John B. Ammori

Dermatofibrosarcoma Protuberans: How Wide Should We Resect?

BackgroundDermatofibrosarcoma protuberans (DFSP) is a rare dermal tumor with local recurrence rates ranging from 0 to 50%. Controversy exists regarding margin width and excision techniques, with some advocating Mohs surgery and others wide excision (WE). We reviewed the experience in two tertiary centers using WE with total peripheral margin pathologic evaluation.Materials and MethodsInstitutional Review Board approved retrospective review of patients with DFSP from 1991 to 2008. Patients had initial WE using 1–2xa0cm margins with primary or delayed closure; further excision was done whenever feasible for positive margins. Pathologic analysis included en face sectioning. We evaluated margin width, number of WE, reconstruction methods, radiation, and outcomes.ResultsA total of 206 DFSP lesions in 204 patients (76 males, 128 females), median age 41xa0years (range 1–84) were treated. Locations were trunk (135), extremities (43), and head and neck (28). The median number of excisions to achieve negative margins was 1 (range 1–4) with a median excision width of 2xa0cm (range 0.5–3xa0cm). Closure techniques included primary closure (142; 69%), skin grafting (52; 25%), and tissue flaps (9; 4%). There were 9 patients who received postoperative radiation, 6 for positive margins after maximal surgical excision. At a median follow-up of 64xa0months (range 1–210), 2 patients (1%) with head and neck primaries recurred locally.ConclusionsUsing a standardized surgical approach including meticulous pathologic evaluation of margins, a very low recurrence rate (1%) was achieved with relatively narrow margins (median 2xa0cm), allowing primary closure in 69% of patients. This approach spares the additional morbidity associated with wider resection margins and in our experience represents the treatment of choice for DFSP occurring on the trunk and extremities.

Up and down or side to side? A systematic review and meta-analysis examining the impact of incision on outcomes after abdominal surgery

BACKGROUNDnThe aim of this study was to examine whether midline, paramedian, or transverse incisions offer potential advantages for abdominal surgery.nnnDATA SOURCESnWe searched MEDLINE, Embase, Web of Science, and The Cochrane Central Register of Controlled Trials from 1966 to 2009 for randomized controlled trials comparing incision choice.nnnMETHODSnWe systematically assessed trials for eligibility and validity and extracted data in duplicate. We pooled data using a random-effects model.nnnRESULTSnTwenty-four studies were included. Transverse incisions required less narcotics than midline incisions (weighted mean difference = 23.4 mg morphine; 95% confidence interval [CI], 6.9 to 39.9) and resulted in a smaller change in the forced expiratory volume in 1 second on postoperative day 1 (weighted mean difference = -6.94%; 95% CI, -10.74 to -3.13). Midline incisions resulted in higher hernia rates compared with both transverse incisions (relative risk = 1.77; 95% CI, 1.09 to 2.87) and paramedian incisions (relative risk = 3.41; 95% CI, 1.02 to 11.45).nnnCONCLUSIONSnBoth transverse and paramedian incisions are associated with a lower hernia rate than midline incisions and should be considered when exposure is equivalent.

Folate receptor-α expression in resectable hepatic colorectal cancer metastases: patterns and significance.

Folate receptor alpha (FRα), encoded by folate receptor 1 (adult) gene, has emerged as a cancer biomarker and potential therapeutic target. In addition, its expression in tumors may offer prognostic information. The aim of this study was to assess the prognostic value of FRα expression and other common molecular markers in resected liver metastases from colorectal cancer. To maximize potential biological differences, we selected two groups of patients with markedly different outcomes as study subjects. Immunohistochemical analysis of FRα expression and other common markers (thymidylate synthase, p53, p27, BCL2, ki67, MLH1, MSH2 and MGMT) on tissue microarrays was carried out on samples from 160 patients; 56 patients survived at least 10 years following liver resection, and 104 died within 2 years of surgery. These markers were evaluated and compared with standard clinical predictors of outcome including a previously validated clinical risk score. Our results showed that in addition to known clinical risk factors, FRα positivity was significantly associated with the early death group (32% compared with 13%; P=0.03). None of the other common molecular markers were differentially expressed between the two groups. On multivariate analysis, clinical risk score, margin status and FRα expression were independently associated with outcome. Specific multivariate comparisons confirmed that FRα expression was associated with outcome independent of the clinical risk score and margin. These data demonstrate that FRα expression is present in a subset of resected hepatic colorectal cancer metastases, and this marker is independently associated with survival after hepatic resection. The prognostic value of FRα expression and the utility of FRα-targeted therapies in stage-IV colorectal cancer patients deserve further exploration.

Treatment and Outcome of Patients with Gastric Remnant Cancer After Resection for Peptic Ulcer Disease

BackgroundTo study the pathology, treatment, and outcome of patients with gastric remnant cancer (GRC) after resection for peptic ulcer disease (PUD).MethodsReview of a prospective gastric cancer database identified patients with GRC after gastrectomy for PUD. Clinicopathologic and treatment-related variables were obtained. Multivariate analysis was performed for factors associated with disease-specific survival (DSS).ResultsFrom January 1985 to April 2010, 4402 patients with gastric adenocarcinoma were treated at our institution and 105 patients (2.4%) had prior gastrectomy for PUD. Prior resections were most often Billroth II (Nxa0=xa097, 92%). The median time from initial resection to development of GRC was 32xa0years (3–60xa0years), and the majority of tumors were located at the gastrointestinal anastomosis (Nxa0=xa072, 69%). Median DSS was 1.3xa0years (0.6–2.1xa0years). Patients who had resection had a significantly better outcome than patients who did not have resection (median DSS 5 vs 0.35xa0years, Pxa0<xa0.0001). Factors associated with DSS on multivariate analysis included advanced T-stage (HR 16.5 (CI 2.2–123.4), Pxa0=xa0.0006) and lymph node metastasis (HR 1.1 (CI 1.0–1.2), Pxa0<xa0.0001). Stage-specific survival following R0 resection was similar to patients with conventional gastric cancer.ConclusionsPatients have a lifetime risk for the development of GRC following resection for PUD. As with conventional gastric cancer, determinants of survival of patients with GRC include advanced T stage and nodal metastasis. Patients with GRC amenable to curative resection exhibit the best DSS and have stage-specific outcomes similar to patients with conventional gastric cancer.

Conversion to Complete Resection and/or Ablation Using Hepatic Artery Infusional Chemotherapy in Patients with Unresectable Liver Metastases from Colorectal Cancer: A Decade of Experience at a Single Institution

BackgroundWhen feasible, surgical treatment of colorectal liver metastases (CRLM) is the treatment of choice. Regional hepatic artery infusional (HAI) chemotherapy effectively treats CRLM. The combination of HAI and systemic chemotherapy may downsize tumors and allow for complete resection and/or ablation (R/A). This study analyzes the combination of HAI and systemic chemotherapy for treating unresectable CRLM, focusing on conversion to complete R/A.MethodsAll patients with unresectable CRLM treated with HAI and systemic chemotherapy from 2000 to 2009 were included. Patients who responded sufficiently to undergo complete R/A were compared to those who did not convert. Survival was compared using a landmark analysis to account for bias.ResultsA total of 373 patients were included; 93 patients (25xa0%) subsequently underwent complete R/A. The percentage of patients submitted to complete R/A increased from 16xa0% during 2000–2003 to 30xa0% during 2004–2009. Factors associated with conversion on multivariate analysis were more recent treatment (2004–2009), no prior chemotherapy, clinical risk score <3, treatment on clinical protocol, and younger age. Median and predicted 5-year survival from the time of HAI pump placement was 59xa0months and 47xa0%, respectively, in the patients who converted to complete R/A, compared with 16xa0months and 6xa0%, respectively in those who did not (pxa0<xa00.001).ConclusionsDespite extensive disease, 25xa0% of patients with unresectable CRLM responded sufficiently to undergo complete R/A following HAI plus systemic chemotherapy. Combination HAI and systemic chemotherapy is an effective strategy to convert patients to complete resection with an associated excellent long-term survival.

Predictors of surgical quality for retroperitoneal sarcoma: Volume matters

The volume‐outcome relationship is well recognized. We sought to investigate this relationship in retroperitoneal sarcoma (RPS) surgery.

Hepatic artery infusional chemotherapy in patients with unresectable colorectal liver metastases and extrahepatic disease.

Hepatic arterial infusional (HAI) chemotherapy combined with systemic chemotherapy is effective palliative therapy for unresectable colorectal cancer liver metastases (CRLM). Some patients considered for HAI have evidence of minimal extrahepatic disease (EHD), and the role of HAI in these situations is unknown.

Regional Hepatic Chemotherapies in Treatment of Colorectal Cancer Metastases to the Liver

Colorectal cancer metastases to the liver are primarily supplied by the hepatic artery. Therefore, delivery of regional chemotherapy via the hepatic artery is a viable treatment option. Chemotherapy can be delivered in high concentration to the liver with minimal systemic toxicity. Hepatic artery infusional (HAI) chemotherapy both alone and in combination with systemic chemotherapy in the treatment of isolated hepatic metastases from colorectal cancer has resulted in high response rates and increased resection rates for previously unresectable liver disease. Regional chemotherapy can also be used as adjuvant treatment after complete resection of liver metastases to reduce hepatic recurrences. The combination of HAI therapy with modern systemic chemotherapy has a role in the palliative, adjuvant, and neoadjuvant settings.

MP69-14 ACADEMIC AND HIGH-VOLUME HOSPITALS ARE ASSOCIATED WITH IMPROVED OUTCOMES IN THE MANAGEMENT OF RETROPERITONEAL SARCOMA

RESULTS: We identified 377,248 patients with advanced GU malignancies between 2004-2014. Only 24,224 (6%) were referred to palliative care and 12,284 (15%) died within 1 year of diagnosis. Multivariable analysis revealed that advanced disease and death within one year of diagnosis were most strongly associated with palliative care. Additionally, older age, more co-morbidities, uninsured, female gender, lower income and decreased education and treatment at low volume and academic centers were associated with utilization of palliative care, p<0.05, respectively (Table). Over the study period there was a significant, although, modest increase in the utilization of palliative services (5.5% in 2004 to 7.7% in 2014, p<.001). CONCLUSIONS: Relatively few patients with advanced GU malignancies receive palliative care. While referrals increased in recent years, palliative care remains under-utilized and remains an opportunity for educational engagement with patients and physicians alike.