69.18 Breast Cancer Outcomes in a Population with a High Prevalence of Obesity

Posted on December 22, 2014

V. C. Herlevic1, R. S. Mowad1, J. K. Miller1, N. A. Darensburg1, B. D. Li1, R. H. Kim1  1Louisiana State University Health Sciences Center – Shreveport,Surgery,Shreveport, LA, USA

Introduction:

Obesity has been associated with poor prognosis in breast cancer. However, most previous studies examined populations with relatively low proportions of obese patients. Given that forecasts predict obesity rates to exceed 50% by 2030, it is important to examine breast cancer outcomes in populations with higher rates of obesity. We hypothesized that obesity, as measured by Body Mass Index (BMI), is associated with decreased overall survival and disease-free survival in patients with invasive breast cancer in a population with a high prevalence of obesity.

Methods:

A retrospective review of a prospectively maintained database was conducted on patients treated for invasive breast cancer at an academic medical center between July 1987 and May 2013. BMI was calculated from each patient’s height and weight at time of diagnosis. Patients were categorized as normal (BMI < 25 kg/m2), overweight (BMI 25 – 30 kg/m2), or obese (BMI > 30 kg/m2), as per the definitions established by the World Health Organization. The endpoints of overall survival and disease-free survival were analyzed.

Results:

A total of 740 patients with invasive breast cancer were included for analysis. Based on BMI, 127 (17.2%) were categorized as normal, 203 (27.4%) were overweight, and 410 (55.4%) were obese. The median follow-up was 49 months. There were 17 deaths (13.3%) in normal patients, 34 (16.7 %) in overweight patients, and 64 (15.6%) in obese patients (p=0.74). By Kaplan-Meier survival analysis, there were no differences in overall survival (p=0.91) or in disease-free survival (p=0.99) between the three groups.

Conclusion:

Obesity is not associated with decreased overall or disease-free survival in a patient population with a high prevalence of obesity. These findings suggest that there may be other factors that contribute to the poor prognosis of obese breast cancer patients observed in populations with lower rates of obesity.

69.19 Breast Density, BMI, and Outcomes in Premenopausal Women with Breast Cancer

Posted on December 22, 2014

M. K. Wright1, A. Soran1,2, M. Zamanian1, C. Thomas2, G. M. Ahrendt1,2, M. Bonaventura1,2, E. J. Diego1,2, R. R. Johnson1,2, P. F. McAuliffe1,2, K. P. McGuire1,2  1University Of Pittsburg,School Of Medicine,Pittsburgh, PA, USA 2Magee Women’s Hospital Of UPMC,Surgical Oncology,Pittsburgh, PA, USA

Introduction:  

Breast density is a well-established risk factor for the development of breast cancer.  Some studies suggest that breast density is associated with a tumorigenic microenvironment within the breast, leading to more cancers and higher stage at presentation. We hypothesize that premenopausal women with dense breasts will present with breast cancer at a  higher stage and will have worse long-term outcomes compared to their non-dense breasted counterparts. 

Methods:

We performed a retrospective study of a prospectively collected database identifying premenopausal women with breast cancer who presented to a single institution between 2006 and 2010.  Premenopausal status was defined as age less than 50 years or no menstrual period for at least one year. Patient and tumor characteristics were collected, as well as long-term outcomes.  Patients were stratified into two categories of breast density: ‘non-dense’, defined as fatty replaced  or scattered fibroglandular densities (BIRADS Density Categories 1 & 2, respectively) and ‘dense’, defined as heterogeneously dense or homogeneously dense (BIRADS Density Categories 3 & 4, respectively). The two breast density groups were compared for differences in presentation and outcomes using univariate and multivariate analyses.

Results:

477 premenopausal women with breast cancer were identified.  Clinicopathologic factors, including age, race, tumor histology, receptor status, and treatment types were well balanced between the two breast density groups.  On univariate analysis, breast density did not correlate with stage at presentation, tumor grade, lymphovascular invasion, clinical stage, treatment type, surgery type or overall survival.  Lower breast density was strongly correlated with higher BMI, poorer disease free survival (DFS), and larger tumor size on univariate analysis (Table 1).  Multivariate analysis also showed that BMI (p = 0.05) and tumor size (p = 0.001) were significantly associated with DFS, whereas breast density was not.  

Conclusion: 

In this retrospective study of premenopausal women with breast cancer, we found that higher breast density was not associated with higher stage at presentation or with poorer outcomes.  This study suggests that higher BMI and tumor size at presentation, although related to breast density, are more predictive of recurrence than breast density in premenopausal patients. Further study is needed to elucidate the link between BMI, breast density and outcome in premenopausal breast cancer.
 

69.20 Is routine excision of Pseudoangiomatous Stromal Hyperplasia (PASH) an unnecessary surgery?

Posted on December 22, 2014

D. R. Layon1, A. D. Brooks2  1Drexel University College Of Medicine,Philadelphia, Pa, USA 2University Of Pennsylvania,Endocrine And Oncologic Surgery,Philadelphia, PA, USA

Introduction:  Pseudoangiomatous stromal hyperplasia (PASH) is a benign breast lesion of mesenchymal origin for which the optimal treatment strategy is unclear. We performed a systematic review of the literature in order to determine if excision is necessary for managing PASH found on a biopsy. 

Methods:  Keyword searches for “pseudoangiomatous stromal hyperplasia” and “pseudoangiomatous hyperplasia of the mammary stroma” were queried in PubMed. Exclusion criteria were: articles not about relevant pathology, extra-mammary lesions, and inability to extract PASH data from mixed patient cohorts. Eligible articles were reviewed for patient demographics and study characteristics. We determined whether each reported cancer was incidentally or directly related to the PASH lesion. Incidental malignancies were: detected independently, temporally or spatially separate from the PASH lesions, or contained only microscopic foci of PASH. Malignancies were classified as directly related if located within PASH lesions. 

Results: The search returned 122 results; 6 studies were obtained from other sources for a total of 128 studies. 18 studies were excluded. Eligible articles included: 51 case studies, 41 case series 17 review articles, and 1 textbook. The articles had a population of 1,508 individuals. 104 were male, 1,394 were female and 10 were not reported. 73% of PASH cases were managed via excision, 10% by observation, 1% by mastectomy, 0.79% by other methods (incisional biopsy, mammoplasty, or removal via core needle or vacuum-assisted biopsy), and 14% of cases had no reported management. There were 91 cases of malignant or pre-malignant lesions reported in the PASH literature (Table 1): invasive or noninvasive lesions, subtype not specified (48 cases), invasive ductal carcinoma (14), ductal carcinoma in-situ (DCIS, 16), Non-Hodgkins Lymphoma (3), invasive micro papillary carcinoma (1), invasive adenocarcinoma (5), and myofibroblastic sarcoma (4). Of the 91 cases, 34 were temporally separate, 21 spatially separate, 22 were identified independently of PASH, 8 had only microscopic foci of PASH and 5 were unable to be classified. The other 5 malignancies appear to be four cases of primary myofibroblastic sarcomas arising from PASH tumors and a single case of DCIS found within a PASH tumor. Thus, we estimate the incidence of malignant transformation of PASH lesions at 5/1508 or 0.3%. 

Conclusion: Although most PASH lesions in the literature were treated by excision, the reported incidence of malignant transformation of PASH lesions is 0.3%. Based on the low incidence of malignancies arising from PASH lesions we conclude that the diagnosis of PASH alone, in the absence of other indications, does not require surgical intervention. 

7.01 The Safety of Esophago-Gastrectomy in Patients Older than 80 Years: Risk vs. Benefits

Posted on December 22, 2014

M. Melis1, A. Masi1,2, A. Pinna1, I. Hatzaras1,2, S. Cohen1, R. S. Berman1, G. Ballantyne1, H. Pachter1, E. Newman1  1New York University School Of Medicine,New York, NY, USA

Introduction: Gastro-esophageal surgery can generally be performed with mortality lower than 5% and morbidity of 30-50%, but little is known about results of esophagectomy and gastrectomy in octogenarians. We investigated outcomes after resection of stomach and/or distal esophagus for cancer in patients ≥ 80 year-old.

Methods: From our gastro-esophageal cancer database we identified 289 patients who underwent surgery (1990-2010) for cancer. We categorized patients into two groups, according to age at time of surgery: Group O (≥ 80 year-old) and Group Y (< 80 year-old). The study end-points were overall morbidity, 30-day mortality, overall survival (OS). Differences between groups were evaluated using t-test or chi-squared test. Survival was compared using Kaplan–Meier analysis and log-rank test.

Results: There were 50 patients in group O (mean age 85) and 239 in Group Y (mean age 64.3). As expected, octogenarians had worse ECOG performance status (PS ≤ 1: 84% vs. 91.2%, p < 0.001) and higher incidence of specific comorbidities. Operative time, blood loss, AJCC stage, and status of resection margins were similar between groups. Octogenarians had similar 30-day morbidity (36.0% vs. 37.7%, p=0.82) and post-operative mortality (6% vs. 2.5%, p=1.96). At median follow-up of 21.8 months OS was 13.1 and 29.2 months respectively in Group O and Y (p=0.10)

Conclusions: In our experience, despite a higher incidence of pre-operative co-morbidities, early and long-term post-operative outcomes in octogenarians were similar to those of younger patients. Radical surgery can be safely offered to carefully selected octogenarians with gastric or esophageal cancer.

7.02 Sentinel Lymph Node Mapping for Cutaneous Squamous Cell Cancer

Posted on December 22, 2014

M. A. Bartz-Kurycki1,2, R. S. Krouse1,2  1Southern Arizona VA Health Care System,Tucson, ARIZONA, USA 2University Of Arizona,Surgery,Tucson, AZ, USA

Introduction: Cutaneous squamous cell cancers (cSCC) are typically non-aggressive, although certain features may indicate possible nodal metastasis. As sentinel node (SLN) mapping may be of utility for high risk cSCC, it is important to evaluate patients who have undergone this procedure.

Methods: A prospective database has been developed by a single surgeon who cares for the majority of aggressive cSCC at the Southern Arizona Veterans Affairs Healthcare System. Patients with multiple poor prognostic indicators (age >75, immunocompromised, differentiation, site of tumor, size of tumor, histologic subtype) were offered SLN. The reason for not offering SLN was poor clinical status. Patient characteristics and screening tests were evaluated.

Results: 68 patients with cSCC underwent SLN over 9 years. All patients were male. 5.98% (4/68) patients had positive metastatic cSCC; 3 patients had false negatives seen with nodal recurrences. Screening tests showed a sensitivity of 57.1% and accuracy of 94.1%. Patients with positive SLN (at time of operation or recurrence) were more likely to have moderately to poorly differentiated tumors, be immunocompromised, or age > 75.  All patients with positive nodes had at least 3 poor prognostic indicators.

Conclusion: SLN mapping likely has utility for cSCC patients with multiple poor prognostic indicators. As most patients have head and neck tumors, there are more likely to be false negatives and close follow-up is indicated.

 

7.03 Sentinel Lymph Node Biopsy Is Accurate In Merkel Cell Cancer

Posted on December 22, 2014

A. C. Gasior1, A. Gingrich1, S. Deas1, J. Mammen1  1University Of Kansas,Surgery,Kansas City, KS, USA

Introduction:
Merkel cell cancer (MCC) is a rare and aggressive cutaneous neuroendocrine neoplasm. Sentinel lymph node biopsy (SLNB) is often used to assess for nodal metastases in breast cancer and melanoma, but the accuracy of SLNB for MCC is less well described with false negative rates varying from 0 to 50% (most studies based on administrative databases without consistent follow-up).  In this study, we evaluated a single institution retrospective database of patients diagnosed with MCC to establish the accuracy of SLNB.

Methods:
After IRB approval, a single institution database was created spanning from January 2007 through December 2013. Patients had the standard SLNB technique of dual tracer evaluation (vital blue dye and radiolabelled sulfur colloid.) Patients were scheduled for surveillance every 6 months after surgery. Descriptive and chi-square analysis were used for statistical evaluation.

Results:
Of our 17 patients, the majority (64.7%) were male and over 66 years of age (52.9%). 15 patients (88.2%) had SLNB. The mean number of lymph nodes removed for sentinel lymph node biopsy was 2.6. 13/15 (86.7%) of SLNB were negative. Neither age, cancer site, nor size were independent predictors of nodal positivity. Of the 2 patients with positive SLNBs, only one patient had non-sentinel nodes (3/15) positive on subsequent lymphadenectomy. Of patients with negative SLNBs, there was no evidence of lymph basin only recurrence at follow-up in any patients (false negative rate of 0%).  Median length of follow-up was 12 months. 

Conclusion:
Previous MCC studies show extent of disease at presentation to be the greatest factor predictive of survival.  In our study of early clinical stage MCC, patient factors were not identified to predict pathologic nodal involvement.   In one of the largest series of patients with MCC evaluated with SLNB, the false negative rate was identified to be 0% suggesting that SLNB is an accurate technique to stage MCC patients for nodal metastases.

7.04 Goblet Cell Neuroendocrine Carcinomatosis treated with Cytoreductive Surgery and HIPEC

Posted on December 22, 2014

R. W. Randle1, K. F. Griffith1, K. R. Swett2, J. H. Stewart1, P. Shen1, E. A. Levine1, K. I. Votanopoulos1  1Wake Forest University Baptist Medical Center,Surgery,Winston-Salem, NORTH CAROLINA, USA 2Wake Forest University Baptist Medical Center,Biostatistics,Winston-Salem, NORTH CAROLINA, USA

Introduction:  Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an aggressive treatment for patients suffering with peritoneal carcinomatosis.  It is commonly applied to low-grade mucinous tumors of the appendix disseminated throughout the peritoneal cavity, yet some high volume centers have extended this therapy to carcinomatosis from a variety of more aggressive primary malignancies.  Therefore we decided to review our experience with CRS-HIPEC for patients with carcinomatosis from goblet cell neuroendocrine carcinomas.

Methods:  Patients with carcinomatosis and final pathology confirming goblet cell features were identified in a prospectively maintained database of 1069 CRS-HIPEC procedures performed between 1991 and 2013.  Patient demographics, disease characteristics, morbidity, mortality, and survival were reviewed.  

Results:  A total of 25 patients with goblet cell neuroendocrine carcinomatosis underwent CRS-HIPEC during the study period.  Tumors originated in the appendix in 23 (92%) patients and in the colon in 2 (8%).  Patients were generally young (mean age 53 years) and otherwise healthy (84% without comorbidities) with good performance status (92% ECOG 0 or 1).  The mean number of visceral resections was 3.6, and complete cytoreduction of all macroscopic disease was accomplished in 36% prior to HIPEC.  The 30-day major morbidity and mortality were 36% and 8%, respectively.  Median overall survival for all patients was 16.5 months.  In univariate analysis, significant predictors of decreased survival included worse performance status (hazard ration [HR] 2.2, 95% confidence interval [CI] 1.1–4.4, p=0.03) and nodal involvement (HR 9.6, 95% CI 1.2–73.8, p=0.03).  Despite similar volume of peritoneal disease, patients with negative nodes had better survival than those with positive nodes (median overall survival 32.7 months vs. 9.9 months), respectively (p=0.01).  While complete cytoreduction was associated with longer survival following CRS-HIPEC in all patients (R0/R1 median overall survival 28.5 months vs. R2 median overall survival 9.9 months, p=0.19) and in those with nodal disease (R0/R1 median overall survival 16.5 months vs. R2 median overall survival 8.5 months, p=0.07), neither observed difference reached statistical significance.

Conclusion:  CRS-HIPEC may improve survival in patients with node negative goblet cell neuroendocrine carcinomatosis when a complete cytoreduction is achieved.  Patients with disease not amenable to complete cytoreduction should not be offered CRS-HIPEC.

 

7.05 Recurrence and Prognostic Factors after Cytoreductive Surgery and HIPEC for Appendiceal Cancer

Posted on December 22, 2014

M. Mavros1, L. Bijelic1, U. Hyder1, A. Firoozmand1, C. Ihemelandu1, P. Sugarbaker1  1MedStar Washington Hospital Center,Department Of Surgery,Washington, DC, USA

Introduction: Appendiceal cancer most commonly metastasizes to the peritoneum. Cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC) has become the leading treatment modality for peritoneal metastases. We sought to analyze clinical outcomes after CRS and HIPEC for appendiceal cancer in a recent cohort of patients treated at a large referral center and identify prognostic factors and predictors of recurrence.

Methods: Patients undergoing CRS with HIPEC for appendix cancer in a large tertiary care referral center between January 2007 and December 2009 were identified. Prospectively collected data were analyzed, including standard preoperative, intraoperative, and postoperative variables; the impact of prior surgical score (PSS), peritoneal cancer index (PCI), and completeness of cytoreduction score (CCS) was specifically assessed. Multivariate Cox regression models were developed to identify factors independently predicting overall survival and recurrence.

Results: A total of 134 patients were analyzed. Median age was 51 years and 53% were female. Roughly half had previous abdominal operations (PSS≥2, 53%), extensive peritoneal dissemination (PCI≥21, 52%), or the PMCA variant (54%); few had lymph node metastases (11%). Median operative time was 9 hours, and most of the patients received RBC (73%) or FFP (47%) transfusions; 30-day mortality was 0.7%. Half of the patients underwent early postoperative intraperitoneal chemotherapy (49%), and a large proportion experienced at least one postoperative complication (minor, 37%; major, 25%). Overall survival (OS) at 5 years was 74.4%; 5-year recurrence-free survival (RFS) of patients with a complete cytoreduction (CCS≤1) was 65.5%. Factors independently predicting shorter survival included the PMCA variant [Hazards Ratio (HR)=12.74, 95% CI: 3.77–43.05)], lymph node metastasis [HR=2.58 (1.15–5.79)], and incomplete cytoreduction [CCS≥2, HR=5.93 (2.85–12.34)]. Similarly, factors predicting recurrence included the PMCA variant [HR=7.03 (3.35–14.78)] and lymph node metastasis [HR=4.00 (1.74–9.19)]. An incomplete cytoreduction was associated with the PMCA variant (p<0.001), but also more advanced peritoneal disease (PCI≥11, p=0.012) and prior abdominal surgeries (PSS≥2, p=0.033).

Conclusion: CRS with HIPEC can be performed with acceptable morbidity and mortality at an experienced referral center and achieve long term survival for patients with advanced appendix cancer. Histologic subtype and lymph node metastasis, along with complete cytoreduction are the most important predictors of overall survival. Efforts should be made for timely definitive CRS/HIPEC, avoiding prior non-definitive abdominal operations when possible.

7.06 Advanced Nutritional Support after Esophagectomy for Esophageal Cancer

Posted on December 22, 2014

S. Ajmal1, T. Ng1, A. M. Blakely1, W. G. Cioffi1, T. J. Miner1  1Brown University School Of Medicine,Department Of Surgery,Providence, RI, USA

Introduction:  Various modalities are employed to provide nutritional support to patients after esophagectomy for esophageal cancer. Routine Jejunostomy tubes are placed in patients with esophageal cancer to provide nutritional supplementation in perioperative setting. Total parenteral nutrition is also utilized when patients have complications or delayed oral intake. We sought to study the utility and complications associated with these nutritional support modalities.

Methods:  We performed a retrospective chart review of all adult patients who underwent esophagectomy for esophageal cancer from 2001 to 2014 at a single tertiary care institution. We reviewed the utility of jejunostomy tube and complications associated with jejunostomy tubes.

Results: 182 patients underwent esophagectomy for esophageal cancer during the study period. Esphageal cancer types included 158 adenocarcinomas, 15 squamous cell carcinomas, 8 high grade dysplasias and 1 neuroendocrine tumor. 107 patients had Transhiatal resection, 55 had Ivor-lewis esophagectomy, 9 had Thoraco-abdominal resection and 10 patients had Three incision esophagectomy. 181 patients had a jejunostomy tube placed. At the time of discharge 88 (48.6%) patients were receiving nutrition through tube feeds. Out of these 88 patients, 34 (18.7%) had partial tube reliance while 53 (29.3%) had total tube reliance. 6 patients (3.3%) needed both jejunostomy tube feeds and total parenteral nutrition (TPN) while only one patient was just placed on TPN. Patient group that required tube feeds on discharge were more likely to have a complicated course than patients not on tube feeds (61 vs 12; p<0.05). Out of 181 patients with jejunostomy tubes, only 1 patient required surgical intervention due to catheter related complication. No mortality was reported due to catheter related complications.

Conclusion: Our data reveals that a significant number of patients require tube feeds at discharge. Serious morbidity secondary to jejunostomy feeding tube was rare. This further supports the current practice of placing routine feeding J-tubes for esophagectomies.

 

7.07 Patient Demographics and Clinical Outcomes in Pancreatic Cancer Based on Histological Subtype.

Posted on December 22, 2014

N. Poulsen1, S. Patil1, R. S. Chamberlain1  2Saint George’s University,Grenada, Grenada, Grenada 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA

Introduction:  Pancreatic ductal adenocarcinoma (PDC) makes up more than 90% of pancreatic tumors; however, other less common histological subtypes exist including acinar cell carcinoma (ACC), islet cell tumors (IC), neuroendocrine tumors (NE) and squamous cell carcinoma (SCC). While information on the clinical course, management and outcomes associated with adenocarcinoma of the pancreas has been extensively studied, information on other histological subtypes is limited. 

Methods:  Data on 100,727 patients with pancreatic cancer from the Surveillance Epidemiology and End Results (SEER) database (1973- 2008) was abstracted. Patients with PDC, ACC, IT, NE, and SCC were separately analyzed for age, gender, race, stage, treatment, and long-term survival. Categorical variables were compared using the Chi square test, and continuous variables were compared using ANOVA.

Results: PDC (N=95,271; 94.6%) was the most common form of pancreatic cancer identified followed by NE (N=2,922; 2.90%), IC (N=1,845; 1.83%), SCC (N=355; 0.34%) and ACC tumors (N=334; 0.33%). Pancreatic cancer occurs most commonly in Caucasian men in the 6th decade of life, however patients with IC tumors and NE tumors were significantly younger than those with PDC, ACC and SCC. All five subtypes presented most commonly with metastatic disease (PDC: 57.2%; ACC: 48.8%; IC: 48.3%; NE: 60.8%; and SCC: 60.0%). Overall survival was 1.43 years. Patients with IC tumors had the greatest mean survival (5.08 years), followed by NE tumors (2.96 years), ACC (2.79 years), and PDC/SCC (1.31 years each) (p< 0.001). Mortality was significantly greater in patients with SCC and PDC (96.3% and 93.9% respectively, p<0.001) compared to all other subtypes. Combination surgery and radiation therapy demonstrates the greatest 5- and 10-year survival rate in patients with PDC (19% and 10%), ACC (54% and 37%), and SCC (25% and 13%) (p<0.001). Surgical intervention alone demonstrates the greatest 5- and 10-year survival in IC tumors (74% and 56%) and NE tumors (76% and 58%) (p< 0.001). PDC and SCC had the lowest 5- and 10-year survival for all treatment modalities.

Conclusion: Pancreatic cancer is a devastating disease with an overall mortality greater than 65% independent of histological subtype. PDC and SCC demonstrate the lowest mean survival, highest mortality and appear to follow a similar clinical course independent of treatment modality. Despite an overall mortality rate of 66% and a mean survival of 5 years, pancreatic IC tumors are the most indolent pancreatic tumors. Surgical intervention appears to offer the greatest survival benefit to patients with IC and NE tumors, while combined surgical and radiation therapy appears to offer the greatest survival benefit to patients with PDC, SCC and ACC.      

7.08 Effect of High-Grade Disease on Colon Cancer Outcomes

Posted on December 22, 2014

R. Amri1,2, L. G. Bordeianou1,2, P. Sylla1,2, D. L. Berger1,2  1Massachusetts General Hospital,General And Gastrointestinal Surgery,Boston, MA, USA 2Harvard Medical School,Surgery,Brookline, MA, USA

Introduction:
Tumor grade is one of the cardinal characteristics used in the surgical pathological assessment of a malignancy. High-grade disease invariably has a negative impact on the eventual outcomes of the concerned malignancy. We aimed to measure the magnitude of its influence as well as its stage-independent effect in colon cancer. 

Methods:
All patients treated surgically at our center (2004 through 2011) with known disease grade were included in an institutional review board-approved database. We measured the relative risk (RR) of encountering distant and nodal spread of the disease in baseline pathology, as well as the risk of recurrence and overall and disease-specific mortality. In addition, a multivariate logistic regression adjusted for stage was used to assess the stage-adjusted odds ratio (OR).

Results:
A total of 961 patients with specified tumor grade were included for analysis. Of these, 191 (19.9%) patients had high-grade disease on baseline pathology. These patients were invariably at far higher risk of lymph node metastasis (63.7 vs. 38.2%; RR: 1.67) and metastatic presentation (30.9 vs. 15.3%; RR: 2.02) (both P<0.001). These baseline differences also led to a significantly higher risk of poor outcomes (all P<0.001), including disease recurrence (23.5 vs. 11.8%; RR: 1.99), overall mortality (56.5 vs. 31.8%; RR: 1.77) and colon cancer-specific mortality (34.6 vs. 16.6%; RR: 2.08). All of these findings were still statistically significant and within the same order of magnitude after adjusting of odds ratios for baseline staging in multivariate analysis.

Conclusion:
High-grade disease on baseline colon cancer surgical pathology is associated with a considerably higher rate of nodal and distant metastasis. As a result, the colon cancer-related mortality doubles for patients with high-grade disease. More interestingly, all of these findings were shown to be independent of baseline staging, confirming that high tumor grade is a stage-independent factor greatly influencing colon cancer outcomes and mortality.
 

7.09 Colon Cancer Patients with Inflammatory Bowel Disease Do Not Necessarily Have Worse Outcomes

Posted on December 22, 2014

R. Amri1,2, L. G. Bordeianou1,2, P. Sylla1,2, D. Berger1,2  1Massachusetts General Hospital,General And Gastrointestinal Surgery,Boston, MA, USA 2Harvard Medical School,Surgery,Boston, MA, USA

Introduction:
Inflammatory bowel disease (IBD) is associated with a high risk of developing colon cancer. Its relationship with the eventual outcomes is less evident, although recent reports have indicated that comorbid IBD may be associated with worse survival. We therefore aimed to review characteristics of colon cancer associated with IBD in our population.

Methods:
We evaluated outcomes of a patient cohort operated on for colon cancer between 2004 through 2011 in a public tertiary care center in a state providing universal healthcare, focusing on comparing surgical pathological characteristics and long-term outcomes between IBD patients and the remainder of the population.

Results:
We included 1071 patients, of whom 38 (3.5%) had a concurrent diagnosis of IBD: 21 (2.0%) having Crohn’s, 16 (1.5%) having ulcerative colitis, and 1 patient with a mixed form. IBD patients were significantly younger (median age 59.5 vs. 67 years; P<0.001). These patients had a significantly higher rate of high-grade disease (33.3 vs. 19.4%; P=0.034) and borderline significantly higher rates of AJCC stage I disease (36.8 vs. 24.4%; P=0.06). In terms of outcomes however, no statistically significant differences were encountered between patients with or without IBD. Clinically significant but not statistically significant differences demonstrated lower rates of lymph-node metastasis (31.6 vs. 40.6%; P=0.27) and metastatic presentation (13.2 vs, 17%; P=0.54), as well as better outcomes in terms of metastatic recurrence (9.1 vs. 12.7%; P=0.55), and colon cancer mortality (26.3 vs. 35.6% P=0.27). Point estimates in multivariate analysis adjusted for age and staging where appropriate showed no changes in these trends.

Conclusion:
IBD patients who develop colon cancer appear to have relatively better staging and outcomes compared to non-IBD patients. These differences were present despite significantly higher-grade disease on presentation. More aggressive tumor characteristics in colon cancer patients with comorbid IBD fit the findings in earlier literature, while slightly better outcomes in IBD patients are an uncommon finding. This incongruence may potentially be explained by regular surveillance in patients with IBD, which may provide a protective effect through early detection of cancers. Differences with earlier reports in outcomes and staging could potentially be related to universal healthcare in our state, facilitating comprehensive IBD follow-up at our center. These findings suggest that under adequate and regular follow up, IBD patients are not necessarily inherently worse off when diagnosed with colon cancer.

7.10 Predicting Success in Small Renal Mass Biopsy

Posted on December 22, 2014

J. M. Prince1, E. M. Bultman2, A. Drewry1, J. L. Hinshaw2, E. J. Abel1  1University Of Wisconsin,Department Of Urology,Madison, WI, USA 2University Of Wisconsin,Department Of Radiology,Madison, WI, USA

Introduction:   Percutaneous biopsy may provide important information for patients with small renal masses (SRM) prior to treatment.  However, 15-20% of patients undergoing biopsy receive indeterminate results, and thus do not benefit from the procedure.  The objective of this study was to evaluate clinical and anatomical factors that are predictive of obtaining indeterminate results from percutaneous SRM biopsy.

Methods:   Comprehensive clinical and anatomical factors were reviewed for consecutive SRM (≤4cm) patients treated with renal mass biopsy at the University of Wisconsin Hospital from 2000 to 2014.  Univariable and multivariable logistic regression analysis was performed to determine which factors were associated with indeterminacy. 

Results:  A total of 413 SRM biopsies were performed in 386 patients.  The median tumor size was 2.35 cm (IQR 1.90-2.95).  15.5% of the masses were cystic and 84.5% were solid.  Enhancement (>20 HU ) was seen in 84.0%, while 5.3% were pseudo-enhancing (10-20 HU), and 1.9% were non-enhancing.  A skin-to-tumor distance of ≥14 cm was observed in 4.1% of the masses.  Similar to previous studies, we observed an indeterminate rate of 17.4% in the entire cohort and among cystic lesions, the indeterminate rate was 43.8%.

After multivariable analysis, independent predictors of indeterminate biopsy included: cystic features (OR 4.91, 95% CI 2.46-9.83, p < 0.0001), tumor diameter (OR 0.59, 95% CI 0.39-0.90, p = 0.015), skin-to-tumor distance ≥14cm (OR 4.29, 95% CI 1.50-12.25, p = 0.0065), and radiographic enhancement (OR 3.61, 95% CI 1.52-8.56, p = 0.0036).

Other factors evaluated but not significant to predict indeterminate biopsy included: exophytic shape, hemorrhage, necrosis, fat content, calcifications, type of imaging modality used prior to and for guidance during biopsy, biopsy type (i.e. core or fine needle aspiration), patient BMI, proximity to adjacent organs, anteroposterior and polar positioning within the kidney and laterality of the mass.

Conclusion:  Four independent predictors for indeterminate biopsy are described including: cystic features, mean mass size, enhancement ≤20 HU, and skin-to-tumor distance ≥14cm.  These factors can be used to identify patients with a significant risk for a non-diagnostic biopsy result and facilitate better patient selection for this procedure.

7.11 Robotic and Laparoscopic Surgery for Colorectal Cancer Offer Comparable 3-5 Year Oncologic Outcomes

Posted on December 22, 2014

F. G. Wilder1,2, A. Burnett1, J. Oliver1, R. J. Chokshi1  1Rutgers – New Jersey Medical School,Surgery,Newark, NJ, USA 2Memorial Sloan-Kettering Cancer Center,New York, NY, USA

Introduction: Robotic surgery has been demonstrated to be a viable option for the resection of benign and malignant colorectal diseases. However, data thus far is lacking with regards to long-term oncologic outcomes. We sought to compare the longer term oncologic outcomes of robotic versus laparoscopic resection of colorectal cancer.

Methods: A literature search was performed using the Pubmed, EMBASE, Cochrane, and Medline databases for studies published between 2000 and 2014.  Search terms were: colon, rectal, robot, cancer, laparoscopic, oncologic and outcomes.  Studies that compared the overall and disease free survival of robotic versus laparoscopic surgery for patients with colon or rectal cancer were included.  Meta-analysis was performed using OpenMeta[Analyst] for Windows 8.

Results:There were 5 studies published between 2000-2014 that reported on overall survival (OS), disease free survival (DFS), lymph node (LN) extraction, circumferential resection margin (CRM), short and long-term recurrence. 317 patients across the 5 studies underwent either totally robotic or hybrid (robotic-assisted) resection of colon or rectal cancer.  Mean DFS with laparoscopic resection versus robotic resection was 86.2% (±4.4) and 86.9% (±4.0), respectively.  Mean OS with laparoscopic resection versus robotic resection was 93.4% (±3.2) and 91.3% (±4.1), respectively. Except for the Park study whose values were at 5 years, all groups reported DFS and OS at 3 years. At 5 years, Park found a DFS of 78.7% (±4.5) for LCS and 81.9% (±3.3) for RCS.  OS was 93.5% (±3.2) for LCS and 92.8% (±2.2) for RCS.  Robotic surgery was associated with slightly smaller resection margins (0.318cm, p=0.042), resection of fewer nodes (2.173 fewer nodes, p=0.0001), but equivalent odds of a positive CRM (OR 1.08, p=0.859).  

Conclusion: Robotic surgery offers comparable overall and disease free survival when compared to laparoscopic surgery for colorectal cancer.  However, longer-term follow up and larger patient populations need to be studied before official recommendations can be made.

 

69.03 Delaying I-131 Treatment For Papillary Thyroid Cancer Is Not Associated With Increased Recurrence

Posted on December 22, 2014

P. H. Dedhia1, S. Grzegorski1, M. S. Cohen1, B. S. Miller1, P. G. Gauger1, D. T. Hughes1  1University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction:  Radioactive iodine (RAI) ablation is frequently used in patients with papillary thyroid cancer (PTC) larger than 1 cm to ablate the thyroid remnant and facilitate detection of recurrent disease. Treatment with RAI is usually performed 6-8 weeks after thyroidectomy. Here we assess the effect of delay in RAI on post-RAI thyroglobulin levels and PTC recurrence. 

Methods:  This is a retrospective review of 447 patients with pathologically confirmed PTC from thyroidectomy procedures performed between 2009 to 2013 in the endocrine surgery division at the University of Michigan. Clinical characteristics, pathology, postoperative stimulated thyroglobulin (Tg) levels, days elapsed from surgery to radioactive iodine treatment, unstimulated Tg levels after RAI, and recurrence were examined.

Results: Of the 447 patients with papillary thyroid cancer from 2009 to 2013 who underwent thyroidectomy, 50.5% (n=226) were treated with RAI. Of the patients treated with RAI, 37% of patients underwent RAI greater than 60 days after thyroidectomy. The average tumor size in patients treated with immediate RAI and patients who underwent delayed RAI were 2.2 cm and 2.1 cm, respectively. 89% of patients with immediate RAI had undetectable Tg compared to 83% of patients with delayed RAI (p=0.20). Of patients that underwent immediate RAI, 5.9% (n=8) developed recurrence, whereas 2.5% of patients undergoing delayed RAI developed recurrence (n=2; p = 0.25). 

Conclusion: Administration of RAI in a delayed manner is not associated with decreased likelihood to achieve undetectable Tg or with increased recurrence of PTC after RAI treatment. 

 

69.04 Body Mass Index and Vitamin D Deficiency in Multi-gland Primary Hyperparathyroidism

Posted on December 22, 2014

J. A. Glenn1, T. W. Yen1, D. B. Evans1, T. S. Wang1  1Medical College Of Wisconsin,Division Of Surgical Oncology – Section Of Endocrine Surgery,Milwaukee, WI, USA

Introduction: Sporadic primary hyperparathyroidism (pHPT) is due to multi-gland disease (MGD) in up to 15% of cases. MGD may occur due to systemic disease and/or variations in the parathyroid hormone (PTH)-calcium-vitamin D axis. Vitamin D deficiency is more pronounced in obese patients due to sequestration of fat-soluble vitamins in adipose tissue. The aim of this study is to explore the relationship between obesity, vitamin D deficiency, and MGD.

Methods: This is a retrospective chart review of a prospective parathyroid database of 583 patients with sporadic pHPT who underwent parathyroidectomy between 1/1/2009 – 12/31/2013. Demographic, clinicopathological (number and weight of enlarged glands), and laboratory (serum calcium, PTH, 25-OH vitamin D, creatinine) data were collected.  Patients were equally divided into 4 groups based on body mass index (BMI; kg/m2). The association between BMI and age, gender, race, perioperative vitamin D, PTH, and calcium levels were assessed. Multivariable logistic regression models were performed to determine clinicopathological predictors of MGD.

Results: Mean age of the cohort was 59.8 ± 12.0 years (range, 18-90); 463 (79%) were women, and 507 (87%) were Caucasian. Of these, 103 (18%) patients had MGD. Patients with a higher BMI tended to have higher preoperative PTH levels, although this was not statistically significant (Table 1). There was an association between BMI and vitamin D deficiency (<30 ng/mL, p<0.001). In unadjusted analyses, there was no association between BMI (Table 1), age, gender, or race and the occurrence of MGD. Of the 549 patients with recorded gland weights, the median gland weight was 470 mg (interquartile range, 240-923). There was no association between BMI and gland weight or vitamin D deficiency and gland weight in patients with MGD. On multivariate logistic regression, after adjusting for preoperative calcium and PTH levels, BMI and vitamin D levels were not predictors of MGD.

Conclusion:  There is no association between obesity, vitamin D deficiency and occurrence of MGD in pHPT patients, in adjusted analyses. In addition, BMI and vitamin D deficiency are not associated with increased gland weight for MGD patients. Further studies evaluating the molecular influences of obesity and vitamin D deficiency on parathyroid tissue are needed to help clarify relationships between these factors and MGD.

 

69.05 The Underappreciated Problem of Thyroid Cancer and Hypothyroidism

Posted on December 22, 2014

S. Zaheer1, L. E. Kuo1, J. C. Morrison1, H. Wachtel1, G. C. Karakousis1, D. L. Fraker1, R. R. Kelz1  1University Of Pennsylvania,Department Of Endocrine And Oncologic Surgery,Philadelphia, PA, USA

Introduction:  

Hypothyroidism has been estimated to affect 3.7% of the United States population.  It has been suggested that hypothyroidism may be a risk factor for thyroid cancer.  We sought to examine the association between hypothyroidism and thyroid cancer characteristics.

Methods:

We identified thyroid surgery patients enrolled in our institutional prospective endocrine surgery registry from 2007 to 2013. Patients were included in the study if they were either hypothyroid (Thyroid stimulating hormone (TSH) >4.0 mIU/L) or euthyroid (TSH between 0.4-4.0 mIU/L) at the time of surgical intervention. The primary outcome of interest was thyroid cancer.  Tumor characteristics were examined in the subset of patients with thyroid cancer identified on pathologic review.   Univariate analyses were performed using the Wilcoxon ranksum test, Fisher’s exact test and Chi square test, as appropriate.

Results:

Of 901 patients included in the study, 537 patients were euthyroid and 364 patients were hypothyroid. There were 634 patients (70%) with a confirmed diagnosis of thyroid cancer. Age, gender and race were evenly distributed in the two groups. Patients with hypothyroidism had an increased incidence of cancer compared with euthyroid patients (88% vs. 58% respectively, p<0.01). Tumor characteristics were more aggressive among hypothyroid patients (see table).

Conclusion:

Amongst a population of thyroid surgery patients, there was a significant association between thyroid cancer and elevated TSH.  Moreover, the tumor characteristics associated with hypothyroidism were more aggressive than those seen in the euthyroid state. Clinicians should carefully screen patients with elevated TSH level for nodular disease and, when appropriate, evaluate for thyroid malignancy in a timely fashion.

 

69.06 Increased Rate of Incidental Papillary Thyroid Cancer in Surgical Patients with Benign Thyroid Disease

Posted on December 22, 2014

A. R. Marcadis1, S. Liu1, M. Rodriguez1, J. I. Lew1  1University Of Miami Miller School Of Medicine,Division Of Endocrine Surgery,Miami, FL, USA

Introduction: Patients who undergo surgical resection for benign thyroid disease may have incidental papillary thyroid cancer (PTC) discovered on final pathology. The incidence of PTC has historically been between 5 to 10% in patients treated operatively for benign thyroid disease. This study attempts to determine if there are any preoperative factors for incidental PTC that may help determine the extent of thyroidectomy in patients with benign thyroid disease.

Methods: A retrospective review of prospectively collected data of 1822 consecutive patients who underwent thyroidectomy at a single institution was performed. Of these patients, 355 underwent surgical resection for benign thyroid disease. Indications for surgery were obstructive or compressive symptoms (n=142), hyperthyroid symptoms including Graves’ disease (n=111), goiter size >4 cm (n=92), and substernal goiter (n=10). Patients with indeterminate or malignant preoperative FNA results were excluded. Of all patients, 74% (n=263) underwent total thyroidectomy, and 26% (n=93) underwent a lobectomy. Benign final pathology included nontoxic multinodular goiter (MNG) (n=136), toxic MNG (n=75), nontoxic solitary nodule (n=67), toxic solitary nodule (n=21) and Graves’ disease (n=6). Incidental cancers were defined as PTC discovered only upon final pathology. Age and gender were examined to determine if certain subsets of these categories had a higher indication for incidental cancers, using a two-tailed Z-test at a significance of 0.05.

Results: Overall, 14% (50/355) of patients who underwent surgical resection for benign thyroid disease had incidental PTC on final pathology. Women constituted 90% (n=322) of patients. There was no significant difference between incidental PTC rates in women (14%, 46/322) and men (12%, 4/33). Patients treated for obstructive symptoms had the highest incidental PTC rate at 19% (27/142), followed by goiters >4 cm at 15% (14/92), hyperthyroidism at 8% (9/111). Patients <50 years of age with benign indications for surgical resection had incidental PTC rates of 18% (33/187) compared to a 10% (17/169) incidental PTC rate for patients >50 years of age. Patients <50 years of age with benign thyroid disease had a significantly higher percentage of incidental PTC on final pathology than those patients >50 years of age (p=0.0394).

Conclusion: There is a higher than expected rate of incidental PTC in patients who undergo operations for benign thyroid disease, especially in patients <50 years of age. Therefore, total thyroidectomy by an experienced surgeon should be strongly considered when managing benign thyroid disease in such patients.

 

69.07 Accuracy of data collected in a hereditary cancer registry, the MEN2 experience

Posted on December 22, 2014

Z. Farhood1, C. Trotter1, M. Hu2, M. Cabanillas2, M. Jackson3, T. Rich1,3, P. Graham1, J. Lee1, N. Perrier1, E. G. Grubbs1  2University Of Texas MD Anderson Cancer Center,Department Of Endocrine Neoplasia & Hormonal Disorders, Division Of Internal Medicine,Houston, TX, USA 3University Of Texas MD Anderson Cancer Center,Clinical Cancer Genetics Department,Houston, TX, USA 1University Of Texas MD Anderson Cancer Center,Surgical Oncology,Houston, TX, USA

Introduction:  Hereditary cancer registries have been established globally to identify and educate at-risk relatives and to pool genotypic and phenotypic data from a large number of patients, allowing research in rare hereditary syndromes. We recently initiated an international Multiple Endocrine Neoplasia Type 2 (MEN2) Registry including components of both an online patient questionnaire (PQ) and collection of medical records (MR). We have evaluated registrants enrolled within the first 18 months to determine how the PQ correlates with the MR, identifying in what instances the more easily acquired PQ may be used as a surrogate in this complicated hereditary disease and also areas in which patient education may be improved.

Methods:  A retrospective review was conducted of MEN2 registrants who submitted a PQ and had a complete MR obtained through the MEN2 Registry from 7/2012 to 3/2014.  The PQ is a comprehensive 83-item document containing demographic, genetic, specific disease (medullary thyroid cancer (MTC)/hyperparathyroidism/pheochromocytoma) pathology and treatment history, general health, and family history data available in English and Arabic.  PQ answers were compared to MR variables and the level of agreement scored as discordant, concordant, registrant did not report, and records did not report. Potential demographic predictors of discordance were evaluated.

Results: 117 registrants (rt) were eligible for this study; 70 females and 47 males with a median age of 48 years (range 3 to 74). Concordance between PQ and MR was >85% in 23/31 (74%) of the key variables. Variables in which concordance occurred in <80% of cases included whether the rt had undergone RET testing (79%), current status of MTC (disease free vs. alive with disease) (79%), and pathology results from thyroid surgery (68%). Non-Caucasian races were less likely to provide concordant answers for MTC status (85% vs. 43%, p=0.03).  Female, Caucasian, married rt with greater than a high school education were significantly more likely to know their RET testing status. Reasonable concordance was found for diagnosis and current status of adrenal (97%) and parathyroid (90%) disease. Rt were accurate in reporting their age at MEN2 diagnosis (96% within 1yr), the year in which they underwent RET testing (99% within 1 yr), and their thyroid surgery date (98% within 1yr).

Conclusion: In the majority of self-reported data acquired through a MEN2 registry questionnaire, registrants’ answers exhibited an acceptable concordance with the medical record suggesting that a rt questionnaire may be a reliable source of data. Notable exceptions were status of RET testing and treatment course of MTC in which interrogation of the medical record remains necessary. Need for further patient education in these discordant fields is essential with special attention to those with certain demographics. Ability to rely on registrant-generated data is important for research in such rare diseases.

69.08 Family History of Thyroid Cancer Correlates with More Aggressive Papillary Thyroid Cancer Variants

Posted on December 22, 2014

A. R. Marcadis1, S. Liu1, M. Rodriguez1, J. I. Lew1  1University Of Miami Miller School Of Medicine,Division Of Endocrine Surgery,Miami, FL, USA

Introduction: Thyroid malignancy is the most common endocrine cancer in the United States. Papillary thyroid cancer (PTC) is the most common form, comprising 85% of all thyroid cancers. Although most PTC occurs sporadically, about 5% may be familial in origin. Furthermore, family history has shown to be an influential risk factor for papillary thyroid cancer (PTC). Whether these familial forms of PTC are more aggressive than its sporadic form, however, remains unclear. This study determines if patients with a family history of thyroid cancer harbor more aggressive variants of PTC than patients without a positive family history.

Methods: A retrospective review of prospectively collected data of 1822 consecutive patients who underwent thyroidectomy at a single institution was performed. Patients with malignancies other than PTC were excluded from the study (n=447). Remaining patients were divided into 2 groups: those patients who had a history of PTC in first degree relatives (n=39), and those who did not (n=1336). Patients with PTC on final pathology were further subdivided into those with less aggressive (classic and follicular), and those with more aggressive (diffuse sclerosing and tall cell) variants of PTC. A two tailed Z test at a significance level of 0.05 was used to compare both groups.

Results: Of the 1375 patients included, 3% (39/1375) of patients had a family history of PTC in first degree relatives. Of these patients with a positive family history, 54% (21/39) had PTC on final pathology whereas 28% (374/1336) of patients with no family history had PTC on final pathology. Patients with a family history of PTC had 21% (8/39) follicular, 10% (4/39) diffuse sclerosing, 10% (4/39) classic, 8% (3/39) combined follicular and classic, and 5% (2/39) tall cell variants of PTC.  Patients with no familial history of PTC had 19% (257/1336) follicular, 4% (55/1336) classic, 2% (25/1336) both classic and follicular, 1% (9/1336) both diffuse sclerosing and tall cell, 1% (10/1336) tall cell only, and 1% (18/1336) diffuse sclerosing only variants of PTC. Of those patients with a positive family history, there was a significantly increased incidence of more aggressive variants (diffuse sclerosing and tall cell) of PTC at 15% (6/39) compared to those patients with no family history of PTC at 3% (37/1336) (p<0.05).

Conclusion: Patients with a positive family history of PTC have a significantly higher incidence of more aggressive PTC variants. Any positive PTC family history, therefore, should be considered a risk factor for more aggressive disease that may necessitate earlier recognition and treatment for PTC in these patients and their affected family members.

 

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