mortality (55%) appeared to be driven by sepsis and its complications, whereas in the GE group, mortality (29%) was attributable to comorbid conditions and the underlying illness. CONCLUSIONS: Prompt surgical intervention is more commonly indicated for severe EG and is directed at removal of the septic organ, while the primary indication for surgical intervention in GE is the uncertainty of the diagnosis.

Measuring surgical quality: a national clinical registry versus administrative claims data.

BACKGROUND: This study compared postoperative complications of patients who underwent pancreaticoduodenectomy (PD) recorded in the National Surgical Quality Improvement Program (NSQIP) to patients who underwent PD recorded in the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS). METHODS: Data included 8,822 PD cases recorded in NSQIP and 9,827 PD cases recorded in NIS performed between 2005 and 2010. Eighteen postoperative adverse outcomes were identified in NSQIP and then matched to corresponding International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes in NIS. Using logistic regression, the relationship between database and postoperative complications was determined while accounting for patient factors. RESULTS: Patients undergoing PD in the NIS were more likely to have several adverse outcomes, including urinary tract infection (odds ratio (OR) = 1.42, p < 0.001), pneumonia (OR = 1.51, p < 0.001), renal insufficiency (OR = 2.39, p < 0.001), renal failure (OR = 1.67, p = 0.005), graft/prosthetic failure (OR = 9.35, p < 0.001), and longer length of stay (1.1 days, p < 0.001). They were less likely to have cardiac arrest (OR = 0.45, p = 0.002), postoperative sepsis (OR = 0.38, p < 0.001), deep vein thrombosis (OR = 0.18, p < 0.001), and cerebrovascular accident (OR = 0.04, p = 0.003). CONCLUSIONS: There is considerable discordance between NSQIP and NIS in the assessment of postoperative complications following PD, which underscores the value of recognizing the capabilities and limitations of each data source.