Kelly R. Haisley

Association of Intervals Between Neoadjuvant Chemoradiation and Surgical Resection With Pathologic Complete Response and Survival in Patients With Esophageal Cancer.

Importance Pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (CRT) may be a clinical prognostic marker of superior outcomes. In patients with esophageal cancer, pCR is associated with increased survival. While mechanisms for increasing the likelihood of pCR remain unknown, in other solid tumors, higher rates of pCR have been associated with longer time intervals between CRT completion and surgical procedures. Objective To determine the association between time intervals from the completion of CRT to surgical procedure with rates of pCR in patients with esophageal cancer. Design, Setting, and Participants A prospectively maintained multidisciplinary foregut database was reviewed for consecutively enrolled patients with esophageal cancer from January 2000 to July 2015 presenting for surgical evaluation at a single National Cancer Institute-designated cancer center within a quaternary academic medical center. Interventions Included patients successfully completed neoadjuvant CRT followed by esophagectomy. Main Outcomes and Measures Rate of pCR by logistic regression based on a categorized time interval (ie, 0 to 42, 43 to 56, 57 to 70, 71 to 84, 85 to 98, and 99 or more days) from the completion of CRT to surgical resection, adjusted for clinical stage, demographic information, and CRT regimen. Results Of the 234 patients who met inclusion criteria, 191 (81.6%) were male, and the median (range) age was 64 (58-70) years; 206 (88.0%) were diagnosed as having adenocarcinoma, and 65 (27.9%) had a pCR. Patients in the 85 to 98-day group had significantly increased odds of a pCR compared with other groups (odds ratio, 5.46; 95% CI, 1.16-25.68; P = .03). No significant differences in survival were seen between time groups overall or among patients with residual tumor. Conclusions and Relevance This study suggests that a time interval of 85 to 98 days between CRT completion and surgical resection is associated with significantly increased odds of a pCR in patients with esophageal cancer. No adverse association with survival was detected as a result of delaying resection, even in patients with residual tumor.

Neoadjuvant chemoradiotherapy with concurrent cisplatin/5-fluorouracil is associated with increased pathologic complete response and improved survival compared to carboplatin/paclitaxel in patients with locally advanced esophageal cancer.

Trimodal therapy consisting of neoadjuvant chemoradiation followed by esophagectomy has become the standard of care in North America for locally advanced esophageal cancer. While cisplatin/5-fluorouracil has been a common concurrent chemotherapy regimen since the 1980s, its utilization has declined in recent years as the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) trial regimen of carboplatin/paclitaxel has become widely adopted. The efficacy of the CROSS regimen compared to alternate chemotherapy choices, however, has rarely been evaluated when each is used as a component of a trimodal treatment approach. The aim of this study is to report our institutional experience with these two concurrent chemotherapy regimens at a specialized esophageal cancer center.We performed an Institutional Review Board-approved retrospective review of a prospectively maintained institutional foregut registry from a single National Cancer Institute-designated cancer center. Esophageal cancer patients who completed trimodal therapy with a chemotherapy regimen of either carboplatin/paclitaxel or cisplatin/5-fluorouracil were identified and divided into groups based on their chemotherapy regimens. Multivariable logistic regression was used to analyze pathologic complete response rates, while the Kaplan-Meier and Cox proportional hazards models were utilized to evaluate recurrence-free and overall survival. Analytical models were adjusted for age, clinical stage, radiation dose, histologic subtype (adenocarcinoma vs. squamous cell carcinoma), and time interval from completion of neoadjuvant therapy to surgery.One hundred and forty-two patients treated between January of 2000 and July of 2015 were identified as meeting inclusion criteria. Of this group, 87 had received the CROSS regimen of carboplatin/paclitaxel, while 55 had completed cisplatin/5-fluorouracil. Multivariable analysis demonstrated that the cisplatin/5-fluorouracil.group had an increased odds of pathologic complete response (odds ratio = 2.68, 95% confidence interval, P = 0.032), as well as significantly improved recurrence-free survival (hazard ratio = 0.39, 95% confidence interval 0.21-0.73, P = 0.003) and overall survival (hazard ratio = 0.46, 95% confidence interval 0.24-0.87, P = 0.016), compared to the carboplatin/paclitaxel group.Concurrent chemotherapy with cisplatin/5-fluorouracil in locally advanced esophageal cancer is associated with higher rates of pathologic complete response and improved recurrence-free and overall survival compared to the CROSS regimen of carboplatin/paclitaxel. This suggests that, for select patients, alternate neoadjuvant chemotherapy approaches, such as cisplatin/5-fluorouracil, merit reconsideration as potential primary treatment choices in the management of this highly morbid disease.

Long-Term Follow-Up of Bariatric Patients

Our emerging recognition of the chronic and relapsing nature of the metabolic dysfunction that contributes to obesity, as well as the numerous life-threatening comorbidities related to excess weight, dictates the importance of long-term follow-up in obese populations. This tenet cannot be overstated in the success of bariatric surgery patients. While follow-up has frequently been relegated to primary care personnel in the past, recent investigations have shown the benefit of longitudinal monitoring by a multidisciplinary bariatric team. Such support is associated with greater improvements in sustained weight loss, prevention of vitamin deficiencies, and better maintenance of comorbidities. Establishing a successful long-term follow-up protocol is vital for bariatric practitioners in order to optimize patient outcomes. This should include but is not limited to a standard clinic visit schedule, periodic laboratory monitoring, ongoing dietary counseling, and bariatric support groups. In addition, specialty providers such as psychologists and physical therapists should be available to help guide patients successfully through the myriad changes that accompany extreme weight loss.

Node-Negative Esophageal Cancer With Short-Interval Isolated Metastasis to the Gallbladder: A Case Report

A 55 year old male smoker presented with clinical T3N0 esophageal adenocarcinoma of the GE junction. He completed neoadjuvant chemoradiotherapy with carboplatin/paclitaxel and 5040cGy of radiation. He had limited clinical response on restaging but no evidence of metastatic disease and completed a minimally invasive three field esophagectomy. This was complicated by a chyle leak requiring thoracic duct embolization from which he recovered well. Surgical pathology showed no apparent nodal disease or metastases but a poorly differentiated primary tumor with signet-cell features. Approximately 3 months after his surgery, he developed right upper quadrant abdominal pain and elevated liver function tests and was taken for laparoscopic cholecystectomy. Gallbladder pathology demonstrated poorly differentiated adenocarcinoma with extensive lymphovascular invasion with immunohistochemistry analysis and comparison with the original surgical specimen confirming metastatic adenocarcinoma of esophageal origin. Literature review suggests that signet cell features and limited response to neoadjuvant therapy point to a more aggressive biology in esophageal cancer and increase the risk of metastatic disease, even in the setting of node negativity.

Major Barbara Stimson: A Historical Perspective on the American Board of Surgery Through the Accomplishments of the First Woman to Achieve Board Certification

&NA;Dr. Barbara Bartlett Stimson, AB, MD, MedScD, FACS (1898–1986) was a pioneering orthopedic surgeon from a prominent American family who, in 1940, became the first woman certified by the American Board of Surgery (ABS, certificate number 860). It would be another 7 years and approximately 2500 candidates before the next female surgeon would be certified. A member of the third class to admit women to Columbia Medical School and the second female surgical resident to complete training at Columbia-Presbyterian Medical Center, Dr. Stimson was a confident and exceptionally accomplished trailblazer for women in surgery. In this biographical sketch based upon documents from the ABS, and the archives of Vassar College and the College of Physicians and Surgeons at Columbia-Presbyterian Medical Center, Dr. Stimsons motivations, attitudes, and unique accomplishments emerge as testimony to the exceptional career of this driven, self-possessed woman. Stimson was undaunted by the sex-based conventions of her time, and achieved a notable career as a surgeon in the profession she loved; first honing her skills at a busy urban fracture service in New York, then serving with distinction in the Royal Army Medical Corps during World War II, and finally returning to the states to become a respected leader in her field. Her life story and unprecedented ABS certification affirm her conviction that proven skill and ability can be used as a means of overcoming unfounded biases, and helped pave the way for future generations of board certified female surgeons in the United States.

Surgical Management of GERD: Recommendations for Patient Selection and Preoperative Work-Up

While first-line therapy for uncomplicated gastroesophageal reflux disease (GERD) continues to be medical management with proton pump inhibitors (PPIs), anti-reflux surgery remains an important tool in the stepwise management of the disease. In general, surgery is justified in patients with GERD symptoms that have been present for an extended period of time (typically greater than 1 year), who have objectively documented reflux, and who have failed medical therapy, either through an inability to tolerate medications, or by suffering from persistent symptoms despite adequate medical therapy. Because surgical approaches vary depending on esophageal function and anatomy, patients must be carefully evaluated prior to operative intervention. Given the complex physiology of GERD and its multitude of potential effects on the esophagus, there is no single test that can provide all the essential information needed to plan a safe and appropriate operation. Thus, a thorough, multimodal preoperative evaluation is necessary. This should include a detailed history and physical, as well as objective, evaluation of the degree and severity of reflux through upper endoscopy and/or pH monitoring. Additionally, it is vital to document esophageal anatomy and function with upper GI series and esophageal manometry prior to embarking on surgery. On completion of this evaluation, the surgeon should be able to discern whether or not the patient’s symptoms are compatible with and correlate to the presence of objectively documented pathological reflux, and whether there is any indication of abnormal anatomy or function that would require alterations of surgical approach. Armed with this information, patients can be selected and managed appropriately, allowing us to optimize surgical outcomes in anti-reflux procedures.