Eisar Al-Sukhni

Current Delivery of Hyperthermic Intraperitoneal Chemotherapy with Cytoreductive Surgery (CS/HIPEC) and Perioperative Practices: An International Survey of High-Volume Surgeons.

BackgroundCytoreductive surgery and heated intraperitoneal chemotherapy (CS/HIPEC) is performed for selected indications at a limited number of specialized centers worldwide. Currently there is no standardized approach to the perioperative care process. We sought to capture current practices in the perioperative management of patients who undergo CS/HIPEC at high-volume centers.MethodsSurgeon members of the American Society of Peritoneal Surface Malignancies working at high-volume CS/HIPEC centers (>10 cases/year) were invited to complete an online survey. The survey included questions relating to preoperative preparation of patients, intraoperative practices, and postoperative care.ResultsNinety-seven surgeons from five continents completed the survey (response rate 55%). The majority (80%) practiced in academic environments. Most respondents (68%) indicated that a formal preoperative preparatory pathway for CS/HIPEC surgery existed at their centers, but few (26%) had used enhanced recovery protocols in this group of patients. Whereas the intraoperative technical practices of the CS/HIPEC procedure were relatively consistent across respondents, there was little agreement on pre- and postoperative care practices, including use of mechanical bowel preparation, nutritional supplementation, methods of perioperative analgesia, timing of physical therapy and ambulation, nasogastric tube and Foley removal, intravenous fluids, blood transfusion parameters, and postoperative use of deep-vein thrombosis prophylaxis and antibiotics.ConclusionsPerioperative care practices for CS/HIPEC are widely variable nationally and internationally. Standardization of such practices offers an opportunity to incorporate evidence-based interventions and may enhance patient outcomes and improve care standards across all centers that offer this procedure.Cytoreductive surgery and heated intraperitoneal chemotherapy (CS/HIPEC) is performed for selected indications at a limited number of specialized centers worldwide. Currently there is no standardized approach to the perioperative care process. We sought to capture current practices in the perioperative management of patients who undergo CS/HIPEC at high-volume centers. Surgeon members of the American Society of Peritoneal Surface Malignancies working at high-volume CS/HIPEC centers (>10 cases/year) were invited to complete an online survey. The survey included questions relating to preoperative preparation of patients, intraoperative practices, and postoperative care. Ninety-seven surgeons from five continents completed the survey (response rate 55%). The majority (80%) practiced in academic environments. Most respondents (68%) indicated that a formal preoperative preparatory pathway for CS/HIPEC surgery existed at their centers, but few (26%) had used enhanced recovery protocols in this group of patients. Whereas the intraoperative technical practices of the CS/HIPEC procedure were relatively consistent across respondents, there was little agreement on pre- and postoperative care practices, including use of mechanical bowel preparation, nutritional supplementation, methods of perioperative analgesia, timing of physical therapy and ambulation, nasogastric tube and Foley removal, intravenous fluids, blood transfusion parameters, and postoperative use of deep-vein thrombosis prophylaxis and antibiotics. Perioperative care practices for CS/HIPEC are widely variable nationally and internationally. Standardization of such practices offers an opportunity to incorporate evidence-based interventions and may enhance patient outcomes and improve care standards across all centers that offer this procedure.

Lymphovascular and perineural invasion are associated with poor prognostic features and outcomes in colorectal cancer: A retrospective cohort study

BACKGROUND Lymphovascular and perineural invasion (LVI and PNI) are associated with poor outcomes in several cancers. We sought to identify clinical variables associated with LVI and PNI in colorectal cancer (CRC) and to determine their impact on survival. METHODS A retrospective review was performed of the National Cancer Data Base (NCDB), 2004-2011. Patients with CRC and a documented LVI or PNI status were included. Multivariate analysis was conducted to examine the associations between clinical variables and LVI/PNI, PNI and survival, and LVI/PNI and lymph node (LN) status in patients with T1 and T2 tumors. RESULTS In total, 158,777 patients were included. LVI status was documented for 139,026 patients, 26.3% of whom were positive. PNI status was documented in 142,034 patients, 11.1% of whom were positive. The multivariable model identified a number of pathologic and clinical characteristics associated with the presence of LVI and PNI, including a number of features of advanced CRC. PNI was independently associated with reduced survival (HR 3.55, 95%CI 1.78-7.09). In T1 or T2 tumors, LVI and PNI were significantly associated with LN involvement. CONCLUSIONS LVI and PNI are associated with advanced CRC. PNI is an independent poor prognostic marker for survival in CRC. LVI and PNI are associated with LN involvement in T1 and T2 tumors. Documentation of LVI and PNI status on biopsy specimens may help in prognostication and decision-making in the management of these early tumors.

Predicting Individualized Postoperative Survival for Stage II/III Colon Cancer Using a Mobile Application Derived from the National Cancer Data Base.

BACKGROUND Prediction calculators estimate postoperative survival and assist the decision-making process for adjuvant treatment. The objective of this study was to create a postoperative overall survival (OS) calculator for patients with stage II/III colon cancer. Factors that influence OS, including comorbidity and postoperative variables, were included. STUDY DESIGN The National Cancer Data Base was queried for patients with stage II/III colon cancer, diagnosed between 2004 and 2006, who had surgical resection. Patients were randomly divided to a testing (nt) cohort comprising 80% of the dataset and a validation (nv) cohort comprising 20%. Multivariable Cox proportional hazards regression of nt was performed to identify factors associated with 5-year OS. These were used to build a prediction model. The performance was assessed using the nv cohort and translated into mobile software. RESULTS A total of 129,040 patients had surgery. After exclusion of patients with carcinoma in situ, nonadenocarcinoma histology, more than 1 malignancy, stage I or IV disease, or missing data, 34,176 patients were used in the development of the calculator. Independent predictors of OS included patient-specific characteristics, pathologic factors, and treatment options, including type of surgery and adjuvant therapy. Length of postoperative stay and unplanned readmission rates were also incorporated as surrogates for postoperative complications (1-day increase in postoperative stay, hazard ratio [HR] 1.019, 95% CI 1.018 to 1.021, p < 0.001; unplanned readmission vs no readmission HR 1.35, 95% CI 1.25 to 1.45, p < 0.001). Predicted and actual 5-year OS rates were compared in the nv cohort with 5-year area under the curve of 0.77. CONCLUSIONS An individualized, postoperative OS calculator application was developed for patients with stage II/III colon cancer. This prediction model uses nationwide data, culminating in a highly comprehensive, clinically useful tool.

Age-related rates of colorectal cancer and the factors associated with overall survival

Background The purpose of this study was to identify differences in both demographic and pathologic factors associated with the age-related rates of colorectal cancer (CRC) and overall survival (OS). Methods The National Cancer Data Base (NCDB), 2004-2013, was queried for patients with CRC. Patients were stratified by age (≤50 vs. ≥60 years). Multivariable analysis was performed to identify factors associated with OS. Results A total of 670,030 patients were included; 488,121 with colon, and 181,909 with rectal or rectosigmoid cancer. For colon cancer, patients ≤50 years had higher proportions of pathologic stage III and IV disease than patients ≥60 (III: 33.7% vs. 28.6%, IV: 25.5% vs. 14.3%, respectively; P≤0.001). Similar differences were found for patients with rectal cancer (III: 35.8% vs. 28.6%, IV: 16.5% vs. 11.6%, respectively for age ≤50 and ≥60 years; P≤0.001). More aggressive pathologic factors were identified in the ≤50 cohort and were associated with worse OS, including higher tumor grade, lymphovascular invasion (LVI), perineural invasion (PNI), and elevated serum carcinoembryonic antigen (CEA). Disparities associated with OS were also identified for both colon and rectal cancer. For patients ≤50 with CRC, African-American and Hispanic race, lower income and lower education were associated with increased risk of mortality compared to the ≥60 cohort. Conclusions There are clear differences in biological factors and in racial and socioeconomic disparities of patients with early onset CRC. Earlier screening should be seriously considered in patients under 50 years who are African-American and Hispanic, as these populations present with more aggressive and advanced disease.

Sarcoidosis Presenting with Primary Pancreatic Manifestations: A Case Report and Review of the Literature

Background: Pancreatic sarcoidosis in the absence of systemic sarcoidosis is a rare entity with few reported cases. Most described cases are in black females and typically involve the head of the pancreas. This report describes a case of sarcoidosis involving the tail of the pancreas in a Caucasian male. Case Presentation: A previously healthy 48 year old Caucasian male presented with abdominal pain following an episode of heavy alcohol ingestion. Serum amylase was elevated and imaging was consistent with acute pancreatitis. Workup ruled out gallstones or autoimmune pancreatitis and his presentation was attributed to alcohol use. Despite abstaining from further alcohol intake, his abdominal pain persisted for several weeks, and subsequent imaging revealed persistent pancreatitis with narrowing of the pancreatic duct in the tail with an associated area of hypoechogenicity. FNA of this region showed rare benign ductal epithelial cells without evidence of malignancy. He was offered resection for his ongoing symptoms and to rule out a malignancy as an underlying etiology. He underwent laparoscopic distal pancreatectomy and splenectomy. Pathology from the resected specimen showed non-necrotizing granulomas involving the pancreas, spleen and the majority of 25 resected lymph nodes. Acid-fast bacteria and Gomori methenamine silver stains were negative for fungal or mycobacterial organisms and there was no evidence of polarizable materials within these granulomas. These findings are consistent with sarcoidosis. The patient recovered and was discharged without complication. He was subsequently referred to a rheumatologist for further workup and management. Conclusions: Sarcoidosis can present with isolated pancreatic symptoms and may be difficult to distinguish from other causes of pancreatitis. In the absence of systemic disease, surgery alone may be both diagnostic and therapeutic.

Interpreting the Evidence on Neoadjuvant Treatment of Esophageal Adenocarcinoma : In Reply to Yim and Colleagues

Cancer Data Base (NCDB). This demonstrated no significant difference in long-term survival when neoadjuvant chemoradiotherapy (nCRT) and neoadjuvant chemotherapy (nCT) were compared for resectable adenocarcinoma of the gastroesophageal junction. Another group, again using the NCDB confirmed these findings. The results are in contrast to our use of “meta-data” in a networked meta-analysis of 7 different treatment modalities, encompassing 33 RCTs, which compared surgery with neoadjuvant and adjuvant therapies to produce 21 treatment comparisons. This demonstrated nCRT conferred a survival benefit when resectable esophageal cancer was considered. This disparity arises for several reasons. Randomized controlled trials (RCT) have stringent inclusion criteria with methods to minimize bias and confounding to obtain precise measures of efficacy and clinical effectiveness. These homogenous populations are different than entire populations, which include elderly and comorbid patients and those with higher disease stages. Observational studies have external validity, which better represents usual care, and they provide insight into the delivery of care across those excluded from RCTs. A significant limitation of observational studies is confounding from unrecognized or unmeasurable factors in the study population that range from changes in disease biology to new treatment regimens or changes in the indication for treatment. Although the confounding can be mitigated, it cannot be completely eliminated. Moreover, different treatment schedules have been likely used in the NCDB, and the effect of this can be underestimated. The NCDB itself promotes local quality assessment by collecting data across small community hospitals to large academic medical centers for more than 70% of the cancer cases diagnosed in the US. Although there has been reported variation in state coverage for esophageal cancer, lower coverage was also seen with increasing age and different ethnicities. The 2008 NCDB peer review acknowledged that the validation of the accuracy and data completeness required further action. Because the NCDB includes only the Committee on Cancer (CoC)accredited facilities, studies based on the NCDB have a high likelihood of hospital selection bias. Part of the basis for the NCDB has been to improve outcomes, but ensuring that radiotherapy and surgery are delivered to the highest standards. However, the quality of care for esophageal cancer patients reported in the NCDB has been scrutinized due to the variations in practice reported. Both RCTs and large population-based analyses have limitations and benefits and may yield conflicting results, depending on the questions asked. The real question is, how should we use this information to treat the individual patient with esophageal cancer who sat in front of us in clinic? We need to understand that care needs to be taken when interpreting results in isolation, and pragmatic study designs may be needed to supplement decision-making for our group of patients in the future.

Surgical Management of the Colorectal Cancer Patient with Simultaneous Liver and Lung Metastases

Although the liver and lung are the two most common sites of metastatic disease for colon and rectal cancer, management of simultaneous liver and lung metastases is ill-defined. The objective of this review is not only to review long-term outcomes after resection of simultaneous colorectal liver and lung metastases but also apply recent data regarding the (1) evolution of indeterminate pulmonary nodules discovered during staging evaluation of colorectal liver metastases, (2) impact of genetic mutations in colorectal cancer on disease outcomes, and (3) influence of lung metastases on overall survival outcomes to the management of patients with simultaneous colorectal liver and lung metastases.