70.08 Neoadjuvant Radiation Does Not Increase Perioperative Morbidity in Gastrectomy for Gastric Cancer

Posted on December 22, 2014

Z. Sun1, D. P. Nussbaum1, P. J. Speicher1, B. Czito1, D. Tyler1, D. G. Blazer1  1Duke University Medical Center,Durham, NC, USA

Introduction:
Neoadjuvant radiotherapy (RT) as a component of the multimodality approach to gastric cancer has demonstrated promising results in terms of locoregional recurrence, pathologic response, and survival in several institutional series. However, concerns remain about its effect on perioperative morbidity and mortality.

Methods:
The 2005-2011 National Surgical Quality Improvement Program (NSQIP) Participant Data Use File (PUF) was queried for patients undergoing gastrectomy for gastric cancer. Subjects were classified by use of neoadjuvant RT. Perioperative variables and outcomes were compared.  Groups were then propensity matched using a 3:1 nearest-neighbor algorithm and multivariable logistic regression was performed to assess neoadjuvant RT as a predictor of outcomes. 

Results:
A total of 2,772 patients were identified, among whom 55 (2.0%) underwent neoadjuvant RT.  Patients who received neoadjuvant RT were more likely to have received preoperative chemotherapy within 30 days (p<0.001) and steroids (7.3 vs. 1.6%, p=0.007); they were also more likely to have recent weight loss (30.9 vs. 16.2%, p=0.007).   However, after propensity matching, all baseline characteristics between groups were highly similar.  Concomitant major resection was common for all patients (28.1%), and there was no difference between groups.  Total gastrectomy was more common among patients who underwent neoadjuvant RT (70.9 vs. 46.7%, p=0.003), and operative time was considerably longer (290 vs. 236 minutes, p=0.009).  There were no differences in overall complications (23.6 vs. 29.7%, p=0.489) or 30-day mortality (3.6 vs. 3.6%, p=0.999).  There were also no differences in major complications, surgical site infection, or early reoperation.  

Conclusion:
Neoadjuvant RT was not associated with an increase in 30-day mortality or perioperative morbidity after gastrectomy.  Given reasonable morbidity demonstrated in our study and other institutional series, neoadjuvant RT warrants further investigation as part of the multidisciplinary management of resectable gastric cancer
 

70.09 Major Depression in Colorectal Cancer Survivors: a population-based study of 1783 patients.

Posted on December 22, 2014

J. Liang3, N. Fitzgerald2, S. Ahmed1, D. Hiller1, J. Bohl1, C. J. Clark1  1Wake Forest Baptist Health,Department Of Surgical Oncology,Winston Salem, NC, USA 2Wake Forest Baptist Health,Public Health Sciences,Winston Salem, NC, USA 3Wake Forest School Of Medicine,Winston Salem, NC, USA

Introduction:
Colorectal cancer survivorship has improved significant over the last 20 years due to earlier detection through screening programs and better multimodality treatment options. Few studies have evaluated the health-related quality of life (HRQOL) for colorectal cancer patients and the long-term risk of major depressive disorder (MDD) among survivors. The current study hypothesizes that lower socio-economic status (SES) increases the risk of major depression among colorectal cancer survivors. 

Methods:
A population-based cohort study was conducted based on linkage data from the Surveillance, Epidemiology, and End-Result registry and the Medicare Health Outcome Survey (SEER-MHOS).  Patients with pathology confirmed and resected colorectal cancer over 65 years who completed a survey after diagnosis were identified in the SEER-MHOS.  Survey respondents with a VR12 mental component score (MCS) less than 42 and positive depression screen were defined as patients with MDD.  Using univariate and multiple variable analyses, patients with and without MDD were evaluated to identify risk factors for MDD.   

Results:
1783 resected colorectal cancer patients (median age 77, 50.8% female) were identified in the SEER-MHOS dataset.  The majority of patients were white (n=1337, 75%) and Stage II (n = 603, 43%).  Median time from diagnosis to last follow-up was 130 months with median time from diagnosis to survey of 62 months.  In this cohort, 278 (15.6%) had MDD.  On univariate analysis, risks factors for MDD included female sex, non-white race, less than high school education, income less than $30,000 per year, no home ownership, more than two comorbidities, and inability to perform more than two out of six activities of daily living (ADLs) (all p < 0.05).  Larger tumor size and advanced cancer stage did not predict MDD.  After adjusting for comorbidities, ADLs, and time from diagnosis to survey, income less than $30,000 per year (OR 1.5, 1.02-2.22 95% CI, p = 0.042) and non-white race (OR 1.51, 1.05-2.17 95% CI, p =0.0259) were independent predictors of MDD. 

Conclusion:
In the current study, lower socioeconomic status, specifically patient income, is associated with major depressive disorder among colorectal cancer survivors.
 

70.10 Bleeding Complications Post-Mastectomy for Breast Cancer: Incidence, Predictors, and Economic Impact

Posted on December 22, 2014

I. Nwaogu1, M. Olsen1, J. A. Margenthaler1  1Washington University,Surgery,St. Louis, MO, USA

Introduction: Bleeding complications are serious complications following breast cancer surgery but very few single-institution studies have estimated and reported the incidence. Additionally, no studies have examined the economic impact of postoperative bleeding. The present study aims to determine the incidence of bleeding events following mastectomy, identify potential risk factors for bleeding, and evaluate the impact on hospital utilization and treatment costs.

Methods: Using the 2011 Healthcare Cost and Utilization Project National Inpatient Sample (HCUP NIS), mastectomy hospital discharges for a primary diagnosis of breast cancer were extracted using ICD-9-CM procedure codes 85.34-85.48 for mastectomy and diagnosis codes 174.0-174.9 for breast cancer. Discharges with postoperative bleeding were identified based on ICD-9-CM diagnosis codes 998.11 and 998.12. Discharges with male gender or a history of coagulation disorders were excluded from the study. Overall bleeding complication rates and re-operation rates (for bleeding) were assessed. Risk factors and the impact of bleeding on length of stay and hospital costs were determined using regression analysis. The results were projected to the national level.

Results:7907 discharges coded for mastectomy met inclusion criteria. Of these, 201 had bleeding complications (2.54%), with 42 cases requiring re-operation during the mastectomy admission. On univariate analysis, the presence of congestive heart failure (CHF), obesity, diabetes, chronic pulmonary disease, and the absence of concomitant reconstructive surgery were associated with increased bleeding event. On multivariate analysis, only the presence of CHF remained as a statistically significant predictor of bleeding complications (Odds ratio [95% CI]: 2.45, [1.25, 4.92], p = 0.009). On average, bleeding complications extended the length of stay by 1.3 days (p < 0.0001) while increasing hospital costs by $5,495 per admission (p <0.0001). Projected to the national level, bleeding complications accounted for an additional 1,254 days of hospital stay with costs exceeding $5.3 million.

Conclusion:Bleeding complications following mastectomy for breast cancer had an incidence of 2.5%, with CHF the only identified risk factor for bleeding complications. Finally, such bleeding events, although infrequent, are associated with substantial economic costs in terms of extended length of stay and increased treatment costs.

 

70.11 Placement of a Feeding Jejunostomy Tube Is Safe at the Time of Gastrectomy for Gastric Cancer

Posted on December 22, 2014

D. P. Nussbaum1, Z. Sun1, B. C. Gulack1, J. E. Keenan1, D. S. Tyler1, P. J. Speicher1, D. G. Blazer1  1Duke University Medical Center,Department Of Surgery,Durham, NC, USA 2Duke University Medical Center,Department Of Surgery,Durham, NC, USA

Introduction: Feeding tube placement is common among patients undergoing gastrectomy, and national guidelines currently recommend consideration of a feeding jejunostomy tube (FJT) for all patients undergoing resection of gastric cancer.  However, to date there is no comparative effectiveness data regarding the safety of FJT placement at the time of gastrectomy for gastric cancer.  

Methods: The 2005-2011 ACS-NSQIP Participant User Files were queried to identify patients who underwent gastrectomy for gastric cancer.  Subjects were classified by the concomitant placement of a FJT.  Groups were then propensity matched using a 1:1 nearest neighbor algorithm, and outcomes were compared between groups.  The primary outcomes of interest were overall 30-day morbidity and mortality.  Secondary endpoints included major complications, surgical site infection, and early reoperation.  

Results: In total, 2,980 subjects underwent gastrectomy for gastric cancer, among whom 715 (24%) also had a FJT placed.  Patients who had a FJT placed were more likely to be male (61.6 vs. 56.6%, p=0.02), have recent weight loss (21.0 vs. 14.8%, p<0.01), and to have undergone recent chemotherapy (7.9 vs. 4.2%, p<0.01) and radiation therapy (4.2 vs. 1.3%, p<0.01).  They were also more likely to have undergone total (compared to partial) gastrectomy (66.6 vs. 28.6%, p<0.01) and have concomitant resection of an adjacent organ (40.4 vs. 24.1%, p<0.01).  After adjustment with propensity matching, however, all baseline characteristics and treatment variables were highly similar.  Among propensity-matched groups, there were no statistically significant differences in either primary outcome: 30-day overall complications (38.8 vs. 36.1%, p=0.32) or mortality (5.8 vs. 3.7%, p=0.08).  There were also no differences in major complications, surgical site infection, or early reoperation.  Operative time was slightly longer among patients with feeding tubes placed (median 248 vs. 234 minutes, p=0.01), but otherwise there were no significant differences in any outcomes between groups. 

Conclusion: Placement of a FJT may result in slightly increased operative times, but does not appear to result in increased perioperative morbidity or mortality.  Further investigation is needed to define the patients most likely to benefit from FJT placement.  

70.13 How Effective is the “Two-Week Wait” Target in Improving Survival in Colorectal and Breast Cancer?

Posted on December 22, 2014

K. M. Guest1, I. Nikolopoulos1, M. Kumari1, K. Thakur1  1Queen Elizabeth Hospital,General Surgery,London, LONDON, United Kingdom

Introduction: Incidence rates of colorectal cancer have risen very slowly for two decades, while mortality rates have fallen by over 25%. Incidence rates for breast cancer have continued to rise in the last 20 years chiefly among more affluent women, while mortality rates have fallen by one quarter. Suspected cancer waiting time targets were introduced in the UK to monitor service performance via process improvement. The intention was to improve the outcome (survival) of the disease. The “Two-Week Wait” system denotes that any patient with suspected cancer must be seen by a specialist within 2 weeks of referral. The aim of this study was to assess whether the Two-Week Wait target can improve survival in patients with colorectal and breast cancer.

Methods: 613 and 625 patients were diagnosed with colorectal and breast cancer respectively between January 2002 and December 2006. Data were retrospectively collected from the cancer database at Queen Elizabeth Hospital, England UK. Survival was compared in patients that were referred via the Two-Week Wait system (Group1) and those not referred via this pathway (Group2).

Results: Only 29% of colorectal cancer patients were referred under the Two-Week Wait rule, with the remainder a significant proportion coming from Accident & Emergency (n=131) and General Practitioners (n=144). The mean survival for Group 1 was 3.88 years (1415 days, 95% confidence interval 1283-1546 days) and for Group 2 was 3.41 years (1245 days, 95% confidence interval 1155-1331 days) (p-value=0.005). Kaplan-Meier comparison showed 2-year survival to be 71% for Group 1 and approximately 60% for Group 2.

44% of breast cancer patients were referred under the Two-Week Wait rule and of the remainder a significant proportion came from breast cancer screening (n=122) and GPs (n=135). The mean survival for Group 1 was 4.63 years (1690 days, 95% confidence interval 1604-1775 days) and for Group 2 was 5 years (1825 days, 95% confidence interval 1759-1891 days) (p-value=0.142). Kaplan-Meier comparison showed 2-year survival to be similar in both groups at approximately 83%.

Conclusions: The Two-Week Wait rule significantly improves the survival of patients with colorectal cancer. However the under-utilisation of this referral route cannot be ignored, as an unacceptably high percentage of colorectal cancer patients (30%) come via Accident & Emergency. On the other hand, the Two-Week Wait rule does not appear to affect the survival of patients diagnosed with breast cancer. A well established breast cancer screening programme can lead to equally good survival rates for those referred via the non-Two-Week wait route.

 

70.14 Age Impacts Efficacy of Radiotherapy in Patients with Soft Tissue Sarcoma

Posted on December 22, 2014

N. K. Yuen1, C. Li1, R. Bold1, A. Monjazeb1, D. Borys1, R. Canter1  1University Of California – Davis,Surgical Oncology,Sacramento, CA, USA

Introduction:

Radiation therapy (RT) is a standard component in the multimodality management of soft tissue sarcoma (STS), although increasing studies are focusing on the selective implementation of this modality. We hypothesized that the effects of RT would be influenced by age, potentially contributing to differences in treatment outcome. We sought to evaluate the effect of age on RT in a national database of STS patients.

 

Methods:

Using the Surveillance Epidemiology and End Results registry (1990-2011), we identified 30,898 adult patients (>18) with non-metastatic STS of major histologies undergoing surgery with or without RT. We compared patient demographics, tumor characteristics, and treatments by age. Multivariable analyses were used to examine the effect of these variables on overall (OS) and disease-specific survival (DSS). Hazard ratios were calculated based on multivariable Cox proportional hazards models.

 

Results:

The mean age at diagnosis was 54.9 years old. 31.5% of patients were ≥ 65 years old. 47.5% of patients were male, and 66.6% were white. Histologic grade was 32.4% high, 12.9% intermediate, 13.5% low, and 41.3% unknown. Leimoyosarcoma was the most common histology (27.9%), and extremity was the most common tumor site (37.4%). 70.2% of patients underwent surgery alone, 25.1% received adjuvant RT, and 4.7% neoadjuvant RT. On multivariable analysis, gender, year of diagnosis, histology, grade, size, marital status, and RT modality predicted OS, while year of diagnosis, ethnicity, histology, site, grade, RT, size, and marital status predicted DSS. The hazard ratio (HR) for OS was 1.11 (95% CI 1.02-1.21) and DSS was 1.13 (95% CI 1.03-1.25) comparing neoadjuvant to adjuvant RT in all age groups. In patients < 65 years old, the HR for OS was 1.23 (95% CI 1.09-1.39) and DSS was 1.24 (95% CI 1.10-1.39) for neoadjuvant to adjuvant RT. For patients ≥ 65, the HR for OS was 0.98 (95% CI 0.85-1.13), and DSS was 0.99 (95% CI 0.83-1.17) for neoadjuvant to adjuvant RT.

 

Conclusions:

Adjuvant RT was associated with superior oncologic outcome compared to neoadjuvant RT among STS patients undergoing surgical resection. The negative effect of neoadjuvant RT was exaggerated in younger patients, suggesting an age-related effect of RT. Further investigation into the etiology of this age-related association is indicated.

 

70.15 Defining the Burden of Rectal Cancer: A Population Study

Posted on December 22, 2014

D. Hayden1, M. Ostrowski2, T. Markossian3, J. Eberhardt1, T. Saclarides1  1Loyola University Medical Center,Department of General Surgery,Maywood, Illinois, USA 2Loyola University Medical Center,Stritch School Of Medicine,Maywood, Illinois, USA 3Loyola University Medical Center,Department Of Public Health Sciences,Maywood, Illinois, USA

Introduction:  The treatment course of rectal cancer is long and wrought with morbidity.  The burden of this disease is underappreciated and impacts patients, their families and the health care system.

Methods:  Secondary analysis of the 2011 National Inpatient Sample was performed using the ICD-9CM codes for rectal cancer, most common secondary diagnoses and co-morbidities. 

Results: For the 24,575 rectal cancer discharges in 2011, mean age was 64.2 (17-99); 58.1% were male.  69.8% were white, 9.3% black, 7.7% Hispanic and 2.8% Asian/Pacific Islander.  5.6% were obese and 3.1% morbidly obese.  Most common comorbidity listed as the secondary diagnosis was hypertension (4.6%).  50.6% of patients resided in or near metropolitan areas with population ≥ 1 million; 16.5% from those 250,000-999,999, 9.7% from those 50,000-249,999 and 11.3% from micropolitan areas.  Inpatient admissions seemed to be evenly distributed across income quartiles. Medicare (46.5%) and private insurance (36.8%) were most common; Medicaid accounted for 9.3% of payer distribution and 3.8% was self-pay.  Admissions were most frequently elective (72.4%).  Mean length of stay was 7.42 (0-277) days.  47.8% of patients were discharged home; 35.4% required home health nursing; 13.9% were transferred to rehab or skilled nursing. 2.4% of patients died during the hospital admission.  For the obese and morbidly obese rectal cancer patients, LOS was increased: 8.27 days (0-64), were younger 60.4 (27-89), higher percentage were white (74.0%) and more had private insurance (48.6%, all p=0.00).    

Conclusion: Rectal cancer impacts patients and the health care system due to lengthy hospitalizations and postoperative healthcare utilization of home health nursing and short-term facilities. Obesity and related comorbidities contribute to poorer outcomes; however, lifestyle interventions at diagnosis may decrease this burden.

 

70.01 Ventriculoperitoneal shunt in patients with CNS neoplasms: An analysis of 59 cases

Posted on December 22, 2014

F. Nigim1, J. Critchlow1, E. Kasper1  1Beth Israel Deaconess Medical Center,Department Of Surgery,Brookline, MA, USA

Introduction:
About 1-5% of patients with cerebral metastasis suffer from hydrocephalus, and so do about 40% of patients with primary brain tumors. These patients often carry a poor prognosis. The aim of the present study is to reassess the validity of VPS placement with the assistance of the general surgeon in the abdominal part in oncological patients.

Methods:
 A total of 59 patients underwent first time VPS placement at BIDMC between 2004 and 2012; 40 had hydrocephalus from brain metastasis and 19 from primary tumors. Analyzed independent variables included demographics, BMI, PMH, clinical presentation, indication for surgery, Karnofsky performance status (KPS) score, and surgical technique; dependent variables were post-operative symptoms and occurrence, cause, and time of shunt failures. Outcomes were analyzed via T-test and Kaplan-Meier estimates for shunt survival.

Results:
Mean age was 57.2 years; and mean operative time was 50.4 minutes. Symptomatic palliation was achieved in 93%; patients with severe symptoms (e.g. debilitating headaches and nausea and vomiting) did benefit significantly from VPS placement. Mean follow-up time was 6.3 months, complications occurred in only 6.7% (n=4) patients during follow up; with 2 wound infections treated with antibiotics, and 2 shunt obstructions requiring revision. Initial KPS and 3-month KPS were 65 ± 16.4 and 75 ± 16.0, respectively. We started with 59 patients, 16 (27.1%) patients were alive at 6-month and 10 (16.9%) patients were alive at 1-year, in all survived patients the shunt was functioning. 

Conclusion:
VPS remains a valid option for cancer patients with low KPS and improves the quality of life in those patients, even in the setting of previous infection, hemorrhage, or leptomeningeal disease since shunt patency outlasts the overall survival of nearly all patients. 
 

7.12 Irradiated Rectal Cancer: Is There a Role for Preoperative Interventions?

Posted on December 22, 2014

D. M. Hayden1, C. Holmes1, A. Lasinski1, S. Nassoiy1, M. Chiodo2, K. Wolin1, T. Saclarides1  1Loyola University Medical Center,Department of General Surgery,Maywood, Illinois, USA 2Loyola University Medical Center,Stritch School Of Medicine,Maywood, Illinois, USA

Introduction:  The treatment course of locally advanced rectal cancer is long, tedious and wrought with morbidity.  This disease burden is underappreciated; however there may be amenable factors to improve peri- and postoperative outcomes. 

Methods:  Retrospective review of patients with stage II and III rectal cancer treated with neoadjuvant chemoradiation followed by radical resection at a single tertiary care center 2006-2013.

Results: 57 patients were included; mean age was 60.4 (36-82); 57.9% were male.  Mean BMI was 29.0 (19.0-43.4); 40.4% were obese and 15.8% had BMI>35.  Co-morbidities were common: 40.4% had hypertension, 24.6% diabetes, 8.8% CAD and 5.3% had COPD. 12.3% were current smokers and 49.1% previously smoked.  37 (64.9%) patients had LAR and 35.1% had APR. Only 7.0% had laparoscopic resection. Mean operative time 355.2 (120-630) minutes.  Mean blood loss was 452 ml (50.0-3000); 14.0% required transfusion and 28.1% ICU admission. Mean length of stay was 11.0 (4.0-62.0) days.  45.6% had complications, most commonly fever, ileus and abscess.  36.8% of patients required readmission.  Obese patients had longer LOS that trended toward significance (13.6 vs.9.2, p=0.078); however, complications were not more common. Those with BMI>35 had higher risk of pneumonia, DVT and sepsis (p=0.02-0.05).  Current and previous smokers were more likely to be readmitted (p=0.043).  4 of the 6 patients discharged to rehab/skilled nursing had BMI>30. 

Conclusion: The treatment of irradiated rectal cancer involves morbid operations, complications and readmissions. Our patients are obese with multiple comorbidities that contribute to poorer outcomes. However, lifestyle interventions like exercise and smoking cessation at diagnosis may help to decrease this burden. 

 

7.13 CA19-9 Levels Can Predict Findings at Diagnostic Laparoscopy in Pancreatic Cancer:A Prospective Study

Posted on December 22, 2014

S. Gopinath1, U. Ballehaninna1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2Rutgers University, New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 3Saint George’s University,Department Of Surgery,Grenada, Grenada, Grenada

Introduction: Serum CA 19-9 levels assessment is a cornerstone of pancreatic cancer management as it plays an important role in the diagnosis, prognosis, response to treatment and staging.  To date very few studies have assessed whether preoperative serum CA 19-9 levels can reliably predict laparoscopic findings, in terms of both resectability and the identification of  pancreatic cancer metastases in pancreatic cancer patients deemed resectable on traditional imaging studies. 

Methods: Clinico-pathologic characteristics including serum CA 19-9 levels were prospectively collected in 58 patients with pancreatic cancer deemed resectable by preoperative work up.  Intraoperative data collection included findings at laparoscopy (peritoneal and liver metastasis) and/or operative exploration (resectable or unresectable). Wilcoxon-Rank- Sum test was used to determine whether preoperative serum CA 19-9 levels correlated with findings at laparoscopy, assess tumor resectability and staging.

Results:Fifty-eight patients with pancreatic cancer underwent diagnostic laparoscopy followed by surgical exploration with curative intent. Mean age was 67.5 years (range, 43-88 years).  Preoperative serum CA 19-9 levels in these patients ranged from 2-3344 u/ml. Peritoneal or liver metastasis was identified by laparoscopy in 23 patients (40%) whereas 35 patients (60%) underwent curative pancreatic resection. Mean serum CA 19-9 levels for resectable tumors were 927.5 u/ml (range; 9-6137) compared to 2362.9 u/ml (range 2-26871) in unresectable tumors. A mean serum CA 19-9 level of 2362.9 u/ml was statistically significant in predicting inoperable pancreatic tumor at the time of laparoscopy.  A linear correlation of serum CA 19-9 levels with pancreatic cancer stage was also observed (Figure)

Conclusion:Preoperative serum CA 19-9 levels have excellent correlation with diagnostic laparoscopy findings in regards to determining pancreatic cancer resectability. Given the wide range of serum CA-19-9 levels observed in this small study, large scale studies are necessary to more precisely define more narrow  serum CA-1-9-9 levels that can be used clinically to accurately predict pancreatic cancer stage and to differentiate resectable from unresectable pancreatic cancer.

 

7.14 Safety and efficacy of intraoperative radiotherapy in treating locally advanced pancreatic cancer

Posted on December 22, 2014

X. Che1, Y. Chen1, J. Zhang1, C. Wang1  1Cancer Hospital Chinese Academy Of Medical Sciences,Department Of Abdominal Surgical Oncology,Beijing, BEIJING, China

Introduction: Several studies have shown that intraoperative radiotherapy provides a marginal increase in the survival rate for patients with resectable pancreatic cancer. For locally advanced unresectable pancreatic cancer patients, however, the result was scarce and inconsistent. The aim of present study is to assess the safety and efficacy of intraoperative radiotherapy in unresectable pancreatic cancer.

Methods: From January 2008 to October 2013, 176 cases of locally advanced pancreatic cancer were treated with intraoperative radiotherapy and postoperative concurrent chemoradiotherapy and chemotherapy including 61 T3 cases and 115 T4 cases; maximum diameter of tumor: 3-9cm with an average of 5.1 ± 1.5cm; diameter of  applicator for IORT: 4-10cm with an average of 5.9 ± 1.0cm; irradiation intensity:6-15Mev with an average of 11.6 ± 1.1Mev; irradiation dose:1000-2000cGry with an average of 1400 ± 245cGry.

Results:Intraoperative blood loss of intraoperative radiotherapy was 50.5ml in average, postoperative pancreatic fistula was 4%, delayed gastric emptying was 9.9%, and the differences were not statistically significant compared with surgery alone. There was no level 3 or more hematologic toxicity. 49 patients were treated with intraoperative radiotherapy plus postoperative concurrent chemoradiotherapy and chemotherapy: median survival time was 14.7 months and survival rate for 1 year was 65%; rate of pain relief was 72%. As for conventional chemoradiotherapy without intraoperative radiotherapy, median survival time was 11.1 months, survival rate for 1 year was 23% and rate of pain relief was 41%. 

Conclusion:In conclusion, intraoperative radiotherapy may be delivered safely and effectively in combination with chemoradiotherapy for patients with locally advanced unresectable pancreatic cancer.

 

7.15 Preoperative Platelet to Lymphocyte Ratio is a Prognostic Factor for Pancreatic Cancer.

Posted on December 22, 2014

Y. Shirai1, H. Shiba1, T. Horiuchi1, R. Iwase1, K. Haruki1, K. Abe1, Y. Fujiwara1, K. Furukawa1, S. Onda1, D. Hata1, T. Sakamoto1, Y. Futagawa1, Y. Toyama1, Y. Ishida1, K. Yanaga1  1The Jikei University School Of Medicine,Department Of Surgery,Tokyo, TOKYO, Japan

Introduction

Pancreatic cancer is one of the most common digestive cancers, and only 10-20% are operable disease. There are several prognostic indices such as tumor size, nodal involvement, resection margin status, and tumor differentiation. However, preoperative estimation of oncological prognosis remains to be established. In several reports, preoperative platelet to lymphocyte ratio (PLR) and neutrophil to lymphocyte ratio (NLR) are significant prognostic indicators in digestive malignancies. The objective of this study was to evaluate whether preoperative PLR or NLR is a significant prognostic index in resected pancreatic invasive ductal adenocarcinoma.

Methods

A total of 131 patients who underwent pancreatic resection for pancreatic invasive ductal adenocarcinoma were available from prospective maintained database. The patients were divide into two groups as PLR <150 or ≥150, and as NLR <5 or NLR ≥5, respectively. Survival data were analyzed using the Log-rank test for univariate analysis and Cox proportional hazards for multivariate analysis. P value <0.05 was judged as significant.

Results

The preoperative PLR was a significant prognostic index by Kaplan-Meier and Log rank tests. The median Overall Survival in patients with PLR <150 was 38.6 months, which was significantly better than 17.6 months for PLR ≥150 (p=0.001). The PLR retained its significance on multivariate analysis (HR, 1.688; 95 % CI, 1.045–2.726; p = 0.032) along with tumor size (p=0.035), resection margin status (p=0.048), and tumor differentiation (p=0.002).

Conclusion

The preoperative PLR is a significant independent prognostic index in resected pancreatic invasive ductal adenocarcinoma.

 

7.16 Should I Stay or Should I Go Now: Factors Influencing High Length of Stay After Pancreatectomy

Posted on December 22, 2014

M. Radomski1, A. Zureikat1, S. M. Novak1, J. Steve1, J. Marsh1, K. K. Lee1, A. Tsung1, D. Bartlett1, H. J. Zeh1, M. E. Hogg1  1University Of Pittsburgh,Pittsburgh, PA, USA

Introduction: In this healthcare climate, much scrutiny is being paid to cost, readmission, and length of stay (LOS).  Complex pancreatic surgeries have been associated with prolonged postoperative courses.  Many studies have looked at overall data and low outliers for pancreaticoduodenectomy.  However, little exists on high outliers and factors that contribute to prolonged stays.  We sought to evaluate the contribution of social, preoperative, operative, and postoperative patient related factors to extended LOS in major pancreatic resections.

Methods: A retrospective review of a single institution’s pancreaticoduodenectomies (PD) and distal pancreatectomies (DP) was performed from 6/2009 to 3/2014 for all pathologies and technical approaches. Interquartile ranges (IQR) were calculated and the highest quartile was evaluated and compared to the lower three quartiles.

Results:A total of 350 PD (42% open) and 127 DP (21% open) patients were analyzed with a 3rd IQR of >14 and >8 days respectively. Social factors including race, distance, insurance status, and marital status were not significant for PD; however, divorce was associated with longer LOS in DP (p<0.0001).  Pre-operative characteristics of higher age (p=0.0003), age adjusted Charlson Comorbidity Index (p=0.002), body mass index (p=0.01), and American Society of Anesthesia assessment (ASA, p=0.005) were associated with increased LOS in PD; whereas, only higher ASA (p=0.0188) was associated in DP.  Albumin, Ca19-9, previous abdominal surgery, and neoadjuvant therapy were not significant for PD or DP.  Increased operative time (p=0.009), blood loss (EBL, p=0.03), and transfusion (p=0.03) all were associated with longer LOS in PD; however, only EBL (p=0.03) was associated with longer LOS in DP.  A trend toward more LOS outliers was seen in the open PD group (p=0.06) compared with robotic, but not in the DP group (p=0.63). For the PD group, pancreatic fistula (p<0.0001), delayed gastric emptying (p<0.0001), and pseudoaneurysm (p<0.0001) were associated with extended hospitalizations.  No specific post-operative complications led to increased LOS in the DP group but the high LOS group was more likely to have had any complication (p=0.007) compared to the rest of the cohort.  High LOS outliers were more likely to go to skilled nursing facilities, acute care facilities, and rehab than home in both PD (p=<0.0001) and DP (p=0.005) groups.  The high LOS group had more readmission in the PD group (p=0.005) but not in the DP group (p=0.64).

Conclusion:More patient pre-, intra-, and post-operative factors lead to high LOS outliers seen in the PD group than the DP group; but the DP group also had a social factor associated with increased LOS.  Pre- and Intraoperative factors are hard to change, but further subgroup analysis in the PD group looking at management of specific complications and physician related factors may help identify better or sooner management to decrease LOS for these factors.

7.17 The Bipedicled, Conjoined Deep Inferior Epigastric Perforator (DIEP) Flap: a Concept in Evolution

Posted on December 22, 2014

P. G. Koolen1, B. T. Lee1, H. Erhard3, D. Greenspun2  1Beth Israel Dearoness Medical Center,Division Of Plastic Surgery,Boston, MA, USA 2Greenwich Hospital,Division Of Plastic Surgery,Greenwich, CT, USA 3Albert Einstein College Of Medicine,Division Of Plastic Surgery,Bronx, NY, USA

Introduction:

Autologous tissue transfer remains a mainstay for reconstruction of the breast. The deep inferior epigastric perforator artery (DIEP) flap has become a primary option at many institutions, yielding satisfactory aesthetic results. This type of reconstruction remains a challenge in thin patients with scant abdominal tissue or in previously irradiated breasts. Previous studies have described the use of stacked DIEP flaps, divided at the midline. We report on a modification with the use of a bipedicled, conjoined DIEP flap in thin patients; this avoids division of preexisting midline vasculature. 

Methods:

Patients undergoing a bipedicled, conjoined DIEP flap procedure for unilateral breast reconstruction over the course of two years were included in this study. Pre-operative imaging was obtained using MRA or CTA to support surgical planning of the primary and secondary vascular pedicles. Utilization of the entire abdomen was required for volume and the vascular networks were isolated on both sides. The primary flap was anastomosed to the internal mammary vessels and inset medially, whereas the secondary flap was folded towards the lateral side and a vascular anastomosis was performed from the secondary pedicle to side branches of the primary pedicle (Figure 1). Surgical technique was standardized for consistency.

Results:

We report on our experience with 27 patients undergoing bipedicled, conjoined, stacked DIEP flaps for unilateral (n=25) or bilateral (n=2) breast reconstruction. Important advantages included good volume, projection, ability to sculpt the flap, and creation of a teardrop shaped breast mound. In patients with previous radiation, the additional skin supplied by using both sides of the abdomen allowed for extensive replacement of damaged mastectomy skin. The secondary flap has blood supply across the midline as well as the second vascular pedicle and had “supercharged” perfusion, unlike in stacked flaps where the midline tissue is divided.
 

Conclusion:

Bipedicled, conjoined DIEP flap procedures are a reliable modification in patients requiring the entire abdominal tissue volume to create a unilateral breast. In using both vascular pedicles and preserving the midline blood supply, this allows for maximal perfusion of both flaps. This modification can be used in thin patients with limited abdominal tissue and does not require contralateral reduction procedures or use of alternative flaps.  
 

7.18 The Impact of Tumescent Technique on Outcomes of Autologous Breast Reconstruction

Posted on December 22, 2014

C. R. Vargas1, P. G. Koolen1, J. A. Ricci1, B. T. Lee1  1Beth Israel Deaconess Medical Center,Surgery / Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:
Use of the tumescent dissection technique during mastectomy has been reported to facilitate development of a hydrodissection plane, to shorten operating time, to reduce operative blood loss, and to provide additional local anesthesia.  Despite these advantages, the impact of this technique on post-operative outcomes remains unclear.  Several prior studies have suggested that tumescent dissection has a negative impact on post-operative complications following immediate implant placement, however, the effect on autologous reconstruction has not been clearly established.

Methods:
A retrospective review was conducted, using a prospectively maintained database, of all immediate autologous breast reconstruction procedures performed at a single academic center between January 2004 and December 2013.  Electronic patient records were queried for age, BMI, diabetes, active smoking, pre-reconstruction radiation therapy, mastectomy weight, and tumescent technique during mastectomy.  Mastectomy weight was divided into quartiles for improved clinical interpretation.  All post-operative occurrences of breast hematoma, seroma, and mastectomy skin necrosis were also collected.

Results:
A total of 698 immediate autologous post-mastectomy breast reconstruction flaps were performed during the study period; mean patient age was 49.3±8.3 years and average mastectomy weight was 769.3±413 grams.  49.2% of the mastectomies were performed using the tumescent dissection technique.  Univariate analysis revealed no significant difference in the incidence of breast hematoma (p=0.779), seroma (p=0.180), or mastectomy skin necrosis (p=0.688) in patients who underwent tumescent dissection during mastectomy.  Multivariate analysis, adjusted for clustering related to bilateral reconstruction, also demonstrated no significant association between the use of tumescent technique and post-operative breast hematoma (p=0.978), seroma (p=0.340), or mastectomy skin necrosis (p=0.759) after covariate adjustment.

Conclusion:
Use of the tumescent dissection technique during mastectomy is not significantly associated with adverse outcomes following autologous breast reconstruction.  Despite concern for its impact on implant reconstruction, our findings suggest that the tumescent method can be used safely in conjunction with autologous procedures.

7.19 From Free Flaps to Freestyle Locoregional Perforator Subunit Flaps- a Paradigm Shift over 230 Cases.

Posted on December 22, 2014

M. W. Findlay1,2,3,4, S. Sinha2, A. Rotman2, J. Ting2, S. Fairbank1, T. Wu2, F. Behan2  1Stanford University,Division Of Plastic And Reconstructive Surgery,Palo Alto, CA, USA 2The Peter MacCallum Cancer Centre,Divison Of Surgical Oncology,East Melbourne, VIC, Australia 3The University Of Melbourne,Department Of Surgery Royal Melbourne Hospital,Parkville, VIC, Australia 4Monash University,Combined Plastic And Reconstructive Surgery Unit,Clayton, VIC, Australia

Introduction: Perforator-based locoregional flaps provide tissue reconstruction with a shorter operative time, length of stay and fewer complications than free flaps in the head and neck. However, the vascular pedicles for common locoregional flaps can be compromised by previous surgery and/or injury and outcomes data based on large case series are lacking within the literature. Our practice has evolved from ‘random’ Keystone flaps to bespoke freestyle perforator subunit-based flaps over the past 6 years and we examined the outcomes data of over 230 cases during this time to examine the outcomes from our approach relative to large published series of free flap reconstructions.

Methods: Over 230 flaps performed over a 6-year period at two clinical centres within Australia were reviewed with institutional ethics approval.  The technique for perforator selection, flap design, elevation and closure are described using operative sequences along with our modifications to subunit-based reconstruction using Keystone flap principles. Prospectively collected data including patient comorbidities, pathology, defect size, flap type and perioperative complications were combined with retrospective data such as complication profile and length of follow up for the analysis. 

Results:Over 230 flaps were performed in the period between 2006 and 2012 for defects ranging from 4cm2 to 121cm2. Median patient age was 76 (range 19-98 years) with an average of 2 comorbidities per patient. The median operative time was under 100 minutes (inclusive of resective time). There was one peri-operative death (Day 5 post-op), 7 major complications including one complete flap loss and 4 partial flap losses requiring operative management. Pre- or post-operative radiotherapy and/or chemotherapy were associated with increased risk of complications.

Conclusion:An analysis of the outcomes from over 230 perforator-based island flaps in the head and neck demonstrates comparable results to free flap reconstruction, but with the added benefits provided by locoregional reconstruction. Our technique has evolved from ‘random’ Keystone flaps through to bespoke flaps based on specific perforators for esthetic unit reconstruction with shorter operative times and lower morbidity than free flap reconstruction.

 

7.20 Occult Neoplasms in Appendicitis: A Single-Institution Experience of 1793 Appendectomies

Posted on December 22, 2014

C. M. Forleiter1, J. A. Schwartz1, D. Y. Lee1, G. J. Kim1  1Mount Sinai School Of Medicine,Mount Sinai Roosevelt Hospital / Department Of Surgery,New York, NY, USA

Introduction: The incidence of appendiceal neoplasms may have been underreported in the past. Patients undergoing incidental appendectomies or appendectomies for chronic appendicitis may be at a higher risk for an occult appendiceal neoplasm. 

Methods:  Retrospective review of a pathology specimen database spanning four years at a tertiary care hospital center.  

Results: A total of 1,793 appendectomy specimens were evaluated.  There were 31 (1.7%) appendiceal neoplasms.  Fourteen neoplasms were discovered in 1,337 (1.0%) cases of acute appendicitis compared to 2 in 41 (4.9%) cases of chronic and 15 in 415 (3.6%) cases of incidental appendectomies (p < 0.001).  Patients with carcinoid tumors were significantly younger compared to others (p = 0.0001).  On multivariate analysis, indication for operation was the only significant factor for predicting a tumor.

Conclusion: Patients undergoing interval or incidental appendectomies may be at a higher risk for appendiceal neoplasm compared to other indications.  Younger patients may be at a higher risk of occult appendiceal carcinoid neoplasms than other age groups.  Pathologic diagnosis in specific high-risk patient groups may be the only way to effectively capture these tumors for optimal treatment. 
 

69.15 Clinicopathologic Factors Associated With a False Negative AUS in Patients With Breast Cancer

Posted on December 22, 2014

I. Nwaogu1, Y. Yan1, J. A. Margenthaler1  1Washington University,Surgery,St. Louis, MO, USA

Introduction: Axillary ultrasound (AUS) has been used in an attempt to identify sub-clinical node-positive disease and improve clinical staging and treatment recommendations. We sought to identify clinicopathologic factors potentially related to false negative AUS results.

Methods: Patients with a clinically node-negative Stage I-II invasive breast cancer who also had a normal AUS were identified from our prospectively maintained database. All AUS studies were performed by dedicated breast radiologists and interpreted as “normal” according to the absence of specific characteristics previously shown to be more commonly associated with metastatic involvement. True- and false-negative AUS studies were compared statistically based on clinical, radiographic, and histologic parameters.

Results:Of the 118 patients with a normal AUS, 25 (21%) were ultimately found to be node-positive on final pathologic assessment following axillary surgery. On bivariate analysis, primary tumor size, lymphovascular invasion (LVI), and Her2neu receptor status were found to be significantly different between true- and false-negative AUS. The average tumor size was smaller in the true-negative group compared to the false-negative group [16 vs 21mm (p< 0.01)]. The presence of LVI was more likely in the false-negative group [11/25 (44%)] compared to the true-negative group [7/93 (8%)] (p< 0.0001). Her2neu receptor status was more likely amplified in the false-negative group [8/25 (32%)] compared to the true-negative group [13/93 (14%)] (p=0.037). No significant difference was noted between groups with regard to patient age, race, body mass index, tumor grade, histologic type, estrogen or progesterone receptor status, and time between AUS and axillary surgery. On multivariate analysis, only the presence of LVI achieved statistical significance (p=0.0007).

Conclusion:AUS is a valuable tool that accurately predicted absence of axillary disease in 79% of patients with clinically node-negative breast cancer. AUS findings may be less accurate in the setting of LVI, and a negative AUS in patients with this feature should be interpreted with caution.

 

69.16 Use of a Recurrence Score In Locally Recurrent/New Primary Breast Cancer

Posted on December 22, 2014

N. C. Vera4, D. Carr4, J. Mullinax1, D. Korz1, W. Sun1, C. Laronga1, S. Hoover1, W. Fulp2, G. Acs3, M. C. Lee1  1Moffitt Cancer Center And Research Institute,Breast Program,Tampa, FL, USA 2Moffitt Cancer Center And Research Institute,Biostatistics,Tampa, FL, USA 3Women’s Pathology Consultants,Ruffolo Hooper & Associates,Tampa, FL, USA 4University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction: Treatment planning for locally recurrent estrogen receptor positive (ER+) invasive breast cancer is controversial. The Recurrence Score (RS) from the 21-gene breast cancer assay (ODX) is commonly used for primary early stage ER+ invasive breast cancer for adjuvant treatment recommendations, but not generally obtained in locally recurrent ER+ tumors. We reviewed our experience with RS first performed on the recurrent tumor.  

Methods: An IRB-approved, single-institution retrospective chart review of a prospective ODX database was performed. Most patients had ODX performed on an initial invasive breast cancer (1o cancer); another set of patients, the minority, had ODX performed on an ipsilateral local recurrence/new primary (2nd cancer); none had clinical evidence of concurrent regional or distant metastasis at presentation. Performance of the ODX assay was based on NCCN guidelines (1o cancer) or physician discretion (2nd cancer). Data collected included demographics, clinical-pathologic variables, surgery type, RS, adjuvant treatment and outcomes. Comparisons between patients with 1o breast cancer and patients with 2nd cancers were made by general linear regression model and the exact Wilcoxon Rank Sum Test. 

Results:594 patients with 1o breast cancer and 7 patients with 2nd breast cancer had ODX and RS.  Median age of patients at time of ODX was 58 years (range 27-84) for 1o cancer and 58.5 years (range 36-63) for 2nd cancers (p=0.411) respectively. The majority of patients with a 2nd breast cancer had a prior history of breast conservation (6/7). Median invasive tumor size of 1o cancer was 1.5cm and 2nd cancer was 1.4cm. One 2nd cancer was ILC, otherwise all documented 1o and 2nd breast cancers were ER+ and of invasive ductal histology. For 2nd cancers, median time from 1o breast cancer surgery to diagnosis with 2nd breast cancer was 92 months (range 13-120)[Table of 2nd cancers]. Median RS was higher in patients with 2nd cancer at 22 (range 15-37) compared to 1o cancer at 16 (range 0-63) (p=0.03). Categorically, more 2nd cancer patients had a high RS (28.6%) than those with 1o cancer (8.1%) but it was not significant (p=0.08). Tumor size, nodal status, degree of ER expression, nuclear grade, number of mitoses, and compliance with endocrine therapy were not significantly different between patients with 2nd cancer and 1o cancer. Overall survival tended to be better in patients with 1o breast cancer (P=0.049).

Conclusion:Performance of ODX in ER+, locally recurrent/new primary invasive breast cancer (2nd breast cancer) should be considered for prognostication and adjuvant systemic treatment recommendations.
 

69.17 Menopausal Status Affects Presentation but Not Outcome in Invasive Lobular Carcinoma

Posted on December 22, 2014

M. Zamanian1, A. Soran1, M. K. Wright1, C. Thomas1, G. M. Ahrendt1, M. Bonaventura1, E. J. Diego1, R. R. Johnson1, P. F. McAuliffe1, K. McGuire1  1University Of Pittsburgh School Of Medicine,Division Of Surgical Oncology, Department Of Surgery,Pittsburgh, PA, USA 2Magee Women’s Hospital Of UPMC,Surgical Oncology,Pittsburgh, PA, USA

Introduction: Invasive lobular carcinoma (ILC) is the second most common form of breast cancer, with rates increasing over the past 10-15 years. ILC has unique molecular and clinical characteristics, distinct from invasive ductal carcinoma. Studies of ILC, especially in the premenopausal population, remain limited. We hypothesize that premenopausal patients diagnosed with ILC will present with higher stage tumors and with lower estrogen receptor (ER) expression and will have poorer disease free and overall survival (DFS, OS).

Methods: A retrospective review of a prospectively collected database identified all pre- and postmenopausal patients treated for ILC at a single institution between 2004 and 2010. Patient and tumor characteristics were collected as well as outcome data. Patients whose menopausal status at diagnosis was not recorded were categorized as postmenopausal if they were over age 50 and premenopausal if they were under age 45. Patients age 46-49 were considered perimenopausal and were excluded. ER/PR (progesterone receptor) expression was measured using H-score (H-score = sum of % nuclear staining x intensity 0, 1+, 2+, 3+, giving a range from 0-300).  The two groups were compared for differences in presentation and outcome using uni- and multivariate analysis.

Results: 87 premenopausal and 226 postmenopausal patients were treated for ILC during the study period. Demographics were well balanced between the groups with the exception of age (p<0.001). Univariate analysis showed significantly larger tumor size (3.4±2.9 versus 2.5±2 cm, p=0.002), higher clinical stage (p=0.003), higher PR H-score (158±91 versus 121±100,p=0.005), and lower ER H-score (216±67 versus 242±65, p=0.004) in premenopausal versus postmenopausal patients, respectively. Significant differences in treatment with surgical and systemic therapy were also identified (Table 1). HER2 status was similar between groups. Multivariate analysis showed menopausal status to be independently predictive of tumor size (p=0.012), ER and PR (p<0.001) H-score and likelihood of receiving chemotherapy (p=0.013). DFS and OS were similar between the two groups (p=0.14 and p=0.16, respectively).

Conclusion: In this retrospective review of patients with ILC, premenopausal patients presented with larger tumors and with lower ER H-scores than post-menopausal patients. Despite these adverse clinical factors, there were no significant differences in DFS or OS. Premenopausal patients received systemic therapy more often, which may have contributed to equivalent outcomes. Further research is needed to understand how local and systemic therapy affect outcome in premenopausal patients with ILC.

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