Debrah Wirtzfeld

Hereditary diffuse gastric cancer: diagnosis, genetic counseling, and prophylactic total gastrectomy

A subset of patients with diffuse gastric cancer harbor deleterious cancer‐causing germline mutations in the type 1 E‐cadherin (epithelial) gene (CDH1), which predisposes to the autosomal dominantly inherited hereditary diffuse gastric cancer (HDGC) syndrome. These mutations are associated with a 70% life‐time risk for diffuse gastric cancer (DGC) and an additional 40% risk for lobular breast cancer in women. Management options for unaffected mutation carriers include prophylactic total gastrectomy.

Practice patterns and career satisfaction of Canadian female general surgeons

BACKGROUND We wanted to study how female general surgeons in Canada manage lifestyle and career demands. METHODS All female Canadian general surgeons registered with the Royal College of Physicians and Surgeons of Canada were asked to complete a survey evaluating their practice patterns, personal lives, and levels of satisfaction related to these factors. RESULTS Eighty-five surveys (66%) were returned. Most respondents work in full-time clinical practices. While it was rare to find women in part-time or shared practices, 35% of women reported interest in these alternative models. Respondents described the necessary factors for a transition into alternative models. Job satisfaction was high (3.8 out of 5), with personal and parenting satisfaction being less highly rated (3.3 and 3.2, respectively). CONCLUSIONS Canadian female general surgeons have active and satisfying careers, although many would like to work in alternative practice models that better conform to their lifestyle demands. This pressure will have a significant impact on the future surgical workforce.

133: Predictors of Nodal Response after Neoadjuvant Chemoradiotherapy for Rectal Adenocarcinoma; A Retrospective Study

Purpose: Pathological response to neoadjuvant therapy has been linked to long-term outcome in rectal cancer (RC). Predicting nodal response is important especially in cases where watch and wait strategy is being considered. This study was carried out to identify potential predictors of pathological nodal response after long course chemoradiotherapy (CRT). Methods and Materials: A retrospective review of all patients with clinically node positive RC who received neoadjuvant CRT in Manitoba between January 2007 and December 2012 was conducted. Pre CRT tumour staging, treatment-related hematologic toxicities and pathologic nodal response data were recorded. Univariable and Multivariable analyses were performed using Bayesian logistic regression models. Results: Two hundred and six patients with clinically node positive RC were included in this study. The mean number of excised nodes was 16.35. One hundred and seventeen patients (56.8%) achieved a pathologic complete nodal response. Higher pre-treatment carcinoembryonic antigen (CEA) level (p = 0.0072) and presence of lymphovascular space invasion (LVI) in the surgical specimen (p = 0.0002) were independent predictors of lack of nodal response. In the univariable analysis, there was a tendency to a better response in patients who developed less treatment-induced lymphocytopenia. Conclusions: Pre-treatment CEA and presence of LVI predicted less pathological nodal response post CRT for rectal cancer. LVI is a pathological finding, however, signs of vascular invasion can be detected on the pre-treatment MRI. These results could potentially be used to identify favourable responders to CRT and guide management strategies of rectal cancer especially when organ and function preservation are pursued.

A RAND/UCLA appropriateness study of the management of familial gastric cancer.

16 Background: Hereditary diffuse gastric cancer (HDGC) makes up 0.1-0.3% of all gastric cancers. Management of patients with HDGC is inconsistent and there is disagreement regarding management. METHODS A multi-disciplinary expert panel of 16 physicians from 6 countries scored 47 scenarios using the RAND/UCLA Appropriateness Methodology. Appropriateness was scored from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores (AS) from 1-3 were considered inappropriate, 4-6 uncertain, and 7-9, appropriate. Agreement was reached when 11 of 16 panelists scored the statement similarly. If a statement was agreed to be appropriate, it was given a necessity score (NS) in the same manner. AS and NS are reported if agreement was met. RESULTS Gastric cancer (GC) patients with a family history of diffuse gastric cancer (DGC), lobular breast cancer or multiple family members with GC should be referred for genetics assessment and multidisciplinary decision-making (AS 8.0). It is appropriate for patients with DGC to have CDH1 mutation testing in a family with: (1) two or more cases of GC, with at least one case of DGC diagnosed before the age of 50 (AS 8.0); (2) three or more cases of GC diagnosed at any age, one or more of which is DGC (AS 8.0); (3) a patient diagnosed with DGC and lobular breast cancer (AS 8.0); or (4) a patient diagnosed with DGC under the age of 35 (AS 7.0, NS 5.0). A prophylactic total gastrectomy should be offered to CDH1 mutation carriers 20 years or older (AS 7.0). CONCLUSIONS The Gastric Cancer Processes of Care panelists have outlined high risk patients in whom CDH1 mutation status should be determined, and cases in which a prophylactic gastrectomy is appropriate.