A prospective Canadian gastroesophageal cancer database: What have we learned?

BACKGROUND: Minimal literature exists on outcomes for Canadian patients with gastroesophageal adenocarcinoma (GEA). The objective of our study was to establish a prospective clinical database to evaluate demographic characteristics, presentation and outcomes of patients with GEA. METHODS: Patients diagnosed with GEA were recruited from Jan. 30, 2017, to Aug. 30, 2020. Data collected included demographic characteristics, presentation, treatment and survival. A multivariable model for overall survival in patients treated with curative intent was created using sex, lymph node status, resection margin status, age and tumour location as variables. RESULTS: A total of 122 patients with adenocarcinoma of the stomach or gastroesophageal junction were included. Median age was 65 years (interquartile range [IQR] 59-74), 70% of patients were male and 26% were born outside of Canada. Median follow-up time was 14.5 (IQR 8.0-31.0) months. Following staging computed tomography scanning, 88% of patients were deemed to have potentially resectable disease. Eighty-one (76%) received staging laparoscopy and 74 (61%) were treated with curativeintent surgery. Forty-six (62%) patients had nodal metastases. The median number of nodes harvested was 22 (IQR 18-30). The R0 resection margin rate was 82%. The 3-year overall survival for patients who received curative-intent treatment was 63% and 38% for all patients. On multivariable analysis, female sex (hazard ratio [HR] 3.88, p = 0.01), positive nodal status (HR 3.58, p = 0.02), positive margins (HR 3.11, p = 0.03) and tumour location (HR 3.00, p = 0.03) were associated with decreased overall survival. CONCLUSION: Many of the patients with GEA in this study presented with advanced disease, and only 61% were offered curative-intent surgery. A prospective multicentre national GEA database is now being established.

Yield of routine staging laparoscopy in patients with gastric cancer in Alberta, Canada.

BACKGROUND: Despite guidelines recommending diagnostic laparoscopy in patients with gastric cancer, implementation is low. We aimed to explore trends in the use of laparoscopy for staging of gastric cancer in Alberta, Canada, determine the rate of positive findings and identify factors predictive of positive staging laparoscopy (SL) findings in this patient population. METHODS: In August 2018, we sent a survey to all general surgeons in Alberta who were members of the Alberta Association of General Surgeons to identify those treating gastric cancer. The survey inquired about type of practice (academic or community), gastric cancer case volume, routine versus selective use of SL and, if selective use of SL, criteria used to select cases. Participants were also asked to provide data from their SL cases from July 2007 to February 2019. We double-checked surgeon records with chart review. The primary outcome was evidence of metastatic disease on SL or cytologic examination or both. We performed logistic regression analysis to identify factors predictive of positive laparoscopy findings. RESULTS: The survey was completed by 41 of 127 surgeons (response rate 32.3%). We reviewed 116 cases from 5 surgeons at 4 centres. Gross metastatic disease or positive findings on cytologic examination or both were identified in 37 patients (31.9%). On univariate analysis, the following were associated with an increased risk of identification of metastatic disease at laparoscopy: visualization of the primary tumour on computed tomography (CT) (odds ratio [OR] 9.8, 95% confidence interval [CI] 1.2-76.5), presence of abdominal lymphadenopathy greater than 1 cm (OR 2.4, 95% CI 1.1-5.4) and presence of ascites (OR 19.1, 95% CI 2.2-161.8). Visualization of the primary tumour on CT (OR 8.4, 95% CI 1.0-68.3) and the presence of ascites (OR 15.9, 95% CI 1.8-137.0) remained statistically significant predictors on multivariate analysis. CONCLUSION: Metastatic disease was identified at SL in almost one-third of cases, which suggests that SL should still be used routinely in gastric cancer staging in Canadian centres. Our study identified several preoperative imaging findings associated with evidence of metastatic disease on laparoscopy; however, further studies are needed to establish robust predictors of positive findings before advocating for a selective SL approach.

Spatial Tools for Integrated and Inclusive Landscape Governance: Toward a New Research Agenda.

Participatory spatial tools-community mapping, PGIS, and others-find increasing resonance among research and non-governmental organizations to make stakeholder claims and community perspectives explicit for more inclusive landscape governance. In this paper, we situate the use of participatory spatial tools in debates on integrated landscape approaches and inclusive development. We show that using such spatial tools is not new but argue that their application for inclusive landscape governance requires a new research agenda that focuses on expanding the scope of application of the tools, improving the inclusivity of the processes, and developing new technologies.

A Laser-Activated Membrane Introduction Mass Spectrometry Study of Proton Spillover Promoted Alkane Dehydrogenation.

Operando high-throughput evaluation of heterogeneous catalysts by laser-activated membrane introduction mass spectrometry (LAMIMS) elucidates the Pt loading dependence of methylcyclohexane dehydrogenation on platinized γ-alumina beads. A CO2 marking laser rapidly and sequentially heats catalyst beads positioned on a heat-dissipating carbon paper support that overlays a silicone membrane, separating the bead library reaction zone from a quadrupole mass analyzer. The toluene m/z peak varies logarithmically with Pt loading, suggesting that reactivity includes factors that are negatively correlated to Pt loading. These factors may include the Pt/γ-Al2O3 surface interfacial region as one component of a heterogeneous catalytically active surface area/mass. This work demonstrates LAMIMS as a broadly applicable high-throughput operando screening method for heterogeneous catalysts.

Evaluating the utility of computed tomography of the chest for gastric cancer staging

Background: International guidelines recommend routine computed tomography (CT) of the chest for gastric cancer staging. In Asian countries, where the incidence of pulmonary metastases is less than 1%, some guidelines recommend chest CT only for gastroesophageal junction cancers. If the incidence of pulmonary metastases is also low in Canada, routine chest CT may not be beneficial. Methods: We performed a retrospective review of patients in northern Alberta with newly diagnosed gastric cancer from January 2010 to July 2016. The primary aim of the study was to determine the incidence of pulmonary metastases at the time of diagnosis in this population. A secondary aim was to identify potential predictors of pulmonary metastases. We reviewed CT reports for pulmonary metastases. Imaging data also included liver metastases, abdominal lymphadenopathy (> 1 cm), ascites and omental or peritoneal nodules. Other data recorded were age, sex, primary tumour location, histologic type and tumour grade. Results: Four hundred and sixty-two patients (311 men, 151 women) were included in the analysis. Pulmonary metastases were identified in 25 patients (5.4%) overall and in 11 of 299 patients (3.7%) whose primary cancer was not in the cardia. On univariate analysis the presence of liver metastases (odds ratio [OR] 7.72, 95% confidence interval [CI] 3.24­18.37, p < 0.001) and abdominal lymphadenopathy (OR 3.30, 95% CI 1.29­8.48, p = 0.01) was associated with an increased risk of pulmonary metastases. Liver metastases retained statistical significance on multivariate analysis (OR 6.17, 95% CI 2.53­15.03, p < 0.001). Conclusion: The incidence of pulmonary metastases at the time of gastric cancer diagnosis is higher in northern Alberta than previously reported in Asian studies. Abdominal lymphadenopathy and liver metastases confer an elevated risk of pulmonary metastases.

Contexte: Les lignes directrices internationales recommandent une tomodensitométrie (TDM) thoracique de routine pour la stadification du cancer de l'estomac. Dans les pays asiatiques, où l'incidence des métastases pulmonaires est inférieure à 1 %, certaines lignes directrices recommandent la TMD thoracique seulement dans les cancers de la jonction gastro-oesophagienne. Si l'incidence des métastases pulmonaires est également faible au Canada, la TDM thoracique de routine pourrait ne pas être bénéfique. Méthodes: Nous avons procédé à une analyse rétrospective des patients du Nord de l'Alberta ayant reçu un diagnostic de cancer de l'estomac entre janvier 2010 et juillet 2016. L'objectif principal de l'étude était de déterminer l'incidence des métastases pulmonaires au moment du diagnostic chez cette population. Un objectif secondaire consistait à identifier les prédicteurs potentiels des métastases pulmonaires. Les rapports de TDM ont été passés en revue pour ce qui est des métastases pulmonaires. Les données provenant des épreuves d'imagerie incluaient aussi les métastases hépatiques, la lymphadénopathie abdominale (> 1 cm), l'ascite et les nodules épiploïques ou péritonéaux. Parmi les autres données consignées, mentionnons l'âge, le sexe, de même que la localisation, le type histologique et le grade de la tumeur principale. Résultats: Quatre cent soixante-deux patients (311 hommes, 151 femmes) ont été inclus dans l'analyse. Globalement, des métastases pulmonaires ont été observées chez 25 patients (5,4 %), et chez 11 patients sur 299 (3,7 %) dont le cancer principal ne se situait pas dans le cardia. À l'analyse univariée, la présence de métastases hépatiques (rapport des cotes [RC] 7,72, intervalle de confiance [IC] de 95 % de 3,24 à 18,37, p < 0,001) et de lymphadénopathie abdominale (RC 3,30, IC de 95 %, de 1,29 à 8,48, p = 0,01) a été associée à un risque accru de métastases pulmonaires. Les métastases hépatiques ont conservé leur portée statistique lors de l'analyse multivariée (RC 6,17, IC de 95 % de 2,53 à 15,03, p < 0,001). Conclusion: L'incidence des métastases pulmonaires au moment où un diagnostic de cancer de l'estomac est posé s'est révélée plus élevée dans le Nord de l'Alberta que dans les rapports d'études asiatiques précédentes. La lymphadénopathie abdominale et les métastases hépatiques confèrent un risque élevé de métastases pulmonaires.

Left Ventricular Assist Device Malfunctions: It Is More Than Just the Pump.

BACKGROUND: Reports of left ventricular assist device (LVAD) malfunction have focused on pump thrombosis. However, the device consists of the pump, driveline, and peripherals, all of which are potentially subject to failure. METHODS: Prospectively collected data were reviewed for all LVAD device malfunctions (DMs) occurring in rotary LVADs implanted at a single center between April 2004 and May 2016. Durable LVADs included 108 Heartmate II (HM II) and 105 HeartWare VAD (HVAD). DM data were categorized according to device type and into categories related to the component that failed: (1) controller, (2) peripheral components, and (3) implantable blood pump or its integral electric driveline. Pump-related events were analyzed as pump-specific (suspected or confirmed thrombosis) or nonpump-specific (driveline failure). DM rates were reported as events per 1000 patient-days, and Cox proportional hazard models were used for time-to-event analyses. Cumulative rates of malfunction were examined for the main components of each type of LVAD. RESULTS: Types of DM included controller failure (30%), battery failure (19%), or patient cable failure (14%), whereas only 13% were because of pump failure. DMs were more common in the HM II device (3.73 per 1000 patient-days versus 3.06 per 1000 patient-days for the HVAD, P<0.01). A higher rate of pump-specific malfunctions was discovered in those implanted with an HM II versus an HVAD (0.55 versus 0.39, respectively; P<0.01) and peripheral malfunctions (2.32 versus 1.78 for the HM II and HVAD, respectively; P<0.01); no difference occurred in the incidence of controller DM between the 2 LVADs. Patients with HVAD were 90% free of a pump-specific malfunction at 3 years compared with 56% for the HM II (log-rank P<0.003). Only 74% of the patients with HM II were free of pump thrombosis at 3 years compared with 90% of the patients with HVAD. Freedom from failure of the integrated driveline was 79% at 3 years for the HM II but 100% for the HVAD (log-rank P<0.02). CONCLUSIONS: Device malfunction is much broader than pump failure alone and occurs for different components at different rates based on the type of LVAD.

Fractionated Er:YAG laser versus fully ablative Er:YAG laser for scar revision: Results of a split scar, double blinded, prospective trial.

BACKGROUND AND OBJECTIVE: Ablative laser resurfacing is a common treatment for post-surgical scars. Fractional ablative laser resurfacing has been an emerging treatment option that is replacing fully ablative lasers in many applications. Data comparing fractionated and fully ablative lasers in treating post-operative scars are lacking. STUDY DESIGN: Twenty patients were enrolled in a split scar study following excisions from dermatologic surgery. Wounds had to be older than 8 weeks but less than 1 year. The scars were randomly divided into two halves. One half of the scar was treated with fully ablative erbium-doped yttrium aluminum garnet (Er:YAG) and the other was treated with fractionated Er:YAG. The scars were treated at monthly intervals for 3 months, then followed up at months 1 and 2 after the last treatment. POSAS was used to evaluate the scars by a panel of dermatologists blinded to the lasers in conjunction with the patients, who were also blinded. RESULTS: Physicians and patients both observed a superior outcome of 32.5% (P = 0.019) and 58.1% (P = 0.001), respectively, using the POSAS. There was no trend in difference in pain reported by the patient between the two lasers. Patients overwhelmingly preferred the fractionated Er:YAG laser (94%) to the fully ablative laser when asked at the end of the study. CONCLUSIONS: Although this study is limited by a short follow-up period, it shows a statistically significant superior outcome in fractionated Er:YAG over fully ablative Er:YAG for scar revision. It also adds quantitative values to the assessment of scar appearance when treated with fractionated lasers compared to fully ablative lasers. It was also found that the fractionated Er:YAG had increased patient satisfaction, but there was no difference in reported pain scores. These data are useful when counseling patients undergoing laser surgery. Lasers Surg. Med. 48:837-843, 2016. © 2016 Wiley Periodicals, Inc.

Chronic institutional failure and enhanced vulnerability to flash-floods in the Cuenca Altadel Río Lerma, Mexico.

The dominant paradigm in disaster risk reduction (DRR) policies has been seriously contested because of its reliance on interventions based on technocratic expertise. In the Mexican context, the influence of informal practices such as clientelism and cartelisation of the political system produces environmental degradation and vulnerability to disasters within the communities in the study site. This paper contributes to understanding of failed institutional processes and parallel practices that intensify vulnerability to disasters by contrasting the discourses of agents within a peri-urban community in central Mexico. Employing the Situational Analysis Approach as a methodological framework, the study identifies divergent views and practices within the community, leading to different responses to disasters and to different perceptions regarding institutional performance. In addition, it finds that institutional decision-making, based only on scientific and technical expertise, has resulted in unintended consequences that influence ongoing vulnerability to floods in the site under review.

Smallholder farms as stepping stone corridors for crop-raiding elephant in northern Tanzania: integration of Bayesian expert system and network simulator.

Crop-raiding elephants affect local livelihoods, undermining conservation efforts. Yet, crop-raiding patterns are poorly understood, making prediction and protection difficult. We hypothesized that raiding elephants use corridors between daytime refuges and farmland. Elephant counts, crop-raiding records, household surveys, Bayesian expert system, and least-cost path simulation were used to predict four alternative categories of daily corridors: (1) footpaths, (2) dry river beds, (3) stepping stones along scattered small farms, and (4) trajectories of shortest distance to refuges. The corridor alignments were compared in terms of their minimum cumulative resistance to elephant movement and related to crop-raiding zones quantified by a kernel density function. The "stepping stone" corridors predicted the crop-raiding patterns. Elephant presence was confirmed along these corridors, demonstrating that small farms located between refuges and contiguous farmland increase habitat connectivity for elephant. Our analysis successfully predicted elephant occurrence in farmland where daytime counts failed to detect nocturnal presence. These results have conservation management implications.

Increased CD4/CD8 Lymphocyte ratio predicts favourable neoadjuvant treatment response in gastric cancer: A prospective pilot study.

BACKGROUND: Despite optimal neoadjuvant chemotherapy only 40% of gastric cancer tumours achieve complete or partial treatment response. In the absence of treatment response, neoadjuvant chemotherapy in gastric cancer contributes to adverse events without additional survival benefit compared to adjuvant treatment or surgery alone. Additional strategies and methods are required to optimize the allocation of existing treatment regimens such as FLOT chemotherapy (5-Fluorouracil, Leucovorin, Oxaliplatin and Docetaxel). Predictive biomarkers detected using immunohistochemistry (IHC) methods may provide useful data regarding treatment response. AIM: To investigate the utility of CD4, CD8, Galectin-3 and E-cadherin in predicting neoadjuvant FLOT chemotherapy tumour response in gastric adenocarcinoma. METHODS: Forty-three adult patients with gastric adenocarcinoma, of which 18 underwent neoadjuvant chemotherapy, were included in a prospective clinical cohort. Endoscopic biopsies were obtained from gastric cancer and normal adjacent gastric mucosa. Differences in expression of Galectin-3, E-cadherin, CD4+ and CD8+ molecules between tumours with and without treatment response to neoadjuvant chemotherapy were assessed with IHC. Treatment response was graded by clinical pathologists using the Tumour Regression Score according to the College of American Pathologists criteria. Treatment response was defined as complete or near complete tumour response, whereas partial or poor/no response was defined as incomplete. Digital IHC images were annotated and quantitatively assessed using QuPath 0.3.1. Biomarker expression between responsive and incomplete response tumours was assessed using a two-sided Wilcoxon test. Biomarker expression was also compared between normal and cancer tissue and between 15 paired tumour samples before and after chemotherapy. We performed a preliminary multivariate analysis and power analysis to guide future study. Statistical analyses were completed using R 4.1.2. RESULTS: The ratio between CD4+ and CD8+ lymphocytes was significantly greater in treatment responsive tumours (Wilcoxon, P = 0.03). In univariate models, CD4+/CD8+ ratio was the only biomarker that significantly predicted favourable treatment response (Accuracy 86%, P < 0.001). Using a glmnet multivariate model, high CD4+/CD8+ ratio and low Galectin-3 expression were the most influential variables in predicting a favourable treatment response. Analyses of paired samples found that FLOT chemotherapy also results in increased expression of CD4+ and CD8+ tumour infiltrating lymphocytes (Paired Wilcoxon, P = 0.002 and P = 0.008, respectively). Our power analysis suggests future study requires at least 35 patients in each treatment response group for CD8 and Galectin-3 molecules, whereas 80 patients in each treatment response group are required to assess CD4 and E-cadherin biomarkers. CONCLUSION: We demonstrate that an elevated CD4+/CD8+ Ratio is a promising IHC-based biomarker to predict favourable treatment response to FLOT neoadjuvant chemotherapy in locally advanced gastric cancer.

Coping strategies and risk manageability: using participatory geographical information systems to represent local knowledge.

The accumulated knowledge and perceptions of communities 'at risk' are key elements in managing disaster risk at the local level. This paper demonstrates that local knowledge of flood hazards can be structured systematically into geographic information system (GIS) outputs. When combined with forecasting models and risk scenarios, they strengthen the legitimacy of local knowledge of at-risk populations. This is essential for effective disaster risk reduction practices by external actors, local non-governmental organisations (NGOs) and municipal authorities. The research focused on understanding coping strategies and 'manageability' of flood hazards as defined by communities. 'Manageability' is how people experience flooding in relation to their household capacity and the coping mechanisms available. The research in the Philippines highlights the significance of localised factors, including socioeconomic resources, livelihoods, seasonality and periodicity, for understanding manageability. The manageability concept improves practice at the municipal level by legitimising local coping strategies, providing better indicators, and developing understanding of flooding as a recurrent threat.

Skeletal muscle is prognostic in resected stage III malignant melanoma.

BACKGROUND: Sarcopenia (low skeletal muscle index, SMI) and myosteatosis (low skeletal muscle radiodensity, SMD) have been associated with worse survival in cancer. This study evaluated associations of body composition with survival in patients with resected stage III melanoma. METHODS: A retrospective review was performed of resected stage III melanoma patients in Alberta, Canada from 2007 to 2017. Preoperative CT scans were analyzed to determine SMI and SMD. Cohort-specific SMI and SMD cut-offs that optimally predicted overall survival (OS) were identified through stratification, in addition to testing cut-offs previously established in the literature. Overall (OS), melanoma-specific (MSS), and recurrence-free survival (RFS) were determined from date of surgery and analysed using multivariable Cox regressions with age, sex, BMI, stage subgroup, ECOG PS, and tumor location as covariates. RESULTS: We included 330 patients in the final analysis. Mean age was 56 years and 62.4% of patients were male. At time of censoring 150 patients (45.6%) had died. Sarcopenia based on literature cut-offs was associated with decreased OS (HR 1.55, 95% CI 1.00-2.21, p = 0.016). Using cohort-specific cut-offs, sarcopenic patients also had significantly decreased OS (HR 1.87, 95% CI 1.27-2.76, p = 0.002). Myosteatosis defined using cohort-specific cut-offs predicted worse OS (HR 2.15, 95% CI 1.42-3.25, p < 0.001), MSS (HR 2.29, 95% CI 1.40-3.75, p = 0.001) and RFS (HR 1.52, 95% CI 1.02-2.27, p = 0.041). Increased BMI ( ≥ 25) and visceral fat index were not significantly associated with survival. CONCLUSIONS: Sarcopenia and myosteatosis, defined using two sets of cut-offs, are associated with decreased OS and MSS in resected stage III melanoma.

Association Between Gastrointestinal Symptoms and Depression in a Representative Sample of Adults in the United States: Findings From National Health and Nutrition Examination Survey (2005-2016).

BACKGROUND: The microbiome's role in the etiology of depression has been a topic of many recent investigations. Findings suggest that dysbiosis, which describes a general disturbance in the gut microbiome, underlies negative gastrointestinal symptoms and is implicated in depression. We studied associations between gastrointestinal symptoms and depressive symptoms at a population level using cross-sectional data from the National Health and Nutrition Examination Survey (2005-2016, n = 36,287). We hypothesized that the odds of depressive symptoms would be significantly higher in those showing signs of gastrointestinal distress. METHODS: We analyzed 31,191 adults participating in the National Health and Nutrition Examination Survey from 2005-2016. Outcomes included presence of mucus or liquid in bowel leakage and stomach illness in the past month, diarrhea in the past year, and number of weekly bowel movements. The survey (and thus, our analyses) does not include microbiome samples, only self-reported gastrointestinal symptoms. Depressive symptoms were measured using the Patient Health Questionnaire. Moderate, moderately severe, and severe scores were coded as a positive outcome. RESULTS: Compared to those without depressive symptoms, those with moderate-to-severe depressive symptoms had elevated odds of bowel mucus (odds ratio = 2.78; 95% confidence interval = 1.82-4.24), bowel liquid (odds ratio = 2.16; 95% confidence interval = 1.63-2.86), stomach illness (odds ratio = 1.82; 95% confidence interval = 1.31-2.53), diarrhea (sometimes vs. never odds ratio = 1.72; 95% confidence interval = 1.30-2.29), and constipation (sometimes vs. never odds ratio = 2.76; 95% confidence interval = 2.11-3.62). Overall, those with gastrointestinal symptoms were significantly more likely to have depressive symptoms. CONCLUSIONS: While the intricacies of the brain-gut axis are being investigated at the molecular level, these population data provide further evidence for the association between depressive symptoms and signs of dysbiosis, which may inform health care providers' patient interactions.

Positron emission tomography/computed tomographic scans compared to computed tomographic scans for detecting colorectal liver metastases: a systematic review.

OBJECTIVE: To review diagnostic accuracy of positron emission tomography/computed tomography (PET/CT) for colorectal liver metastases. BACKGROUND: Colorectal liver metastases can be treated with surgical resection; however, recurrence is seen in 58% of patients. PET/CT may better detect extra-hepatic disease before surgery to more accurately identify eligible candidates for surgery and, through better selection, improve patient prognosis. METHODS: We conducted a comprehensive systematic review on adults with colorectal liver metastases who received PET/CT and CT scans to detect metastases. The gold standard to confirm the diagnosis was histology. Study selection, quality assessment, and data extraction were completed independently by 2 investigators. Pooling of results was not feasible because of heterogeneity. A qualitative summary of results is presented. RESULTS: From 1083 citations, we identified 6 studies (440 patients) for the review. For extra-hepatic lesions (3 studies; 178 patients), PET/CT was more sensitive than CT, but specificities were similar (PET/CT sensitivity [SN] = 75%-89% and specificity [SP] = 95%-96% vs. CT SN = 58%-64% and SP = 87%-97%). For hepatic lesions (5 studies; 316 patients), PET/CT had higher SN and SP than CT (PET/CT SN = 91%-100% and SP = 75%-100%; CT SN = 78%-94% and SP = 25%-98%). For local recurrence (3 studies; 206 patients), PET/CT also had better accuracy than CT with SN = 93% to 100% and SP = 97% to 98% versus SN = 0 %-100% and SP = 97%-98%. CONCLUSION: Based on this systematic review, we conclude that PET/CT has a higher accuracy for detection of extra-hepatic and hepatic colorectal metastatic disease than CT alone. However, the results are based on a small number of studies and should be interpreted cautiously.

24-7 Dressing Technique to Optimize Wound Healing After Mohs Micrographic Surgery.

Postoperative wound care can be troublesome, time consuming, and expensive. Patients often are unable to personally take proper care of their wounds at home, leading to complications. We describe the use of a comfortable, effective, and simple technique for wound dressings after dermatologic surgery in patients who are vulnerable to wound complications.

CT-based assessment of body composition and skeletal muscle in melanoma: A systematic review.

BACKGROUND/OBJECTIVES: Sarcopenia (low skeletal muscle index) and myosteatosis (low skeletal radiodensity) have been associated with poor outcomes in melanoma. This systematic review was performed to summarize and critically evaluate current literature surrounding body composition in melanoma. METHODS: MEDLINE and Embase databases were searched for studies of melanoma patients with computed tomography (CT) based body composition analysis from 2000 to 2020. Outcomes of interest were survival, including overall survival (OS), progression-free survival (PFS), and disease-free survival (DFS), as well as treatment-related adverse events (AEs). RESULTS: Nine studies of 914 patients were included in the final review. The majority of studies were of metastatic melanoma patients treated with immunotherapy. Studies demonstrated a variety of CT analysis techniques and cut-offs to define sarcopenia and myosteatosis. Associations of sarcopenia or myosteatosis with survival (OS, PFS, DFS) or risk of treatment-related AEs were conflicting. Multiple studies had low quality of evidence due to small sample sizes, use of non-validated CT measures, and lack of multivariable analyses. CONCLUSIONS: Due to methodologic heterogeneity and low quality of evidence, impacts of CT-derived body composition parameters on outcomes in melanoma are unclear. Further research should be conducted to elucidate impacts of body composition in melanoma.

Gastric cancer management in elderly patients: a population-based study of treatment patterns and outcomes in gastric cancer patients ≥ 75 years from Alberta, Canada.

BACKGROUND: As Canada's population ages, incidence of gastric cancer in elderly patients is increasing. There is little data on treatment and outcomes of gastric cancer in patients older than age 75. This study aimed to assess treatment patterns and outcomes of non-metastatic elderly gastric cancer patients in Alberta, Canada. METHODS: Records of elderly patients (age 75 or older) diagnosed with localized gastric or gastroesophageal junction cancer between 2007 and 2012 who received curative intent surgery were retrospectively collected from the Alberta Cancer Registry. A chart review was completed to gather demographics; treatment details of surgery, chemotherapy, and radiotherapy; and outcomes. Descriptive analyses were undertaken, and variables were compared with parametric and nonparametric tests where appropriate. RESULTS: 130 predominantly male (69%) patients, median age 80 (range 75-96) were included. 17 patients (13%) received multimodality therapy. 115 (88.5%) had negative margins on final pathology. Mean lymph nodes retrieved were 16 (range 0-43). 46 surgical patients (35.4%) had grade II or higher complications. 13 patients had a perioperative death (Clavien grade V). Four (3.1%) patients completed perioperative chemotherapy, and 13 (10%) patients had adjuvant chemo/radiotherapy. 50 (38.5%) recurred at median 13 months, while 80 (61.5%) did not have a recurrence of their cancer at any time during follow up. The 5 year DFS for the surgery only group was 67.3% and multimodality group was 52.9% (p = 0.25). The 5 year OS for the surgery only group was 38.9% and multimodality group was 47.1% (p = 0.52). CONCLUSIONS: Our findings suggest that even with surgery alone, selected elderly patients with non-metastatic gastric cancer can obtain apparent prolonged survival, despite not receiving standard of care multimodality therapy. More studies are needed to optimise elderly patients' treatment selection.

An exploratory study of body composition as a predictor of dose-limiting toxicity in metastatic pancreatic cancer treated with gemcitabine plus nab-paclitaxel.

BACKGROUND: Body composition is increasingly being studied as a method of predicting chemotherapy toxicity. Our study aimed to evaluate associations of body composition with treatment toxicity in a group of pancreatic cancer patients treated with gemcitabine plus nab-paclitaxel. METHODS: A retrospective review was performed for all patients who received first-line gemcitabine plus nab-paclitaxel for metastatic pancreatic cancer at a northern Alberta cancer institute (Canada) from 2014 to 2017. Total lean body mass (LBM) was derived from measurements of muscle surface area at L3 on baseline computed tomography (CT) scans. Optimal stratification, or minimal p-value analysis, was used to assess for a threshold of nab-paclitaxel dose per LBM (mg/kg) associated with a higher risk of dose-limiting toxicity (DLT). RESULTS: 152 patients were included in the study, of whom 62 (40.8%) experienced DLT. nab-Paclitaxel dose/LBM ranged from 0.98 to 8.76 mg/kg. A threshold for nab-paclitaxel dose/LBM that optimally predicted risk of DLT was identified at 5.83 mg/kg. Above this cut-off, 18/31 (58.1%) patients experienced DLT, compared to 44/121 (36.4%) patients below (p = 0.028). Patients above this cut-off had a higher incidence of peripheral neuropathy compared to those below, though this was not statistically significant based on an adjusted p-value threshold (48.4 vs. 29.8% respectively, p = 0.050). Body mass index, body surface area, and absolute initial doses of nab-paclitaxel or gemcitabine did not significantly impact likelihood of DLT. CONCLUSIONS: nab-Paclitaxel dose normalized to LBM, based on CT-derived measures of skeletal muscle, has potential to predict risk of chemotherapy toxicity. Chemotherapy dosing based on body composition, rather than conventional anthropometric measures, may be effective in reducing treatment toxicity.

Evaluation of the Implementation of Multiple Enhanced Recovery After Surgery Pathways Across a Provincial Health Care System in Alberta, Canada.

Importance: Engaging multidisciplinary care teams in surgical practice is important for the improvement of surgical outcomes. Objective: To evaluate the association of multiple Enhanced Recovery After Surgery (ERAS) pathways with ERAS guideline adherence and outcomes. Design, Setting, and Participants: This quality improvement study compared a pre-ERAS cohort (2013-2017) with a post-ERAS cohort (2014-2018). All patients were from Alberta Health Services in Alberta, Canada, and had available ERAS and up to 1-year postsurgery administrative data. Data collected included age, sex, body mass index, tobacco and alcohol use, diabetes, comorbidity index, and surgical characteristics. Data analysis was performed from May 7, 2020, to February 1, 2021. Interventions: Implementation of 5 ERAS pathways (colorectal, liver, pancreas, gynecologic oncology, and radical cystectomy) across 9 sites. Main Outcomes and Measures: Adherence to ERAS guidelines was measured by the percentage of patients whose care met the common ERAS pathway care element criteria. Surgical procedures were grouped by complexity; complications were classified by severity. Outcome measures for the pre-post-ERAS cohorts included length of stay (LOS), readmission, complications, and mortality. Results: A total of 7757 patients participated in the study, including 984 in the pre-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 526 [53.5%] female) and 6773 in the post-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 3470 [51.2%] male). In the total cohort, care-element adherence improved from 52% to 76% (P < .001), no significant differences were found in serious complications (from 6.2% to 4.9%; P = .08) or 30-day mortality (from 0.71% to 0.93%; P = .50), 1-year mortality decreased from 7.1% to 4.6% (P < .001), mean (SD) LOS decreased from 9.4 (7.0) to 7.8 (5.0) days (P < .001), and 30-day readmission rates were unchanged (from 13.4% to 11.7%; P = .12). After adjustment for patient characteristics, the LOS mean difference decreased 0.71 days (95% CI, -1.13 to -0.29 days; P < .001), with no significant differences in adjusted 30-day readmission (-3.5%; 95% CI, -22.7% to 20.4%; P = .75), serious complications (1.3%; 95% CI, -26.2% to 39.0%; P = .94), or mortality (30-day mortality: 42% [95% CI, -35.4% to 212.3%]; P = .38; 1-year mortality: 8% [95% CI, -20.5% to 46.8%]; P = .62). The adjusted 1-year readmission rate was -15.6% (95% CI, -27.7% to -1.5%; P = .03) in favor of ERAS, and readmission LOS was shorter by 1.7 days (95% CI, -3.3 to -0.1 days; P = .04). Conclusions and Relevance: The results of this quality improvement study suggest that implementation of ERAS across multiple pathways may improve health care practitioner adherence to ERAS guidelines, LOS, and readmission rates at a system level.