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1.
HPB (Oxford) ; 2022 Apr 14.
Artigo em Inglês | MEDLINE | ID: mdl-35504832

RESUMO

BACKGROUND: We analyzed the outcomes of patients with hepatic epithelioid hemangioendothelioma (HEHE) in the United States after stratification by their most definitive treatment. METHODS: The National Cancer Data Base was used to identify patients with HEHE between 2004 and 2018. Patients were divided in four treatment groups: no surgical therapy, ablation, liver resection or liver transplantation. Demographics and clinical characteristics were compared, and Kaplan Meier functions and Cox-regression were used for unadjusted and adjusted survival analyses. RESULTS: Among a total of 334 patients, 218 (65.2%) were managed non-surgically, 74 (22.1%) underwent hepatic resections, 35 (10.4%) underwent liver transplantation and 7 (2.1%) underwent ablations. The overall median survival was 111 months (95%CI 73-149) after liver transplantation, 69 months (95%CI 45-92) after hepatic resection, 38 months (95%CI 0-78) after ablation and 80 months (95%CI 70-90) for patients managed by watchful waiting (P < 0.001). After adjustment, patients who underwent liver transplantation were found to have a better survival when compared to other therapies (Hazard Ratio: 0.61, 95% Confidence Interval: 0.38-0.97, p = 0.035). CONCLUSIONS: This study reports the outcomes of the largest cohort of patients with HEHE. The longest survival was observed after liver transplantation, followed by non-surgical management and hepatic resection. Because of selection bias, future studies to better characterize what criteria should be used for the selection of treatment modalities for HEHE are urgently needed.

3.
Am Surg ; 88(1): 83-92, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33369487

RESUMO

BACKGROUND: Hepatocellular carcinoma (HCC) is a leading cause of cancer mortality worldwide. Liver resections and transplantations have increasingly become feasible options for potential cure. These complex surgeries are inherently associated with increased rates of readmission. In the meanwhile, hospital readmission rates are rapidly becoming an important quality of care metric. Therefore, it is very important to understand the effect of 30-day readmission on mortality and the factors associated with increased 30- and 90-day mortality rates. METHODS: This is a retrospective cohort study utilizing data from the National Cancer Database. Patients included were 18 years or older who underwent liver resection or liver transplantation for HCC between 2003 and 2011. Our primary outcomes of interest were 30- and 90-day mortality rates. Our primary independent variable of interest was 30-day readmission. RESULTS: 16 658 patients underwent either a liver resection or transplantation for HCC between 2003 and 2011. For patients with liver transplantations, increased readmission rates were associated with lower risks of 30-day mortality (P = .012) but a trend toward higher 90-day mortality (P = .057). Patients who underwent liver resection for HCC also demonstrated increased readmission rates to be associated with lower risk of 30-day mortality (P = .014) but higher 90-day mortality (P ≤ .001). CONCLUSION: This is the only study to utilize a national database to investigate the association between readmission rates and mortality rates of both liver transplantations and resections for patients with HCC. We demonstrate 30-day readmission to show no increase in 30-day mortality, but rather higher 90-day mortality.


Assuntos
Carcinoma Hepatocelular/mortalidade , Neoplasias Hepáticas/mortalidade , Transplante de Fígado/mortalidade , Readmissão do Paciente/estatística & dados numéricos , Carcinoma Hepatocelular/cirurgia , Bases de Dados Factuais , Feminino , Hepatectomia/mortalidade , Hepatectomia/estatística & dados numéricos , Humanos , Neoplasias Hepáticas/cirurgia , Transplante de Fígado/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Estudos Retrospectivos , Fatores de Tempo , Estados Unidos/epidemiologia
4.
Can J Gastroenterol Hepatol ; 2021: 5212953, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34888264

RESUMO

Introduction: Hepatocellular carcinoma (HCC) accounts for approximately 90% of primary liver malignancies and is currently the fourth most common cause of cancer-related death worldwide. Due to varying underlying etiologies, the prognosis of HCC differs greatly among patients. It is important to develop ways to help stratify patients upon initial diagnosis to provide optimal treatment modalities and follow-up plans. The current study uses Artificial Neural Network (ANN) and Classification Tree Analysis (CTA) to create a gene signature score that can help predict survival in patients with HCC. Methods: The Cancer Genome Atlas (TCGA-LIHC) was analyzed for differentially expressed genes. Clinicopathological data were obtained from cBioPortal. ANN analysis of the 75 most significant genes predicting disease-free survival (DFS) was performed. Next, CTA results were used for creation of the scoring system. Cox regression was performed to identify the prognostic value of the scoring system. Results: 363 patients diagnosed with HCC were analyzed in this study. ANN provided 15 genes with normalized importance >50%. CTA resulted in a set of three genes (NRM, STAG3, and SNHG20). Patients were then divided in to 4 groups based on the CTA tree cutoff values. The Kaplan-Meier analysis showed significantly reduced DFS in groups 1, 2, and 3 (median DFS: 29.7 months, 16.1 months, and 11.7 months, p < 0.01) compared to group 0 (median not reached). Similar results were observed when overall survival (OS) was analyzed. On multivariate Cox regression, higher scores were associated with significantly shorter DFS (1 point: HR 2.57 (1.38-4.80), 2 points: 3.91 (2.11-7.24), and 3 points: 5.09 (2.70-9.58), p < 0.01). Conclusion: Long-term outcomes of patients with HCC can be predicted using a simplified scoring system based on tumor mRNA gene expression levels. This tool could assist clinicians and researchers in identifying patients at increased risks for recurrence to tailor specific treatment and follow-up strategies for individual patients.


Assuntos
Carcinoma Hepatocelular , Neoplasias Hepáticas , Biomarcadores Tumorais/genética , Carcinoma Hepatocelular/diagnóstico , Proteínas de Ciclo Celular , Estudos de Coortes , Humanos , Estimativa de Kaplan-Meier , Aprendizado de Máquina , Prognóstico , Fatores de Risco
5.
Cancers (Basel) ; 13(23)2021 Dec 06.
Artigo em Inglês | MEDLINE | ID: mdl-34885240

RESUMO

Metastasis is the leading cause of cancer related morbidity and mortality. The metastatic process involves several identifiable biological stages, including tumor cell dissemination, intravasation, and the extravasation of circulating cancer cells to facilitate colonization at a distant site. Immune cell infiltration and inflammation within the tumor microenvironment coincide with tumor progression and metastatic spread and are thought to be the key mediators of this complex process. Amongst many infiltrating cells, neutrophils have recently emerged as an important player in fueling tumor progression, both in animal models and cancer patients. The production of Neutrophil Extracellular Traps (NETs) is particularly important in the pathogenesis of the metastatic cascade. NETs are composed of web-like DNA structures with entangled proteins that are released in response to inflammatory cues in the environment. NETs play an important role in driving tumor progression both in experimental and clinical models. In this review, we aim to summarize the current advances in understanding the role of NETs in cancer, with a specific focus on their role in promoting premetastatic niche formation, interaction with circulating cancer cells, and in epithelial to mesenchymal transition during cancer metastasis. We will furthermore discuss the possible role and different treatment options for targeting NETs to prevent tumor progression.

6.
Curr Pathobiol Rep ; : 1-11, 2021 Dec 08.
Artigo em Inglês | MEDLINE | ID: mdl-34900401

RESUMO

PURPOSE OF REVIEW: COVID-19 has rapidly evolved into a global pandemic infecting over two hundred and forty-four million individuals to date. In addition to the respiratory sequelae and systemic infection that ensues, an alarming number of micro and macrovascular thrombotic complications have been observed. This review examines the current understanding of COVID-19-associated thrombotic complications, potential mechanisms, and pathobiological basis for thromboses development. RECENT FINDINGS: The endothelium plays a major role in the process due to direct and indirect injury. The immune system also contributes to a pro-thrombotic environment with immune cell dysregulation leading to excessive formation of cytokines, also called cytokine storm, and an eventual promotion of a hypercoagulable environment, known as immunothrombosis. Additionally, neutrophils play an important role by forming neutrophil extracellular traps, which are shown to be pro-thrombotic and further enhanced in COVID-19 patients. A disruption of the fibrinolysis system has also been observed. SUMMARY: Multiple pathways likely contribute synergistically to form a pro-thrombotic milieu. A better understanding of these factors and the complex interplay between them will lead to the improvement of diagnostic and therapeutic interventions.

7.
Front Immunol ; 12: 785222, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34899751

RESUMO

While neutrophil extracellular traps (NETs) are important for directly promoting cancer growth, little is known about their impact on immune cells within the tumor microenvironment (TME). We hypothesize that NETs can directly interact with infiltrating T cells to promote an immunosuppressive TME. Herein, to induce a NET-rich TME, we performed liver Ischemia/Reperfusion (I/R) in an established cancer metastasis model or directly injected NETs in subcutaneous tumors. In this NET-rich TME, the majority of CD4+ and CD8+ tumor infiltrating lymphocytes expressed multiple inhibitory receptors, in addition these cells showed a functional and metabolic exhausted phenotype. Targeting of NETs in vivo by treating mice with DNAse lead to decreased tumor growth, decreased NET formation and higher levels of functioning T cells. In vitro, NETs contained the immunosuppressive ligand PD-L1 responsible for T cell exhaustion and dysfunction; an effect abrogated by using PD-L1 KO NETs or culturing NETs with PD-1 KO T cells. Furthermore, we found elevated levels of sPDL-1 and MPO-DNA, a NET marker, in the serum of patients undergoing surgery for colorectal liver metastases resection. Neutrophils isolated from patients after surgery were primed to form NETs and induced exhaustion and dysfunction of human CD4+ and CD8+ T cells. We next targeted PD-L1 in vivo by injecting a blocking antibody during liver I/R. A single dose of anti-PD-L1 during surgery lead to diminished tumors at 3 weeks and functional T cells in the TME. Our data thus reveal that NETs have the capability of suppressing T cell responses through metabolic and functional exhaustion and thereby promote tumor growth. Furthermore, targeting of PD-L1 containing NETs at time of surgery with DNAse or anti-PD-L1 lead to diminished tumor growth, which represents a novel and viable strategy for sustaining immune competence within the TME.


Assuntos
Adenocarcinoma/imunologia , Neoplasias Colorretais/imunologia , Armadilhas Extracelulares/imunologia , Neoplasias Hepáticas/imunologia , Linfócitos do Interstício Tumoral/imunologia , Neutrófilos/imunologia , Linfócitos T/imunologia , Evasão Tumoral , Microambiente Tumoral/imunologia , Adenocarcinoma/genética , Adenocarcinoma/metabolismo , Adenocarcinoma/secundário , Animais , Antígeno B7-H1/genética , Antígeno B7-H1/metabolismo , Linhagem Celular Tumoral , Neoplasias Colorretais/genética , Neoplasias Colorretais/metabolismo , Neoplasias Colorretais/patologia , Armadilhas Extracelulares/metabolismo , Humanos , Neoplasias Hepáticas/genética , Neoplasias Hepáticas/metabolismo , Neoplasias Hepáticas/secundário , Linfócitos do Interstício Tumoral/metabolismo , Masculino , Camundongos Endogâmicos C57BL , Camundongos Knockout , Neutrófilos/metabolismo , Fenótipo , Receptor de Morte Celular Programada 1/genética , Receptor de Morte Celular Programada 1/metabolismo , Linfócitos T/metabolismo
8.
Am Surg ; 87(11): 1766-1774, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34766506

RESUMO

INTRODUCTION: Resection of colorectal liver metastases provides the best chance for survival in patients with Stage IV colorectal cancer; however, hepatic recurrence is frequent and the main cause of death. Multiple epidemiological studies have documented an association between metformin and anti-neoplastic effects in a variety of cancers. Given the vast literature, we evaluated the incidence on recurrence and survival of patients on metformin who undergo surgery for colorectal liver metastasis (CRLM). METHODS: We selected 270 consecutive patients with known CRLM who underwent hepatic metastases resection at our institution between January 1st 2012 and December 31st 2019. Patients were divided based on their use of metformin (n = 62) or no metformin (n = 208). Adjusted analysis of recurrence-free (RFS) and overall survival (OS) was performed. RESULTS: Patients on metformin had significantly longer RFS (HR: .44, 95% CI: .26-.75, P < .002; Median RFS: 49 months vs 33 months) and OS (HR .60, 95% CI .31-.97, P < .048, Median OS: 72 months vs 60 months). Additional factors associated with shorter RFS on univariate analysis included the following: CEA > 200 ng/ml (HR: 2.23, 95% CI 1.21-4.03, P < .010), positive liver margin (HR: 3.70, 95% CI 2.27-6.03, P < .001), and >1 tumor (HR: 1.98, 95% CI 1.26-3.09, P < .003). Liver margin remained a significant factor for predicting shorter OS (HR: 4.99, 95% CI 2.49-10.0, P < .001). CONCLUSION: In this study, we found that patients with CRLM on metformin have prolonged RFS and OS postliver resection. Further prospective randomized trials need to be carried out to evaluate the anti-neoplastic effect of metformin in diabetic and non-diabetic cancer patients.


Assuntos
Neoplasias Colorretais/cirurgia , Hepatectomia/mortalidade , Hipoglicemiantes/efeitos adversos , Neoplasias Hepáticas/secundário , Metformina/efeitos adversos , Recidiva Local de Neoplasia/epidemiologia , Idoso , Estudos de Casos e Controles , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/patologia , Intervalo Livre de Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Fatores de Risco , Análise de Sobrevida
10.
J Surg Oncol ; 124(3): 324-333, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33939838

RESUMO

BACKGROUND: Medicaid expansion under the Affordable Care Act has improved access to screening and treatment for certain cancers. It is unclear how this policy has affected the diagnosis and management of pancreatic cancer. METHODS: Using a quasi-experimental difference-in-differences (DID) approach, we analyzed Medicaid and uninsured patients in the National Cancer Data Base during two time periods: pre-expansion (2011-2012) and postexpansion (2015-2016). We investigated changes in cancer staging, treatment decisions, and surgical outcomes. RESULTS: In this national cohort, pancreatic cancer patients in expansion states had increased Medicaid coverage relative to those in nonexpansion states (DID = 17.49, p < 0.01). Medicaid expansion also led to an increase in early-stage diagnoses (Stage I/II, DID = 4.71, p = 0.03), higher comorbidity scores among surgical patients (Charlson/Deyo score 0: DID = -13.69, p = 0.02), a trend toward more neoadjuvant radiation (DID = 6.15, p = 0.06), and more positive margins (DID = 11.69, p = 0.02). There were no differences in rates of surgery, postoperative outcomes, or overall survival. CONCLUSION: Medicaid expansion was associated with improved insurance coverage and earlier stage diagnoses for Medicaid and uninsured pancreatic cancer patients, but similar surgical outcomes and overall survival. These findings highlight both the benefits of Medicaid expansion and the potential limitations of policy change to improve outcomes for such an aggressive malignancy.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Neoplasias Pancreáticas/economia , Neoplasias Pancreáticas/mortalidade , Adulto , Idoso , Estudos de Coortes , Humanos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/cirurgia , Patient Protection and Affordable Care Act , Sistema de Registros , Estudos Retrospectivos , Estados Unidos/epidemiologia
11.
Pancreas ; 50(3): 386-392, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33835970

RESUMO

OBJECTIVES: The objective of this study was to create a composite measure, optimal oncologic surgery (OOS), for patients undergoing distal pancreatectomy for pancreatic adenocarcinoma and identify factors associated with OOS. METHODS: Adult patients undergoing distal pancreatectomy were identified from the National Cancer Database between 2010 and 2016. Patients were stratified based on receipt of OOS. Criteria for OOS included 90-day survival, no 30-day readmission, length of stay ≤7 days, negative resection margins, ≥12 lymph nodes harvested, and receipt of chemotherapy. Multivariate logistic regression was performed to identify predictors of OOS. Survival curves and a Cox proportional hazards model were created to compare survival and identify risk factors for mortality. RESULTS: Three thousand five hundred forty-six patients were identified. The rate of OOS was 22.3%. Diagnosis after 2012, treatment at an academic medical center, and a minimally invasive surgical approach (MIS) were associated with OOS. Survival was superior for patients undergoing OOS. Decreasing age at diagnosis, fewer comorbidities, surgery at an academic medical center, MIS, and lower pathologic stage were also associated with improved survival on multivariate analysis. CONCLUSIONS: Rates of OOS for distal pancreatectomy are low. Time trends show increasing rates of OOS that may be related to increasing MIS, adjuvant chemotherapy, and referrals to academic medical centers.


Assuntos
Adenocarcinoma/cirurgia , Bases de Dados Factuais/estatística & dados numéricos , Pancreatectomia/estatística & dados numéricos , Neoplasias Pancreáticas/cirurgia , Idoso , Feminino , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Análise Multivariada , Avaliação de Resultados em Cuidados de Saúde/métodos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Modelos de Riscos Proporcionais , Estados Unidos
12.
J Surg Res ; 264: 279-286, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33839343

RESUMO

BACKGROUND: Safety-net hospitals serve a vital role in society by providing care for vulnerable populations. Existing data regarding oncologic outcomes of patients with colon cancer treated at safety-net hospitals are limited and variable. The objective of this study was to delineate disparities in treatment and outcomes for patients with colon cancer treated at safety-net hospitals. METHODS: This retrospective cohort study identified 802,304 adult patients with colon adenocarcinoma from the National Cancer Database between 2004-2016. Patients were stratified according to safety-net burden of the treating hospital as previously described. Patient, tumor, facility, and treatment characteristics were compared between groups as were operative and short-term outcomes. Cox proportional hazards regression was utilized to compare overall survival between patients treated at high, medium, and low burden hospitals. RESULTS: Patients treated at safety-net hospitals were demographically distinct and presented with more advanced disease. They were also less likely to receive surgery, adjuvant chemotherapy, negative resection margins, adequate lymphadenectomy, or a minimally invasive operative approach. On multivariate analysis adjusting for patient and tumor characteristics, survival was inferior for patients at safety-net hospitals, even for those with stage 0 (in situ) disease. CONCLUSION: This analysis revealed inferior survival for patients with colon cancer treated at safety-net hospitals, including those without invasive cancer. These findings suggest that unmeasured population differences may confound analyses and affect survival more than provider or treatment disparities.


Assuntos
Adenocarcinoma/mortalidade , Neoplasias do Colo/mortalidade , Disparidades em Assistência à Saúde/estatística & dados numéricos , Provedores de Redes de Segurança/estatística & dados numéricos , Populações Vulneráveis/estatística & dados numéricos , Adenocarcinoma/diagnóstico , Adenocarcinoma/economia , Adenocarcinoma/terapia , Idoso , Idoso de 80 Anos ou mais , Quimioterapia Adjuvante/economia , Quimioterapia Adjuvante/estatística & dados numéricos , Colectomia/economia , Colectomia/estatística & dados numéricos , Colo/patologia , Colo/cirurgia , Neoplasias do Colo/diagnóstico , Neoplasias do Colo/economia , Neoplasias do Colo/terapia , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Disparidades em Assistência à Saúde/economia , Humanos , Masculino , Margens de Excisão , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Retrospectivos , Medição de Risco/estatística & dados numéricos , Provedores de Redes de Segurança/economia , Análise de Sobrevida , Estados Unidos/epidemiologia
13.
Am Surg ; : 3134820988810, 2021 Jan 31.
Artigo em Inglês | MEDLINE | ID: mdl-33517684

RESUMO

BACKGROUND: Colorectal adenocarcinoma is a leading cause of cancer mortality worldwide, often requiring patients to undergo anatomy-altering surgical interventions leading to increased postoperative readmission. Hospital readmission rates have been correlated with increased mortality. Therefore, it is important to understand the association between 30-day readmission rates and mortality as well as the factors associated with increased readmission rates. STUDY DESIGN: This is a retrospective review utilizing data from the National Cancer Database. Our primary outcomes of interest were 30- and 90-day mortality rates. Our primary independent variable of interest was 30-day readmission. RESULTS: Between 2010 and 2016, 207 299 patients underwent surgery for rectal cancer and 754 895 for colon cancer. The readmission rates within 30 days of discharge were 5.4% and 5.5% for patients after surgery for rectal or colon cancer, respectively. 30-day readmission was not associated with 30-day mortality, but it was independently associated with increased 90-day mortality and inferior long-term survival for both cohorts (P = .001). Independent risk factors significantly associated with increased readmission included race, non-private insurance, and low income. CONCLUSION: This study provides a large, up-to-date, and comprehensive analysis of readmission rates for colon and rectal cancers. We demonstrate that socioeconomic factors are associated with increased 30-day readmission. 30-day readmission is also independently associated with increased 90-day mortality as well as lower overall survival rates. Our study supports the need for implementation of programs that support patients of lower socioeconomic status undergoing surgery to further decrease readmission rates and mortality.

14.
Hepatology ; 73(6): 2494-2509, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-32924145

RESUMO

BACKGROUND AND AIMS: Liver ischemia/reperfusion injury (IRI) induces local and systemic inflammation in which neutrophil extracellular traps (NETs) are major drivers. IRI markedly augments metastatic growth, which is consistent with the notion that the liver IRI can serve as a premetastatic niche. Exercise training (ExT) confers a sustainable protection, reducing IRI in some animal models, and has been associated with improved survival in patients with cancer; however, the impact of ExT on liver IRI or development of hepatic metastases is unknown. APPROACH AND RESULTS: Mice were randomized into exercise (ExT) and sedentary groups before liver IRI and tumor injection. Computerized dynamic network analysis of 20 inflammatory mediators was used to dissect the sequence of mediator interactions after ischemia/reperfusion (I/R) that induce injury. ExT mice showed a significant decrease in hepatic IRI and tissue necrosis. This coincided with disassembly of complex networks among inflammatory mediators seen in sedentary mice. Neutrophil infiltration and NET formation were decreased in the ExT group, which suppressed the expression of liver endothelial cell adhesion molecules. Concurrently, ExT mice revealed a distinct population of infiltrating macrophages expressing M2 phenotypic genes. In a metastatic model, fewer metastases were present 3 weeks after I/R in the ExT mice, a finding that correlated with a marked increase in tumor-suppressing T cells within the tumor microenvironment. CONCLUSIONS: ExT preconditioning mitigates the inflammatory response to liver IRI, protecting the liver from injury and metastases. In light of these findings, potential may exist for the reduction of liver premetastatic niches induced by liver IRI through the use of ExT as a nonpharmacologic therapy before curative surgical approaches.


Assuntos
Armadilhas Extracelulares/imunologia , Inflamação , Hepatopatias , Metástase Neoplásica , Infiltração de Neutrófilos/imunologia , Condicionamento Físico Animal/métodos , Traumatismo por Reperfusão , Animais , Proliferação de Células , Modelos Animais de Doenças , Imunidade , Inflamação/etiologia , Inflamação/imunologia , Inflamação/terapia , Hepatopatias/imunologia , Hepatopatias/patologia , Hepatopatias/terapia , Camundongos , Metástase Neoplásica/imunologia , Metástase Neoplásica/terapia , Fatores de Proteção , Traumatismo por Reperfusão/imunologia , Traumatismo por Reperfusão/patologia , Traumatismo por Reperfusão/terapia , Resultado do Tratamento
15.
HPB (Oxford) ; 23(2): 309-320, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32811764

RESUMO

BACKGROUND: The incidence of primary hepatic malignancies including Hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC) is on the rise. (i) Surgery remains the mainstay of potential curative treatment, however the vast majority of patients will recur and not be amenable to curative therapy. (ii) Inflammation has been associated with poor prognosis, however there is no preoperative marker that can predict recurrence-free- or overall survival. Our aim is to correlate inflammation measured as neutrophil extracellular traps (NETs) with survival. METHODS: A retrospective analysis was performed using sera/tissue from patients with hepatic malignancies. NET levels were measured in the serum (MPO-DNA) or tumor (Cit-H3). Log rank analysis for RFS/OS was performed. RESULTS: Cancer patients had higher pre-surgery MPO-DNA levels compared to healthy individuals (healthy vs cancer: 2.6 ± 1.0 ng/ml vs 34.7 ± 2.13 ng/ml; p < 0.0001). High pre-surgery serum NET levels were associated with shorter RFS/OS compared to those with low levels (RFS-HCC: HR: 2.91, 95% CI: 1.61-5.26, p < 0.0001, RFS-CC: HR: 3.22, 95% CI: 1.33-7.77 p < 0.0093). High Cit-H3 tumor levels similarly predicted shorter RFS/OS. CONCLUSION: The current study shows a correlation between pre-operative NET levels and survival. Studying NET formation as a biomarker pre-surgery can help identify patients that could benefit from closer follow-up due to higher risk for recurrence.


Assuntos
Neoplasias dos Ductos Biliares , Carcinoma Hepatocelular , Armadilhas Extracelulares , Neoplasias Hepáticas , Neoplasias dos Ductos Biliares/cirurgia , Ductos Biliares Intra-Hepáticos , Biomarcadores , Carcinoma Hepatocelular/cirurgia , Humanos , Neoplasias Hepáticas/cirurgia , Recidiva Local de Neoplasia , Prognóstico , Estudos Retrospectivos
16.
Surg Endosc ; 35(5): 2248-2254, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-32440928

RESUMO

BACKGROUND: Emerging data from multi-institutional and national databases suggest that robotic pancreaticoduodenectomy is safe and feasible for pancreatic adenocarcinoma. Nevertheless, there are limited reports evaluating its safety and oncologic efficacy following neoadjuvant chemotherapy. METHOD: This is a retrospective study from the 2010-2016 National Cancer Database comparing the postoperative, pathological and long-term oncologic outcomes between robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) for pancreatic adenocarcinoma following neoadjuvant chemotherapy. RESULTS: We identified 155 (5%) RPD and 3329 (95%) OPD following neoadjuvant chemotherapy. The use of the robot increased from 3 cases in 2010 to 50 cases in 2016. RPD patients were more likely to receive adjuvant chemotherapy and to be treated at academic centers. After adjustment, RPD was associated with a higher proportion of adequate lymphadenectomy, receipt of adjuvant chemotherapy, decreased rate of prolonged length of stay, and similar 90-day mortality. There was no difference in median overall survival between RPD and OPD (25.6 months vs. 27.5 months, Log Rank p = 0.879). The 1-, 3- and 5-year overall survival rates for RPD were 83%, 36% and 22% and for OPD were 86%, 38% and 22%. After adjustment, the use of robotic surgery was associated with similar overall survival compared to the open approach (HR 1.011, 95% confidence interval (CI) 0.776-1.316). CONCLUSIONS: Following neoadjuvant chemotherapy, RPD is associated with similar short- and long-term mortality with the advantage of shorter length of stay, higher proportion of adequate lymphadenectomy and receipt of adjuvant chemotherapy.


Assuntos
Adenocarcinoma/cirurgia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/mortalidade , Idoso , Feminino , Humanos , Tempo de Internação , Excisão de Linfonodo , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Neoplasias Pancreáticas/tratamento farmacológico , Neoplasias Pancreáticas/mortalidade , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/estatística & dados numéricos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Taxa de Sobrevida , Resultado do Tratamento , Estados Unidos
17.
J Gastrointest Surg ; 25(4): 1093-1104, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-32410172

RESUMO

Understanding liver anatomy and anatomic hilar vascular variants is important for the practicing surgeon. This knowledge is essential for cholecystectomy, hepatobiliary, pancreatic, and upper GI surgery. The attached quiz is intended to provide a liver anatomy teaching guide for surgical oncology, transplant, and HPB fellows; general surgery residents; and medical students, as well as a refresher for general and GI surgeons. It is hoped that dissemination will serve as a valuable teaching tool for surgeons at all levels of training.


Assuntos
Cirurgia Geral , Internato e Residência , Cirurgiões , Competência Clínica , Cirurgia Geral/educação , Humanos , Fígado/diagnóstico por imagem
18.
Surg Endosc ; 35(2): 524-535, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32989544

RESUMO

BACKGROUND: The implementation of the laparoscopic and robotic approaches for major hepatectomy (LMH and RMH) was slower than that for minor hepatectomy, but has significantly increased over the past years. The role or advantages of RMH remains controversial, and we aimed to compare the peri-/postoperative outcomes of LMH versus RMH. METHODS: A systematic literature review was conducted using the MEDLINE and Cochrane Library databases according to the PRISMA guidelines (end-of-search date: March 16th, 2020). Only comparative studies (LMH vs. RMH) reporting on outcomes of interest were included. Meta-analysis was performed using the random-effects model when substantial heterogeneity was encountered; otherwise, the fixed-effects model was implemented. Quality of evidence assessment was performed using the Newcastle-Ottawa Scale. RESULTS: Seven retrospective cohort studies comparing LMH (n = 300) versus RMH (n = 225) were identified. No significant difference was observed between LMH and RMH regarding overall complications [odds ratio (OR) 1.42, 95% confidence interval (CI) 0.90-2.23; p = 0.13], severe complications (Clavien-Dindo grade ≥ 3) [risk difference (RD) 0.01, 95% CI - 0.03 to 0.05; p = 0.72], and overall mortality (RD 0.00, 95% CI - 0.02 to 0.03; p = 0.73). The two approaches were also equivalent regarding conversion to open hepatectomy (RD 0.03, 95% CI - 0.01 to 0.08; p = 0.15), margin-positive resection (OR 1.34, 95% CI 0.51-3.52; p = 0.55), and transfusion rate (RD - 0.03, 95% CI - 0.16 to 0.11; p = 0.67). No significant difference was observed for LMH versus RMH regarding blood loss [standardized mean difference (SMD) 0.27, 95% CI - 0.24 to 0.77; p = 0.30), operative time (SMD - 0.08, 95% CI - 0.51 to 0.34; p = 0.70), and length of stay (SMD 0.13, 95% CI - 0.58 to 0.84; p = 0.72). CONCLUSION: LMH and RMH have equivalent peri-/postoperative outcomes when performed in select patients and high-volume centers.


Assuntos
Hepatectomia/métodos , Laparoscopia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
19.
Ann Surg ; 274(6): 1025-1031, 2021 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31850985

RESUMO

PURPOSE: Time to surgery (TTS) is of concern to patients diagnosed with cancer and their physicians. Controversy surrounds the impact of TTS on colon cancer survival. There are limited national data evaluating the association; thus, our aim was to estimate the overall survival (OS) impact from increasing TTS for patients with colon cancer. METHODS: Using the National Cancer Data Base (NCDB), we assessed OS as a function of time between diagnosis and surgery by evaluating intervals encompassing <7, 7 to 30, 31 to 60, 61 to 90, 91 to 120, and 121 to 180 days in length. All patients were diagnosed with nonmetastatic colon cancer and underwent surgery as initial treatment. Our main outcome was OS as a function of time between diagnosis and surgery, after adjusting for patient, demographic, and tumor-related factors using Cox regression models and propensity score-based weighting. RESULTS: A total of 514,103 patients diagnosed between 1998 and 2012 were included. Individuals having <7, 7 to 30, 31 to 60, 61 to 90, 91 to 120, and 121 to 180 days between diagnosis and surgery comprised 35.4%, 45%, 15.1%, 2.9%, 1%, and 0.6% of the patients, respectively. There was a steady increase in median TTS across the years. On multivariable analysis, TTS >30 days or within the first week independently increased mortality risk. There was a significant increase in mortality with TTS 31 to 60 [hazard ratio (HR) 1.13], 61 to 90 (HR 1.49), <7 (HR 1.56), 91 to 120 (HR 2.28), and 121 to 180 (HR 2.46) compared to surgery performed 7 to 30 days after diagnosis (P < 0.001). CONCLUSIONS: TTS is independently associated with OS and this represents a public health issue that should be addressed at a national level. Although time is required for evaluation before surgery, efforts to reduce TTS should be pursued.


Assuntos
Neoplasias do Colo/mortalidade , Neoplasias do Colo/cirurgia , Tempo para o Tratamento , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Estados Unidos/epidemiologia
20.
J Am Coll Surg ; 232(2): 146-156.e1, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33242599

RESUMO

BACKGROUND: The Affordable Care Act facilitated improved insurance coverage for states that expanded Medicaid coverage, but the impact on cancer outcomes is unclear. This study compared changes in the diagnosis and management of colon cancer in states that did and did not participate in Medicaid expansion. STUDY DESIGN: Using a quasi-experimental difference-in-differences (DID) approach, we analyzed Medicaid and uninsured patients in the National Cancer Data Base during 2 time periods: pre (2011-2012) and post expansion (2015-2016). Patients in non-expansion states were compared with those in January 2014 expansion states with regard to changes in patient and facility characteristics, cancer staging, treatment decisions, and surgical outcomes. RESULTS: Along with increased Medicaid coverage (DID = 20.27; p < 0.001), patients in expansion states had an increase in stage I diagnoses (DID = 2.97; p = 0.035), distance traveled (miles, DID = 6.67; p = 0.005), and treatment at integrated network programs (DID = 2.67; p = 0.045). More early-stage patients were treated within 30 days (DID = 7.24; p = 0.035) and more stage IV patients received palliative care (DID = 5.01; p = 0.048). Among surgical patients, Medicaid expansion correlated with fewer urgent cases (< 7 days, DID = -5.88; p = 0.008) and more minimally invasive surgery (DID = 5.00; p = 0.022). There were no observed differences in postoperative outcomes or adjuvant chemotherapy. CONCLUSIONS: Medicaid expansion correlated with earlier diagnosis, enhanced access, and improved surgical care for colon cancer patients. These findings highlight the importance of improving health insurance coverage and can help guide future policy efforts.


Assuntos
Organizações de Assistência Responsáveis/organização & administração , Neoplasias do Colo/diagnóstico , Neoplasias do Colo/cirurgia , Medicaid/organização & administração , Adulto , Quimioterapia Adjuvante , Neoplasias do Colo/patologia , Detecção Precoce de Câncer , Feminino , Política de Saúde , Acesso aos Serviços de Saúde , Humanos , Masculino , Pessoas sem Cobertura de Seguro de Saúde , Pessoa de Meia-Idade , Metástase Neoplásica , Estadiamento de Neoplasias , Cuidados Paliativos , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos
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