Neil Osterweil

ORLANDO – Intensive follow-up of patients who have undergone surgery for hepatocellular carcinoma reduces deaths from tumor recurrence and metastases, Dr. Timothy M. Pawlik said at a symposium sponsored by the Society of Surgical Oncology.

Data from surveillance programs for hepatocellular carcinoma (HCC) and empiric data from centers treating colorectal liver metastases (CRLM) suggest that HCC tends to recur locally, and that recurrent HCC and CRLM, if caught early, can be successfully controlled with a variety of therapeutic options, said Dr. Pawlik, associate professor of surgery and oncology, and hepatobiliary surgery program director at Johns Hopkins Medical Center, Baltimore.

"I would favor high-intensity surveillance for patients with hepatocellular carcinoma. This argument is based on level 1 data showing that high-intensity primary surveillance decreases mortality for patients who have cirrhosis," he said.

Although there is a high HCC recurrence rate following surgery, most recurrences will be contained within the liver, and may be successfully treated with salvage transplantation, ablation, or intra-arterial therapy.

"But if we miss that opportunity and patients recur with advanced disease, all those options are off the table, and their prognosis is abysmal," Dr. Pawlik said.

According to National Cancer Institute data, liver cancer holds the dubious distinction of being the fastest growing cancer in terms of death rate in the United States, outpacing lung cancer in women, esophageal cancer, and thyroid cancer.

Risk factors for HCC include cirrhosis from any cause (hepatitis B and C viruses, alcoholism, nonalcoholic fatty liver disease), hepatitis B primary infection (with or without cirrhosis), and inherited metabolic diseases such as hemochromatosis, alpha-1 antitrypsin deficiency, glycogen storage disease, or tyrosinemia.

"Most patients who have HCC don’t simply have a cancer; they also have significant underlying cirrhosis, so when thinking about the approach to HCC, we have to be thinking about all of the tumor-specific factors such as tumor size, location, and number, and we also have to be thinking about all of the liver-specific factors," Dr. Pawlik said.

Surgical treatment options include resection for HCCs of all sizes; transplantation, for single lesions 5 cm or smaller, or up to three lesions of 3 cm or less or advanced cirrhosis; and ablation for small lesions or inoperable or unresectable tumors as a bridge to transplant.

In various series, overall 5-year survival following resection ranges from 42% to 62%, and following transplantation from 57% to 75%.

But as Dr. Pawlik and colleagues noted in a 2008 study, disease-free survival following resection for HCC is only half of the percentage after transplantation (40% vs. 82%, P less than .01). (J. Gastrointest. Surg. 2008;12:1699-1708).

Intrahepatic recurrence is most frequent among patients with hepatitis C infection, but also occurs with hepatitis B and C coinfection, and hepatitis B alone. A subset of patients who have undergone transplantation (about 20%) will also have recurrence, Dr. Pawlik said.

National Comprehensive Cancer Network guidelines for follow-up of patients with HCC after resection or transplantation include imaging every 3-6 months for 2 years, then every 6-12 months thereafter, and testing of alpha-fetoprotein (AFP) level, if initially elevated, on the same schedule, he noted.

For example, a trial that included 18,816 hepatitis B carriers in China randomized to either intensive surveillance with AFP level and twice-yearly ultrasound versus no screening showed that the intensive surveillance was associated with a significantly lower rate ratio for mortality compared with no screening (RR 0.63) (J. Cancer Res. Clin. Oncol. 2004;130:417-22).

Similar evidence has been found to support intensive follow-up for colorectal cancers, for which there is effective therapy for recurrent disease, Dr. Pawlik noted.

Unlike pancreatic cancer or melanoma, where recurrences tend to be distant metastases, hepatocellular carcinoma is more frequently locally recurrent. It was found that 64%-80% of patients with cirrhosis had an intrahepatic recurrence within 5 years of HCC resection.

In one study, investigators found that 60%-70% of tumors recurred within 2 years, and 30%-40% of patients with recurrences had de novo tumors (J. Hepatol. 2003;38:200-7).

"For patients who have hepatocellular carcinoma, there are two reasons to [monitor] these patients closely. One is that they may truly have recurrence, and two is that a subset of these patients will develop new de novo disease in the cirrhotic liver," Dr. Pawlik said.

Treatment options for late recurrences are very limited and not very effective, he added. Sorafenib (Nexavar) is approved for unresectable HCC, but in the phase III SHARP trial was associated with an improvement in median overall survival of only 2.8 months vs. placebo (P = .00058) (N. Engl. J. Med. 2008;359:378-90).

In contrast, early recurrences generally respond to repeat resection, salvage transplantation, radiofrequency ablation, or transarterial chemoembolization, Dr. Pawlik noted.

Dr. Pawlik said he has no relevant disclosures.

ORLANDO – Intensive follow-up of patients who have undergone surgery for hepatocellular carcinoma reduces deaths from tumor recurrence and metastases, Dr. Timothy M. Pawlik said at a symposium sponsored by the Society of Surgical Oncology.

Data from surveillance programs for hepatocellular carcinoma (HCC) and empiric data from centers treating colorectal liver metastases (CRLM) suggest that HCC tends to recur locally, and that recurrent HCC and CRLM, if caught early, can be successfully controlled with a variety of therapeutic options, said Dr. Pawlik, associate professor of surgery and oncology, and hepatobiliary surgery program director at Johns Hopkins Medical Center, Baltimore.

"I would favor high-intensity surveillance for patients with hepatocellular carcinoma. This argument is based on level 1 data showing that high-intensity primary surveillance decreases mortality for patients who have cirrhosis," he said.

Although there is a high HCC recurrence rate following surgery, most recurrences will be contained within the liver, and may be successfully treated with salvage transplantation, ablation, or intra-arterial therapy.

"But if we miss that opportunity and patients recur with advanced disease, all those options are off the table, and their prognosis is abysmal," Dr. Pawlik said.

According to National Cancer Institute data, liver cancer holds the dubious distinction of being the fastest growing cancer in terms of death rate in the United States, outpacing lung cancer in women, esophageal cancer, and thyroid cancer.

Risk factors for HCC include cirrhosis from any cause (hepatitis B and C viruses, alcoholism, nonalcoholic fatty liver disease), hepatitis B primary infection (with or without cirrhosis), and inherited metabolic diseases such as hemochromatosis, alpha-1 antitrypsin deficiency, glycogen storage disease, or tyrosinemia.

"Most patients who have HCC don’t simply have a cancer; they also have significant underlying cirrhosis, so when thinking about the approach to HCC, we have to be thinking about all of the tumor-specific factors such as tumor size, location, and number, and we also have to be thinking about all of the liver-specific factors," Dr. Pawlik said.

Surgical treatment options include resection for HCCs of all sizes; transplantation, for single lesions 5 cm or smaller, or up to three lesions of 3 cm or less or advanced cirrhosis; and ablation for small lesions or inoperable or unresectable tumors as a bridge to transplant.

In various series, overall 5-year survival following resection ranges from 42% to 62%, and following transplantation from 57% to 75%.

But as Dr. Pawlik and colleagues noted in a 2008 study, disease-free survival following resection for HCC is only half of the percentage after transplantation (40% vs. 82%, P less than .01). (J. Gastrointest. Surg. 2008;12:1699-1708).

Intrahepatic recurrence is most frequent among patients with hepatitis C infection, but also occurs with hepatitis B and C coinfection, and hepatitis B alone. A subset of patients who have undergone transplantation (about 20%) will also have recurrence, Dr. Pawlik said.

National Comprehensive Cancer Network guidelines for follow-up of patients with HCC after resection or transplantation include imaging every 3-6 months for 2 years, then every 6-12 months thereafter, and testing of alpha-fetoprotein (AFP) level, if initially elevated, on the same schedule, he noted.

For example, a trial that included 18,816 hepatitis B carriers in China randomized to either intensive surveillance with AFP level and twice-yearly ultrasound versus no screening showed that the intensive surveillance was associated with a significantly lower rate ratio for mortality compared with no screening (RR 0.63) (J. Cancer Res. Clin. Oncol. 2004;130:417-22).

Similar evidence has been found to support intensive follow-up for colorectal cancers, for which there is effective therapy for recurrent disease, Dr. Pawlik noted.

Unlike pancreatic cancer or melanoma, where recurrences tend to be distant metastases, hepatocellular carcinoma is more frequently locally recurrent. It was found that 64%-80% of patients with cirrhosis had an intrahepatic recurrence within 5 years of HCC resection.

In one study, investigators found that 60%-70% of tumors recurred within 2 years, and 30%-40% of patients with recurrences had de novo tumors (J. Hepatol. 2003;38:200-7).

"For patients who have hepatocellular carcinoma, there are two reasons to [monitor] these patients closely. One is that they may truly have recurrence, and two is that a subset of these patients will develop new de novo disease in the cirrhotic liver," Dr. Pawlik said.

Treatment options for late recurrences are very limited and not very effective, he added. Sorafenib (Nexavar) is approved for unresectable HCC, but in the phase III SHARP trial was associated with an improvement in median overall survival of only 2.8 months vs. placebo (P = .00058) (N. Engl. J. Med. 2008;359:378-90).

In contrast, early recurrences generally respond to repeat resection, salvage transplantation, radiofrequency ablation, or transarterial chemoembolization, Dr. Pawlik noted.

Dr. Pawlik said he has no relevant disclosures.

ORLANDO – Intensive follow-up of patients who have undergone surgery for hepatocellular carcinoma reduces deaths from tumor recurrence and metastases, Dr. Timothy M. Pawlik said at a symposium sponsored by the Society of Surgical Oncology.

Data from surveillance programs for hepatocellular carcinoma (HCC) and empiric data from centers treating colorectal liver metastases (CRLM) suggest that HCC tends to recur locally, and that recurrent HCC and CRLM, if caught early, can be successfully controlled with a variety of therapeutic options, said Dr. Pawlik, associate professor of surgery and oncology, and hepatobiliary surgery program director at Johns Hopkins Medical Center, Baltimore.

"I would favor high-intensity surveillance for patients with hepatocellular carcinoma. This argument is based on level 1 data showing that high-intensity primary surveillance decreases mortality for patients who have cirrhosis," he said.

Although there is a high HCC recurrence rate following surgery, most recurrences will be contained within the liver, and may be successfully treated with salvage transplantation, ablation, or intra-arterial therapy.

"But if we miss that opportunity and patients recur with advanced disease, all those options are off the table, and their prognosis is abysmal," Dr. Pawlik said.

According to National Cancer Institute data, liver cancer holds the dubious distinction of being the fastest growing cancer in terms of death rate in the United States, outpacing lung cancer in women, esophageal cancer, and thyroid cancer.

Risk factors for HCC include cirrhosis from any cause (hepatitis B and C viruses, alcoholism, nonalcoholic fatty liver disease), hepatitis B primary infection (with or without cirrhosis), and inherited metabolic diseases such as hemochromatosis, alpha-1 antitrypsin deficiency, glycogen storage disease, or tyrosinemia.

"Most patients who have HCC don’t simply have a cancer; they also have significant underlying cirrhosis, so when thinking about the approach to HCC, we have to be thinking about all of the tumor-specific factors such as tumor size, location, and number, and we also have to be thinking about all of the liver-specific factors," Dr. Pawlik said.

Surgical treatment options include resection for HCCs of all sizes; transplantation, for single lesions 5 cm or smaller, or up to three lesions of 3 cm or less or advanced cirrhosis; and ablation for small lesions or inoperable or unresectable tumors as a bridge to transplant.

In various series, overall 5-year survival following resection ranges from 42% to 62%, and following transplantation from 57% to 75%.

But as Dr. Pawlik and colleagues noted in a 2008 study, disease-free survival following resection for HCC is only half of the percentage after transplantation (40% vs. 82%, P less than .01). (J. Gastrointest. Surg. 2008;12:1699-1708).

Intrahepatic recurrence is most frequent among patients with hepatitis C infection, but also occurs with hepatitis B and C coinfection, and hepatitis B alone. A subset of patients who have undergone transplantation (about 20%) will also have recurrence, Dr. Pawlik said.

National Comprehensive Cancer Network guidelines for follow-up of patients with HCC after resection or transplantation include imaging every 3-6 months for 2 years, then every 6-12 months thereafter, and testing of alpha-fetoprotein (AFP) level, if initially elevated, on the same schedule, he noted.

For example, a trial that included 18,816 hepatitis B carriers in China randomized to either intensive surveillance with AFP level and twice-yearly ultrasound versus no screening showed that the intensive surveillance was associated with a significantly lower rate ratio for mortality compared with no screening (RR 0.63) (J. Cancer Res. Clin. Oncol. 2004;130:417-22).

Similar evidence has been found to support intensive follow-up for colorectal cancers, for which there is effective therapy for recurrent disease, Dr. Pawlik noted.

Unlike pancreatic cancer or melanoma, where recurrences tend to be distant metastases, hepatocellular carcinoma is more frequently locally recurrent. It was found that 64%-80% of patients with cirrhosis had an intrahepatic recurrence within 5 years of HCC resection.

In one study, investigators found that 60%-70% of tumors recurred within 2 years, and 30%-40% of patients with recurrences had de novo tumors (J. Hepatol. 2003;38:200-7).

"For patients who have hepatocellular carcinoma, there are two reasons to [monitor] these patients closely. One is that they may truly have recurrence, and two is that a subset of these patients will develop new de novo disease in the cirrhotic liver," Dr. Pawlik said.

Treatment options for late recurrences are very limited and not very effective, he added. Sorafenib (Nexavar) is approved for unresectable HCC, but in the phase III SHARP trial was associated with an improvement in median overall survival of only 2.8 months vs. placebo (P = .00058) (N. Engl. J. Med. 2008;359:378-90).

In contrast, early recurrences generally respond to repeat resection, salvage transplantation, radiofrequency ablation, or transarterial chemoembolization, Dr. Pawlik noted.

Dr. Pawlik said he has no relevant disclosures.

ORLANDO – Surgery for ductal carcinoma in situ, with or without adjuvant therapy, saves lives, asserted a breast cancer surgeon at a symposium sponsored by the Society of Surgical Oncology.

Following a surgical biopsy alone, about half of all cases of low-grade ductal carcinoma in situ (DCIS) will progress to invasive cancer within an average of 10-15 years, said Dr. Kimberly J. Van Zee, a surgical oncologist at Memorial Sloan-Kettering Cancer Center in New York.

Additionally, without intervention, low-grade DCIS will result in death from ipsilateral invasive recurrence of breast cancer in about 18% of patients, Dr. Van Zee said.

"With treatment of DCIS, whether it’s breast conservation or mastectomy, with or without radiation, breast cancer–specific survival is over 95%," she noted.

The incidence of DCIS has increased steadily since 1975, when the rate was slightly more than 5 in 100,000 women. In 2009, the rate had reached approximately 36 in 100,000, according to Surveillance, Epidemiology, and End Results (SEER) data. The increase is probably a result of the growing adoption of screening mammography over the same period, Dr. Van Zee commented.

Treatment trends for DCIS showed a gradual but steady decline in mastectomy – from 70% in 1983 to about 28% in 1999 – and a corresponding increase in breast-conserving treatment, which increased from about 25% to 68% over the same period.

Beginning around 2005, however, there was evidence that the trend was reversing, with upticks in both mastectomy for unilateral breast cancer (J. Clin. Oncol. 2010;28:3437-41) and contralateral prophylactic mastectomy, both among women with invasive cancers and DCIS (Ann. Surg. Oncol. 2010;17:2554-62). The trends paralleled the rise in screening mammography in the United States and elsewhere in the world.

The gradual but steady decline in breast cancer deaths that began in the early 1990s appears to be attributable to a combination of increased screening mammography and improvements in adjuvant therapy, Dr. Van Zee noted, citing a 2005 study (N. Engl. J. Med. 2005;353:1784-92).

"They dissected all the various effects of treatment, incidence of screening-detected diseases, etc., and all their analyses concluded that about half of the reduction in death rate was due to screening and the other half was due to adjuvant therapy. So I think this is good circumstantial evidence that screening, with its resultant increased incidence in DCIS and the resulting increased treatment of DCIS, does result in a lower death rate from breast cancer," she said.

Further evidence comes from studies in which pathologists reviewed thousands of slides of biopsy-acquired breast tissue originally reported as benign. In each study (Cancer 1980;46[4 Suppl]:919-25; Cancer 2005;103:2481-84), the investigator identified about 30 samples with evidence of low-grade, relatively low-volume DCIS that was not recognized or treated. After 20-30 years of follow-up, half of the women had developed a clinically apparent ipsilateral breast cancer recurrence. The majority of tumors were invasive. In the second study, the authors noted that 5 of the 28 women (18%) with previously undetected DCIS died of breast cancer.

Evidence from a meta-analysis (Cancer 1999;85:616-28) suggests that the risk for invasive recurrence following a mastectomy for DCIS is 1.1%, and that the risk for breast cancer death is less than 1.1%.

The risk for distant recurrence and/or death from breast-conserving surgery with or without adjuvant radiotherapy in prospective randomized trials of radiotherapy for DCIS was less than 5%. Among patients with invasive local failure in those trials, however, 18%-25% developed metastatic disease, indicating the importance of avoiding local recurrence.

Mastectomy and breast-conserving surgery combined with radiotherapy and/or endocrine therapy all provide excellent disease-specific and overall survival results, Dr. Van Zee said.

"The goal should be avoiding local recurrence and, in particular, invasive recurrence, minimizing morbidity, and perhaps individualizing the treatment to the disease. One could consider age, comorbidities, [and] life expectancy, and weigh those against the morbidity of the treatment and the risk of local recurrence," she said.

Dr. Van Zee reported no relevant financial disclosures.

ORLANDO – Surgery for ductal carcinoma in situ, with or without adjuvant therapy, saves lives, asserted a breast cancer surgeon at a symposium sponsored by the Society of Surgical Oncology.

Following a surgical biopsy alone, about half of all cases of low-grade ductal carcinoma in situ (DCIS) will progress to invasive cancer within an average of 10-15 years, said Dr. Kimberly J. Van Zee, a surgical oncologist at Memorial Sloan-Kettering Cancer Center in New York.

Additionally, without intervention, low-grade DCIS will result in death from ipsilateral invasive recurrence of breast cancer in about 18% of patients, Dr. Van Zee said.

"With treatment of DCIS, whether it’s breast conservation or mastectomy, with or without radiation, breast cancer–specific survival is over 95%," she noted.

The incidence of DCIS has increased steadily since 1975, when the rate was slightly more than 5 in 100,000 women. In 2009, the rate had reached approximately 36 in 100,000, according to Surveillance, Epidemiology, and End Results (SEER) data. The increase is probably a result of the growing adoption of screening mammography over the same period, Dr. Van Zee commented.

Treatment trends for DCIS showed a gradual but steady decline in mastectomy – from 70% in 1983 to about 28% in 1999 – and a corresponding increase in breast-conserving treatment, which increased from about 25% to 68% over the same period.

Beginning around 2005, however, there was evidence that the trend was reversing, with upticks in both mastectomy for unilateral breast cancer (J. Clin. Oncol. 2010;28:3437-41) and contralateral prophylactic mastectomy, both among women with invasive cancers and DCIS (Ann. Surg. Oncol. 2010;17:2554-62). The trends paralleled the rise in screening mammography in the United States and elsewhere in the world.

The gradual but steady decline in breast cancer deaths that began in the early 1990s appears to be attributable to a combination of increased screening mammography and improvements in adjuvant therapy, Dr. Van Zee noted, citing a 2005 study (N. Engl. J. Med. 2005;353:1784-92).

"They dissected all the various effects of treatment, incidence of screening-detected diseases, etc., and all their analyses concluded that about half of the reduction in death rate was due to screening and the other half was due to adjuvant therapy. So I think this is good circumstantial evidence that screening, with its resultant increased incidence in DCIS and the resulting increased treatment of DCIS, does result in a lower death rate from breast cancer," she said.

Further evidence comes from studies in which pathologists reviewed thousands of slides of biopsy-acquired breast tissue originally reported as benign. In each study (Cancer 1980;46[4 Suppl]:919-25; Cancer 2005;103:2481-84), the investigator identified about 30 samples with evidence of low-grade, relatively low-volume DCIS that was not recognized or treated. After 20-30 years of follow-up, half of the women had developed a clinically apparent ipsilateral breast cancer recurrence. The majority of tumors were invasive. In the second study, the authors noted that 5 of the 28 women (18%) with previously undetected DCIS died of breast cancer.

Evidence from a meta-analysis (Cancer 1999;85:616-28) suggests that the risk for invasive recurrence following a mastectomy for DCIS is 1.1%, and that the risk for breast cancer death is less than 1.1%.

The risk for distant recurrence and/or death from breast-conserving surgery with or without adjuvant radiotherapy in prospective randomized trials of radiotherapy for DCIS was less than 5%. Among patients with invasive local failure in those trials, however, 18%-25% developed metastatic disease, indicating the importance of avoiding local recurrence.

Mastectomy and breast-conserving surgery combined with radiotherapy and/or endocrine therapy all provide excellent disease-specific and overall survival results, Dr. Van Zee said.

"The goal should be avoiding local recurrence and, in particular, invasive recurrence, minimizing morbidity, and perhaps individualizing the treatment to the disease. One could consider age, comorbidities, [and] life expectancy, and weigh those against the morbidity of the treatment and the risk of local recurrence," she said.

Dr. Van Zee reported no relevant financial disclosures.

ORLANDO – Surgery for ductal carcinoma in situ, with or without adjuvant therapy, saves lives, asserted a breast cancer surgeon at a symposium sponsored by the Society of Surgical Oncology.

Following a surgical biopsy alone, about half of all cases of low-grade ductal carcinoma in situ (DCIS) will progress to invasive cancer within an average of 10-15 years, said Dr. Kimberly J. Van Zee, a surgical oncologist at Memorial Sloan-Kettering Cancer Center in New York.

Additionally, without intervention, low-grade DCIS will result in death from ipsilateral invasive recurrence of breast cancer in about 18% of patients, Dr. Van Zee said.

"With treatment of DCIS, whether it’s breast conservation or mastectomy, with or without radiation, breast cancer–specific survival is over 95%," she noted.

The incidence of DCIS has increased steadily since 1975, when the rate was slightly more than 5 in 100,000 women. In 2009, the rate had reached approximately 36 in 100,000, according to Surveillance, Epidemiology, and End Results (SEER) data. The increase is probably a result of the growing adoption of screening mammography over the same period, Dr. Van Zee commented.

Treatment trends for DCIS showed a gradual but steady decline in mastectomy – from 70% in 1983 to about 28% in 1999 – and a corresponding increase in breast-conserving treatment, which increased from about 25% to 68% over the same period.

Beginning around 2005, however, there was evidence that the trend was reversing, with upticks in both mastectomy for unilateral breast cancer (J. Clin. Oncol. 2010;28:3437-41) and contralateral prophylactic mastectomy, both among women with invasive cancers and DCIS (Ann. Surg. Oncol. 2010;17:2554-62). The trends paralleled the rise in screening mammography in the United States and elsewhere in the world.

The gradual but steady decline in breast cancer deaths that began in the early 1990s appears to be attributable to a combination of increased screening mammography and improvements in adjuvant therapy, Dr. Van Zee noted, citing a 2005 study (N. Engl. J. Med. 2005;353:1784-92).

"They dissected all the various effects of treatment, incidence of screening-detected diseases, etc., and all their analyses concluded that about half of the reduction in death rate was due to screening and the other half was due to adjuvant therapy. So I think this is good circumstantial evidence that screening, with its resultant increased incidence in DCIS and the resulting increased treatment of DCIS, does result in a lower death rate from breast cancer," she said.

Further evidence comes from studies in which pathologists reviewed thousands of slides of biopsy-acquired breast tissue originally reported as benign. In each study (Cancer 1980;46[4 Suppl]:919-25; Cancer 2005;103:2481-84), the investigator identified about 30 samples with evidence of low-grade, relatively low-volume DCIS that was not recognized or treated. After 20-30 years of follow-up, half of the women had developed a clinically apparent ipsilateral breast cancer recurrence. The majority of tumors were invasive. In the second study, the authors noted that 5 of the 28 women (18%) with previously undetected DCIS died of breast cancer.

Evidence from a meta-analysis (Cancer 1999;85:616-28) suggests that the risk for invasive recurrence following a mastectomy for DCIS is 1.1%, and that the risk for breast cancer death is less than 1.1%.

The risk for distant recurrence and/or death from breast-conserving surgery with or without adjuvant radiotherapy in prospective randomized trials of radiotherapy for DCIS was less than 5%. Among patients with invasive local failure in those trials, however, 18%-25% developed metastatic disease, indicating the importance of avoiding local recurrence.

Mastectomy and breast-conserving surgery combined with radiotherapy and/or endocrine therapy all provide excellent disease-specific and overall survival results, Dr. Van Zee said.

"The goal should be avoiding local recurrence and, in particular, invasive recurrence, minimizing morbidity, and perhaps individualizing the treatment to the disease. One could consider age, comorbidities, [and] life expectancy, and weigh those against the morbidity of the treatment and the risk of local recurrence," she said.

Dr. Van Zee reported no relevant financial disclosures.

ORLANDO – Asthma-related visits to emergency departments spike in the spring, when grass and tree pollen levels are at their highest, according to investigators in two separate studies presented here at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Over a 9-year period, asthma-related ED visits at two hospitals in the Bronx borough of New York City tended to peak in May, coinciding with high tree pollen levels, reported Dr. Jennifer Toh and colleagues from Albert Einstein College of Medicine, New York, and Southern Methodist University in Dallas.

© ideeone/iStockphoto.com

On the other side of the world in Australia, ED visits for asthma care coincided with high grass pollen levels in November and early December, spring months in the antipodean calendar, reported Dr. Bircan Erbas of La Trobe University in Melbourne and colleagues.

"We have a growth corridor in Melbourne which has been predominantly used for grazing of cattle and sheep, and we’ve seen increases in admissions for asthma and allergies," Dr. Erbas said in an interview.

She noted that following several days of high winds and severe thunderstorms in Melbourne in November 2003, there was a peak in ED attendance of 70 visits per day, "consistent with thunderstorm-associated asthma related to the preceding extreme grass pollen days and strong winds."

In the Bronx, where there is a high prevalence of asthma, tree pollen spikes in the Northern Hemisphere’s spring seem to be related to increases in asthma-related ED visits, Dr. Toh said in an interview.

Dr. Toh and colleagues looked at day-by-day asthma-related emergency department visits, as identified by ICD (International Classification of Disease) codes, at two hospitals in the Bronx. They then matched those data to daily pollen counts collected at the nearest pollen trap, located in Armonk, N.Y., about 27 miles north of New York City.

From 2001 through 2008, the investigators noted distinct peaks of increased ED visits for asthma, one each in January, May, and November.

"For most of the years studied, the spring peak was most prominent and consistently overlapped with high tree pollen levels. In addition, our regression analysis [of excess vs. average daily asthma ED visits] revealed that the largest excess asthma-related emergency department visits consistently overlapped the larger tree pollen levels during the month of May every year," they wrote in a poster presentation.

The investigators did not have data on the type of tree pollen.

"I think that in the entire Northeast, tree pollen is the most relevant allergen in terms of severe seasonal allergies. We don’t have as many problems with grass or ragweed as we do with trees," said Dr. Bernard Silverman, of Mount Sinai Hospital in New York. Dr. Silverman commented on the study in an interview, but was not involved in it.

The height of the pollen traps and their distance from the city may have influenced the results, said another clinician not involved in the study. It is important when studying pollen levels to set pollen traps at the appropriate height for the question the investigators hope to address, said Dr. Karl-Christian Bergmann of Charité Hospital in Berlin. Traps lower to the ground are more useful for measuring the amount of pollen that individuals are likely to inhale at the local level, whereas as traps set at a height of about 15-25 m are more useful for gauging airborne pollen levels over a broader geographic area. Results also can be confounded by higher levels of airborne carbon particulates, such as those found in diesel exhaust, he said.

Dr. Erbas and colleagues noted that "lower levels of pollen may contribute to asthma symptoms, levels that are much lower than the current level of 50 g/m³ which is used as the trigger point for warning asthma patients to avoid nonessential outdoor activities and/or take additional asthma medication."

Both Dr. Toh’s and Dr. Erbas’ studies were supported by the participating institutions. Both clinicians reported having no relevant disclosures.

ORLANDO – Asthma-related visits to emergency departments spike in the spring, when grass and tree pollen levels are at their highest, according to investigators in two separate studies presented here at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Over a 9-year period, asthma-related ED visits at two hospitals in the Bronx borough of New York City tended to peak in May, coinciding with high tree pollen levels, reported Dr. Jennifer Toh and colleagues from Albert Einstein College of Medicine, New York, and Southern Methodist University in Dallas.

© ideeone/iStockphoto.com

On the other side of the world in Australia, ED visits for asthma care coincided with high grass pollen levels in November and early December, spring months in the antipodean calendar, reported Dr. Bircan Erbas of La Trobe University in Melbourne and colleagues.

"We have a growth corridor in Melbourne which has been predominantly used for grazing of cattle and sheep, and we’ve seen increases in admissions for asthma and allergies," Dr. Erbas said in an interview.

She noted that following several days of high winds and severe thunderstorms in Melbourne in November 2003, there was a peak in ED attendance of 70 visits per day, "consistent with thunderstorm-associated asthma related to the preceding extreme grass pollen days and strong winds."

In the Bronx, where there is a high prevalence of asthma, tree pollen spikes in the Northern Hemisphere’s spring seem to be related to increases in asthma-related ED visits, Dr. Toh said in an interview.

Dr. Toh and colleagues looked at day-by-day asthma-related emergency department visits, as identified by ICD (International Classification of Disease) codes, at two hospitals in the Bronx. They then matched those data to daily pollen counts collected at the nearest pollen trap, located in Armonk, N.Y., about 27 miles north of New York City.

From 2001 through 2008, the investigators noted distinct peaks of increased ED visits for asthma, one each in January, May, and November.

"For most of the years studied, the spring peak was most prominent and consistently overlapped with high tree pollen levels. In addition, our regression analysis [of excess vs. average daily asthma ED visits] revealed that the largest excess asthma-related emergency department visits consistently overlapped the larger tree pollen levels during the month of May every year," they wrote in a poster presentation.

The investigators did not have data on the type of tree pollen.

"I think that in the entire Northeast, tree pollen is the most relevant allergen in terms of severe seasonal allergies. We don’t have as many problems with grass or ragweed as we do with trees," said Dr. Bernard Silverman, of Mount Sinai Hospital in New York. Dr. Silverman commented on the study in an interview, but was not involved in it.

The height of the pollen traps and their distance from the city may have influenced the results, said another clinician not involved in the study. It is important when studying pollen levels to set pollen traps at the appropriate height for the question the investigators hope to address, said Dr. Karl-Christian Bergmann of Charité Hospital in Berlin. Traps lower to the ground are more useful for measuring the amount of pollen that individuals are likely to inhale at the local level, whereas as traps set at a height of about 15-25 m are more useful for gauging airborne pollen levels over a broader geographic area. Results also can be confounded by higher levels of airborne carbon particulates, such as those found in diesel exhaust, he said.

Dr. Erbas and colleagues noted that "lower levels of pollen may contribute to asthma symptoms, levels that are much lower than the current level of 50 g/m³ which is used as the trigger point for warning asthma patients to avoid nonessential outdoor activities and/or take additional asthma medication."

Both Dr. Toh’s and Dr. Erbas’ studies were supported by the participating institutions. Both clinicians reported having no relevant disclosures.

ORLANDO – Asthma-related visits to emergency departments spike in the spring, when grass and tree pollen levels are at their highest, according to investigators in two separate studies presented here at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Over a 9-year period, asthma-related ED visits at two hospitals in the Bronx borough of New York City tended to peak in May, coinciding with high tree pollen levels, reported Dr. Jennifer Toh and colleagues from Albert Einstein College of Medicine, New York, and Southern Methodist University in Dallas.

© ideeone/iStockphoto.com

On the other side of the world in Australia, ED visits for asthma care coincided with high grass pollen levels in November and early December, spring months in the antipodean calendar, reported Dr. Bircan Erbas of La Trobe University in Melbourne and colleagues.

"We have a growth corridor in Melbourne which has been predominantly used for grazing of cattle and sheep, and we’ve seen increases in admissions for asthma and allergies," Dr. Erbas said in an interview.

She noted that following several days of high winds and severe thunderstorms in Melbourne in November 2003, there was a peak in ED attendance of 70 visits per day, "consistent with thunderstorm-associated asthma related to the preceding extreme grass pollen days and strong winds."

In the Bronx, where there is a high prevalence of asthma, tree pollen spikes in the Northern Hemisphere’s spring seem to be related to increases in asthma-related ED visits, Dr. Toh said in an interview.

Dr. Toh and colleagues looked at day-by-day asthma-related emergency department visits, as identified by ICD (International Classification of Disease) codes, at two hospitals in the Bronx. They then matched those data to daily pollen counts collected at the nearest pollen trap, located in Armonk, N.Y., about 27 miles north of New York City.

From 2001 through 2008, the investigators noted distinct peaks of increased ED visits for asthma, one each in January, May, and November.

"For most of the years studied, the spring peak was most prominent and consistently overlapped with high tree pollen levels. In addition, our regression analysis [of excess vs. average daily asthma ED visits] revealed that the largest excess asthma-related emergency department visits consistently overlapped the larger tree pollen levels during the month of May every year," they wrote in a poster presentation.

The investigators did not have data on the type of tree pollen.

"I think that in the entire Northeast, tree pollen is the most relevant allergen in terms of severe seasonal allergies. We don’t have as many problems with grass or ragweed as we do with trees," said Dr. Bernard Silverman, of Mount Sinai Hospital in New York. Dr. Silverman commented on the study in an interview, but was not involved in it.

The height of the pollen traps and their distance from the city may have influenced the results, said another clinician not involved in the study. It is important when studying pollen levels to set pollen traps at the appropriate height for the question the investigators hope to address, said Dr. Karl-Christian Bergmann of Charité Hospital in Berlin. Traps lower to the ground are more useful for measuring the amount of pollen that individuals are likely to inhale at the local level, whereas as traps set at a height of about 15-25 m are more useful for gauging airborne pollen levels over a broader geographic area. Results also can be confounded by higher levels of airborne carbon particulates, such as those found in diesel exhaust, he said.

Dr. Erbas and colleagues noted that "lower levels of pollen may contribute to asthma symptoms, levels that are much lower than the current level of 50 g/m³ which is used as the trigger point for warning asthma patients to avoid nonessential outdoor activities and/or take additional asthma medication."

Both Dr. Toh’s and Dr. Erbas’ studies were supported by the participating institutions. Both clinicians reported having no relevant disclosures.

BOSTON – A real-time saliva-based polymerase chain reaction assay identifies more newborns with congenital cytomegalovirus infections than a standard rapid-culture assay, investigators reported.

"A PCR [polymerase chain reaction]-based assay would be a better newborn screen as the sample is convenient and noninvasive to collect, and we have already shown that elimination of the DNA extraction step does not interfere with the sensitivity or the specificity of the assay," said Dr. Swetha Pinninti, a pediatric infectious disease fellow at the University of Alabama at Birmingham.

The PCR assay lends itself to high throughput methods, is less expensive than culturing, and could help clinicians identify an additional 400-1,200 infants with congenital cytomegalovirus (CMV) annually, Dr. Pinninti said at the annual meeting of the Pediatric Academic Societies.

Congenital CMV is the leading cause of nongenetic sensorineural hearing loss, but may go undetected, because approximately 90% of infected children have no clinical findings at birth. From 10%-15% of children who are infected but asymptomatic, and 60% of those who are symptomatic will develop hearing loss. In about one-third of cases, the development of sensorineural hearing loss has a delayed onset, Dr. Pinninti said.

Although detection of virus from culture of urine or saliva samples is the current gold standard, the investigators previously showed that PCR of saliva is comparable to culture-based methods (N. Engl. J. Med. 2011;364:2111-8).

In the current study, they tested whether saliva PCR could be a better screening tool for congenital CMV infection than rapid culture (RC)-based techniques.

To do so, they looked at two cohorts of infants. The first, screened from June 2008 through December 2009, included newborns who had saliva samples collected by swab and tested with both PCR and RC.

Due to a change of protocol, a second cohort of infants screened from January 2010 through November 2011 had saliva PCR testing, with RC performed on all samples that tested positive by PCR.

Infants who were positive for CMV by either screening were re-evaluated for confirmation, with testing of saliva and urine samples collected at enrollment. Infants confirmed to have congenital CMV infections were enrolled in follow-up to monitor their hearing outcomes.

Of the 35,334 infants screened in the first cohort, 161 tested positive for CMV and were enrolled for confirmation. Of this group, 152 had confirmed CMV, and 9 were confirmed to be CMV-negative.

Of the 152 confirmed CMV-positive, 147 were positive by both screening methods, 4 were PCR-positive but RC-negative, and 1 was PCR-negative but RC-positive,

In the second cohort, 37,250 infants were screened with PCR, and 123 were enrolled for confirmation. Of this group, 114 were confirmed to be CMV-positive, and 9 were confirmed to be CMV-negative. Of those confirmed positive, 105 were positive on both screening methods, and 9 were PCR-positive but RC-negative.

Of the 14 PCR/RC discordant samples, PCR detected CMV copies in varying amounts in 13, whereas RC detected cells in only 1 of the 14 (4 cells per slide).

Dr. Pinninti acknowledged a few study limitations, including the fact that infants with initially negative screens were not enrolled, and that samples were transported to a central lab, which could have degraded the quality of the cultured samples.

"This is really exciting," commented Dr. Morven S. Edwards, professor of pediatrics at Baylor College of Medicine, Houston, who comoderated the session in which the study was presented, but was not involved in the research.

The study was supported by the National Institute on Deafness and Other Communication Disorders. Dr. Pinninti and Dr. Edwards reported having no conflicts of interest.

BOSTON – A real-time saliva-based polymerase chain reaction assay identifies more newborns with congenital cytomegalovirus infections than a standard rapid-culture assay, investigators reported.

"A PCR [polymerase chain reaction]-based assay would be a better newborn screen as the sample is convenient and noninvasive to collect, and we have already shown that elimination of the DNA extraction step does not interfere with the sensitivity or the specificity of the assay," said Dr. Swetha Pinninti, a pediatric infectious disease fellow at the University of Alabama at Birmingham.

The PCR assay lends itself to high throughput methods, is less expensive than culturing, and could help clinicians identify an additional 400-1,200 infants with congenital cytomegalovirus (CMV) annually, Dr. Pinninti said at the annual meeting of the Pediatric Academic Societies.

Congenital CMV is the leading cause of nongenetic sensorineural hearing loss, but may go undetected, because approximately 90% of infected children have no clinical findings at birth. From 10%-15% of children who are infected but asymptomatic, and 60% of those who are symptomatic will develop hearing loss. In about one-third of cases, the development of sensorineural hearing loss has a delayed onset, Dr. Pinninti said.

Although detection of virus from culture of urine or saliva samples is the current gold standard, the investigators previously showed that PCR of saliva is comparable to culture-based methods (N. Engl. J. Med. 2011;364:2111-8).

In the current study, they tested whether saliva PCR could be a better screening tool for congenital CMV infection than rapid culture (RC)-based techniques.

To do so, they looked at two cohorts of infants. The first, screened from June 2008 through December 2009, included newborns who had saliva samples collected by swab and tested with both PCR and RC.

Due to a change of protocol, a second cohort of infants screened from January 2010 through November 2011 had saliva PCR testing, with RC performed on all samples that tested positive by PCR.

Infants who were positive for CMV by either screening were re-evaluated for confirmation, with testing of saliva and urine samples collected at enrollment. Infants confirmed to have congenital CMV infections were enrolled in follow-up to monitor their hearing outcomes.

Of the 35,334 infants screened in the first cohort, 161 tested positive for CMV and were enrolled for confirmation. Of this group, 152 had confirmed CMV, and 9 were confirmed to be CMV-negative.

Of the 152 confirmed CMV-positive, 147 were positive by both screening methods, 4 were PCR-positive but RC-negative, and 1 was PCR-negative but RC-positive,

In the second cohort, 37,250 infants were screened with PCR, and 123 were enrolled for confirmation. Of this group, 114 were confirmed to be CMV-positive, and 9 were confirmed to be CMV-negative. Of those confirmed positive, 105 were positive on both screening methods, and 9 were PCR-positive but RC-negative.

Of the 14 PCR/RC discordant samples, PCR detected CMV copies in varying amounts in 13, whereas RC detected cells in only 1 of the 14 (4 cells per slide).

Dr. Pinninti acknowledged a few study limitations, including the fact that infants with initially negative screens were not enrolled, and that samples were transported to a central lab, which could have degraded the quality of the cultured samples.

"This is really exciting," commented Dr. Morven S. Edwards, professor of pediatrics at Baylor College of Medicine, Houston, who comoderated the session in which the study was presented, but was not involved in the research.

The study was supported by the National Institute on Deafness and Other Communication Disorders. Dr. Pinninti and Dr. Edwards reported having no conflicts of interest.

BOSTON – A real-time saliva-based polymerase chain reaction assay identifies more newborns with congenital cytomegalovirus infections than a standard rapid-culture assay, investigators reported.

"A PCR [polymerase chain reaction]-based assay would be a better newborn screen as the sample is convenient and noninvasive to collect, and we have already shown that elimination of the DNA extraction step does not interfere with the sensitivity or the specificity of the assay," said Dr. Swetha Pinninti, a pediatric infectious disease fellow at the University of Alabama at Birmingham.

The PCR assay lends itself to high throughput methods, is less expensive than culturing, and could help clinicians identify an additional 400-1,200 infants with congenital cytomegalovirus (CMV) annually, Dr. Pinninti said at the annual meeting of the Pediatric Academic Societies.

Congenital CMV is the leading cause of nongenetic sensorineural hearing loss, but may go undetected, because approximately 90% of infected children have no clinical findings at birth. From 10%-15% of children who are infected but asymptomatic, and 60% of those who are symptomatic will develop hearing loss. In about one-third of cases, the development of sensorineural hearing loss has a delayed onset, Dr. Pinninti said.

Although detection of virus from culture of urine or saliva samples is the current gold standard, the investigators previously showed that PCR of saliva is comparable to culture-based methods (N. Engl. J. Med. 2011;364:2111-8).

In the current study, they tested whether saliva PCR could be a better screening tool for congenital CMV infection than rapid culture (RC)-based techniques.

To do so, they looked at two cohorts of infants. The first, screened from June 2008 through December 2009, included newborns who had saliva samples collected by swab and tested with both PCR and RC.

Due to a change of protocol, a second cohort of infants screened from January 2010 through November 2011 had saliva PCR testing, with RC performed on all samples that tested positive by PCR.

Infants who were positive for CMV by either screening were re-evaluated for confirmation, with testing of saliva and urine samples collected at enrollment. Infants confirmed to have congenital CMV infections were enrolled in follow-up to monitor their hearing outcomes.

Of the 35,334 infants screened in the first cohort, 161 tested positive for CMV and were enrolled for confirmation. Of this group, 152 had confirmed CMV, and 9 were confirmed to be CMV-negative.

Of the 152 confirmed CMV-positive, 147 were positive by both screening methods, 4 were PCR-positive but RC-negative, and 1 was PCR-negative but RC-positive,

In the second cohort, 37,250 infants were screened with PCR, and 123 were enrolled for confirmation. Of this group, 114 were confirmed to be CMV-positive, and 9 were confirmed to be CMV-negative. Of those confirmed positive, 105 were positive on both screening methods, and 9 were PCR-positive but RC-negative.

Of the 14 PCR/RC discordant samples, PCR detected CMV copies in varying amounts in 13, whereas RC detected cells in only 1 of the 14 (4 cells per slide).

Dr. Pinninti acknowledged a few study limitations, including the fact that infants with initially negative screens were not enrolled, and that samples were transported to a central lab, which could have degraded the quality of the cultured samples.

"This is really exciting," commented Dr. Morven S. Edwards, professor of pediatrics at Baylor College of Medicine, Houston, who comoderated the session in which the study was presented, but was not involved in the research.

The study was supported by the National Institute on Deafness and Other Communication Disorders. Dr. Pinninti and Dr. Edwards reported having no conflicts of interest.

ORLANDO – Gastrointestinal stromal tumors of the duodenum can be managed safely with surgery, yielding good overall survival, an investigator reported at a symposium sponsored by the Society of Surgical Oncology.

In addition to surgery for duodenal gastrointestinal stromal tumors (GISTs), adjuvant treatment with imatinib (Gleevec) may reduce the risk of recurrence, and neoadjuvant imatinib may improve surgical outcomes, said Dr. Chiara Colombo, from the sarcoma service of the Fondazione Istituto Nazionale dei Tumori in Milan.

"Imatinib in the neoadjuvant setting might facilitate the surgical resection and possibly help preserve the biliary and pancreatic anatomy," she said.

Only about 5% of GISTs originate in the duodenum, but tumors occurring in this section of the small intestine are anatomically challenging and there is considerable debate about the most appropriate surgical and therapeutic approaches, she added.

To gain a better understanding of the problem, Dr. Colombo and colleagues at her center, as well as the University of Mannheim (Germany), Massachusetts General Hospital in Boston, and the Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology in Gliwice (Poland), pooled data on patients with a primary duodenal GIST treated from February 2000 through August 2011 at their institutions.

There were a total of 39 men and 45 women, median age 58 years, treated with either pancreaticoduodenectomy (28 patients, 33%) or limited resection (56 patients, 67%). In all, 11 patients received preoperative imatinib for a median of 8 months, and 23 received it after surgery for a median of 17 months.

Surgical complication rates were higher among patients who underwent pancreaticoduodenectomy, compared with patients who had limited resection. The complications occurred in 5 patients who underwent limited resection (9%) and 10 who underwent pancreaticoduodenectomy (36%) and included evisceration/wound dehiscence (2 and 1, respectively), infections (1 in each group), gastric obstruction/delayed emptying (0 and 2), and pancreatic/biliary leakage (2 and 6 patients).

Among all patients, overall survival was 98% at 3 years and 89% at 5 years; the median follow-up was 42 months. Overall survival of patients at low or intermediate risk for recurrence was similar whether they received imatinib or did not. Among high-risk patients, however, imatinib was associated with significantly better 5-year overall survival, and the survival curves began to converge after imatinib was withdrawn, Dr. Colombo said.

She noted that the results echo those of a recent phase III study of adjuvant imatinib in patients with operable GISTs (ASCO 2011 Abstract LBA1).

In the intention-to-treat population of the randomized trial, the hazard ratio for overall survival for 36 months vs. 12 months of adjuvant imatinib was 0.45 (P = .019). The longer treatment schedule was also associated with better recurrence-free survival (hazard ratio 0.46, P less than .0001).

In the neoadjuvant setting, imatinib was associated with tumor regression, allowing for safer resection than might otherwise be possible, Dr. Colombo commented. This analysis on tumor regression was based on the combined clinical experience at all the centers.

The study was supported by the participating institutions. Dr. Colombo reported no relevant financial disclosures.

ORLANDO – Gastrointestinal stromal tumors of the duodenum can be managed safely with surgery, yielding good overall survival, an investigator reported at a symposium sponsored by the Society of Surgical Oncology.

In addition to surgery for duodenal gastrointestinal stromal tumors (GISTs), adjuvant treatment with imatinib (Gleevec) may reduce the risk of recurrence, and neoadjuvant imatinib may improve surgical outcomes, said Dr. Chiara Colombo, from the sarcoma service of the Fondazione Istituto Nazionale dei Tumori in Milan.

"Imatinib in the neoadjuvant setting might facilitate the surgical resection and possibly help preserve the biliary and pancreatic anatomy," she said.

Only about 5% of GISTs originate in the duodenum, but tumors occurring in this section of the small intestine are anatomically challenging and there is considerable debate about the most appropriate surgical and therapeutic approaches, she added.

To gain a better understanding of the problem, Dr. Colombo and colleagues at her center, as well as the University of Mannheim (Germany), Massachusetts General Hospital in Boston, and the Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology in Gliwice (Poland), pooled data on patients with a primary duodenal GIST treated from February 2000 through August 2011 at their institutions.

There were a total of 39 men and 45 women, median age 58 years, treated with either pancreaticoduodenectomy (28 patients, 33%) or limited resection (56 patients, 67%). In all, 11 patients received preoperative imatinib for a median of 8 months, and 23 received it after surgery for a median of 17 months.

Surgical complication rates were higher among patients who underwent pancreaticoduodenectomy, compared with patients who had limited resection. The complications occurred in 5 patients who underwent limited resection (9%) and 10 who underwent pancreaticoduodenectomy (36%) and included evisceration/wound dehiscence (2 and 1, respectively), infections (1 in each group), gastric obstruction/delayed emptying (0 and 2), and pancreatic/biliary leakage (2 and 6 patients).

Among all patients, overall survival was 98% at 3 years and 89% at 5 years; the median follow-up was 42 months. Overall survival of patients at low or intermediate risk for recurrence was similar whether they received imatinib or did not. Among high-risk patients, however, imatinib was associated with significantly better 5-year overall survival, and the survival curves began to converge after imatinib was withdrawn, Dr. Colombo said.

She noted that the results echo those of a recent phase III study of adjuvant imatinib in patients with operable GISTs (ASCO 2011 Abstract LBA1).

In the intention-to-treat population of the randomized trial, the hazard ratio for overall survival for 36 months vs. 12 months of adjuvant imatinib was 0.45 (P = .019). The longer treatment schedule was also associated with better recurrence-free survival (hazard ratio 0.46, P less than .0001).

In the neoadjuvant setting, imatinib was associated with tumor regression, allowing for safer resection than might otherwise be possible, Dr. Colombo commented. This analysis on tumor regression was based on the combined clinical experience at all the centers.

The study was supported by the participating institutions. Dr. Colombo reported no relevant financial disclosures.

ORLANDO – Gastrointestinal stromal tumors of the duodenum can be managed safely with surgery, yielding good overall survival, an investigator reported at a symposium sponsored by the Society of Surgical Oncology.

In addition to surgery for duodenal gastrointestinal stromal tumors (GISTs), adjuvant treatment with imatinib (Gleevec) may reduce the risk of recurrence, and neoadjuvant imatinib may improve surgical outcomes, said Dr. Chiara Colombo, from the sarcoma service of the Fondazione Istituto Nazionale dei Tumori in Milan.

"Imatinib in the neoadjuvant setting might facilitate the surgical resection and possibly help preserve the biliary and pancreatic anatomy," she said.

Only about 5% of GISTs originate in the duodenum, but tumors occurring in this section of the small intestine are anatomically challenging and there is considerable debate about the most appropriate surgical and therapeutic approaches, she added.

To gain a better understanding of the problem, Dr. Colombo and colleagues at her center, as well as the University of Mannheim (Germany), Massachusetts General Hospital in Boston, and the Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology in Gliwice (Poland), pooled data on patients with a primary duodenal GIST treated from February 2000 through August 2011 at their institutions.

There were a total of 39 men and 45 women, median age 58 years, treated with either pancreaticoduodenectomy (28 patients, 33%) or limited resection (56 patients, 67%). In all, 11 patients received preoperative imatinib for a median of 8 months, and 23 received it after surgery for a median of 17 months.

Surgical complication rates were higher among patients who underwent pancreaticoduodenectomy, compared with patients who had limited resection. The complications occurred in 5 patients who underwent limited resection (9%) and 10 who underwent pancreaticoduodenectomy (36%) and included evisceration/wound dehiscence (2 and 1, respectively), infections (1 in each group), gastric obstruction/delayed emptying (0 and 2), and pancreatic/biliary leakage (2 and 6 patients).

Among all patients, overall survival was 98% at 3 years and 89% at 5 years; the median follow-up was 42 months. Overall survival of patients at low or intermediate risk for recurrence was similar whether they received imatinib or did not. Among high-risk patients, however, imatinib was associated with significantly better 5-year overall survival, and the survival curves began to converge after imatinib was withdrawn, Dr. Colombo said.

She noted that the results echo those of a recent phase III study of adjuvant imatinib in patients with operable GISTs (ASCO 2011 Abstract LBA1).

In the intention-to-treat population of the randomized trial, the hazard ratio for overall survival for 36 months vs. 12 months of adjuvant imatinib was 0.45 (P = .019). The longer treatment schedule was also associated with better recurrence-free survival (hazard ratio 0.46, P less than .0001).

In the neoadjuvant setting, imatinib was associated with tumor regression, allowing for safer resection than might otherwise be possible, Dr. Colombo commented. This analysis on tumor regression was based on the combined clinical experience at all the centers.

The study was supported by the participating institutions. Dr. Colombo reported no relevant financial disclosures.

BOSTON – Asthma admissions, like politics, are local.

So suggests the wide variability within a single Ohio county in hospitalization rates for children with acute asthma, Dr. Andrew F. Beck, a fellow in general and community pediatrics at Cincinnati Children’s Hospital Medical Center, said at the annual meeting of the Pediatric Academic Societies.

A neighborhood-by-neighborhood analysis of pediatric asthma admissions in Hamilton County (Cincinnati and environs), showed that some neighborhoods had admission rates as high as 27 per 1,000 children aged 1-16 years while others recorded no pediatric asthma hospitalizations at all, Dr. Beck reported.

"Hamilton County had an admission rate double the national average, with profound in-county variation in admission distribution," he noted. "Given this variation, we expect that neighborhood would be a powerful unit of measure that would be easily translatable to members of the community."

Armed with highly localized data, public health authorities could develop more effective interventions targeted at reducing disparities in asthma care, theoretically reducing admissions and saving millions of health care dollars, he explained.

To characterize variations in asthma admission rates among Hamilton County neighborhoods and assess differences in patient- and neighborhood-level characteristics, the investigators drew data from the population-based, prospective, observational Greater Cincinnati Asthma Risks Study.

They looked at 862 sequential admissions of 757 patients for asthma or wheezing from September 2010 through August 2011 of all children aged 1-16 years with addresses within the county.

All of the admissions were at Cincinnati Children’s Hospital Medical Center, which accounts for about 95% of all county admissions, according to Ohio public health data. To reduce the likelihood of confounding variables, the researchers excluded children with respiratory or cardiovascular comorbidities.

The mean overall admission rate for the county was 5.1 per 1,000 children; that compares with a national average of about 2.5 per 1,000, Dr. Beck noted. Neighborhoods whose residents had the highest third of admission rates averaged 17.0 per 1,000, compared with 7.5 per 1,000 for the middle third and 2.6 per 1,000 for the bottom third.

"If the county rate were reduced to that of the lowest tertile, annual admissions would decrease by more than 50% and $2.1 million could be saved," Dr. Beck said.

The researchers used factors chosen from U.S. Census data to determine differences among the three admission-rate groups. They found that lower household incomes, lower levels of education, greater population density, and lower percentage of home ownership within neighborhoods were all significantly predictive of higher asthma admission rates (P less than .0001 for all factors).

The authors also looked at available survey data for 447 patients, grouped into tertiles with respect to patient factors that are known to affect asthma morbidity. Factors significantly associated with a greater chance of admission included patient-reported "difficulty making ends meet," lack of transportation, cockroach infestation, depressive symptoms, and running out of medications (P less than .01 for all comparisons).

The investigators plan to create multilevel models for assessing the degree to which specific factors may affect asthma morbidity, and they hope to better delineate "geographic hot spots" of potentially modifiable risks, Dr. Beck said.

The study was supported by a National Institutes of Health grant and a National Research Service Award grant. The investigators reported having no relevant financial disclosures.

BOSTON – Asthma admissions, like politics, are local.

So suggests the wide variability within a single Ohio county in hospitalization rates for children with acute asthma, Dr. Andrew F. Beck, a fellow in general and community pediatrics at Cincinnati Children’s Hospital Medical Center, said at the annual meeting of the Pediatric Academic Societies.

A neighborhood-by-neighborhood analysis of pediatric asthma admissions in Hamilton County (Cincinnati and environs), showed that some neighborhoods had admission rates as high as 27 per 1,000 children aged 1-16 years while others recorded no pediatric asthma hospitalizations at all, Dr. Beck reported.

"Hamilton County had an admission rate double the national average, with profound in-county variation in admission distribution," he noted. "Given this variation, we expect that neighborhood would be a powerful unit of measure that would be easily translatable to members of the community."

Armed with highly localized data, public health authorities could develop more effective interventions targeted at reducing disparities in asthma care, theoretically reducing admissions and saving millions of health care dollars, he explained.

To characterize variations in asthma admission rates among Hamilton County neighborhoods and assess differences in patient- and neighborhood-level characteristics, the investigators drew data from the population-based, prospective, observational Greater Cincinnati Asthma Risks Study.

They looked at 862 sequential admissions of 757 patients for asthma or wheezing from September 2010 through August 2011 of all children aged 1-16 years with addresses within the county.

All of the admissions were at Cincinnati Children’s Hospital Medical Center, which accounts for about 95% of all county admissions, according to Ohio public health data. To reduce the likelihood of confounding variables, the researchers excluded children with respiratory or cardiovascular comorbidities.

The mean overall admission rate for the county was 5.1 per 1,000 children; that compares with a national average of about 2.5 per 1,000, Dr. Beck noted. Neighborhoods whose residents had the highest third of admission rates averaged 17.0 per 1,000, compared with 7.5 per 1,000 for the middle third and 2.6 per 1,000 for the bottom third.

"If the county rate were reduced to that of the lowest tertile, annual admissions would decrease by more than 50% and $2.1 million could be saved," Dr. Beck said.

The researchers used factors chosen from U.S. Census data to determine differences among the three admission-rate groups. They found that lower household incomes, lower levels of education, greater population density, and lower percentage of home ownership within neighborhoods were all significantly predictive of higher asthma admission rates (P less than .0001 for all factors).

The authors also looked at available survey data for 447 patients, grouped into tertiles with respect to patient factors that are known to affect asthma morbidity. Factors significantly associated with a greater chance of admission included patient-reported "difficulty making ends meet," lack of transportation, cockroach infestation, depressive symptoms, and running out of medications (P less than .01 for all comparisons).

The investigators plan to create multilevel models for assessing the degree to which specific factors may affect asthma morbidity, and they hope to better delineate "geographic hot spots" of potentially modifiable risks, Dr. Beck said.

The study was supported by a National Institutes of Health grant and a National Research Service Award grant. The investigators reported having no relevant financial disclosures.

BOSTON – Asthma admissions, like politics, are local.

So suggests the wide variability within a single Ohio county in hospitalization rates for children with acute asthma, Dr. Andrew F. Beck, a fellow in general and community pediatrics at Cincinnati Children’s Hospital Medical Center, said at the annual meeting of the Pediatric Academic Societies.

A neighborhood-by-neighborhood analysis of pediatric asthma admissions in Hamilton County (Cincinnati and environs), showed that some neighborhoods had admission rates as high as 27 per 1,000 children aged 1-16 years while others recorded no pediatric asthma hospitalizations at all, Dr. Beck reported.

"Hamilton County had an admission rate double the national average, with profound in-county variation in admission distribution," he noted. "Given this variation, we expect that neighborhood would be a powerful unit of measure that would be easily translatable to members of the community."

Armed with highly localized data, public health authorities could develop more effective interventions targeted at reducing disparities in asthma care, theoretically reducing admissions and saving millions of health care dollars, he explained.

To characterize variations in asthma admission rates among Hamilton County neighborhoods and assess differences in patient- and neighborhood-level characteristics, the investigators drew data from the population-based, prospective, observational Greater Cincinnati Asthma Risks Study.

They looked at 862 sequential admissions of 757 patients for asthma or wheezing from September 2010 through August 2011 of all children aged 1-16 years with addresses within the county.

All of the admissions were at Cincinnati Children’s Hospital Medical Center, which accounts for about 95% of all county admissions, according to Ohio public health data. To reduce the likelihood of confounding variables, the researchers excluded children with respiratory or cardiovascular comorbidities.

The mean overall admission rate for the county was 5.1 per 1,000 children; that compares with a national average of about 2.5 per 1,000, Dr. Beck noted. Neighborhoods whose residents had the highest third of admission rates averaged 17.0 per 1,000, compared with 7.5 per 1,000 for the middle third and 2.6 per 1,000 for the bottom third.

"If the county rate were reduced to that of the lowest tertile, annual admissions would decrease by more than 50% and $2.1 million could be saved," Dr. Beck said.

The researchers used factors chosen from U.S. Census data to determine differences among the three admission-rate groups. They found that lower household incomes, lower levels of education, greater population density, and lower percentage of home ownership within neighborhoods were all significantly predictive of higher asthma admission rates (P less than .0001 for all factors).

The authors also looked at available survey data for 447 patients, grouped into tertiles with respect to patient factors that are known to affect asthma morbidity. Factors significantly associated with a greater chance of admission included patient-reported "difficulty making ends meet," lack of transportation, cockroach infestation, depressive symptoms, and running out of medications (P less than .01 for all comparisons).

The investigators plan to create multilevel models for assessing the degree to which specific factors may affect asthma morbidity, and they hope to better delineate "geographic hot spots" of potentially modifiable risks, Dr. Beck said.

The study was supported by a National Institutes of Health grant and a National Research Service Award grant. The investigators reported having no relevant financial disclosures.

ORLANDO – Children with severe asthma may have their already serious symptoms further worsened by sensitization to common household fungi in the genus Alternaria, suggested investigators at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Among 187 children with asthma enrolled in the National Heart, Lung and Blood Institutes’ Severe Asthma Research Program (SARP), 28% had a positive skin prick test reaction to Alternaria, reported Dr. Jennifer Shih, an allergy and immunology fellow in the department of pediatrics at Emory University in Atlanta.

Photo courtesy CDC/Dr. Lucille K. Georg

Sensitization to Alternaria was significantly more prevalent among children with severe vs. mild to moderate asthma (P less than .01), and children with severe presentation were significantly more likely to exhibit increased airway hyperresponsiveness (P less than .01) and to report a history of acute or chronic sinusitis requiring antibiotics (P less than .05).

"In the future, routine evaluation of Alternaria sensitization may be useful in the clinical management of children with severe asthma. Future studies are needed to evaluate the mechanistic underpinning of Alternaria sensitization in children with severe asthma," she said.

Sensitization to Alternaria has been associated in other studies with asthma persistence into early adulthood, Dr, Shih said. One study showed that Alternaria sensitization was associated with an odds ratio (OR) of 3.6 for chronic asthma at age 22 years (Lancet 2008;372:1058-64).

Increased airway hyperresponsiveness, a hallmark of severe asthma in children, was associated with Alternaria sensitization in the Childhood Asthma Management Research Program, she noted.

To see whether there were differences in Alternaria sensitization between school-age children with mild to moderate or severe asthma, and whether sensitization was associated with clinical features of asthma severity, Dr. Shih and her colleague Dr. Anne Fitzpatrick took a retrospective look at 187 children enrolled in SARP at their institution. The children ranged in age from 6 to 18 years, and all had skin prick test data available. In all, 90 had severe asthma, and 97 mild to moderate asthma.

Asthma severity was determined according to American Thoracic Society 2000 criteria, which require daily use of systemic or high-dose inhaled corticosteroids, plus at least two of the following: additional controller medication, beta-agonist use on at least 5 of 7 days, a baseline forced expiratory volume in 1 second (FEV₁)less than 80% of predicted, 1 or more emergency department visits within the past year, 3 or more oral steroid burst within the past year, prompt deterioration with steroid reduction, and/or a history of intubation(Am. J. Respir. Crit. Care Med. 2000;162:2341-51).

The investigators also reviewed asthma questionnaires, lung function–testing results, allergy evaluations, and biomarker evaluations.

In an analysis adjusted for race and socioeconomic status, they found that 37% of the children with severe asthma tested positive for Alternaria sensitization, compared with 21% of children with mild-to-moderate disease (adjusted OR 2.13, P = .015).

Among children with severe asthma, Alternaria sensitization was not significantly associated with differences in either blood eosinophil or total serum immunoglobulin E (IgE) levels, or in FEV₁, airflow limitation, air trapping, medication requirements, or health care use.

However, exhaled nitric oxide levels were significantly higher among those with severe asthma and sensitivity to Alternaria (P = .029), as was airway hyperresponsiveness to methacholine challenge (P = .012).

Additionally, in an analysis adjusted for socioeconomic status, children with severe asthma and a positive skin prick test to Alternaria had an adjusted OR for sinusitis of 2.43 (P = .046).

"These findings support previous observations from the Childhood Asthma Management Research Program," Dr. Shih said.

In the question and answer portion of her presentation, several clinicians commented that Alternaria might be a general marker for atopy rather than for airway hyperresponsiveness and sinusitis as seen in her study, and that other allergens such as cockroach and mites might account for exacerbations of severe asthma. Dr. Shih agreed that further studies would help to resolve this question.

The study was supported by the NHLBI and Emory University. Dr. Shih reported that she had no relevant disclosures.

ORLANDO – Children with severe asthma may have their already serious symptoms further worsened by sensitization to common household fungi in the genus Alternaria, suggested investigators at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Among 187 children with asthma enrolled in the National Heart, Lung and Blood Institutes’ Severe Asthma Research Program (SARP), 28% had a positive skin prick test reaction to Alternaria, reported Dr. Jennifer Shih, an allergy and immunology fellow in the department of pediatrics at Emory University in Atlanta.

Photo courtesy CDC/Dr. Lucille K. Georg

Sensitization to Alternaria was significantly more prevalent among children with severe vs. mild to moderate asthma (P less than .01), and children with severe presentation were significantly more likely to exhibit increased airway hyperresponsiveness (P less than .01) and to report a history of acute or chronic sinusitis requiring antibiotics (P less than .05).

"In the future, routine evaluation of Alternaria sensitization may be useful in the clinical management of children with severe asthma. Future studies are needed to evaluate the mechanistic underpinning of Alternaria sensitization in children with severe asthma," she said.

Sensitization to Alternaria has been associated in other studies with asthma persistence into early adulthood, Dr, Shih said. One study showed that Alternaria sensitization was associated with an odds ratio (OR) of 3.6 for chronic asthma at age 22 years (Lancet 2008;372:1058-64).

Increased airway hyperresponsiveness, a hallmark of severe asthma in children, was associated with Alternaria sensitization in the Childhood Asthma Management Research Program, she noted.

To see whether there were differences in Alternaria sensitization between school-age children with mild to moderate or severe asthma, and whether sensitization was associated with clinical features of asthma severity, Dr. Shih and her colleague Dr. Anne Fitzpatrick took a retrospective look at 187 children enrolled in SARP at their institution. The children ranged in age from 6 to 18 years, and all had skin prick test data available. In all, 90 had severe asthma, and 97 mild to moderate asthma.

Asthma severity was determined according to American Thoracic Society 2000 criteria, which require daily use of systemic or high-dose inhaled corticosteroids, plus at least two of the following: additional controller medication, beta-agonist use on at least 5 of 7 days, a baseline forced expiratory volume in 1 second (FEV₁)less than 80% of predicted, 1 or more emergency department visits within the past year, 3 or more oral steroid burst within the past year, prompt deterioration with steroid reduction, and/or a history of intubation(Am. J. Respir. Crit. Care Med. 2000;162:2341-51).

The investigators also reviewed asthma questionnaires, lung function–testing results, allergy evaluations, and biomarker evaluations.

In an analysis adjusted for race and socioeconomic status, they found that 37% of the children with severe asthma tested positive for Alternaria sensitization, compared with 21% of children with mild-to-moderate disease (adjusted OR 2.13, P = .015).

Among children with severe asthma, Alternaria sensitization was not significantly associated with differences in either blood eosinophil or total serum immunoglobulin E (IgE) levels, or in FEV₁, airflow limitation, air trapping, medication requirements, or health care use.

However, exhaled nitric oxide levels were significantly higher among those with severe asthma and sensitivity to Alternaria (P = .029), as was airway hyperresponsiveness to methacholine challenge (P = .012).

Additionally, in an analysis adjusted for socioeconomic status, children with severe asthma and a positive skin prick test to Alternaria had an adjusted OR for sinusitis of 2.43 (P = .046).

"These findings support previous observations from the Childhood Asthma Management Research Program," Dr. Shih said.

In the question and answer portion of her presentation, several clinicians commented that Alternaria might be a general marker for atopy rather than for airway hyperresponsiveness and sinusitis as seen in her study, and that other allergens such as cockroach and mites might account for exacerbations of severe asthma. Dr. Shih agreed that further studies would help to resolve this question.

The study was supported by the NHLBI and Emory University. Dr. Shih reported that she had no relevant disclosures.

ORLANDO – Children with severe asthma may have their already serious symptoms further worsened by sensitization to common household fungi in the genus Alternaria, suggested investigators at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Among 187 children with asthma enrolled in the National Heart, Lung and Blood Institutes’ Severe Asthma Research Program (SARP), 28% had a positive skin prick test reaction to Alternaria, reported Dr. Jennifer Shih, an allergy and immunology fellow in the department of pediatrics at Emory University in Atlanta.

Photo courtesy CDC/Dr. Lucille K. Georg

Sensitization to Alternaria was significantly more prevalent among children with severe vs. mild to moderate asthma (P less than .01), and children with severe presentation were significantly more likely to exhibit increased airway hyperresponsiveness (P less than .01) and to report a history of acute or chronic sinusitis requiring antibiotics (P less than .05).

"In the future, routine evaluation of Alternaria sensitization may be useful in the clinical management of children with severe asthma. Future studies are needed to evaluate the mechanistic underpinning of Alternaria sensitization in children with severe asthma," she said.

Sensitization to Alternaria has been associated in other studies with asthma persistence into early adulthood, Dr, Shih said. One study showed that Alternaria sensitization was associated with an odds ratio (OR) of 3.6 for chronic asthma at age 22 years (Lancet 2008;372:1058-64).

Increased airway hyperresponsiveness, a hallmark of severe asthma in children, was associated with Alternaria sensitization in the Childhood Asthma Management Research Program, she noted.

To see whether there were differences in Alternaria sensitization between school-age children with mild to moderate or severe asthma, and whether sensitization was associated with clinical features of asthma severity, Dr. Shih and her colleague Dr. Anne Fitzpatrick took a retrospective look at 187 children enrolled in SARP at their institution. The children ranged in age from 6 to 18 years, and all had skin prick test data available. In all, 90 had severe asthma, and 97 mild to moderate asthma.

Asthma severity was determined according to American Thoracic Society 2000 criteria, which require daily use of systemic or high-dose inhaled corticosteroids, plus at least two of the following: additional controller medication, beta-agonist use on at least 5 of 7 days, a baseline forced expiratory volume in 1 second (FEV₁)less than 80% of predicted, 1 or more emergency department visits within the past year, 3 or more oral steroid burst within the past year, prompt deterioration with steroid reduction, and/or a history of intubation(Am. J. Respir. Crit. Care Med. 2000;162:2341-51).

The investigators also reviewed asthma questionnaires, lung function–testing results, allergy evaluations, and biomarker evaluations.

In an analysis adjusted for race and socioeconomic status, they found that 37% of the children with severe asthma tested positive for Alternaria sensitization, compared with 21% of children with mild-to-moderate disease (adjusted OR 2.13, P = .015).

Among children with severe asthma, Alternaria sensitization was not significantly associated with differences in either blood eosinophil or total serum immunoglobulin E (IgE) levels, or in FEV₁, airflow limitation, air trapping, medication requirements, or health care use.

However, exhaled nitric oxide levels were significantly higher among those with severe asthma and sensitivity to Alternaria (P = .029), as was airway hyperresponsiveness to methacholine challenge (P = .012).

Additionally, in an analysis adjusted for socioeconomic status, children with severe asthma and a positive skin prick test to Alternaria had an adjusted OR for sinusitis of 2.43 (P = .046).

"These findings support previous observations from the Childhood Asthma Management Research Program," Dr. Shih said.

In the question and answer portion of her presentation, several clinicians commented that Alternaria might be a general marker for atopy rather than for airway hyperresponsiveness and sinusitis as seen in her study, and that other allergens such as cockroach and mites might account for exacerbations of severe asthma. Dr. Shih agreed that further studies would help to resolve this question.

The study was supported by the NHLBI and Emory University. Dr. Shih reported that she had no relevant disclosures.

ORLANDO – Patients who undergo surgical resection with narrow distal margins for ultra low rectal cancers can have local control of disease and overall survival comparable to those in patients with wider resection margins, investigators reported at a symposium of the Society of Surgical Oncology.

Dr. Wim P. Ceelen and coauthors reviewed 109 patients who underwent neoadjuvant chemoradiation and surgery for rectal cancers 5 cm or less from the anal verge from 1998 to 2010. Overall survival and local control were found to be the same in a comparison of patients with distal resection margins 1 cm wide or less and those with margins greater than 1 cm.

"Close but free distal margins after neoadjuvant radiation and sphincter-saving surgery do not compromise local or systemic control," said Dr. Ceelen, a surgical oncologist at University Hospital in Ghent, Belgium.

Neoadjuvant chemoradiation has made sphincter-sparing procedures available to more patients, but the surgical results often leave distal margins that some surgeons find too close for comfort, because they fall short of the so-called "1-cm rule" holding that margins should be a minimum of 1 cm from the tumor.

"There is some controversy about the oncological safety of having very close margins, i.e., less than 1 cm," Dr. Ceelen said.

To see whether margins matter, he and colleagues reviewed records in a prospective database on the 109 patients with ultra-low rectal cancers (median pretreatment distance of 3 cm from the anal verge). All patients underwent neoadjuvant chemoradiation with 5-fluorouracil and 45 Gy radiation delivered in 25 fractions, followed by sphincter-saving surgery with R0 (cancer-free) resections. In all, 59% of the patients were clinically node positive.

Surgeries included intersphincteric resection and coloanal anastomosis in 38 patients, and stapled anastamosis in 71. The large majority of patients (98) had protective loop ileostomies.

Surgical specimens showed tumors were stage 0 (pathologic complete response to chemoradiation) in 16%, stage 1 (T1-T2) in 30%, stage II (T3-T4) in 21%, and stage III (node-positive) in 19%. The median distal resection margin was 10 mm.

At a median follow-up of 33 months, 5 patients (4.6%) had a local recurrence. Two of these patients had had surgical margins of 1 cm or less, and 3 had margin greater than 1 cm. Of the 30 patients (27.5%) who had a systemic recurrence, 12 had resections with margins of 1 cm or less, and 18 had margins greater than 1 cm. Neither difference was statistically significant.

Overall 5-year survival was 70%, and again there was no significant difference in survival by margin size.

Dr. Ceelen noted that the results echo those of a recently published systematic review (Ann. Surg. Oncol. 2012;19: 801-8).

The study was internally funded. Dr. Ceelen had no disclosures.

ORLANDO – Patients who undergo surgical resection with narrow distal margins for ultra low rectal cancers can have local control of disease and overall survival comparable to those in patients with wider resection margins, investigators reported at a symposium of the Society of Surgical Oncology.

Dr. Wim P. Ceelen and coauthors reviewed 109 patients who underwent neoadjuvant chemoradiation and surgery for rectal cancers 5 cm or less from the anal verge from 1998 to 2010. Overall survival and local control were found to be the same in a comparison of patients with distal resection margins 1 cm wide or less and those with margins greater than 1 cm.

"Close but free distal margins after neoadjuvant radiation and sphincter-saving surgery do not compromise local or systemic control," said Dr. Ceelen, a surgical oncologist at University Hospital in Ghent, Belgium.

Neoadjuvant chemoradiation has made sphincter-sparing procedures available to more patients, but the surgical results often leave distal margins that some surgeons find too close for comfort, because they fall short of the so-called "1-cm rule" holding that margins should be a minimum of 1 cm from the tumor.

"There is some controversy about the oncological safety of having very close margins, i.e., less than 1 cm," Dr. Ceelen said.

To see whether margins matter, he and colleagues reviewed records in a prospective database on the 109 patients with ultra-low rectal cancers (median pretreatment distance of 3 cm from the anal verge). All patients underwent neoadjuvant chemoradiation with 5-fluorouracil and 45 Gy radiation delivered in 25 fractions, followed by sphincter-saving surgery with R0 (cancer-free) resections. In all, 59% of the patients were clinically node positive.

Surgeries included intersphincteric resection and coloanal anastomosis in 38 patients, and stapled anastamosis in 71. The large majority of patients (98) had protective loop ileostomies.

Surgical specimens showed tumors were stage 0 (pathologic complete response to chemoradiation) in 16%, stage 1 (T1-T2) in 30%, stage II (T3-T4) in 21%, and stage III (node-positive) in 19%. The median distal resection margin was 10 mm.

At a median follow-up of 33 months, 5 patients (4.6%) had a local recurrence. Two of these patients had had surgical margins of 1 cm or less, and 3 had margin greater than 1 cm. Of the 30 patients (27.5%) who had a systemic recurrence, 12 had resections with margins of 1 cm or less, and 18 had margins greater than 1 cm. Neither difference was statistically significant.

Overall 5-year survival was 70%, and again there was no significant difference in survival by margin size.

Dr. Ceelen noted that the results echo those of a recently published systematic review (Ann. Surg. Oncol. 2012;19: 801-8).

The study was internally funded. Dr. Ceelen had no disclosures.

ORLANDO – Patients who undergo surgical resection with narrow distal margins for ultra low rectal cancers can have local control of disease and overall survival comparable to those in patients with wider resection margins, investigators reported at a symposium of the Society of Surgical Oncology.

Dr. Wim P. Ceelen and coauthors reviewed 109 patients who underwent neoadjuvant chemoradiation and surgery for rectal cancers 5 cm or less from the anal verge from 1998 to 2010. Overall survival and local control were found to be the same in a comparison of patients with distal resection margins 1 cm wide or less and those with margins greater than 1 cm.

"Close but free distal margins after neoadjuvant radiation and sphincter-saving surgery do not compromise local or systemic control," said Dr. Ceelen, a surgical oncologist at University Hospital in Ghent, Belgium.

Neoadjuvant chemoradiation has made sphincter-sparing procedures available to more patients, but the surgical results often leave distal margins that some surgeons find too close for comfort, because they fall short of the so-called "1-cm rule" holding that margins should be a minimum of 1 cm from the tumor.

"There is some controversy about the oncological safety of having very close margins, i.e., less than 1 cm," Dr. Ceelen said.

To see whether margins matter, he and colleagues reviewed records in a prospective database on the 109 patients with ultra-low rectal cancers (median pretreatment distance of 3 cm from the anal verge). All patients underwent neoadjuvant chemoradiation with 5-fluorouracil and 45 Gy radiation delivered in 25 fractions, followed by sphincter-saving surgery with R0 (cancer-free) resections. In all, 59% of the patients were clinically node positive.

Surgeries included intersphincteric resection and coloanal anastomosis in 38 patients, and stapled anastamosis in 71. The large majority of patients (98) had protective loop ileostomies.

Surgical specimens showed tumors were stage 0 (pathologic complete response to chemoradiation) in 16%, stage 1 (T1-T2) in 30%, stage II (T3-T4) in 21%, and stage III (node-positive) in 19%. The median distal resection margin was 10 mm.

At a median follow-up of 33 months, 5 patients (4.6%) had a local recurrence. Two of these patients had had surgical margins of 1 cm or less, and 3 had margin greater than 1 cm. Of the 30 patients (27.5%) who had a systemic recurrence, 12 had resections with margins of 1 cm or less, and 18 had margins greater than 1 cm. Neither difference was statistically significant.

Overall 5-year survival was 70%, and again there was no significant difference in survival by margin size.

Dr. Ceelen noted that the results echo those of a recently published systematic review (Ann. Surg. Oncol. 2012;19: 801-8).

The study was internally funded. Dr. Ceelen had no disclosures.

ORLANDO – Patients with stage IA to IIA gastric adenocarcinoma are frequently managed with surgery alone, but a subset of these patients may benefit from adjuvant chemotherapy and/or radiation, suggested Boston-based investigators at a symposium sponsored by the Society of Surgical Oncology.

A review of Surveillance Epidemiology and End Results (SEER) registry data on 8,515 patients treated for gastric adenocarcinoma found that stages, age, tumor differentiation status, tumor size, and location are significantly associated with worse disease-specific survival (DSS) among patients with earlier diseases, reported Dr. Jason S. Gold, chief of surgical oncology at the VA Boston Healthcare System.

"Patients with at least two of these adverse features had a 5-year disease-specific survival of 76% or less, and perhaps these patients would be benefited by adjuvant treatment," said Dr. Gold.

Although the benefit of adjuvant therapy for stage IIB to IIIC gastric adenocarcinomas has been well documented in randomized trials, there are patients with less advanced-stage disease who have a poor prognosis and might also benefit from adjuvant therapy, Dr. Gold said.

Consensus guideline recommendations on the use of adjuvant therapy vary, with U.S. (National Comprehensive Cancer Network) and Canadian (Cancer Care Ontario) guidelines recommending adjuvant therapy for all patients except those with T1 tumors with no lymph node involvement. In contrast, European guidelines (Norwegian and Dutch) generally recommend adjuvant treatment for cancers with serosal invasion or nodal positivity, but not for patients with T1 tumors and 0-2 involved nodes, Dr. Gold said.

To tease out the natural history of stage IA- to II cancers and identify predictive factors for worse outcomes, he and colleagues combed through SEER data to identify patients with local or local-regional gastric adenocarcinoma who underwent surgery and pathologic evaluation of at least 15 lymph nodes, and who also had disease-specific survival data. They found that 2,431 patients had stages IA - IIA disease.

Not surprisingly, 887 patients with stage IA disease (T1N0) had the best odds, with a 5-year DSS of 91%. The investigators determined that these patients would be unlikely to benefit from adjuvant therapy, and excluded them from further analyses.

Among patients with stages IB through IIA disease, 5-year DSS rates ranged from 81% for patients with T1N2 and T2N0 disease, to 66% for patients with T1N1, T2N1, and T3NO disease.

In univariate analysis, factors associated with worse outcomes were older age (P less than .001), higher grade disease (P = .03), larger tumor size (P less than .001), proximal vs. distal location (P less than .001), T stage (P = .006), and TN grouping (P = .004).

In multivariate analysis, variables associated with worse outcomes were age (relative risk 1.025, P = .001), moderately or poorly differentiated or undifferentiated vs. well differentiated cancers (RR, 2.160, 3.323, and 3.306, respectively, P = .004 for all), size (RR, 1.027, P = .001) and location relative to the antrum/pylorus (gastric body RR, 1.289, and cardia/fundus RR, 2.508, P = .001 for both comparisons).

However, neither T stage, N stage nor TN grouping were independent predictors of outcome, the investigators found.

Based on these variables, they devised a risk score for stages IB-IIA, with each of the following four factors receiving 1 point: age greater than 60, tumor size greater than 5 cm, proximal location (cardia or fundus), and histologic grade other than well differentiated.

Under this risk classification system, they saw that 5-year DSS with no risk factors (two patients) was 100%, compared with 86% for patients with one risk factor (92 patients), 76% for those with two risk factors (325), 72% for those with three (372 patients), and 48% for those with all four (136 patients, P less than .001).

The study was internally funded. Dr. Gold reported having no relevant disclosures.

ORLANDO – Patients with stage IA to IIA gastric adenocarcinoma are frequently managed with surgery alone, but a subset of these patients may benefit from adjuvant chemotherapy and/or radiation, suggested Boston-based investigators at a symposium sponsored by the Society of Surgical Oncology.

A review of Surveillance Epidemiology and End Results (SEER) registry data on 8,515 patients treated for gastric adenocarcinoma found that stages, age, tumor differentiation status, tumor size, and location are significantly associated with worse disease-specific survival (DSS) among patients with earlier diseases, reported Dr. Jason S. Gold, chief of surgical oncology at the VA Boston Healthcare System.

"Patients with at least two of these adverse features had a 5-year disease-specific survival of 76% or less, and perhaps these patients would be benefited by adjuvant treatment," said Dr. Gold.

Although the benefit of adjuvant therapy for stage IIB to IIIC gastric adenocarcinomas has been well documented in randomized trials, there are patients with less advanced-stage disease who have a poor prognosis and might also benefit from adjuvant therapy, Dr. Gold said.

Consensus guideline recommendations on the use of adjuvant therapy vary, with U.S. (National Comprehensive Cancer Network) and Canadian (Cancer Care Ontario) guidelines recommending adjuvant therapy for all patients except those with T1 tumors with no lymph node involvement. In contrast, European guidelines (Norwegian and Dutch) generally recommend adjuvant treatment for cancers with serosal invasion or nodal positivity, but not for patients with T1 tumors and 0-2 involved nodes, Dr. Gold said.

To tease out the natural history of stage IA- to II cancers and identify predictive factors for worse outcomes, he and colleagues combed through SEER data to identify patients with local or local-regional gastric adenocarcinoma who underwent surgery and pathologic evaluation of at least 15 lymph nodes, and who also had disease-specific survival data. They found that 2,431 patients had stages IA - IIA disease.

Not surprisingly, 887 patients with stage IA disease (T1N0) had the best odds, with a 5-year DSS of 91%. The investigators determined that these patients would be unlikely to benefit from adjuvant therapy, and excluded them from further analyses.

Among patients with stages IB through IIA disease, 5-year DSS rates ranged from 81% for patients with T1N2 and T2N0 disease, to 66% for patients with T1N1, T2N1, and T3NO disease.

In univariate analysis, factors associated with worse outcomes were older age (P less than .001), higher grade disease (P = .03), larger tumor size (P less than .001), proximal vs. distal location (P less than .001), T stage (P = .006), and TN grouping (P = .004).

In multivariate analysis, variables associated with worse outcomes were age (relative risk 1.025, P = .001), moderately or poorly differentiated or undifferentiated vs. well differentiated cancers (RR, 2.160, 3.323, and 3.306, respectively, P = .004 for all), size (RR, 1.027, P = .001) and location relative to the antrum/pylorus (gastric body RR, 1.289, and cardia/fundus RR, 2.508, P = .001 for both comparisons).

However, neither T stage, N stage nor TN grouping were independent predictors of outcome, the investigators found.

Based on these variables, they devised a risk score for stages IB-IIA, with each of the following four factors receiving 1 point: age greater than 60, tumor size greater than 5 cm, proximal location (cardia or fundus), and histologic grade other than well differentiated.

Under this risk classification system, they saw that 5-year DSS with no risk factors (two patients) was 100%, compared with 86% for patients with one risk factor (92 patients), 76% for those with two risk factors (325), 72% for those with three (372 patients), and 48% for those with all four (136 patients, P less than .001).

The study was internally funded. Dr. Gold reported having no relevant disclosures.

ORLANDO – Patients with stage IA to IIA gastric adenocarcinoma are frequently managed with surgery alone, but a subset of these patients may benefit from adjuvant chemotherapy and/or radiation, suggested Boston-based investigators at a symposium sponsored by the Society of Surgical Oncology.

A review of Surveillance Epidemiology and End Results (SEER) registry data on 8,515 patients treated for gastric adenocarcinoma found that stages, age, tumor differentiation status, tumor size, and location are significantly associated with worse disease-specific survival (DSS) among patients with earlier diseases, reported Dr. Jason S. Gold, chief of surgical oncology at the VA Boston Healthcare System.

"Patients with at least two of these adverse features had a 5-year disease-specific survival of 76% or less, and perhaps these patients would be benefited by adjuvant treatment," said Dr. Gold.

Although the benefit of adjuvant therapy for stage IIB to IIIC gastric adenocarcinomas has been well documented in randomized trials, there are patients with less advanced-stage disease who have a poor prognosis and might also benefit from adjuvant therapy, Dr. Gold said.

Consensus guideline recommendations on the use of adjuvant therapy vary, with U.S. (National Comprehensive Cancer Network) and Canadian (Cancer Care Ontario) guidelines recommending adjuvant therapy for all patients except those with T1 tumors with no lymph node involvement. In contrast, European guidelines (Norwegian and Dutch) generally recommend adjuvant treatment for cancers with serosal invasion or nodal positivity, but not for patients with T1 tumors and 0-2 involved nodes, Dr. Gold said.

To tease out the natural history of stage IA- to II cancers and identify predictive factors for worse outcomes, he and colleagues combed through SEER data to identify patients with local or local-regional gastric adenocarcinoma who underwent surgery and pathologic evaluation of at least 15 lymph nodes, and who also had disease-specific survival data. They found that 2,431 patients had stages IA - IIA disease.

Not surprisingly, 887 patients with stage IA disease (T1N0) had the best odds, with a 5-year DSS of 91%. The investigators determined that these patients would be unlikely to benefit from adjuvant therapy, and excluded them from further analyses.

Among patients with stages IB through IIA disease, 5-year DSS rates ranged from 81% for patients with T1N2 and T2N0 disease, to 66% for patients with T1N1, T2N1, and T3NO disease.

In univariate analysis, factors associated with worse outcomes were older age (P less than .001), higher grade disease (P = .03), larger tumor size (P less than .001), proximal vs. distal location (P less than .001), T stage (P = .006), and TN grouping (P = .004).

In multivariate analysis, variables associated with worse outcomes were age (relative risk 1.025, P = .001), moderately or poorly differentiated or undifferentiated vs. well differentiated cancers (RR, 2.160, 3.323, and 3.306, respectively, P = .004 for all), size (RR, 1.027, P = .001) and location relative to the antrum/pylorus (gastric body RR, 1.289, and cardia/fundus RR, 2.508, P = .001 for both comparisons).

However, neither T stage, N stage nor TN grouping were independent predictors of outcome, the investigators found.

Based on these variables, they devised a risk score for stages IB-IIA, with each of the following four factors receiving 1 point: age greater than 60, tumor size greater than 5 cm, proximal location (cardia or fundus), and histologic grade other than well differentiated.

Under this risk classification system, they saw that 5-year DSS with no risk factors (two patients) was 100%, compared with 86% for patients with one risk factor (92 patients), 76% for those with two risk factors (325), 72% for those with three (372 patients), and 48% for those with all four (136 patients, P less than .001).

The study was internally funded. Dr. Gold reported having no relevant disclosures.