Umut Sarpel

Outcome for Patients Treated with Laparoscopic Versus Open Resection of Hepatocellular Carcinoma: Case-Matched Analysis

IntroductionThis is a case-matched analysis of patients undergoing laparoscopic versus open hepatectomy for hepatocellular carcinoma (HCC), with specific regard to margin status and survival.Methods Laparoscopic cases were matched with open controls by cirrhosis and tumor size (within 10%). Data were evaluated by logistic regression using the generalized estimating equation method. Mixed linear regression models were used to assess operative duration in the groups. Overall and disease-free survival were compared using a Cox proportional frailty model.Results Twenty laparoscopic cases were matched to 56 open resections. Thirty patients (39%) developed recurrence and 13 patients (17%) died, including one (1.3%) death within 30xa0days. There were no significant differences in age, gender, cirrhosis or tumor size. Paired univariate and multivariate analyses showed cases of laparoscopic resection had similar rates of transfusion and positive margins compared with open resection. Operative duration was similar in laparoscopic (mean 161xa0±xa037xa0min) and open (mean 165xa0±xa053xa0min) groups. The adjusted odds of length of stayxa0≥xa06xa0days was significantly lower in patients with laparoscopic resection [odds ratio (OR)xa0=xa00.07, 95% confidence interval (CI)xa0=xa00.02–0.27]. Both unadjusted and adjusted analyses showed no significant association between type of resection and overall or disease-free survival.Discussion Neither margin status, nor recurrence, nor survival was significantly different between the two cohorts. Laparoscopic resection for malignancy is safe, with a similar operative time as open hepatectomy. If tumor location is amenable, laparoscopic resection for HCC is a reasonable alternative to open resection with the added benefits of improved cosmesis and sooner discharge home.

Does Anatomic Versus Nonanatomic Resection Affect Recurrence and Survival in Patients Undergoing Surgery for Colorectal Liver Metastasis

Anatomic resection of colorectal liver metastases may offer a survival advantage because (1) it removes the hepatic functional unit as a whole and (2) nonanatomic resection has been reported to have a higher incidence of positive margins.A retrospective review was performed of patients undergoing hepatic resection for colorectal liver metastases. 183 patients met inclusion criteria of undergoing either anatomic or nonanatomic resection with the aim of removing all gross disease. Mean age was 61xa0years (range 31–90xa0years), 57% were male. 89 patients (49%) underwent nonanatomic resection, the remaining 94 (51%) had anatomic resection. Average duration of inflow occlusion was 10xa0min. Average length of stay was 7.4xa0days. There were three deaths, yielding a 1.6% 30-day mortality rate. There was no difference in the incidence of positive margins between types of resection. Recurrence was 27%, 55%, and 59% at 1, 3, and 5xa0years respectively. Overall survival was 89%, 67%, and 55% at 1, 3, and 5xa0years, respectively. Type of resection was not associated with significant differences in recurrence or survival even when adjusted for differences in preoperative risk.We conclude that hepatic resection for colorectal metastases can be performed safely and offers select patients with stage IV disease prolonged survival. Resection type should be based on the number and location of tumors, rather than on segmental anatomy. An emphasis on the preservation of hepatic parenchyma may be of increasing importance in the setting of chemotherapy-associated steatohepatitis, and the growing number of patients undergoing repeated metastasectomy.

Spontaneous regression of hepatocellular carcinoma is most often associated with tumour hypoxia or a systemic inflammatory response

BACKGROUNDnSpontaneous regression of hepatocellular carcinoma (HCC) is well documented, although the aetiology of this phenomenon remains unknown.nnnMETHODSnA review of the English literature was performed for reports of spontaneous regression of HCC. Reports were classified by mechanism based on the available information.nnnRESULTSnSpontaneous regression of HCC has been identified in 75 patients. The most common mechanisms of regression identified were tumour hypoxia (n= 21, 28.0%), a systemic inflammatory response (n= 25, 33.3%) and unknown (n= 29, 38.7%). In patients where tumour hypoxia was described as the aetiology, mechanisms included spontaneous hepatic artery thrombosis and sustained systemic hypotension. In patients where a systemic inflammatory response was the aetiology, mechanisms included cholangitis, trauma and elevated cytokine levels.nnnDISCUSSIONnSpontaneous regression of HCC is most commonly associated with tumour hypoxia or a systemic inflammatory response. Determining the aetiology of spontaneous regression may identify potential therapeutic pathways. Tumour hypoxia is already the basis of treatment modalities such as hepatic artery embolization and the anti-angiogenic agent sorafenib. However, treatment modalities for HCC do not currently include immune-directed therapies; this may prove to be a worthy target for future research.

The safety of a pancreaticoduodenectomy in patients older than 80 years: risk vs. benefits

BACKGROUNDnA pancreaticoduodenectomy (PD) offers the only chance of a cure for pancreatic cancer and can be performed with low mortality and morbidity. However, little is known about outcomes of a PD in octogenarians.nnnMETHODSnDifferences in two groups of patients (Group Y, <80 and Group O, ≥80 year-old) who underwent a PD for pancreatic adenocarcinoma were analysed. Study end-points were length of post-operative stay, overall morbidity, 30-day mortality and overall survival.nnnRESULTSnThere were 175 patients in Group Y (mean age 64 years) and 25 patients in Group O (mean age 83 years). Octogenarians had worse Eastern Cooperative Oncology Group (ECOG) Performance Status (PS ≥1: 90% vs. 51%) and American Society of Anesthesiology (ASA) score (>2: 71% vs. 47%). The two groups were similar in underlying co-morbidities, operative time, rates of portal vein resection, intra-operative complications, blood loss, pathological stage and status of resection margins. Octogenarians had a longer post-operative stay (20 vs. 14 days) and higher overall morbidity (68% vs. 44%). There was a single death in each group. At a median follow-up of 13 months median survival appeared similar in the two groups (17 vs. 13 months).nnnCONCLUSIONSnAs 30-day mortality and survival are similar to those observed in younger patients, a PD can be offered to carefully selected octogenarians.

Effect of intra-operative fluid volume on peri-operative outcomes after pancreaticoduodenectomy for pancreatic adenocarcinoma.

Excess use of intravenous fluid can increase post‐operative complications. We examined the influence of intra‐operative crystalloid (IOC) administration on complications following pancreaticodudenectomy (PD) for pancreatic adenocarcinoma.

Identifying the informational and psychosocial needs of Chinese immigrant cancer patients: a focus group study

PurposeThe Chinese immigrant community faces multiple barriers to quality cancer care and cancer survivorship. Psychosocial interventions can positively impact quality of life, anxiety, and distress in cancer patients. In this study, we explored the informational and psychosocial needs of Chinese cancer patients to inform the development of culturally targeted support and survivorship interventions.MethodsWe conducted four focus groups with a total of 28 Chinese cancer patients to elucidate their cancer informational and psychosocial needs. The groups were conducted using standard methodology and guided by community-based participatory research principles. Sessions were audio recorded, transcribed, and translated into English. The research team conducted the analysis.ResultsFrequently occurring themes included (1) the need for accurate information on cancer and treatment options, (2) the role of language barriers in accessing cancer care, (3) the role of food in cancer and the need for nutritional information, and (4) the role of Chinese medicine in cancer treatment. Participants expressed significant dissatisfaction with the amount, reliability, and/or comprehensibility of available information.ConclusionsSupport groups and programs should be developed to address participants’ needs for more information on cancer and its treatment. Programs should educate and empower patients on how to find further Chinese language information and resources and effectively communicate their questions and needs to providers in an interpreted encounter. System-level approaches should be implemented to ensure provision of interpretation services. Additionally, programs should incorporate the unique cultural needs of this population related to food/nutrition and Chinese medicine.

Risk Factors for Early-Onset and Late-Onset Hepatocellular Carcinoma in Asian Immigrants With Hepatitis B in the United States

OBJECTIVES:Routine screening for hepatocellular carcinoma (HCC) is recommended in chronic hepatitis B (HBV) patients with cirrhosis and select non-cirrhotic HBV populations including Asian males ages 40 and older and females ages 50 and older. However, many younger HBV patients develop HCC and there have been few studies examining this group. Additionally, studies of HCC in the Asian immigrant population in the United States have been limited. The objective of this study was to determine the associated risk factors for the development of early-onset (males and females under ages 40 and 50, respectively) and late-onset HCC in immigrants with chronic HBV in the United States.METHODS:Clinical, demographic, and laboratory data were retrospectively collected on all Asian immigrants with HBV at Bellevue Hospital Center from 2003 to 2009. Patients with HCC were identified within this cohort. Features of early-onset and late-onset HCC cases were compared with age-matched HBV controls without HCC.RESULTS:We identified 168 cases of HCC in Asians with HBV. In all, 74% (124/168) of cases were late-onset, and 26% (44/168) were early-onset. When comparing the 124 late-onset HCC cases with 199 age-matched HBV controls, gender (odds ratio (OR)=4.4; P<0.05) and cirrhosis (OR=9.6; P<0.05) or surrogate labs (i.e., platelets, international normalized ratio, total bilirubin, albumin) were found to be associated with HCC development. When comparing the 44 early-onset HCC cases with 432 age-matched HBV controls, family history of HCC (OR=2.7; P<0.05), and smoking history (OR=3.4; P<0.05) were independently associated risk factors in addition to gender (OR=2.7; P<0.05), and cirrhosis (OR=19.5; P<0.05) or surrogate labs. In all, 54.8% of late-onset HCC cases were cirrhotic and 29.5% of early-onset HCC cases were cirrhotic.CONCLUSIONS:HCC occurs in Asian immigrant HBV patients younger than currently recommended screening guidelines. A large majority of these early-onset patients did not have cirrhosis at the time of their HCC diagnosis; therefore, factors other than cirrhosis need to be considered when evaluating HCC risk in young patients. Factors associated with HCC development across all ages include cirrhosis and male gender, while family history and smoking history may identify younger Asian immigrant HBV patients at risk for HCC. Prospective validation, including cost-effectiveness evaluation, is necessary, but our results suggest that younger Asian HBV patients, especially those with a smoking history or family history of HCC, appear to have an increased risk for HCC and should be considered for enrollment in early screening programs regardless of their age.

Impact of socioeconomic status and sociodemographic factors on melanoma presentation among ethnic minorities.

Minority melanoma patients have worse survival. In this study, we evaluated the impact of socioeconomic and demographic factors on minority melanoma patients presenting to two different New York City hospitals (one public and one private) managed by the same multidisciplinary team. Sociodemographic and clinicopathologic characteristics were retrieved for melanoma patients presenting to Bellevue Hospital Center (BHC), a public hospital, and the New York University Cancer Institute (NYUCI), a private cancer center. Socioeconomic data was obtained from the United States Census Bureau database. The Kruskal-Wallis and chi-square tests were used to evaluate the associations between race/ethnicity and continuous and categorical variables (e.g. income, stage at presentation), respectively. Minorities comprised 2% (27/1296) of melanoma patients at the NYUCI compared to 42% (50/119) at BHC. Those presenting to the NYUCI were more likely to have a higher median household income (Pxa0=xa00.05), a higher educational level (Pxa0=xa00.04), and an earlier stage at presentation (Pxa0=xa00.02) than those at BHC. NYUCI patients were predominantly covered by commercial insurance (70%), whereas Medicaid (62%) was common among BHC patients. Only 19% of Hispanic patients at BHC chose English as their preferred language. Our data demonstrate that language and health care system factors affect melanoma presentation in minorities.

The Development of a Peritoneal Surface Malignancy Program: a Tale of Three Hospitals

An increasing amount of evidence supports the use of cytoreductive surgery and heated intraperitoneal chemotherapy (HIPEC) for the treatment of select patients with carcinomatosis. The care of such patients is optimal at centers where physicians with expertise in the recognition, treatment, and follow-up of carcinomatosis collaborate to manage issues particular to patients undergoing HIPEC. New Peritoneal Surface Malignancy Programs should be introduced to meet the growing interest in this field; however, there are few guidelines available on how to propose, develop, and safely implement them across different hospital models. A new Peritoneal Surface Malignancy Program was initiated at a large academic medical center affiliated with three hospital systems serving distinct patient populations: a private hospital, a public hospital, and a Veterans Affairs hospital. Ten groups were identified as playing key roles in program implementation. Program approval was successfully obtained at all three hospitals. The initial two-year experience included a total of 20 cases across the three sites. Six of these cases were aborted due to high tumor volume, most of which (4/6) were at the public hospital. No 30-day mortalities occurred. Hospitals vary significantly in their approval process and timeline for new Peritoneal Surface Malignancy Program development. Patient populations differ in their awareness of HIPEC as a therapeutic modality. Public hospitals may serve patient populations with more advanced disease presentations. Careful coordination by the surgical oncologist with ten key groups allows for the safe introduction of a complex procedure within varied hospital models.