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1.
J Am Acad Dermatol ; 2021 Feb 04.
Artigo em Inglês | MEDLINE | ID: mdl-33549653

RESUMO

BACKGROUND: The Affordable Care Act's Medicaid expansion is associated with earlier diagnosis and improved care among lower socioeconomic status populations with cancer, but its impact on melanoma is undefined. OBJECTIVE: To determine the association of Medicaid expansion with stage of diagnosis and utilization of sentinel lymph node biopsy (SLNB) in non-elderly adult patients with newly diagnosed clinically localized melanoma. METHODS: Quasi-experimental, difference-in-differences retrospective cohort analysis using data from the National Cancer Database from 2010 to 2017. Patients from expansion versus non-expansion states and diagnosed before (2010-13) versus after (2014-17) expansion were identified. RESULTS: Of 83,322 patients, 46.6% were female, and the median age was 55 (interquartile range 49-60) years. Following risk adjustment, Medicaid expansion was associated with a decrease in the diagnosis of ≥T1b stage melanoma (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.88-0.98, P=0.011) and decrease in uninsured status (OR 0.61, 95% CI 0.52-0.72, P<0.001), but was not associated with a difference in SLNB performance when indicated (OR 1.06, 95% CI 0.95-1.20, P=0.29). LIMITATIONS: Retrospective study using a national database. CONCLUSION: In this study of patients with clinically localized melanoma, Medicaid expansion was associated with a decrease in the diagnosis of later T-stage tumors.

2.
Am J Surg ; 2021 Feb 04.
Artigo em Inglês | MEDLINE | ID: mdl-33573763

RESUMO

BACKGROUND: It is unclear how the Affordable Care Act's state-based Medicaid Expansion (ME) has impacted surgeon selection for colorectal resections (CRS). METHODS: We performed a risk-adjusted DID analysis on state discharge data of CRS patients aged 26-64 from NY (Expansion) and FL (non-Expansion) before (2012-2013) and after (2016-2017) ME. Primary outcome was use of a high-volume or colorectal-boarded surgeon. Subset analysis performed on insurance status. RESULTS: Among 78,866 CRS patients, ME was associated with a 5.9% increase in Medicaid enrollment. ME was associated with a 0.73 (95%CI: 0.67-0.69; p < 0.001) reduced odds of high-volume surgeon usage by commercially insured patients when compared to usage by commercially insured patients in the non-expansion state. No statistically significant difference was noted in the use of a colorectal-boarded surgeon following reform. CONCLUSIONS: ME was associated with an increase in Medicaid enrollment and a decrease in the use of high-volume surgeons by the commercially insured.

3.
Ann Surg Oncol ; 2021 Feb 16.
Artigo em Inglês | MEDLINE | ID: mdl-33591480

RESUMO

INTRODUCTION: Preoperative biopsy (PBx) is often recommended for retroperitoneal sarcoma (RPS), but its utilization rate and impact on perioperative management and outcomes remains undefined. METHODS: Using the National Cancer Database, patients who underwent resection of non-metastatic RPS were identified (2006-2014). Patients who did and did not undergo PBx of the primary tumor were compared using propensity matching, and factors associated with survival were assessed by multivariable analysis. RESULTS: Of 2620 patients, 1110 (42.4%) underwent PBx. Factors significantly associated with performance of PBx included male sex [odds ratio (OR) 1.2, P = 0.035], tumor size ≤ 5 cm (OR 1.5, P = 0.012), tumor size > 5 to ≤ 10 cm (OR 1.3, P = 0.009), non-well-differentiated liposarcoma histology (OR 2.0, P ≤ 0.001), and treatment at a high-volume center (OR 1.3, P = 0.021). Receipt of PBx was significantly associated with administration of neoadjuvant radiation (OR 8.8, P < 0.001) or systemic therapy (OR 3.3, P < 0.001), radical surgical resection (OR 1.6, P < 0.001), and complete tumor resection (OR 1.5, P < 0.003). Neoadjuvant radiation [hazard ratio (HR) 0.7, P = 0.003] and complete tumor resection (HR 0.6, P < 0.001) were significantly associated with improved overall survival (OS). Performance of PBx was not associated with OS (HR 1.1, P = 0.070), and following propensity matching, 5-year OS did not differ between the two groups (56.5% PBx vs 58.4% no PBx, P = 0.247). CONCLUSIONS: A minority of patients with non-metastatic RPS undergo PBx. PBx does not negatively impact survival, but may indirectly improve outcomes in select patients by virtue of receipt of neoadjuvant therapy and attainment of complete tumor resection.

4.
Nat Med ; 27(2): 301-309, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33558722

RESUMO

The association among pathological response, recurrence-free survival (RFS) and overall survival (OS) with neoadjuvant therapy in melanoma remains unclear. In this study, we pooled data from six clinical trials of anti-PD-1-based immunotherapy or BRAF/MEK targeted therapy. In total, 192 patients were included; 141 received immunotherapy (104, combination of ipilimumab and nivolumab; 37, anti-PD-1 monotherapy), and 51 received targeted therapy. A pathological complete response (pCR) occurred in 40% of patients: 47% with targeted therapy and 33% with immunotherapy (43% combination and 20% monotherapy). pCR correlated with improved RFS (pCR 2-year 89% versus no pCR 50%, P < 0.001) and OS (pCR 2-year OS 95% versus no pCR 83%, P = 0.027). In patients with pCR, near pCR or partial pathological response with immunotherapy, very few relapses were seen (2-year RFS 96%), and, at this writing, no patient has died from melanoma, whereas, even with pCR from targeted therapy, the 2-year RFS was only 79%, and OS was only 91%. Pathological response should be an early surrogate endpoint for clinical trials and a new benchmark for development and approval in melanoma.

5.
Am J Surg ; 2021 Jan 19.
Artigo em Inglês | MEDLINE | ID: mdl-33487402

RESUMO

BACKGROUND: Insurance status has been strongly associated with both access to and outcomes of colon resection (CRS). Under the Affordable Care Act (ACA), individual states opted to participate in Medicaid expansion (ME) and adopt essential health benefits (EHB). METHODS: We performed a quasi-experimental difference-in-differences (DID) analysis of 2012-2017 state-level inpatient claims with risk adjustment. We examined frequency of emergent presentation and in-hospital death. Subset analyses were performed by insurance type. RESULTS: Among the 73,961 CRS patients, 49.6% were in a state with both ME and EHB, 34.7% presented emergently, and 2.0% died. Adoption of ME and EHB was associated with a significant, 24%, reduction in the likelihood of in-hospital mortality, and no significant change in emergent presentation for CRS. CONCLUSIONS: The ACA's ME was strongly associated with a decrease in mortality following colon resection among Medicaid beneficiaries. These findings support the adoption of healthcare policies that improve access to insurance.

6.
World J Surg ; 2021 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-33511422

RESUMO

BACKGROUND: The COVID-19 pandemic has resulted in large-scale healthcare restrictions to control viral spread, reducing operating room censuses to include only medically necessary surgeries. The impact of restrictions on which patients undergo surgical procedures and their perioperative outcomes is less understood. METHODS: Adult patients who underwent medically necessary surgical procedures at our institution during a restricted operative period due to the COVID-19 pandemic (March 23-April 24, 2020) were compared to patients undergoing procedures during a similar time period in the pre-COVID-19 era (March 25-April 26, 2019). Cardinal matching and differences in means were utilized to analyze perioperative outcomes. RESULTS: 857 patients had surgery in 2019 (pre-COVID-19) and 212 patients had surgery in 2020 (COVID-19). The COVID-19 era cohort had a higher proportion of patients who were male (61.3% vs. 44.5%, P < 0.0001), were White (83.5% vs. 68.7%, P < 0.001), had private insurance (62.7% vs. 54.3%, p 0.05), were ASA classification 4 (10.9% vs. 3%, P < 0.0001), and underwent oncologic procedures (69.3% vs. 42.7%, P < 0.0001). Following 1:1 cardinal matching, COVID-19 era patients (N = 157) had a decreased likelihood of discharge to a nursing facility (risk difference-8.3, P < 0.0001) and shorter median length of stay (risk difference-0.6, p 0.04) compared to pre-COVID-19 era patients. There was no difference between the two patient cohorts in overall morbidity and 30-day readmission. CONCLUSIONS: COVID-19 restrictions on surgical operations were associated with a change in the racial and insurance demographics in patients undergoing medically necessary surgical procedures but were not associated with worse postoperative morbidity. Further study is necessary to better identify the causes for patient demographic differences.

7.
Cell Rep ; 33(13): 108571, 2020 Dec 29.
Artigo em Inglês | MEDLINE | ID: mdl-33378668

RESUMO

Here, we report that functional heterogeneity of macrophages in cancer could be determined by the nature of their precursors: monocytes (Mons) and monocytic myeloid-derived suppressor cells (M-MDSCs). Macrophages that are differentiated from M-MDSCs, but not from Mons, are immune suppressive, with a genomic profile matching that of M-MDSCs. Immune-suppressive activity of M-MDSC-derived macrophages is dependent on the persistent expression of S100A9 protein in these cells. S100A9 also promotes M2 polarization of macrophages. Tissue-resident- and Mon-derived macrophages lack expression of this protein. S100A9-dependent immune-suppressive activity of macrophages involves transcription factor C/EBPß. The presence of S100A9-positive macrophages in tumor tissues is associated with shorter survival in patients with head and neck cancer and poor response to PD-1 antibody treatment in patients with metastatic melanoma. Thus, this study reveals the pathway of the development of immune-suppressive macrophages and suggests an approach to their selective targeting.

9.
Ann Surg Oncol ; 2020 Nov 23.
Artigo em Inglês | MEDLINE | ID: mdl-33230747

RESUMO

BACKGROUND: Adjuvant radiation therapy (RT) can decrease lymph node basin (LNB) recurrences in patients with clinically evident melanoma lymph node (LN) metastases following lymphadenectomy, but its role in the era of modern systemic therapies (ST), immune checkpoint or BRAF/MEK inhibitors, is unclear. PATIENTS AND METHODS: Patients at four institutions who underwent lymphadenectomy (1/1/2010-12/31/2019) for clinically evident melanoma LN metastases and received neoadjuvant and/or adjuvant ST with RT, or ST alone, but met indications for RT, were identified. Comparisons were made between ST alone and ST/RT groups. The primary outcome was 3-year cumulative incidence (CI) of LNB recurrence. Secondary outcomes included 3-year incidences of in-transit/distant recurrence and survival estimates. RESULTS: Of 98 patients, 76 received ST alone and 22 received ST/RT. Median follow-up time for patients alive at last follow-up was 44.6 months. The ST/RT group had fewer inguinal node metastases (ST 36.8% versus ST/RT 9.1%; P = 0.04), and more extranodal extension (ST 50% versus ST/RT 77.3%; P = 0.02) and positive lymphadenectomy margins (ST 2.6% versus ST/RT 13.6%; P = 0.04). The 3-year CI of LNB recurrences was lower for the ST/RT group compared with the ST group (13.9% versus 25.2%), but this reduction was not statistically significant (P = 0.36). Groups did not differ significantly in in-transit/distant recurrences (P = 0.24), disease-free survival (P = 0.14), or melanoma-specific survival (P = 0.20). CONCLUSIONS: In the era of modern ST, RT may still have value in reducing LNB recurrences in melanoma with clinical LN metastases. Further research should focus on whether select patient populations derive benefit from combination therapy, and optimizing indications for RT following neoadjuvant ST.

10.
J Surg Oncol ; 2020 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-33169840

RESUMO

BACKGROUND: Rates of nonoperative management of acute appendicitis and appendiceal adenocarcinoma have increased over a decade, but the presentation and outcomes of appendiceal adenocarcinoma over this period is not well-characterized. METHODS: Patients with surgically resected Stage I-III appendiceal adenocarcinoma were identified from the 2006 to 2015 National Cancer Data Base and classified into two cohorts, 2006-2010 and 2011-2015, based on year of diagnosis. Three-year overall survival (OS) was analyzed using Cox proportional hazards regression and Kaplan-Meier survival estimates. RESULTS: Of 4233 patients, 1369 (32.3%) and 2864 (67.7%) were diagnosed in 2006-2010 and 2011-2015, respectively. Following multivariable analysis, patients in 2011-2015 were more likely to be <40 years of age (6.4% vs. 4.7%, odds ratio [OR] 1.53, p .015), present with pT4 tumors (40.2% vs. 34.4%, OR 1.46, p .004), and undergo hyperthermic intraperitoneal chemotherapy (4.4% vs. 2.4%, OR 1.97, p .001). Comparing patients diagnosed in 2011-2015 to 2006-2010, adjusted 3-year OS was no different among all patients (81.1% vs. 79%, p .778). CONCLUSIONS: There has been an increase in the proportion of patients with pT4 appendix tumors over time, primarily among older (≥60 years) patients. Even so, these shifts in presentation have not resulted in differences in survival outcomes.

12.
Clin Cancer Res ; 26(21): 5709-5719, 2020 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-33097493

RESUMO

PURPOSE: Angiogenesis is thought to be critical for tumor metastasis. However, inhibiting angiogenesis using antibodies such as bevacizumab (Avastin), has had little impact on melanoma patient survival. We have demonstrated that both angiogenesis and metastasis are increased in older individuals, and therefore sought to investigate whether there was an age-related difference in response to bevacizumab, and if so, what the underlying mechanism could be. EXPERIMENTAL DESIGN: We analyzed data from the AVAST-M trial of 1,343 patients with melanoma treated with bevacizumab to determine whether there is an age-dependent response to bevacizumab. We also examined the age-dependent expression of VEGF and its cognate receptors in patients with melanoma, while using syngeneic melanoma animal models to target VEGF in young versus old mice. We also examined the age-related proangiogenic factor secreted frizzled-related protein 2 (sFRP2) and whether it could modulate response to anti-VEGF therapy. RESULTS: We show that older patients respond poorly to bevacizumab, whereas younger patients show improvement in both disease-free survival and overall survival. We find that targeting VEGF does not ablate angiogenesis in an aged mouse model, while sFRP2 promotes angiogenesis in vitro and in young mice. Targeting sFRP2 in aged mice successfully ablates angiogenesis, while the effects of targeting VEGF in young mice can be overcome by increasing sFRP2. CONCLUSIONS: VEGF is decreased during aging, thereby reducing response to bevacizumab. Despite the decrease in VEGF, angiogenesis is increased because of an increase in sFRP2 in the aged tumor microenvironment. These results stress the importance of considering age as a factor for designing targeted therapies.

13.
Ann Surg ; 2020 Oct 14.
Artigo em Inglês | MEDLINE | ID: mdl-33074899

RESUMO

OBJECTIVE: The study objective is to determine the association between travel distance and surgical volume on outcomes after esophageal, pancreatic, and rectal cancer resections. SUMMARY OF BACKGROUND DATA: "Take the Volume Pledge" aims to centralize esophagectomies, pancreatectomies, and proctectomies to hospitals meeting minimum volume standards. The impact of travel, and possible care fragmentation, on potential benefits of centralized surgery is not well understood. METHODS: Using the National Cancer Database (2004-2016), patients who underwent esophageal, pancreatic, or rectal resections at far HVH meeting volume standards versus local intermediate (IVH) and low-volume (LVH) hospitals were identified. Perioperative outcomes and 5-year OS were compared. RESULTS: Of 49,454 patients, 17,544 (34.5%) underwent surgery at far HVH, 11,739 (23.7%) at local IVH, and 20,171 (40.8%) at local LVH. The median (interquartile range) travel distances were 77.1 (51.1-125.4), 13.2 (5.8-27.3), and 7.8 (3.1-15.5) miles to HVH, IVH, and LVH, respectively. By multivariable analysis, LVH was associated with increased 30-day mortality for all resections compared to HVH, but IVH was associated with mortality only for proctectomies [odds ratio 1.90, 95% confidence interval (CI) 1.31-2.75]. Compared to HVH, both IVH (hazard ratio 1.25, 95% CI 1.19-1.31) and LVH (hazard ratio 1.35, 95% CI 1.29-1.42) were associated with decreased 5-year OS. CONCLUSIONS: Compared to far HVH, 30-day mortality was higher for all resections at LVH, but only for proctectomies at IVH. Five-year OS was consistently worse at local LVH and IVH. Improving long-term outcomes at IVH may provide opportunities for greater access to quality cancer care.

14.
Surgery ; 2020 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-32863011

RESUMO

BACKGROUND: Although tumor size and mitotic rate are established prognostic factors for worse survival in patients undergoing surgical resection for gastric gastrointestinal stromal tumors, the impact of microscopic margins, or R1 resection, is not completely established. METHODS: Patients who received no neoadjuvant therapy and underwent surgical resection for stage I to III gastric gastrointestinal stromal tumors were identified from the 2010 to 2013 National Cancer Database and divided into 2 cohorts, R0 and R1 resections. Cox proportional hazards ratio and Kaplan Meier survival estimates were utilized to analyze 5-y overall survival. RESULTS: Of 2,084 patients, those with R1 resection (57, 2.7%) were more likely to have tumors >10 cm (28.1% vs 11.9%, odds ratio 3.51, P = .017) and stage III disease (26.3% vs 11.2%, odds ratio 2.26, P = .047). Although margin status was associated with higher risk tumors, it was not associated with receipt of adjuvant therapy. After multivariate Cox regression, R1 and R0 patients did not have a difference in 5-y overall survival (82.5% vs 88.6%, hazards ratio 1.26, P = .49). When stratified by stage of disease, there remained no difference in survival across all stages when comparing R1 and R0 patients. CONCLUSION: Positive microscopic margins are uncommon but do not appear to impact survival outcomes in patients with resected localized gastric gastrointestinal stromal tumors.

16.
Ann Surg Oncol ; 2020 Aug 10.
Artigo em Inglês | MEDLINE | ID: mdl-32779048

RESUMO

BACKGROUND: The use of sentinel lymph node biopsy in patients with T1 melanoma ≤ 1 mm has not been reported in a prospective clinical trial setting, so these clinical outcomes remain understudied. This study seeks to evaluate overall survival (OS) with and without lymph node biopsy (LNB) in patients with clinical T1N0M0 melanoma (0.5-1.0 mm). PATIENTS AND METHODS: Patients were identified using the National Cancer Data Base (2004-2012). After stratification into 0.5-0.7-mm and 0.8-1.0-mm groups, patients undergoing LNB were propensity score-matched 1:1 to patients not undergoing LNB. OS was compared using the Kaplan-Meier method and the stratified log-rank test. RESULTS: Resection was performed in 28,846 patients, and LNB in 14,028 (49%); 15,194 were included in propensity score-matched analysis. The LNB and no-LNB groups were well balanced on all studied covariates (standardized mean difference < 0.10). Among patients with tumors 0.5-0.7 mm, 5- and 10-year OS were 94.7% and 82.7%, respectively, for the LNB group compared with 94.3% and 84.4% for the no-LNB group (p = 0.35). Among patients with tumors 0.8-1.0 mm in thickness, 5- and 10-year OS were 93.9% and 81.6%, respectively, for the LNB group compared with 90.3% and 74.3% for the no-LNB group (p < 0.0001). CONCLUSIONS: There was no difference in OS by LNB status in patients with lesions 0.5-0.7 mm, consistently with recommendations against its routine use in this group. In lesions 0.8-1.0 mm, receipt of LNB was associated with a clinically small but significant improvement in OS. Further study is warranted to better understand this outcome difference.

17.
J Cutan Pathol ; 47(12): 1196-1199, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32740977

RESUMO

We report a case of tumor-to-tumor metastasis of a cutaneous malignant melanoma to a synchronous thyroid Hurthle cell carcinoma. A 42-year-old male underwent a biopsy of right inguinal lymphadenopathy which showed metastatic melanoma. The primary lesion was identified on his right posterior leg, and staging workup discovered a synchronous left thyroid lobe nodule concerning for a follicular neoplasm. He underwent excision of the primary melanoma, right inguinal lymphadenectomy, and total thyroidectomy. The resected thyroid contained a 6.6-cm, well-encapsulated left-sided nodule, red-brown in color and homogenous in consistency, with areas of focal hemorrhage and no grossly identifiable calcification. Microscopically, large tumor cells with distinct cell borders were present, with deeply eosinophilic and granular cytoplasm, large nuclei with prominent nucleoli, and loss of polarity consistent with oncocytes. A microscopic single focus of vascular invasion was identified, and a diagnosis of angioinvasive Hurthle cell carcinoma was made. Within the Hurthle cell carcinoma, multiple deposits of metastatic melanoma were seen. These findings were indicative of tumor-to-tumor metastasis of the cutaneous melanoma to the angioinvasive Hurthle cell carcinoma. Our findings show the ability of melanoma to metastasize to a pre-existing neoplasm.

18.
19.
Surg Oncol Clin N Am ; 29(3): 369-386, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32482314

RESUMO

Age plays a dynamic role in incidence, presentation, and extent of disease for cutaneous melanoma. Even within the spectrum of juvenile melanoma, there exists a range of spitzoid and nonspitzoid melanocytic and melanoma lesions. Spitzoid melanomas, a more favorable disease in juvenile patients, are malignant lesions and require treatment as such. Lymph node metastases in melanoma occur at lower rates in older patients compared with younger counterparts, yet the rate of metastases is still high. Age appears to play an important role in the development and progression of melanoma, and understanding the differences across age populations is important when counseling patients.

20.
J Surg Oncol ; 2020 Jun 20.
Artigo em Inglês | MEDLINE | ID: mdl-32563196

RESUMO

BACKGROUND: Regionalization of oncologic care has increased, but less is known whether patient outcomes are influenced by receipt of multimodality care through multicenter care (MCC) or single-center care (SCC). METHODS: Patients from 2004 to 2015 National Cancer Data Base diagnosed with stage II-III esophageal (EA), stage II-III pancreatic (PA), and stage II-IV rectal (RA) adenocarcinoma who underwent resection at a high volume center (HVC) and required radiation and/or chemotherapy were included. MCC (care at 2+ facilities) and SCC patients were propensity-score matched 1:2 and Cox proportional hazards regression used to analyze survival. RESULTS: On multivariable regression analysis, MCC in RA patients (N = 325/2097, 15.5%) was more associated with residing ≥40 miles from the HVC (odds ratio [OR] = 2.37; P = .044) and receipt of neoadjuvant chemotherapy (1.42, P = .040). In PA patients (N = 75/380, 19.7%), residing ≥40 miles from the HVC (OR = 3.22; P = .001), and in EA patients (N = 88/534, 16.5%), younger patients (<50 years: OR = 2.96; P = .011) were associated with MCC. Following propensity score matching, EA (N = 147), PA (N = 133), and RA (N = 661) patients had no difference in 1-year and 3-year overall survival when comparing MCC to SCC. CONCLUSIONS: The use of MCC appears safe without a difference in survival and may offer significant advantages in convenience to patients as they undergo their complex oncologic care.

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