The Surgeon as a Professional: Changes and Challenges Over Time.

OBJECTIVE: In this article, we seek to use a case-study discussion of a woman seeking treatment guidance for an elective, complex surgical ailment to discuss how professionalism has changed within the past century and where it may be headed with specific regard for the medical profession and surgeons. BACKGROUND: Traditionally, professionals were those who possessed a certain knowledge base, committed to an ╗altruistic mission through serving the general populace while adhering to certain performance standards that were established by other members of the field. In the 20th century, we saw certain abuses from those who held positions of power within medicine including the Tuskegee Syphilis and Nuremberg trials calling into question the trust the public has placed within professional actors. With many competing opinions and forces shaping the medical profession, including the prominent dissemination of health care information making access to both true and misinformation more rampant than ever before, discussion about the evolving nature of the medical profession is important. METHODS/RESULTS: We conducted a literature review to investigate the historical context of the physician-patient relationship with regard for the surgeon. Our work suggests that the core structure of a professional is a foundation rooted in moral excellence that merits trust from the client. In medicine, further efforts at healing from prior abuses necessitates an emphasis on ethical principles, as well as communicating this commitment not only to the patient but also to the society at large. We emphasize the importance of these changes through a case-based discussion.

The safety of hepatectomy after transarterial radioembolization: Single institution experience and review of the literature.

BACKGROUND AND OBJECTIVES: The liver is a frequent site of malignancy, both primary and metastatic. The treatment goal of patients with liver cancer may include transarterial radioembolization (TARE). There are limited reports on the safety of hepatectomy following TARE. Our study's purpose is to review patients who have received TARE followed by hepatectomy. METHODS: A retrospective study was performed on patients diagnosed with any liver cancer from 2013 to 2019 who underwent TARE followed by hepatectomy. Postoperative complications were prospectively collected. Descriptive statistics and the Kaplan-Meier test were used to assess survival outcomes. RESULTS: Twelve patients were treated with a TARE followed by a hepatectomy (nine with ≥4 segments resected). Diagnoses included: six HCC, four cholangiocarcinoma, one metastatic neuroendocrine tumor, and one metastatic colorectal cancer. There were no 90-day post-hepatectomy mortalities and the overall morbidity was 66% (16% severe ≥MAGS 3). Hepatectomy-specific complications after hepatectomy included two (16%) bile leaks and no post-hepatectomy liver failures. The median recurrence free survival was 26 months. Overall survival at 1-year was 78% and at 3 years was 47%. CONCLUSIONS: Our results support the safety of hepatectomy in select patients after TARE. Additional comparison to patients who receive hepatectomy as a first-line treatment for liver cancers should be investigated.

Comparison of Response and Outcomes of Drug-eluting Bead Chemoembolization (DEB-TACE) Versus Radioembolization (TARE) for Patients With Colorectal Cancer Liver Metastases.

BACKGROUND: To compare outcomes for patients with colorectal cancer liver metastases (CRCLM) treated by drug-eluting bead chemoembolization (DEB-TACE) or radioembolization (TARE). PATIENTS AND METHODS: A single-center retrospective review was carried out on 202 patients with CRCLM, treated by DEB-TACE (n=47) or TARE (n=155) patients. Propensity-matching yielded 44 pairs. Paired statistical analysis was performed on matched pair demographics, treatment response, and survival. RESULTS: Patients treated with DEB-TACE had worse extra-hepatic metastasis (68.1 vs. 47.7%, p=0.014) and ≥10 liver lesions (42.2 vs. 68.8%, p=0.001). Matched patients treated with DEB-TACE had a trend towards worse toxicity (27% vs. 9.1% (p=0.057). Index DEB-TACE treatment was not a prognostic factor for overall survival (hazard ratio=0.94, 95% confidence intervaI=0.54-1.65; p=0.83). CONCLUSION: In the matched CRCLM cohort, there was a trend towards worse toxicity post-DEB-TACE treatment, but it was not an independent prognostic factor for survival.

Radiofrequency Ablation vs. Cryoablation for Localized Hepatocellular Carcinoma: A Propensity-matched Population Study.

BACKGROUND/AIM: To compare overall survival (OS) and liver cancer-specific survival (LCSS) of Surveillance, Epidemiology and End Results (SEER) hepatocellular carcinoma (HCC) database patients treated with cryoablation (cryo) or radiofrequency ablation (RFA). MATERIALS AND METHODS: This was a retrospective review of Stage I or II HCC patients from the SEER database treated with cryo and RFA from 2004-2013. Kaplan-Meier and Cox regressions were performed on pooled and propensity-matched cohort. RESULTS: Out of 3,239 patients, RFA showed a significant survival advantage over cryo in liver cancer specific survival (LCSS) (HR=1.634 p=0.0004). A total of 91 propensity-matched pairs had similar OS (HR=1.006 p=0.9768), but no difference in LCSS was observed between the groups [HR=1.412 (95%CI=0.933-2.137) p=0.1023]. Survival Cox models did not reveal treatment type as an independent prognostic factor. CONCLUSION: Propensity-matched cohort showed no significant difference in terms of OS and LCSS was found for patients treated with either cryo or RFA for localized HCC.

SEER study of ablation versus partial nephrectomy in cT1A renal cell carcinoma.

AIM: Compare ablation versus partial nephrectomy (PN) in T1A renal cell carcinoma (RCC) treatment, using the SEER database. METHODS: Patients with diagnosed T1A RCC from 2004 to 2013 were identified. Propensity matching paired subjects with similar background variables. Kaplan-Meier and Cox proportional hazards regression were performed before and after matching. RESULTS: Cohort included 4592 patients (809 ablation, 3783 PN). PN compared with ablation group had significantly increased overall survival (OS; 93.6% vs 81.9% 5-year survival; p < 0.0001) and cancer-specific survival (CSS; p < 0.0001). After matching (1222 pairs), PN group had significantly increased OS (91.0% vs 86.3% 5-year survival; p = 0.0457) but similar CSS (p = 0.4023). CONCLUSION: Ablation offers similar CSS but lower OS as PN for T1A RCC in this SEER database.

Liver-dominant Breast Cancer Metastasis: A Comparative Outcomes Study of Chemoembolization Versus Radioembolization.

AIM: To compare toxicity, response, and survival outcomes of patients with hepatic metastases from breast cancer who underwent transarterial chemoembolization (TACE) or radioembolization (TARE). MATERIALS AND METHODS: A retrospective review was carried out of all patients who underwent TACE or TARE for liver-dominant breast cancer metastases between January 2006 and March 2016 at an academic medical center in the United States. RESULTS: Seventeen patients in the TACE group and 30 patients in the TARE group received 32 TACE and 49 TARE treatments, respectively. Median follow-up was 9 months. Both groups had similar background variables. More all-grade adverse events were seen in the TACE group (71% vs. 44%; p=0.02). Median overall survival in the TACE group was 4.6 months compared to 12.9 months in the TARE group (p=0.2349). Treatment type was not an independent prognostic factor. CONCLUSION: TARE is better tolerated than TACE for the treatment of liver-dominant breast cancer metastasis. There was a trend towards improved survival with TARE; however, it did not approach statistical significance. Larger studies are needed to validate these findings.

Survival comparison of hepatocellular carcinoma patients treated with radioembolization versus nonoperative/interventional treatment.

AIM: To compare the overall survival (OS) and liver cancer-specific survival of advanced-stage hepatocellular carcinoma (HCC) patients who received transarterial radioembolization (TARE) with those who received nonoperative/interventional treatment (NOT). MATERIALS & METHODS: A total of 12,520 HCC patients from the Surveillance, Epidemiology and End Results database were categorized by treatment with either radioembolization or NOT. Kaplan-Meier and multivariate Cox regression were conducted. RESULTS: The TARE group had both a significantly longer median overall survival than the NOT group (TARE = 9 months; NOT = 2 months; p < 0.0001) and a significantly higher probability of liver cancer-specific survival (hazard ratio = 0.474). CONCLUSION: TARE appears to provide a significant survival advantage over the NOT population in advanced HCC patients.

Thermal ablation versus surgical resection for localized hepatocellular carcinoma: a population study using the SEER database.

AIM: To compare overall survival (OS) and liver cancer-specific survival (LCSS) in patients with localized hepatocellular carcinoma treated with surgical resection (SR) or thermal ablation (TA) using the Surveillance, Epidemiology and End Results database. MATERIALS & METHODS: Kaplan-Meier, competing risk and Cox regression analyses were performed after identifying patients. Propensity score matching was then applied. RESULTS: There was significantly better OS in the SR group and significantly lower probability of LCSS in the TA group. After matching, there was significantly longer OS in the SR group and a lower probability of LCSS in the TA group. CONCLUSION: SR offered a significant survival benefit over TA for localized hepatocellular carcinoma.

Chemoembolization versus radioembolization for the treatment of unresectable intrahepatic cholangiocarcinoma in a single institution image-based efficacy and comparative toxicity.

AIM: Compare radioembolization (Y90) and chemoembolization (CE) for the treatment of unresectable intrahepatic cholangiocarcinoma (UICC). MATERIALS & METHODS: Institutional Review Board-approved, retrospective search was performed. Forty patients with UICC were treated with either Y90 (n = 25, 39 treatments) or CE (n = 15, 35 treatments). Comparative analysis was performed using Student's t and fisher-exact tests. Multivariable-logistic regression was also performed. RESULTS: Median ages were 60 and 64 years for CE and Y90 groups, respectively (p = 0.798). Patient variables including age, Eastern Cooperative Oncology Group score, tumor burden, extra-hepatic disease, prior chemotherapy and prior surgery were similar between groups. Adverse events were similar in both groups (CE 20%, Y90 26%; p > 0.9). Overall response rate (CE 6%, Y90 4%; p > 0.9) and disease control rate (CE 46%, Y90 48%; p > 0.9) were statistically similar. Multilogistic regression did not identify any variables that correlated with disease control rate, including Eastern Cooperative Oncology Group score and tumor burden. CONCLUSION: Our observation shows that CE and Y90 display similar toxicity and disease control in the treatment of UICC.