SSO 2014

PHOENIX – There is more evidence that it’s best to go with the pros: Adrenalectomies performed by higher-volume surgeons are associated with fewer complications, lower costs, and shorter lengths of stay than are those done by surgeons who dabble in the procedure.

The findings, presented at the annual Society of Surgical Oncology Cancer Symposium, come from a cross-sectional study of outcomes on all patients who underwent unilateral, partial, or bilateral adrenalectomies in the United States over a 7-year span.

©Jana Blašková/ Thinkstockphotos.com

"The frequency of adrenalectomy has steadily increased in the United States within the last few years, and with improvement of diagnostic and imaging modalities it’s likely that the rate of adrenal surgery will continue to rise," said Dr. Adam Hauch, a research resident in the department of surgery at Tulane University, New Orleans.

The prospects for the growth in the procedure prompted Dr. Hauch and colleagues to look at clinical and economic outcomes following adrenalectomy, and to see how surgeon volume, diagnosis, and type of surgery might affect outcomes.

They drew on discharge data from the Healthcare Cost and Utilization Project – National Inpatient Sample (HCUP-NIS), an administrative database sponsored by the U.S. Agency for Healthcare Research and Quality.

The information included International Classification of Diseases, Ninth Revision (ICD-9) codes identifying all adult patients who underwent adrenalectomies in U.S. hospitals from 2003 through 2009. Patients were divided into benign and malignant lesion groups.

The investigators found 7,829 procedures. Mean patient age was 50 years, most of the patients (74.4%) were white, and the majority were female (58.2%) and were privately insured (58.9%). Nearly all of the patients (98.3%) had one or no comorbidities at the time of admission. Only 42 patients (0.5%) died during their hospital stays.

More than three-fourths of the procedures (79.2%) were for benign disease; the remaining 20.8% of surgeries were for malignancies.

Low-volume surgeons, defined as those who performed one or fewer adrenalectomies on average per year, performed 41.7% of all procedures, compared with 34.7% for intermediate-volume surgeons (two to five per year) and 23.6% for high-volume surgeons (more than five per year).

The vast majority (97.1%) of procedures were unilateral/partial, and approximately 95% of surgeons in each experience category performed such procedures. Procedures for malignant disease accounted for 10.6% of cases for low-volume surgeons, 6.3% for intermediate-volume docs, and 4.3% of the most prolific surgeons.

It’s complicated

Risks for any complication were significantly higher among low-volume surgeons (18.8% of their cases), compared with 14.6% for those in the middle, and 11.6% for the high-volume operators (P less than .0001). High-volume performers had significantly lower risk for cardiovascular complications (P = .0008), pulmonary complications (P = .0481), bleeding (P = .0106), and technical difficulties during surgery (P = .0024).

In an analysis adjusted for patient demographic factors, payer, primary diagnosis, obesity, comorbidities, inpatient death, admission type, hospital teaching status and volume, surgeon, and type of procedure, low-volume surgeons were nearly twice as likely as were high-volume surgeons to have complications (adjusted odds ratio [aOR] 1.822, P less than .0001), and intermediate-volume surgeons had a nearly 1.5-fold higher risk (aOR 1.479, P = .0044).

Other risk factors for complications were bilateral vs. unilateral procedures (aOR 2.165, P = .0018), and malignant vs. benign disease (aOR 1.685, P less than .0001).

Not surprisingly, complications more than doubled mean total case charges, which ranged from $33,659 for uncomplicated unilateral cases to $73,021 for complicated cases (P = .0013), and from $47,284 for bilateral cases with no complications, to $141,461 for two-sided procedures with complications (P = .0221). Charges were higher for malignant cases than for benign cases without complications (P less than .0001), but complications brought the charges for both benign and malignant cases closer together .

Charges for noncomplicated procedures performed by high-volume surgeons were a comparative bargain at $27,324, compared with $33,499 for low- and intermediate-volume surgeons combined (P = .001). However, there were no significant differences by surgeon volume when complications arose.

Similarly, lengths of stay were prolonged when complications ensued for both unilateral cases (mean 3.7 days vs. 9.3 for complicated cases, P = .0042) and for bilateral cases (9.3 vs. 19.8, P = .025).

Higher volume surgeons managed to get patients out faster, averaging 2.7 days for cases without complications, compared with 4.2 for low/intermediate-volume surgeons (P less than .0001). When complications arose, patients of higher-volume surgeons still had shorter lengths of stay (8.5 vs. 10.4 days), but this difference was not statistically significant.

Dr. Lawrence Kim, professor of surgery at the University of North Carolina, Chapel Hill, said after the presentation that the study showed the limitations of using administrative data.

He said that approximately "98% of the patients [in the study presented] had no comorbidities, which just does not mesh with the realities I have ever faced with adrenal patients."

The study was internally funded. Dr. Hauch reported having no financial disclosures.

PHOENIX – There is more evidence that it’s best to go with the pros: Adrenalectomies performed by higher-volume surgeons are associated with fewer complications, lower costs, and shorter lengths of stay than are those done by surgeons who dabble in the procedure.

The findings, presented at the annual Society of Surgical Oncology Cancer Symposium, come from a cross-sectional study of outcomes on all patients who underwent unilateral, partial, or bilateral adrenalectomies in the United States over a 7-year span.

©Jana Blašková/ Thinkstockphotos.com

"The frequency of adrenalectomy has steadily increased in the United States within the last few years, and with improvement of diagnostic and imaging modalities it’s likely that the rate of adrenal surgery will continue to rise," said Dr. Adam Hauch, a research resident in the department of surgery at Tulane University, New Orleans.

The prospects for the growth in the procedure prompted Dr. Hauch and colleagues to look at clinical and economic outcomes following adrenalectomy, and to see how surgeon volume, diagnosis, and type of surgery might affect outcomes.

They drew on discharge data from the Healthcare Cost and Utilization Project – National Inpatient Sample (HCUP-NIS), an administrative database sponsored by the U.S. Agency for Healthcare Research and Quality.

The information included International Classification of Diseases, Ninth Revision (ICD-9) codes identifying all adult patients who underwent adrenalectomies in U.S. hospitals from 2003 through 2009. Patients were divided into benign and malignant lesion groups.

The investigators found 7,829 procedures. Mean patient age was 50 years, most of the patients (74.4%) were white, and the majority were female (58.2%) and were privately insured (58.9%). Nearly all of the patients (98.3%) had one or no comorbidities at the time of admission. Only 42 patients (0.5%) died during their hospital stays.

More than three-fourths of the procedures (79.2%) were for benign disease; the remaining 20.8% of surgeries were for malignancies.

Low-volume surgeons, defined as those who performed one or fewer adrenalectomies on average per year, performed 41.7% of all procedures, compared with 34.7% for intermediate-volume surgeons (two to five per year) and 23.6% for high-volume surgeons (more than five per year).

The vast majority (97.1%) of procedures were unilateral/partial, and approximately 95% of surgeons in each experience category performed such procedures. Procedures for malignant disease accounted for 10.6% of cases for low-volume surgeons, 6.3% for intermediate-volume docs, and 4.3% of the most prolific surgeons.

It’s complicated

Risks for any complication were significantly higher among low-volume surgeons (18.8% of their cases), compared with 14.6% for those in the middle, and 11.6% for the high-volume operators (P less than .0001). High-volume performers had significantly lower risk for cardiovascular complications (P = .0008), pulmonary complications (P = .0481), bleeding (P = .0106), and technical difficulties during surgery (P = .0024).

In an analysis adjusted for patient demographic factors, payer, primary diagnosis, obesity, comorbidities, inpatient death, admission type, hospital teaching status and volume, surgeon, and type of procedure, low-volume surgeons were nearly twice as likely as were high-volume surgeons to have complications (adjusted odds ratio [aOR] 1.822, P less than .0001), and intermediate-volume surgeons had a nearly 1.5-fold higher risk (aOR 1.479, P = .0044).

Other risk factors for complications were bilateral vs. unilateral procedures (aOR 2.165, P = .0018), and malignant vs. benign disease (aOR 1.685, P less than .0001).

Not surprisingly, complications more than doubled mean total case charges, which ranged from $33,659 for uncomplicated unilateral cases to $73,021 for complicated cases (P = .0013), and from $47,284 for bilateral cases with no complications, to $141,461 for two-sided procedures with complications (P = .0221). Charges were higher for malignant cases than for benign cases without complications (P less than .0001), but complications brought the charges for both benign and malignant cases closer together .

Charges for noncomplicated procedures performed by high-volume surgeons were a comparative bargain at $27,324, compared with $33,499 for low- and intermediate-volume surgeons combined (P = .001). However, there were no significant differences by surgeon volume when complications arose.

Similarly, lengths of stay were prolonged when complications ensued for both unilateral cases (mean 3.7 days vs. 9.3 for complicated cases, P = .0042) and for bilateral cases (9.3 vs. 19.8, P = .025).

Higher volume surgeons managed to get patients out faster, averaging 2.7 days for cases without complications, compared with 4.2 for low/intermediate-volume surgeons (P less than .0001). When complications arose, patients of higher-volume surgeons still had shorter lengths of stay (8.5 vs. 10.4 days), but this difference was not statistically significant.

Dr. Lawrence Kim, professor of surgery at the University of North Carolina, Chapel Hill, said after the presentation that the study showed the limitations of using administrative data.

He said that approximately "98% of the patients [in the study presented] had no comorbidities, which just does not mesh with the realities I have ever faced with adrenal patients."

The study was internally funded. Dr. Hauch reported having no financial disclosures.

PHOENIX – There is more evidence that it’s best to go with the pros: Adrenalectomies performed by higher-volume surgeons are associated with fewer complications, lower costs, and shorter lengths of stay than are those done by surgeons who dabble in the procedure.

The findings, presented at the annual Society of Surgical Oncology Cancer Symposium, come from a cross-sectional study of outcomes on all patients who underwent unilateral, partial, or bilateral adrenalectomies in the United States over a 7-year span.

©Jana Blašková/ Thinkstockphotos.com

"The frequency of adrenalectomy has steadily increased in the United States within the last few years, and with improvement of diagnostic and imaging modalities it’s likely that the rate of adrenal surgery will continue to rise," said Dr. Adam Hauch, a research resident in the department of surgery at Tulane University, New Orleans.

The prospects for the growth in the procedure prompted Dr. Hauch and colleagues to look at clinical and economic outcomes following adrenalectomy, and to see how surgeon volume, diagnosis, and type of surgery might affect outcomes.

They drew on discharge data from the Healthcare Cost and Utilization Project – National Inpatient Sample (HCUP-NIS), an administrative database sponsored by the U.S. Agency for Healthcare Research and Quality.

The information included International Classification of Diseases, Ninth Revision (ICD-9) codes identifying all adult patients who underwent adrenalectomies in U.S. hospitals from 2003 through 2009. Patients were divided into benign and malignant lesion groups.

The investigators found 7,829 procedures. Mean patient age was 50 years, most of the patients (74.4%) were white, and the majority were female (58.2%) and were privately insured (58.9%). Nearly all of the patients (98.3%) had one or no comorbidities at the time of admission. Only 42 patients (0.5%) died during their hospital stays.

More than three-fourths of the procedures (79.2%) were for benign disease; the remaining 20.8% of surgeries were for malignancies.

Low-volume surgeons, defined as those who performed one or fewer adrenalectomies on average per year, performed 41.7% of all procedures, compared with 34.7% for intermediate-volume surgeons (two to five per year) and 23.6% for high-volume surgeons (more than five per year).

The vast majority (97.1%) of procedures were unilateral/partial, and approximately 95% of surgeons in each experience category performed such procedures. Procedures for malignant disease accounted for 10.6% of cases for low-volume surgeons, 6.3% for intermediate-volume docs, and 4.3% of the most prolific surgeons.

It’s complicated

Risks for any complication were significantly higher among low-volume surgeons (18.8% of their cases), compared with 14.6% for those in the middle, and 11.6% for the high-volume operators (P less than .0001). High-volume performers had significantly lower risk for cardiovascular complications (P = .0008), pulmonary complications (P = .0481), bleeding (P = .0106), and technical difficulties during surgery (P = .0024).

In an analysis adjusted for patient demographic factors, payer, primary diagnosis, obesity, comorbidities, inpatient death, admission type, hospital teaching status and volume, surgeon, and type of procedure, low-volume surgeons were nearly twice as likely as were high-volume surgeons to have complications (adjusted odds ratio [aOR] 1.822, P less than .0001), and intermediate-volume surgeons had a nearly 1.5-fold higher risk (aOR 1.479, P = .0044).

Other risk factors for complications were bilateral vs. unilateral procedures (aOR 2.165, P = .0018), and malignant vs. benign disease (aOR 1.685, P less than .0001).

Not surprisingly, complications more than doubled mean total case charges, which ranged from $33,659 for uncomplicated unilateral cases to $73,021 for complicated cases (P = .0013), and from $47,284 for bilateral cases with no complications, to $141,461 for two-sided procedures with complications (P = .0221). Charges were higher for malignant cases than for benign cases without complications (P less than .0001), but complications brought the charges for both benign and malignant cases closer together .

Charges for noncomplicated procedures performed by high-volume surgeons were a comparative bargain at $27,324, compared with $33,499 for low- and intermediate-volume surgeons combined (P = .001). However, there were no significant differences by surgeon volume when complications arose.

Similarly, lengths of stay were prolonged when complications ensued for both unilateral cases (mean 3.7 days vs. 9.3 for complicated cases, P = .0042) and for bilateral cases (9.3 vs. 19.8, P = .025).

Higher volume surgeons managed to get patients out faster, averaging 2.7 days for cases without complications, compared with 4.2 for low/intermediate-volume surgeons (P less than .0001). When complications arose, patients of higher-volume surgeons still had shorter lengths of stay (8.5 vs. 10.4 days), but this difference was not statistically significant.

Dr. Lawrence Kim, professor of surgery at the University of North Carolina, Chapel Hill, said after the presentation that the study showed the limitations of using administrative data.

He said that approximately "98% of the patients [in the study presented] had no comorbidities, which just does not mesh with the realities I have ever faced with adrenal patients."

The study was internally funded. Dr. Hauch reported having no financial disclosures.

PHOENIX – More than one-fourth of men under age 50 undergoing surgery for benign goiter were found to have thyroid cancers, based on a chart review performed at the University of Pennsylvania.

The overall incidence of thyroid cancers in the patient series was 12%. Among men under age 45, the rate was "surprisingly" 28%, said Douglas R. Farquhar, a medical student at the University of Pennsylvania School of Medicine in Philadelphia.

Neil Osterweil/Frontline Medical News

Although thyroid goiters have traditionally been thought to be associated with a low risk for malignancy, recent studies have suggested otherwise. "In the literature we have seen published rates of up to 35%, which is much higher than we all had anticipated," Mr. Farquhar said at the annual Society of Surgical Oncology Cancer Symposium.

To get a better handle on the preoperative and patient characteristics associated with incident thyroid cancer and characterize the types of thyroid cancer discovered incidentally, Mr. Farquhar and his colleagues reviewed charts on all patients who underwent either total thyroidectomy or thyroid lobectomy for goiter at the center from 2004 through 2012.

Many cases of goiter can be medically managed, but surgery may be indicated in cases of pressure symptoms, cosmesis, or suspicion of malignancy, the investigators noted.

They excluded from their study patients with preoperative fine-needle aspiration pathology findings of Bethesda level III-VI (follicular lesion of undetermined significance, follicular neoplasm, suspicious or positive for malignancy).

Among 418 patients undergoing goiter surgery, 367 had goiter only, and 51 (12%) had an incident thyroid cancer. In all, 38 (75%) had papillary carcinomas, 10 (20%) had follicular carcinomas, 3 (6%) had Hürthle cell carcinomas, and 2 (4%) had thyroid lymphomas (two patients had multiple thyroid cancers, explaining the percentage greater than 100). An additional 67 patients (16%) were found to have micropapillary lesions.

Looking at the population as a whole, the investigators found that patients with thyroid cancer tended to be younger, with a mean age of 49.5 vs. 54.6 years (P = .012). There was a trend toward more cancers among men than women, but it was not significant.

There were no significant differences in any preoperative factors between patients with cancers and those with goiter only, including number of nodules, site of dominant nodule (right, left, or isthmus), thyroid function, thyroid weight, or fine-needle aspiration results (percentage deemed benign or nondiagnostic).

In a multivariate analysis, male sex was associated with a more than twofold risk for thyroid cancer (odds ratio, 2.39; 95% confidence interval, 1.152-4.978). There were also trends toward a lower risk of cancer with each additional decade of life, and a higher risk among patients who had undergone thyroid lobectomy, but these were nonsignificant associations.

"Knowledge of these associations may prove to be useful for both patient counseling and surgical decision making," Mr. Farquhar said.

The study was internally funded. The senior author was Dr. Douglas L. Fraker, chief of the division of endocrine and oncologic surgery at the University of Pennsylvania.

Mr. Farquhar and his coauthors reported having no relevant financial disclosures.

PHOENIX – More than one-fourth of men under age 50 undergoing surgery for benign goiter were found to have thyroid cancers, based on a chart review performed at the University of Pennsylvania.

The overall incidence of thyroid cancers in the patient series was 12%. Among men under age 45, the rate was "surprisingly" 28%, said Douglas R. Farquhar, a medical student at the University of Pennsylvania School of Medicine in Philadelphia.

Neil Osterweil/Frontline Medical News

Although thyroid goiters have traditionally been thought to be associated with a low risk for malignancy, recent studies have suggested otherwise. "In the literature we have seen published rates of up to 35%, which is much higher than we all had anticipated," Mr. Farquhar said at the annual Society of Surgical Oncology Cancer Symposium.

To get a better handle on the preoperative and patient characteristics associated with incident thyroid cancer and characterize the types of thyroid cancer discovered incidentally, Mr. Farquhar and his colleagues reviewed charts on all patients who underwent either total thyroidectomy or thyroid lobectomy for goiter at the center from 2004 through 2012.

Many cases of goiter can be medically managed, but surgery may be indicated in cases of pressure symptoms, cosmesis, or suspicion of malignancy, the investigators noted.

They excluded from their study patients with preoperative fine-needle aspiration pathology findings of Bethesda level III-VI (follicular lesion of undetermined significance, follicular neoplasm, suspicious or positive for malignancy).

Among 418 patients undergoing goiter surgery, 367 had goiter only, and 51 (12%) had an incident thyroid cancer. In all, 38 (75%) had papillary carcinomas, 10 (20%) had follicular carcinomas, 3 (6%) had Hürthle cell carcinomas, and 2 (4%) had thyroid lymphomas (two patients had multiple thyroid cancers, explaining the percentage greater than 100). An additional 67 patients (16%) were found to have micropapillary lesions.

Looking at the population as a whole, the investigators found that patients with thyroid cancer tended to be younger, with a mean age of 49.5 vs. 54.6 years (P = .012). There was a trend toward more cancers among men than women, but it was not significant.

There were no significant differences in any preoperative factors between patients with cancers and those with goiter only, including number of nodules, site of dominant nodule (right, left, or isthmus), thyroid function, thyroid weight, or fine-needle aspiration results (percentage deemed benign or nondiagnostic).

In a multivariate analysis, male sex was associated with a more than twofold risk for thyroid cancer (odds ratio, 2.39; 95% confidence interval, 1.152-4.978). There were also trends toward a lower risk of cancer with each additional decade of life, and a higher risk among patients who had undergone thyroid lobectomy, but these were nonsignificant associations.

"Knowledge of these associations may prove to be useful for both patient counseling and surgical decision making," Mr. Farquhar said.

The study was internally funded. The senior author was Dr. Douglas L. Fraker, chief of the division of endocrine and oncologic surgery at the University of Pennsylvania.

Mr. Farquhar and his coauthors reported having no relevant financial disclosures.

PHOENIX – More than one-fourth of men under age 50 undergoing surgery for benign goiter were found to have thyroid cancers, based on a chart review performed at the University of Pennsylvania.

The overall incidence of thyroid cancers in the patient series was 12%. Among men under age 45, the rate was "surprisingly" 28%, said Douglas R. Farquhar, a medical student at the University of Pennsylvania School of Medicine in Philadelphia.

Neil Osterweil/Frontline Medical News

Although thyroid goiters have traditionally been thought to be associated with a low risk for malignancy, recent studies have suggested otherwise. "In the literature we have seen published rates of up to 35%, which is much higher than we all had anticipated," Mr. Farquhar said at the annual Society of Surgical Oncology Cancer Symposium.

To get a better handle on the preoperative and patient characteristics associated with incident thyroid cancer and characterize the types of thyroid cancer discovered incidentally, Mr. Farquhar and his colleagues reviewed charts on all patients who underwent either total thyroidectomy or thyroid lobectomy for goiter at the center from 2004 through 2012.

Many cases of goiter can be medically managed, but surgery may be indicated in cases of pressure symptoms, cosmesis, or suspicion of malignancy, the investigators noted.

They excluded from their study patients with preoperative fine-needle aspiration pathology findings of Bethesda level III-VI (follicular lesion of undetermined significance, follicular neoplasm, suspicious or positive for malignancy).

Among 418 patients undergoing goiter surgery, 367 had goiter only, and 51 (12%) had an incident thyroid cancer. In all, 38 (75%) had papillary carcinomas, 10 (20%) had follicular carcinomas, 3 (6%) had Hürthle cell carcinomas, and 2 (4%) had thyroid lymphomas (two patients had multiple thyroid cancers, explaining the percentage greater than 100). An additional 67 patients (16%) were found to have micropapillary lesions.

Looking at the population as a whole, the investigators found that patients with thyroid cancer tended to be younger, with a mean age of 49.5 vs. 54.6 years (P = .012). There was a trend toward more cancers among men than women, but it was not significant.

There were no significant differences in any preoperative factors between patients with cancers and those with goiter only, including number of nodules, site of dominant nodule (right, left, or isthmus), thyroid function, thyroid weight, or fine-needle aspiration results (percentage deemed benign or nondiagnostic).

In a multivariate analysis, male sex was associated with a more than twofold risk for thyroid cancer (odds ratio, 2.39; 95% confidence interval, 1.152-4.978). There were also trends toward a lower risk of cancer with each additional decade of life, and a higher risk among patients who had undergone thyroid lobectomy, but these were nonsignificant associations.

"Knowledge of these associations may prove to be useful for both patient counseling and surgical decision making," Mr. Farquhar said.

The study was internally funded. The senior author was Dr. Douglas L. Fraker, chief of the division of endocrine and oncologic surgery at the University of Pennsylvania.

Mr. Farquhar and his coauthors reported having no relevant financial disclosures.

PHOENIX, ARIZ. – Induction therapy does not appear to significantly increase the risk of postoperative complications in patients who undergo minimally invasive esophagectomy for esophageal adenocarcinoma, according to results of a study reported at the annual Society of Surgical Oncology Cancer Symposium.

"After balancing pretreatment variables that can potentially influence treatment decisions, we found that induction therapy does not significantly impact on perioperative outcomes compared with patients who are treated with minimally invasive esophagectomy as primary therapy," said Dr. Katie Sue Nason, of the department of cardiothoracic surgery at the University of Pittsburgh.

That conclusion comes from a propensity-matched analysis in which patients with similar pretreatment predictor variables were paired in an attempt to reduce comparison biases.

The investigators found no significant differences in mortality, major adverse events, readmissions, reoperations, or length of stay between 197 patients who received induction therapy and minimally invasive esophagectomy and 178 who had esophagectomy alone.

Although induction chemoradiation therapy may reduce the incidence of local and distant treatment failures in patients with esophageal cancer, it has the potential to increase the risk of postoperative adverse outcomes.

"What’s often not considered is that these factors that influence postoperative outcomes may also be influencing treatment allocation," Dr. Nason said.

In observational studies, for example, there may be larger differences in observed covariates between treatment groups that could lead to biased estimates of treatment effects.

"This could be adjusted for using propensity score matching, where you generate the conditional probability of one individual being treated with a particular treatment approach given multiple pretreatment covariates. By doing propensity score matching, you can then balance these covariates such as age and various comorbid illnesses between the two groups, and perhaps eliminate this treatment allocation bias that impacts on the relationship between the treatment and the postoperative outcomes," Dr. Nason explained.

She and her colleagues applied the technique to an analysis of outcomes from 375 patients with clinical stage II or greater esophageal adenocarcinoma treated with minimally invasive esophagectomy. They assessed tumor variables, comorbidities, treatments, and outcomes, and created propensity matching scores to match surgery-only patients one-on-one with no repeats to a patient who also underwent induction therapy and had a propensity score within 0.05 of that for the surgery-only patient.

Patients without suitable matches were excluded from the data set.

The extensive list of variables included age, smoking status, alcohol use, history of Barrett’s esophagus, myriad comorbidities, cancer location, pretreatment clinical stage, and many others.

Among the 375 patients, the investigators were able to generate propensity-matching scores for 82 pairs for the comparison of treatments and outcome.

They found that there were no significant differences between induction and surgery-only patients in the primary outcome of adverse events within 30 days of surgery, including in-hospital and 30-day mortality, major adverse events or at least 1 postoperative adverse event, readmission within 30 days, reoperation in-hospital or within 30 days, or length of stay greater than 10 days.

Dr. Nason noted that although unmatched patients differed in age, presentation with alarm symptoms, daily alcohol use, clinical stage and comorbid illnesses, the pretreatment variables were all well balanced in the propensity-matched analysis.

Mortality after minimally invasive esophagectomy was 1.8% among all 375 patients, 1.5% among patients who underwent induction, and 2.3% among patients who underwent surgery alone; these differences were not significant.

Major adverse events occurred in 28% of patients overall, 27% of those who received induction, and 30% of those who had surgery alone, also not significant.

The study was internally funded. Dr. Nason reported having no financial disclosures.

PHOENIX, ARIZ. – Induction therapy does not appear to significantly increase the risk of postoperative complications in patients who undergo minimally invasive esophagectomy for esophageal adenocarcinoma, according to results of a study reported at the annual Society of Surgical Oncology Cancer Symposium.

"After balancing pretreatment variables that can potentially influence treatment decisions, we found that induction therapy does not significantly impact on perioperative outcomes compared with patients who are treated with minimally invasive esophagectomy as primary therapy," said Dr. Katie Sue Nason, of the department of cardiothoracic surgery at the University of Pittsburgh.

That conclusion comes from a propensity-matched analysis in which patients with similar pretreatment predictor variables were paired in an attempt to reduce comparison biases.

The investigators found no significant differences in mortality, major adverse events, readmissions, reoperations, or length of stay between 197 patients who received induction therapy and minimally invasive esophagectomy and 178 who had esophagectomy alone.

Although induction chemoradiation therapy may reduce the incidence of local and distant treatment failures in patients with esophageal cancer, it has the potential to increase the risk of postoperative adverse outcomes.

"What’s often not considered is that these factors that influence postoperative outcomes may also be influencing treatment allocation," Dr. Nason said.

In observational studies, for example, there may be larger differences in observed covariates between treatment groups that could lead to biased estimates of treatment effects.

"This could be adjusted for using propensity score matching, where you generate the conditional probability of one individual being treated with a particular treatment approach given multiple pretreatment covariates. By doing propensity score matching, you can then balance these covariates such as age and various comorbid illnesses between the two groups, and perhaps eliminate this treatment allocation bias that impacts on the relationship between the treatment and the postoperative outcomes," Dr. Nason explained.

She and her colleagues applied the technique to an analysis of outcomes from 375 patients with clinical stage II or greater esophageal adenocarcinoma treated with minimally invasive esophagectomy. They assessed tumor variables, comorbidities, treatments, and outcomes, and created propensity matching scores to match surgery-only patients one-on-one with no repeats to a patient who also underwent induction therapy and had a propensity score within 0.05 of that for the surgery-only patient.

Patients without suitable matches were excluded from the data set.

The extensive list of variables included age, smoking status, alcohol use, history of Barrett’s esophagus, myriad comorbidities, cancer location, pretreatment clinical stage, and many others.

Among the 375 patients, the investigators were able to generate propensity-matching scores for 82 pairs for the comparison of treatments and outcome.

They found that there were no significant differences between induction and surgery-only patients in the primary outcome of adverse events within 30 days of surgery, including in-hospital and 30-day mortality, major adverse events or at least 1 postoperative adverse event, readmission within 30 days, reoperation in-hospital or within 30 days, or length of stay greater than 10 days.

Dr. Nason noted that although unmatched patients differed in age, presentation with alarm symptoms, daily alcohol use, clinical stage and comorbid illnesses, the pretreatment variables were all well balanced in the propensity-matched analysis.

Mortality after minimally invasive esophagectomy was 1.8% among all 375 patients, 1.5% among patients who underwent induction, and 2.3% among patients who underwent surgery alone; these differences were not significant.

Major adverse events occurred in 28% of patients overall, 27% of those who received induction, and 30% of those who had surgery alone, also not significant.

The study was internally funded. Dr. Nason reported having no financial disclosures.

PHOENIX, ARIZ. – Induction therapy does not appear to significantly increase the risk of postoperative complications in patients who undergo minimally invasive esophagectomy for esophageal adenocarcinoma, according to results of a study reported at the annual Society of Surgical Oncology Cancer Symposium.

"After balancing pretreatment variables that can potentially influence treatment decisions, we found that induction therapy does not significantly impact on perioperative outcomes compared with patients who are treated with minimally invasive esophagectomy as primary therapy," said Dr. Katie Sue Nason, of the department of cardiothoracic surgery at the University of Pittsburgh.

That conclusion comes from a propensity-matched analysis in which patients with similar pretreatment predictor variables were paired in an attempt to reduce comparison biases.

The investigators found no significant differences in mortality, major adverse events, readmissions, reoperations, or length of stay between 197 patients who received induction therapy and minimally invasive esophagectomy and 178 who had esophagectomy alone.

Although induction chemoradiation therapy may reduce the incidence of local and distant treatment failures in patients with esophageal cancer, it has the potential to increase the risk of postoperative adverse outcomes.

"What’s often not considered is that these factors that influence postoperative outcomes may also be influencing treatment allocation," Dr. Nason said.

In observational studies, for example, there may be larger differences in observed covariates between treatment groups that could lead to biased estimates of treatment effects.

"This could be adjusted for using propensity score matching, where you generate the conditional probability of one individual being treated with a particular treatment approach given multiple pretreatment covariates. By doing propensity score matching, you can then balance these covariates such as age and various comorbid illnesses between the two groups, and perhaps eliminate this treatment allocation bias that impacts on the relationship between the treatment and the postoperative outcomes," Dr. Nason explained.

She and her colleagues applied the technique to an analysis of outcomes from 375 patients with clinical stage II or greater esophageal adenocarcinoma treated with minimally invasive esophagectomy. They assessed tumor variables, comorbidities, treatments, and outcomes, and created propensity matching scores to match surgery-only patients one-on-one with no repeats to a patient who also underwent induction therapy and had a propensity score within 0.05 of that for the surgery-only patient.

Patients without suitable matches were excluded from the data set.

The extensive list of variables included age, smoking status, alcohol use, history of Barrett’s esophagus, myriad comorbidities, cancer location, pretreatment clinical stage, and many others.

Among the 375 patients, the investigators were able to generate propensity-matching scores for 82 pairs for the comparison of treatments and outcome.

They found that there were no significant differences between induction and surgery-only patients in the primary outcome of adverse events within 30 days of surgery, including in-hospital and 30-day mortality, major adverse events or at least 1 postoperative adverse event, readmission within 30 days, reoperation in-hospital or within 30 days, or length of stay greater than 10 days.

Dr. Nason noted that although unmatched patients differed in age, presentation with alarm symptoms, daily alcohol use, clinical stage and comorbid illnesses, the pretreatment variables were all well balanced in the propensity-matched analysis.

Mortality after minimally invasive esophagectomy was 1.8% among all 375 patients, 1.5% among patients who underwent induction, and 2.3% among patients who underwent surgery alone; these differences were not significant.

Major adverse events occurred in 28% of patients overall, 27% of those who received induction, and 30% of those who had surgery alone, also not significant.

The study was internally funded. Dr. Nason reported having no financial disclosures.

PHOENIX, ARIZ. – Cost and quality are not always synonymous, particularly when it comes to complex surgical procedures such as esophagectomy.

A review of records on more than 6,700 patients who underwent esophagectomy during a 4-year period showed that factors such as patient age, severity of illness, and hospital/surgeon volume can have a major effect on resource utilization and costs, said Dr. Daniel E. Abbott, assistant professor of surgery at the University of Cincinnati.

"There are certainly actionable risk factors for poor outcomes, such as mortality, and increased resource utilization, including dollar costs, the opportunity costs of increased length of stay, readmission, and rehabilitation and skilled nursing facilities," he reported at the annual Society of Surgical Oncology Cancer Symposium.

"I would argue that careful patient selection can have profound influences on cost-effectiveness. I think that as our health care is evolving and our outcomes are increasingly scrutinized, there will be increasing pressure to have better outcomes at lower costs," he added.

Neil Osterweil/Frontline Medical News

Dr. Abbott and his colleagues examined clinical variables in the cases of 6,737 esophagectomy patients treated from 2009 through 2012 in the University Healthsystems Consortium (UHC), an organization comprising 120 university hospitals and 299 affiliates.

They evaluated patient characteristics such as age and race, severity of illness index (1-4), esophagectomy type, and center and surgeon volume, and evaluated the effects of these variables on clinical outcomes that contribute to resource utilization, including deaths, readmissions, length of stay (LOS), and discharge disposition.

They found that the median LOS for all patients was 10 days (interquartile range, 8-17 days), but for patients over age 70, the median LOS was 11 days (P less than .01 vs. patients 70 and under).

Older patients did not have significantly higher readmission rates, but of the 4.2% of all patients who died in hospital, those over age 70 had more than twice the death rate of younger patients (7.0% vs. 3.2%, P less than .01).

Older patients were also significantly more likely to be discharged to a skilled nursing or rehabilitation facility than were younger patients (31.9% vs. 10.6%; P less than .01).

Total median cost per patient was $25,952, but again, older patients accounted for more of the expenses, at a median of $27,628 vs. $25,841 for those 70 and under (P less than .01).

In a multivariate analysis, patients over 70 had a more than twofold increase in risk of death (odds ratio, 2.12; P less than .01). Other factors significantly associated with greater risk for death were greater severity of illness (OR, 14.0; P less than .01) and black race vs. other races (OR, 1.88; P less than .01).

Factors associated with more frequent readmissions included greater severity of illness (OR, 1.33; P less than .01), and black race (OR, 1.34; P = .01), while patients of high-volume surgeons were less likely to need readmission (OR, 0.87; P = .04).

Lengths of stay were greater among patients over age 70, with every year over 70 translating into a 6% greater LOS (OR, 1.06; P =.03); older patients had a 16% increase in LOS for every year over 70 (OR, 1.16; P less than .01).

Similarly, each increase in severity of illness index score above 2 was associated with a 31% increase in LOS (OR, 1.31) and a 475% increase in intensive care unit (ICU) days (OR, 4.75; P less than .01 for both LOS and ICU days).

Black patients had a 22% increase in LOS vs. other races (OR, 1.22; P less than .01) and a 31% relative increase in ICU days (OR, 1.31; P = .01).

Because age and severity of illness were both strong predictors for mortality, readmission, and other perioperative outcomes, the authors conducted a further analysis combining the two variables, and found that for every 5 years of age, there were significant increases in the risk for death among patients with a greater severity of illness, compared with low severity.

Dr. Abbott noted that some of the odds ratios for older, sicker patients were "ridiculously high," probably because of the smaller sample sizes.

In a multivariate analysis of cost, factors associated with higher costs were age (OR, 1.14; P less than .01), greater severity of illness (OR, 2.14; P less than .01), and black race (OR, 1.15; P less than .01).

And in an analysis of cumulative resource use, the authors found what Dr. Abbott called a "snowball effect," in that hospitals with the lowest total costs discharged the majority of patients home, and that as costs increased, hospitals were less likely to discharge patients home and more likely to discharge them either to home health services or to extended care. In addition, as costs rose, the percentage of patients who died in hospital also rose.

He acknowledged that because the study used administrative data from university hospitals, it was skewed toward high-volume centers, and that the database did not include survival data, information about longitudinal resource use, or procedure-specific complications.

The authors did not disclose the funding source of the study. Dr. Abbott reported having no financial disclosures.

PHOENIX, ARIZ. – Cost and quality are not always synonymous, particularly when it comes to complex surgical procedures such as esophagectomy.

A review of records on more than 6,700 patients who underwent esophagectomy during a 4-year period showed that factors such as patient age, severity of illness, and hospital/surgeon volume can have a major effect on resource utilization and costs, said Dr. Daniel E. Abbott, assistant professor of surgery at the University of Cincinnati.

"There are certainly actionable risk factors for poor outcomes, such as mortality, and increased resource utilization, including dollar costs, the opportunity costs of increased length of stay, readmission, and rehabilitation and skilled nursing facilities," he reported at the annual Society of Surgical Oncology Cancer Symposium.

"I would argue that careful patient selection can have profound influences on cost-effectiveness. I think that as our health care is evolving and our outcomes are increasingly scrutinized, there will be increasing pressure to have better outcomes at lower costs," he added.

Neil Osterweil/Frontline Medical News

Dr. Abbott and his colleagues examined clinical variables in the cases of 6,737 esophagectomy patients treated from 2009 through 2012 in the University Healthsystems Consortium (UHC), an organization comprising 120 university hospitals and 299 affiliates.

They evaluated patient characteristics such as age and race, severity of illness index (1-4), esophagectomy type, and center and surgeon volume, and evaluated the effects of these variables on clinical outcomes that contribute to resource utilization, including deaths, readmissions, length of stay (LOS), and discharge disposition.

They found that the median LOS for all patients was 10 days (interquartile range, 8-17 days), but for patients over age 70, the median LOS was 11 days (P less than .01 vs. patients 70 and under).

Older patients did not have significantly higher readmission rates, but of the 4.2% of all patients who died in hospital, those over age 70 had more than twice the death rate of younger patients (7.0% vs. 3.2%, P less than .01).

Older patients were also significantly more likely to be discharged to a skilled nursing or rehabilitation facility than were younger patients (31.9% vs. 10.6%; P less than .01).

Total median cost per patient was $25,952, but again, older patients accounted for more of the expenses, at a median of $27,628 vs. $25,841 for those 70 and under (P less than .01).

In a multivariate analysis, patients over 70 had a more than twofold increase in risk of death (odds ratio, 2.12; P less than .01). Other factors significantly associated with greater risk for death were greater severity of illness (OR, 14.0; P less than .01) and black race vs. other races (OR, 1.88; P less than .01).

Factors associated with more frequent readmissions included greater severity of illness (OR, 1.33; P less than .01), and black race (OR, 1.34; P = .01), while patients of high-volume surgeons were less likely to need readmission (OR, 0.87; P = .04).

Lengths of stay were greater among patients over age 70, with every year over 70 translating into a 6% greater LOS (OR, 1.06; P =.03); older patients had a 16% increase in LOS for every year over 70 (OR, 1.16; P less than .01).

Similarly, each increase in severity of illness index score above 2 was associated with a 31% increase in LOS (OR, 1.31) and a 475% increase in intensive care unit (ICU) days (OR, 4.75; P less than .01 for both LOS and ICU days).

Black patients had a 22% increase in LOS vs. other races (OR, 1.22; P less than .01) and a 31% relative increase in ICU days (OR, 1.31; P = .01).

Because age and severity of illness were both strong predictors for mortality, readmission, and other perioperative outcomes, the authors conducted a further analysis combining the two variables, and found that for every 5 years of age, there were significant increases in the risk for death among patients with a greater severity of illness, compared with low severity.

Dr. Abbott noted that some of the odds ratios for older, sicker patients were "ridiculously high," probably because of the smaller sample sizes.

In a multivariate analysis of cost, factors associated with higher costs were age (OR, 1.14; P less than .01), greater severity of illness (OR, 2.14; P less than .01), and black race (OR, 1.15; P less than .01).

And in an analysis of cumulative resource use, the authors found what Dr. Abbott called a "snowball effect," in that hospitals with the lowest total costs discharged the majority of patients home, and that as costs increased, hospitals were less likely to discharge patients home and more likely to discharge them either to home health services or to extended care. In addition, as costs rose, the percentage of patients who died in hospital also rose.

He acknowledged that because the study used administrative data from university hospitals, it was skewed toward high-volume centers, and that the database did not include survival data, information about longitudinal resource use, or procedure-specific complications.

The authors did not disclose the funding source of the study. Dr. Abbott reported having no financial disclosures.

PHOENIX, ARIZ. – Cost and quality are not always synonymous, particularly when it comes to complex surgical procedures such as esophagectomy.

A review of records on more than 6,700 patients who underwent esophagectomy during a 4-year period showed that factors such as patient age, severity of illness, and hospital/surgeon volume can have a major effect on resource utilization and costs, said Dr. Daniel E. Abbott, assistant professor of surgery at the University of Cincinnati.

"There are certainly actionable risk factors for poor outcomes, such as mortality, and increased resource utilization, including dollar costs, the opportunity costs of increased length of stay, readmission, and rehabilitation and skilled nursing facilities," he reported at the annual Society of Surgical Oncology Cancer Symposium.

"I would argue that careful patient selection can have profound influences on cost-effectiveness. I think that as our health care is evolving and our outcomes are increasingly scrutinized, there will be increasing pressure to have better outcomes at lower costs," he added.

Neil Osterweil/Frontline Medical News

Dr. Abbott and his colleagues examined clinical variables in the cases of 6,737 esophagectomy patients treated from 2009 through 2012 in the University Healthsystems Consortium (UHC), an organization comprising 120 university hospitals and 299 affiliates.

They evaluated patient characteristics such as age and race, severity of illness index (1-4), esophagectomy type, and center and surgeon volume, and evaluated the effects of these variables on clinical outcomes that contribute to resource utilization, including deaths, readmissions, length of stay (LOS), and discharge disposition.

They found that the median LOS for all patients was 10 days (interquartile range, 8-17 days), but for patients over age 70, the median LOS was 11 days (P less than .01 vs. patients 70 and under).

Older patients did not have significantly higher readmission rates, but of the 4.2% of all patients who died in hospital, those over age 70 had more than twice the death rate of younger patients (7.0% vs. 3.2%, P less than .01).

Older patients were also significantly more likely to be discharged to a skilled nursing or rehabilitation facility than were younger patients (31.9% vs. 10.6%; P less than .01).

Total median cost per patient was $25,952, but again, older patients accounted for more of the expenses, at a median of $27,628 vs. $25,841 for those 70 and under (P less than .01).

In a multivariate analysis, patients over 70 had a more than twofold increase in risk of death (odds ratio, 2.12; P less than .01). Other factors significantly associated with greater risk for death were greater severity of illness (OR, 14.0; P less than .01) and black race vs. other races (OR, 1.88; P less than .01).

Factors associated with more frequent readmissions included greater severity of illness (OR, 1.33; P less than .01), and black race (OR, 1.34; P = .01), while patients of high-volume surgeons were less likely to need readmission (OR, 0.87; P = .04).

Lengths of stay were greater among patients over age 70, with every year over 70 translating into a 6% greater LOS (OR, 1.06; P =.03); older patients had a 16% increase in LOS for every year over 70 (OR, 1.16; P less than .01).

Similarly, each increase in severity of illness index score above 2 was associated with a 31% increase in LOS (OR, 1.31) and a 475% increase in intensive care unit (ICU) days (OR, 4.75; P less than .01 for both LOS and ICU days).

Black patients had a 22% increase in LOS vs. other races (OR, 1.22; P less than .01) and a 31% relative increase in ICU days (OR, 1.31; P = .01).

Because age and severity of illness were both strong predictors for mortality, readmission, and other perioperative outcomes, the authors conducted a further analysis combining the two variables, and found that for every 5 years of age, there were significant increases in the risk for death among patients with a greater severity of illness, compared with low severity.

Dr. Abbott noted that some of the odds ratios for older, sicker patients were "ridiculously high," probably because of the smaller sample sizes.

In a multivariate analysis of cost, factors associated with higher costs were age (OR, 1.14; P less than .01), greater severity of illness (OR, 2.14; P less than .01), and black race (OR, 1.15; P less than .01).

And in an analysis of cumulative resource use, the authors found what Dr. Abbott called a "snowball effect," in that hospitals with the lowest total costs discharged the majority of patients home, and that as costs increased, hospitals were less likely to discharge patients home and more likely to discharge them either to home health services or to extended care. In addition, as costs rose, the percentage of patients who died in hospital also rose.

He acknowledged that because the study used administrative data from university hospitals, it was skewed toward high-volume centers, and that the database did not include survival data, information about longitudinal resource use, or procedure-specific complications.

The authors did not disclose the funding source of the study. Dr. Abbott reported having no financial disclosures.

PHOENIX, ARIZ. – Neoadjuvant therapy appears to be safe in patients with rectal cancer and inflammatory bowel disease, investigators from the Netherlands reported at the annual Society of Surgical Oncology Cancer Symposium.

Among Dutch patients with a diagnosis of Crohn’s disease (CD), ulcerative colitis (UC), or unspecified colitis who underwent total mesorectal excision, neither neoadjuvant therapy nor immunosuppressive therapy significantly increased the rate of acute postsurgical complications, said Dr. Stefanus van Rooijen.

Patients with inflammatory bowel disease (IBD) have typically been excluded from studies of neoadjuvant chemotherapy and radiation because of fear of complications, but this study shows that "in IBD patients, rectal cancer can be treated the same way as in patients with sporadic rectal cancer, because there were no differences in complications after operations or after getting neoadjuvant therapy," Dr. van Rooijen said in an interview.

Neil Osterweil/Frontline Medical News

To determine whether neoadjuvant therapies might make life more difficult after surgery for patients with IBD and rectal cancer, the investigators reviewed records on all patients with IBD and rectal cancer treated in the Netherlands from 1990 through 2010, and compared their cases to those other patients with rectal cancer treated in the nation during the same period.

They identified a total of 173 patients with IBD: 89 with UC, 70 with CD, and 14 with indeterminate colitis. The majority of patients (112, 64.7%) were male. The mean age at rectal cancer diagnosis was 60.7 years, and the mean duration of IBD before diagnosis was 17.4 years, Dr. van Rooijen and his colleagues at Radboud University Medical Center, Nijmegen, the Netherlands, reported in a poster.

In all, 63 patients with IBD (36.4%) received neoadjuvant therapy, including short-course radiotherapy (29 patients), long-course radiotherapy (13) and chemoradiation (21).

Of the 154 patients who went on to tumor resection, 145 had a known diagnosis of rectal cancer, with significantly more patients with UC having a preoperative rectal cancer diagnosis (90.9% vs. 72.7% for patients with CD; P = .022).

Patients with CD were significantly younger at the time of rectal cancer diagnosis, at a mean of 53.7 years, compared with 63.5 years for patients with UC, and 76 years for those with indeterminate colitis (P = .022).

In all, 42% of patients developed one or more complications after surgery, as scored by the Clavien-Dindo Classification scale (Ann. Surg. 2004;240:205-13).

The most frequent complications reported were grade 2 complications in 27.4% of cases, including presacral or intra-abdominal abscesses, perineal or abdominal wounds, or urologic problems. A total of 48 grade 3 or greater complications were seen in 41 patients.

Rates of complications were similar between patients with IBD who were on chronic immunosuppressive therapy and those who were not, and between patients who received neoadjuvant therapy of any kind and those who did not, and were similar to those seen in the general rectal cancer population, Dr. van Rooijen said.

The authors also found that because rectal cancer may go unrecognized in patients with IBD until they undergo surgery for another reason, there are a relatively high number of incomplete (R1) resections compared with patients with sporadic rectal cancers.

The study was supported by Radboud Medical Center. Dr. van Rooijen reported having no financial disclosures.

PHOENIX, ARIZ. – Neoadjuvant therapy appears to be safe in patients with rectal cancer and inflammatory bowel disease, investigators from the Netherlands reported at the annual Society of Surgical Oncology Cancer Symposium.

Among Dutch patients with a diagnosis of Crohn’s disease (CD), ulcerative colitis (UC), or unspecified colitis who underwent total mesorectal excision, neither neoadjuvant therapy nor immunosuppressive therapy significantly increased the rate of acute postsurgical complications, said Dr. Stefanus van Rooijen.

Patients with inflammatory bowel disease (IBD) have typically been excluded from studies of neoadjuvant chemotherapy and radiation because of fear of complications, but this study shows that "in IBD patients, rectal cancer can be treated the same way as in patients with sporadic rectal cancer, because there were no differences in complications after operations or after getting neoadjuvant therapy," Dr. van Rooijen said in an interview.

Neil Osterweil/Frontline Medical News

To determine whether neoadjuvant therapies might make life more difficult after surgery for patients with IBD and rectal cancer, the investigators reviewed records on all patients with IBD and rectal cancer treated in the Netherlands from 1990 through 2010, and compared their cases to those other patients with rectal cancer treated in the nation during the same period.

They identified a total of 173 patients with IBD: 89 with UC, 70 with CD, and 14 with indeterminate colitis. The majority of patients (112, 64.7%) were male. The mean age at rectal cancer diagnosis was 60.7 years, and the mean duration of IBD before diagnosis was 17.4 years, Dr. van Rooijen and his colleagues at Radboud University Medical Center, Nijmegen, the Netherlands, reported in a poster.

In all, 63 patients with IBD (36.4%) received neoadjuvant therapy, including short-course radiotherapy (29 patients), long-course radiotherapy (13) and chemoradiation (21).

Of the 154 patients who went on to tumor resection, 145 had a known diagnosis of rectal cancer, with significantly more patients with UC having a preoperative rectal cancer diagnosis (90.9% vs. 72.7% for patients with CD; P = .022).

Patients with CD were significantly younger at the time of rectal cancer diagnosis, at a mean of 53.7 years, compared with 63.5 years for patients with UC, and 76 years for those with indeterminate colitis (P = .022).

In all, 42% of patients developed one or more complications after surgery, as scored by the Clavien-Dindo Classification scale (Ann. Surg. 2004;240:205-13).

The most frequent complications reported were grade 2 complications in 27.4% of cases, including presacral or intra-abdominal abscesses, perineal or abdominal wounds, or urologic problems. A total of 48 grade 3 or greater complications were seen in 41 patients.

Rates of complications were similar between patients with IBD who were on chronic immunosuppressive therapy and those who were not, and between patients who received neoadjuvant therapy of any kind and those who did not, and were similar to those seen in the general rectal cancer population, Dr. van Rooijen said.

The authors also found that because rectal cancer may go unrecognized in patients with IBD until they undergo surgery for another reason, there are a relatively high number of incomplete (R1) resections compared with patients with sporadic rectal cancers.

The study was supported by Radboud Medical Center. Dr. van Rooijen reported having no financial disclosures.

PHOENIX, ARIZ. – Neoadjuvant therapy appears to be safe in patients with rectal cancer and inflammatory bowel disease, investigators from the Netherlands reported at the annual Society of Surgical Oncology Cancer Symposium.

Among Dutch patients with a diagnosis of Crohn’s disease (CD), ulcerative colitis (UC), or unspecified colitis who underwent total mesorectal excision, neither neoadjuvant therapy nor immunosuppressive therapy significantly increased the rate of acute postsurgical complications, said Dr. Stefanus van Rooijen.

Patients with inflammatory bowel disease (IBD) have typically been excluded from studies of neoadjuvant chemotherapy and radiation because of fear of complications, but this study shows that "in IBD patients, rectal cancer can be treated the same way as in patients with sporadic rectal cancer, because there were no differences in complications after operations or after getting neoadjuvant therapy," Dr. van Rooijen said in an interview.

Neil Osterweil/Frontline Medical News

To determine whether neoadjuvant therapies might make life more difficult after surgery for patients with IBD and rectal cancer, the investigators reviewed records on all patients with IBD and rectal cancer treated in the Netherlands from 1990 through 2010, and compared their cases to those other patients with rectal cancer treated in the nation during the same period.

They identified a total of 173 patients with IBD: 89 with UC, 70 with CD, and 14 with indeterminate colitis. The majority of patients (112, 64.7%) were male. The mean age at rectal cancer diagnosis was 60.7 years, and the mean duration of IBD before diagnosis was 17.4 years, Dr. van Rooijen and his colleagues at Radboud University Medical Center, Nijmegen, the Netherlands, reported in a poster.

In all, 63 patients with IBD (36.4%) received neoadjuvant therapy, including short-course radiotherapy (29 patients), long-course radiotherapy (13) and chemoradiation (21).

Of the 154 patients who went on to tumor resection, 145 had a known diagnosis of rectal cancer, with significantly more patients with UC having a preoperative rectal cancer diagnosis (90.9% vs. 72.7% for patients with CD; P = .022).

Patients with CD were significantly younger at the time of rectal cancer diagnosis, at a mean of 53.7 years, compared with 63.5 years for patients with UC, and 76 years for those with indeterminate colitis (P = .022).

In all, 42% of patients developed one or more complications after surgery, as scored by the Clavien-Dindo Classification scale (Ann. Surg. 2004;240:205-13).

The most frequent complications reported were grade 2 complications in 27.4% of cases, including presacral or intra-abdominal abscesses, perineal or abdominal wounds, or urologic problems. A total of 48 grade 3 or greater complications were seen in 41 patients.

Rates of complications were similar between patients with IBD who were on chronic immunosuppressive therapy and those who were not, and between patients who received neoadjuvant therapy of any kind and those who did not, and were similar to those seen in the general rectal cancer population, Dr. van Rooijen said.

The authors also found that because rectal cancer may go unrecognized in patients with IBD until they undergo surgery for another reason, there are a relatively high number of incomplete (R1) resections compared with patients with sporadic rectal cancers.

The study was supported by Radboud Medical Center. Dr. van Rooijen reported having no financial disclosures.

PHOENIX, ARIZ. – For patients with locally advanced esophageal cancer involving four or more lymph nodes, neoadjuvant chemoradiation and surgery may offer overall survival rates comparable with those of surgery alone in patients with less advanced disease, reported Dr. Hiroshi Okumura.

In a prospective study of 50 consecutive patients the 3-year survival rate for patients who received neoadjuvant chemoradiation because of extensive lymph node involvement was 71%, compared with 72% for patients with three or fewer involved nodes who were treated with surgery alone, a difference that was not significant, he reported at the annual Society for Surgical Oncology Cancer Symposium.

"The prognosis is poor for patients with esophageal squamous-cell cancer with multiple lymph-node metastases. In particular, the prognosis in patients with four or more lymph-node metastases is significantly poorer than in those with three or fewer. Chemoradiation therapy [CRT] is one of the most useful treatments. However, it remains controversial whether neoadjuvant CRT provides a significant advantage," he said.

To examine this question, Dr. Okumura of Kagoshima University, Japan, and his colleagues followed 50 patients with locally advanced esophageal squamous-cell carcinomas stages T3 or T4. Of this group, 20 patients had four or more metastatic lymph nodes and underwent CRT with 5-fluourouracil and cisplatin plus 40 Gy of radiation, and 30 patients had three or fewer metastatic lymph nodes and underwent surgery alone.

Two patients in the CRT group were subsequently found to have metastases, one to bone and one to the liver. These patients did not undergo surgery and were excluded from the final analysis.

The investigators found that of the CRT-treated patients, 8 had a grade 1 response, defined as tumor present in more than one-third of the whole lesion; 2 had a grade 2 response (tumor present in than one-third of the lesion); and 8 had a grade 3 response (no visible tumor cells).

Eight patients became node-negative (ypN0) after CRT, resulting in a decrease in mean overall metastatic lymph nodes from seven before treatment to three afterward.

Relapses occurred in four patients in the CRT group, three of whom died from cancer and one from pneumonia. In the surgery group, eight patients had relapses, and all died from their cancers.

Three-year survival by histologic response in the CRT cohort was 50% for grade 1, 100% for grade 2, and 80% for grade 3 (P = .05).

Following the presentation, Dr. Mitchell C. Posner, chief of surgical oncology at the University of Chicago, asked whether, given their results, Dr. Okumura and his colleagues would consider offering chemoradiation to patients with three or fewer metastatic lymph nodes.

Dr. Okumura replied that the number of involved lymph nodes was the key factor in the decision to offer chemoradiation in his practice.

The study was internally supported. Dr. Okumura reported having no financial disclosures.

PHOENIX, ARIZ. – For patients with locally advanced esophageal cancer involving four or more lymph nodes, neoadjuvant chemoradiation and surgery may offer overall survival rates comparable with those of surgery alone in patients with less advanced disease, reported Dr. Hiroshi Okumura.

In a prospective study of 50 consecutive patients the 3-year survival rate for patients who received neoadjuvant chemoradiation because of extensive lymph node involvement was 71%, compared with 72% for patients with three or fewer involved nodes who were treated with surgery alone, a difference that was not significant, he reported at the annual Society for Surgical Oncology Cancer Symposium.

"The prognosis is poor for patients with esophageal squamous-cell cancer with multiple lymph-node metastases. In particular, the prognosis in patients with four or more lymph-node metastases is significantly poorer than in those with three or fewer. Chemoradiation therapy [CRT] is one of the most useful treatments. However, it remains controversial whether neoadjuvant CRT provides a significant advantage," he said.

To examine this question, Dr. Okumura of Kagoshima University, Japan, and his colleagues followed 50 patients with locally advanced esophageal squamous-cell carcinomas stages T3 or T4. Of this group, 20 patients had four or more metastatic lymph nodes and underwent CRT with 5-fluourouracil and cisplatin plus 40 Gy of radiation, and 30 patients had three or fewer metastatic lymph nodes and underwent surgery alone.

Two patients in the CRT group were subsequently found to have metastases, one to bone and one to the liver. These patients did not undergo surgery and were excluded from the final analysis.

The investigators found that of the CRT-treated patients, 8 had a grade 1 response, defined as tumor present in more than one-third of the whole lesion; 2 had a grade 2 response (tumor present in than one-third of the lesion); and 8 had a grade 3 response (no visible tumor cells).

Eight patients became node-negative (ypN0) after CRT, resulting in a decrease in mean overall metastatic lymph nodes from seven before treatment to three afterward.

Relapses occurred in four patients in the CRT group, three of whom died from cancer and one from pneumonia. In the surgery group, eight patients had relapses, and all died from their cancers.

Three-year survival by histologic response in the CRT cohort was 50% for grade 1, 100% for grade 2, and 80% for grade 3 (P = .05).

Following the presentation, Dr. Mitchell C. Posner, chief of surgical oncology at the University of Chicago, asked whether, given their results, Dr. Okumura and his colleagues would consider offering chemoradiation to patients with three or fewer metastatic lymph nodes.

Dr. Okumura replied that the number of involved lymph nodes was the key factor in the decision to offer chemoradiation in his practice.

The study was internally supported. Dr. Okumura reported having no financial disclosures.

PHOENIX, ARIZ. – For patients with locally advanced esophageal cancer involving four or more lymph nodes, neoadjuvant chemoradiation and surgery may offer overall survival rates comparable with those of surgery alone in patients with less advanced disease, reported Dr. Hiroshi Okumura.

In a prospective study of 50 consecutive patients the 3-year survival rate for patients who received neoadjuvant chemoradiation because of extensive lymph node involvement was 71%, compared with 72% for patients with three or fewer involved nodes who were treated with surgery alone, a difference that was not significant, he reported at the annual Society for Surgical Oncology Cancer Symposium.

"The prognosis is poor for patients with esophageal squamous-cell cancer with multiple lymph-node metastases. In particular, the prognosis in patients with four or more lymph-node metastases is significantly poorer than in those with three or fewer. Chemoradiation therapy [CRT] is one of the most useful treatments. However, it remains controversial whether neoadjuvant CRT provides a significant advantage," he said.

To examine this question, Dr. Okumura of Kagoshima University, Japan, and his colleagues followed 50 patients with locally advanced esophageal squamous-cell carcinomas stages T3 or T4. Of this group, 20 patients had four or more metastatic lymph nodes and underwent CRT with 5-fluourouracil and cisplatin plus 40 Gy of radiation, and 30 patients had three or fewer metastatic lymph nodes and underwent surgery alone.

Two patients in the CRT group were subsequently found to have metastases, one to bone and one to the liver. These patients did not undergo surgery and were excluded from the final analysis.

The investigators found that of the CRT-treated patients, 8 had a grade 1 response, defined as tumor present in more than one-third of the whole lesion; 2 had a grade 2 response (tumor present in than one-third of the lesion); and 8 had a grade 3 response (no visible tumor cells).

Eight patients became node-negative (ypN0) after CRT, resulting in a decrease in mean overall metastatic lymph nodes from seven before treatment to three afterward.

Relapses occurred in four patients in the CRT group, three of whom died from cancer and one from pneumonia. In the surgery group, eight patients had relapses, and all died from their cancers.

Three-year survival by histologic response in the CRT cohort was 50% for grade 1, 100% for grade 2, and 80% for grade 3 (P = .05).

Following the presentation, Dr. Mitchell C. Posner, chief of surgical oncology at the University of Chicago, asked whether, given their results, Dr. Okumura and his colleagues would consider offering chemoradiation to patients with three or fewer metastatic lymph nodes.

Dr. Okumura replied that the number of involved lymph nodes was the key factor in the decision to offer chemoradiation in his practice.

The study was internally supported. Dr. Okumura reported having no financial disclosures.

PHOENIX, ARIZ. – Even small pancreatic neuroendocrine tumors have the potential for malignancy and need excision or close monitoring, investigators caution.

A retrospective cohort study following outcomes for patients with nonfunctional pancreatic neuroendocrine tumors (PNETs) 2 cm in diameter or less found that in an unadjusted analysis stratified by surgery type, those who did not have surgery had significantly worse overall survival 5 years after diagnosis, although there were no significant survival differences among all surgery types, reported Dr. Lauren Gratian of Duke University, Durham, N.C.

PNETs 2 cm in size or smaller are increasing in incidence in the United States, Dr. Gratian said at the annual Society of Surgical Oncology Cancer Symposium. "This is important, because their malignant potential is uncertain, and optimal surgical management remains unclear."

Neil Osterweil/Frontline Medical News

She pointed to National Comprehensive Cancer Network (NCCN) guidelines, which say that nonfunctional PNETs 2 cm or smaller are candidates for either enucleation or partial pancreatic resection, and that in certain cases, observation may be considered. Specifically, tumors smaller than 1 cm that were discovered incidentally may be candidates for observation, with the decision based on estimated surgical risk, site of the tumor, and patient comorbidities.

To get a better handle on the incidence of nonfunctional PNETs over time, discern their malignant potential, and see what factors are associated with survival, the investigators drew from the American College of Surgeons’ National Cancer Data Base (NCDB) for records on patients diagnosed from 1998 through 2011 with nonfunctional PNETs that met the criteria. Patients with functional PNETs, carcinoids, and/or exocrine tumors were excluded.

Of the 1,854 patients identified, 487 with more than 1 malignant primary, unknown surgical status, or surgery/pancreatectomy not otherwise specified were excluded, leaving a survival cohort of 1,367. Of this group, 368 (27%) had no surgery, 586 (43%) had a partial pancreatic resection, 324 (24%) had a pancreatoduodenectomy (Whipple procedure) with or without a partial gastrectomy, and 89 (6%) underwent total pancreatectomy.

The researchers found that the incidence of small nonfunctional PNETs as a percentage of all PNETs increased significantly over time, from 7% in 1998 to 20% in 2010.

When they grouped tumors by size (5 mm or smaller, more than 5 mm up to 1 cm, and more than 1 cm up to 2 cm), they found that there were no differences in tumor propensity for either distant metastases (11%, 9%, and 13%, respectively) or regional lymph node involvement (34%, 21%, and 29%).

Patients with distant metastases were significantly more likely to have had no surgery (P less than .001), and patients with partial pancreatic sections were significantly more likely than those who had undergone Whipple or total procedures to have positive surgical margins (P = .009).

An unadjusted analysis of 5-year overall survival by surgery type showed no significant differences among patients treated with the various procedures, but significantly worse outcomes for patients who had no surgery vs. any surgery (P less than .01).

There were no significant differences in survival between patients who had some regional lymph nodes examined compared with those who had no nodal dissection.

In a proportional hazards analysis adjusted for demographic and clinical features, factors significantly associated with overall survival were older age at diagnosis, which was associated with a higher risk of death (hazard ratio, 1.04; 95% confidence interval, 1.02-1.06); later year of diagnosis, associated with a lower risk (HR, 0.85; 95% CI, 0.77-0.94); and Whipple procedure, which was associated with an increased risk for death vs. partial pancreatectomy (HR, 1.88; 95% CI, 1.13-3.11).

Dr. Gratian noted that the study was limited by the inclusion of only malignant tumors in the database; potential coding errors; missing data on grade and stage of diseases; and the lack of information on variables such as disease recurrence, mitotic rates, or the Ki67 proliferative index.

The funding source for the study was not disclosed. Dr. Gratian and her coauthors reported having no financial disclosures.

PHOENIX, ARIZ. – Even small pancreatic neuroendocrine tumors have the potential for malignancy and need excision or close monitoring, investigators caution.

A retrospective cohort study following outcomes for patients with nonfunctional pancreatic neuroendocrine tumors (PNETs) 2 cm in diameter or less found that in an unadjusted analysis stratified by surgery type, those who did not have surgery had significantly worse overall survival 5 years after diagnosis, although there were no significant survival differences among all surgery types, reported Dr. Lauren Gratian of Duke University, Durham, N.C.

PNETs 2 cm in size or smaller are increasing in incidence in the United States, Dr. Gratian said at the annual Society of Surgical Oncology Cancer Symposium. "This is important, because their malignant potential is uncertain, and optimal surgical management remains unclear."

Neil Osterweil/Frontline Medical News

She pointed to National Comprehensive Cancer Network (NCCN) guidelines, which say that nonfunctional PNETs 2 cm or smaller are candidates for either enucleation or partial pancreatic resection, and that in certain cases, observation may be considered. Specifically, tumors smaller than 1 cm that were discovered incidentally may be candidates for observation, with the decision based on estimated surgical risk, site of the tumor, and patient comorbidities.

To get a better handle on the incidence of nonfunctional PNETs over time, discern their malignant potential, and see what factors are associated with survival, the investigators drew from the American College of Surgeons’ National Cancer Data Base (NCDB) for records on patients diagnosed from 1998 through 2011 with nonfunctional PNETs that met the criteria. Patients with functional PNETs, carcinoids, and/or exocrine tumors were excluded.

Of the 1,854 patients identified, 487 with more than 1 malignant primary, unknown surgical status, or surgery/pancreatectomy not otherwise specified were excluded, leaving a survival cohort of 1,367. Of this group, 368 (27%) had no surgery, 586 (43%) had a partial pancreatic resection, 324 (24%) had a pancreatoduodenectomy (Whipple procedure) with or without a partial gastrectomy, and 89 (6%) underwent total pancreatectomy.

The researchers found that the incidence of small nonfunctional PNETs as a percentage of all PNETs increased significantly over time, from 7% in 1998 to 20% in 2010.

When they grouped tumors by size (5 mm or smaller, more than 5 mm up to 1 cm, and more than 1 cm up to 2 cm), they found that there were no differences in tumor propensity for either distant metastases (11%, 9%, and 13%, respectively) or regional lymph node involvement (34%, 21%, and 29%).

Patients with distant metastases were significantly more likely to have had no surgery (P less than .001), and patients with partial pancreatic sections were significantly more likely than those who had undergone Whipple or total procedures to have positive surgical margins (P = .009).

An unadjusted analysis of 5-year overall survival by surgery type showed no significant differences among patients treated with the various procedures, but significantly worse outcomes for patients who had no surgery vs. any surgery (P less than .01).

There were no significant differences in survival between patients who had some regional lymph nodes examined compared with those who had no nodal dissection.

In a proportional hazards analysis adjusted for demographic and clinical features, factors significantly associated with overall survival were older age at diagnosis, which was associated with a higher risk of death (hazard ratio, 1.04; 95% confidence interval, 1.02-1.06); later year of diagnosis, associated with a lower risk (HR, 0.85; 95% CI, 0.77-0.94); and Whipple procedure, which was associated with an increased risk for death vs. partial pancreatectomy (HR, 1.88; 95% CI, 1.13-3.11).

Dr. Gratian noted that the study was limited by the inclusion of only malignant tumors in the database; potential coding errors; missing data on grade and stage of diseases; and the lack of information on variables such as disease recurrence, mitotic rates, or the Ki67 proliferative index.

The funding source for the study was not disclosed. Dr. Gratian and her coauthors reported having no financial disclosures.

PHOENIX, ARIZ. – Even small pancreatic neuroendocrine tumors have the potential for malignancy and need excision or close monitoring, investigators caution.

A retrospective cohort study following outcomes for patients with nonfunctional pancreatic neuroendocrine tumors (PNETs) 2 cm in diameter or less found that in an unadjusted analysis stratified by surgery type, those who did not have surgery had significantly worse overall survival 5 years after diagnosis, although there were no significant survival differences among all surgery types, reported Dr. Lauren Gratian of Duke University, Durham, N.C.

PNETs 2 cm in size or smaller are increasing in incidence in the United States, Dr. Gratian said at the annual Society of Surgical Oncology Cancer Symposium. "This is important, because their malignant potential is uncertain, and optimal surgical management remains unclear."

Neil Osterweil/Frontline Medical News

She pointed to National Comprehensive Cancer Network (NCCN) guidelines, which say that nonfunctional PNETs 2 cm or smaller are candidates for either enucleation or partial pancreatic resection, and that in certain cases, observation may be considered. Specifically, tumors smaller than 1 cm that were discovered incidentally may be candidates for observation, with the decision based on estimated surgical risk, site of the tumor, and patient comorbidities.

To get a better handle on the incidence of nonfunctional PNETs over time, discern their malignant potential, and see what factors are associated with survival, the investigators drew from the American College of Surgeons’ National Cancer Data Base (NCDB) for records on patients diagnosed from 1998 through 2011 with nonfunctional PNETs that met the criteria. Patients with functional PNETs, carcinoids, and/or exocrine tumors were excluded.

Of the 1,854 patients identified, 487 with more than 1 malignant primary, unknown surgical status, or surgery/pancreatectomy not otherwise specified were excluded, leaving a survival cohort of 1,367. Of this group, 368 (27%) had no surgery, 586 (43%) had a partial pancreatic resection, 324 (24%) had a pancreatoduodenectomy (Whipple procedure) with or without a partial gastrectomy, and 89 (6%) underwent total pancreatectomy.

The researchers found that the incidence of small nonfunctional PNETs as a percentage of all PNETs increased significantly over time, from 7% in 1998 to 20% in 2010.

When they grouped tumors by size (5 mm or smaller, more than 5 mm up to 1 cm, and more than 1 cm up to 2 cm), they found that there were no differences in tumor propensity for either distant metastases (11%, 9%, and 13%, respectively) or regional lymph node involvement (34%, 21%, and 29%).

Patients with distant metastases were significantly more likely to have had no surgery (P less than .001), and patients with partial pancreatic sections were significantly more likely than those who had undergone Whipple or total procedures to have positive surgical margins (P = .009).

An unadjusted analysis of 5-year overall survival by surgery type showed no significant differences among patients treated with the various procedures, but significantly worse outcomes for patients who had no surgery vs. any surgery (P less than .01).

There were no significant differences in survival between patients who had some regional lymph nodes examined compared with those who had no nodal dissection.

In a proportional hazards analysis adjusted for demographic and clinical features, factors significantly associated with overall survival were older age at diagnosis, which was associated with a higher risk of death (hazard ratio, 1.04; 95% confidence interval, 1.02-1.06); later year of diagnosis, associated with a lower risk (HR, 0.85; 95% CI, 0.77-0.94); and Whipple procedure, which was associated with an increased risk for death vs. partial pancreatectomy (HR, 1.88; 95% CI, 1.13-3.11).

Dr. Gratian noted that the study was limited by the inclusion of only malignant tumors in the database; potential coding errors; missing data on grade and stage of diseases; and the lack of information on variables such as disease recurrence, mitotic rates, or the Ki67 proliferative index.

The funding source for the study was not disclosed. Dr. Gratian and her coauthors reported having no financial disclosures.

PHOENIX – Seeing is not always believing when it comes to determining whether pancreatic adenocarcinomas are resectable.

In patients with locally advanced or borderline resectable pancreatic adenocarcinoma who underwent neoadjuvant therapy with the FOLFIRINOX regimen (leucovorin, fluorouracil, irinotecan, and oxaliplatin), presurgical imaging was not a reliable determinant of resectability, said Dr. Cristina R. Ferrone from the department of general and gastrointestinal surgery at Massachusetts General Hospital in Boston.

Neil Osterweil/Frontline Medical News

"It really is a paradigm shift that we can’t rely on CT scans and MRIs the way we did before," she said at the annual Society of Surgical Oncology Cancer Symposium.

An important case

For her team, the paradigm shift was sparked by the case of a 41-year-old woman who presented with a 3.6-cm pancreatic adenocarcinoma involving the superior mesenteric artery (SMA), and a cancer antigen 19-9 (CA 19-9) level of 985 U/mL (normal values for the nonspecific biomarker range from 0 to 37 U/mL, according to National Comprehensive Cancer Network guidelines).

Following 4 months of FOLFIRINOX and 50.4 Gy of chemoradiation, her CA 19-9 level normalized to 37 U/mL. But her postchemotherapy imaging studies appeared identical to her prechemotherapy studies, with no apparent evidence of tumor regression and apparent continued involvement of the SMA following FOLFIRINOX.

"We had a big debate about this woman, because she had a normalized CA 19-9. Do we attempt to resect a patient like this?" Dr. Ferrone said.

After considerable discussion, the decision was made to take the patient into the operating room, approach the pancreas from the left side, and perform intraoperative biopsies on the SMA. If the biopsies were positive, the surgical team would either perform intraoperative radiation therapy (IORT) or use a soft-tissue ablation system (Nanoknife). If the biopsies were negative, the team would proceed to resection.

The patient went on to resection, and was found to have only minimal residual tumor on postoperative pathology samples, Dr. Ferrone reported.

Case comparisons

To see whether other patients could benefit from a similar approach, the investigators compared outcomes for 87 patients who underwent upfront resection for presumed organ-confined disease and 38 patients who received neoadjuvant FOLFIRINOX before surgery. Of the latter group, 5 received FOLFIRINOX chemotherapy only; 16 received FOLFIRINOX and 50.4 Gy of radiation; 10 received FOLFIRINOX, radiation, and IORT; 4 received FOLFIRINOX and proton-beam therapy; and 3 had FOLFIRINOX with other drug therapies.

The median CA 19-9 level fell from 169 U/mL before FOLFIRINOX to 16 U/mL after (P = .003), and more than twice as many patients had levels below 40 U/mL after therapy (31% vs. 72%; P = .03)

Median tumor diameter on CT also decreased after chemotherapy, from 3.6 cm to 2.2 cm (P = .001).

Pathology review of images from 20 cases with the observer blinded to treatment status showed 14 cases judged to be locally advanced disease and 6 borderline pre-FOLFIRINOX, and 12 locally advanced cases, 3 borderline, and 5 cases deemed resectable post-FOLFIRINOX.

When the investigators compared clinical and operative results in the surgery-only patients vs. results in those who had neoadjuvant FOLFIRINOX, they found that the latter group had higher mean operative times (300 minutes for surgery-only patients vs. 393 minutes for FOLFIRINOX-treated patients; P less than .001) and higher mean blood loss (400 mL vs. 600 mL, respectively; P = .01).

However, patients who received neoadjuvant therapy had significantly fewer postoperative complications (63% vs. 35% of patients; P = .004) and fewer pancreatic fistulas (29% vs. 0%; P less than .001).

Patients who received FOLFIRINOX also had a lower proportion of readmissions within 90 days (30% vs. 21%); shorter lengths of stay (7 days vs. 6 days); and no deaths, compared with 1 in the up-front surgery group, but these differences were not significant.

Pathology results showed that 79% of the surgery-only patients had positive lymph nodes, compared with only 37% of those in the neoadjuvant group (P less than .001). The neoadjuvant group also had lower proportions of both lymphatic invasion (70% vs. 37%, P less than .001) and perineural invasion (P less than .001).

There were proportionally more R0 (clean margin) resections in the FOLFIRINOX group, but the difference was not significant.

After a median follow-up of 10 months for the up-front surgery patients and 12 months for the FOLFIRINOX-treated patients, there have been no differences in local or distant progression or deaths from pancreatic cancer. Dr. Ferrone acknowledged that a larger patient sample and longer follow-up may be needed to detect significant differences.

However, Kaplan-Meier overall survival estimates from the time of diagnosis out to 34 months significantly favor the FOLFIRINOX-treated patients (P = .02).

"With this therapeutic modality and intensive surgical interventions, we hope that we are making an impact in these patients’ lives and improving their survival," she said.

The study was internally supported. Dr. Ferrone reported having no financial disclosures.

PHOENIX – Seeing is not always believing when it comes to determining whether pancreatic adenocarcinomas are resectable.

In patients with locally advanced or borderline resectable pancreatic adenocarcinoma who underwent neoadjuvant therapy with the FOLFIRINOX regimen (leucovorin, fluorouracil, irinotecan, and oxaliplatin), presurgical imaging was not a reliable determinant of resectability, said Dr. Cristina R. Ferrone from the department of general and gastrointestinal surgery at Massachusetts General Hospital in Boston.

Neil Osterweil/Frontline Medical News

"It really is a paradigm shift that we can’t rely on CT scans and MRIs the way we did before," she said at the annual Society of Surgical Oncology Cancer Symposium.

An important case

For her team, the paradigm shift was sparked by the case of a 41-year-old woman who presented with a 3.6-cm pancreatic adenocarcinoma involving the superior mesenteric artery (SMA), and a cancer antigen 19-9 (CA 19-9) level of 985 U/mL (normal values for the nonspecific biomarker range from 0 to 37 U/mL, according to National Comprehensive Cancer Network guidelines).

Following 4 months of FOLFIRINOX and 50.4 Gy of chemoradiation, her CA 19-9 level normalized to 37 U/mL. But her postchemotherapy imaging studies appeared identical to her prechemotherapy studies, with no apparent evidence of tumor regression and apparent continued involvement of the SMA following FOLFIRINOX.

"We had a big debate about this woman, because she had a normalized CA 19-9. Do we attempt to resect a patient like this?" Dr. Ferrone said.

After considerable discussion, the decision was made to take the patient into the operating room, approach the pancreas from the left side, and perform intraoperative biopsies on the SMA. If the biopsies were positive, the surgical team would either perform intraoperative radiation therapy (IORT) or use a soft-tissue ablation system (Nanoknife). If the biopsies were negative, the team would proceed to resection.

The patient went on to resection, and was found to have only minimal residual tumor on postoperative pathology samples, Dr. Ferrone reported.

Case comparisons

To see whether other patients could benefit from a similar approach, the investigators compared outcomes for 87 patients who underwent upfront resection for presumed organ-confined disease and 38 patients who received neoadjuvant FOLFIRINOX before surgery. Of the latter group, 5 received FOLFIRINOX chemotherapy only; 16 received FOLFIRINOX and 50.4 Gy of radiation; 10 received FOLFIRINOX, radiation, and IORT; 4 received FOLFIRINOX and proton-beam therapy; and 3 had FOLFIRINOX with other drug therapies.

The median CA 19-9 level fell from 169 U/mL before FOLFIRINOX to 16 U/mL after (P = .003), and more than twice as many patients had levels below 40 U/mL after therapy (31% vs. 72%; P = .03)

Median tumor diameter on CT also decreased after chemotherapy, from 3.6 cm to 2.2 cm (P = .001).

Pathology review of images from 20 cases with the observer blinded to treatment status showed 14 cases judged to be locally advanced disease and 6 borderline pre-FOLFIRINOX, and 12 locally advanced cases, 3 borderline, and 5 cases deemed resectable post-FOLFIRINOX.

When the investigators compared clinical and operative results in the surgery-only patients vs. results in those who had neoadjuvant FOLFIRINOX, they found that the latter group had higher mean operative times (300 minutes for surgery-only patients vs. 393 minutes for FOLFIRINOX-treated patients; P less than .001) and higher mean blood loss (400 mL vs. 600 mL, respectively; P = .01).

However, patients who received neoadjuvant therapy had significantly fewer postoperative complications (63% vs. 35% of patients; P = .004) and fewer pancreatic fistulas (29% vs. 0%; P less than .001).

Patients who received FOLFIRINOX also had a lower proportion of readmissions within 90 days (30% vs. 21%); shorter lengths of stay (7 days vs. 6 days); and no deaths, compared with 1 in the up-front surgery group, but these differences were not significant.

Pathology results showed that 79% of the surgery-only patients had positive lymph nodes, compared with only 37% of those in the neoadjuvant group (P less than .001). The neoadjuvant group also had lower proportions of both lymphatic invasion (70% vs. 37%, P less than .001) and perineural invasion (P less than .001).

There were proportionally more R0 (clean margin) resections in the FOLFIRINOX group, but the difference was not significant.

After a median follow-up of 10 months for the up-front surgery patients and 12 months for the FOLFIRINOX-treated patients, there have been no differences in local or distant progression or deaths from pancreatic cancer. Dr. Ferrone acknowledged that a larger patient sample and longer follow-up may be needed to detect significant differences.

However, Kaplan-Meier overall survival estimates from the time of diagnosis out to 34 months significantly favor the FOLFIRINOX-treated patients (P = .02).

"With this therapeutic modality and intensive surgical interventions, we hope that we are making an impact in these patients’ lives and improving their survival," she said.

The study was internally supported. Dr. Ferrone reported having no financial disclosures.

PHOENIX – Seeing is not always believing when it comes to determining whether pancreatic adenocarcinomas are resectable.

In patients with locally advanced or borderline resectable pancreatic adenocarcinoma who underwent neoadjuvant therapy with the FOLFIRINOX regimen (leucovorin, fluorouracil, irinotecan, and oxaliplatin), presurgical imaging was not a reliable determinant of resectability, said Dr. Cristina R. Ferrone from the department of general and gastrointestinal surgery at Massachusetts General Hospital in Boston.

Neil Osterweil/Frontline Medical News

"It really is a paradigm shift that we can’t rely on CT scans and MRIs the way we did before," she said at the annual Society of Surgical Oncology Cancer Symposium.

An important case

For her team, the paradigm shift was sparked by the case of a 41-year-old woman who presented with a 3.6-cm pancreatic adenocarcinoma involving the superior mesenteric artery (SMA), and a cancer antigen 19-9 (CA 19-9) level of 985 U/mL (normal values for the nonspecific biomarker range from 0 to 37 U/mL, according to National Comprehensive Cancer Network guidelines).

Following 4 months of FOLFIRINOX and 50.4 Gy of chemoradiation, her CA 19-9 level normalized to 37 U/mL. But her postchemotherapy imaging studies appeared identical to her prechemotherapy studies, with no apparent evidence of tumor regression and apparent continued involvement of the SMA following FOLFIRINOX.

"We had a big debate about this woman, because she had a normalized CA 19-9. Do we attempt to resect a patient like this?" Dr. Ferrone said.

After considerable discussion, the decision was made to take the patient into the operating room, approach the pancreas from the left side, and perform intraoperative biopsies on the SMA. If the biopsies were positive, the surgical team would either perform intraoperative radiation therapy (IORT) or use a soft-tissue ablation system (Nanoknife). If the biopsies were negative, the team would proceed to resection.

The patient went on to resection, and was found to have only minimal residual tumor on postoperative pathology samples, Dr. Ferrone reported.

Case comparisons

To see whether other patients could benefit from a similar approach, the investigators compared outcomes for 87 patients who underwent upfront resection for presumed organ-confined disease and 38 patients who received neoadjuvant FOLFIRINOX before surgery. Of the latter group, 5 received FOLFIRINOX chemotherapy only; 16 received FOLFIRINOX and 50.4 Gy of radiation; 10 received FOLFIRINOX, radiation, and IORT; 4 received FOLFIRINOX and proton-beam therapy; and 3 had FOLFIRINOX with other drug therapies.

The median CA 19-9 level fell from 169 U/mL before FOLFIRINOX to 16 U/mL after (P = .003), and more than twice as many patients had levels below 40 U/mL after therapy (31% vs. 72%; P = .03)

Median tumor diameter on CT also decreased after chemotherapy, from 3.6 cm to 2.2 cm (P = .001).

Pathology review of images from 20 cases with the observer blinded to treatment status showed 14 cases judged to be locally advanced disease and 6 borderline pre-FOLFIRINOX, and 12 locally advanced cases, 3 borderline, and 5 cases deemed resectable post-FOLFIRINOX.

When the investigators compared clinical and operative results in the surgery-only patients vs. results in those who had neoadjuvant FOLFIRINOX, they found that the latter group had higher mean operative times (300 minutes for surgery-only patients vs. 393 minutes for FOLFIRINOX-treated patients; P less than .001) and higher mean blood loss (400 mL vs. 600 mL, respectively; P = .01).

However, patients who received neoadjuvant therapy had significantly fewer postoperative complications (63% vs. 35% of patients; P = .004) and fewer pancreatic fistulas (29% vs. 0%; P less than .001).

Patients who received FOLFIRINOX also had a lower proportion of readmissions within 90 days (30% vs. 21%); shorter lengths of stay (7 days vs. 6 days); and no deaths, compared with 1 in the up-front surgery group, but these differences were not significant.

Pathology results showed that 79% of the surgery-only patients had positive lymph nodes, compared with only 37% of those in the neoadjuvant group (P less than .001). The neoadjuvant group also had lower proportions of both lymphatic invasion (70% vs. 37%, P less than .001) and perineural invasion (P less than .001).

There were proportionally more R0 (clean margin) resections in the FOLFIRINOX group, but the difference was not significant.

After a median follow-up of 10 months for the up-front surgery patients and 12 months for the FOLFIRINOX-treated patients, there have been no differences in local or distant progression or deaths from pancreatic cancer. Dr. Ferrone acknowledged that a larger patient sample and longer follow-up may be needed to detect significant differences.

However, Kaplan-Meier overall survival estimates from the time of diagnosis out to 34 months significantly favor the FOLFIRINOX-treated patients (P = .02).

"With this therapeutic modality and intensive surgical interventions, we hope that we are making an impact in these patients’ lives and improving their survival," she said.

The study was internally supported. Dr. Ferrone reported having no financial disclosures.

PHOENIX – Hope remains for patients with advanced cancers, even after curative-intent surgery fails them, investigators reported at the annual Society of Surgical Oncology Cancer Symposium.

A study of the effects of an online decision aid for advance care planning showed that patients whose cancers had advanced despite initial curative-intent surgery had degrees of hope and desires for the aggressiveness of additional therapy similar to those of patients who had undergone palliative therapy only, said Dr. Niraj J. Gusani, FACS, of Penn State College of Medicine, Hershey, Pa.

"As we do more advance care planning, stratify patients, and get them into these programs to help them figure out what their wishes really are, we should treat everybody the same , and they should all have a durable advance care planning process, maybe using a decision aid such as this," he said.

The results show that outcomes beyond whether a patient lives or dies also matter, commented Dr. Steven Chen, FACS, from City of Hope Medical Center, Duarte, Calif.

"The thing that patients care about at least as much as how long they’re going to live is how well they’re going to live until they die," he said in an interview. Dr. Chen was not involved in the study, but comoderated the poster discussion session where it was presented.

"Almost all of my patients have very advanced cancers with poor prognosis, and it’s all about their quality of life and how they’re going to feel," Dr. Gusani agreed. "They intuitively get that they have a poor prognosis, but if we can get them through with a better experience with their time and they are able to maintain their hope, then it makes a world of difference for the patient and the family as well."

Multimedia advance care planning

Dr. Gusani and his colleagues looked at data from a clinical trial evaluating the effects of an online multimedia decision aid tool for patients with advanced-stage disease. The program, called Making Your Wishes Known: Planning Your Medical Future, was developed by two of the authors.

The program "provides tailored education, values-clarification exercises, and a decision-making tool that translates an individual’s values and preferences into a specific medical plan than can be implemented by a health care team," they wrote.

The investigators hypothesized that patients who went into surgery hoping for or expecting a cure might opt for more aggressive treatment at the end of life and have more hope and/or less hopelessness than patients who underwent treatments that they knew would not be curative.

The researchers administered the advance care planning program to 159 patients from the parent clinical trial, in which 200 patients with stage IV cancers who were judged to have less than 12 months to live were randomly assigned to receive either standard advance care planning or the decision aid. All of the patients had non–central nervous system and nonhematologic malignancies and were classified as having had initial curative-intent surgery or treatment without curative intent (e.g., palliative therapy and tumor debulking).

Making patients’ wishes known

Both at baseline and after the intervention, the patients were rated for hope on the 12-item Herth Hope Index, with scores from 12 (low hope) to 48 (high hope), and for hopelessness on the 7-item Beck Hopelessness Scale, in which 0 is no hopelessness and 7 is the highest level of despair.

The patients were also asked to rate their desires for aggressiveness of additional therapy by choosing one of six general wishes statements. For this scale, questions 1-4 were deemed to be more aggressive, and 5-6 less aggressive.

Additionally, patients who used the decision aid were rated on a treatment aggressiveness scale scored from 0 (least aggressive) to 40 (most) based on their responses to questions within the decision aid that asked about their wishes for eight different treatments (such as mechanical ventilation or cardiopulmonary resuscitation) under five clinical scenarios (such as stroke or dementia).

In all, 46 of 95 patients (48%) who had originally had curative-intent surgery received the control intervention, and 49 (52%) received the decision aid. Of the 64 patients who had non–curative-intent therapy, 35 (52%) received standard advance care planning and 31 (48%) received the Making Your Wishes Known aid.

After either intervention, patients who had curative-intent surgery had a slight but not significant increase in hope, and patients in the non–curative-intent group had a slight but not significant decrease. There was no significant between-group difference.

Similarly, each group had a slight decrease in hopelessness scores, with no significant differences between the groups.

There were also no significant variations in the distribution of the general wishes statements between the curative and noncurative groups or between the decision-aid and control groups, nor were there differences in the median treatment aggressiveness score of patients who used the decision aid, regardless of whether they had initially had curative-intent surgery.

"Regardless of what they choose in terms of their level of aggressiveness, the patients are more satisfied with their decision, they feel more informed, and caregiver satisfaction has improved with the decision aid compared with traditional materials," Dr. Gusani said.

"This is really important work," commented Dr. Sandra L. Wong of the University of Michigan Medical Center, Ann Arbor, who comoderated the poster discussion session.

The study was supported by Penn State College of Medicine. Dr. Gusani, Dr. Chen, and Dr. Wong reported having no financial conflicts of interest.

PHOENIX – Hope remains for patients with advanced cancers, even after curative-intent surgery fails them, investigators reported at the annual Society of Surgical Oncology Cancer Symposium.

A study of the effects of an online decision aid for advance care planning showed that patients whose cancers had advanced despite initial curative-intent surgery had degrees of hope and desires for the aggressiveness of additional therapy similar to those of patients who had undergone palliative therapy only, said Dr. Niraj J. Gusani, FACS, of Penn State College of Medicine, Hershey, Pa.

"As we do more advance care planning, stratify patients, and get them into these programs to help them figure out what their wishes really are, we should treat everybody the same , and they should all have a durable advance care planning process, maybe using a decision aid such as this," he said.

The results show that outcomes beyond whether a patient lives or dies also matter, commented Dr. Steven Chen, FACS, from City of Hope Medical Center, Duarte, Calif.

"The thing that patients care about at least as much as how long they’re going to live is how well they’re going to live until they die," he said in an interview. Dr. Chen was not involved in the study, but comoderated the poster discussion session where it was presented.

"Almost all of my patients have very advanced cancers with poor prognosis, and it’s all about their quality of life and how they’re going to feel," Dr. Gusani agreed. "They intuitively get that they have a poor prognosis, but if we can get them through with a better experience with their time and they are able to maintain their hope, then it makes a world of difference for the patient and the family as well."

Multimedia advance care planning

Dr. Gusani and his colleagues looked at data from a clinical trial evaluating the effects of an online multimedia decision aid tool for patients with advanced-stage disease. The program, called Making Your Wishes Known: Planning Your Medical Future, was developed by two of the authors.

The program "provides tailored education, values-clarification exercises, and a decision-making tool that translates an individual’s values and preferences into a specific medical plan than can be implemented by a health care team," they wrote.

The investigators hypothesized that patients who went into surgery hoping for or expecting a cure might opt for more aggressive treatment at the end of life and have more hope and/or less hopelessness than patients who underwent treatments that they knew would not be curative.

The researchers administered the advance care planning program to 159 patients from the parent clinical trial, in which 200 patients with stage IV cancers who were judged to have less than 12 months to live were randomly assigned to receive either standard advance care planning or the decision aid. All of the patients had non–central nervous system and nonhematologic malignancies and were classified as having had initial curative-intent surgery or treatment without curative intent (e.g., palliative therapy and tumor debulking).

Making patients’ wishes known

Both at baseline and after the intervention, the patients were rated for hope on the 12-item Herth Hope Index, with scores from 12 (low hope) to 48 (high hope), and for hopelessness on the 7-item Beck Hopelessness Scale, in which 0 is no hopelessness and 7 is the highest level of despair.

The patients were also asked to rate their desires for aggressiveness of additional therapy by choosing one of six general wishes statements. For this scale, questions 1-4 were deemed to be more aggressive, and 5-6 less aggressive.

Additionally, patients who used the decision aid were rated on a treatment aggressiveness scale scored from 0 (least aggressive) to 40 (most) based on their responses to questions within the decision aid that asked about their wishes for eight different treatments (such as mechanical ventilation or cardiopulmonary resuscitation) under five clinical scenarios (such as stroke or dementia).

In all, 46 of 95 patients (48%) who had originally had curative-intent surgery received the control intervention, and 49 (52%) received the decision aid. Of the 64 patients who had non–curative-intent therapy, 35 (52%) received standard advance care planning and 31 (48%) received the Making Your Wishes Known aid.

After either intervention, patients who had curative-intent surgery had a slight but not significant increase in hope, and patients in the non–curative-intent group had a slight but not significant decrease. There was no significant between-group difference.

Similarly, each group had a slight decrease in hopelessness scores, with no significant differences between the groups.

There were also no significant variations in the distribution of the general wishes statements between the curative and noncurative groups or between the decision-aid and control groups, nor were there differences in the median treatment aggressiveness score of patients who used the decision aid, regardless of whether they had initially had curative-intent surgery.

"Regardless of what they choose in terms of their level of aggressiveness, the patients are more satisfied with their decision, they feel more informed, and caregiver satisfaction has improved with the decision aid compared with traditional materials," Dr. Gusani said.

"This is really important work," commented Dr. Sandra L. Wong of the University of Michigan Medical Center, Ann Arbor, who comoderated the poster discussion session.

The study was supported by Penn State College of Medicine. Dr. Gusani, Dr. Chen, and Dr. Wong reported having no financial conflicts of interest.

PHOENIX – Hope remains for patients with advanced cancers, even after curative-intent surgery fails them, investigators reported at the annual Society of Surgical Oncology Cancer Symposium.

A study of the effects of an online decision aid for advance care planning showed that patients whose cancers had advanced despite initial curative-intent surgery had degrees of hope and desires for the aggressiveness of additional therapy similar to those of patients who had undergone palliative therapy only, said Dr. Niraj J. Gusani, FACS, of Penn State College of Medicine, Hershey, Pa.

"As we do more advance care planning, stratify patients, and get them into these programs to help them figure out what their wishes really are, we should treat everybody the same , and they should all have a durable advance care planning process, maybe using a decision aid such as this," he said.

The results show that outcomes beyond whether a patient lives or dies also matter, commented Dr. Steven Chen, FACS, from City of Hope Medical Center, Duarte, Calif.

"The thing that patients care about at least as much as how long they’re going to live is how well they’re going to live until they die," he said in an interview. Dr. Chen was not involved in the study, but comoderated the poster discussion session where it was presented.

"Almost all of my patients have very advanced cancers with poor prognosis, and it’s all about their quality of life and how they’re going to feel," Dr. Gusani agreed. "They intuitively get that they have a poor prognosis, but if we can get them through with a better experience with their time and they are able to maintain their hope, then it makes a world of difference for the patient and the family as well."

Multimedia advance care planning

Dr. Gusani and his colleagues looked at data from a clinical trial evaluating the effects of an online multimedia decision aid tool for patients with advanced-stage disease. The program, called Making Your Wishes Known: Planning Your Medical Future, was developed by two of the authors.

The program "provides tailored education, values-clarification exercises, and a decision-making tool that translates an individual’s values and preferences into a specific medical plan than can be implemented by a health care team," they wrote.

The investigators hypothesized that patients who went into surgery hoping for or expecting a cure might opt for more aggressive treatment at the end of life and have more hope and/or less hopelessness than patients who underwent treatments that they knew would not be curative.

The researchers administered the advance care planning program to 159 patients from the parent clinical trial, in which 200 patients with stage IV cancers who were judged to have less than 12 months to live were randomly assigned to receive either standard advance care planning or the decision aid. All of the patients had non–central nervous system and nonhematologic malignancies and were classified as having had initial curative-intent surgery or treatment without curative intent (e.g., palliative therapy and tumor debulking).

Making patients’ wishes known

Both at baseline and after the intervention, the patients were rated for hope on the 12-item Herth Hope Index, with scores from 12 (low hope) to 48 (high hope), and for hopelessness on the 7-item Beck Hopelessness Scale, in which 0 is no hopelessness and 7 is the highest level of despair.

The patients were also asked to rate their desires for aggressiveness of additional therapy by choosing one of six general wishes statements. For this scale, questions 1-4 were deemed to be more aggressive, and 5-6 less aggressive.

Additionally, patients who used the decision aid were rated on a treatment aggressiveness scale scored from 0 (least aggressive) to 40 (most) based on their responses to questions within the decision aid that asked about their wishes for eight different treatments (such as mechanical ventilation or cardiopulmonary resuscitation) under five clinical scenarios (such as stroke or dementia).

In all, 46 of 95 patients (48%) who had originally had curative-intent surgery received the control intervention, and 49 (52%) received the decision aid. Of the 64 patients who had non–curative-intent therapy, 35 (52%) received standard advance care planning and 31 (48%) received the Making Your Wishes Known aid.

After either intervention, patients who had curative-intent surgery had a slight but not significant increase in hope, and patients in the non–curative-intent group had a slight but not significant decrease. There was no significant between-group difference.

Similarly, each group had a slight decrease in hopelessness scores, with no significant differences between the groups.

There were also no significant variations in the distribution of the general wishes statements between the curative and noncurative groups or between the decision-aid and control groups, nor were there differences in the median treatment aggressiveness score of patients who used the decision aid, regardless of whether they had initially had curative-intent surgery.

"Regardless of what they choose in terms of their level of aggressiveness, the patients are more satisfied with their decision, they feel more informed, and caregiver satisfaction has improved with the decision aid compared with traditional materials," Dr. Gusani said.

"This is really important work," commented Dr. Sandra L. Wong of the University of Michigan Medical Center, Ann Arbor, who comoderated the poster discussion session.

The study was supported by Penn State College of Medicine. Dr. Gusani, Dr. Chen, and Dr. Wong reported having no financial conflicts of interest.