Time to Adjuvant Systemic Therapy Following Pancreatic Cancer Resection and Effect on Outcome.

OBJECTIVES: The appropriate timing of chemotherapy following surgery for resectable pancreatic adenocarcinoma is controversial. Using the National Cancer Database we evaluated time to initiation of chemotherapy postresection and correlated with outcome. METHODS: We identified stage I-III pancreatic adenocarcinoma treated surgically with adjuvant chemoradiotherapy. Receiver operator curve analysis identified an interval of 66 days as the a priori value for largest discrepancy in outcome. Multivariable logistic regression analysis identified variables associated with increased time to chemotherapy postoperatively (>66 days). Propensity matching was performed to account for indication bias. RESULTS: In total, 6873 and 3348 patients received chemotherapy before and after the 66-day cutoff, respectively. Predictors of expedited chemotherapy included lower comorbidity, treatment outside a community program in an urban location, having insurance, white race, and treatment after 2009. Propensity-matched median survival was 21.8 months for all patients, and of these, 6462 were stage 1. Five-year survival was 20% in patients receiving chemotherapy within 66 days and 18% in those not (P = 0.0266). In stage 1 patients, 5-year survival was 23% versus 21% (P = 0.0116) in favor of expedited chemotherapy. CONCLUSIONS: The present propensity-matched analysis showed a significant association with survival for earlier delivery of chemotherapy in the adjuvant setting.

Incidence and risk factors for post-operative mortality, hospitalization, and readmission rates following pancreatic cancer resection.

BACKGROUND: The only potentially curative approach for pancreatic cancer is surgical resection, but this technically challenging procedure carries risks for postoperative morbidities and mortality. This study of a large, contemporary national database illustrates incidences of, and risk factors for, post-procedural mortality, prolonged hospital stay, and 30-day readmission. METHODS: From the National Cancer Database (NCDB), stage I-III pancreatic adenocarcinomas were identified [2004-2015]. Surgical techniques included pancreaticoduodenectomy, partial pancreatectomy (selective removal of the pancreatic body/tail), total pancreatectomy (removal of the entire pancreas) with or without subtotal resection of the duodenum and/or stomach, and extended pancreatectomy. Predictors of 30/90-day post-operative mortality, 30-day readmission rates, and prolonged hospital stay (>17 days per receiver operating curve analysis) were identified via multivariable logistic regression. RESULTS: Overall, 24,798 patients were analyzed (median age of 66). The majority of cases were T3 (47%), N0 (65%), pancreatic head lesions (83%), and treated with pancreaticoduodenectomy (57%). Only 16% received neoadjuvant therapy. Overall unadjusted risk of 30- and 90-day mortality ranged from 1.3-2.5% and 4.1-7.1%, respectively, depending on extent of surgery. Independent predictors of 30-/90-day mortality included preoperative therapy, increasing age, higher comorbidity score, lower income, case volume, and more extensive surgery. Similar findings were demonstrated regarding prolonged hospital stay and 30-day readmission. Age ≥70 was most associated with 30-day mortality, whereas age ≥60 was most associated with 90-day mortality and prolonged hospital stay. CONCLUSIONS: Quantitation of incidences and risk factors for postoperative outcomes following resection for pancreatic cancer is essential for judicious patient selection and shared decision-making between providers and patients.

Abdominal computed tomography and the placement of inferior vena caval filters.

BACKGROUND: Standard cavography is performed with iodinated contrast material with plain film or digital subtraction technique. However, preplacement imaging may change final inferior vena cava filter (IVC) placement in 11 to 26% of patients. This study will examine the use and reliability of incidental spiral computed abdominal tomography (CAT) scans for the placement of IVC filters. METHODS: Over a 25-month period, CAT scan data were prospectively collected on patients at high risk for pulmonary embolism (PE) or with PE that required an IVC filter. CAT scans were then evaluated specifically for vena cava anatomy and relationship to renal veins and lumbar spine. IVC filters were then placed before cavography under fluoroscopy (performed only to confirm accurate placement) based on the static relationship of the renal veins/IVC and spine. RESULTS: One hundred twenty-two patients had IVC filters placed. In the last 78 eligible patients, CAT scan placement was verified with post deployment cavography. IVC filters were deployed an average of 3.25 mm below the lowest renal vein with no veins misidentified. No strut malposition was noted on post deployment cavography. 12.1% had findings by CAT scan that altered some aspect of IVC filter placement. CONCLUSIONS: Admission or same hospital stay spiral CAT scan can provide enough anatomic detail to safely guide placement of an IVC filter. IVC filters can be deployed at bedside without contrast cavography if the preplacement CAT scan is adequate.