A Prognostic Model To Predict Survival After Recurrence Among Patients With Recurrent Hepatocellular Carcinoma.

OBJECTIVE: We sought to develop and validate a preoperative model to predict survival after recurrence (SAR) in hepatocellular carcinoma (HCC). BACKGROUND: Although HCC is characterized by recurrence as high as 60%, models to predict outcomes after recurrence remain relatively unexplored. METHODS: Patients who developed recurrent HCC between 2000 and 2020 were identified from an international multi-institutional database. Clinicopathologic data on primary disease and laboratory and radiologic imaging data on recurrent disease were collected. Multivariable Cox regression analysis and internal bootstrap validation (5000 repetitions) were used to develop and validate the SARScore. Optimal Survival Tree analysis was used to characterize SAR among patients treated with various treatment modalities. RESULTS: Among 497 patients who developed recurrent HCC, median SAR was 41.2 months (95% CI 38.1-52.0). The presence of cirrhosis, number of primary tumors, primary macrovascular invasion, primary R1 resection margin, AFP>400 ng/mL on the diagnosis of recurrent disease, radiologic extrahepatic recurrence, radiologic size and number of recurrent lesions, radiologic recurrent bilobar disease, and early recurrence (≤24 months) were included in the model. The SARScore successfully stratified 1-, 3- and 5-year SAR and demonstrated strong discriminatory ability (3-year AUC: 0.75, 95% CI 0.70-0.79). While a subset of patients benefitted from resection/ablation, Optimal Survival Tree analysis revealed that patients with high SARScore disease had the worst outcomes (5-year AUC; training: 0.79 vs. testing: 0.71). The SARScore model was made available online for ease of use and clinical applicability ( https://yutaka-endo.shinyapps.io/SARScore/ ). CONCLUSION: The SARScore demonstrated strong discriminatory ability and may be a clinically useful tool to help stratify risk and guide treatment for patients with recurrent HCC.

Optimal policy tree to assist in adjuvant therapy decision-making after resection of colorectal liver metastases.

BACKGROUND: Although systemic postoperative therapy after surgery for colorectal liver metastases is generally recommended, the benefit of adjuvant chemotherapy has been debated. We used machine learning to develop a decision tree and define which patients may benefit from adjuvant chemotherapy after hepatectomy for colorectal liver metastases. METHODS: Patients who underwent curative-intent resection for colorectal liver metastases between 2000 and 2020 were identified from an international multi-institutional database. An optimal policy tree analysis was used to determine the optimal assignment of the adjuvant chemotherapy to subgroups of patients for overall survival and recurrence-free survival. RESULTS: Among 1,358 patients who underwent curative-intent resection of colorectal liver metastases, 1,032 (76.0%) received adjuvant chemotherapy. After a median follow-up of 28.7 months (interquartile range 13.7-52.0), 5-year overall survival was 67.5%, and 3-year recurrence-free survival was 52.6%, respectively. Adjuvant chemotherapy was associated with better recurrence-free survival (3-year recurrence-free survival: adjuvant chemotherapy, 54.4% vs no adjuvant chemotherapy, 46.8%; P < .001) but no overall survival significant improvement (5-year overall survival: adjuvant chemotherapy, 68.1% vs no adjuvant chemotherapy, 65.7%; P = .15). Patients were randomly allocated into 2 cohorts (training data set, n = 679, testing data set, n = 679). The random forest model demonstrated good performance in predicting counterfactual probabilities of death and recurrence relative to receipt of adjuvant chemotherapy. According to the optimal policy tree, patient demographics, secondary tumor characteristics, and primary tumor characteristics defined the subpopulation that would benefit from adjuvant chemotherapy. CONCLUSION: A novel artificial intelligence methodology based on patient, primary tumor, and treatment characteristics may help clinicians tailor adjuvant chemotherapy recommendations after colorectal liver metastases resection.

Association of Minority-Serving Hospital Status with Post-Discharge Care Utilization and Expenditures in Gastrointestinal Cancer.

BACKGROUND: Disparities in utilization of post-discharge care and overall expenditures may relate to site of care and race/ethnicity. We sought to define the impact of minority-serving hospitals (MSHs) on postoperative outcomes, discharge disposition, and overall expenditures associated with an episode of surgical care. METHODS: Patients who underwent resection for esophageal, colon, rectal, pancreatic, and liver cancer were identified from Medicare Standard Analytic Files (2013-2017). A MSH was defined as the top decile of facilities treating minority patients (Black and/or Hispanic). The impact of MSH on outcomes of interest was analyzed using multivariable logistic regression and generalized linear regression models. Textbook outcome (TO) was defined as no postoperative complications, no prolonged length of stay, and no 90-day mortality or readmission. RESULTS: Among 113,263 patients, only a small subset of patients underwent surgery at MSHs (n = 4404, 3.9%). While 52.3% of patients achieved TO, rates were lower at MSHs (MSH: 47.2% vs. non-MSH: 52.5%; p < 0.001). On multivariable analysis, receiving care at an MSH was associated with not achieving TO (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.76-0.87) and concomitantly higher odds of additional post-discharge care (OR 1.10, 95% CI 1.01-1.20). Patients treated at an MSH also had higher median post-discharge expenditures (MSH: $8400, interquartile range [IQR] $2300-$22,100 vs. non-MSH: $7000, IQR $2200-$17,900; p = 0.002). In fact, MSHs remained associated with a 11.05% (9.78-12.33%) increase in index expenditures and a 16.68% (11.44-22.17%) increase in post-discharge expenditures. CONCLUSIONS: Patients undergoing surgery at a MSH were less likely to achieve a TO. Additionally, MSH status was associated with a higher likelihood of requiring post-discharge care and higher expenditures.

Persistent poverty impacts access to minimally invasive surgery among patients with hepatopancreatobiliary cancer.

BACKGROUND AND OBJECTIVES: Minimally invasive surgery (MIS) has been successfully adopted in hepatopancreatobiliary (HPB) cancer, and has been associated with improved perioperative and comparable oncological outcomes. We sought to define the impact of county-level duration of poverty on access to MIS and clinical outcomes among patients with HPB cancer undergoing surgical treatment. MATERIALS AND METHODS: Data on patients diagnosed with HPB cancer were obtained from the Surveillance, Epidemiology, and End Results (SEER)-Medicare data (2010-2016). County-level poverty data were obtained from the American Community Survey and the U.S. Department of Agriculture, and categorized into three groups: never high poverty (NHP), intermittent high poverty (IHP), and persistent poverty (PP). Multivariable regression was used to assess the relationship between PP and MIS. RESULTS: Among 8098 patients, 82% (n = 664) resided in regions with NHP, 13.6% (n = 1104) resided in regions with IHP, and 4.4% (n = 350) resided in regions with PP. Median age at the diagnosis was 71 years (interquartile range [IQR]: 67-77). Patients from IHP and PP counties had lower odds of undergoing MIS (IHP/PP vs. NHP, odds ratio [OR]: 0.59, 95% confidence interval [CI]: 0.36-0.96, p = 0.034) and being discharged home (IHP/PP vs. NHP, OR: 0.64, 95% CI: 0.43-0.99, p = 0.043), as well as a higher risk of 1-year mortality (IHP/PP vs. NHP, HR: 1.51, 95% CI: 1.036-2.209, p = 0.032) compared with patients residing in NHP counties. CONCLUSIONS: Duration of county-level poverty was associated with lower receipt of MIS and unfavorable clinical and survival outcomes among patients with HPB cancer. There is a need to improve access to modern surgical treatment options among vulnerable, PP populations.

The impact of recurrence timing and tumor burden score on overall survival among patients undergoing repeat hepatectomy for colorectal liver metastases.

INTRODUCTION: Approximately 15% of patients experience a resectable intrahepatic recurrence after an index curative-intent hepatectomy for colorectal liver metastases (CRLM). We sought to investigate the impact of recurrence timing and tumor burden score (TBS) at the time of recurrence on overall survival among patients undergoing repeat hepatectomy. METHODS: Patients with CRLM who experienced recurrent intrahepatic disease after initial hepatectomy between 2000 and 2020 were identified from an international multi-institutional database. The impact of time-TBS, defined as TBS divided by the time interval of recurrence, was assessed relative to overall survival. RESULTS: Among 220 patients, the median age was 60.9 years (interquartile range [IQR]: 53.0-69.0), and 144 (65.5%) patients were male. Most patients experienced multiple recurrences (n = 120, 54.5%) within 12 months after the initial hepatectomy (n = 139, 63.2%). The median tumor size of the recurrent CRLM was 2.2 cm (IQR: 1.5-3.0 cm) with a median TBS of 3.5 (2.3-4.9) at the time of recurrence. Overall, 121 (55.0%) patients underwent repeat hepatectomy, whereas 99 (45.0%) individuals were treated with systemic chemotherapy or other nonsurgical treatments; repeat hepatectomy was associated with better postrecurrence survival (PRS) (p < 0.001). Three-year PRS incrementally worsened (low time-TBS: 71.7%, 95% confidence interval [CI], 57.9-88.8 vs. medium: 63.6%, 95% CI, 47.7-84.8 vs. high: 49.2%, 95% CI, 31.1-77.7, p = 0.02) as time-TBS values increased. Each unit increase in time-TBS score was independently associated with a 41% higher possibility of death (hazard ratio: 1.41; 95% CI, 1.04-1.90, p = 0.03). CONCLUSIONS: Time-TBS was associated with long-term outcomes after repeat hepatectomy for recurrent CRLM. Time-TBS may be an easy tool to help select patients who may benefit the most from repeat hepatic resection of recurrent CRLM.