71.16 Lung Resection is Safe and Feasible Among Stage IV Cancer Patients: An ACS-NSQIP Analysis

Posted on January 18, 2016

S. B. Bateni1, E. A. David2, R. J. Bold3, D. T. Cooke2, F. J. Meyers4, R. J. Canter3 1University Of California – Davis,General Surgery,Sacramento, CA, USA 2University Of California – Davis,Cardiothoracic Surgery,Sacramento, CA, USA 3University Of California – Davis,Surgical Oncology,Sacramento, CA, USA 4University Of California – Davis,Hematology/Oncology,Sacramento, CA, USA

Introduction: Although surgical intervention among patients with disseminated malignancy (DMa) carries high morbidity and mortality, recent single institution retrospective studies have demonstrated improvements in survival among advanced lung cancer patients and patients with lung metastases undergoing lung resection. We sought to evaluate the rates of acute morbidity and mortality following lung resection in stage IV cancer patients to further describe risks associated with such intervention.

Methods: For the years 2011-2012, we identified 6,360 patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) undergoing lung segmentectomy, wedge resection, lobectomy, or pneumonectomy, including 603 patients (9.5%) with a diagnosis of DMa. Standard parametric and nonparametric statistical analyses were used to evaluate the 30-day morbidity and mortality associated with lung resection and compare outcomes among patients with and without DMa.

Results: Among DMa patients, 200 (33.2%) were diagnosed with primary lung cancer, 357 (59.2%) had metastases to the lung, and 46 (7.6%) were unspecified. Most DMa patients had independent functional status (99.2%) and were without any dyspnea symptoms (84.4%). Overall 30-day morbidity, serious morbidity and mortality for DMa patients were 12.1%, 7.6% and 1.8%, respectively, and 95.9% of patients were discharged home. DMa patients with a primary diagnosis of lung cancer had a significantly greater mortality compared to patients with lung metastases (3.5% vs. 0.6%, p < 0.01). Pneumonectomy among DMa patients had far worse overall morbidity, serious morbidity and mortality compared to other types of lung resections (28.6% vs 12.1%, 28.6% vs 7.6%, and 7.1% vs 1.8%, respectively, p < 0.05). Of most clinical significance, when comparing outcomes for DMa versus non-DMa, overall morbidity was lower among DMa patients (12.1% vs. 15.4%, p < 0.05) and there were no significant differences in serious morbidity (8.3% vs. 9.8%, p > 0.05) or mortality (1.8% vs. 1.8%, p > 0.05) for all lung resections. Subgroup analysis by segmentectomy, wedge resection, lobectomy and pneumonectomy also demonstrated no significant differences in rates of overall morbidity, serious morbidity and mortality for DMa versus non-DMa patients (p > 0.05 for all).

Conclusion: With the exception of pneumonectomy, DMa patients undergoing pulmonary resections experienced low rates of overall morbidity, serious morbidity, and mortality. Moreover, surgical outcomes for pulmonary resections were comparable among DMa and non-DMA patients. Taken together, these data suggest that lung resections may be performed safely on select patients with DMa with both primary lung cancer and pulmonary metastatic disease, with important implications for both symptom palliation and multimodality care.

71.17 Factors Affecting Lymph Node Postivity in Intrahepatic Cholangiocarcinoma

Posted on January 18, 2016

O. Kutlu1, K. Staveley-O’Carroll1, E. R. Camp1, E. Kimchi1 1Medical University Of South Carolina,Division Of Surgical Oncology,Charleston, Sc, USA

Introduction:

Lymph node metastasis (LNM) is one of the strongest prognostic indicators of survival in intrahepatic cholangiocarcinoma (IHCC). Despite the improvements in imaging modalities, sensitivity of CT scan assessment for LNM still is low. The value of regional lymph node dissection for IHCC is an area of debate. Routine nodal dissection has been investigated to aid in prognostication and as a possible preventive measure for disease recurrence. In this study we investigate the incidence of LNM and factors affecting metastasis in a large epidemiological database.

Methods:

A SEER (Survival Epidemiology and End Results) case listing was acquired for histologically proven IHCC diagnosed between 1988-2011. Patients over 18 years of age, who underwent surgical therapy with known tumor size, T-stage, number of lymph nodes dissected, lymph node positivity, location of lymph nodes, M status, type of surgery performed, tumor grade, disease extension and vascular invasion status were selected for analyses. For patients with positive lymph a binary logistic regression analysis was performed with SPSS 21 and factors affecting lymph node positivity were analyzed.

Results:

Of the 9846 patients, 569 fit our criteria of whom 53.6% were female. Mean age was 62.9 years (21-85), mean tumor size was 5.9 cm (0.3-19), and lymph nodes were sampled in 261(45.8%) patients (mean 4.5 nodes, n=1-32). Among the patients who underwent lymph node sampling, 115 (44%) had nodal disease (hepatoduodenal n=110, inferior phrenic n=1, unspecified n=3, combined n=1). Binary regression analysis showed tumor grade, T stage (vascular invasion, extension of the tumor to extrahepatic bile ducts) to be significant factors associated lymph node positivity. The number of lesions, patient age, tumor size, involvement of contiguous sites, presence of metastatic disease and sex were found to be insignificant.

Conclusion:

The number of LNM in this patient cohort was similar to other reports where findings of routine nodal dissections are published. Identification of patients with high risk features such as high grade tumors, vascular invasion and extension to extrahepatic bile ducts may aid in selection of patients for lymph node dissection. Performed at experienced institutions, lymph node dissection may aid in staging of IHCC, however further studies are needed to confirm our findings.

71.18 The Risk of Gastrointestinal Adverse Events among Cancer Patients Treated with CTLA-4 blockade.

Posted on January 18, 2016

S. Lew1,2, R. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2Saint George’s University,Grenada, Grenada, Grenada 3University Of Medicine And Dentistry Of New Jersey,Surgery,Newark, NJ, USA

Introduction:
Cancer cells employ diverse mechanisms to evade anti-tumor immune responses, one of which expresses a ligand activating negative costimulatory molecules which downregulate the T cell immune response; lymphocyte antigen-4 (CTLA-4). Many studies with CTLA-4 monoclonal antibody have demonstrated antitumor activity in advanced melanoma and other solid tumors with varying degrees of treatment related gastrointestinal (GI) adverse effects. This study sought to determine the incidence of CTLA-4 blockade-associated severe GI adverse effects, risk stratified by the type of malignancy treated, and to investigate dosage related risk of severe diarrhea or colitis.

Methods:
A comprehensive literature search of PubMed, Google Scholar and the Cochrane Central Registry of Controlled Trials was completed. Keywords searched were ‘ipilimumab’, ‘Yervoy’, ‘MDX-010′, ‘MDX101′, ‘tremelimumab’, ‘ticilimumab’, ‘diarrhea’, ‘colitis’, and ‘clinical trial’. All clinical trials were analyzed for patient recruitment, intervention, and outcomes. Incidence and risk ratio (RR) were calculated with 95% confidence intervals.

Results:
13 single or double arm, phase II/III clinical trials involving 4,383 patients treated with ipilimumab or tremelimumab were identified. The incidence of CTLA-4 blockade associated severe (grade 3-4) diarrhea was 9.5% (95% CI [5.4-16.2]; p<0.0001) and severe colitis was 6.3% (95% CI [4.9-8.0]; p<0.001) among 1,464 patients in 9 clinical trials in which CTLA-4 blockade monotherapy was used in a single arm trial or RCT. Among 4,383 ipilimumab or tremelimumab treated patients in 10 RCTs, the risk of severe diarrhea in the treatment group was 9% compared to 1.5% in control (RR 4.18, 95% CI [1.44-12.15]; p=0.009) while severe colitis in the treatment group was 5.3% compared to 0.2% in the control (RR 11.53, 95% CI [3.65-36.44]; p=<0.001). The incidence and risk of severe CTLA-4 blockade-associated GI adverse events were not significantly different between melanoma and solid tumor, between 3mg and 10mg dosage regimens, or when monotherapy and/or concomitant chemotherapy were used. Significant heterogeneity was found among identified trials with regards to underlying malignancies, the dosage of the treatment, and duration of the treatment.

Conclusion:
CTLA-4 blockade is associated with a significantly increased risk of all- and high-grade diarrhea and colitis. Altering in dosing regimens or combinational chemotherapy utilizing CTLA-4 blockade did not significantly reduce the risk of GI adverse events. Although adequately powered large studies are needed to further investigate contributing risk factors for the GI adverse events, GI adverse events should be carefully monitored in patients treated with CTLA-4 blockade.

71.14 Enhanced Recovery After Surgery (ERAS) on a High-Volume Surgical Oncology Unit: Details Matter

Posted on January 18, 2016

C. Mosquera1, N. J. Koutlas1, K. K. Myatt1, N. A. Vohra1, E. E. Zervos1, T. L. Fitzgerald1 1East Carolina University Brody School Of Medicine,Division Of Surgical Oncology,Greenville, NC, USA

Introduction: Benefits from ERAS have been documented in various clinical settings; however, it is unclear if improvement stems from the protocol or by shifts in expectations. To clarify, outcomes from a pilot ERAS project were reviewed.

Methods: Introductory interdisciplinary educational seminars involving unit surgeons, residents, nurses, dieticians, and rehabilitation therapists were conducted. In order to validate our initial test of change, this protocol was adopted by one of three surgical oncologists with the others serving as controls.

Results: A total of 394 patients undergoing elective abdominal surgery from June 2013-April 2015 were included. Median age was 63 years, a majority were female (51.8%), white (59.9%), had a Charlson comorbidity score of 0-2 (40.4%), and a Clavien complication grade of 0-I (63.2%). Implementation of ERAS resulted in a significant decrease in length of stay (LOS) (6.0 vs. 8.0 days; p= 0.016) and in-hospital mortality (0% vs. 2.9%; p= 0.033); the difference in cost ($21,674 vs. $25,994; p= 0.060) did not reach significance. Gender (p= 0.63), age (p= 0.36), race (p= 0.89), type of surgery (p= 0.49), comorbidities (p= 0.76), complications (p= 0.31), and readmission rates (p= 0.21) were similar. For the test surgeon, ERAS was associated with a decreased LOS (6.2 vs. 9.6 days, p= 0.024), cost ($21,674 vs. $30,380, p= 0.029), and mortality (0 vs. 3.3%, p= 0.044); differences in complications (grade II-V 32.2 vs. 42.6%, p= 0.064) and readmission rates (11.5 vs. 21.4%, p= 0.076) did not reach significance. For the control providers LOS, cost, mortality, readmission rates, and complications were similar before and after implementation of ERAS on this unit.

Conclusion: Full implementation of an ERAS protocol on a single high-volume surgical unit decreases cost, LOS, and mortality. This change can be attributed to protocol adherence rather than an ethereal change in unit culture.

71.15 Breast Reconstruction Outcomes Of Breast Cancer Patients In Medically Underinsured Population

Posted on January 18, 2016

S. Roh1, L. K. Viennas1, D. Chin1, J. N. Collins1, R. C. Britt1, R. R. Perry1, E. C. Feliberti1 1Eastern Virginia Medical School,Surgery,Norfolk, VA, USA

Introduction:
Healthcare disparities exist in various stages of breast cancer treatment among different socioeconomic classes. With increased number of uninsured patients having access and receiving immediate breast reconstruction (IBR) due to the Breast and Cervical Cancer Early Detection Program (Every Woman’s Life), an analysis of IBR in these women was performed to compare perioperative outcomes with insured patients and assess for persistent disparities.

Methods:
A retrospective chart review was performed on a database of newly diagnosed female breast cancer patients that underwent total mastectomy with IBR at an urban academic medical center from January 2009 to June 2014. Patient demographics and oncologic and operative variables including postoperative outcomes were compared in women with and without medical insurance at the time of diagnosis.

Results:
Fifty-nine patients met the study criteria, 40 with insurance and 19 without insurance at the time of diagnosis. Mean age at time of diagnosis was similar in uninsured and insured cohorts (51.2 y.o. vs. 48.3 y.o., p = 0.18) and uninsured patients had a higher makeup of African-American patients (73.7% vs. 40%, p =0.01). There were no differences noted between the two groups in body mass index (33.5 vs. 31.7, p = 0.3), mean Charlson Comorbidity Index (2.6 vs. 1.8, p = 0.11), the percentage of smokers (42.1% vs. 25%, p = 0.22) or the receipt of neoadjuvant chemotherapy (15.8% vs. 25%, p = 0.41) or postmastectomy radiation (26.3% vs. 32.5%, p = 0.77). Uninsured patients exclusively received IBR with tissue expanders compared to insured patients, (100% vs. 85%, p = 0.01). Both overall (84.2% vs. 67.5%, p = 0.22) and major (15.8% vs. 30%, p = 0.6) perioperative complication rates were similar between the 2 cohorts, even in those receiving IBR with tissue expanders (major complication rate 15.8% vs. 25%, p = 0.76).

Conclusion:
IBR in uninsured breast cancer patients was performed safely in this study with similar perioperative risk factors and postoperative complications. The higher use of IBR with tissue expanders in uninsured patients suggests hidden disparities. Further studies should analyze for possible provider level and patient level bias.

71.12 Tumor Size Remains Better than Hounsfield Units for Predicting Adrenal Malignancy on Unenhanced CT

Posted on January 18, 2016

C. C. Taylor1, G. A. Rubio1, J. D. Egusquiza2, M. LoPinto1, J. I. Lew1 1University Of Miami,Division Of Endocrine Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2University Of Miami,Department Of Radiology,Miami, FL, USA

Introduction: Many recent studies suggest unenhanced CT attenuation values expressed in Hounsfield units (HU) are superior for differentiating between benign and malignant adrenal tumors. Surgical removal is warranted when the risk of malignancy is significant (i.e. adrenal tumor >4cm), or if the tumor is hyperfunctional biochemically. With recent enthusiasm for its use to differentiate between benign and malignant adrenal tumors, the purpose of this study was to determine if HU are more effective than tumor size by unenhanced CT in predicting adrenal malignancy.

Methods: A retrospective review of prospectively collected data of 40 patients who underwent adrenalectomies with reviewable unenhanced transverse CT scans at a single institution was performed. Based on final pathology, 32 patients had benign adrenal tumors and 8 had malignant tumors. CT densities were obtained in HU by placement of a region of interest (ROI) over the adrenal gland, avoiding any necrotic or hemorrhagic areas. Adrenal tumor size was determined using the maximum diameter on transverse CT views. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy at 2, 3, 4, 5, and 6 cm; and at 10, 20, 30, and 40 HU were also compared. Size and HU on CT were compared for benign and malignant adrenal tumors using unpaired T-tests.

Results: Of 40 patients studied, those with benign adrenal tumors had statistically (p<0.001) smaller diameters (3.6cm +/- 1.5) than malignant tumors (7.7cm +/- 4.4) [ROC curve 0.813, p<0.05]. The mean HU of benign tumors (26.5HU +/- 27) were not significantly different (p=0.28) compared to malignant tumors (37.8HU +/- 21) [ROC curve 0.659, p=0.169]. Unenhanced CT had a sensitivity of >85% and specificity of <55% for adrenal tumors measuring 2 to 4cm and a sensitivity of <63% and specificity >70% for tumors measuring 5 to 6cm. PPV, NPV, and accuracy for determining malignancy in adrenal tumors by size were: 24.2%, 100%, and 35.9% respectively at 2cm; 25.9%, 91.7%, and 46.2% at 3cm; 33.3%, 94.4%, and 61.5% at 4cm; 35.7%, 88%, and 69.2% at 5cm; and 80%, 88.2%, and 87.2% at 6cm. The sensitivity, specificity, PPV, NPV, and accuracy for determining malignancy in adrenal tumors by HU were: 100%, 16.1%, 23.5%, 100%, and 33.3% respectively at 10HU; 87.5%, 32.3%, 25%, 90.9%, and 43.6% at 20HU; 62.5%, 54.8%, 26.3%, 85%, and 56.4% at 30HU; and 50%, 83.9%, 44.4%, 86.7%, and 76.9% at 40HU.

Conclusion: This study suggests adrenal tumor size remains a better predictor for adrenal malignancy than HU on unenhanced CT. At 4cm, tumor size has a better sensitivity and specificity for predicting adrenal malignancy than HU. Furthermore, at 2cm or less, size is a more reliable predictor of adrenal benignity than HU. While use of HU has gained popularity, surgeons should remain confident in using tumor size as a criterion for those patients who require adrenalectomies.

71.13 Trend of Survival Outcomes in Duodenal Adenocarcinoma

Posted on January 18, 2016

T. Oyasiji1, W. Tan2, N. Wilkinson3 1Karmanos Cancer Institute,Surgical Oncology,Flint, MI, USA 2Roswell Park Cancer Institute,Biostatistics,Buffalo, NY, USA 3Kalispel Regional Medical Center,Surgical Oncology,Kalispel, MONTANA, USA

Introduction: Duodenal adenocarcinoma (DA) is rare. We sought to evaluate trends and predictors of survival outcomes from analysis of a large national database.

Methods: We identified all DA patients between 1988 and 2011 using the SEER database. Patients were grouped into two 12-year periods, 1988-1999 (group 1) and 2000-2011 (group 2). Each group was subdivided into those who had surgery for treatment of DA and those who did not. Overall survival (OS) and disease -specific survival (DSS) were determined for the groups and subgroups, and compared to identify trend in survival outcomes for the two periods. Survival analysis was done using Kaplan Meier method and Cox proportional hazards model was utilized for univariate and multivariate analyses.

Results: Of 3183 patients, 1411(44.3%) were treated with surgery. 51% were males while 75% were Caucasians. 76% of patients were in Group 2. Mean age, gender and race distribution were comparable for both groups (p >0.05). Median OS was 8 months for both groups (p=0.5). Median DSS was 11.0 months for both groups (p=0.58). For the two groups, median OS and median DSS were significantly better for those treated with surgery compared to those who were not treated with surgery ( Group 1- OS 21 vs 3 months, DSS 27 versus 4 months; Group 2- OS 25 vs 4 months , DSS 33 vs 5 months; p values<0.001). The surgery subgroup for Group 2 had better OS and DSS compared to Group 1 surgery subgroup, with a trend toward significance (OS 25 vs 21 months and DSS 33 versus 27 months, p values=0.06). On multivariate analysis, advanced age, AJCC stage and T stage were independent negative predictors of OS and DSS while treatment with surgery was an independent favorable predictor of OS and DSS.

Conclusion: There is a trend for improved OS and DSS for DA patients treated with surgery between 2000 & 2011 compared to those treated with surgery between 1988 & 1999. Patients treated with surgery have significantly better OS and DSS than those who did not undergo surgery, regardless of time period. Early detection (when disease is resectable) and surgical treatment might translate to improved survival outcomes.

71.09 Ultrasound Validation of Mathematically Modeled Irreversible Electroporation (IRE) Ablation Volumes

Posted on January 18, 2016

N. Bhutiani1, C. A. Doughtie1, R. C. Martin1 1University Of Louisville,Surgical Oncology,Louisville, KY, USA

Introduction:
Currently, the prediction of irreversible electroporation (IRE) ablation dimensions are modeled using algorithms derived from mathematical and ex-vivo models. These have not been validated using in-vivo studies. The aim of this study is to assess the correlation between the mathematical prediction model to and ultrasound and histopathology findings for in vivo ablations in a porcine model.

Methods:
IRE ablations were performed on porcine liver and spleen with probe spacings ranging from 0.6 to 2.6 cm. Pre and 2 hour post-ablation ultrasound images were recorded and validated with histopathology confirmation. Three dimensions of the ablation regions were recorded and ablation volumes were calculated and correlated with theoretical mathematical models for each given probe spacing.

Results:
In-vivo axial and anterior-posterior (AP) ablation distances were significantly greater than predicted for nearly all probe spacings (p<0.05). Ablation volumes were significantly less than predicted for the all probe spacings when modeled using both a cylinder and an ellipsoid. Geometrically, mathematically derived ablation regions demonstrated more central tapering (‘necking’) and diminished volumes compared to their in-vivo counterparts. The relationships between probe spacing and AP ablation dimensions were less linear (r2=0.57) than the relationships observed via ultrasound.

Conclusion:
The current mathematical models poorly predict ablation regions observed in vivo. They underestimate ablation dimensions and, by extension, ablation volumes. Further work should be done to improve models for ablative planning, and physicians should recognize the limitations of existing models when planning ablative treatments.

71.10 Chest Wall Ewing Sarcoma: The Results of a Population Based Analysis

Posted on January 18, 2016

A. J. Jacobs2, J. Fishbein3, C. Fein Levy4, R. D. Glick1 1North Shore University And Long Island Jewish Medical Center,CCMC, Division Of Pediatric Surgery,Manhasset, NY, USA 2Hofstra North Shore-LIJ School Of Medicine,Hempstead, NY, USA 3Feinstein Institute For Medical Research,Biostatistics Unit,Manhasset, NY, USA 4North Shore University And Long Island Jewish Medical Center,CCMC, Department Of Pediatric Hematology/Oncology,Manhasset, NY, USA

Introduction:
The globally low incidence of pediatric chest wall Ewing sarcoma (CWES) has limited prior studies of this disease to mostly small, single institution reviews. Our objective was to assess incidence, demographics, treatment patterns, and long-term survival of this disease through a population based analysis.

Methods:
The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients aged 0-21 diagnosed with CWES from 1973-2011. Patients were grouped by decade to assess changes in treatment patterns and outcomes. The effects of clinical, demographic, and treatment variables on overall survival were assessed by the computation of Kaplan-Meier curves and the log-rank test, with Cox proportional hazard regression used for multivariate analysis.

Results:
A total of 193 pediatric patients with histologically-confirmed CWES were identified. The disease was more common in males (60.6%), whites (92.2%), and 11-17 year-olds (48.7%). It was metastatic at presentation in 36.8% of patients. When grouped approximately by decade, 10-year overall survival improved progressively from 38.2% in 1973-1979 to 65.4% in 2000-2011 (p=0.033). The use of radiation decreased from 84.2% in the earliest time period to 40.0% in the most recent, while the proportion of patients receiving surgery increased from 75.0% to 84.9%. When controlling for covariates on multivariate analysis, male patients were found to have a higher mortality than female patients (HR: 2.4; CI: 1.4, 4.4; p=0.0028).

Conclusion:
This population-based analysis of CWES demonstrated an impressive trend of improving overall survival, with increasing use of surgery and decreasing use of radiation therapy. As has been previously noted for Ewing sarcoma in general, our study demonstrated a gender difference in survival of CWES, with girls having a better prognosis.

71.11 Volumetric Liver Analysis Guides Determination of Resectability

Posted on January 18, 2016

G. J. Bundley1, S. K. Geevarghese2 1Meharry Medical College,School Of Medicine,Nashville, TN, USA 2Vanderbilt University Medical Center,Liver Transplant,Nashville, TN, USA

Introduction:
Resection is an important therapeutic modality for benign and malignant disease of the liver. Volumetric analysis of the liver in addition to standard assessment of patient performance status and liver function can help determine the ideal treatment plan for patients with risk factors for postoperative liver insufficiency such as cirrhosis and hepatic steatosis. Analysis using Pathfinder Scout,™ which utilizes contrasted CT or MRI data, can provide accurate future liver remnant (FLR) volume and guide assessment of resectability.

Methods:
Between 2009 and 2015, 50 patients at Vanderbilt University Medical Center were evaluated for liver resection using Pathfinder Scout™. After approval by the Institutional Review Board, the medical record of each patient was reviewed for pertinent clinical information. Data extracted from the records included preoperative diagnosis, laboratory data, type of resection planned, final pathological findings, and postoperative complications such as liver insufficiency.

Results:
Optimal candidates for liver resection were defined as good performance status, FLR>35%, and limited risk factors. Risk factors for liver insufficiency were defined as hepatic steatosis by imaging or biopsy, fibrosis, or cirrhosis. Sixteen patients were deemed unresectable based on FLR < 35% (n=12) or adequate FLR but possessed one or more risk factors (n=4). An additional 3 resections were intraoperatively aborted due to vascular invasion or additional lesions. Four of the unresectable patients underwent locoregional therapy (LRT e.g. radiofrequency ablation, chemoembolization, radioembolization) and/or systemic therapy; two of the patients were rendered resectable. Eight patients underwent portal vein embolization (PVE) and 4 patients’ FLR improved above 35% leading to resection.

Conclusion:
Formal volumetric assessment prior to liver resection is an important consideration for patients with cirrhosis, steatosis, and multifocal disease. Based on volumetric data 24 % of patients in our cohort underwent LRT rather than resection, mitigating the risks of liver failure postresection in these patients. In addition to standard assessment of liver function and performance status, volumetric analysis of the FLR can determine the success of PVE as an adjunct to improve FLR.

71.07 Socioeconomic Status, Medical History, and Pathologic Findings in Breast Cancer Surgery Decisions

Posted on January 18, 2016

V. J. Tapia4, G. F. D’Souza1, F. Qiu5, G. Nguyen3, Q. Ly2 1University Of California, San Diego,Plastic Surgery,SAN DIEGO, CA, USA 2University Of Nebraska Medical Center,Surgical Oncology,Omaha, NE, USA 3Medical College Of Wisconsin,Milwaukee, WI, USA 4University Of California – San Diego,School Of Medicine,San Diego, CA, USA 5University Of Nebraska Medical Center,College Of Public Health,Omaha, NE, USA

Introduction:
Currently accepted research in oncology has demonstrated that, in early stage breast cancer (BC), lumpectomy followed by whole breast radiation, also known as breast conservation therapy (BCT), has comparable survival to that of mastectomy. Initial investigations on surgical decision-making reported that a patient’s choice was related to socioeconomic status (SES), geographic location, patient characteristics, and physician influence. However, little research has been conducted on the influence of tumor characteristics on surgical decision-making.

Methods:
A retrospective analysis of the 2002-2010 University of Nebraska Breast Cancer Collaborative Registry was performed. The demographic, medical history, and tumor characteristics of patients were compared between oncologic surgery decision groups (BCT, unilateral mastectomy, bilateral mastectomy) in a univariate analysis. A multinomial logistic regression analysis was performed on the predictor variables that were associated with the outcome variable of surgical decision to the 0.2 significance level.

Results:
320 women were included with 100 receiving BCT, 176 unilateral mastectomy, and 44 bilateral mastectomy. On univariate analysis, factors associated with surgery decision were bilateral carcinoma (p=0.0001), staging (p=0.0006), tumor metastasis (p=0.02), tumor histology (p=0.03), BRCA mutation (p=0.04), unilateral multifocal lesions (p=0.047), and lymphoma history (p=0.04). On multinomial analysis, tumor stage and bilateral carcinoma were independently associated with treatment decision. Patients with bilateral tumors had 12.1 times higher odds of choosing bilateral mastectomy (95% OR CI: 2.3-63.3, p=0.003). When compared to patients with in situ tumors, stage II patients had 8.8 times higher odds of choosing bilateral mastectomy (p=0.048) and a 2.9 times higher odds of choosing a unilateral mastectomy (p=0.02). Subjects with stage III tumors had 32.1 times higher odds of choosing bilateral mastectomy than those with in situ tumors (p=0.007), and 13.6 times higher odds of choosing a unilateral mastectomy (p=0.0003). Stage IV patients had 36.1 times higher odds of choosing a bilateral mastectomy than those with in situ tumors (p=0.009), and an 11.5 times higher odds of choosing a unilateral mastectomy (p=0.004).

Conclusion:
Our findings suggest that our patients’ decision of surgical procedure had greater association with tumor characteristics rather than demographic or medical history, as previously demonstrated in other studies. Women with stage II-IV BC and bilateral tumors are still more likely to opt for more extensive surgical interventions despite evidence to the safety, efficacy, and comparable survival rates of more conservative treatments in patients with stages I-III, and well established education on surgical options. Patients with in situ and stage I BC may be more willing to undergo BCT, underscoring the efficacy of current patient education endeavors.

71.08 Financial Implications of Routine Postoperative ICU Care after CRS/HIPEC – More is Not Always Better

Posted on January 18, 2016

H. D. Mogal1, E. A. Levine1, N. F. Fino2, T. I. Fleming1, V. Getz1, P. Shen1, J. H. Stewart1, K. I. Votanopoulos1 1Wake Forest University School Of Medicine,Department Of Surgery, Division Of Surgical Oncology,Winston-Salem, NC, USA 2Wake Forest University School Of Medicine,Department Of Biostatistics,Winston Salem, NC, USA

Introduction: The financial considerations of admitting patients undergoing Cytoreductive surgery and Heated Intraperitoneal chemotherapy (CRS/HIPEC) routinely to the ICU for postoperative care have not been elucidated. Our aim was to study cost differences between patients admitted postoperatively to the ICU and floor and to assess if avoiding routine ICU admission in selected patients can minimize costs without compromising quality.

Methods: Single index-surgical encounter costs for patients admitted directly to the floor or to the ICU for less than 48 hours were retrospectively analyzed from a prospectively maintained institutional database of CRS/HIPEC patients between April 2012 and June 2014. Comparison of clinicopathological variables, complications and average costs between the groups was performed.

Results: 65 patients were observed in the ICU for less than 48 hours, while 51 patients were sent directly to the floor. The two groups were similar for race (p = 0.87), sex (p = 0.12), number of comorbidities (p = 0.17), primary site of tumor (p = 0.37) and ECOG status (p = 0.16). PCI (Peritoneal Cancer Index) score was higher for patients in the ICU (mean 15.6 ± 7.4) compared to those on the floor (mean 10.3 ± 8.1; p = 0.0006). Estimated blood loss (OR 1.26, p = 0.0075) and PCI scores (OR 1.12, p = 0.02) were independent risk factors for admission to ICU. For patients that were observed directly on the floor, average costs were $4460 less than for patients who were observed in the ICU for less than 48-hours ($15209 and $19669 respectively; p < 0.0001). Analysis between these two groups showed no significant difference in minor complications (p = 0.23) or major morbidity (p = 0.44).

Conclusion: Selective postoperative ICU admission is associated with a substantial reduction in cost and no increase in major or minor morbidity.

71.05 Social Support for Patients undergoing Colorectal Cancer Treatment: A Diverse Population-Based Study

Posted on January 18, 2016

M. R. Kapadia1, C. M. Veenstra3, R. E. Davis4, S. T. Hawley3, A. M. Morris2 1University Of Iowa,Surgery,Iowa City, IA, USA 2University Of Michigan,Surgery,Ann Arbor, MI, USA 3University Of Michigan,Medicine,Ann Arbor, MI, USA 4University Of South Carolina,Public Health,Columbia, SC, USA

Introduction:
Social support is associated with adherence to recommended treatment, quality of life, and survival. Colorectal cancer (CRC) often requires extensive treatment, but little is known of needs, sources, and availability of social support among CRC patients.

Methods:
We surveyed Stage III CRC patients from the Detroit and Georgia SEER registries regarding socio-demographics and emotional support desired and received from spouses/partners, families, important others, and providers. We examined differences using chi-square and t- tests.

Results:
Among 1351 eligible respondents (68% response rate), 68% were white and 25% were black. Patients were evenly distributed in age, sex, and income categories. Most endorsed high support from all sources, especially family (88.6%), followed by important others (82.9%), healthcare providers (71.3%), and spouses/partners (55.6%). Only 58% of patients had spouses/partners and among these, 95% endorsed high support. Older patients, black patients, women, or those with <$20,000 annual income were less likely to have spouses/partners (p<0.001). Blacks were significantly less likely than whites to report that the support they received was ‘just right’ (vs. too little or too much, p<0.001). Increasing age and income were significantly associated with increased likelihood that the support received was just right (p<0.006).

Conclusion:
Most patients undergoing CRC treatment reported high social support from all sources. However, black and lower income patients were at risk for low support or support that did not meet their needs. Spouse/partner support was important and met needs, but was only available to 58% of respondents. In future work, we will examine how social support affects long-term outcomes for CRC patients.

71.06 Black and White Pancreatic Adenocarcinoma Patients Receiving Similar Treatment Have Similar Survival

Posted on January 18, 2016

B. J. Flink1,2, Y. Liu3,4, R. Rochat3, D. A. Kooby1,4, J. Lipscomb3,4, T. W. Gillespie1,4 1Emory University School Of Medicine,Surgery,Atlanta, GA, USA 2VA Atlanta Health System,Surgery,Atlanta, GA, USA 3Emory University Rollins School Of Public Health,Atlanta, GA, USA 4Winship Cancer Institue,Atlanta, GA, USA

Introduction: Pancreatic adenocarcinoma (PA) is a lethal cancer that newly affects over 41,000 Americans annually. Prior evidence demonstrates treatment and survival disparities between black and white patients. Our study examines receipt of surgery and overall survival by race, using novel data from a large population cancer database.

Methods: Using the National Cancer Data Base Participant User Files from 2003 to 2011, we identified PA patients with potentially resectable (T1-3M0) disease. Only patients resected with curative intent were included. Univariate, and multivariate logistic and Cox regression models were used to examine resection and survival. Multivariate models were adjusted for demographic factors, comorbidities, T stage, tumor size, facility type, and facility volume (20 or more resections/year = high volume).

Results: Of 33,255 patients with potentially resectable disease, 3,727 (11.2%) were black and 27,908 (85.2%) were white. Black patients had lower odds of undergoing resection as compared with their white patients on univariate (OR 0.69 [95% CI 0.65-0.74, p<0.0001] and multivariable logistic regression (OR 0.64 [95% CI 0.58-0.71], p<0.0001). There was no significant difference in the refusal of surgery by race. By univariate survival analyses, resected patients survived 11.2 months longer in median survival time than unresected patients and had a lower hazard of death (HR 0.39 [95% CI 0.37-0.41], p<0.0001) while across both resected and unresected, black patients had a higher hazard of death and a reduced median survival time (HR 1.10 [95% CI 1.02-1.17], p=0.007; 9 vs. 9.66 months). This persisted in a multivariable Cox regression model that did not account for treatment factors (HR 1.10 [95% CI 1.01-1.21], p=0.03). Survival by race was similar after controlling for method of treatment (Table 1).

Conclusion: Our analyses demonstrate the importance of treating patients with resectable disease the same irrespective of race. Black patients are at much lower odds of resection as compared with white patients, but they have similar survival in multivariate models when they do undergo resection. These data highlight the importance of improving access to resection for all potential resectable PA patients.

71.03 Frailty Markers and Thyroid/Parathyroid Surgical Outcomes in the Elderly

Posted on January 18, 2016

S. X. Jin1, T. W. Yen1, A. A. Carr1, B. Lalande1, K. Doffek1, D. B. Evans1, T. S. Wang1 1Medical College Of Wisconsin,Surgical Oncology/Surgery,Milwaukee, WI, USA

Introduction: Frailty, defined as decreased physiologic reserves due to decline of multiple organ systems, is a risk factor for poorer postoperative outcomes in the elderly. Cervical endocrine surgery (thyroidectomy and parathyroidectomy) is associated with low rates of morbidity and mortality, and is increasingly being performed in the elderly. This study sought to identify potential frailty biomarkers in patients undergoing cervical endocrine surgery.

Methods: A retrospective chart review of prospective databases was performed of 309 patients who underwent thyroidectomy and/or parathyroidectomy between 7/1/2012 to 6/30/2013. Demographic and clinical data were collected, including pre- and postoperative lab values, extent of surgery, length of stay (LOS) and postoperative complications within 30 days of surgery. Endocrine-specific complications were documented for 6 months in order to categorize transient vs. permanent injury; patients with <6 months of follow-up were not excluded from the cohort. Patients were divided into groups by age: <50, 50-64, and ≥65 years. Finally, to identify potential frailty markers, preoperative biochemical data were compared between patients who experienced complications and those who did not. Kruskal-Wallis test was used for continuous variables and chi-squared test was used for categorical data; a p-value <0.05 was considered statistically significant.

Results: Median age was 57 years (range, 19-86) and 252 (82%) patients were female. The median LOS was one day, and there was no difference in LOS among the three age groups (p=0.87). Overall, there were 28 complications; 14 (50%) were endocrine-specific (Table 1). Patients ≥65 years experienced more complications (n=15; p=0.03) overall and more cardiac events (n=5; p=0.002) than patients 50-64 and patients <50 years. There was no difference in endocrine-specific complication rates by age group. When analyzed by preoperative biochemical values and comorbidities, there were no biochemical factors that were associated with the development of complications. However, patients who experienced complications had a higher rate of anticoagulant use (22% vs. 5%; p=0.001) and congestive heart failure (CHF) (9% vs. 2%; p=0.03), compared to those who did not.

Conclusion: In this cohort, age correlated with higher postoperative complications but was not predictive of hospital LOS. Preoperative factors such as anticoagulant use and history of CHF may be markers for frailty in cervical endocrine patients.

71.04 Influence of HIV infection on hepatocellular carcinoma incidence and survival

Posted on January 18, 2016

A. Mokdad1, A. Singal3, J. Mansour1, H. Zhu2, A. Yopp1 1University Of Texas Southwestern Medical Center,Surgical Oncology,Dallas, TX, USA 2University Of Texas Southwestern Medical Center,Medical Oncology,Dallas, TX, USA 3University Of Texas Southwestern Medical Center,Digestive And Liver Diseases,Dallas, TX, USA

Introduction:

Liver-related complications such as hepatocellular carcinoma (HCC) are a major cause of morbidity and mortality in individuals infected with HIV, particularly among those also infected with hepatitis B or hepatitis C viruses. There is a lack of consensus regarding the clinical presentation, treatment, and outcomes in HIV-infected patients with HCC. We compared the clinical presentation, treatment, and survival of patients with HCC, with and without HIV infection.

Methods:

We linked the Texas cancer registry to the HIV/AIDS data for all years between 2001 and 2011. Patient demographics, socioeconomic status, cancer stage, and treatment were compared between patients with HCC and patients with HCC and HIV. Using a standard HIV population, we calculated annual age, sex, and race standardized incidence and all-cause mortality of HCC in patients with and without HIV. We estimated standardized incidence and mortality ratios for the entire study period. We calculated the fraction of mortality related to the following cause-of-death categories: HCC, end-stage liver disease, and HIV. We used a shared frailty model to evaluate risk-adjusted survival in patients with HCC and HIV and with HCC only. We explored the association between HIV infection and treatment of HCC using a mixed-effects logistic regression model.

Results:

18,291 patients with HCC were included in the study; 236 had HIV infection. Compared to patients with HCC only, patients with HCC and HIV were younger at the time of HCC diagnosis (63 years vs. 53 years, p-value < 0.01), male (91.3% vs. 71.9%; p-value < 0.01), African American (41.8% vs. 12.9%; p-value < 0.01), and of lower socioeconomic status (52.6% vs 41.9%; p-value = 0.02). Overall cancer stage and treatment provision were similar. The unadjusted median survival was 6.1 and 6.4 months (log-rank test p-value = 0.38) in the HCC and the HCC and HIV groups, respectively. Age, sex, and race standardized incidence increased and mortality decreased in both groups over the study period. The mean standardized incidence ratio for patients with HCC and HIV was 2.4 ± 0.35; the mean standardized mortality ratio was 2.7 ± 0.36. The most common cause of death was liver cancer, 70 percent and 54 percent, in patients with HCC only and with HCC and HIV, respectively. In the HCC and HIV group, 23 percent died from HIV sequelae. Adjusted survival was worse in patients with concurrent HIV infection (hazard ratio = 1.23, 95% confidence interval: 1.04 – 1.46). After accounting for facility effect, patient demographics, socioeconomic status, and HCC characteristics, there was no difference in provision of resection, ablation procedure, or chemotherapy between both groups.

Conclusion:

Patients with HIV are associated with a higher risk of developing HCC. HCC and concurrent HIV infection is associated with worse survival. It is imperative to improve screening, diagnosis, and management of HCC in patients with HIV.

70.20 Neutrophil-to-Lymphocyte Ratio Predicts Outcomes of Pancreaticoduodenectomy for Pancreatic Cancer

Posted on January 18, 2016

A. I. Salem1, E. R. Winslow1, C. S. Cho1, S. M. Weber1 1University Of Wisconsin School Of Medicine And Public Health,General Surgery,Madison, WI, USA

Introduction:

Neutrophil-to-lymphocyte ratio (NLR) has been introduced as a serological marker with a potential prognostic role for many cancer types. The role of NLR in predicting pancreas cancer outcome is understudied. Previous reports have suggested that higher NLRs are associated with worse survival. We sought to investigate the relation between NLR and both short and long term outcomes after pancreatic ductal adenocarcinoma resection in our institution.

Methods:

Patients with pancreas cancer who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma between 1999 and 2012 were evaluated. NLR was calculated by dividing the absolute neutrophilic count value by the absolute lymphocytic count value. We identified 216 patients from our prospectively maintained database with 104 patients excluded for lack of data on neutrophilic or lymphocytic counts within 30 days prior to surgery. Out of 112 eligible patients analyzed, 33 (29.5%) had NLR ≥ 4.5.

Results:

There was no difference in 30-day mortality between patients with NLR ≥ 4.5 and those with NLR < 4.5 (0 (0%) vs 1 (1.3%), p=0.5) and no differences in overall 30-day morbidity (16 (49%) vs 45 (57%), p=0.4). Patients with NLR < 4.5 were more likely to have nodal metastases than their counterpart group (69 (87%) vs 16 (49%), p<0.001), while patients with NLR ≥ 4.5 had a higher median estimated blood loss (EBL) (550 mL (150-12,500) vs 500 mL (150-1,400), p=0.02), a higher median number of intraoperatively-transfused packed red cell units (2 units (0-23) vs 0 units (0-9), p=0.01), and a longer hospital stay (LOS) (10 days (5-39) vs 8 days (4-35), p=0.04). Kaplan-Meier survival analysis showed improved median overall survival in the NLR ≥ 4.5 group (21 months vs 18 months, p=0.02). On multivariable analysis, after adjusting for nodal status, EBL, intraoperative packed red cell transfusion, NLRs ≥ 4.5 were found to be the only predictor of improved overall survival (HR=0.54 , CI=0.30 – 0.97, p=0.04) (Figure.1).

Conclusion:

In our experience of pancreas cancer patients undergoing pancreaticoduodenectomy, elevated NLR was associated with an increased risk of EBL, need for transfusion, and longer LOS, but improved long-term survival. This is in contrast to previous reports describing elevated NLR as a negative prognostic variable. Further studies on larger numbers of patients are required to better assess the prognostic role of preoperative NLR for both short and long-term outcomes after curative resection of pancreas cancer.

70.21 Murine Breast cancer cells eliminated in non-derived strain mice; using an improved breast cancer model

Posted on January 18, 2016

E. Katsuta1, S. DeMasi1, K. P. Terracina1, H. Aoki1, M. Aoki1, P. Mukhopadhyay1, K. Takabe1 1Virginia Commonwealth University School Of Medicine And Massey Cancer Center,Division Of Surgical Oncology, Department Of Surgery,Richmond, VA, USA

Introduction: We have previously established a murine syngeneic breast cancer model utilizing cell implantation under direct vision technique, which mimic human cancer progression (Rashid, Takabe et al. Breast Cancer Research and Treatment 2014). Other groups have reported that cell implantation using Matrigel produced stable results in xenograft models. Here, we report the establishment of improved syngeneic orthotopic murine breast cancer model using Matrigel. In this study, we determined the maximum amount of Matrigel to be implanted without spillage, the tumor growth with various number of cells, and utilizing this new model, we investigated the growth of murine cancer cell derived from different strain mice.

Methods: Matrigel was injected to #2 and #4 mammary glands. Various number of murine breast cancer E0771cells in Matrigel were implanted into bilateral #2 and #4 mammary gland of C57Blk6 mice. Three weeks after inoculation, tumorigenesis were compared. 1 x 104 of murine breast cancer 4T1-luc2 cells, derived from Balb/C mice, were implanted into the Right side #2 gland of Balb/C or C57Blk6 mice. Tumor growth was monitored by bioluminescence (IVIS) imaging.

Results: We found that implantation of the cells will be more efficient with less variability when the cells are suspended in Matrigel compared with PBS, which was the technique we reported previously. Maximum volume of Matrigel inoculated without spillage was 20 μl in #2 gland, 30 μl in #4 gland, respectively. Therefore, we implanted 20 μl of Matrigel in #2 gland, and 30 μl in #4 gland in the subsequent experiments. In order to determine the difference of tumor development, 504, 105, 505, 106 E0771 cells suspended in 20µl Matrigel were inoculated. Three weeks after inoculation, ‘the take rates’ (tumorigenesis) were 0%, 12.5%, 75%, 75%, 100%, respectively. Utilizing 4T1-luc2 cells in Matrigel suspended cell implantation method, we investigated how long the mouse-derived cancer cells survive in mice from a different background. The fold increase in tumor growth in both backgrounds were nearly identical 24 h after inoculation at 5-fold increase measured by bioluminescence imaging. By 7 days after inoculation, tumor in C57Blk6 reached a maximum increase of approximately 720-fold their Day 0 size, whereas the tumor in Balb/C had almost a 2000-fold increase in tumor size. The Balb/C tumor continued to increase rapidly to reach an almost 3000-fold increase in size, while the C57Blk/6 mice tumors swiftly decreased from Day 7 and was eliminated by Day 14.

Conclusion: We identified the maximum amount of Matrigel that can be implanted into #2 or #4 mammary gland without spillage, and the difference in take rates with various number of cells for murine orthotopic breast cancer model. Utilizing Matrigel implantation method, we found that cancer cells will continue to grow until one week, then it will eliminated by 2 weeks when implanted into different background strain mice.

71.01 Preoperative Platelet to Albumin Ratio is a Prognostic Factor for Pancreatic Cancer.

Posted on January 18, 2016

Y. Shirai1, H. Shiba1, N. Saito1, T. Horiuchi1, K. Haruki1, Y. Nakaseko1, Y. Takano1, K. Furukawa1, M. Kanehira1, S. Onda1, T. Sakamoto1, T. Gocho1, Y. Ishida1, K. Yanaga1 1The Jikei University School Of Medicine,Surgery,Minato-ku, TOKYO, Japan

Introduction:
Pancreatic cancer is one of the most aggressive digestive cancers. Because pancreatic cancer recurs after pancreatic resection in as many as 70-80%, it is important to predict tumor recurrence and prognosis in regard to decision making of additional adjuvant therapy. There are several inflammation based prognostic index such as Glasgow prognostic score (GPS), mGPS, neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, CRP/Albumin, and prognostic nutrition index. However, preoperative estimation of oncological prognosis remains to be established. The aim of this study is to evaluate the prognostic value of preoperative platelet to albumin ratio (PAR) in pancreatic ductal adenocarcinoma after pancreatic resection.

Methods:
A total of 115 patients who underwent pancreatic resection for pancreatic invasive ductal adenocarcinoma were available from prospectively maintained database. The patients were divided into two groups as PAR ≥ 53.1 x 103 or < 53.1 x 103 on the basis of ROC curve analysis (2 years survival, AUC=0.640, p=0.011). 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 PAR was significant prognostic index on univariate analysis for disease-free and overall survivals. The median overall survival in patients with PAR ≥ 53.1 x 103 was 17.6 months, which was poorer than 36.1 months for patients with PAR < 53.1 x 103 (p=0.0039). The PAR retained its significance on multivariate analysis for overall survival (HR 1.666, 95%CI 1.021-2.717, p=0.041) along with tumor stage (p=0.047) and serum CA19-9 (p=0.010). PAR ≥ 53.1 x 103 was also a significant independent prognostic index for poor disease-free survival on multivariate analysis (HR 1.771, 95%CI 1.055-2.973, p=0.031).

Conclusion:
The preoperative PAR is a novel significant independent prognostic index for disease-free and overall survival in resected pancreatic invasive ductal adenocarcinoma.

71.02 Conservative Management of Desmoid Tumors is Safe and Effective

Posted on January 18, 2016

J. S. Park1, Y. Nakache4, J. Katz3, R. D. Boutin3, A. Monjazeb2, R. J. Canter1 1University Of California – Davis,Surgical Oncology,Sacramento, CA, USA 2University Of California – Davis,Radiation Oncology,Sacramento, CA, USA 3University Of California – Davis,Radiology,Sacramento, CA, USA 4University Of California – Davis,Medical School,Sacramento, CA, USA

Introduction:

Desmoid tumors are locally aggressive neoplasms without metastatic potential. Although surgical resection was once thought to be the mainstay of therapy, this is a potentially morbid approach associated with a high risk of local recurrence. There is an increasing role for watchful waiting and conservative management for these tumors.

Methods:

We identified 36 desmoid tumor patients who were categorized by the nature of treatment rendered (surgical resection versus observation). Data were abstracted on clinical and pathological factors. Disease stability or progression was determined radiographically. Univariate and Kaplan-Meier analysis was used to determine predictors of recurrence/progression of disease. Main outcome measurements were tumor recurrence following surgical resection versus tumor progression with conservative management.

Results:

Of the 36 patients, 58% were female and average age was 44 years old. The tumors were primarily located in the extremities including hip and shoulder girdle at 58%. 33% were located in the trunk and 8% in the retoperitoneum. Median tumor size was 9.2 cm (range 2.7-24 cm). Of the patients that had beta catenin staining, 96% were positive. The patients were categorized into surgical versus nonsurgical therapy. 18 patients underwent operation either prior to referral, due to refractory symptoms or due to patient preference. 17 patients were observed without surgical resection, including 3 patients who received nonsurgical therapy such as chemoradiation and/or medical therapy. One patient was lost to follow up. Median follow up time was 23 months.

Among 17 of the patients who underwent surgical resection, ten patients developed recurrent disease (59%). Among those who developed recurrent disease, 8 (80%) patients were stable or partially responding to subsequent observation. Of the 17 patients who underwent conservative management, one patient experienced disease progression (5%) and 94% of patients had no disease progression, including one patient with complete response and three patients with partial responses.

Conclusion:

This retrospective analysis adds to growing data that observation of both primary and recurrent desmoid tumors is safe and effective with higher rates of stable disease than other published series. Conservative management of desmoid tumors appears to be safe and effective, sparing patients the morbidity and risk of recurrence that is associated with extensive operations.

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