Communication Frameworks for Palliative Surgical Consultations: A Randomized Study of Advanced Cancer Patients.

OBJECTIVE: To evaluate whether patients with advanced cancer prefer surgeons to use the best case/worst case (BC/WC) communication framework over the traditional risk/benefit (R/B) framework in the context of palliative surgical scenarios. BACKGROUND: Identifying the patient's preferred communication frameworks may improve satisfaction and outcome measures during difficult clinical decision-making. METHODS: In a video-vignette-based randomized, double-blinded study from November 2020 to May 2021, patients with advanced cancer viewed 2 videos depicting a physician-patient encounter in a palliative surgical scenario, in which the surgeon uses either the BC/WC or the R/B framework to discuss treatment options. The primary outcome was the patients' preferred video surgeon. RESULTS: One hundred fifty-five patients were approached to participate; 66 were randomized and 58 completed the study (mean age 55.8 ± 13.8 years, 60.3% males). 22 patients (37.9%, 95% CI: 25.4%-50.4%) preferred the surgeon using the BC/WC framework, 21 (36.2%, 95% CI: 23.8%-48.6%) preferred the surgeon using the R/B framework, and 15 (25.9%, 95% CI: 14.6%-37.2%) indicated no preference. High trust in the medical profession was inversely associated with a preference for the surgeon using BC/WC framework (odds ratio: 0.83, 95% CI: 0.70-0.98, P = 0.03). The BC/WC framework rated higher for perceived surgeon's listening (4.6 ± 0.7 vs 4.3±0.9, P = 0.03) and confidence in the surgeon's trustworthiness (4.3 ± 0.8 vs 4.0 ± 0.9, P = 0.04). CONCLUSIONS: Surgeon use of the BC/WC communication framework was not universally preferred but was as acceptable to patients as the traditional R/B framework and rated higher in certain aspects of communication. A preference for a surgeon using BC/WC was associated with lower trust in the medical profession. Surgeons should consider the BC/WC framework to individualize their approach to challenging clinical discussions.

Assessment of nephrotoxicity associated with combined cisplatin and mitomycin C usage in laparoscopic hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) has been used to treat various peritoneal malignancies. Cisplatin and mitomycin C (MMC) are agents commonly used in these procedures and, individually, each has been associated with acute kidney injury (AKI). There is limited literature on the complications associated with the use of both agents in HIPEC. Therefore, we sought to determine the incidence of nephrotoxicity and electrolyte abnormalities in patients undergoing laparoscopic HIPEC using this chemotherapeutic combination. METHODS: We retrospectively evaluated patients undergoing laparoscopic HIPEC for gastric or gastroesophageal adenocarcinoma using both cisplatin and MMC. Sodium thiosulfate was given for renal protection and kidney function was evaluated daily up to postoperative day #2. Details regarding patient characteristics, selection criteria, chemotherapeutic regimen, perioperative lab values and anesthetic management were collected. RESULTS: Twenty-three patients underwent 31 laparoscopic HIPEC procedures. Fifteen (65%) were male and the median age was 57 (range 21-75). Thirteen procedures were associated with an elevation in creatinine (Cr) with the median difference between POD#2 and baseline being 0.09 mg/dL (range 0-0.43). The glomerular filtration rate median difference between POD#2 and baseline was -17 mL/min/1.37 sq. m (range -42 to 11). No cases demonstrated AKI, defined as a 50% increase in Cr levels above baseline. An 84% incidence of postoperative hypophosphatemia (26/31) and 94% incidence of postoperative hypocalcemia (29/31) was observed. CONCLUSION: The laparoscopic approach to HIPEC using both cisplatin and MMC in our cohort was not associated with an increased incidence of AKI. The incidence of hypophosphatemia and hypocalcemia needs further evaluation to determine the exact etiology. Precis' statement: We retrospectively studied the association of AKI with the combined use of cisplatin and MMC in laparoscopic HIPEC.

Stratification of outcomes for mucinous appendiceal adenocarcinoma with peritoneal metastasis by histological grade.

AIM: To investigate the importance of a three-tiered histologic grade on outcomes for patients with mucinous appendiceal adenocarcinoma (MAA). METHODS: Two hundred and sixty-five patients with MAA undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were identified from a prospective database from 2004 through 2014. All pathology was reviewed by our gastrointestinal subspecialty pathologists and histological grade was classified as well-differentiated, moderately differentiated, and poorly differentiated. Survival analysis was performed using Cox proportional hazards regression. RESULTS: There were 201 (75.8%) well-, 45 (16.9%) moderately- and 19 (7.2%) poorly-differentiated tumors. Histological grade significantly stratified the 5-year overall survival (OS), 94%, 71% and 30% respectively (P < 0.001) as well as the 5-year disease-free survival (DFS) 66%, 21% and 0%, respectively (P < 0.001). Independent predictors of DFS included tumor grade (HR = 1.78, 95%CI: 1.21-2.63, P = 0.008), lymph node involvement (HR = 0.33, 95%CI: 0.11-0.98, P < 0.02), previous surgical score (HR = 1.31, 95%CI: 1.1-1.65, P = 0.03) and peritoneal carcinomatosis index (PCI) (HR = 1.05, 95%CI: 1.02-1.08, P = 0.002). Independent predictors of OS include tumor grade (HR = 2.79, 95%CI: 1.26-6.21, P = 0.01), PCI (HR = 1.10, 95%CI: 1.03-1.16, P = 0.002), and complete cytoreduction (HR = 0.32, 95%CI: 0.11-0.92, P = 0.03). Tumor grade and PCI were the only independent predictors of both DFS and OS. Furthermore, histological grade and lymphovascular invasion stratified the risk of lymph node metastasis into a low (6%) and high (40%) risk groups. CONCLUSION: Our data demonstrates that moderately differentiated MAA have a clinical behavior and outcome that is distinct from well- and poorly-differentiated MAA. The three-tier grade classification provides improved prognostic stratification and should be incorporated into patient selection and treatment algorithms.