86.03 Non-radiographic Severity Measurement of Pectus Excavatum

Posted on January 18, 2018

D. P. Bliss1, N. M. Vaughan2, R. A. Walk3, J. A. Naiditch4, A. A. Kane5, R. R. Hallac6  1Childrens Hospital Colorado/University Of Colorado School Of Medicine,Division Of Pediatric Surgery/Department Of Surgery,Colorado Springs, CO, USA 2Baylor University Medical Center At Dallas,Dallas, TX, USA 3Brooke Army Medical Center/US Army Medical Corps,San Antonio, TX, USA 4Dell Children’s Medical Center Of Central Texas,Austin, TX, USA 5UT Southwestern Medical Center,Division Of Plastic Surgery,Dallas, TX, USA 6Children’s Medical Center Dallas,Dallas, TX, USA

Introduction:
In order to avoid the radiation exposure of CT imaging and the expense of either CT or MRI studies, we sought to develop a non-radiographic severity measurement of pectus excavatum.  3D photographic imaging of patients with chest wall deformities provided the non-radiographic data collection for this evaluation.

Methods:
Over a twenty-eight month period, ten consecutive patient volunteers with pectus excavatum underwent 3D stereo-photogrammetric imaging of the torso.  The 3D photographic surface images were manipulated in cross section and then evaluated by three separate examiners. Body measurements such as surface lengths, surface areas, and volumes were collected for each patient by each examiner on three separate occasions. The surface width to surface depth ratio was calculated for each patient (Surface Lengths Pectus Index), using averaged measurements obtained across the maximal pectus excavatum defect (see Figure).  Likewise, the chest deformity’s surface area to total chest surface area (Pectus Surface Area Ratio) and the chest deformity’s volume to total chest volume (Pectus Volume Ratio) were calculated. Simple linear regression analysis was used to compare the Surface Lengths Pectus Index, Pectus Surface Area Ratio, and Pectus Volume Ratio calculations each to the corresponding known CT Pectus Index values.

Results:
For the pectus excavatum patients imaged (n=10), simple linear regression analysis of the CT Pectus Index versus Surface Lengths Pectus Index (see Figure) yielded a coefficient of determination (R squared) of 0.7637 and a p value of 0.0013.  A CT
Pectus Index equal to or greater than 3.4 was measured in eight patients.  A CT Pectus Index of 3.4 or greater corresponded to a Surface Lengths Pectus Index of 1.86 or greater, measured in six of these eight patients.  In contrast, the CT Pectus Index versus Pectus Surface Area Ratio yielded a coefficient of determination (R squared) of 0.4627 and a p value of 0.0305 and the CT Pectus Index versus the Pectus Volume Ratio yielded a coefficient of determination (R squared) of 0.3048 and a p value of 0.0990.

Conclusion:
The use of Surface Lengths Pectus Index corresponds to the CT Pectus Index in this study cohort.  Importantly, manipulation of photographic surface measurements is analogous to physical exam.  The use of a chest radiograph and physical exam measurements alone to calculate a Surface Lengths Pectus Index may be adequate to determine severity of pectus excavatum in some patients and thereby improve safety and cost effectiveness in the preoperative evaluation of patients with pectus excavatum.

 

86.01 Metabolic abnormalities are not different in morbid (BMI>35) and Super obese (BMI>50) Adolescents.

Posted on January 18, 2018

B. Farber1, S. Burjonrappa1  1Montefiore Medical Center,Pediatric Surgery,Bronx, NY, USA

Purpose:

Obesity rates have been increasing in adolescents (14-21 years) over the past 30 years, and bariatric surgery has been increasingly used to facilitate weight loss and optimize health in this age group. We reviewed preoperative nutritional parameters in these patients to identify nutritional deficiencies that will need to be carefully addressed in the pre and post operative phases.

Methods:  

We retrospectively reviewed the records of adolescent patients who had undergone evaluation for bariatric surgery at our institution between 2016 and 2017. Variables assessed included age, gender, preoperative body mass index (BMI), nutritional parameters, lipid profiles and iron studies. Continuous variables were evaluated using a student’s t test and categorical variables were evaluated with chi square analysis.

Results:

Thirty-nine patients with morbid obesity underwent evaluation for bariatric surgery during the study period. Twenty-two were female (56%) and 17 were male (44%). Median age was 18 years (range 14-21 years). Patients with BMI over 50 (super obese) were more likely to be male gender (p<0.05). In the overall study population more than 60% had Iron deficiency, 20% had dyslipidemias, 25% had anemia, and 100% had Vitamin D deficiency. Levels of other B vitamins were normal for most of the study population. No statistical difference in incidence of nutritional and metabolic abnormalities was noted between morbidly obese and super obese adolescents(Table 1).  

 

Conclusions: 

Preoperative nutritional parameters and metabolic profiles do not differ amongst morbidly obese and super obese adolescent bariatric patients.

 

85.19 Male Breast Cancer: A Review of One Tertiary Center Hospital Experience

Posted on January 18, 2018

A. Alhefdhi1,2, M. Almarghoub1, B. Aladrees1, S. AlSani1, O. Almalik1,2, A. Alhefdhi1,2  1King Faisal Specialist Hospital & Research Center,General Surgery/Breast And Endocrine Surgery,Riyadh, RIYADH, Saudi Arabia 2Alfaisal University,General Surgery/Breast And Endocrine Surgery,Riyadh, RIYADH, Saudi Arabia

Introduction:  Breast cancer is a rare malignant tumor in males. This study aimed to investigate the clinicopathological characteristics of those patients in Saudi population.

Methods:  A 15-year retrospective review conducted, including all males diagnosed with breast cancer at a single institution.

Results: Forty-six cases were identified with a mean age of 58±13 years. The majorities were Saudi 40(87%), married 43(93.5%), and live in the central region of the Saudi Arabia 28(61%). Fifty-three (93.5%) cases presented with a palpable mass, and 2(4.4%) cases presented with nipple discharge. The majority has IDC 45(97.8%). ER was positive in 43(93.5%) patients, PR was positive in 37(80.4%) patients, and Her-2 was positive in 4(8.7%) patients. Regarding the tumor stage; 27(58.9%) had T4, 12(26%) had T2, 4(8.6%) had T1, and 3(6.5%) had T3. Moreover, 33(71.7%) had intermediate grades, 8(17.4%) had high grades, and 5(10.9%) had low grades. On presentation 16(34.8%) cases presented with distant metastases, which were mainly to bone and lung in 7(15.2%) cases. Forty-four (95.6%) received hormonal-therapy, 22(47.8%) received chemotherapy, and 19(41.3%) radiotherapy. Thirty-eight (82.6%) patients underwent surgical intervention; among them 31(67.4%) were therapeutic and 7(15.2%) were palliative. Twenty-nine (63%) patients underwent modified radical mastectomy, 8(17.4%) underwent simple mastectomy with SLNB, and 1(2.2%) patient underwent lumpectomy and axillary lymph node dissection. The local recurrence rate was 2.6% with a mean follow-up of 45±32 months. 

Conclusion: Based on our data; in our population the majority of males with breast cancer have IDC with positive estrogen receptors, and they usually present late.

 

85.20 COMPARISON OF MASTECTOMY USING ULTRASONIC DISSECTING VERSUS ELECTRO-SURGICAL DEVICE IN CA BREAST

Posted on January 18, 2018

S. Gogna1, J. Con1  1New York Medical College,General Surgery,Valhalla, NY, USA

Introduction: The Ultrasonic Dissecting Device (USD) is based on the principles of piezo-electric crystals. In this study we compared the post-operative outcomes of patients undergoing Modified Radical Mastectomy (MRM) for breast cancer with USD and Electrosurgical Device (ESD).

Methods: All patients of breast cancer who underwent MRM between January 2016 and November 2016 were recruited into the study. The patients were matched and randomly divided into USD and ESD group on basis of instruments to be used. A total of 70 patients were inducted in the study with  35 patients in  each group.

Results:There was longer operative time with ESD. Lymph Node harvest with USD was higher. There was significantly lower blood loss, post-op drainage, seroma volume and hospital stay with USD.

Conclusion:
USD is associated with lower post-operative drainage and duration compared to ESD. There is a small learning curve, following which the duration of surgery is equivalent but the intra-op blood loss is lower and a cleaner operative field can be achieved. The post-op stay is reduced with decreased drainage and seroma formation and adequate LN Harvest. USD do not use electric current for cutting hence the nerves in the vicinity are not stimulated and there is lack of feedback (muscle twitching and contraction). This may lead to inadvertent nerve injury in cases with anatomic anomalies. . The use of USD is safe without any significant complications.
 

85.18 Colorectal Cancer in Patients with Type 2 Diabetes Mellitus: Patterns in Molecular Profiling

Posted on January 18, 2018

F. Lambreton1, W. Ward1, J. Purchla1, N. Nweze1, N. Goel1, S. Reddy1, E. Sigurdson1, J. Farma1  1Fox Chase Cancer Center,Department Of Surgical Oncology,Philadelphia, PA, USA

Introduction: Type 2 Diabetes mellitus (DM2) is a known risk factor for the development of colorectal cancer (CRC). Although evidence suggests that patients with both CRC and DM2 have a worse prognosis, an exact pathologic mechanism has not been elucidated. Our aim was to define mutation patterns in CRC patients with DM2.

Methods: Patients who underwent molecular profiling (MP) while receiving treatment for CRC at Fox Chase Cancer Center between 2006 and 2017 were retrospectively reviewed. Patients who were tested with our in-house targeted cancer panel, Caris or Foundation One were also included. The samples were obtained from primary tumors or metastases. Relevant clinical and pathological data were also recorded.

Results: A total of 57 patients diagnosed with CRC and DM2 were identified who underwent MP. Mean age was 66 years (range=45-86). Fourteen (24.5%) patients were stage III and 19 (33.3%) were stage IV. Of these patients, 27 (47.3%) had a mutation. Mutations in P53 and APC genes were present in 10 (37%) patients each. KRAS mutation was present in 8 (29.6%) patients, while BRAF was abnormal in 2 (7.4%) patients. Other mutations found include PIK3CA in 3 (11.1%) cases, SMAD4 in 2 (7.4%), PTEN in 1 (3.7%),  and STK11 in 1 (3.7%) patient. Eleven (40.7%) patients displayed microsatellite instability (MSI).  The mean number of mutations per patient was 2.0 (range= 1-5). Mean overall survival for the whole cohort was 16 months.

Conclusion: Mutation rates in the genes studied in our cohort approach those previously reported by other authors in patients with CRC but without DM2. This suggests that mutation status might not be a contributing factor into the poorer prognosis observed in this cohort. Further, larger studies are needed to confirm these results.

85.16 Pregnancy and melanoma: what are the relationships?

Posted on January 18, 2018

J. A. DiSano1, E. W. Schaefer1, K. Kjerulff1, C. S. HollenbeaK1, C. R. Pameijer1  1Penn State Hershey Medical Center,Hershey, PA, USA

Introduction:  Melanoma is the third most common cancer in women 18-39 years old. Few studies have examined pregnancy after melanoma. Our aims were to investigate the pregnancy rate after melanoma diagnosis and the relationship between melanoma treatment and subsequent pregnancy.

Methods:  We studied women with a melanoma diagnosis in the Truven Health MarketScan database. Women were matched 1:1 to women with no melanoma diagnosis to compare pregnancy rates between groups. For women with melanoma, Cox models were fitted for rates of pregnancy overall, pregnancy if post-surgical treatment was received, and for treatment after pregnancy. The primary outcome was rates of pregnancy within two years of melanoma diagnosis. The secondary outcomes were rates of pregnancy in the setting of more advanced melanoma, and the impact of pregnancy on rates of additional treatment for melanoma.

Results: The sample included 12,674 women aged 18-40 years with melanoma. These women had a higher rate of pregnancy within 2 years compared to matched controls (19.6% vs 18.0%, p<0.001). For 0-9 months after diagnosis, women who received post-surgical treatment for their melanoma had a 74% lower hazard of becoming pregnant (HR=0.26, P=0.003). Rates of treatment received after pregnancy were not significantly different (HR=0.68, P=0.23).

Conclusion: Our study represents the largest population-based study of women with melanoma and the incidence of post-melanoma pregnancy in the United States to date. Women with melanoma were more likely to become pregnant than matched controls, but had a lower rate of pregnancy if they received post-surgical treatment. Recurrence rates were low in this time period, and no higher for women who became pregnant after their melanoma diagnosis.

 

85.17 Patterns of Medical Management in Patients with Gastric Adenocarcinoma

Posted on January 18, 2018

S. Willis1,5, D. Maurente1,4, A. Ardeljan1,3, A. Johns1, M. Bustos1,3, S. Sennhauser1,2, M. Ghali1,2, L. Ramsaran1,2, Z. Segota1,2, L. Siegel1,2, D. Drew1,2, G. Azzi1,2, D. Dammrich1,2, O. M. Rashid1,2  1Holy Cross Hospital,Michael And Dianne Bienes Comprehensive Cancer Center,Fort Lauderdale, FL, USA 2Massachusetts General Hospital,Cancer Center,Boston, MA, USA 3University Of Miami Miller School Of Medicine,Miami, FL, USA 4Charles E. Schmidt College Of Medicine At Florida Atlantic University,Boca Raton, FL, USA 5Nova Southeastern University College Of Osteopathic Medicine,Ft. Lauderdale, FL, USA

Introduction: Gastric malignancies, of which 90% are pathologically gastric adenocarcinomas, typically present at an advanced stage. Current standard of care involves a combination of chemotherapeutics, radiation therapy, antibody therapy, and surgical resection. This study reviews patient outcomes following various treatment modalities.

Methods: Data mining techniques were used to analyze the Medicare patient database from 2005-2013 for total charges, Charleston Comorbidity index (CCI), length of stay (LOS), and readmission rates at 30 days, 90 days, and 1 year for all different modalities of treatment.

Results: Statistically significant differences in charges between surgery only ($127,075), chemotherapy only ($135,969), and combination surgery with chemotherapy ($127,613) were found (P < 0.001, 95% confidence interval, or CI). CCI analysis between surgery only vs. chemotherapy only, surgery only vs. surgery with chemotherapy, and chemotherapy only versus surgery with chemotherapy was statistically significant (P < 0.001, 95% CI). Length of stay analysis was statistically significant between comparison groups (P < 0.001, 95% CI). Average lengths of stay were 14.95 days for surgery only, 16.49 days for chemotherapy only, and 13.63 for combination therapy. Readmission rates for Surgery only at 30 day, 90 day, and 1 year were 3.7%, 18.2%, and 32.0 % respectively.  Combination therapy had readmission rates of 8.2%, 22.5%, and 40.7%, respectively. Chemotherapy only had readmission rates of 16.9%, 44.9%, and 59.1%, respectively.

Conclusion: Data analysis of the Medicare database demonstrated that patients treated with surgical resection only had the lowest CCI, readmission rates, and cost. Highest cost, CCI, LOS, and readmission rates were found for patients receiving chemotherapy only. Surgery may have had the lowest CCI and readmission costs, due to the fact that adenocarcinomas at earlier stages are more ideal for resection. Combination therapy may have pre-conditioned patients with chemotherapy and reduced tumor burden, resulting in a shorter hospital stay during resection.
 

85.14 A Pilot Study Investigating Upgrade Rate and Chemoprevention Use in High-Risk Breast Lesion Patients

Posted on January 18, 2018

R. A. Shuford1, J. Richman1, C. Parker1, R. B. Lancaster1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction:  Women with high-risk breast lesions (HRLs) frequently undergo excisional biopsies to evaluate for upgrade to invasive breast cancer (BC) or DCIS. Women with confirmed HRLs can reduce their risk of developing BC with chemoprevention (CP). This study sought to estimate how often, at a single institution, these HRLs are upgraded to DCIS or BC at the time of excisional biopsy and to estimate the frequency of chemoprevention use within this population of women with HRLs. Secondary aims included identifying factors associated with upgrade of lesions and chemoprevention use in HRL patients.

Methods:  After obtaining IRB approval, all patients who underwent breast core needle biopsy from January 2010 to June 2016 were identified. Data for patients with HRLs without history of, or concurrent DCIS, pleomorphic LCIS, or BC was extracted, including age, race, family history, menopausal status, parity, breast density, use of hormone replacement therapy, and palpable breast lesion. HRL type was classified using binary indicators for ADH, ALH or LCIS, allowing for multiple lesion types per person. Chi-square and t-tests were used to test bivariate associations.

Results: 101 biopsies were included. Patients’ mean age was 57, and they were 72% white and 23% black.  Overall, 64% had ADH, 25% had LCIS, and 29% had ALH. The overall upgrade rate was 16%, and did not differ significantly by age (upgrade mean age 56 vs. age 57, p=0.18), race (16% white, 22% black, p=0.90), family history (p=0.83), breast density (p=0.18), or menopausal status (p=0.79).

In bivariate analysis, the presence of ADH with or without other HRLs significantly increased the upgrade rate (23% upgrade rate with ADH vs. 6% without ADH, p=0.048). No significant effect on upgrade rate was observed with presence of ALH (10% vs. 19%, p=0.42) or LCIS (8% vs. 20%, p=0.29) with or without the presence of other HRLs.

Among patients without an upgrade, (n = 67), 28% used CP, and CP use did not significantly differ by age (p=0.62), race (black 31%, white 27%, p=0.39), or family history (p=1). A specific reason for declining CP was recorded in 54% of cases (n=48). 

Conclusion: Although findings were not statistically significant, likely due to the small sample size, interesting trends were observed. Black patients had a higher estimated upgrade rate. Consistent with other recent studies, our study also showed that a diagnosis of ALH or LCIS alone with the presence of radiographic concordance is associated with a low risk of upgrade to malignancy (6%), making routine surgical excision of these lesions a less favored practice. ADH, present alone or with other HRL, demonstrated the highest risk of upgrade. Future work should identify factors that predict ADH upgrade.

Although our institution has an active High-Risk Clinic, relatively few patients with a HRL initiated CP. Facilitators and barriers to CP treatment should be evaluated in a larger study leading to interventions that increase the use of CP.

85.15 Process Development and Implementation of an Enhanced Recovery Program after Radical Cystectomy

Posted on January 18, 2018

A. A. Henderson1, K. Staveley-O’Carroll2, E. Kimchi2, A. Dickinson3, K. Clements4, M. Wakefield1, K. Murray1  1University Of Missouri,Division Of Urology-Department Of Surgery,Columbia, MO, USA 2University Of Missouri,Division Of Surgical Oncology-Department Of Surgery,Columbia, MO, USA 3University Of Missouri,Department Of Health Management And Informatics, University Of Missouri,Columbia, MO, USA 4University Of Missouri,Center For Health Care Quality,Columbia, MO, USA

Introduction:  Historically, patients undergoing radical cystectomy (RC) for bladder cancer have long hospital stays often characterized by high complication and readmission rates. This presents a unique opportunity to improve quality and standardization in overall care. In this report we describe our hospital supported and surgery organized initiative to create an enhanced recovery protocol after RC and assess its effects on patient outcomes.

Methods:  A comprehensive plan was developed using a collaborative, multi-disciplinary approach utilizing hospital and departmental administration, urologists, anesthesiologists, nursing, pharmacy, nutrition, wound care, physical therapy, resident physicians, patient experience representatives, electronic medical record personnel, and Health Administrative fellows. A reporting system was organized to prospectively evaluate protocol outcome measures.   

Results: A project manager and advisor were identified from the Health Administration fellowship and Quality Improvement office of the University, respectively. Key stakeholders were invited to a standing meeting that occurs biweekly. Additional needs were identified, leading to a total invite list of 53 participants. To date, 14 meetings have occurred with an average of 26 participants attending each meeting. Ten leaders visited another tertiary referral center to learn about the implementation of enhanced recovery at the institution. New educational packets were devised in addition to an electronic order set pathway and hospital-wide uniformed education including a grand rounds showing leadership support. It took 6 months from idea inception to go-live with the first patient on protocol (Fig. 1). To this point, every patient undergoing RC is being placed on this enhanced recovery pathway.

Conclusion: RC is a costly procedure from the perspective of patients and hospital systems, which presents an opportunity for meaningful improvement. The production of a uniform service specific pathway requires collaboration, organization and dedication from many individuals. We plan to continue to assess our protocol adherence, patient outcomes and satisfaction, and make appropriate changes.   

 

85.11 The Impact of Emergency General Surgery on Survival in Patients with Metastatic Cancer

Posted on January 18, 2018

K. C. Lee1,2, E. Lilley1,3, D. Sturgeon1, E. Roeland4, G. N. Mody1,5, Z. Cooper1,6  1Brigham & Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2University Of California, San Diego,Department Of Surgery,San Diego, CA, USA 3Rutgers-Robert Wood Johnson Medical School,Department Of Surgery,Newark, NJ, USA 4University Of California, San Diego,Moores Cancer Center,La Jolla, CA, USA 5Brigham & Women’s Hospital,Division Of Thoracic Surgery, Department Of General Surgery,Boston, MA, USA 6Brigham & Women’s Hospital,Department Of Surgery,Boston, MA, USA

Introduction: Prior studies have reported 30-day mortality in Emergency General Surgery (EGS) patients with advanced cancer; however, a paucity of data exists on the impact of EGS on longer-term survival and healthcare utilization among these patients. Such information is critical for patient counseling and care planning. We hypothesized that older patients with metastatic cancer who underwent an EGS procedure would have worse survival and higher healthcare utilization in the year after surgery than matched patients without EGS.

Methods: This retrospective cohort study used Surveillance, Epidemiology, and End Results-Medicare data from 2001-2013.  Patients included were 65 years or older with Stage IV cancer (lung, colorectal, breast, ovarian, pancreatic, or skin) who had an emergent admission for one of seven EGS procedures (partial colectomy, small-bowel resection, cholecystectomy, peptic ulcer disease surgery, lysis of adhesions, appendectomy, and laparotomy). Patients were exact matched to a non-EGS patient by age, sex, race, cancer type, and time from cancer diagnosis to EGS admission. Multi-variable competing-risks and logistic regression models adjusted for region, comorbidity, and income were used to compare the following outcomes up to one year after EGS admission: 30, 90, and 365-day mortality and healthcare utilization (defined as hospitalization, emergency department (ED) visit, and intensive care unit (ICU) stay). Survival analysis was performed to compare overall survival over the study period between EGS and non-EGS patients.

Results: Among the 1,531 metastatic cancer patients who received EGS, in-hospital mortality was 16.5%. After multivariate adjustment, EGS patients were more likely to die within 30 days (hazard ratio (HR) [95% confidence interval (CI)]: 2.66 [2.03-3.49]), 90 days (2.19 [1.83-2.62]), and 365 days (1.34 [1.19-1.50]). EGS patients had a lower overall median survival after admission (120 v. 281 days, p<0.0001) and were more likely to die over the study period compared to non-EGS patients (1.22 [1.10-1.35]), Figure). EGS patients discharged alive were more likely to be hospitalized (odds ratio (OR)[CI]: 1.66 [1.42-1.95]) but not to have ED visits (1.02 [0.80-1.19]) or ICU stays (1.01 [0.83-1.22]).

Conclusion: Older patients with metastatic cancer who receive EGS have decreased overall survival compared to patients who do not receive EGS. The increased likelihood of dying peaked at 30 days but persists beyond the year after admission. EGS patients discharged alive are more likely to be hospitalized in the year after admission. These findings can inform prognostic estimates, deliberations for surgery, and care planning for older EGS patients with advanced cancer. 

85.12 Adrenal Oncocytoma: A Systematic Review

Posted on January 18, 2018

J. J. Kanitra2, J. C. Hardaway1, T. Soleimani1, N. Mehrabi2, M. K. McLeod1, S. Kavuturu1  1Michigan State University,Department Of Surgery,Lansing, MI, USA 2Michigan State University,Lansing, MI, USA

Introduction:
Adrenal Oncocytomas (AO) were first described in 1986 by Kawamoto et al. They are often incidentally identified and have previously been described as a benign, nonfunctional, female predominant tumor with an average age at diagnosis of 47. Although there are suggested immunohistochemical profiles, AO are diagnosed based on their characteristic histology. Since the literature is composed of predominately singular case reports, we took this opportunity to perform a systematic review to update the literature on AO by reviewing patient and tumor characteristics, and management trends.

Methods:

A comprehensive search was performed in PubMed, Embase, and Cochrane Library through June 15, 2017. Variables extracted included patient demographics (eg, age, sex), tumor characteristics (eg, adrenal laterality, hormonal functionality, size), management (eg, adrenalectomy + nephrectomy, open or laparoscopic, adjuvant therapy), immunohistochemical profiles, and follow-up (eg, time followed, recurrence, mortality). Malignant potential was determined by the Lin-Weiss-Bisceglia (LWB) criteria, regardless of the original authors diagnosis.

Using bivariate analysis, the patient demographics and tumor characteristics were compared between the benign, borderline, and malignant cases. 

Results:

The initial search algorithm retrieved 360 citations, of which 103 were included for analysis, which described a total of 170 cases of AO.  These were predominantly diagnosed in females (67%), on the left side (64%), and were nonfunctional (62%). The average age at diagnosis was 45 (2.5-81) and the median tumor size was 82 mm. The tumors stained positive for alpha-inhibin (68%), melanin-A (85%), synaptophysin (71%), vimentin (79%), mES-13 (100%), calretinin (67%), and neuron specific enolase (92%).

Of the reported AO, 38% were benign, 36% borderline and 26% diagnosed as malignant. Bivariate analysis showed that male patients were more likely to have a malignant tumor compared to females (39% vs 19%, p=0.016). There was also a statistically significant association between hormonal functionality and malignant potential (p=0.004; 44% of malignant tumors were functional, compared to 50% of benign tumors. There was no statistically significant association between malignant potential and laterality (p=0.594) or age (p=0.189). Also, there were no statistically significant associations between any immunohistochemical stain and malignant potential.

Conclusion:

In this systematic review of the literature, we found that the majority of the AO are either malignant or have a malignant potential. This finding is contrary to previous literature, which reported AO as a benign tumor. Distinguishing between benign and malignant adrenal oncocytomas has always been challenging. Since AO are a pathologic diagnosis, it is important to identify pre-operative characteristics suggestive of a malignant tumor. The follow up after an adrenalectomy should be determined based on the pathology results.

85.13 Comparing Different Preoperative Workflows in Surgical Oncology Clinics

Posted on January 18, 2018

A. S. Manjunathan1, S. Gupta1, S. S. Yang1, C. E. Kein1, A. A. Mazurek1, R. M. Reddy1  1University Of Michigan,Ann Arbor, MI, USA

Introduction:  Although many institutions have focused on improving patient-centered care, there has been little study on how preoperative clinic workflows affect patients. We hypothesized that a streamlined clinic workflow is associated with decreased burden of cost and time on patients in a surgical oncology clinic.

Methods:  A retrospective chart review was performed for all adult patients who underwent surgical treatment for esophageal cancer within a Thoracic Surgery clinic and pancreatic, liver, or biliary cancer within a Hepatopancreaticobiliary (HPB) clinic in a single tertiary care center in 2016. The clinics varied in preoperative visit and test scheduling practices, with the Thoracic clinic focused on minimizing patient visits prior to surgery. Data collected included the number of clinic visits, testing visits, and phone calls during the patient’s workup. Distance traveled to appointments, cost of travel, and total time burden were estimated. Visits, phone calls, travel costs, and time spent were compared using t-tests. 

Results: We compared 70 esophageal cancer and 60 HPB cancer patients, who were demographically similar in age (63.3 +/- 10.7 vs. 63.5 +/- 11.6, respectively; p=0.93).  Patients undergoing workup in the Thoracic Surgery clinic required significantly fewer preoperative appointments compared to patients in the HPB clinic (2.4 +/- 0.7 vs. 4.0 +/- 1.9, respectively; p<0.00001). 45 of 60 patients in the HPB cohort had an extra visit the day prior to surgery for lab work, whereas the Thoracic clinic incorporated this into the patient’s last clinic visit. There was no significant difference in the average number of phone calls received, which we used as an indicator of clinic resource utilization, in the Thoracic versus HPB clinic (7.4 +/- 4.9 vs. 6.4 +/- 6.2, respectively; p=0.31). The mean distance travelled in miles by patients in the Thoracic versus HPB clinic was not significantly different (105.9 +/- 109.2 vs. 93.5 +/- 59.3, respectively; p=0.44); however, the estimated total cost burden due to gas was significantly lower for Thoracic clinic patients than HPB clinic patients ($44.0 +/- 43.0 vs. $73.6 +/- 63.0, respectively; p=0.0029). There was also a significant reduction in time burden for patients in the Thoracic versus HPB clinic (11.3hrs +/- 6.7 vs. 18.5hrs +/- 11.7, respectively; p<0.00001).

Conclusion: This study demonstrated that with a streamlined preoperative workflow that consolidates necessary tests into fewer visits, one clinic has reduced cost and time burden to patients without a significant increase in clinic resource use. Furthermore, the true burden to patients is likely far greater, given potential lost wages and unnecessary stress. These findings should encourage all surgical clinics to evaluate their own preoperative workflow to identify areas in which care can be streamlined in an effort to improve patient-centered care.

85.09 Prognostic significance of the neutrophil-to-lymphocyte ratio in cutaneous melanoma

Posted on January 18, 2018

N. Paez Arango1, P. Philips1, C. R. Scoggins1, A. R. Quillo1, R. C. Martin1, K. M. McMasters1, M. E. Egger1  1University Of Louisville,Hiram C. Polk, Jr., MD Department Of Surgery,Louisville, KY, USA

Introduction:

An elevated neutrophil-to-lymphocyte ratio (NLR) has been reported to be a significant prognostic factor for several solid organ malignancies.  The significance of the NLR has not been well studied in cutaneous melanoma. In this study the value of the NLR as a predictor of lymph node metastasis and survival in cutaneous melanoma was assessed.

Methods:
A retrospective review of patients who underwent either a sentinel lymph node (SLN) biopsy or complete lymph node dissection (CLND) between 2002 to 2017 at a single academic referral center was performed.  The NLR was determined by reviewing preoperative complete blood counts drawn within 30 days prior to the procedure. Differences in the NLR according to SLN and non-SLN status were evaluated by Wilcoxon rank sum tests.  The predictive ability of NLR to determine SLN and non-SLN status was evaluated with NLR as continuous variable in logistic regression models and using cut points according to the NLR distribution.  Survival was compared using Kaplan-Meier survival curves and the log rank test.

Results:
In this study, 162 patients underwent sentinel lymph node (SLN) biopsy, and 46 (28.4%) had a positive SLN biopsy. The median NLR for the patients with negative SLN was 2.2 compared to 2.1 for those who had a positive SLN (P=0.6). There were 23 patients who underwent a CLND, and 8 (35%) had a positive non-SLN.   The median NLR for patients with a negative CLND (non-SLN negative) was 1.6 versus 2.6 for those with a positive non-SLN (p=0.6).  When measured as a continuous variable, NLR did not predict a positive SLN (odds ratio 1.08, 95% CI 0.93 – 1.26), nor did it predict a positive non-SLN in patients undergoing CLND (odds ratio 1.41, 95% CI 0.78 –  2.56).  Using a cutoff of 2, there was no significant difference in the rate of positive SLN for patients with a NLR <2 (27%) vs NLR >= 2 (30%, p = 0.68).  There was no significant difference in the rate of positive non-SLN for patients undergoing CLND with a NLR < 2 (25%) vs NLR >=2 (45%, p = 0.40).   There was no statistically significant difference in overall survival for patients undergoing SLN biopsy with NLR >= 2 compared to < 2 (Figure 1).

Conclusion:
In this study pre-procedure NLR does not predict SLN or non-SLN metastases in cutaneous melanoma.  NLR does not predict survival differences in patients staged with SLN biopsy for cutaneous melanoma. 

85.10 The Impact of Lymph Node Involvement on Survival in Stage II and III Esophageal Adenocarcinoma

Posted on January 18, 2018

S. Cresse1, O. Picado1, B. Azab1, D. Franceschi1, A. Livingstone1, D. Yakoub1  1University Of Miami Leonard M. Miller School Of Medicine,Division Of Surgical Oncology, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction:

Esophageal adenocarcinoma presents with high incidence of lymph node metastases even in early disease. We aimed to evaluate the impact of regional lymph node involvement on survival of locally advanced stage II and III esophageal adenocarcinoma.

Methods:  

The National Cancer Database (2004-2013) was used to identify patients with clinical stage II and III esophageal adenocarcinoma who had esophagectomy and regional lymphadenectomy. Patients with ≥15 lymph nodes sampled (as recommended by NCCN) were analyzed. The proportion of positive lymph nodes for metastatic disease was identified. The association between pathological N stage, positive/examined lymph node ratio and hazard of death was assessed using Kaplan-Meier method and Cox regression model.

Results: 

We identified 3123 with clinical stage II and III esophageal adenocarcinoma. Mean age was 61 years. M/F ratio was 9:1. Perioperative chemotherapy was administered to 2808 (90%) patients with or without radiation. Patients were distributed as follows, clinical T1, T2, T3 and T4 in 4%, 22%, 71%, and 1%, respectively. Clinical N0, N1, N2, and N3 were present in 33% 56%, 8%, and 1%, respectively. Upon histopathological examination of surgical specimens, 9% of cN0/cN1 were pathologically upstaged to pN1, pN2 and pN3, while 60% of cN2/cN3 were downstaged to pN0 and pN1. Median follow-up time was 39 months. Increasing pathological T stage was associated with worse overall survival. Analysis of pathological N stage showed a median overall survival of 60, 26, 24, and 20 months for N0, N1, N2 and N3, respectively. N0 had significantly better survival than N1-3 (p<0.001). Among N1, 2 and 3 there was no difference in survival. However, analysis of positive/examined lymph node ratio showed that overall survival significantly dropped when the positive/examined lymph node ratio was above 0.25 (18 months vs. 31 months, p<0.05).

Conclusion: 

Lymph node involvement is the major determinant of poor survival in stage II and III esophageal adenocarcinoma patients. Positive/examined lymph node ratio greater than 0.25 is associated with significantly worse survival.

85.08 Gastric Cancer: Experience with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Posted on January 18, 2018

C. U. Ihemelandu1, C. U. Ihemelandu1  1MedStar Washington Hospital Center,Surgical Oncology,Washington, DC, USA

Introduction: Most stage IV gastric cancer patients present with non-operable disease, and even in those with operable disease, rates of relapse are high and prognosis is poor. Our aim was to analyze the clinicopathologic characteristics, prognostic factors, and overall survival associated with stage IV gastric cancer

Methods: A retrospective analysis of a tumor registry for all patients treated for stage IV gastric cancer between 1991-2016 at a tertiary institution. 

Results:Of 231 patients there were 127(55.0%) males vs. 104(45.0%) females.  The mean age at diagnosis was 66 years. Seventy-eight (33.8%) patients presented with a signet ring vs. 153(66.2%) with an intestinal histology. Twenty-six (11.3%) patients were treated with CS and HIPEC vs. 64(27.7%) and 141(61%) respectively who were treated with surgery and systemic chemotherapy, and no surgical intervention. In univarate analysis signet ring tumors had a better overall median survival 5 vs. 3 months (p= 0.04). Amongst the cohort of patients treated with CS and HIPEC the median survival was 40 months for the signet ring histology vs. 8 months for the intestinal. Median survival time was 14 months for patients treated with CS and HIPEC vs. 6 and 2 months respectively for those treated with surgery and systemic chemotherapy or no surgery. One, 3 and 5 year survival was 51%, 38% and 29% respectively for patients treated with CS and HIPEC vs.39%, 16% and 9%, and 14%, 2% and 0% for surgery and no surgery. Significant predictors of an improved survival in multivariate analysis were a young age at diagnosis (p<0.000), treatment with CS and HIPEC (p<0.000). Gender, race, tumor pathology, use of radiation therapy and systemic chemotherapy did not achieve significant status.

Conclusion:Young age at diagnosis and use of CS and HIPEC are independent predictors for an improved overall survival in patients diagnosed with stage IV gastric cancer. Paradoxically signet ring pathology demonstrated an improved survival over an intestinal pathology when treated with CS and HIPEC.

 

85.06 Impact of Age on Surgically Resected Retroperitoneal Sarcoma at a High-Volume Tertiary Center

Posted on January 18, 2018

H. N. Overton1, F. Gani1, J. Singh1, A. Blair1, M. Umair3, C. Meyer2, F. M. Johnston1, N. Ahuja1  1Johns Hopkins University School Of Medicine,Division Of Surgical Oncology, Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Division Of Oncology, Department Of Medicine,Baltimore, MD, USA 3Saint Louis University School Of Medicine,Department Of Radiology,Saint Louis, MO, USA

Introduction:
Retroperitoneal sarcoma (RPS) is a rare tumor type that accounts for approximately 15% of soft tissue sarcomas. An expanding elderly population in the United States presents a need to understand associations between age and outcomes in primary or recurrent RPS. We investigated features of RPS in a cohort of surgical patients to determine if any differences exist along the spectrum of adult age.

Methods:
Patients undergoing surgery for RPS with curative intent at the Johns Hopkins Hospital between 1994 and 2015 were identified. Overall (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meir method. Univariable and multivariable Cox proportional hazards regression analysis was performed to identify factors associated with worse OS and DFS.

Results:
A total of 223 patients were identified who met inclusion criteria. The median age at time of index surgery was 61 years (IQR: 51-68) with 57.5% (n=106) of patients being female. Among all patients, 168 patients (75.3%) presented with primary RPS while 55 (24.6%) presented with recurrent disease. Pathology was 48.9% (n=109) liposarcoma, 34.5% (n=77) leiomyosarcoma, and 16.6% (n=37) other. Median tumor size was 12cm (IQR: 7-20). High grade tumors were most common at 48.8% (n=105) compared to 28.8% (n=62) grade 1 and 22.3% (n=48) grade 2. Complete resection (R0/R1) was achieved in 86.8% (n=191) of patients. Administration of chemotherapy was significantly different among age groups (39.4% <45years, 25.5% 45-64 years, 13.7% 65-79years, 0.00% ≥ 80 years, p=0.007) as was likelihood of an incomplete (R2) resection (21.2% <45years, 6.6% 45-64 years, 16.9% 65-79years, 30.0% ≥ 80 years, p=0.027). Postoperatively, 61.3%  (n=119) developed a tumor recurrence; 54.6% (n=65) developed local disease while 38.6% (n=46) developed distant disease and 6.7 % (n=8) developed local and distant disease. The median OS and DFS were 67.5 months (IQR: 27.4-130.6) and 17.8 months (IQR 6.4 -47.4), respectively. On multivariable analysis, increasing patient age was associated with a shorter OS (Hazard Ratio [HR] = 1.02, 95% CI:1.00-1.04, p=0.046) but was not associated with DFS (HR= 1.001, 95% CI:0.98-1.02, p=.879). Of note, other risk factors associated with poor OS were high grade tumor (G1/G2 vs G3) (HR = 2.83, 95% CI:1.47-5.44, p=0.002) and postoperative recurrence (HR= 6.11, 95% CI: 2.92-12.79, p<0.001, Figure 1).

Conclusion:
Increasing age at time of index operation for primary or recurrent RPS, high grade tumor and post-operative recurrence correlates with decreased OS. Further study is needed to understand the characteristics and interactions of pathology, multiple recurrences and aggressive surgical and medical therapy on different age categories of patients with RPS.
 

85.07 Can It Wait? – Delayed Operative Intervention for Small Gastric GIST

Posted on January 18, 2018

Z. E. Stiles1, P. V. Dickson1, M. G. Martin2, E. S. Glazer1, S. W. Behrman1, J. L. Deneve1  1University Of Tennessee Health Science Center,Department Of Surgery,Memphis, TN, USA 2West Cancer Center,Memphis, TN, USA

Introduction:
Potentially curative therapy for gastrointestinal stromal tumors (GISTs) involves surgical resection.  Recently, it has been suggested that there is a subgroup of patients with small (≤ 2 cm) gastric GISTs that may undergo regular endoscopic surveillance in lieu of surgical resection given their likely indolent nature.  The purpose of this study was to examine the pathologic and known prognostic features of tumors within this subgroup and to compare outcomes among patients undergoing resection at different time points.

Methods:
A retrospective review of the 2004 – 2014 National Cancer Database was performed. Patients with tumors ≤ 2 cm were compared to those with larger tumors with regard to clinical and pathologic features.  Among tumors ≤ 2 cm, short and long term outcomes were then evaluated for patients undergoing surgical resection at different time periods: early (0 – 90 days), and late (> 90 days).

Results:
Patients with tumors ≤ 2 cm (n = 1732) were more often younger (median age 65 vs 66, p < 0.001), female (59.2% vs 49.8%, p < 0.001) and Caucasian (72.7% vs 68.2%, p = 0.001) compared to those with tumors > 2 cm (n = 10518).  A smaller proportion of tumors ≤ 2 cm were found to be high grade (2.4% vs 11.0%, p < 0.001) and small tumors were less likely to be associated with distant metastases (2.5% vs 10.3%, p < 0.001).  Among patients with tumors ≤ 2 cm, no significant differences were seen with regard to margin status, LOS, unplanned readmission, 30-day, or 90-day mortality based on the timing of surgical resection (all p > 0.4).  Overall survival (OS) was favorable for all patients with tumors ≤ 2 cm as the median OS was not reached (NR) (mean 116.9 months). No difference in OS was observed based on the time from diagnosis to surgical resection (mean OS 117.8 months [95% CI 112.6 – 122.9] vs. 107.5 months [95% CI 84.4 – 130.6], log rank p = 0.804).

Conclusion:
In this large database, patients with small gastric GIST exhibited overall favorable findings compared to larger tumors.  Delayed resection (> 90 days) was not associated with a negative impact on short term outcomes or overall survival for small gastric GIST.  Prospective evaluation of a protocol involving longitudinal surveillance of small gastric GISTs is warranted.
 

85.04 Functional Status in Patients Requiring Skilled Care in a Nursing Home after Radical Cystectomy

Posted on January 18, 2018

A. A. Henderson1, M. Prunty2, T. Haden1, G. Petroski3, B. Ge3, N. Pokala1, M. Wakefield1, R. Kruse4, D. Mehr4, K. Murray1, K. Murray1  1University Of Missouri,Department Of Surgery-Division Of Urology,Columbia, MO, USA 2University Of Missouri,School Of Medicine,Columbia, MO, USA 3University Of Missouri,Office Of Medical Research,Columbia, MO, USA 4University Of Missouri,Family And Community Medicine,Columbia, MO, USA

Introduction: Radical cystectomy (RC) is the standard of care for muscle-invasive bladder cancer. This is a major surgery that can impair patients’ ability to perform activities of daily living (ADLs) and lead to admission to a nursing home (NH) post-operatively. The goal of this study is to evaluate changes in functional status and ADLs in patients who required NH care both pre- and postoperatively following RC.

Methods:  Medicare inpatient claims were linked with NH assessment data to identify patients undergoing RC who required a nursing home stay at hospital discharge. The Minimum Data Set (MDS)-ADL Long Form score (0−28; higher equals greater functional impairment) is based on seven activities of daily living (ADLs). MDS scores were compared pre- and post-operatively for patients who were initially residing in NH prior to RC and scores were evaluated postoperatively for patients who were initially living independently but went to NH after RC. Paired t-test was used for comparison between groups and multiple regression modeling was used to evaluate additional variables. 

Results: The dataset identified 471 patients that underwent RC and had at least one completed MDS−ADL assessment. Within this group, 245 patients lived at home prior to RC but were admitted to a NH after RC; 122 patients lived at a NH prior to RC and returned to the NH post-operatively. Mean age was 80.8±5.4 years. Most patients were Caucasian (92%) and male (71%). The median length of hospitalization after RC was 12 days.

Of the 245 patients who lived at home before RC, 84% of patients were discharged directly to a NH and 16% were discharged to another location before NH admission. There was no statistical difference in MDS−ADL score if patients went directly to NH upon leaving the hospital or to another location prior to NH (score 16 vs 15.2, p=0.39). Baseline MDS-ADL scores are not available for patients living independently prior to RC. 

Among the patients who lived in a NH both before and after RC, the mean pre- and post-operative MDS-ADL scores were significantly different (score 12.1 and 16.6, p<0.0001).

Conclusion: RC leads to significant decline in functional status as measured by ADLs.  The score of ADLs upon NH admission was high, representing an overall low functional status. The utilization of ADLs prior to and throughout hospitalization after RC may be beneficial in determining need for post-operative care and assistance.  

85.05 Does Oncoplastic Surgery Offer Low Positive Margin Rate Using New SSO/ASBrS/ASTRO Margin Guidelines?

Posted on January 18, 2018

M. Jonczyk1, K. Patel1, R. Graham1, S. Naber1, L. Chen1, A. Chatterjee1  1Tufts Medical Center,Surgery,Boston, MA, USA

Introduction:
Large volume displacement oncoplastic surgery (LVOS) is a technique that uses reconstructive mastopexy and breast reduction techniques to allow for larger oncologic resections while providing good aesthetic outcomes in a single operation. To date, however, no study has used the most recent the Society of Surgical Oncology, American Society of Breast Surgeons, American Society for Radiation Oncology (SSO/ASBrS/ASTRO) surgical margin recommendations to assess oncoplastic surgery. Recent guidelines established no ink on tumor as an adequate margin for invasive breast cancer and at least 2mm as adequate margins for ductal carcinoma in situ. The purpose of this study was to investigate the surgical margin rates of LVOS using the new guidelines. We presumed that under the stricter guidelines, LVOS would have a higher positive margin rate than reported in the past literature.

Methods:
First, a literature review to assess margin rates before the introduction of SSO/ASBrS/ASTRO guidelines was done using PRISMA guidelines with an international Pubmed search and reviewed by two blinded authors. The search included keywords such as “oncoplastic breast surgery,” “lumpectomy,” “partial mastectomy,” and “positive margins associated with breast surgery.” All articles either pertained to LVOS, standard lumpectomy (SL) or both. The inclusion criteria for our study included histology discrepancy, and new guideline margin status. From this, we determined the published positive margin for SL and LVOS.  Second, we analyzed all LVOS performed at our institution since the adoption of the new margin guidelines and compared these margin rates to the literature review outcomes.

Results:
Our study consisted of 1702 patients. There were 847 patients in LVOS group and 855 patients in the SL group. 34 of 45 papers evaluated were not included due to exclusion criteria (missing: new margin guidelines, histology, or margin status). The pre-guideline positive margin rate for LVOS was lower than with SL (12.51% vs. 20.4%, P-value <0.001). Of the 50 LVOS operations done at our institution since adoption of the margin guidelines, no statistical difference in the positive margin rates was noted when compared to the literature rates (10% vs. 12.67% respectively, P-value 0.5796). Positive margin rates for LVOS at our institution were lower than SL margin rates reported in the literature (P-value 0.0358).

Conclusion:
This study demonstrates that even with the stricter margin guidelines, LVOS still has a low positive margin rate comparable to pre-guideline literature reports. LVOS continues to have a significantly lower positive margin rate than SL.  This is the first study to report margin rates for LVOS after the adoption of the SSO/ASBrS/ASTRO guidelines, and confirms the importance of LVOS in providing optimal oncologic outcomes for patient with large locally advanced breast cancer.

85.01 Pancreatic Adenosquamous Carcinoma with Worse Clinicial Outcome Compared to Pancreatic Adenocarcinoma

Posted on January 18, 2018

C. A. Hester1, M. R. Porembka1, M. A. Choti1, P. M. Polanco1,2, J. C. Mansour1, R. M. Minter1, S. C. Wang1, A. C. Yopp1  1University Of Texas Southwestern Medical Center,Surgical Oncology,Dallas, TX, USA 2Department Of Veterans Affairs North Texas Health Care System,Surgical Oncology,Dallas, TX, USA

Introduction:
Pancreatic adenosquamous carcinoma (PASC) is a histopathologic diagnosis distinct from pancreatic adenocarcinoma (PAC), characterized by ≥ 30% malignant keratinized squamous cell histology admixed with ductal adenocarcinoma.  A paucity of data regarding the natural history of PASC and clinicopathological variables associated with outcome has limited value in individual patient counseling and therapeutic decision-making, especially in comparison to the more prevalent PAC histology. The aims of this study are to characterize the clinicopathological variables of PASC associated with outcome and compare these variables with PAC in surgically resected patients.

Methods:
We conducted a retrospective analysis of the prospectively collected National Cancer Database participant user file between 2004 and 2012. All patients with ICD-O-3 morphological codes corresponding to PASC and PAC were included for analysis. Patients with missing vital status data or in situ disease were excluded.  Demographics, tumor characteristics, treatment regimens, and outcomes were abstracted. Differences between the groups were determined with Fisher’s exact and Chi-squared tests. Survival was estimated and compared using Kaplan-Meier and log-rank. Multivariate analysis was performed to determine variables associated with overall survival.

Results:
Of the 207,073 patients meeting the inclusion/exclusion criteria, 205,328 PAC and 1,745 PASC histologies were identified. There was no significant difference in age, race/ethnicity and insurance status between patients with PAC and PASC. PASC patients have tumors that are significantly larger (56% vs 33% with tumors ≥ 4 cm, p<0.001), more likely to originate in the pancreatic body and tail (36% vs 24%, p<0.001), undifferentiated histology (41% vs 17%, p<0.001), higher rate of positive lymph nodes (22% vs 15%, p<0.001), and presention at AJCC stage I/II (39% vs 32%, p<0.001). Patients with stage I and II PASC are more likely to undergo curative-intent surgery compared to PAC (75% vs 54%, p<0.001) and have lower rates of lymph node involvement within surgical specimens (29% vs 39%, p<0.001).  There is no significant difference in overall survival when comparing all patients with PAC and PASC (6.2 months and 5.7 months, p=0.601). However, patients with PASC undergoing curative-intent surgery have significantly worse outcome (median survival 12.9 months vs 19.1 months, p<0.001).  In patients with PASC, increased Charlson comorbidity score, positive lymph node status, AJCC stage III/IV, and lack of receipt of treatment (surgical, chemotherapy, and/or radiotherapy) were associated with worse overall survival.

Conclusion:

Although curative-intent surgery is more often performed in PASC patients, PAC histology is more favorable with regards to overall survival. Despite relative infavorable biology, receipt of therapy is associated with improved survival in patients with early and late stage PASC.
 

« Previous Page
Next Page »