Gary B. Deutsch

Long-Term Survival with Long-Acting Somatostatin Analogues Plus Aggressive Cytoreductive Surgery in Patients with Metastatic Neuroendocrine Carcinoma.

BACKGROUND Long-acting somatostatin analogues (S-LAR) improve recurrence-free survival in patients with metastatic neuroendocrine tumor (NET) from gastrointestinal (GI) primary, but their impact on overall survival when combined with aggressive cytoreductive surgery is unclear. STUDY DESIGN We reviewed our institutional cancer database to identify patients who underwent cytoreductive surgery for metastatic NET from GI primary between December 1997 and June 2013. Additionally, a cohort selected from 3,384 metastatic neuroendocrine cases in the SEER-Medicare database (January 2003 to December 2009) was used to verify and expand on our results. RESULTS Most of the 49 patients from our institution had primary lesions in the small intestine (22 of 49 [44.9%]) or pancreas (14 of 49 [28.6%]); 37 patients (75.5%) had metastatic disease at initial diagnosis. These patients underwent 1 (32 of 49 [65.3%]), 2 (11 of 49 [22.4%]), or at least 3 (6 of 49 [12.3%]) surgical procedures; 33 patients (67.3%) underwent resection plus ablation, 19 (38.7%) underwent major hepatectomy, and 34 (69.4%) received S-LAR (29.4% administered preoperatively). Median follow-up was 112 months. Rates of 1-, 5-, 10-, and 15-year disease-specific survival (DSS) were 94%, 78%, 64%, and 31%, respectively, in the 34 patients undergoing aggressive cytoreductive surgery plus S-LAR. Of the SEER-Medicare population, 1,741 patients met inclusion criteria. The DSS for the 104 patients treated with combination therapy was 68.3% at 5 years and 60.6% at 10 years, as compared with 54.7% and 51.8%, respectively, for the 202 patients receiving surgery alone, and 50.0% and 36.0%, respectively, for the 342 patients receiving S-LAR alone (p < 0.0001). The group receiving neither treatment (n = 1,093) had 5-year and 10-year DSS of 34.3% and 26.3%, respectively. CONCLUSIONS Long-acting somatostatin analogues combined with aggressive cytoreductive surgery improves the long-term survival of select patients with metastatic NET from GI primary.

Laparoscopic vertical sleeve gastrectomy after open gastric banding in a patient with situs inversus totalis

While several equivalent alternatives are available in the bariatric algorithm, more recently the laparoscopic sleeve gastrectomy (SG) has been gaining traction as an effective means of weight loss in patients with morbid obesity. We present the case of a 39-year-old woman with situs inversus totalis, who was taken to the operating room for laparoscopic SG. The patient had previously undergone a failed open gastric banding procedure 20 months earlier. Awareness of the inherited condition before performing the operation allows for advanced planning and preparation. Subsequent modifications to the standard trocar placement help make the procedure more technically feasible. To our knowledge, this is the first published report of a laparoscopic SG after open gastric banding in a patient with situs inversus totalis. After encountering the initial disorientation, we believe experienced laparoscopic surgeons can perform this procedure successfully and safely.

Association of Surgical Treatment, Systemic Therapy, and Survival in Patients With Abdominal Visceral Melanoma Metastases, 1965-2014: Relevance of Surgical Cure in the Era of Modern Systemic Therapy

Importance Systemic therapy for metastatic melanoma has evolved rapidly during the last decade, and patient treatment has become more complex. Objective To evaluate the survival benefit achieved through surgical resection of melanoma metastatic to the abdominal viscera in patients treated in the modern treatment environment. Design, Setting, and Participants This retrospective review of the institutional melanoma database from the John Wayne Cancer Institute at Providence St Johns Health Center, a tertiary-level melanoma referral center, included 1623 patients with melanoma diagnosed as having potentially resectable abdominal metastases before (1969-2003) and after (2004-2014) advances in systemic therapy. Main Outcomes and Measures Overall survival (OS). Results Of the 1623 patients identified in the database with abdominal melanoma metastases, 1097 were men (67.6%), and the mean (SD) age was 54.6 (14.6) years. Of the patients with metastatic melanoma, 1623 (320 [19.7%] in the 2004-2014 period) had abdominal metastases, including 336 (20.7%) with metastases in the gastrointestinal tract, 697 (42.9%) in the liver, 138 (8.5%) in the adrenal glands, 38 (2.3%) in the pancreas, 109 (6.7%) in the spleen, and 305 (18.8%) with multiple sites. Median OS was superior in surgical (n = 392; 18.0 months) vs nonsurgical (n = 1231; 7.0 months) patients (P < .001). The most favorable 1-year and 2-year OS was seen after surgery for gastrointestinal tract (52% and 41%) and liver (51% and 38%) metastases, respectively. Multivariable analysis found increasing age (hazard ratio [HR], 1.01; 95% CI, 1.00-1.01; P = .02) and the presence of ulceration (HR, 1.21; 95% CI, 1.01-1.45; P = .04) were associated with a worse OS. Alternatively, treatment with metastasectomy (HR, 0.59; 95% CI, 0.46-0.74; P < .001) and metastases involving the gastrointestinal tract (HR, 0.65; 95% CI, 0.48-0.87; P = .004) were associated with a better OS. The systemic treatment era did not significantly affect outcomes (HR, 0.82; 95% CI, 0.67-1.02; P = .15). Overall, patients with gastrointestinal tract metastases undergoing complete, curative resection derived the greatest benefit, with a median OS of 64 months. Conclusions and Relevance To our knowledge, this series is the largest single-institution experience with abdominal melanoma metastases, demonstrating that surgical resection remains an important treatment consideration even in the systemic treatment era.

A Comparison Between Customized and Premixed Parenteral Nutrition Cost Really Matters

Background. Parenteral route is accepted for delivering nutrition when enteral feeding is not possible. Standardized premixed parenteral nutrition solution (SPNS) formulations are uniform in their ...

Predicting the incidence and timing of central nervous system disease in metastatic melanoma: Implications for surveillance and preventative therapy

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Surgical resection of metastatic melanoma in the era of immunotherapy and targeted therapy

Melanoma is the deadliest form of skin cancer and one of the few malignancies whose incidence is on the rise. The treatment of metastatic melanoma continues to be quite challenging, although in recent years, there has been significant progress. Current National Comprehensive Cancer Network guidelines list immunotherapy, chemotherapy, surgery and clinical trials as potential options for patients with metastatic disease but do not clearly recommend which is superior. Additionally, when utilizing combined modality treatment there are no clear guidelines for the optimal timing of surgery in the treatment of metastatic melanoma. In this paper we sought to compile the current evidence and on-going trials in order to provide a comprehensive review of the different options available and underway in regards to the treatment of metastatic melanoma. It is clear that with the responses now seen with systemic immunotherapies and targeted therapies, an expanded role for surgery is the logical next step.

A 45-Year Experience with Abdominal Melanoma Metastases: Is Surgical Cure Still Relevant in the Era of Modern Systemic Therapy?

METHODS: We examined our records for melanoma patients diagnosed with potentially resectable abdominal metastases before (1969-2001) and after (2002-2014) recent advances in systemic therapies to determine the survival impact of surgical treatment and metastatic site. Multivariable regression analysis included age, sex, primary tumor characteristics, regional nodal status, abdominal metastasis-free interval, and treatment era.

Abstract 859: Impact of obesity in melanoma outcomes: Analysis of data from a multinational randomized controlled sentinel lymph node trial

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA Introduction: In the United States and around the world, obesity rates have been rising. While rates of some cancers are higher in the obese population, the data related to melanoma incidence is conflicting. Furthermore, the impact of obesity on outcomes in melanoma is unknown. We aim to discern the impact of rising body mass index (BMI) on survival and surgical outcomes in melanoma. Methods: The first Multicenter Selective Lymphadenectomy Trial (MSLT-I) is a multinational randomized controlled trial evaluating the role of sentinel lymph node biopsy in melanoma. We queried this prospective trial database for all patients with height and weight data at the time of enrollment into the trial. Patients were stratified by BMI as obese (BMI ≥30) or not obese (BMI<30). Patient age, sex, Breslow thickness, and lymph node status were assessed for their impact on melanoma specific survival (MSS) and surgical complications. Pathologic data and primary site data were also analyzed with regards to obesity. Results: A total of 1,839 patients were included in the analysis, 741 from the observation group (OBS, no sentinel lymph node biopsy), and 1098 from the sentinel node group (SLN). 376 patients (20%) were obese and 1,463 (80%) were not. MSS at 5 years was 88.8% (±1.7) for obese patients and 82.2% (±1.0) for non-obese patients (p = 0.0512, univariate). A small minority of patients were underweight (n = 27, 1.5%, BMI < 18.5) and they experienced a trend towards worse survival than obese patients (5-yr MSS 79.0% ±8.4). We assessed BMI in a multivariable analysis as a continuous and categorical variable and found a consistent direct association with MSS (for BMI ≥30: HR 0.69 [0.52-0.91], p = 0.010). Multivariable analysis identified decreased BMI, male sex, older age, thicker Breslow level, lymphatic spread, and ulceration as significant predictors of worse survival. Despite a trend towards increased local complications in the obese (23.1% vs. 20.5%, p = 0.267), there was no significant difference in rate of complications based on BMI. The distribution of primary melanoma sites was not different among obese and non-obese populations and there was no difference in pathologic variables (Breslow thickness, ulceration, regression, number of lymph nodes excised, or presence of tumor infiltrating lymphocytes). Conclusions: In this prospective trial database, obesity offers a protective effect on survival without a significantly increased rate of complications. Future studies may look for obesity-related factors and mechanisms to explain the improved outcomes. Citation Format: Daniel D. Kirchoff, Gary B. Deutsch, Stacey L. Stern, Simon Lavotshkin, Delphine J. Lee, Leland J. Foshag, Mark B. Faries. Impact of obesity in melanoma outcomes: Analysis of data from a multinational randomized controlled sentinel lymph node trial. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 859. doi:10.1158/1538-7445.AM2015-859