Regional immunotherapy for liver and peritoneal metastases.

Pancreatic adenocarcinoma is a biologically aggressive disease, with liver and peritoneal metastases being a frequent cause of death. We examine how the pancreatic carcinoma microenvironment and immunosuppressive landscape favor tumor progression. Immunotherapy has shown promise in select solid tumors, yet challenges remain in applying these gains to stage IV pancreatic adenocarcinoma. We discuss how regional therapy strategies may be leveraged to open new avenues for treating pancreatic carcinoma metastases with immunotherapy.

Predictors of surgical non-referral for colorectal liver metastases.

BACKGROUND: Surgical resection is the only curative option for patients with colorectal liver metastases (CRLM). The objective of our study was to identify factors associated with failure to refer patients with CRLM to a surgeon with oncologic and hepatobiliary expertise. MATERIALS AND METHODS: Data were retrospectively reviewed on 75 patients with CRLM treated at our institution. Patients were divided into referred and nonreferred groups for comparison. Quantitative assessment of association was tabulated using the odds ratio (OR). Statistical comparison was performed using the chi-square test and multiple regression models. Overall survival (OS) was calculated using the Kaplan-Meier method. Multivariate analysis was done using Cox regression. RESULTS: Factors independently associated with lower surgical referral rates included age ≥ 65 y (OR 0.29, 95% confidence interval [CI] 0.09-0.89, P = 0.032), bilobar CRLM (OR 0.35, 95% CI 0.09-0.97, P = 0.048), and presence of >3 CRLM (OR 0.33, 95% CI 0.11-0.94, P = 0.044). The 5-y OS for referred patients was 33% compared with only 8% in patients who were not referred (P < 0.001). Factors independently associated with worse OS included age ≥ 65 y (hazard ratio [HR] 2.01, 95% CI 1.12-3.59, P = 0.019), bilobar hepatic metastases (HR 3.04, 95% CI 1.62-5.70, P < 0.001), and the presence of extrahepatic metastases (HR 2.11, 95% CI 1.02-4.16, P = 0.011). Referral to a surgeon was associated with improved OS (HR 0.42, 95% CI 0.24-0.74, P = 0.003). CONCLUSIONS: Failure to refer CRLM patients for surgical evaluation is associated with aggressive biologic features that do not necessarily preclude resection. Determination of resectability should be made with input from appropriately trained surgical experts.

Race does not impact pancreatic cancer treatment and survival in an equal access federal health care system.

BACKGROUND: Black patients with pancreatic adenocarcinoma (PDAC) have been reported to undergo surgical resection less frequently and to have a shorter overall survival duration than white patients. We sought to determine whether disparities in clinical management and overall survival exist between black and white patients with PDAC treated in an equal access health care system. METHODS: Using the Department of Defense (DoD) tumor registry database from 1993 to 2007, patient, tumor, and treatment factors were analyzed to compare rates of therapy and survival between black and white patients. RESULTS: Of 1,008 patients with PDAC, 157 were black (15 %). Thirty-six percent of black and 37 % of white patients presented with locoregional disease (p = 0.85). Among those with locoregional cancers, the odds of black patients having received surgical resection (odds ratio [OR] 1.06, 95 % confidence interval [CI] 0.60-1.89), chemotherapy (OR 0.92, 95 % CI 0.49-1.73) and radiotherapy (OR 1.14, 95 % CI 0.61-2.10) were not different from those of whites. Among those with distant disease, the odds of having received palliative chemotherapy were also similar (OR 0.91, 95 % CI 0.55-1.51). Black and white patients with PDAC had a similar median overall survival. In a multivariate analysis, as compared to whites, black race was not associated with shorter overall survival. CONCLUSIONS: We observed no disparities in either management or survival between white and black patients with PDAC treated in the DoD's equal access health care system. These data suggest that improving the access of minorities with PDAC to health care may reduce disparities in their oncologic outcomes.

Subcutaneous mass concerning for sarcoma: a peculiar presentation of diffuse large B-cell lymphoma.

Diffuse large B-cell lymphoma (DLBCL) can present in a number of different ways, including as a primary cutaneous lesion or at various other extranodal sites. However, it is rare for a DLBCL to present as a clinically subcutaneous mass without visible skin changes or nodal involvement. A 36-year-old man presented with a 4×4×1 cm subcutaneous mass to his shoulder with normal overlying skin which had been enlarging over 6 months. Physical exam and imaging together made a strong case for sarcoma, and the patient underwent a radical resection. The final pathological diagnosis returned as a diffuse B-cell lymphoma (germinal centre type). The patient subsequently healed and tolerated chemotherapy well. DLBCL can masquerade as a soft tissue mass at initial presentation. If the diagnosis is not clear, a biopsy should be pursued.

Adequate lymph node evaluation in the elderly is associated with improved survival in patients with stage I-III colon cancer: A validation study using the National Cancer Data Base.

BACKGROUND: Lymph node involvement (LNI) is an important prognostic factor in colon cancer. But, variations in LNI among different age groups are less known. Adequate lymph node evaluation (LNE) requires assessment of ≥12 nodes. In our previous study, using Surveillance, Epidemiology and End Results (SEER) data, we demonstrated that older patients are less likely to have LNI (Khan et al. 2014). Our current study validates those findings using National Cancer Data Base (NCDB). METHODS: NCDB was queried for patients diagnosed with stages I-III colon adenocarcinoma from 2004 to 2008 who underwent surgical resections. Pearson Chi-square test and Cox proportional hazards regression model were utilized for statistical analysis. RESULTS: A cohort of 97,831 patients was identified for analysis. Among patients belonging to 18-64, 65-74 and >75 years age groups, frequency of adequate LNE was 73.6%, 69% and 67.4% respectively, with pathologically confirmed LNI rates being 44.7%, 37.8% and 29.3% respectively (p < 0.0001). Adequate LNE was associated with improved 5-year overall survival (OS) regardless of age, gender, race, comorbidity index, insurance, income, year of diagnosis, pathologic tumor status, stage, grade, type of colectomy, adjuvant chemotherapy or academic level of facility. Rates of adequate LNE increased from 2004 to 2008, with a corresponding increase in survival outcomes (p < 0.0001). CONCLUSION: Adequate LNE is very crucial for appropriate staging of colon cancer, and carries a high prognostic value. This study validates our previous findings of lower rates of LNI in elderly and reiterates the importance of adequate LNE, which is associated with improved survival. Also identified were increasing rates of adequate LNE over the years, with corresponding improvement in OS.

Association of primary tumor lymph node ratio with burden of liver metastases and survival in stage IV colorectal cancer.

BACKGROUND: The primary objective of our study was to assess the association of primary tumor lymph node ratio (LNR) in stage IV colorectal adenocarcinomas (CRC) with overall survival (OS) and the extent of metastatic disease in the liver. METHODS: We analyzed data on 53 stage IV CRC patients who underwent surgical resection of the primary tumor. The median LNR of 0.25 was used to stratify patients into high LNR (H-LNR) and low LNR (L-LNR) groups. Statistical comparison was performed using chi square test and multiple regression models. OS was calculated using the Kaplan-Meier (KM) method while cox regression was used for multivariate analysis. RESULTS: H-LNR status was associated with the presence of >3 liver metastases (LM) [odds ratio (OR): 2.43, P=0.047] and bilobar LM (OR: 3.94, P=0.039). The OS in H-LNR patients was significantly worse in the entire cohort compared to L-LNR (9% vs. 34% at 3 years, P=0.027). The 5-year OS in patients undergoing liver resection for LM was also significantly worse in the H-LNR group (0% vs. 37%, P=0.013). LNR was independently associated with survival on multivariate analysis [HR: 2.63; 95% confidence intervals (CI), 1.13-6.14; P=0.025]. CONCLUSIONS: In stage IV CRC, LNR is associated with the extent of hepatic tumor burden and was an independent predictor of survival in patients undergoing liver resection.

Occult Pneumomediastinum in the Deployed Setting: Evaluation and Management.

Pneumomediastinum can occur after both blunt and penetrating trauma. The greatest concern involving this finding in a trauma patient is an aerodigestive tract injury. Prompt evaluation, identification, and management of these injuries are extremely important. This case describes a soldier who was involved in an improvised explosive device blast with no evidence of cavity penetration. During the routine evaluation of his head and neck an occult pneumomediastinum was identified. The patient was asymptomatic and was further evaluated with computed tomography because of the absence of endoscopy and bronchoscopy in theatre. The imaging showed no evidence of esophageal or tracheobronchial injury. The patient was observed and when noted to be stable was transferred to the local Role 3 hospital for management of his other injuries.

Dermatofibrosarcoma Protuberans.

Dermatofibrosarcoma protuberans (DFSP) is a rare superficial soft tissue sarcoma. Its rarity precludes large prospective studies. Clinical diagnosis requires an high index of suspicion. Effective management requires an appreciation of tumor biology and the nature of the characteristic infiltrative growth pattern. DFSP tends to recur locally, with a low risk of dissemination. Aggressive surgical resection with widely negative margins is essential to management. Radiotherapy may be indicated in special circumstances. Understanding the molecular pathogenesis has resulted in use of tyrosine kinase inhibitor therapy for patients with locally advanced disease or in metastatic disease. DFSP patients require long-term follow-up.

Prevalence and predictors of nonalcoholic steatohepatitis in obese patients undergoing bariatric surgery: a Department of Defense experience.

Nonalcoholic steatohepatitis (NASH) is a silent liver disease that can lead to inflammation and subsequent scaring. If left untreated, cirrhosis may ensue. Morbidly obese patients are at an increased risk of NASH. We report the prevalence and predictors of NASH in patients undergoing morbid obesity surgery. A retrospective review was conducted on morbidly obese patients undergoing weight reduction surgery from September 2005 through December 2008. A liver biopsy was performed at the time of surgery. Patients who had a history of hepatitis infection or previous alcohol dependency were excluded. Prevalence of NASH was studied. Predictors of NASH among clinical and biochemical variables were analyzed using multivariate regression analysis. One hundred thirteen patients were analyzed (84% female; mean age, 42.6 ± 11.4 years; mean body mass index, 45.1 ± 5.7 kg/m(2)). Sixty-one patients had systemic hypertension (54%) and 35 patients had diabetes (31%). The prevalence of NASH in this study population was 35 per cent (40 of 113). An additional 59 patients (52%) had simple steatosis without NASH. Only 14 patients had normal liver histology. On multivariate analysis, only elevated aspartate aminotransferase (AST) (greater than 41 IU/L) was the independent predictor for NASH (odds ratio, 5.85; confidence interval, 1.06 to 32.41). Patient age, body mass index, hypertension, diabetes, hypercholesterolemia, and abnormal alanine aminotransferase did not predict NASH. NASH is a common finding in obese population. Abnormal AST was the only predictive factor for NASH.