Daniel E. Abbott

Hepatobiliary cancers, version 1.2017 featured updates to the NCCN guidelines

The NCCN Guidelines for Hepatobiliary Cancers provide treatment recommendations for cancers of the liver, gallbladder, and bile ducts. The NCCN Hepatobiliary Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panels discussion and most recent recommendations regarding locoregional therapy for treatment of patients with hepatocellular carcinoma.

Are the Current Guidelines for the Surgical Management of Intraductal Papillary Mucinous Neoplasms of the Pancreas Adequate? A Multi-Institutional Study

BACKGROUNDnControversy persists regarding the management of patients with intraductal papillary mucinous neoplasms (IPMN). International consensus guidelines stratify patients into high-risk, worrisome, and low risk categories.nnnSTUDY DESIGNnThe medical records of 7 institutions were reviewed for patients who underwent surgical management of IPMN between 2000 andxa02015.nnnRESULTSnThere were 324 patients included in the analysis; 60.4% of patients had main-duct/mixed type, and 39.7% had branch-duct IPMN. The median cyst size was 2.65 cm, invasive cancer (IC) or high-grade dysplasia (HGD) was present in 42% (nxa0= 136); 68.9% of patients with high-risk, 40.0% of patients with worrisome, and 24.6% of patients with low risk features exhibited HGD/IC. Multivariate analysis demonstrated that only 1 of 3 high-risk features and 2 of 7 worrisome features predicted the presence of HGD/IC. Positive predictive values for HGD/ IC in patients with obstructive jaundice and lymphadenopathy were 0.83 (95% CI 0.65 to 0.94) and 0.69 (95% CI 0.39 to 0.91), respectively. In the absence of high-risk features, HGD/IC was still present in 57.4% of patients with 2 or more worrisome features. Regression analysis demonstrated that each additional worrisome factor present was additive in predicting HGD/IC in a linear fashion (odds ratio 1.39; 95% CI 1.08 to 1.80; p < 0.01).nnnCONCLUSIONSnThese data demonstrate that the current consensus guidelines for surgical resection of IPMN may not adequately stratify and identify patients at risk for having HGD or invasive cancer. Patients with multiple worrisome features, in the absence of high-risk factors, should be considered for resection.

Does radiologic response correlate to pathologic response in patients undergoing neoadjuvant therapy for borderline resectable pancreatic malignancy

In patients with borderline resectable pancreas cancers, clinicians frequently consider radiographic response as the primary driver of whether patients should be offered surgical intervention following neoadjuvant therapy (NT). We sought to determine any correlation between radiographic and pathologic response rates following NT.

Early Recurrence and Omission of Adjuvant Therapy after Pancreaticoduodenectomy Argue against a Surgery-First Approach

BackgroundSequencing therapy for patients with periampullary malignancy is controversial. Clinical trial data report high rates of adjuvant therapy completion, though contemporary, real-world rates remain incomplete. We sought to identify patients who failed to receive adjuvant therapy and those at risk for early recurrence (ER) who might benefit most from neoadjuvant therapy (NT).MethodsWe retrospectively reviewed medical records of 201 patients who underwent pancreaticoduodenectomy for periampullary malignancies between 1999 and 2015; patients receiving NT were excluded. Univariate and multivariate analyses were performed to identify predictors of failure to receive adjuvant therapy and ER (within 6xa0months) as the primary end points.ResultsThe median age at the time of surgery was 65.5xa0years (interquartile range 57–74xa0years). The majority of tumors were pancreatic ductal adenocarcinoma (76.6xa0%), and 71.6xa0% of patients received adjuvant therapy after resection. Univariate predictors of failure to undergo adjuvant therapy were advanced age, age-adjusted Charlson comorbidity index, operative transfusion, reoperation, length of stay, and 30- to 90-day readmissions (all pxa0<xa00.05). Advanced age, specifically among patientsxa0>70xa0years, persisted as a significant preoperative predictor on multivariate analysis (pxa0<xa00.01). Patients who failed to receive adjuvant therapy and/or developed ER had significantly worse overall survival rates compared to all other patients (27.8 vs. 9.7xa0months; pxa0<xa00.01).ConclusionsApproximately one-third of surgery-first patients undergoing pancreaticoduodenectomy at our institution did not receive adjuvant therapy and/or demonstrated ER. This substantial subset of patients may particularly benefit from NT, ensuring completion of multimodal therapy and/or avoiding futile surgical intervention.

Socioeconomic disparities, financial toxicity, and opportunities for enhanced system efficiencies for patients with cancer

Cancer care continues to stress the US healthcare system with increases in life expectancy, cancer prevalence, and survivors’ complex needs. These challenges are compounded by socioeconomic, racial, and cultural disparities that are associated with poor clinical outcomes. One innovative and resource‐wise strategy to address this demand on the system is expanded use of telehealth. This paradigm has the potential to decrease healthcare and patient out‐of‐pocket costs and improve patient adherence to recommended treatment and/or surveillance.

Distal Cholangiocarcinoma and Pancreas Adenocarcinoma: Are They Really the Same Disease? A 13-Institution Study from the US Extrahepatic Biliary Malignancy Consortium and the Central Pancreas Consortium

BACKGROUNDnDistal cholangiocarcinoma (DC) and pancreatic ductal adenocarcinoma (PDAC) are often managedxa0as 1 entity, yet direct comparisons are lacking. Our aim was to use 2 large multi-institutional databases to assess treatment, pathologic, and survival differences between these diseases.nnnSTUDY DESIGNnThis study included patients with DC and PDAC who underwent curative-intent pancreaticoduodenectomy from 2000 to 2015 at 13 institutions comprising the US Extrahepatic Biliary Malignancy and Central Pancreas Consortiums. Primary endpoint was disease-specific survival (DSS).nnnRESULTSnOf 1,463 patients, 224 (15%) had DC and 1,239 (85%) had PDAC. Compared with PDAC, DC patients were less likely to be margin-positive (19% vs 25%; pxa0= 0.005), lymph node (LN)-positive (55% vs 69%; p < 0.001), and receive adjuvant therapy (57% vs 71%; pxa0<xa00.001). Of DC patients treated with adjuvant therapy, 62% got gemcitabine alone and 16% got gemcitabine/cisplatin. Distal cholangiocarcinoma was associated with improved median DSS (40 months) compared with PDAC (22 months; p < 0.001), which persisted on multivariable analysis (hazard ratio 0.65; 95% CI 0.50 to 0.84; pxa0= 0.001). Lymph node involvement was the only factor independently associated with decreased DSS for both DC and PDAC. The DC/LN-positive patients had similar DSS as PDAC/LN-negative patients (pxa0= 0.74). Adjuvant therapy (chemotherapy ± radiation) was associated with improved median DSS for PDAC/LN-positive patients (21 vs 13 months; pxa0= 0.001), but not for DC patients (38 vs 40 months; pxa0= 0.62), regardless of LN status.nnnCONCLUSIONSnDistal cholangiocarcinoma and pancreatic ductal adenocarcinoma are distinct entities. Distal cholangiocarcinoma has a favorable prognosis compared with PDAC, yet current adjuvant therapy regimens are only associated with improved survival in PDAC, not DC. Therefore, treatment paradigms used for PDAC should not be extrapolated to DC, despite similar operative approaches, and novel therapies for DC should be explored.

Surgeon, not technique, defines outcomes after central venous port insertion

BACKGROUNDnAlthough central venous access for port placement is common and relatively safe, complications and poor resource utilization occur. We hypothesized that despite the simplicity of port placement, surgeon and/or resident performance-rather than technique-is associated with clinical outcomes and operating room efficiency.nnnMATERIALS AND METHODSnMedical records of 1200 patients who underwent port placement between 2012 and 2015 at our institution were retrospectively reviewed. Insertion route (subclavian, internal jugular, cephalic cutdown), individual surgeon (A-G), surgeon volume, body mass index, patient age, and resident presence were evaluated to determine their association with operating room time, complications, and need for alternate insertion route.nnnRESULTSnOn univariate analysis, operating room times were significantly different among individual surgeons, with surgeons E and F having the longest operating room times (50 and 63 versus 31-40xa0min; Pxa0<xa00.01) and switching to an alternate method more frequently (13.5% and 21.3%, versus 0%-10.3%, Pxa0<xa00.01). On multivariate analyses, operating time was increased with elevated body mass index, resident presence, and switching to an alternate method. Individual surgeons had varied effects on operating time with two surgeons found to be the predominant drivers (OR 19 and 27; Pxa0<xa00.01). With residents excluded, these two surgeons continued to increase operating times (OR 15 and 29; Pxa0<xa00.01) and procedural complications (OR 3.2 and 5.9; Pxa0<xa00.05).nnnCONCLUSIONSnAlthough port placement is ostensibly simple, individual surgeon performance is the primary driver of patient outcome and operative efficiency. In an era requiring optimized resource utilization and outcomes, these data demonstrate potential for enhanced programmatic organization and case distribution.

Improvement and persistent disparities in completion lymph node dissection: Lessons from the National Cancer Database

Completion lymph node dissection (CLND) is recommended for melanoma patients with positive sentinel lymph node biopsies (SLNB); however, 50% do not undergo CLND. We sought to determine CLND trends over time, and factors contributing to variability.

The diagnosis of pancreatic mucinous cystic neoplasm and associated adenocarcinoma in males: An eight-institution study of 349 patients over 15 years

Per WHO, 2000 classification, pancreatic mucinous cystic neoplasms (MCN) are defined by presence of ovarian stroma, and are primarily located in the pancreatic body/tail of females. The incidence of MCN and associated malignancy in males, since, standardization of MCN diagnostic‐criteria is unknown.

Pancreas fistula risk prediction: implications for hospital costs and payments

BACKGROUNDnAs payment models evolve, disease-specific risk stratification may impact patient selection and financial outcomes. This study sought to determine whether a validated clinical risk score for post-operative pancreatic fistula (POPF) could predict hospital costs, payments, and profit margins.nnnMETHODSnA multi-institutional cohort of 1193 patients undergoing pancreaticoduodenectomy (PD) were matched to an independent hospital where cost, in US