Danielle A. Bischof

Surgical management of disappearing colorectal liver metastases

Owing to expanded surgical indications for colorectal liver metastasis (CRLM) and improved systemic therapy, hepatic surgeons are increasingly faced with the problem of disappearing (no longer visible on imaging) liver metastasis (DLM).

Conditional Disease-Free Survival After Surgical Resection of Gastrointestinal Stromal Tumors A Multi-institutional Analysis of 502 Patients

IMPORTANCE Gastrointestinal stromal tumors (GISTs) are the most commonly diagnosed mesenchymal tumors of the gastrointestinal tract. The risk of recurrence following surgical resection of GISTs is typically reported from the date of surgery. However, disease-free survival (DFS) over time is dynamic and changes based on disease-free time already accumulated following surgery. OBJECTIVES To assess the comparative performance of established GIST recurrence risk prognostic scoring systems and to characterize conditional DFS following surgical resection of GISTs. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of 502 patients who underwent surgery for a primary, nonmetastatic GIST between January 1, 1998, and December 31, 2012, at 7 major academic cancer centers in the United States and Canada. MAIN OUTCOMES AND MEASURES Disease-free survival of the patients was classified according to 5 prognostic scoring systems, including the National Institutes of Health criteria, modified National Institutes of Health criteria, Memorial Sloan Kettering Cancer Center GIST nomogram, and American Joint Committee on Cancer gastric and nongastric categories. The concordance index (also known as the C statistic or the area under the receiver operating curve) of established GIST recurrence risk prognostic scoring systems. Conditional DFS estimates were calculated. RESULTS Overall 1-year, 3-year, and 5-year DFS following resection of GISTs was 95%, 83%, and 74%, respectively. All the prognostic scoring systems had fair prognostic ability. For all tumor sites, the American Joint Committee on Cancer gastric category demonstrated the best discrimination (C = 0.79). Using conditional DFS, the probability of remaining disease free for an additional 3 years given that a patient was disease free at 1 year, 3 years, and 5 years was 82%, 89%, and 92%, respectively. Patients with the highest initial recurrence risk demonstrated the greatest increase in conditional survival as time elapsed. CONCLUSIONS AND RELEVANCE Conditional DFS improves over time following resection of GISTs. This is valuable information about long-term prognosis to communicate to patients who are disease free after a period following surgery.

The role of fiber supplementation in the treatment of irritable bowel syndrome: a systematic review and meta-analysis

Irritable bowel syndrome (IBS) is a functional bowel disorder associated with a wide variety of clinical symptoms. The use of fiber in treatment of IBS is well established, but recent reviews have shown conflicting evidence. The aim of our review was to study the effects of fiber (soluble and insoluble) on the symptoms of IBS. Medline, EMBASE, Cochrane Central, CINAHL, LILACS, and ClinicalTrials.gov were searched for appropriate studies. Two reviewers screened the title/abstract and full text against the inclusion criterion – that is, randomized control trials/crossover studies that compare fiber with placebo for its effect on IBS in an outpatient setting. Independent double data extraction was performed across multiple fields. An assessment of the risk of bias and tests for heterogeneity were carried out, along with a meta-analysis of the outcomes of interest. The search yielded 4199 unique records: 121 were selected after title/abstract screening and 22 after full screening. There was moderate clinical, methodological, and statistical heterogeneity across studies, with a moderate risk of bias. Overall, there was a significant improvement in global assessment of symptoms among those randomized to fiber [risk ratio: 1.27; 95% confidence interval (CI): 1.05–1.54]. Soluble fiber improved assessment of symptoms (risk ratio 1.49; 95% CI: 1.09–2.03), as well as the abdominal pain score (mean difference: −1.84; 95% CI: −2.72 to −0.97), with insoluble fiber not showing improvement in any outcome. Soluble fiber appears to improve symptoms of IBS, whereas there is no evidence for recommending insoluble fiber for IBS.

Surgical Management of Advanced Gastrointestinal Stromal Tumors: An International Multi-Institutional Analysis of 158 Patients

BACKGROUND Patients with advanced gastrointestinal stromal tumors (GIST) are at high risk for recurrence after surgery. The aim of this study was to characterize outcomes of advanced GIST treated with surgery from a large multi-institutional database in the tyrosine kinase inhibitor (TKI) era. STUDY DESIGN Patients who underwent surgery for an advanced GIST from 1998 through 2012 were identified. Demographic, clinicopathologic, perioperative, and survival data were collected and analyzed. RESULTS There were 87 patients with locally advanced GIST and 71 patients with recurrent/metastatic GIST. The vast majority (95%) of patients with locally advanced GIST required a multivisceral resection; most patients (87%) underwent a microscopically complete (R0) resection. Although 82% of patients had high-risk tumors according to modified NIH criteria or had recurrent/metastatic disease, only 56% of patients received adjuvant TKI therapy. Among patients with locally advanced GIST, 3-year recurrence-free survival and overall survival rates were 65% and 87%, respectively. In contrast, 3-year recurrence-free survival and overall survival rates among patients with recurrent/metastatic GIST were 49% and 82%, respectively. On multivariate analysis, predictors of worse outcomes included high mitotic rate and male sex for patients with locally advanced GIST, and age and lack of adjuvant TKI therapy were associated with adverse outcomes among patients with recurrent/metastatic GIST (all p < 0.05). CONCLUSIONS Resection of advanced GIST can be safely accomplished with high rates of R0 resection. Among patients with advanced GIST, TKI therapy was underused. Barriers to the use of TKI therapy in this population should be explored.

A nomogram to predict disease-free survival after surgical resection of GIST.

BackgroundGastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Adjuvant imatinib therapy has resulted in improved disease-free survival (DFS) following resection of primary GIST. The aim of our study was to create a nomogram to predict DFS following resection of GIST.MethodUsing a multi-institutional cohort of patients who underwent surgery for primary GIST at 7 academic hospitals in the USA and Canada between January 1998 and December 2012, a multivariable Cox proportional hazards model predicting DFS was created using backward stepwise selection. A nomogram to predict DFS following surgical resection of GIST was constructed with the variables selected in the multivariable model. We tested nomogram discrimination by calculating the C-statistic and compared the nomogram to four existing GIST prognostic stratification systems.ResultsA total of 365 patients who underwent surgery for primary GIST was included in the study. Using backward stepwise selection, sex, tumor size, tumor site, and mitotic rate were selected for incorporation into the nomogram. The nomogram demonstrated superior discrimination compared to the NIH criteria, modified NIH criteria, and Memorial Sloan-Kettering Nomogram and had similar discrimination to the Miettinen criteria (C-statistic 0.77 vs 0.73, 0.71, 0.71, and 0.78, respectively).ConclusionFour independent predictors of recurrence following surgery for primary GIST were used to create a nomogram to predict DFS. The nomogram stratified patients into prognostic groups and performed well on internal validation.

Open versus minimally invasive management of gastric GIST: An international multi-institutional analysis of short- and long-term outcomes.

85 Background: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the GI tract. Overall surgical experience with minimally invasive surgery (MIS) has increased, however, published reports on MIS resection of GIST are currently limited to small, single institution experiences. Methods: 397 patients who underwent surgical resection of a gastric GIST between 1998 and 2012 were identified from an international, multi-center database. The impact of the MIS approach on recurrence and survival was analyzed by the use of propensity-score matching by comparing clinicopathologic factors between patients who underwent open vs MIS resection. Results: Median patient age was 65 years and 50% were female. Median tumor size was 4.3cm (IQR 3.0-7.6cm). A minority of patients received neoadjuvant therapy (6%). Overall, 186 (47%) patients had a MIS approach: laparoscopic (89%), laparoscopic hand assist (4%), combined laparo-endoscopic (3%) and robotic (4%). There were 19 (10%) conversions to ope...

Surveillance for hepatocellular carcinoma with ultrasound and AFP is associated with improvements in tumour detection, receipt of curative therapy and overall survival in patients with cirrhosis

Commentary on : Singal AG, Pillai A, Tiro J. Early detection, curative treatment, and survival. Rates for hepatocellular carcinoma surveillance in patients with cirrhosis: a meta-analysis. PLoS Med 2014;11:e1001624.[OpenUrl][1][CrossRef][2][PubMed][3] Hepatocellular carcinoma (HCC) represents a significant global health burden: HCC is the third most common cause of cancer death worldwide.1 Established risk factors for HCC include chronic liver disease, hepatitis B viral infection, hepatitis C viral infection and inherited metabolic diseases.2 Surveillance for HCC using ultrasound is recommended by the American Association for the Study of Liver Diseases (AASLD) in all patients with cirrhosis, starting at the time of diagnosis.3 This recommendation is supported by a single randomised controlled trial in which surveillance for HCC in patients with chronic hepatitis B infection improved early stage detection of HCC, rates of resection of HCC and overall survival.4 There are, however, no randomised trials examining the role of surveillance for HCC in patients with cirrhosis. This systematic review with meta-analysis examines the association of HCC surveillance in patients having cirrhosis with … [1]: {openurl}?query=rft.jtitle%253DPLoS%2BMed%26rft.volume%253D11%26rft.spage%253De1001624%26rft_id%253Dinfo%253Adoi%252F10.1371%252Fjournal.pmed.1001624%26rft_id%253Dinfo%253Apmid%252F24691105%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1371/journal.pmed.1001624&link_type=DOI [3]: /lookup/external-ref?access_num=24691105&link_type=MED&atom=%2Febmed%2F19%2F6%2F225.atom