RESUMO
BACKGROUND: Management of patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CS/HIPEC) has historically favored liberal fluid administration owing to lengthy duration of surgery and hyperthermia. This practice has been challenged in recent years with studies demonstrating improved outcomes with restrictive fluid administration. METHODS: Patients who underwent CS/HIPEC between March 2010 and September 2018 were included for analysis. Patients who received an above-median fluid rate (high-IVF) versus below-median fluid rate (low-IVF) were compared, and multivariate analyses were performed for length of stay, 90-day unplanned readmissions, and major complications. RESULTS: The 167 patients had a mean age of 56.7 ± 11.4 years and body mass index of 29.5 ± 6.9 kg/m2. The median rate of total intraoperative crystalloid and colloid was 7.4 mL/kg/h. The low-IVF group had less blood loss (183 vs. 330 mL, p = 0.002), were less likely to need intraoperative vasopressor drip (2.4% vs. 11.9%, p = 0.018), and experienced fewer cardiac complications (2.4% vs. 10.7%, p = 0.031), pneumonias (0% vs. 6.0%, p = 0.024), and Clavien-Dindo grade 3-5 complications (14.5% vs. 33.3%, p = 0.004). Multivariate analyses identified bowel resection (HR 4.65, p = 0.0008) as a risk factor for 90-day unplanned readmission, while bowel resection, intraoperative fluid rate, and estimated blood loss were associated with increased length of stay. CONCLUSION: Higher intraoperative fluid intake was associated with multiple postoperative complications and increased length of stay, and represents a potentially avoidable risk factor for morbidity in CS/HIPEC.
Assuntos
Procedimentos Cirúrgicos de Citorredução , Quimioterapia Intraperitoneal Hipertérmica , Idoso , Humanos , Pessoa de Meia-IdadeRESUMO
INTRODUCTION: Cytoreduction and hyperthermic intraperitoneal chemotherapy (CS/HIPEC) has variable uptake, with referrals reliant on other physicians. To characterize barriers to referral for CS/HIPEC, we created a pragmatic "tailoring grid", incorporating the concepts of Pathman's 4 As of awareness, agreement, adoption, and adherence and barriers acting at the individual, practice group, and organization level. METHODS AND MATERIALS: We invited surgeons and medical oncologists from Western New York State who potentially refer patients for CS/HIPEC to participate in tailoring grid interviews. RESULTS: Interviews of 10 surgeons and 10 medical oncologists were completed. The participants were positioned in the Pathman 4 A's with respect to referrals for CS/HIPEC as follows: (1) A 19 aware (1 not aware); (2) A 3 in agreement (17 not in agreement); (3) A 9 adopters; and (4) A 6 adherent. Among the 9 participants who had referred at least one patient for CS/HIPEC (adopters/adherent), only 2 were in agreement with the appropriateness of CS/HIPEC. Barriers to awareness of included lack of interaction with colleagues and knowledge of indications. Barriers to agreement included lack of high quality of evidence supporting CS/HIPEC such as well-designed RCTs. Barriers to adoption included lack of communication with CS/HIPEC surgeons; lack of inclusion of the procedure into algorithms and defined morbidity/mortality rates. Barriers to adherence included lack of inclusion into guidelines by major societies; perceptions that the procedure is resource-intensive; lack of defined quality measures. CONCLUSIONS: The tailoring grid efficiently identified barriers to awareness, agreement, adoption and adherence for routine referral for CS/HIPEC. Barriers to increased referrals included lack of high-quality evidence supporting CS/HIPEC. Barriers more easily addressed included communication between referring and CS/HIPEC surgeons, and outcomes at the individual patient and hospital level.
Assuntos
Hipertermia Induzida , Neoplasias Peritoneais , Terapia Combinada , Procedimentos Cirúrgicos de Citorredução/métodos , Humanos , Hipertermia Induzida/métodos , Quimioterapia Intraperitoneal Hipertérmica , New York , Neoplasias Peritoneais/cirurgia , Encaminhamento e ConsultaRESUMO
INTRODUCTION: The cytoreduction and hyperthermic intraperitoneal chemotherapy (CS/HIPEC) procedure is complex, involving lengthy preparation and recovery in a heterogeneous patient group. Understanding the patient experience is essential to improving interactions with health professionals that is critical to recovery. OBJECTIVE: This study sought to characterize the early recovery and return to quality of life (at 3 and 6-12 months post-surgery, respectively) in patients having undergone CS/HIPEC, through structured interviews. METHODS: Two sets of interviews were conducted among 20 CS/HIPEC patients. Interviews were uploaded into QSR NVivo 10 qualitative software (QSR International, Australia) and coded by two study personnel. Interview 1 focused on initial treatment decision making and postoperative hospitalization, while interview 2 focused on recovery, supports, and return to quality of life. RESULTS: Among the participants, 60% were female and the mean age was 57 years (range 31-71). Diagnoses included disseminated peritoneal adenomucinosis (n = 6), appendiceal adenocarcinoma (n = 4), colorectal adenocarcinoma (n = 6), goblet cell (n = 2), and mesothelioma (n = 2). The first interview identified common themes of perioperative psychosocial isolation, lack of direction, and the importance of an established support system. Patients requested printed and audiovisual materials focused on addressing expectations. The main findings from the second interview captured patient experiences with longer-term complications, as well as surveillance. CONCLUSION: Focused interviews with patients recently having undergone CS/HIPEC identified key issues that may be addressed in programs to improve the patient experience. These issues were distinctly different in relation to phase of recovery, and patient-centered programs designed with these factors in mind have the potential to enhance the recovery process.
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Quimioterapia do Câncer por Perfusão Regional/mortalidade , Procedimentos Cirúrgicos de Citorredução/mortalidade , Hipertermia Induzida/mortalidade , Neoplasias/terapia , Assistência Centrada no Paciente/normas , Neoplasias Peritoneais/terapia , Adulto , Idoso , Quimioterapia Adjuvante , Terapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/patologia , Neoplasias Peritoneais/secundário , Prognóstico , Taxa de SobrevidaRESUMO
BACKGROUND: Malignant adnexal tumors of the skin (MATS) are rare. We aimed to measure the survival of patients with MATS and identify predictors of improved survival. METHODS: A retrospective review of MATS treated at our institution from 1990 to 2012. RESULTS: There were 50 patients within the time period. Median age was 59.5 years (range 22-95); primary site was the head and neck (52%); most common histologic subtypes were skin appendage carcinoma (20%) and eccrine adenocarcinoma (20%); and the vast majority were T1 (44%). Most patients (98%) underwent surgical treatment. Chemotherapy and radiation were administered to 8 and 14% of patients, respectively. Recurrence rate was 12%. Median OS was 158 months (95% CI, 52-255). OS and recurrence-free survival at 5 years were 62.4 and 47.4% and at 10 years 56.7 and 41.5%, respectively. Five-year and 10-year disease-specific survival (DSS) was 62.9%. Age > 60 years was an unfavorable predictor of OS (HR 12.9, P < .0008) and recurrence-free survival (RFS) (HR 12.53, P < .0003). Nodal metastasis was a negative predictor of RFS (HR 2.37, P < 0.04) and DSS (HR 7.2, P < 0.03) while treatment with chemotherapy was predictive of poor DSS (HR 14.21, P < 0.03). CONCLUSIONS: Younger patients had better OS and RFS. Absence of nodal metastasis translated to better RFS and DSS. Lymph node basin staging is worth considering in the workup and treatment.
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Glândulas Écrinas/patologia , Recidiva Local de Neoplasia/patologia , Neoplasias de Anexos e de Apêndices Cutâneos/patologia , Neoplasias Cutâneas/patologia , Neoplasias das Glândulas Sudoríparas/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Recidiva Local de Neoplasia/terapia , Neoplasias de Anexos e de Apêndices Cutâneos/terapia , Prognóstico , Estudos Retrospectivos , Neoplasias Cutâneas/terapia , Taxa de Sobrevida , Neoplasias das Glândulas Sudoríparas/terapia , Adulto JovemRESUMO
BACKGROUND: Cytoreductive surgery and heated intraperitoneal chemotherapy (CS/HIPEC) is performed for selected indications at a limited number of specialized centers worldwide. Currently there is no standardized approach to the perioperative care process. We sought to capture current practices in the perioperative management of patients who undergo CS/HIPEC at high-volume centers. METHODS: Surgeon members of the American Society of Peritoneal Surface Malignancies working at high-volume CS/HIPEC centers (>10 cases/year) were invited to complete an online survey. The survey included questions relating to preoperative preparation of patients, intraoperative practices, and postoperative care. RESULTS: Ninety-seven surgeons from five continents completed the survey (response rate 55%). The majority (80%) practiced in academic environments. Most respondents (68%) indicated that a formal preoperative preparatory pathway for CS/HIPEC surgery existed at their centers, but few (26%) had used enhanced recovery protocols in this group of patients. Whereas the intraoperative technical practices of the CS/HIPEC procedure were relatively consistent across respondents, there was little agreement on pre- and postoperative care practices, including use of mechanical bowel preparation, nutritional supplementation, methods of perioperative analgesia, timing of physical therapy and ambulation, nasogastric tube and Foley removal, intravenous fluids, blood transfusion parameters, and postoperative use of deep-vein thrombosis prophylaxis and antibiotics. CONCLUSIONS: Perioperative care practices for CS/HIPEC are widely variable nationally and internationally. Standardization of such practices offers an opportunity to incorporate evidence-based interventions and may enhance patient outcomes and improve care standards across all centers that offer this procedure.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Procedimentos Cirúrgicos de Citorredução , Hipertermia Induzida , Assistência Perioperatória/métodos , Neoplasias Peritoneais/terapia , Padrões de Prática Médica , Adulto , Idoso , Analgesia/métodos , Anestesia/métodos , Antibioticoprofilaxia , Transfusão de Sangue , Deambulação Precoce , Hidratação , Hospitais com Alto Volume de Atendimentos , Humanos , Infusões Parenterais , Cuidados Intraoperatórios/métodos , Pessoa de Meia-Idade , Monitorização Intraoperatória , Apoio Nutricional , Modalidades de Fisioterapia , Cuidados Pós-Operatórios/métodos , Cuidados Pré-Operatórios/métodos , Inquéritos e Questionários , Trombose Venosa/prevenção & controleRESUMO
Adjuvant radiation therapy reduces the risk of local recurrence of breast cancer. Our study identifies patient and tumor characteristics that guide the use of adjuvant radiation therapy and evaluates our adherence to recommended guidelines. A retrospective review was undertaken of 1,667 stage I-III breast cancer patients treated at a regional cancer center from 2004 to 2007. Univariate analysis was used to select factors for entry into a multivariate stepwise logistic regression model. Descriptive statistics was used to compare use of radiation therapy of 382 stage I-III breast cancer patients diagnosed in 2013 to those from 2004 to 2007. The primary indicators for any radiation therapy (n = 935) were breast conserving surgery (OR 79.5, 95% CI [47.6-132.9]), four to nine positive lymph nodes (71.9, [17.0-304.7]), and greater than nine positive lymph nodes (60.5, [7.9-460.8]). In post-mastectomy patients (n = 408), the indicators for radiation therapy were four to nine positive lymph nodes (29.4, [12.9-67.4]) and greater than nine positive lymph nodes (108.3, [14.5-807.5]). In breast conserving surgery patients (n = 1,081) 96.1% were offered radiation therapy. Patients offered local-regional radiation therapy were more likely to have any positive nodes (ORs 4.3-91.0), have had a mastectomy (4.3, [2.2-8.4]), and had larger tumors (1.6, [1.3-2.0]). Local-regional radiation therapy was recommended less frequently in node positive patients in 2004-2007 (35.0%) compared to in 2013 (70.5%) [p < 0.001]. Patients who had a breast conserving surgery or had four or more positive lymph nodes were more likely to receive radiation therapy. Patients with any positive lymph nodes, larger tumors, or who had a mastectomy were more likely to receive local-regional radiation therapy. Our institution was more likely to offer local-regional radiation therapy in node positive breast cancer in 2013 compare to 2004-2007.
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Neoplasias da Mama/radioterapia , Radioterapia Adjuvante/métodos , Idoso , Neoplasias da Mama/patologia , Neoplasias da Mama/terapia , Estudos Transversais , Feminino , Humanos , Modelos Logísticos , Linfonodos/patologia , Metástase Linfática/patologia , Mastectomia Segmentar , Pessoa de Meia-Idade , Estudos Retrospectivos , Biópsia de Linfonodo SentinelaRESUMO
INTRODUCTION: The prognosis of appendiceal mucinous neoplasms (AMN) is directly related to their histopathology. Existing classification schemes encompass tumors with widely divergent clinical behaviors within a single diagnosis, making it difficult for clinicians to interpret pathology reports to counsel patients on optimal management. We sought to examine pathology reports generated for AMN for inclusion of essential histologic features. METHODS: Pathology reports of appendectomy specimens with a diagnosis of AMN (2002-2015) at our center ("internal") and from referring institutions ("external") were retrospectively reviewed for inclusion of the following 5 essential items: layer of invasion, mucin dissection (low grade neoplasms only), perforation, margins, and serosal implants. RESULTS: Sixty-nine patients were included, 54 with external reports available. Benign/low grade tumors comprised 29.0% and 27.8% of internal and external reports, respectively. Thirty-seven internal reports (53.6%) were signed out by specialist gastrointestinal pathologists. External reports were 66.7% complete for layer of invasion, 26.7% for mucin dissection, 64.8% for perforation, 68.5% for margins, 53.7% for serosal implants, and 18.5% for all items. Internal reports were 75.4% complete for layer of invasion, 40.0% for mucin dissection, 40.6% for perforation, 82.6% for margins, 69.6% for serosal implants, and 17.4% for all items. Eight external (14.8%) and 24 internal (34.8%) reports were synoptic. Synoptic reports were more likely to be complete for all key items both external and internal. CONCLUSION: Most pathology reports are incomplete for essential features needed for management and discussion of AMN with patients. Synoptic reports improve completeness of reporting for these tumors.
Assuntos
Neoplasias do Apêndice/patologia , Patologia Clínica/estatística & dados numéricos , Projetos de Pesquisa/estatística & dados numéricos , Humanos , Patologia Clínica/tendências , Prognóstico , Projetos de Pesquisa/tendências , Estudos Retrospectivos , Estatística como AssuntoRESUMO
BACKGROUND: In most jurisdictions, a minority of patients are discussed at multidisciplinary cancer conference (MCC) despite recommendations for such reviews. We assessed the impact of MCC review of gastrointestinal (GI) cancers at a stand-alone cancer center. METHODS: Patient data were prospectively collected on consecutive cases presented at a GI MCC during a 6-month period. Original treatment plans were collected confidentially before presentation and compared to post-MCC treatment plans. We defined changes in management plans as major (change in treatment modality) or minor (testing prior to original plan). RESULTS: A total of 149 cases were evaluated: 115 upper GI (gastric/small bowel-10 %, liver-32 %, pancreaticobiliary-36 %), and 34 lower GI (23 %). Reasons for presentation were: questions regarding progression/metastases (44 %), management (26 %), diagnosis (21 %), pathology (15 %), and resectability (7 %). Physicians were certain of their original plans being the final recommendations in 84 % (n = 125). Change in management was recommended in 36 %; 72 % were major and 28 % were minor. Patients underwent all recommended treatments at our institution in 77 % of cases, a portion in 5 %, and no recommended treatments in 18 %. On multivariate analysis, physician degree of certainty for original management plan was not predictive of a change in management plan (p = 0.61). CONCLUSIONS: Although certainty of prediscussion treatment plan is high, changes in treatment recommendations occurred in more than one-third of patients after GI MCC. This prospective study demonstrates the value of MCC in GI cancer sites, even at a stand-alone cancer center.
Assuntos
Neoplasias Gastrointestinais/diagnóstico , Neoplasias Gastrointestinais/terapia , Comunicação Interdisciplinar , Planejamento de Assistência ao Paciente , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Equipe de Assistência ao Paciente , Prognóstico , Estudos Prospectivos , Adulto JovemRESUMO
INTRODUCTION: In many jurisdictions geographic and resource constraints are barriers to multidisciplinary cancer conference review of all patients undergoing cancer surgery. We piloted an internet-based collaborative cancer conference (I-CCC) for rectal cancer to overcome these barriers in the LHIN4 region of Ontario (population 1.4 million). METHODS: Surgeons practicing at one of 10 LHIN4 hospitals were invited to participate in I-CCC reviews. A secure internet audio and visual link facilitated review of cross-sectional images and case details. Before review, referring surgeons detailed initial treatment plans. Main treatment options included preoperative radiation, straight to surgery, and plan uncertain. Changes were noted following I-CCC review from initial to final treatment plan. Major changes included: redirect patient to preoperative radiation from straight to surgery or plan uncertain; and redirect patient to straight to surgery from preoperative radiation or plan uncertain. Minor changes included: change type of neoadjuvant therapy; request additional tests (e.g., pelvic MRI); or formal MCC review. RESULTS: From November 2010 to May 2012, 20 surgeons (7 academic and 13 community) submitted 57 rectal cancer cases for I-CCC review. After I-CCC review, 30 of 57 (53 %) cases had treatment plan changes: 17 major and 13 minor. No patient or tumour factors predicted for treatment plan change. CONCLUSIONS: An I-CCC for rectal cancer in a large geographic region was feasible and influenced surgeon treatment recommendations in 53 % of cases. Because no factor predicted for treatment plan change, it is likely prudent that all rectal cancer patients undergo some form of collaborative review.
Assuntos
Comportamento Cooperativo , Comunicação Interdisciplinar , Internet , Planejamento de Assistência ao Paciente , Equipe de Assistência ao Paciente , Neoplasias Retais/terapia , Cirurgiões , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Estudos Transversais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Projetos Piloto , Prognóstico , Estudos Prospectivos , Neoplasias Retais/diagnósticoRESUMO
BACKGROUND: Patients with stage IV cancer and bowel obstruction (BO) present a complicated management problem. We sought to determine if specific parameters could predict outcome after surgery. METHODS: Records of patients with stage IV cancer and BO treated from 1991 to 2008 were reviewed. For surgical patients, 30-day morbidity and 90-day mortality were assessed using exact multivariable logistic regression methods. RESULTS: Of 198 patients, 132 (66.7%) underwent surgery, 66 medical treatment alone, and demographics were similar. A total of 41 patients (20.7%) were diagnosed with stage IV cancer and BO synchronously, all treated surgically; the remaining presented metachronously. Medically managed patients were more likely to have received chemotherapy in the 30 days prior to BO (45 of 66 [68.2%] vs 40 of 132 [30.3%], p < .01). In the surgical group, 30-day morbidity was 35.6%, while 90-day mortality was 42.3%. Median overall survival for synchronous patients was 14.1 months (95% confidence interval [95% CI] 7.6-23.2), and 3.7 months (95% CI 2.5-5.2) and 3.6 months (95% CI 1.5-5.2) for metachronous patients treated surgically and medically, respectively. A multivariate model for 90-day surgical mortality identified low serum albumin, metachronous presentation, and ECOG > 1 as predictors of death (p < .05). A model for 30-day surgical morbidity yielded low hematocrit as a predictive factor (p < .05). CONCLUSIONS: This cohort identifies characteristics indicative of morbidity and mortality in stage IV cancer and BO. Low serum albumin, ECOG > 1, and metachronous presentation predicted for 90-day surgical mortality. These data suggest factors that can be used to frame treatment discussion plans with patients.
Assuntos
Obstrução Intestinal/etiologia , Neoplasias/complicações , Complicações Pós-Operatórias , Gerenciamento Clínico , Endoscopia Gastrointestinal , Feminino , Seguimentos , Humanos , Obstrução Intestinal/mortalidade , Obstrução Intestinal/cirurgia , Masculino , Morbidade , Estadiamento de Neoplasias , Neoplasias/mortalidade , Neoplasias/cirurgia , Cuidados Paliativos , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de SobrevidaRESUMO
BACKGROUND: The Quality Initiative in Rectal Cancer (QIRC) trial targeted surgeon intraoperative technique and not radiation therapy (RT) use. We performed a post hoc analysis of RT use among patients in the QIRC trial, not by arm of trial but rather for the entire group. We wished to identify associations between local recurrence risk and use of preoperative, postoperative or no RT. METHODS: We compared demographic, tumour and process of care measures among patients receiving preoperative, postoperative or no RT. A multivariable Cox regression model assessed local recurrence risk. RESULTS: The QIRC trial enrolled 1015 patients at 16 hospitals between 2002 and 2004. Radiation therapy use did not differ between trial arms, and median follow-up was 3.6 years. For the preoperative, postoperative and no RT groups, respectively, the percentage of patients was 12.8%, 19.3% and 67.9%; the percentage of stage II/III tumours was 57.0%, 88.7% and 48.1%; and the local recurrence rate was 5.3%, 10.2% and 5.5% (p = 0.05). After controlling for patient and tumour characteristics, including tumour stage, the hazard ratio (HR) for local recurrence was increased in the postoperative RT versus the no RT group (HR 1.64, 95% confidence interval 1.04-2.58, p = 0.027). CONCLUSION: Use of preoperative RT was low; most patients with stage II/III disease did not receive RT and, as expected, the postoperative RT group had the highest risk of local recurrence. Our results suggest opportunities to improve rectal cancer RT use in Ontario.
CONTEXTE: L'essai QIRC (Quality Initiative in Rectal Cancer) portait sur la technique peropératoire des chirurgiens et non sur l'utilisation de la radiothérapie (RT). Nous avons effectué une analyse rétrospective de l'utilisation de la RT chez les patients inclus dans l'essai QIRC, non pas en fonction des différents groupes de l'essai, mais en fonction de sa population entière. Nous avons voulu vérifier les liens entre le risque de récurrences locales et l'utilisation préopératoire ou postopératoire de la RT ou l'abstention de toute RT. MÉTHODES: Nous avons comparé les paramètres démographiques, les caractéristiques de la tumeur et le processus de soins chez les patients soumis à une RT préopératoire ou postopératoire, ou non traités par RT. Un modèle de régression multivariée de Cox a permis d'évaluer le risque de récurrences locales. RÉSULTATS: L'essai QIRC a regroupé 1015 patients de 16 hôpitaux entre 2002 et 2004. Le recours à la radiothérapie n'a pas différé entre les groupes de l'essai, et le suivi médian a été de 3,6 ans. Pour ce qui est des groupes soumis à une RT préopératoire ou postopératoire, ou non soumis à la RT, respectivement, le pourcentage de patients était de 12,8 %, 19,3 % et 67,9 %; le pourcentage de tumeurs de stade II/III était de 57,0 %, 88,7 % et 48,1 %, et le taux de récurrences locales, de 5,3 %, 10,2 % et 5,5 % (p = 0,05). Après ajustement pour tenir compte des caractéristiques des patients et des tumeurs, y compris le stade de la tumeur, le risque relatif (RR) de récurrences locales a augmenté dans le groupe soumis à une RT postopératoire par rapport au groupe non soumis à la RT (RR 1,64; intervalle de confiance de 95 %, 1,042,58, p = 0,027). CONCLUSION: Le recours à la RT préopératoire a été faible; la plupart des patients atteints d'une maladie de stade II/III n'ont pas reçu de RT et comme prévu, le groupe soumis à une RT postopératoire a présenté le risque le plus élevé de récurrences locales. Nos résultats indiquent qu'il serait possible d'améliorer l'utilisation de la RT pour le cancer rectal en Ontario.
Assuntos
Padrões de Prática Médica , Neoplasias Retais/radioterapia , Idoso , Feminino , Humanos , Masculino , Radioterapia/estatística & dados numéricos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Importance: Merkel cell carcinoma (MCC) is an aggressive cutaneous neuroendocrine carcinoma. Due to its relatively low incidence and limited prospective trials, current recommendations are guided by historical single-institution retrospective studies. Objective: To evaluate the overall survival (OS) of patients in Canada with head and neck MCC (HNMCC) according to American Joint Committee on Cancer 8th edition staging and treatment modalities. Design, Setting, and Participants: A retrospective cohort study of 400 patients with a diagnosis of HNMCC between July 1, 2000, and June 31, 2018, was conducted using the Pan-Canadian Merkel Cell Cancer Collaborative, a multicenter national registry of patients with MCC. Statistical analyses were performed from January to December 2022. Main Outcomes and Measures: The primary outcome was 5-year OS. Multivariable analysis using a Cox proportional hazards regression model was performed to identify factors associated with survival. Results: Between 2000 and 2018, 400 patients (234 men [58.5%]; mean [SD] age at diagnosis, 78.4 [10.5] years) with malignant neoplasms found in the face, scalp, neck, ear, eyelid, or lip received a diagnosis of HNMCC. At diagnosis, 188 patients (47.0%) had stage I disease. The most common treatment overall was surgery followed by radiotherapy (161 [40.3%]), although radiotherapy alone was most common for stage IV disease (15 of 23 [52.2%]). Five-year OS was 49.8% (95% CI, 40.7%-58.2%), 39.8% (95% CI, 26.2%-53.1%), 36.2% (95% CI, 25.2%-47.4%), and 18.5% (95% CI, 3.9%-41.5%) for stage I, II, III, and IV disease, respectively, and was highest among patients treated with surgery and radiotherapy (49.9% [95% CI, 39.9%-59.1%]). On multivariable analysis, patients treated with surgery and radiotherapy had greater OS compared with those treated with surgery alone (hazard ratio [HR], 0.76 [95% CI, 0.46-1.25]); however, this was not statistically significant. In comparison, patients who received no treatment had significantly worse OS (HR, 1.93 [95% CI, 1.26-2.96)]. Conclusions and Relevance: In this cohort study of the largest Canada-wide evaluation of HNMCC survival outcomes, stage and treatment modality were associated with survival. Multimodal treatment was associated with greater OS across all disease stages.
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Carcinoma de Célula de Merkel , Neoplasias de Cabeça e Pescoço , Neoplasias Cutâneas , Masculino , Humanos , Criança , Carcinoma de Célula de Merkel/patologia , Carcinoma de Célula de Merkel/cirurgia , Estudos Retrospectivos , Estudos de Coortes , Estudos Prospectivos , Radioterapia Adjuvante , Canadá/epidemiologia , Neoplasias de Cabeça e Pescoço/terapia , Neoplasias Cutâneas/patologiaRESUMO
In this article we provide a critical review of the evidence available for surgical management of the nodal basin in melanoma, with an aim to ensure an understanding of risks and benefits for all lymph node surgery offered to patients, and alternatives to surgical management where appropriate.
Assuntos
Linfonodos/efeitos dos fármacos , Melanoma/patologia , Neoplasias Cutâneas/patologia , Humanos , Linfonodos/diagnóstico por imagem , Metástase Linfática , Melanoma/diagnóstico por imagem , Melanoma/tratamento farmacológico , Melanoma/terapia , Ensaios Clínicos Controlados Aleatórios como Assunto , Biópsia de Linfonodo Sentinela , Neoplasias Cutâneas/diagnóstico por imagem , Neoplasias Cutâneas/tratamento farmacológico , Neoplasias Cutâneas/terapiaRESUMO
This article provides a comprehensive evaluation of surgical management of the lymph node basin in melanoma, with historical, anatomic, and evidence-based recommendations for practice.
Assuntos
Excisão de Linfonodo/métodos , Linfonodos/cirurgia , Melanoma/patologia , Neoplasias Cutâneas/patologia , Humanos , Linfonodos/patologia , Metástase Linfática , Prognóstico , Biópsia de Linfonodo Sentinela/métodosRESUMO
BACKGROUND: Nonoperative or "watch and wait" strategies have emerged as a potential option for patients with rectal cancer that obtain a complete clinic response (cCR) after neoadjuvant therapy. We sought to evaluate our patients that experienced a cCR and their outcomes after non-operative management. METHODS: We performed a retrospective review of patients at our center with rectal cancer from 2012 to 2016. We then identified patients that had a documented "complete clinical response" of their tumors after different neoadjuvant treatments and underwent non-operative management. Patients were followed on a surveillance schedule that included physical exam, endoscopy and imaging. RESULTS: A total of 29 patients elected to undergo nonoperative management with a mean patient age of 67 years old. All patients were treated with neoadjuvant long course chemoradiotherapy. Seven patients were treated with initial induction chemotherapy followed by chemoradiation and 11 received consolidation chemotherapy. During a median follow-up of 27.6 months, there were 6 (21%) recurrences (1â¯=â¯local, 1â¯=â¯local and distant, 4 distant). Of the 6 total recurrences, 5 patients were candidates for salvage surgical resection. CONCLUSION: Neoadjuvant treatment strategies may facilitate durable rates of cCR. Continued responses after these treatments could possibly enable more patients to undergo nonoperative management. We believe nonoperative management can be offered to patients seeking rectal preservation, but more research is required to select the appropriate patients. For those patients experiencing recurrence, the majority of patients can be salvaged surgically.
Assuntos
Adenocarcinoma/terapia , Quimiorradioterapia Adjuvante , Terapia Neoadjuvante , Recidiva Local de Neoplasia/terapia , Neoplasias Retais/terapia , Terapia de Salvação , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Gerenciamento Clínico , Feminino , Seguimentos , Humanos , Quimioterapia de Indução , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Prognóstico , Neoplasias Retais/patologia , Estudos Retrospectivos , Taxa de Sobrevida , Conduta ExpectanteAssuntos
Adenocarcinoma/patologia , Neoplasias da Mama/diagnóstico , Reação a Corpo Estranho/diagnóstico , Neoplasias Ovarianas/patologia , Adenocarcinoma/tratamento farmacológico , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Feminino , Reação a Corpo Estranho/patologia , Humanos , Neoplasias Ovarianas/tratamento farmacológicoRESUMO
BACKGROUND: In locally advanced rectal adenocarcinoma, 15% to 20% of patients treated with neoadjuvant chemoradiation (nCRT) achieve a pathologic complete response (pCR). The benefit of adjuvant chemotherapy is controversial in rectal cancer. Our objective was to evaluate the effect of clinical risk factors and adjuvant chemotherapy usage on the outcomes of the pCR patient population. PATIENTS AND METHODS: We performed a retrospective study using the National Cancer Data Base from 2006 to 2013. The primary outcome was overall survival (OS). The association between OS and patient characteristics (demographics, tumor variables, and treatment) was examined using multivariable Cox regression modelling. RESULTS: A total of 2891 patients were identified who had achieved a pCR. Of these 2891 patients, 2102 received nCRT and 789 received nCRT followed by adjuvant chemotherapy. The median follow-up duration was 43.2 months. The factors significantly associated with OS included age (P < .001), gender (P = .011), Charlson-Deyo comorbidity score (P < .001), grade (P = .029), clinical T stage (P = .030), carcinoembryonic antigen negativity (P = .002), and receipt of adjuvant chemotherapy (P < .001). Nodal status was not significantly associated with survival. The 5-year OS rate was 94% in the nCRT plus adjuvant group compared with 84% in the nCRT-alone group. Adjuvant chemotherapy was more likely to be given to younger patients (aged < 60 years), higher grade, lower Charlson-Deyo comorbidity score, elevated carcinoembryonic antigen level, higher clinical T stage, and higher clinical N stage. CONCLUSION: Our findings showed a significant improvement in OS for patients who received nCRT plus adjuvant chemotherapy compared with those who received nCRT alone. The nCRT plus adjuvant patients were more likely to be younger, have a lower comorbidity score, have clinical ≥ T3 disease, and have clinical node-positive disease. Thus, a selection bias could have been present. Nonetheless, even in the setting of already excellent outcomes, for patients with locally advanced rectal adenocarcinoma who achieve a pCR, the additional benefit of adjuvant chemotherapy should be weighed against the potential for toxicity.
Assuntos
Adenocarcinoma/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Neoplasias Retais/terapia , Adenocarcinoma/patologia , Fatores Etários , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Biomarcadores Tumorais , Quimiorradioterapia Adjuvante/métodos , Quimioterapia Adjuvante/efeitos adversos , Quimioterapia Adjuvante/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Estadiamento de Neoplasias , Modelos de Riscos Proporcionais , Neoplasias Retais/patologia , Estudos Retrospectivos , Viés de Seleção , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Patients with stage IV cancer and bowel obstruction present a complicated management problem. The aim of this study was to evaluate the role of the palliative care service (PC) in the management of this complex disease process. METHODS: A retrospective analysis was conducted of all patients admitted to Roswell Park Cancer Institute with stage IV cancer and bowel obstruction from 2009 to 2012 after the institution of a formal PC. This cohort was matched to similar patients from 2005 to 2008 (no palliative care service or NPC). Patient characteristics and outcomes included baseline demographics, comorbid conditions, do-not-resuscitate (DNR) status, laboratory parameters, medical and surgical management, length of stay, symptom relief, and disposition status. RESULTS: A total of 19 patients were identified in the PC group. Based on the PC group baseline characteristics, 19 patients were identified for the NPC group using matched values. Regarding outcomes, there were significant differences in the medication regimens (narcotics, octreotide, and Decadron) between the 2 groups. In the PC group, 14 of 19 patients showed improvement compared to 9 of 19 in the NPC group. Nearly 60% of patients in the PC group had a formal DNR order versus 10.5% in NPC ( P = .002). A significantly higher percentage of patients were discharged to hospice in the PC group (47.4% vs 0.0%, P = .006). CONCLUSION: Palliative care consultation improves the quality of care for patients with stage IV cancer and bowel obstruction, with particular benefits in symptom management, end-of-life discussion, and disposition to hospice.