Andrew T. Wong

Barbed sutures in total knee arthroplasty: are these safe, efficacious, and cost-effective?

The use of barbed sutures has become increasingly popular; however, their efficacy and safety continues to be debated. We review the records of 333 primary total knee arthroplasties (TKAs) to determine the difference in wound closure and total operative time between patients closed with a barbed versus standard sutures. We also evaluated complication rates and cost differences between the two groups. Overall, we saw no significant difference in either wound closure time (31 vs. 30 minutes) or total operative time (115 vs. 114 minutes). No significant differences were observed in the complication rate. Material costs were lower overall in the barbed suture group (

Prostate biopsy concordance in a large population-based sample: a Surveillance, Epidemiology and End Results study

66.78 vs. 82.59). Further studies will be required to determine the role of barbed sutures in TKA.

Impact of the use of an endorectal balloon on rectal dosimetry during stereotactic body radiation therapy for localized prostate cancer

Aims To use the Surveillance, Epidemiology and End Results database in order to evaluate prostate biopsy concordance in a large population-based sample. Methods We identified 34 195 men who were diagnosed with prostate cancer and underwent a radical prostatectomy from 2010 to 2011. All patients also had to have both clinical and pathological Gleason scores available for analysis. The concordance of the biopsy Gleason score to the pathological Gleason score was analysed using the coefficient of agreement (κ). Univariate and multivariate logistic regression analyses were performed to determine potential factors that may impact concordance of Gleason score. Results Overall, the clinical and pathological Gleason scores matched in 55.4% of patients. The concordance rates were 55.3% for Gleason 6, 66.9% for Gleason 3+4, 42.9% for Gleason 4+3 and 24.8% for Gleason 8, with frequent downgrading to Gleason 7. The κ for Gleason score concordance was 0.36 (95% CI 0.35 to 0.37), indicating fair agreement. The weighted κ for Gleason score concordance was 0.51 (95% CI 0.50 to 0.52), indicating moderate agreement. Additionally, the Bowker tests of symmetry were highly significant (p<0.001), indicating that when discordant findings were present, pathological upgrading was more common than downgrading. Conclusions This study is, to our knowledge, the largest contemporary study of prostate biopsy concordance. We found that there continues to be significant Gleason migration both upward from biopsy Gleason 6 or 3+4 and downgrading from biopsy Gleason ≥8. Further studies are needed to better determine other potential genomic or biologic factors that may help increase the biopsy Gleason concordance.

Assessing the Impact of Postoperative Radiation Therapy for Completely Resected Limited-Stage Small Cell Lung Cancer Using the National Cancer Database

PURPOSE Endorectal balloons may be of benefit during stereotactic body radiation therapy of the prostate to limit intrafraction prostatic motion and potentially minimize rectal toxicity. We evaluated the effect of the endorectal balloon (ERB) on rectal dosimetry, specifically the absolute volume of rectum receiving high dose. METHODS AND MATERIALS Eleven patients with localized prostate cancer underwent stereotactic body radiation therapy planning with computed tomography simulation with and without a RadiaDyne ERB inflated with 60 mL of water. Prescription dose was 3625 cGy in 5 fractions of 725 cGy. The V3600 (volume receiving 3600 cGy), V3440 (volume receiving 3440 cGy), and volume receiving 50% of the prescription dose were calculated for both the rectum and rectal wall. Repeat plans were generated using smaller planning target volume margins (reduced to 1 mm from 3 mm posteriorly) and after virtually replacing the water-filled ERB with air equivalent density. Comparisons were made using the Wilcoxon signed-rank test. RESULTS The rectal V3600 and V3440 were significantly lower without ERB than with water-filled ERB using standard 3-mm posterior margin (P = .003 for both V3600/V3440), water-filled ERB using reduced 1-mm posterior margin (P = .016 and .003), or air-filled ERB (P = .003 and .004). Regarding the rectal wall, V3600 and V3440 were also significantly lower without ERB than with any ERB, except when using the water-filled ERB with reduced posterior margin (P = .328). The volumes of rectum and rectal wall receiving lower dose (volume receiving 50% of the prescription dose) were not significantly greater without the ERB. CONCLUSION We found an increase in the volume of rectum and rectal wall receiving high dose radiation utilizing an ERB. Consideration in using an ERB should account for potential increased rectal dose and subsequent toxicity.

Endoscopic and non-endoscopic approaches for the management of radiation-induced rectal bleeding

Introduction: Surgical resection is being increasingly used for early‐stage small cell lung cancer (SCLC). However, there are sparse data regarding the role of adjuvant therapies, particularly postoperative radiation therapy (PORT). We investigated the impact of PORT on survival after complete surgical resection for SCLC using the National Cancer Database. Methods: There were 3017 patients diagnosed with nonmetastatic SCLC between 1998 and 2011 who underwent R0 sublobar resection, lobectomy, or pneumonectomy. Patients were stratified by the use of PORT, and only those who received a minimum dose of 45 Gy were included. The overall survival (OS) of patients based on PORT use were analyzed by Kaplan–Meier analysis and compared using the log‐rank test. Multivariate Cox regression analysis was used to identify factors associated with survival. Results: For the entire study population, the 5‐year OS was significantly poorer with the addition of PORT (33.9% versus 40.6%; p = 0.005). When analyzed by subgroup, patients with pN0 stage had significantly decreased OS with PORT (39.3% versus 46.3%; p = 0.07) and patients with pN2 stage had significantly improved OS with PORT (29.0% versus 18.6%; p < 0.001). No differences in OS were observed in patients with pN1 stage. On multivariate analysis, the hazard ratio for PORT in pN0 disease was 1.36 (95% confidence interval, 1.09–1.70; p < 0.001) and the hazard ratio for PORT in pN2 disease was 0.60 (95% confidence interval, 0.45–0.80; p < 0.001). Conclusion: The use of PORT was associated with a deleterious effect on OS in patients with pN0 disease but significantly improved OS in patients with pN2 disease.

Utilization of adjuvant therapies and their impact on survival for women with stage IIIC endometrial adenocarcinoma

Pelvic radiation is a commonly utilized treatment for malignancy of the genitourinary and lower gastrointestinal tract. Radiation proctitis and the resultant clinical picture varies from asymptomatic to potentially life threatening. Similarly, treatment options also vary greatly, from medical therapy to surgical intervention. Commonly utilized medical therapy includes sucralfate enemas, antibiotics, 5-aminosalicylic acid derivatives, probiotics, antioxidants, short-chain fatty acids, formalin instillation and fractionated hyperbaric oxygen. More invasive treatments include endoscopic-based, focally ablative interventions such as dilation, heater and bipolar cautery, neodymium/yttrium aluminum garnet argon laser, radiofrequency ablation or argon plasma coagulation. Despite its relatively common frequency, there is a dearth of existing literature reporting head-to-head comparisons of the various treatment options via a randomized controlled approach. The purpose of our review was to present the reader a consolidation of the existing evidence-based literature with the goal of highlighting the comparative effectiveness and risks of the various treatment approaches. Finally, we outline a pragmatic approach to the treatment of radiation proctitis. In light of the lack of randomized data, our goal is to pursue as least invasive an approach as possible, with escalation of care tailored to the severity of the patients symptoms. For those cases that are clinically asymptomatic or only mildly symptomatic, observation or medical management can be considered. Once a patient fails such management or symptoms become more severe, invasive procedures such as endoscopically based focal ablation or surgical intervention can be considered. Although not all recommendations are supported by level I evidence, reported case series and single-institutional studies in the literature suggest that successful treatment with cessation of symptoms can be obtained in the majority of cases.

The Impact of Adjuvant Postoperative Radiation Therapy and Chemotherapy on Survival After Esophagectomy for Esophageal Carcinoma.

PURPOSE/OBJECTIVES Adjuvant treatment options following surgical staging for women with stage IIIC endometrial carcinoma include chemotherapy (CT) with or without radiation therapy (RT). We utilized the National Cancer Database (NCDB) to investigate utilization of adjuvant CT and RT for this group of patients and assess their impact on overall survival (OS). MATERIALS/METHODS The NCDB was queried for patients diagnosed with non-metastatic surgically staged uterine adenocarcinoma between 2004 and 2011 with at least one pathologically positive lymph node. Overall survival (OS) was analyzed using the Kaplan-Meier method. Comparison was made between patients receiving no additional therapy, RT alone, CT alone, or a combination of CT and RT (CMT). Multivariable cox regression analysis (MVA) was performed to evaluate the effect of covariates on OS. RESULTS A total of 6720 patients were included in this study. Of whom, 1409 received no adjuvant treatment, 1533 received CT only, 1265 received RT only, and 2522 received CMT. The 5-year OS for patients receiving no adjuvant therapy, RT alone, CT alone, and CMT were 54.9%, 63.9%, 64.4%, and 72.6%, respectively. On pairwise analysis, CMT was associated with improved survival compared to all other subgroups (p<0.001). On MVA, CMT (HR 0.58, 95% CI 0.52-0.66, p<0.001) was the strongest predictor for improved OS compared to RT alone (HR 0.79, 95% CI 0.69-0.89, p<0.001) or CT alone (HR 0.75, 95% CI 0.66-0.85, p<0.001). CONCLUSIONS Both adjuvant CT and adjuvant RT were associated with improved OS for women with stage IIIC endometrial adenocarcinoma, but CMT was associated with the largest improvement in OS.

Adjuvant radiation with hormonal therapy is associated with improved survival in men with pathologically involved lymph nodes after radical surgery for prostate cancer

Objective: The objective of this study was to analyze the impact on overall survival (OS) from the addition of postoperative radiation with or without chemotherapy after esophagectomy, using a large, hospital-based dataset. Background: Previous retrospective studies have suggested an OS advantage for postoperative chemoradiation over surgery alone, although prospective data are lacking. Methods: The National Cancer Data Base was queried to select patients diagnosed with stage pT3-4Nx-0M0 or pT1-4N1-3M0 esophageal carcinoma (squamous cell or adenocarcinoma) from 1998 to 2011 treated with definitive esophagectomy ± postoperative radiation and/or chemotherapy. OS was analyzed using the Kaplan-Meier method and compared using the log-rank test. Multivariate Cox regression analysis was used to identify covariates associated with OS. Results: There were 4893 patients selected, of whom 1153 (23.6%) received postoperative radiation. Most patients receiving radiation also received sequential/concomitant chemotherapy (89.9%). For the entire cohort, postoperative radiation was associated with a statistically significant but modest absolute improvement in survival (hazard ratio 0.77; 95% CI, 0.71–0.83; P < 0.001). On subgroup analysis, postoperative radiation was associated with improved OS for patients with node-positive disease (3-yr OS 34.3 % vs 27.8%, P < 0.001) or positive margins (3-yr OS 36.4% vs 18.0%, P < 0.001). When chemotherapy usage was incorporated, sequential chemotherapy was associated with the best survival (P < 0.001). Multivariate analysis revealed that the addition of chemotherapy to radiation therapy, whether sequentially or concurrently, was a strong prognostic factor for OS. Conclusions: In this hospital-based study, the addition of postoperative chemoradiation (either sequentially or concomitantly) after esophagectomy was associated with improved OS for patients with node-positive disease or positive margins.

Utilization of Hyperfractionated Radiation in Small-Cell Lung Cancer and Its Impact on Survival

PURPOSE Recent studies have suggested that the addition of adjuvant radiation therapy (aRT) may improve outcomes in men with pathologically involved lymph nodes (pN+). The objective of this study was to assess the treatment patterns and the overall survival (OS) outcomes in men with pN+prostate cancer using the National Cancer Data Base. METHODS Men diagnosed with nonmetastatic prostate cancer between 2004 and 2011, who underwent radical prostatectomy for pN+were identified in the National Cancer Data Base. Patients were stratified into subgroups of those receiving no adjuvant therapy and those receiving adjuvant hormonal therapy (aHT) alone, aRT alone, and aRT+aHT. OS was analyzed using Kaplan-Meier method and compared between the groups using the log-rank test. Multivariable Cox regression was used to identify covariates that affected OS. RESULTS A total of 7,225 patients were included in this analysis, of whom 3,636 (50.3%) received no adjuvant therapy, 2,041 (28.2%) received aHT alone, 350 (4.8%) received aRT alone, and 1,198 (16.5%) received aRT+aHT. The 5-year OS rates were 85.2% for no adjuvant therapy, 82.9% for aHT alone, 88.3% for aRT alone, and 88.8% for combination hormonal therapy, i.e., aRT+aHT (P<0.001). On multivariable analysis, aRT+aHT was associated with a significantly decreased risk of death (hazard ratio [HR] = 0.67; 95% CI: 0.54-0.83; P<0.001) compared with no adjuvant therapy, whereas aHT alone (HR = 0.99; 95% CI: 0.85-1.15; P = 0.90) and aRT alone (HR = 1.02; 95% CI: 0.74-1.40; P = 0.92) were not. CONCLUSION Patients treated with multimodal aRT+aHT had significantly higher OS rate than patients treated without adjuvant therapy or with aHT/aRT alone.

Patterns of adjuvant radiation usage and survival outcomes for stage I endometrial carcinoma in a large hospital-based cohort

Introduction: Twice-daily radiation with concurrent chemotherapy is recognized as the standard of care for the treatment of limited stage small-cell lung carcinoma (SCLC), but its utilization in this setting is unclear. The objective of this study was to analyze modern patterns of treatment for limited stage SCLC and the impact on survival utilizing the National Cancer Database. Methods: Between 1999 and 2012, there were 25,045 patients diagnosed with nonmetastatic SCLC who met the selection criteria, of whom 22,626 had survival data. Those receiving 45 Gy in 1.5 Gy fractions twice-daily (BID) were compared with those receiving 45 to 72 Gy in 1.8 or 2.0 Gy fractions. Overall survival was analyzed via Kaplan–Meier analysis and compared using the log-rank test. Multivariate Cox regression analysis was used to identify covariates associated with survival. Results: The utilization of BID radiation overall was 11.3%. Treatment at an academic center was associated with a higher likelihood of receiving BID treatment (odds ratio: 2.29, 95% confidence interval [CI]: 1.95–2.69; p < 0.001). Median survival was 22.1, 17.2, 18.3, 19.2, and 19.5 months for patients receiving 45 Gy BID, 45 Gy once-daily, 46 to 59.4 Gy once-daily, 60 to 61.2 Gy once-daily, and 62 to 72 Gy once-daily, respectively (p < 0.001 for all pairwise comparisons to BID). On multivariate analysis, treatment at an academic center (hazard ratio: 0.88, 95% CI: 0.83–0.93; p < 0.001) and receipt of BID radiation (hazard ratio: 0.92, 95% CI: 0.86–0.98; p = 0.008) were associated with improved survival. Conclusions: The adoption of BID radiation remains very limited, but is more commonly utilized in the academic setting. In this hospital-based study, BID fractionation was associated with improved survival over once-daily fractionation, even at doses ≥60 Gy.