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1.
Ann Surg Oncol ; 27(2): 333-341, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31605347

RESUMO

BACKGROUND: The size and importance of socioeconomic status (SES)-based disparities in use of surgery for non-advanced stage gastrointestinal (GI) cancers have not been quantified. METHODS: The exposure in this study of patients age 18-80 with one of nine non-advanced stage GI cancers in the 2007-2015 SEER database was a census tract-level SES composite. Multivariable models assessed associations of SES with use of surgery. Causal mediation analysis was used to estimate the proportion of survival disparities in SES quintiles 1 versus 5 that were mediated by disparities in use of surgery. RESULTS: Lowest SES quintile patients underwent surgery at significantly lower rates than highest quintile patients in each cancer. SES-based disparities in use of surgery were large and graded in esophagus adenocarcinoma, intrahepatic and extrahepatic cholangiocarcinoma, and pancreatic adenocarcinoma. Smaller but clinically relevant disparities were present in stomach, ampulla, and small bowel adenocarcinoma, whereas disparities were small in colorectal adenocarcinoma. Five-year all-stage overall survival (OS) was correlated with the size of disparities in use of surgery in SES quintiles 1 versus 5 (r = - 0.87; p = 0.003). Mean OS was significantly longer (range 3.5-8.9 months) in SES quintile 5 versus 1. Approximately one third of SES-based survival disparities in poor prognosis GI cancers were mediated by disparities in use of surgery. The size of disparities in use of surgery in SES quintiles 1 versus 5 was correlated with the proportion mediated (r = 0.98; p < 0.001). CONCLUSIONS: Low SES patients with poor prognosis GI cancers are at substantial risk of undertreatment. Disparities in use of surgery contribute to diminished survival.

3.
Am J Surg ; 218(6): 1035-1039, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31761053
4.
Dermatol Online J ; 25(3)2019 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-30982303

RESUMO

Dermatomyositis (DM) is an idiopathic inflammatory myopathy characterized by proximal muscle weakness associated with a distinct cutaneous eruption. The association of DM with malignancy has been extensively described in the literature. Patients with DM that also have transcriptional intermediary factor 1γ (TIF1γ) autoantibodies (anti-p155, anti-p155/140) have higher rates of malignancy when compared to those without the autoantibody. We report the case of a 65-year-old woman with TIF1γautoantibody positive dermatomyositis associated with a non-functional pancreatic neuroendocrine tumor (PNET). Surgical resection of the PNET resulted in significant clinical improvement and a reduction of TIF1γ autoantibody levels in our patient.


Assuntos
Dermatomiosite/diagnóstico , Tumores Neuroendócrinos/diagnóstico , Neoplasias Pancreáticas/diagnóstico , Síndromes Paraneoplásicas/diagnóstico , Idoso , Autoanticorpos/imunologia , Dermatomiosite/etiologia , Dermatomiosite/imunologia , Feminino , Humanos , Tumores Neuroendócrinos/complicações , Tumores Neuroendócrinos/patologia , Tumores Neuroendócrinos/cirurgia , Neoplasias Pancreáticas/complicações , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Síndromes Paraneoplásicas/etiologia , Síndromes Paraneoplásicas/imunologia , Fatores de Transcrição/imunologia
5.
Ann Surg ; 2019 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-30973391

RESUMO

OBJECTIVE: The aim of the study was to describe county-level variation in use of surgery for stage I-II pancreatic ductal adenocarcinoma (PDAC) and the association between county surgery rates and cancer-specific survival (CSS). BACKGROUND: The degree of small geographic area variation in use of surgery for stage I-II PDAC and the association between area surgery rates and CSS remain incompletely defined. METHODS: This is a retrospective cohort study of patients aged 18 to 80 years in the 2007 to 2015 Surveillance, Epidemiology, and End Results database with stage I-II PDAC without contraindications to surgery or refusal. Multilevel models were used to characterize county-level variation in use of surgery and CSS. County-specific risk- and reliability-adjusted surgery rates and CSS rates were calculated. RESULTS: Of 18,100 patients living in 581 counties, 10,944 (60.5%) underwent surgery. Adjusted county-specific surgery rates varied 1.5-fold from 49.9% to 74.6%. Median CSS increased in a graded fashion from 13 months [interquartile range (IQR) 13-14] in counties with surgery rates of 49.9% to 56.9% to 18 months (IQR 17-19) in counties with surgery rates of 68.0% to 74.6%. Results were similar in multivariable analyses. Adjusted county 18-month CSS rates varied 1.6-fold from 32.7% to 53.7%. Adjusted county surgery and 18-month CSS rates were correlated (r = 0.54; P < 0.001) and county surgery rates explained approximately half of county-level variation in CSS. Only 18 (3.1%) counties had adjusted surgery rates of 68.0% to 74.6%, which was associated with the longest CSS. CONCLUSIONS: County-specific rates of surgery varied substantially, and patients living in areas with higher surgery rates lived longer. These data suggest that increasing use of surgery in stage I-II PDAC could lead to improvements in survival.

6.
J Natl Compr Canc Netw ; 17(3): 202-210, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30865919

RESUMO

The NCCN Guidelines for Pancreatic Adenocarcinoma discuss the diagnosis and management of adenocarcinomas of the exocrine pancreas and are intended to assist with clinical decision-making. These NCCN Guidelines Insights discuss important updates to the 2019 version of the guidelines, focusing on postoperative adjuvant treatment of patients with pancreatic cancers.

7.
Nat Med ; 25(5): 861, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30918364

RESUMO

In the version of this article initially published, the label over the bottom schematic in Fig. 1a was "pH > 5.0"; it should have been "pH < 5.0". Further, the original article misspelt the surname of Katrin P. Guillen as "Gullien". These errors have been corrected in the print, PDF and HTML versions of the article.

8.
Nat Med ; 25(4): 620-627, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30833748

RESUMO

Pancreatic ductal adenocarcinoma (PDA) was responsible for ~ 44,000 deaths in the United States in 2018 and is the epitome of a recalcitrant cancer driven by a pharmacologically intractable oncoprotein, KRAS1-4. Downstream of KRAS, the RAF→MEK→ERK signaling pathway plays a central role in pancreatic carcinogenesis5. However, paradoxically, inhibition of this pathway has provided no clinical benefit to patients with PDA6. Here we show that inhibition of KRAS→RAF→MEK→ERK signaling elicits autophagy, a process of cellular recycling that protects PDA cells from the cytotoxic effects of KRAS pathway inhibition. Mechanistically, inhibition of MEK1/2 leads to activation of the LKB1→AMPK→ULK1 signaling axis, a key regulator of autophagy. Furthermore, combined inhibition of MEK1/2 plus autophagy displays synergistic anti-proliferative effects against PDA cell lines in vitro and promotes regression of xenografted patient-derived PDA tumors in mice. The observed effect of combination trametinib plus chloroquine was not restricted to PDA as other tumors, including patient-derived xenografts (PDX) of NRAS-mutated melanoma and BRAF-mutated colorectal cancer displayed similar responses. Finally, treatment of a patient with PDA with the combination of trametinib plus hydroxychloroquine resulted in a partial, but nonetheless striking disease response. These data suggest that this combination therapy may represent a novel strategy to target RAS-driven cancers.


Assuntos
Autofagia/efeitos dos fármacos , Sistema de Sinalização das MAP Quinases/efeitos dos fármacos , Quinases de Proteína Quinase Ativadas por Mitógeno/antagonistas & inibidores , Neoplasias Pancreáticas/enzimologia , Neoplasias Pancreáticas/patologia , Inibidores de Proteínas Quinases/farmacologia , Proteínas Proto-Oncogênicas B-raf/antagonistas & inibidores , Proteínas ras/metabolismo , Animais , Antígeno CA-19-9/metabolismo , Linhagem Celular Tumoral , Cloroquina/farmacologia , Humanos , Camundongos SCID , Quinases de Proteína Quinase Ativadas por Mitógeno/metabolismo , Proteínas Proto-Oncogênicas B-raf/metabolismo , Piridonas/farmacologia , Pirimidinonas/farmacologia , Ensaios Antitumorais Modelo de Xenoenxerto
9.
Am J Clin Oncol ; 42(4): 355-362, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30844850

RESUMO

OBJECTIVES: To determine the risk and risk factors for mental illness among colorectal cancer (CRC) survivors across short-term and long-term follow-up periods. METHODS: We used the Utah Cancer Registry to identify CRC survivors diagnosed between 1997 and 2013. Mental health diagnoses were available in electronic medical records and statewide facilities data that were linked by the Utah Population Database. CRC survivors were matched to individuals from a general population cohort. The risk of developing a mental illness was compared between cohorts. The association between mental illness and mortality was also analyzed. RESULTS: In total, 8961 CRC survivors and 35,897 individuals in a general population cohort were identified. CRC survivors were at increased risk for any mental health diagnosis at 0 to 2 years (hazard ratio [HR], 3.70; 95% confidence interval [CI], 3.47-3.95), >2 to 5 years (HR, 1.23; 95% CI, 1.09-1.38), and >5 years (HR, 1.20; 95% CI, 1.07-1.36) after cancer diagnosis. CRC survivors were also at increased risk of depressive disorders specifically during the same time periods. At >5 years, CRC survivors still had an increased risk of developing many mental health diagnoses. Factors associated with increased risk of any mental health disorder among CRC survivors included colostomy and Charlson Comorbidity Index of 1+. There was an increased risk of death for CRC survivors diagnosed with any mental health disorder (HR, 2.18; 95% CI, 2.02-2.35) and depression (HR, 2.10; 95% CI, 1.92-2.28). CONCLUSIONS: CRC survivors are at increased risk for mental health disorders in the short-term and long-term. Survivors who develop mental health disorders also experience decreased survival.


Assuntos
Sobreviventes de Câncer/psicologia , Sobreviventes de Câncer/estatística & dados numéricos , Neoplasias Colorretais/complicações , Transtornos Mentais/mortalidade , Sistema de Registros/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Estudos de Coortes , Neoplasias Colorretais/psicologia , Feminino , Seguimentos , Humanos , Masculino , Transtornos Mentais/etiologia , Transtornos Mentais/psicologia , Pessoa de Meia-Idade , Prognóstico , Fatores de Risco , Taxa de Sobrevida
10.
J Gastrointest Surg ; 23(4): 659-669, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30706375

RESUMO

INTRODUCTION: Neoadjuvant therapy (NT) is the standard of care for clinical stage II-III rectal adenocarcinoma, but utilization remains suboptimal. We aimed to determine the underlying reasons for omission of local staging and NT. METHODS: We conducted a retrospective study of patients with clinical stage II-III or undocumented clinical stage/pathologic stage II-III rectal adenocarcinoma who were treated in 2010-2016 in one of nine Intermountain Healthcare hospitals. The outcomes of omission of local staging and NT were examined with multivariable models. Risk- and reliability-adjusted rates of local staging and NT were calculated for surgeons who treated ≥ 3 patients. Pathologic and long-term outcomes were examined after excluding patients who were not resected or who underwent local excision (N = 11). RESULTS: Local staging was omitted in 43/240 (17.9%) patients and NT was omitted in 41/240 (17.1%). The strongest risk factors for local staging and NT omission were upper rectal tumors and surgeons who treated ≤ 3 cases/year. Thirty-six of 41 (87.8%) cases of omitted NT had local staging omitted. Adjusted surgeon-specific local staging rates varied 1.6-fold (56.3-92.4%) and NT rates varied 2.8-fold (34.1-97.1%). Surgeon local staging and NT rates were strongly correlated (r = 0.92). NT was associated with lower rates of positive circumferential radial margins (7.9 vs. 20.0%; P = 0.02), node positivity (33.3 vs. 55.0%; P = 0.01), and local recurrences (7.6 vs. 14.9% at 5 years; P = 0.0176). CONCLUSIONS: NT omission should be understood as a consequence of surgeon failure to perform local staging in most cases. Quality improvement efforts should focus on improving utilization of local staging.

11.
J Gastrointest Surg ; 23(7): 1401-1413, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30187332

RESUMO

BACKGROUND: Single-center studies in pancreatic adenocarcinoma have suggested that preoperative chemotherapy (PCT) is associated with higher lymph node ratio (LNR) than preoperative chemoradiation (PCRT). The association of postoperative chemotherapy with overall survival (OS) in patients treated with PCT and PCRT remains unclear. Our objectives were to investigate whether (1) PCT is associated with higher LNR than PCRT and (2) postoperative chemotherapy is associated with longer OS after PCT and PCRT in LNR-stratified cohorts. METHODS: A retrospective cohort study was performed of patients with pancreatic adenocarcinoma treated with PCT or PCRT followed by resection between 2006 and 2014 in the National Cancer Database. Temporal trends were evaluated with Cuzick's test. OS was evaluated with multivariable Cox regression and inverse probability weighted (IPW) Cox regression. RESULTS: Of 4187 patients, 1993 (47.6%) received PCT. PCT rates were stable at approximately 30% in 2006-2010 (p = 0.33) but increased to 64.9% by 2014 (p < 0.001). Node positivity rates were higher after PCT than PCRT (62.7 vs. 41.8%, P < 0.001) and mean LNR was higher (0.10 [95% CI 0.096, 0.11] vs. 0.058 [95% CI 0.052, 0.063], P < 0.001). Postoperative chemotherapy was associated with longer OS in patients with LNR 0.01-0.149 after PCT by univariate analysis (median OS 34.5 vs. 26.5 months, P = 0.002), multivariable Cox regression (HR 0.64, 95% CI 0.48, 0.84), and IPW Cox regression (HR 0.72, 95% CI 0.55, 0.94). Postoperative chemotherapy was not associated with longer OS for patients who were node-negative or who had LNR ≥ 0.15 after PCT or for any patient subgroups after PCRT. CONCLUSIONS: PCT is associated with a higher LNR and higher rates of node positivity than PCRT. Postoperative chemotherapy is associated with longer OS than observation in patients with a LNR of 0.01-0.149 after PCT.

12.
Am J Surg ; 217(6): 1112-1115, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30343874

RESUMO

BACKGROUND: Although good sleep during hospitalization may promote positive outcomes, some patients and clinicians may have concerns about nursing interventions designed to reduce night-time sleep disturbances. METHODS: A randomized prospective trial of an intervention to promote sleep was conducted with stable, post-operative oncology patients. Eligible patients were randomized to receive usual nursing care overnight or sleep-promoting interventions. RESULTS: All thirty-seven surgeons in the organization agreed to let their qualified patients participate. One hundred and forty-four patients met the study criteria. Of those, 117 (81%) consented to participate, while 27 (19%) declined. The primary reason for non-enrollment was wanting to be checked on throughout the night (n = 21, 78%). There were no adverse events during the study period. Patients' perceptions of pain and nausea control among the two groups were equivalent. CONCLUSION: An intervention to decrease sleep disturbances can be safely executed in a post-operative population while maintaining adequate symptom management.


Assuntos
Segurança do Paciente , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/prevenção & controle , Privação do Sono/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos Clínicos , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , Assistência Centrada no Paciente/métodos , Assistência Centrada no Paciente/normas , Cuidados Pós-Operatórios/normas , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Qualidade da Assistência à Saúde , Privação do Sono/etiologia , Resultado do Tratamento , Adulto Jovem
13.
Ann Surg ; 269(1): 133-142, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-28700442

RESUMO

OBJECTIVE: To (1) evaluate rates of surgery for clinical stage I-II pancreatic ductal adenocarcinoma (PDAC), (2) identify predictors of not undergoing surgery, (3) quantify the degree to which patient- and hospital-level factors explain differences in hospital surgery rates, and (4) evaluate the association between adjusted hospital-specific surgery rates and overall survival (OS) of patients treated at different hospitals. BACKGROUND: Curative-intent surgery for potentially resectable PDAC is underutilized in the United States. METHODS: Retrospective cohort study of patients ≤85 years with clinical stage I-II PDAC in the 2004 to 2014 National Cancer Database. Mixed effects multivariable models were used to characterize hospital-level variation across quintiles of hospital surgery rates. Multivariable Cox proportional hazards models were used to estimate the effect of adjusted hospital surgery rates on OS. RESULTS: Of 58,553 patients without contraindications or refusal of surgery, 63.8% underwent surgery, and the rate decreased from 2299/3528 (65.2%) in 2004 to 4412/7092 (62.2%) in 2014 (P < 0.001). Adjusted hospital rates of surgery varied 6-fold (11.4%-70.9%). Patients treated at hospitals with higher rates of surgery had better unadjusted OS (median OS 10.2, 13.3, 14.2, 16.5, and 18.4 months in quintiles 1-5, respectively, P < 0.001, log-rank). Treatment at hospitals in lower surgery rate quintiles 1-3 was independently associated with mortality [Hazard ratio (HR) 1.10 (1.01, 1.21), HR 1.08 (1.02, 1.15), and HR 1.09 (1.04, 1.14) for quintiles 1-3, respectively, compared with quintile 5] after adjusting for patient factors, hospital type, and hospital volume. CONCLUSIONS: Quality improvement efforts are needed to help hospitals with low rates of surgery ensure that their patients have access to appropriate surgery.


Assuntos
Adenocarcinoma/cirurgia , Hospitais/estatística & dados numéricos , Estadiamento de Neoplasias , Pancreatectomia/estatística & dados numéricos , Neoplasias Pancreáticas/cirurgia , Adenocarcinoma/diagnóstico , Adenocarcinoma/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/epidemiologia , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
14.
J Gastrointest Surg ; 23(6): 1206-1217, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30421120

RESUMO

BACKGROUND: Guidelines recommend neoadjuvant therapy (NT) for clinical stage II-III (locally advanced) rectal adenocarcinoma, but utilization remains suboptimal. The causes of NT omission remain poorly understood. METHODS: The main outcomes in this study of patients with resected clinically non-metastatic rectal adenocarcinoma in the 2010-2015 National Cancer Database were local staging utilization in patients with non-metastatic tumors (i.e., undocumented clinical stage/pathologic stage I-III) and NT utilization for locally advanced tumors. Multivariable regression was used to examine predictors of these outcomes. Facility-specific risk- and reliability-adjusted local staging and NT rates were calculated. Positive margins and overall survival (OS) were examined as secondary outcomes. RESULTS: Local staging was omitted in 7737/43,819 (17.7%) patients with clinically non-metastatic tumors and NT was omitted in 5199/31,632 (16.4%) patients with locally advanced tumors. NT was utilized in 24,826 (91.1%) locally advanced patients who had local staging vs. 1607 (36.6%) patients who did not; 2785 (53.6%) locally advanced patients with NT omitted also had local staging omitted. Treatment at facilities with lowest quintile local staging rates was associated with NT omission (relative risk 2.41, 95% confidence interval 2.11, 2.75). Adjusted facility local staging rates varied sixfold (16.1-98.0%), facility NT rates varied twofold (43.9-95.9%), and they were correlated (r = 0.58; P < 0.001). Local staging omission and NT omission were independently associated with positive margins and decreased OS. CONCLUSIONS: Local staging omission is a common care process in over half of cases of omitted NT. These data emphasize the need for quality improvement efforts directed at providing facilities feedback about their local staging rates.

15.
Surgery ; 165(4): 751-759, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30551868

RESUMO

BACKGROUND: Utilization of multimodality therapy for clinical stage I-II pancreatic ductal adenocarcinoma is associated with meaningful prolongation of survival. Although the qualitative existence of disparities in treatment utilization by socioeconomic status and race/ethnicity is well documented, the absolute magnitudes of these disparities have not been previously quantified. METHODS: The exposures in this retrospective cohort study of the 2010-2015 National Cancer Database were a 7-value area-level socioeconomic status index and race/ethnicity. Main outcomes were surgery, chemotherapy, and multimodality therapy (surgery and chemotherapy). Adjusted rate differences were calculated after logistic regression. Models excluded intermediate variables. Overall survival was evaluated in unadjusted and adjusted analyses. RESULTS: Of 43,760 patients, 63.4% underwent surgery. Of 39,808 patients without chemotherapy contraindications, refusal, or missing data, 75.1% received chemotherapy and 51.4% received multimodality therapy. Adjusted rate differences for utilization of surgery, chemotherapy, and multimodality therapy in the lowest socioeconomic status patients were -10.0 (95% confidence interval [CI] -12.4 to -7.5), -12.7 (95% CI -16.3 to -9.1), and -15.4 (95% CI -18.8 to -12.0), respectively, versus the highest socioeconomic status patients. Adjusted rate differences for multimodality therapy utilization in non-Hispanic Black and Hispanic patients were -10.1 (95% CI -13.6 to -6.7) and -11.8 (95% CI -14.3 to -9.2), respectively, versus non-Hispanic White patients. Median overall survival increased in a graded fashion from 14.1 (95% CI 13.4-14.8) months in the lowest socioeconomic status patients to 20.2 months (95% CI 19.6-20.8) in the highest socioeconomic status patients. Survival differences were attenuated but not eliminated in multivariable Cox models. CONCLUSION: Socioeconomic status and race/ethnicity are more powerful determinants of whether patients receive treatment for clinical stage I-II pancreatic ductal adenocarcinoma than previously appreciated. Nationwide quality improvement efforts aimed at addressing these inequities are warranted.


Assuntos
Adenocarcinoma/terapia , Disparidades em Assistência à Saúde/etnologia , Neoplasias Pancreáticas/terapia , Classe Social , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Feminino , Acesso aos Serviços de Saúde , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Estudos Retrospectivos
16.
Am J Surg ; 216(6): 1135-1143, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30268417

RESUMO

OBJECTIVE: To quantify risk for CRI based on PABX use in CVAP placement for cancer patients. SUMMARY BACKGROUND DATA: Central venous access ports (CVAP) are totally implanted devices used for chemotherapy. There is a temporal risk for catheter related infection (CRI) to insertion and perioperative prophylactic antibiotics (PABX) use is a contested issue among practitioners. METHODS: Data was collected from a single center, academic oncology center. Treatment with a perioperative PABX was compared to non-treatment, to examine the incidence of 14-day CRI. Propensity scores with matched weights controlled for confounding, using 15 demographic, procedural and clinical variables. RESULTS: From 2007 to 2012, 1,091 CVAP were placed, where 59.7 % received PABX. The 14-day CRI rate was 0.82%, with 78% of those not receiving PABX. While results did not achieve statistical significance, use of PABX was associated with a 58% reduction in the odds of a 14-day CRI (OR = 0.42, 95% CI: 0.08-2.24, p = 0.31). CONCLUSION: The findings suggest a reduction in early CRI with the use of PABX. Since CRI treatment can range from a course of oral antibiotics, port removal, to hospital admission, we suggest clinicians consider these data when considering PABX in this high-risk population.


Assuntos
Antibacterianos/uso terapêutico , Antibioticoprofilaxia , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/prevenção & controle , Cateterismo Venoso Central/efeitos adversos , Cateteres de Demora/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo Venoso Central/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos , Adulto Jovem
17.
Surgery ; 164(6): 1178-1184, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30170819

RESUMO

BACKGROUND: Significant overtreatment of intraductal papillary mucinous neoplasms can be attributed to low specificity of the current International Consensus Guidelines as well as nonconformity with the guidelines. We compare the ability of the 2012 and revised 2017 intraductal papillary mucinous neoplasms International Consensus Guidelines to predict high-grade dysplasia/invasive cancer and to determine the preoperative variables that predict resection of benign or low-grade dysplasia in tertiary care centers. METHODS: Clinical, radiographic, and pathologic data for resected intraductal papillary mucinous neoplasms at 3 high-volume National Cancer Institute Cancer Centers were reviewed and the 2012 and 2017 consensus criteria were retrospectively applied. When International Consensus Guidelines were not met, clinical decision analysis was used to determine the primary indication for resection. Logistic regression identified variables associated with pathologic grade. RESULTS: Records for a total of 251 patients were reviewed, 129 of whom (52%) had low-grade dysplasia. The revised 2017 International Consensus Guidelines had high sensitivity (98.4%) and negative predicted value (96.1%), and all high-risk stigmata predicted high-grade dysplasia/invasive cancer; however, specificity remained low (14.8%). Nonconformity with International Consensus Guidelines was the most powerful predictor of low-grade dysplasia on final pathologic examination (9.5; 2.12-40.78). Independent predictors of low-grade dysplasia included age younger than 50 (2.46; 1.08-5.62), fine-needle aspiration without epithelial cells (2.6; 1.43-4.72), and normal duct diameter (3.07; 1.99-4.75). Diabetes developed in 30% of patients after resection. CONCLUSION: Management of intraductal papillary mucinous neoplasms remains clinically challenging. Low specificity of the International Consensus Guidelines and nonconformity with the guidelines continue to contribute to unnecessary pancreatic resections. Improved tools for disease classification as well as a better understanding of the natural history, biology, and rates of progression of intraductal papillary mucinous neoplasms are needed to avoid surgical overtreatment of low-grade intraductal papillary mucinous neoplasms.


Assuntos
Sobremedicalização , Neoplasias Intraductais Pancreáticas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pâncreas/patologia , Neoplasias Intraductais Pancreáticas/patologia , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Adulto Jovem
18.
ESMO Open ; 3(5): e000386, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30094072

RESUMO

Background: Oesophageal cancer (OC) survival rates have improved since the widespread adoption of neoadjuvant chemoradiation therapy (NACRT) followed by oesophagectomy (trimodality therapy). Unfortunately, the overall prognosis for patients with locally advanced disease remains poor. In this study, we sought to assess the effect of adjuvant chemotherapy (AC) in patients treated with trimodality therapy. Methods: Using the National Cancer Database we retrospectively identified 6785 patients with locally advanced (cT1b-T4a, N0-N+, M0) OC who were treated with trimodality therapy from 2006 to 2014. Patients were separated based on receipt of AC (n=463), as well as clinical and pathological lymph node involvement. Overall survival (OS) between groups was compared using the Kaplan-Meier method and Cox proportional hazard modelling. Results: Based on multivariate analysis, AC was associated with a statistically significantly reduced risk of death (HR 0.77, p<0.001). Subgroup analysis revealed that AC was associated with reduced risk of death compared with NACRT alone in the cN+/pN0 (median OS 64 vs 43 months; p=0.019) and the cN+/pN+ (median OS 27 vs 22 months; p=0.010) groups, but not in the cN0/pN0 (median OS 48 vs 49 months; p=0.253) or cN0/pN+ (median OS 31 vs 24 months; p=0.077) groups. Conclusion: AC following trimodality therapy may improve survival in patients with locally advanced OC. Patients who undergo lymph node downstaging may be the most likely to benefit from AC. Prospective studies are needed to confirm this finding.

20.
ESMO Open ; 3(1): e000282, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29387477

RESUMO

Background: Surgical resection remains the best chance at long-term survival in pancreatic cancer, though margin-positive resections are associated with diminished survival. We examined the effect of margin-positive resection on survival, as well as the role and timing of additional therapies through the National Cancer Database (NCDB). Patients and methods: Patients with stage IIA-III pancreatic adenocarcinoma diagnosed from 2004 to 2013 were identified in NCDB. Survival was compared using univariate and multivariate Cox proportional hazards modelling for patients who underwent surgery with negative (R0), microscopically positive (R1) and macroscopically positive (R2) margins or non-surgical treatment. We further analysed patients by margin status, timing of additional therapy (neoadjuvant therapy (NAT) vs adjuvant therapy (AT) vs none) and clinical stage. Results: We analysed 44 852 patients. Median survival (MS) for patients who did not undergo surgery was 10.3 months, compared with 19.7 months for R0 (P<0.001), 14.3 months for R1 (P<0.001) and 9.8 months (P=0.07) for R2 resections. NAT (MS 23.2 months) was associated with improved survival compared with AT (MS 21.5 months) in negative-margin patients and equivalent (MS 17.6 months) to AT (MS 16.8 months) in positive-margin patients. Survival for stage III NAT positive-margin patients (MS 19.8 months) was equivalent to AT after negative margins (MS 18.4 months, P=1.00). Improved R0 rates were seen with NAT (88% vs 81%, P<0.001), especially in stage III patients (85% vs 59%, P<0.001). Conclusion: R1 resections portend poorer survival than R0 but do not negate the benefit of surgery when additional therapy is given. NAT was associated with improved R0 rates and improved survival for stage III positive-margin patients.

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