83.03 Skeletal Survey and its Role in Identifying a Non-Accidental Mechanism in Pediatric Trauma Patients

Posted on January 26, 2017

J. Green3, R. N. Damle3, M. Hazeltine2, G. Keefe2, J. Brady2, P. P. Nazarey4, M. P. Hirsh4, J. T. Aidlen4  2University Of Massachusetts Medical School,School Of Medicine,Worcester, MA, USA 3University Of Massachusetts Medical School,General Surgery,Worcester, MA, USA 4University Of Massachusetts Medical School,Pediatric Surgery,Worcester, MA, USA

Introduction:

Skeletal survey is the imaging modality of choice to diagnose skeletal injury in Non-Accidental Trauma (NAT) victims under 2 years. Infants less than 6 months old are potentially the most vulnerable. We explore the utility of skeletal survey in our youngest trauma patients and its frequency of injury detection of NAT.

 

Methods:  

A retrospective analysis of pediatric trauma patients (<18 years old) with a skeletal survey was performed at our institution from 2005-2015. Patients were divided into 2 groups: ≤6months and >6months to 3 years. Chi-squared analysis or Student t-test were performed when appropriate.

 

Results:

Our study identified 184 patients (98 patients were ≤6 months, 86 were >6 months to 3 years). There were no differences in race, gender, injury-severity-score or level of trauma.  A positive skeletal survey was found in 16% of patients: 14% ≤6months and 19% >6months (p=0.43). Most common fractures identified on skeletal survey were long bone (24%), torso (15%), and skull (6.7%), with no statistical difference between groups.  NAT was suspected in 58% of patients, with no difference between groups (58% vs. 57%, p=0.78).  Head computed tomography(CT) scans were performed in 96% of patients ≤6 months old and just 66% of the patients older than 6 months (p<0.01).

 

Conclusion:

Skeletal surveys identify additional injuries at comparable rates in pediatric trauma patients regardless of age. Pediatric trauma patients 6 months old or younger are more likely to receive a head CT scan as part of their trauma workup.

 

83.01 Gastrointestinal Outcomes of Patients with Omphalocele

Posted on January 26, 2017

P. E. Lau1, C. S. Bernardo1, O. O. Olutoye1,2, D. L. Cass1,2, S. M. Cruz1, T. C. Lee1,2, S. Nuthakki2  1Baylor College Of Medicine,Pediatric Surgery,Houston, TX, USA 2Texas Children’s Hospital,Pediatrics,Houston, TX, USA

Introduction: Perinatal management of patients with giant omphaloceles(GO) can be challenging  and be associated with mortality and morbidity. The purpose of this study was to assess the gastrointestinal outcomes in these patients, specifically time to attaining full enteral and oral feeding milestones.

Methods: We performed a retrospective chart review of patients with omphalocele from 1/2003 –2/2014. Patients were classified into isolated, omphalocele with minor or major anomalies categories. Major anomalies were defined as a cardiac defect requiring immediate medical or surgical treatment, congenital diaphragmatic hernias, and major chromosomal abnormalities. All other anomalies were classified as minor. Giant omphalocele was defined as >50% of liver in the sac. Feeding milestones were defined as the time to attain 120 ml/kg/d of enteral/oral feeds. We also evaluated length of stay, days on mechanical ventilation, need for tracheostomy, days of TPN, use of motility agent and achivement of full oral feeds prior to discharge.

Results:Of 82 live born patients, 53 survived to discharge. Patients with major anomalies had significant longer length of stay, delayed feeding milestones and were less likely to feed orally compared to patients with minor and isolated omphaloceles(Table 1). Respiratory morbidity of patients with major anomalies was more severe as shown by a higher rate of tracheostomies and longer length on mechanical ventilation. Patients with GO(n=25) had longer length of stay(36vs13, p=0.002), took longer to reach full enteral feeds(22vs10 days, p=0.015), had more days of TPN(17vs10 day, p=0.022). Fourteen(56%) of the patients with GO did not reach full PO feeds compared to six(21%) in the other group(p=0.045). Three(12%) patients with GO had G-tubes and six(24%) patients required motility agents. No motility agents or G-tubes were observed in non-giant omphalocele group.        

Conclusion:The presence of major anomalies and GO appears to be a strong predictor in prolonging the achievement of full enteral feeds with obvious need for longer duration of TPN. Patients with isolated omphaloceles and patients with minor anomalies achieved full oral feeds at similar times, length of stay is longer with minor patients. This is likely related to the poor pulmonary status of these patients. Patients without GO are less likely to be treated with motility agents or need a g-tube. These findings are important for counseling parents and for the design perinatal interventions to improve outcomes on these patients.

82.20 Sarcopenia is a predictor of postoperative morbidity and mortality in elderly with esophageal cancer

Posted on January 26, 2017

Y. Nakashima1, H. Saeki1, R. Nakanishi1, M. Sugiyama1, J. Kurashige1, E. Oki1, Y. Maehara1  1Kyushu University,Department Of Surgery And Science,Fukuoka, FUKUOKA, Japan

Introduction:
The present study investigated the effect of sarcopenia on short-and long-term surgical outcomes and identified potential prognostic factors for esophageal cancer among patients 65 years of age and older.

Methods:
Patient data were retrospectively collected for 341 consecutive patients who underwent esophagectomy for esophageal cancer. Patients were assigned to two groups according to age (younger than 65 years and 65 years and older), and the presence of sarcopenia. The clinicopathological, surgical outcome, and long-term survival data were analyzed.

Results:
Sarcopenia was present in 170 of 341 patients (49.9%) with esophageal cancer, and 48.5% of patients aged 65 years and older. The incidence of anastomotic leak and in-hospital death were significantly higher in elderly sarcopenia group than in elderly non-sarcopenia group (30.1% versus 16.3%, 6.8% versus 0.0%, respectively). Overall survival rate in patients with sarcopenia correlated with significantly poor prognosis in the group aged 65 years and older (p<0.001). Multivariate analysis revealed that sarcopenia was predictive of anastomotic leak and unfavorable prognosis in the group aged 65 years and older. On the other hand, both of the incidence of surgical complications and overall survival rate were similar between sarcopenia and non-sarcopenia in patients younger than 65.

Conclusion:
This retrospective analysis revealed that sarcopenia was a risk factor for anastomotic leak and a prognostic marker of overall survival after esophagectomy in patients 65 years of age and older with esophageal cancer.
 

82.19 Reconstruction and Functional Status Following Surgical Treatment of Foot Melanoma

Posted on January 26, 2017

G. M. Winter1, J. D. Vargo2, J. M. Mammen3  1Unversity Of Kansas,School Of Medicine,Kansas City, KS, USA 2University Of Kansas,Department Of Plastic Surgery,Kansas City, KS, USA 3University Of Kansas,Department Of Surgery,Kansas City, KS, USA

Introduction:

Melanoma of the foot is often challenging to diagnose and treat due to its subungual, palmar and/or plantar locations. Patients with foot melanomas often present late, after significant radial spreading of malignant cells, and require more extensive resections. Following excision, reconstruction should reflect the functional and weight bearing nature of these locations. However, little is known about the reconstructive strategies needed for patients with melanomas of the foot. This study evaluates a series of patients with foot melanomas to identify disease thickness at time of diagnosis, extent of excision, reconstructive method, and functional status.

Methods:

After IRB approval, a retrospective review was performed to identify all patients with foot melanoma who underwent surgical excision at our institution between January 2010 and May 2016. Following identification, patient charts were reviewed for relevant demographic information, lesion location, tissue diagnosis, Breslow thickness, excision area, exposed structures, reconstructive method, functional status, complications, and survival. Reconstruction was performed either by the primary surgeon or in conjunction with plastic surgery and was determined based upon defect size, location, and exposed structures.  Functional status was determined by the number of days between reconstruction and clearance for weight bearing activities. 

Results:

34 patients met inclusion criteria (21 women and 14 men). Mean patient demographics and lesion characteristics were as follows: age 63±15, BMI 28.2±6.0, Breslow Thickness 2.0±1.8 mm, and excision area 35.5±25.6 cm2. Reconstructions were performed as follows: 11 Full thickness skin grafts (FTSG), 8 split thickness skin grafts (STSG), 7 Integra with STSG, 2 local flaps, 3 primary closures, 2 secondary healing, and 1 DIP amputation. 28 of 34 patients had complete data on functional status. Functional status recovery based on reconstruction were as follows: 23 days for FTSG, 17 for STSG, 29 for Integra with STSG, 35 for local flaps, 6 for primary closure, 8 for secondary healing, and 7 for amputation.

Cellulitis was seen following 3 STSG only, and P. aeruginosa infection was seen following 1 Integra and STSG reconstruction. One death occurred during the study period due to systemic progression of melanoma. Median follow up was 11 months.

Conclusion:

This study demonstrated the utility of a variety of reconstructive options following excision of foot melanoma. FTSG was most commonly used to reconstruct defects of plantar surfaces when there was a healthy wound bed with no exposed tendon or bone. When these structures are exposed, Integra placement with subsequent STSG is a viable option with good result. Functional status was regained first by STSG, then by FTSG, and finally by Integra and STSG. Ability to regain functional status is found to be dependent on reconstruction method.

82.18 Reconstruction of Major Defects after Oncologic Resection: An Institutional Review

Posted on January 26, 2017

K. P. Walsh1, G. Grimberg1, A. J. Scholer1, L. J. Lynch1, J. D. Keith2, R. J. Chokshi1  1New Jersey Medical School,Division Of Surgical Oncology, Department Of Surgery,Newark, NJ, USA 2New Jersey Medical School,Department Of Plastic Surgery,Newark, NJ, USA

Introduction:  Oncologic resections vary in size and technical difficulty due to a multitude of factors: oncologic process, margin needed, surrounding structures involved and subsequent defect size.  After an extensive resection, many surgeons are challenged by the reconstruction due to both the size of the defect and the vital structures that are exposed.  The purpose of this study was to review our institution’s experience with oncology-related resection and subsequent reconstruction in patients with extensive defects. To date, this is the largest series examining oncology-related resection and subsequent reconstruction in adults.

Methods:  We conducted a retrospective review of 95 adult patients who underwent both an operative resection by a surgical oncologist and a subsequent reconstruction by plastic surgery at our institution over a four-year period from 2012 to 2015. Patient demographics were characterized, and an analysis of both the oncologic resection and subsequent reconstructive operations was performed.

Results:  The cohort consisted of 95 patients with a mean age of 52.7 (26-87) years old and mean BMI of 27.8 (16-46). The majority of our patients were smokers (51.6 %) and had significant medical comorbidities (56.8 %). Of the resections, 66% were for malignancy. The most common malignancies were:  adenocarcinoma of the GI tract (22.2 %), sarcoma (15.9 %), squamous cell carcinoma (15.9 %) and basal cell carcinoma (12.7 %). The sites of resection included the trunk (44.2 %), extremities (31.6 %) and head & neck (24.2 %). Major defects (>225 cm2) were encountered in 38.9 % of patients, with a mean defect size of 240 cm2. Many reconstructive techniques were employed, including primary/complex closure (10.1 %), skin graft (10.1 %), adjacent tissue transfer (14.7 %), pedicled flaps (29.5 %) and free flaps (34.7 %). The most frequently used free flap was an anterolateral thigh flap (60.1%), and common pedicled flaps included rectus abdominis (34.2 %), gracilis (13.2 %) and gastrocnemius flaps (10.5 %).

Conclusion:  Radical oncologic resection and subsequent reconstruction of large defects can be safely and effectively performed using a multi-disciplinary approach. Collaborative efforts between surgical oncology and plastic surgery have enabled patients with significant medical comorbidities to undergo a variety of successful oncologic resections with subsequent effective reconstruction of major defects.

 

82.17 Optimal Timing for Surgery following Neoadjuvant Cheomradiation in Patients with Rectal Cancer

Posted on January 26, 2017

N. Ghalyaie1, K. S. Goodman2, C. S. Lau2,3, R. S. Chamberlain2,3,4  1Banner MD Anderson Cancer Center,Surgery,Gilbert, AZ, USA 2Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada 4Rutgers University,Surgery,Newark, NJ, USA

Introduction:  Surgery and either neodadjuvant or adjuvant therapy is the gold standard treatment for rectal cancer.  Advances in fluoropyridine-based neoadjuvant chemoradiation (NCR) regimens have resulted in a high percentage of rectal cancer patients exhibiting a complete pathologic response (pCR) after proctectomy. This implies that a subset of patients may be able to undergo surveillance and ultimately not require proctectomy.  This study sought to examine the impact of the time between completion of NCR and definitive surgical therapy on the likelihood of a achieving a pCR.

Methods:  A comprehensive literature search of PubMed, Google Scholar, Medline, and the Cochrane Central Registry of Controlled Trials (1966-2016) was conducted.  Keywords searched included rectal cancer, neoadjuvant chemoradiation, and surgery, and only articles written in English were included. The outcome analyzed was the incidence of pCR.

Results: 13 studies involving 2,731 patients with stage I, II, or III rectal cancers were included. Studies ranged from neoadjuvant chemoradiation completed 41 days prior to surgery to 12 weeks prior to surgery. 13 of the studies reported higher pCR rates following extended intervals (>6-8 weeks) between neoadjuvant chemoradiation and surgery, 5 of which were statistically significantly. Results ranged from 27.1% – 34.5% for extended intervals, compared to 15.3% – 27.3% for shorter intervals (<6-8 weeks) between neoadjuvant chemoradiation and surgery. 

Conclusions:  Neoadjuvant chemoradiation is capable of achieving a pCR in 15 – 34.5% of patients with rectal cancer.  The optimal interval between NCR and surgery is controversial, however, prolonging the interval time between neoadjuvant cheomradiation and surgery (>6-8 weeks) may increase the chance of pCR, especially with Stage II and III rectal cancer. Additional studies evaluating which specific patients (eg.,T2 N0-2, or T3 N0-2) are most likely to achieve pCR, and the impact of a  prolongation in the interval between NCR and definitive surgical therapy is needed.

 

82.16 Clinical Characterization of Pancreatic Sarcoma: A Longitudinal Single Institution Experience

Posted on January 26, 2017

C. V. De Carvalho Fischer1, H. N. Overton1, C. L. Wolfgang1, C. Meyer2, F. M. Johnston1, N. Ahuja1  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Medical Oncology,Baltimore, MD, USA

Introduction:

Primary pancreatic sarcoma is a rare intra-abdominal neoplasm with relatively unknown survival rates due to limited reports in the literature. We present the only known case series of pancreatic sarcoma from a single-institution 15 year experience and aim to compare to previously reported retroperitoneal sarcoma overall survival (OS) and recurrence free interval (RFI) at the same institution. 

Methods:

Retrospective analysis of all primary pancreatic sarcomas at Johns Hopkins Hospital from 1990 to 2015. Overall survival and recurrence free interval after surgical resection was determined using the Kaplan-Meier method on GraphPad Prism 6.   

Results:

Pancreatic sarcoma patients were an average age of 57.8 years (+/- 13.62) at diagnosis. Liposarcomas were the most common histological tumor type, affecting six of eighteen patients with primary sarcomas of the pancreas. Other histology included leiomyosarcoma or GIST phenotype, epitheloid angiosarcomas and fibrosarcomas of the pancreas, and malignant spindle cell tumor. On average, the largest diameter of the tumor was 11.92cm (+/- 8.32). The tumor was classified as high grade in eight cases whereas only four cases were described as low or intermediate grade malignancies. The tumor grade remained undefined in six cases. Only two out of eighteen sarcomas were deemed unresectable. The remaining patients had surgical interventions, out of which 55.56% (10/18) underwent a Whipple procedure, and 33.33% (6/18) underwent a distal pancreatectomy. Pathology reports defined eight cases as having achieved a R0 resection, four of eighteen with R1 resections and two of eighteen with R2 resections. The median overall survival of this collective was 32 months whereas the median recurrence free interval following surgical resection was 14 months. In comparison, recent analysis of retroperitoneal sarcoma outcomes treated at the Johns Hopkins Hospital within the same time period demonstrated overall survival of 48.7 months and recurrence free survival of 20 months. Given the small smaple size in the case series of pancreatic sarcoma, analysis of variables important in survival, such as grade and resection status, could not be performed.

Conclusion:

Pancreatic sarcoma demonstrated decreased overall survival and recurrence free survival after surgical resection when compared to retroperitoneal sarcoma treated at the same institution. Though a rare tumor type, the data presented warrants further research on pancreatic sarcoma.

82.15 Propensity Matched Analysis of Infection Rates in Wide Local Excision of Melanoma

Posted on January 26, 2017

D. R. Ziazadeh2, E. L. Kalbfell2, R. N. Matar2, S. Mauch2, L. R. Mohey2, J. L. Parker3, M. Melnik1,2  1Spectrum Health,Surgical Oncology,Grand Rapids, MICHIGAN, USA 2Michigan State University,College Of Human Medicine,Grand Rapids, MICHIGAN, USA 3Spectrum Health,Biostatistics & Research,Grand Rapids, MICHIGAN, USA

Introduction: Wide local excision is the current gold standard for patients diagnosed with histologically confirmed cutaneous melanoma. There is no published consensus on the infection rate for common melanoma surgeries. We set out to evaluate the rate of infection in adult patients in wide local excision of melanoma.

Methods: From 11/19/2011 to 11/18/2014, adult patients 18 years and older underwent wide local excision of melanoma at Spectrum Health. The primary outcome variable was presence or absence of infection at surgical site. Clinical patient characteristics and data were extracted from our local electronic medical record. Patients were propensity matched for age, gender, BMI, smoking status, autoimmune diseases, and diabetes yielding 21 well-matched pairs. Operative data collected included method of infection diagnosis, site and size of excision, procedures, complications, histological results and melanoma classification.

Results: A total of 200 patients were identified. Of these, 23 developed a post-operative infection (12.2%) after melanoma excision. Infection sites differed, with 12 occurring at the site of wide local excision, 10 at the site of lymph node biopsy, and one at the skin graft site. 60.8% of those infected were diagnosed clinically and 39.2% were culture confirmed. There was no significant difference in age (61±17 vs 58±17 yr), gender (61±49% vs 43±51% male), BMI (29±7 vs 33±9 kg/m2), history of smoking (35±48% vs 48±51%), autoimmunity (7±25% vs 4±21%), or diabetes (18±39% vs 22±42%) before propensity matching in non-infected vs infected patients. Table 1 summarizes pertinent operative factors and comorbidities on rates of infection after propensity matching. Infection rate varied by specialty: Surgical Oncology, 12.4% (19/153), Plastic Surgery, 8% (2/25), and General Surgery, 7.4% (2/27) respectively.

Conclusion: In wide local excision of melanoma, surgical time, excisional size, Breslow Thickness, and Clark Level provided equivalent clinical outcomes on the rate of infection. Future analysis is pending regarding the impact of histological stage/grade, LNB location, and wound closure on the rate of infection.

 

82.14 Let’s cut the Core; When is Core Biopsy Enough for Sub Centimeter Breast Cancer?

Posted on January 26, 2017

B. Shea1, W. Boyan1, K. Kamrani1, G. Lepis2, S. Chang1, M. Goldfarb1, D. Dupree1, M. Kohli1  2St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada 1Monmouth Medical Center,Surgery,Long Branch, NJ, USA

Introduction:  

Breast conservation therapy has become a preferred method of treating early stage breast cancer by many surgeons and patients. Multiple trials have shown similar survival rates with less invasive surgery to both the breast and axilla thanks in part to adjuvant therapies and a better understanding of breast cancer biology. As care continues to evolve, different sizes and types of lesions are allowed less invasive treatment options. A relatively simple explanation of early breast cancer care is detection, biopsy, surgery and adjuvant therapy. The authors in this article look to challenge that algorithm for a specific type of disease. 

Methods:

A single institution retrospective review was performed to identify all patients over the last five years who have undergone breast biopsy for malignant or pre-malignant lesions. Of these, 115 met the requirements of being less than one centimeter at detection and undergoing the traditional treatment algorithm outlined above. These cases were analyzed for biopsy technique and outcome of final surgical excision to find when no residual disease was found upon final pathology because the entire lesion was removed by the initial biopsy. 

Results:

The authors found that seventeen of 115 patients (14.8%) who underwent biopsy for sub cm breast cancer had no residual disease found on final surgical resection. Neither size of biopsy sample nor size of the lesion correlated with having no residual disease on surgical resection. Although size of needle also didn’t reach statistical significance, the smallest needle biopsies were never found to have no residual disease (ten patients) on final pathology while biopsies with the largest 7 gauge needle was found to have negative pathology in two out of three patients. 

Conclusion:

This study looked at 115 patients that were diagnosed and treated for sub cm breast cancer in the standard: detection, biopsy, surgery pathway. The authors thought that sub cm lesions represents a unique subset of breast cancer that presents a plethora of questions. If the ever shrinking margins can be obtained with a biopsy needle, what benefit does a formal resection provide? Many lumpectomies result in comparatively large resections for a small lesion, causing cosmetic distress. Although 14.8% is not a large portion of the samples, this number was obtained when radiologists were merely trying to get a sample of tissue for diagnosis. If sub cm lesions could be treated with a larger needle and effort to resect the whole mass, the yield could be much higher. Prospective protocol based trials would be needed to truly see how much sub cm breast cancer is truly left after biopsy alone. 

82.13 Long Term Survival After Resection of Sarcomatoid Carcinoma of the Pancreas: An Updated Experience

Posted on January 26, 2017

A. Blair1, R. Burkhart1, J. Griffin1, J. Miller2, M. Weiss1, M. Makary1, J. Cameron1, C. Wolfgang1, J. He1  2Johns Hopkins University School Of Medicine,Department Of Pathology,Baltimore, MD, USA 1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:
Sarcomatoid carcinoma of the pancreas (SCP) is a rare histologic subtype of undifferentiated pancreatic carcinoma. Historically this has been associated with worse overall prognosis than adenocarcinoma. However, owing to the rarity of the disease, clinical course and surgical outcomes remain poorly characterized.

Methods:
A single-institution, prospectively maintained database was queried for patients who underwent pancreatic resection with a final diagnosis of SCP. We describe their histology, clinicopathologic features and perioperative outcomes. Survival data is highlighted and common traits of long-term survivors are examined.

Results:
Over a 15-year period, 7009 patents underwent pancreatic resection at our institution. Eight (0.11%) were diagnosed with SCP on final histopathology as determined by a predominance of spindle cells and sarcomatoid features with epithelial derivation. Further histologic subtyping demonstrated two cases with the presence of osteoclast like giant cells (OCGC). Mean patient age was 67 years and three patients were males (37%). Lesions were equally distributed between the head and the body/tail of the pancreas. R0 resection was achieved in six patients (75%) (Table 1). Four patients had early recurrence leading to death (<3 months). There were no deaths attributed to perioperative complications. Two (25%) experienced long term-survival (>5 years), with the longest surviving nearly 16 years despite the presence of lymph node metastasis at the time of operation. There were no long term survivors amongst those with OCGC identified on histopathology. Both long term survivors had disease in the body/tail of the pancreas and received adjuvant radiotherapy. One (50%) also received additional adjuvant gemcitabine based chemotherapy.

Conclusion:
S SCP is a rarely appreciated subset of pancreatic malignancy with bimodal outcomes. While many have rapid disease recurrence that leads to their early demise, a diagnosis of SCP does not necessarily portend to a uniformly dismal prognosis. Long-term survival is possible. Future studies are needed to better define the cohort with potential for long-term survival so that aggressive therapies may be tailored appropriately in this patient subset.

82.12 Medullary carcinoma thyroid in the RET era

Posted on January 26, 2017

D. Abraham1, A. Cherian1, R. Pai2, S. Chakravarthy1, P. Jacob1  1Christian Medical College, Vellore,Endocrine Surgery,Vellore, TAMIL NADU, India 2Christian Medical College, Vellore,Molecular Pathology,Vellore, TAMIL NADU, India

Introduction:  The management of medullary carcinoma thyroid (MTC) has evolved to incorporate gene testing. We conducted this study to evaluate the impact of RET mutation testing in the management of MTC.

Methods:  Retrospective study of data between January 2008 and December 2015 from the computerised hospital information system was analysed using STATA (v.10).

Results: MTC accounted for 89/1877(4.7%) patients with thyroid cancer. The mean age of presentation was 39.6 years (range of 14-70) with M:F=48:41. Three patients presented with a pheochromocytoma, four were screen detected and the remaining had goitre. FNAC was diagnostic in 67.6% while calcitonin was elevated in 94.9%.RET testing was performed in 69 patients, 24 were positive (34.8%).Seventeen relatives of ten index patients were screened and twelve were RET positive. Patients with hereditary MTC were younger (34.9 vs 39.3) with a female preponderance (M:F = 8:16).Prophylactic thyroidectomy was performed in 3 patients. All patients underwent primary surgery. Persistent hypercalcitoninemia (calcitonin > 50pg/ml) was observed in 50/78(64.1%). Of these, 41 patients underwent metaiodobenzylguanidine scan, three were positive. The median duration of follow up was 14 months. Twelve patients were lost to follow up and two patients succumbed to their disease.

Conclusion:  MTC accounts for 5% of thyroid carcinoma in our series. Hereditary MTC presents at an earlier age than the sporadic type with afemale preponderance. RET screening should be performed for all patients with MTC as they may be the index case and prophylactic surgery may be offered for those children testing positive.

 

82.11 Screening High-Risk Pancreatic Subjects Leads to Acceptable Detection Rates of Precancerous Findings

Posted on January 26, 2017

J. T. Wiseman1, R. Hendrix1, W. Y. Wassef2, K. Flores3, A. Friedrich1, K. Dinh1, E. Rouanet1, G. Whalen1, J. LaFemina1  1University Of Massachusetts,Surgical Oncology,Worcester, MA, USA 2University Of Massachusetts,Gastroenterology,Worcester, MA, USA 3University Of Massachusetts,Pediatrics,Worcester, MA, USA

Introduction:  Pancreatic ductal adenocarcinoma (PDAC) is the 3rd most common cause of cancer death in the United States. As there is no definitive impact of screening on cure, the role of screening high risk cohorts remains controversial. Furthermore, no gold standard screening pathway has been established. Herein we present our initial experience, focusing on the radiologic and endoscopic findings of high-risk subject screening.

Methods:  Subjects were eligible if they were determined to be at intermediate or high personal risk for PDAC as determined by one of the following: personal/family history of a genetic syndrome associated with PDAC; personal history of chronic pancreatitis of unknown etiology; or family history of PDAC. Subjects were recruited from May 2013-November 2015. The screening and evaluation algorithm is summarized in Figure 1.  Analysis is conducted on the radiologic and endoscopic pancreatic findings in all new patients. Subjects with known PDAC were excluded. 

Results: Sixty-eight patients were analyzed during the study period. The average age was 55 years (range: 22-82 years) and 78% were female gender. There were 43 (63%) subjects who completed an MRCP or CT-scan of the abdomen. Fifty-three (78%) subjects completed an endoscopic ultrasound. Precancerous cyst(s) were found in 16% of subjects; 50% were newly diagnosed. Chronic pancreatitis was found in 65% of subjects; 32% were newly diagnosed.

Conclusion: We demonstrate that in a moderate/high-risk population for PDAC, the rate of detecting precancerous findings is acceptable and greater than expected. While it is too early to determine the current impact of a successful screening protocol for PDAC on survival, we believe early diagnosis will lead to earlier treatment and subsequent improvement in patient outcomes.

 

82.10 Pre-Surgical Imiquimod Cream Reduces Extent of Moh’s Surgery on Basal Cell Carcinoma of Head and Neck

Posted on January 26, 2017

H. Foong1, N. Shaikh1, H. Liang1, D. Yakoub1  1University Of Miami,Division Of Surgical Oncology At Department Of Surgery,Miami, FL, USA

Introduction: Extent of surgery for BCC in the face continues to be a cosmetic challenge. Moh’s micrographic surgery is successful in reducing that extent with equal oncologic results. We aimed to evaluate the role of pre-surgical 5% Imiquimod cream application in reducing defect size. 

Methods: Online database search of PubMed, MEDLINE, EMBASE, SCOPUS, COCHRANE, and GOOGLE SCHOLAR was performed; key bibliographies were reviewed. Studies comparing patients using preoperative 5% Imiquimod followed by surgery to those who had surgery alone were analyzed. The primary end point was defect size at surgery for similar sized tumors. Relative risk with the corresponding 95% confidence intervals (CI) were calculated by random effect models of pooled data. Study quality was assessed using STROBE criteria. 

Results:27 Articles were identified, amongst those, 3 studies met our selection criteria. Mean BCC size was 92.42mm2. Most common histologic type was nodular. Average lesion size was 227.8mm2. Meta-analysis of included data showed that application of 5% Imiquimod cream one time daily, 5 days/week for 4 weeks significantly reduced the defect size of the Moh’s micrographic surgery resection with a combined mean difference of -80.37 mm2 (95% CI: -106.67, -54.08, P<0.001). A regimen of similar frequency for 6 weeks showed similar trend compared to 4 weeks, yet did not achieve statistical significance with an additional mean difference of -10.24 mm2 (95% CI: -31.68, 11.20, P=0.35).

Conclusion:5% Imiquimod cream application in BCC of the face, using a regimen of 4 weeks may reduce the defect size of the Moh’s micrographic surgery.

 

82.09 Malignant Phyllodes Tumors of the Breast in Minorities

Posted on January 26, 2017

A. S. Moten1, A. J. Goldberg1,2  1Temple University Hospital,Department Of Surgery,Philadelpha, PA, USA 2Temple University School Of Medicine,Philadelpha, PA, USA

Introduction:  It has been reported that the characteristics of malignant phyllodes tumors among minorities differs from those of whites.

Methods:  The Surveillance Epidemiology and End Results (SEER) Database was used to assess tumor characteristics, treatment and outcomes of minorities with malignant phyllodes tumors diagnosed between 2004 and 2012, and to compare them to whites.

Results: Blacks with malignant phyllodes were significantly more likely to be younger, have nodal metastasis and more extensive tumors than their white counterparts.  Furthermore, although partial mastectomy was the predominant surgery type, blacks and other minorities were more likely to undergo modified radical mastectomy than their white counterparts (16% versus 14% versus 9.1%, respectively; p-value 0.01).  However, after adjusting for age, stage, number of lymph nodes examined, number of positive lymph nodes identified and surgery type, survival was no worse for blacks (HR: 0.98; 95% CI: 0.42 – 2.30) or other minorities (HR: 0.54; 95% CI: 0.24 – 1.24) compared to whites.  Furthermore, when comparing patients who had lymph nodes examined to those whom did not have nodes examined, there was no significant increased risk of death in whites (HR: 1.69; 95% CI: 0.91 – 3.13) or minorities (HR: 0.93; 95% CI: 0.25 – 3.49).

Conclusion: Although minorities have more extensive disease with an increased likelihood of nodal metastasis, there appears to be no added survival benefit to performing nodal sampling or dissection, and such practice should cease.

 

82.08 Outcomes of Oncologic Resection and Subsequent Reconstruction of Major Defects

Posted on January 26, 2017

K. P. Walsh1, G. Grimberg1, A. J. Scholer1, L. J. Lynch1, J. D. Keith2, R. J. Chokshi1  1New Jersey Medical School,Surgical Oncology, Department Of Surgery,Newark, NJ, USA 2New Jersey Medical School,Department Of Plastic Surgery,Newark, NJ, USA

Introduction:  Oncologic resections are often difficult to perform due to the size of defect remaining and exposure of vital structures after resection. At our institution, challenging oncology-related resections are routinely carried out in collaboration, with resection by surgical oncology and reconstruction by plastic surgery. We have previously performed an institutional review demonstrating that radical oncologic resection and subsequent reconstruction of large defects can be safely and effectively performed using this multidisciplinary approach. The aim of the second arm of this study is to identify specific variables in the resection and reconstruction that affect patient outcomes.

 

Methods:  We conducted a retrospective review of 95 adult patients who underwent both an operative resection by a surgical oncologist and subsequent reconstruction by plastic surgery at our institution over a four-year period from 2012 to 2015. Patient demographics were characterized, and an analysis of both the oncologic resection and reconstructive operations was performed. Complications were identified, and the statistical significance of differences in observed outcomes was evaluated using a chi-squared test for categorical data and t-test for continuous data.

 

Results: Extensive oncology-related resections of the trunk, extremities and head/neck were successfully performed in a group of 95 patients.  Major defects (>225 cm2) were encountered in 38.9 % of patients, with a mean size of 240 cm2 (range 3 – 1,125 cm2). A complication was identified in 52.6% of patients, which is similar to the rate of 50% found in the literature for similar operations. As defect size increased, complications were more frequently encountered (p = 0.016). The technique used for reconstruction was also associated with a significant difference in complications (p = 0.017). A complication was observed in 14.3% of adjacent tissue transfers, 40% of skin grafts, 50% of primary/complex closures, 63.6% of free flaps and 64.3% of pedicled flaps. Wound infection (15.8%) and wound dehiscence (9.5%) were the most frequently observed complications. Age, BMI, medical co-morbidity, history of smoking, presence of malignancy, type of insurance, site of surgical resection and tumor pathology were not shown to have a significant impact on the complication rate.

 

Conclusion: This study illustrates that larger defect size after oncologic resection and subsequent reconstruction has a significant increase in morbidity. While defect size represents the main factor influencing the complication rate in these patients, the type of reconstruction performed has a similar impact, with free flaps and pedicled flaps resulting in more complications than adjacent tissue transfers or skin grafts. Major defects continue to be safely and effectively reconstructed after radical oncologic resections at our institution using a multidisciplinary approach, with complication rates similar to those found in comparable studies.

82.07 Subcutaneous Fat Mass Is Independently Associated With Survival In Women With Ovarian Cystadenocarcinoma

Posted on January 26, 2017

J. K. Kays1, A. Desai1, R. Chauhan1, L. G. Koniaris1, T. A. Zimmers1  1Indiana University School Of Medicine,Surgery,Indianapolis, IN, USA

Introduction:  Cachexia, characterized by progressive loss of body fat and muscle mass, is associated with decreased response to therapy, decreased quality of life, and decreased overall survival in malignancy. This study evaluated the associations between body composition and survival in women with ovarian serous cystadenocarcinoma (OSC).

Methods:  The Cancer Imaging Archive was queried for patients with OSC. Demographic, clinical, and survival data along with abdominal computed tomography (CT) scans for 140 patients were acquired. Skeletal muscle and compartmental fat areas were measured and were divided into quartiles. Differences in survival versus tissue quartiles and clinical/demographic data were evaluated by univariate and multivariate analysis.

Results: Overall median survival was 8.0 years. Differences were significant across quartiles of mean skeletal muscle (SKM), visceral adipose tissue (VAT), subcutaneous adipose tissue (SCAT), total adipose tissue (TAT) area quartiles (p<0.001, p<0.001, p<0.001, and p<0.001 respectively). Univariate analysis revealed that the highest quartiles for VAT and SCAT were associated with significant survival advantage when compared to the lowest quartiles (p=0.04 and p=0.005, respectively). Disease stage was also associated with survival (p=0.04). Multivariate analysis showed the lowest SCAT quartile was independently associated with worse overall survival (p=0.023). 

Conclusion: Low subcutaneous adipose tissue is associated with worse overall survival in women with ovarian serous cystadenocarcinoma. This might be due preferential wasting of subcutaneous fat in women with OSC, and blocking this fat wasting may improve outcomes. Further studies need to be undertaken to validate these results and comprehend mechanisms.

 

82.06 Patient-Level Differences Between Individuals With Stage IV Colon and Stage IV Rectal Cancer

Posted on January 26, 2017

E. H. Wood1, A. N. Kothari1, P. C. Kuo1, J. Eberhardt1, T. Saclarides1, D. Hayden1  1Loyola University Medical Center,Surgery,Maywood, ILLINOIS, USA

Introduction:
Metastatic colon cancer and metastatic rectal cancer are pathophysiologically distinct and affect different patient populations. Our aim is to describe patient-level characteristics that may vary between the two diseases.

Methods:
Healthcare Cost and Utilization Project State Inpatient Database from 2006-2011 for Florida was queried using ICD-9 and ICD-9-CM codes to identify adult patients admitted with metastatic colon and metastatic rectal cancer. Descriptive statistics were obtained examining patient demographics as well as details of each hospital admission.

Results:
13,916 patients with metastatic rectal cancer were admitted a total of 27,235 times during our study period (average 1.96 admissions per patient). 45,611 patients with metastatic colon cancer were admitted 67,057 times (average 1.47 admissions per patient). Admissions were more likely to be elective in patients with metastatic rectal cancer (46.3% vs. 38.5%, p<0.001). Average length of stay for all hospitalizations was 7.7 and was similar between both rectal cancer and colon cancer groups, 7.5 and 7.8 days respectively. Rate of inpatient mortality was higher in patients with stage IV colon cancer (4.4% vs. 3.2%, p<0.001). Stage IV rectal cancer patients were younger (66.4 vs 70.8, p<0.001), and more likely to be male (56.8% vs. 50.4%, p<0.001). Rectal cancer patients were more likely to be white (75.5% vs 73.9%, p<0.001) while colon cancer patients were more likely to be black (11.1% vs. 9.0%, p<0.001). Colon cancer patients were more likely to be from the lowest income quartile (28.8% vs. 27.5%, p<0.001) and more likely to use Medicare as their primary payer while rectal cancer patients were more likely to have Medicaid or private insurance. 48.3% of patients with colon cancer underwent surgery while only 27.4% of patients with rectal cancer underwent surgery in the same period. LOS after surgery in patients with colon cancer was greater than for patients with rectal cancer (9.7 vs. 8.8 days, p<0.001). Mortality during the admission for surgery was higher in patients with colon cancer (2.65% vs. 1.48%, p<0.001).

Conclusion:
Patients with metastatic rectal cancer tend to be younger, white, male patients from wealthier socioeconomic areas who are more likely to have elective admissions for their diseases. They are less likely to undergo operative intervention during their hospitalization, and their admissions carry a lower risk of mortality. These results begin to show that metastatic colon and rectal cancers affect distinct patient populations that may have access to different care delivery resources that ultimately impact their overall survival. 
 

82.05 A Comparison of Specialty-based Surgical Approaches and Attitudes to Adrenalectomy

Posted on January 26, 2017

S. C. Oltmann3, D. M. Elfenbein2, R. S. Sippel4, H. Chen1, J. L. Rabaglia3, A. P. Dackiw3, F. E. Nwariaku3, S. A. Holt3, D. F. Schneider4  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA 2University Of California – Irvine,Surgery,Orange, CA, USA 3University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 4University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:
Adrenalectomy is an infrequent surgical procedure performed by multiple specialties, with multiple technical approaches. The hypothesis of this study is surgical approaches and contraindications are consistent regardless of surgical specialty.

Methods:
Members of the American Association of Endocrine Surgeons (AAES) and of the Endourological Society (EUS) were surveyed using an internet based questionnaire, regarding current practice and attitudes toward adrenalectomy.

Results:

109 AAES members and 146 EUS members completed the survey. AAES performed more adrenalectomies annually, and reported familiarity with a greater number of adrenalectomy techniques (Table). EUS used the robot more frequently, and considered themselves high volume laparoscopic surgeons more often.

Laparoscopic transabdominal adrenalectomy was the top preferred approach for both. AAES preferred retroperitoneoscopic more, and robotic transabdominal approach less.

Contra-indications for transabdominal laparoscopic adrenalectomy varied. AAES was more likely to view known adrenal malignancy(69% vs. 10%, p<0.01), and suspected malignancy(43% vs. 9%, p<0.01) as contraindications, and less likely to view a hostile abdomen(39% vs. 58%, p<0.01) or co-morbidities(4% vs. 18%, p<0.01) as contraindications. Tumor size(45% vs. 52%), and location(35% vs. 27%) were equally considered.

For retroperitoneoscopy, known adrenal malignancy(89% vs. 16%, p<0.01), suspected adrenal malignancy(66% vs. 10%, p<0.01) and BMI(36% vs. 15%, p<0.01) were more often considered a contraindication by AAES. Tumor size(76% vs. 71%), and location(35% vs. 43%) were equally viewed. 

Conclusion:
Both surgical specialties perform adrenalectomy with frequency. Attitudes regarding contraindication to a minimally invasive approach vary greatly between AAES and EUS members, most notably regarding malignancy. 

82.04 Use of Axillary Lymph Node Dissection (ALND) in Patients with Micrometastatic Breast Cancer

Posted on January 26, 2017

M. L. Collins2, C. O’Donoghue1, W. Sun1, C. Laronga1, J. Zhou1, Z. Ma1, M. C. Lee1  1Moffitt Cancer Center,Tampa, FL, USA 2Morsani College Of Medicine,Tampa, FL, USA

Introduction: Sentinel lymph node (SLN) biopsy is the current prognostic tool for clinically node negative breast cancer patients. If the SLN reveals macrometastasis, axillary node dissection (ALND) is recommended.  However, the use of ALND in patients with micrometastasis is debated.  The objective of this study was to assess the utilization of ALND in the treatment of micrometastatic breast cancer.

Methods:   An IRB approved, single-institution, retrospective study of a pooled dataset of breast cancer patients with micrometastatic disease on SLN biopsy pathology for incident, invasive breast cancer was performed.  Patients diagnosed from 1999 – 2016 were identified via query of a single-institution NCCN breast cancer database as well as a prospective tumor board.  Data collected included diagnostic and pathologic variables, surgery type, adjuvant treatment, recurrence, and outcomes.  Neoadjuvant therapy cases were excluded.  Demographics were summarized using descriptive statistics. Wilcoxon rank-sum and Kruskal-Wallis Test Fisher exact test were used.

Results:  A total of 91 patients were diagnosed with micrometastatic nodal disease.  7 cases were ER/PR negative, and 5 cases were ER/PR, Her2Neu negative. 50/91 (54.9%) patients had an MRI preoperatively, and 34/91 (37.4%) patients had a preoperative axillary ultrasound; one patient was diagnosed by axillary FNA.  The median age at diagnosis was 56 years (range 31-85); median follow up time was 47 months (range 0-203 months).  The median number of resected SLN was 2 (range 1-8); 81/91 (89.1%) patients had intra operative touch prep of the nodes.  On final pathology, 86/91 (94.5%) patients had 1 positive node, and 5/91 (5.49%) patients had 2 positive nodes.  43/91(47.3%) patients had ALND of which 36/43 (83.7%) were a second operation; 3/43 patients had additional positive nodes found at ALND.  7/91 (7.7%) patients had a recurrence, 5/7 local, including 1 axillary (patient declined ALND).   44/91 (48.4%) patients received radiation; 28/44 (63.6%) whole breast radiation, 16/44 (36.4%) chest wall radiation, and 20/44 (45.5%) also had directed nodal radiation.

Conclusion:  Given that the risk of lymphedema after ALND ranges between 20-53%, the morbidity of ALND may far exceed the likelihood of detecting further nodal involvement in women with micrometastatic disease: 7% in this series.  However, considering our small and highly selected single institution database, the decision to abandon ALND in patients with a micrometastatic SLNB needs further validation.

 

82.03 Nutritional Outcomes Following HIPEC

Posted on January 26, 2017

S. Aronson1, A. M. Blakely1, T. J. Miner1  1Brown University School Of Medicine,Department Of Surgery,Providence, RI, USA

Introduction: The combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been associated with improved overall survival in patients with certain advanced peritoneal surface malignancies. Given often extensive debulking paired with intraperitoneal chemotherapy, nutritional recovery may be impaired postoperatively.

Methods: Retrospective review of a prospectively-maintained HIPEC database was performed. Patient demographics, primary tumor diagnosis, preoperative lab work (C-reactive protein [CRP]), intraoperative factors (extent of surgery score [ESS]), and patient outcomes (return to oral intake, utilization of parenteral nutrition [PN], complications, length of stay [LOS], and overall-survival) were measured.

Results: Seventy-four patients underwent 83 CRS/HIPEC operations (10 for recurrence) between March 1, 2008 to April 30, 2015. Primary tumor diagnoses included 39 pseudomyxoma peritonei, 14 colorectal, 5 mesothelioma, 5 ovarian, and 11 other. PN was delivered following 17 operations (20.5%); 3 patients required PN at discharge (2.4%). BMI was available for 75 operations; 31 were normal weight (BMI <25), 44 were overweight (BMI ≥25). PN administration was not associated with preoperative BMI (BMI ≥25: 24.4% vs. BMI <25: 29.2%; p=0.75), intra-abdominal complications (35.3% vs. 18.8%; p=0.15), overall complications (64.7% vs. 43.8%; p=0.12), or 30-day mortality (0% vs. 10.3%; p=0.10). BMI ≥25 was not associated with increased risk of complications (42.9% vs. 51.6%; p=0.46) but was associated with increased overall survival (median 1082 vs. 861 days; p=0.064) compared to BMI <25. ESS score of 3 was associated with delay to oral intake (median 7 vs. 4 days; p=0.0001), more PN utilization (29.1% vs. 3.8%; p=0.005), increased complications (60.0% vs. 24.0%; p=0.006), greater 30-day mortality (24.0% vs. 0%; p<0.0001), and decreased overall survival (median 959 vs. 1096 days; p=0.037) compared to ESS of 1-2. Patients who underwent bowel resection as part of tumor debulking had no difference in return to oral intake (both median 7 days, p=0.84), PN utilization (20.8% vs. 20.7%, p=0.78), or complications (46.3% vs. 48.3%; p=0.86) versus those who did not undergo bowel resection. Patients with elevated preoperative CRP had no difference in return to oral intake (both median 7 days; p=0.78) or PN utilization (58.3% vs 41.5%; p=0.30) compared to those with normal CRP.

Conclusions: Cytoreductive surgery and HIPEC places patients at risk of postoperative ileus and delay to resumption of oral intake. While performance of bowel resection itself did not further increase delay to oral intake, greater extent of surgery was associated with slower return of bowel function. Postoperative parenteral nutrition, was utilized in a minority of patients, with only three requiring home temporary PN. The combination of CRS and HIPEC was not associated with impaired long-term nutritional recovery.

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