Ponnandai Somasundar

Obstructive Jaundice Expands Intrahepatic Regulatory T Cells, Which Impair Liver T Lymphocyte Function but Modulate Liver Cholestasis and Fibrosis

Although obstructive jaundice has been associated with a predisposition toward infections, the effects of bile duct ligation (BDL) on bulk intrahepatic T cells have not been clearly defined. The aim of this study was to determine the consequences of BDL on liver T cell phenotype and function. After BDL in mice, we found that bulk liver T cells were less responsive to allogeneic or syngeneic Ag-loaded dendritic cells. Spleen T cell function was not affected, and the viability of liver T cells was preserved. BDL expanded the number of CD4+CD25+Foxp3+ regulatory T cells (Treg), which were anergic to direct CD3 stimulation and mediated T cell suppression in vitro. Adoptively transferred CD4+CD25− T cells were converted into Treg within the liver after BDL. In vivo depletion of Treg after BDL restored bulk liver T cell function but exacerbated the degrees of inflammatory cytokine production, cholestasis, and hepatic fibrosis. Thus, BDL expands liver Treg, which reduce the function of bulk intrahepatic T cells yet limit liver injury.

Feasibility of purely laparoscopic resection of locally advanced rectal cancer in obese patients.

BackgroundTotally laparoscopic (without hand-assist) resection for rectal cancer continues to evolve, and both obesity and locally advanced disease are perceived to add to the complexity of these procedures. There is a paucity of data on the impact of obesity on perioperative and oncologic outcomes for totally-laparoscopic rectal cancer resection (TLRR) for locally advanced disease.MethodsIn order to identify potential limitations of TLRR, a single-institution database was queried and identified 26 patients that underwent TLRR for locally advanced rectal cancers (T3/T4) over a three-year period. Patients were classified as normal-weight (NW, body mass index (BMI)=18.5 to 24.9kg/m2), overweight (OW, BMI=25 to 29.9kg/m2) and obese (OB, BMI >/= 30kg/m2). Perioperative outcomes, lymph node harvest and margin status were assessed.ResultsSeven patients were classified as NW (26.9%), 12 as OW (46.2%) and 7 as OB (26.9%). Age, tumor stage, gender and American Society of Anesthesiologists (ASA) scores were similar. OB had more co-morbidities (median 3.0, range 0.0 to 5.0 vs. 2.0, range 0.0 to 3.0 for NW and 1.0, range 0.0 to 3.0 for OW). Five patients had tumors <5cm from anal verge (NW=2; OW=1; OB=2). A median of 19.0, range 9.0 to 32.0; 20.0, range 9.0 to 46.0 and 19.0, range 15.0 to 31.0 lymph nodes were retrieved in the NW, OW and OB, respectively (Not Significant (NS)). Median node ratios for NW, OW and OB were 0.32, 0.13 and 0.00, respectively. All groups had negative proximal and distal margins. Radial margins were negative for 100% of NW, 83.3% of OW and 85.7% of OB (NS). Conversion rates were 14.3% for NW, 16.7% for OW & 0% for OB (NS). NW, OW and OB had complication rates of 28.3%, 33.3% and 14.3%, respectively. Median operative time, median estimated blood loss and median length of hospital stay were similar for all groups.ConclusionThe perceived limitation that obesity would have on TLRR was not demonstrated by the analyzed data. Although our findings are limited by the modest sized cohort, the results suggest that it is reasonable to offer TLRR to obese patients with rectal cancer.

Lymph node involvement in colon cancer patients decreases with age; a population based analysis

BACKGROUND The variation in nodal involvement between age groups has not been thoroughly studied in colon cancer, but it may affect strategies for extent of resection in elderly patients. The objective of our study was to compare nodal involvement in colon cancer patients, with a focus on surgical staging practices in the elderly. METHODS We extracted data from the Surveillance, Epidemiology and End Results registry on 208,077 patients diagnosed with stage I-III colon adenocarcinoma between 2000 and 2010. Patients undergoing colon resection, patients with adequate staging with ≥12 lymph nodes examined (LNE, n = 114,351) and with node-positive cancers were compared in age groups using chi-squared test. Relative risk (RR) of node-positive cancer was compared in a multivariable log-linear model, and relative survival in a flexible parametric model. RESULTS While the rates of colon resection were similar in all age groups, older patients were significantly less likely to have ≥12 LNE (P < 0.0001). When adequately staged, older patients had a significantly lower proportion of node-positive cancers (P < 0.0001). Survival was better in patients with ≥12 LNE, with no significant difference in the benefit between the age groups (P = 0.25). CONCLUSIONS When adequately staged, older patients are less likely to have node positive colon cancer, which may help them avoid adjuvant chemotherapy. Since the survival benefit of adequate nodal staging is similar in every age group, the guidelines for extent of resection and pathological examination should be diligently adhered to in all patients undergoing curative surgery, regardless of age.

Initial experience using a bipolar radiofrequency ablation device for hemostasis during thyroidectomy

The purpose of this study was to evaluate a novel bipolar radiofrequency ablation (BRFA) device using nanotechnology for division of all named vessels during thyroidectomy.

Advances in geriatric oncology: a multidisciplinary perspective

A growing majority of people with cancer is composed of older patients. For many such patients, independence and quality of life are as important as prolongation of survival, emphasizing the need for treatments that are not only effective but also well-tolerated. Given age-related decline in organ function and the prevalence of comorbidities and polypharmacy, optimum management is complex and requires collaboration between oncologists and geriatricians. Advances in surgery now include preoperative assessment and, when indicated, prehabilitation of the patient, as well as the enhanced recovery after surgery approach. Medical treatment is benefiting from the advent of highly effective novel immunomodulatory agents that join the tumor-targeted small molecule tyrosine kinase inhibitors and monoclonal antibodies in modifying the tolerability of therapy. Improved tolerability is evident with radiotherapy (RT). The adoption of stereotactic body RT in community oncology practice is increasing the proportion of elderly patients with comorbidities who can receive curative treatment. A further aspect of precision medicine as it relates to the older cancer patient is the tailoring of intervention to the robustness or frailty and life expectancy of the individual. Quantitative and validated tools for comprehensive geriatric assessment are playing an important role in this process.

Surgical management of metastatic colon cancer: A population-based analysis

BACKGROUND Metastasectomy has a curative potential in colon cancer, but its benefits have not been ascertained in population data. Our objective was to evaluate utilization of metastasectomy in colon cancer and its survival outcomes in groups defined by different age at diagnosis, tumor grade or varying extent of nodal spread. METHODS We extracted data from the Surveillance, Epidemiology and End Results database on adult patients with stage IV colon cancer diagnosed between 2003 and 2011. We analyzed the association of overall survival (OS) with metastasectomy using multivariable Cox models. RESULTS Among 41,137 patients with stage IV cancer, 26,607 (65%) underwent primary surgery and 5028 (12.2%) underwent metastasectomy. Older patients were less likely to have ≥12 lymph nodes examined in the surgical specimen, but also less likely to have nodal metastases when adequately staged (from 86% for age <50 years to 79% for age ≥85 years). Metastasectomy was less common in older patients (from 18% for age <50 years to 7% for age ≥85 years). OS after resection was inversely associated with age and nodal involvement. The association of metastasectomy with survival was favorable in all age groups (hazard ratio, HR, 0.68-0.72, P<0.0001), but it was not significant for those ≥85y ears old (HR, 0.92, P=0.23). It was also favorable regardless of the extent of nodal spread or tumor grade. CONCLUSIONS Resection of metastatic site is favorably associated with survival in patients up to 85 years of age. Older patients undergoing metastasectomy are more likely to be node-negative when adequately staged.

Extrahepatic Cholangiocarcinoma: Current Surgical Strategy

Cholangiocarcinoma is a rare cancer. Although rare, it remains the second most common hepatobiliary cancer and its incidence is increasing worldwide. Extrahepatic cholangiocarcinoma can occur anywhere along the biliary tree and prognosis varies according to the location of disease.

Poor nutritional status is associated with other geriatric domain impairments and adverse postoperative outcomes in onco-geriatric surgical patients - A multicentre cohort study

BACKGROUND Nutritional status (NS), though frequently affected in onco-geriatric patients, is no standard part of a geriatric assessment. The aim of this study was to analyse the association between a preoperatively impaired NS and geriatric domain impairments and adverse postoperative outcomes in onco-geriatric surgical patients. METHODS 309 patients ≥70 years undergoing surgery for solid tumours were prospectively recruited. Nine screening tools were preoperatively administered as part of a geriatric assessment. NS was based on BMI, weight loss and food intake. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated using logistic regression analysis. The occurrence of 30-day adverse postoperative outcomes was recorded. RESULTS At a median age of 76 years, 107 patients (34.6%) had an impaired NS. Decreased performance status and depression were associated with an impaired NS, when adjusted for tumour characteristics and comorbidities (ORPS>1 3.46; 95% CI 1.56-7.67. ORGDS>5 2.11; 95% CI 1.05-4.26). An impaired NS was an independent predictor for major complications (OR 3.3; 95% CI 1.6-6.8). Ten out of 11 patients who deceased had an impaired NS. CONCLUSION An impaired NS is prevalent in onco-geriatric patients considered to be fit for surgery. It is associated with decreased performance status and depression. An impaired NS is a predictor for adverse postoperative outcomes. NS should be incorporated in a geriatric assessment.

Chemotherapy does not adversely impact outcome following post-incisional hernia repair with biomaterial mesh

Patients receiving chemotherapy are at increased risk for developing recurrent or post‐incisional hernias (PIH). Biological materials are an alternative to synthetic mesh in contaminated fields. The impact of chemotherapy on biomaterial tissue ingrowth and integration has not been well studied.

The importance of caregivers in improving the care of geriatric oncology patients.

223 Background: Geriatric patients with cancer have special needs. The diagnosis of cancer is stressful for patients and their caregivers. A new age of medicine has emerged to facilitate caregivers in aiding elderly oncology patients through oncology programs. Many caregivers need support themselves. The purpose of this study is to evaluate our geriatric oncology programs effectiveness and to demonstrate specific factors that caregivers believe have the greatest positive impact. The aim is to determine different interventions that can be implemented to help caregivers of geriatric oncology patients. METHODS This is a qualitative study that used a questionnaire completed by caregivers of patients enrolled in a geriatric oncology program directed towards easing the stressors encountered when caring for patients. Caregivers rated the effectiveness of the program by responding to 12 statements and 2 open-ended questions via telephone. RESULTS There were 94 patients in the program from November 2012 to November 2013. After excluding patients that did not meet criteria 71 caregivers were available. Analysis of results from 37 out of 71 caregivers enrolled identified six areas that the program most helped them with: time management of caregivers (82.8%), delivery of decision-making information (97.3%), resources available to caregivers and patients (88.23%), establishing goals of care (94.59%), and pain control for patients (100%). 83.78% of respondents agreed that the well-being and quality of their life improved with the program. Analysis on the patient survey conducted for the same time period also showed significant improvement. CONCLUSIONS Caregivers play a vital role in cancer management of geriatric patients. In order to help both the patients and their caregivers, programs have emerged focusing on the teamwork of social workers, clinicians, and counselors. Caregivers express that this approach helps them effectively provide care to patients, and helps them get through this stressful period. The specific areas found to be most positively impacted by this type of organized program are what oncology departments may focus on in order to improve quality of life for caregivers which may ultimately improve the patients care.