Seek and ye shall find: The utility of perioperative VTE screening in high-risk oncologic patients undergoing abdominopelvic surgery.

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the prevalence and risk factors associated with perioperative venous thromboembolism (VTE) in patients undergoing major oncologic surgery using an epidural catheter (EC) for postoperative analgesia with mechanical prophylaxis and without chemoprophylaxis. METHODS: Six hundred and twenty-six patients undergoing major oncologic surgery from 2009 to 2023 were evaluated. VTE was defined as deep vein thrombosis above the level of the knee. Lower extremity venous duplexes (LEVDs) were done preoperatively and postoperatively after the EC was removed. All patients received mechanical thromboprophylaxis, but not chemical prophylaxis, while the EC was in place. A generalized linear multivariable model was constructed to identify risk factors that predict pre and postoperative VTE. RESULTS: 29/626 patients (4.6%) were found to have preoperative VTE. 16/626 (2.6%) were found to have a postoperative VTE when their preoperative LEVD was negative. In comparison to patients without preoperative VTE, those with VTE were more likely to be male, anticoagulated, and have a history of coronary artery disease. Patients in the postoperative VTE group were older, male, anticoagulated, and had a history of VTE. On multivariable analysis, previous history of VTE was the risk factor most strongly associated with both pre and postoperative VTE. CONCLUSION: Oncologic patients undergoing elective abdominopelvic surgery with epidural analgesia should be screened in the perioperative setting with LEVD to identify VTE and possibly prevent PE.

Use of the End to End Anastomotic Stapler From Above for Difficult Pelvic Surgery for Distal Rectal Disease.

INTRODUCTION: Transabdominal utilization (TAU) of the end to end anastomotic (EEA) stapler in low anterior resection (LAR) for rectal cancer is an excellent alternative to the most widely performed techhnique. METHODS: We performed a retrospective analysis of a prospectively maintained database which obtained data on 104 patients with rectal disease who underwent EEA-assisted LAR with TAU. Records of all patients were used to evaluate demographics, complications, tumor location, margin status, postoperative complications, clinical sphincter function, adjuvant or neoadjuvant treatment, disease stage, and survival. RESULTS: Of the 104 patients, 48% were women with a mean age of 64 years (range 34-85 years). The average tumor location was 8 cm above the dentate line, and the mean tumor distance from the distal margin was 1.9 cm. All distal margins in cases for patients with rectal cancer were negative. Hospital length of stay averaged 8.7 days (6-15 days). There were no anastomotic complications (leaks, bleeding, or obstruction), and there were no leaks at the separate colotomy site. All patients have had normal postoperative sphincter function. CONCLUSION: Transabdominal utilization of the EEA stapler in LAR for colorectal carcinoma is an alternative to the conventional approach and may be advantageous in avoidance of the lithotomy position with potential nerve injury, risk of deep venous thrombosis, and stapler-induced sphincter trauma.

Secondary Malignancies: The Cost of Progress.

BACKGROUND: With advances in treatment of cancer, patients who survive their first malignancy are at risk of developing additional malignancies. Data on the risks of secondary malignancies after treatment of some of the more common cancers are lacking. METHODS: Our prospectively maintained database was queried from 1996 to 2016 to identify patients with breast cancer, colorectal cancer, melanoma, sarcoma, gastric, and pancreatic adenocarcinoma who developed additional malignancies. Predisposing clinical factors were included in our analysis. RESULTS: We identified 756 patients diagnosed with a solid malignancy who developed a second malignancy, of which 606 (80.1%) had one of the most common treated cancers. 59.5% of patients were women. 810 additional malignancies were identified in the 606 patients with breast and colon cancer being the most common secondary malignancies. Of these 606 patients, 460 (76%) patients had two malignancies; 145 (23.9%) had 3 or more malignancies. 15.2% of patients were diagnosed under the age of 40.63 years. 8.3% patients had a known genetic mutation, with BReast CAncer gene, and Lynch mutations being the most common. CONCLUSION: Advances in cancer treatment have led to higher cure rates. These patients should continue surveillance and undergo screening as they may be at risk of developing additional malignancies.

The Impact of Epidural Analgesia on the Rate of Thromboembolism without Chemical Thromboprophylaxis in Major Oncologic Surgery.

Patients with abdominopelvic cancers are at increased risk of venous thromboembolism (VTE) due to their malignancy. We evaluated outcomes and the rate of VTE in patients undergoing abdominopelvic surgery for malignancy with preoperative epidural analgesia without postoperative chemical VTE prophylaxis. A retrospective review between 2009 and 2015 identified 285 patients with malignancy who underwent abdominopelvic surgery by a single surgeon (AWS). Lower extremity venous duplex scans (VDS) were performed preoperatively and before discharge. Demographics, procedures, and VTE outcomes were reviewed. The median age was 66 years. The average operative time was 315 minutes. All patients ambulated on postoperative day (POD) one or two. Epidural catheters (ECs) were removed on postoperative day four or five. No patient received VTE prophylaxis while an epidural catheter was in place. Preoperative lower extremity VDS revealed above-knee deep vein thrombosis (DVT) in seven patients (2.5%). Postoperative lower extremity VDS revealed acute DVT in 24 patients (8.4%): nine (3.2%) above-knee and 15 (5.2%) below-knee. The nine patients with above-knee DVT were anticoagulated after epidural removal. No patient developed a pulmonary embolism. Our data suggest that patients undergoing major open operations with epidural analgesia have low rates of DVT and may obviate the need for chemical prophylaxis. However, larger studies are required to determine the overall effects of epidural analgesia on the development of DVTs postoperatively.

Prevalence and Predictors of Preoperative Venous Thromboembolism in Asymptomatic Patients Undergoing Major Oncologic Surgery.

BACKGROUND: Postoperative venous thromboembolism (VTE) is a leading cause of in-hospital mortality for cancer patients; however, the prevalence of preoperative VTE remains unclear. OBJECTIVE: The aim of this study was to evaluate the prevalence and risk factors associated with preoperative VTE in asymptomatic patients undergoing major oncologic surgery. METHODS: Retrospective analysis of 346 patients identified from our prospectively maintained database of patients undergoing abdominopelvic oncologic surgery from 2009 to 2016. RESULTS: The prevalence of preoperative VTE found on screening venous duplex scan was 10.1%. Patients with a history of prior VTE were more likely to have a preoperative deep vein thrombosis (DVT) versus those with no prior VTE (42.9% vs. 4.5%, p < 0.01). Relative risk for prior VTE was 8.2 [95% confidence interval (CI) 4.7-14.3]. Older age was also associated with preoperative VTE. Regression modeling determined that patients were 1.24-fold as likely to have a preoperative DVT for every 5-year increase in age (relative risk 1.24, 95% CI 1.09-1.42). Patients with preoperative DVT were more likely to have been diagnosed with sepsis 1 month prior to surgery (8.6% vs. 1.6%, p = 0.04). There were no postoperative pulmonary emboli. The overall postoperative complication rate was higher in those with a preoperative DVT (25.7% vs. 13.2%, p = 0.071). CONCLUSION: Asymptomatic patients undergoing major oncologic surgery have a 10.1% prevalence of preoperative DVT. Increasing age, recent diagnosis of sepsis, and a history of prior VTE are significantly associated with preoperative DVTs. This suggests high-risk oncologic patients may benefit from screening lower extremity venous duplex ultrasound prior to Surgery.

Surgical Resection of Retroperitoneal Sarcomas: Analysis of Factors Determining Outcome.

INTRODUCTION: Retroperitoneal sarcomas (RS) are rare malignant tumors characterized by high local recurrence rates and poor survival, Aggressive surgical resection may improve local recurrence rates and disease-specific survival (DSS), The aim of our study was to determine predictors of survival and local recurrence in primary RS. METHODS: We performed a retrospective analysis and identified 68 patients who underwent surgical resection of a primary RS between 1985 and 2010, Clinical and pathologic variables were used to create univariate and multivariate models for both survival and recurrence. RESULTS: 68 patients (37% male) with mean age 59 (range 25-84) underwent surgical resection for RS. Median tumor size was 12.0 cm (range 7.0-18.0 cm). 75% of tumors were intermediate/high grade, Incontinuity organ resection was performed in 29 (43%) patients. Seven patients (10%) underwent vascular resection with graft placement. Overall survival at 5, 10 and 15 years was 55%, 42%, and 33%, respectively. Grade (p<0.007), tumor size (p=0.048) and margin status (p<0.05) were found to significantly affect local recurrence. In a multivariate analysis, recurrent disease (p<0.001), age (p<0.003) and high/intermediate grade (p<0.001) significantly affected DSS. Incontinuity organ resection did not significantly affect recurrence (HR = 1.1, CI 0.63 - 1.85) or survival (HR = 1.4, CI 0.8 - 2.9). CONCLUSION: Surgical resection of RS affords the best chance of survival. Incontinuity organ resection did not affect outcome on multivariate analysis; however, margin status did significantly affect recurrence and could not be achieved without aggressive resection of incontinuity organs.

Genomic landscape of liposarcoma.

Liposarcoma (LPS) is the most common type of soft tissue sarcoma accounting for 20% of all adult sarcomas. Due to absence of clinically effective treatment options in inoperable situations and resistance to chemotherapeutics, a critical need exists to identify novel therapeutic targets. We analyzed LPS genomic landscape using SNP arrays, whole exome sequencing and targeted exome sequencing to uncover the genomic information for development of specific anti-cancer targets. SNP array analysis indicated known amplified genes (MDM2, CDK4, HMGA2) and important novel genes (UAP1, MIR557, LAMA4, CPM, IGF2, ERBB3, IGF1R). Carboxypeptidase M (CPM), recurrently amplified gene in well-differentiated/de-differentiated LPS was noted as a putative oncogene involved in the EGFR pathway. Notable deletions were found at chromosome 1p (RUNX3, ARID1A), chromosome 11q (ATM, CHEK1) and chromosome 13q14.2 (MIR15A, MIR16-1). Significantly and recurrently mutated genes (false discovery rate < 0.05) included PLEC (27%), MXRA5 (21%), FAT3 (24%), NF1 (20%), MDC1 (10%), TP53 (7%) and CHEK2 (6%). Further, in vitro and in vivo functional studies provided evidence for the tumor suppressor role for Neurofibromin 1 (NF1) gene in different subtypes of LPS. Pathway analysis of recurrent mutations demonstrated signaling through MAPK, JAK-STAT, Wnt, ErbB, axon guidance, apoptosis, DNA damage repair and cell cycle pathways were involved in liposarcomagenesis. Interestingly, we also found mutational and copy number heterogeneity within a primary LPS tumor signifying the importance of multi-region sequencing for cancer-genome guided therapy. In summary, these findings provide insight into the genomic complexity of LPS and highlight potential druggable pathways for targeted therapeutic approach.

Thromboprophylaxis and major oncologic surgery performed with epidural analgesia.

OBJECTIVE: To evaluate clinical outcomes in patients with cancer undergoing major abdominal surgery who received preoperative indwelling epidural catheters (ECs) and no postoperative thromboprophylaxis. DESIGN: Retrospective analysis of a prospective database. SETTING: Tertiary referral medical center. PATIENTS Between January 1, 2009, and July 31, 2011, 119 patients, with a mean age of 64.5 years (range, 34-95 years), underwent major abdominal oncologic surgery with an indwelling EC. MAIN OUTCOME MEASURES: Records of all patients were reviewed for age, duration of surgery, hospital length of stay, and clinical outcomes. All patients underwent lower extremity venous duplex ultrasonography prior to hospital discharge. RESULTS: The average operative time was 338 minutes. Mean (SD) intensive care unit stay was 2.8 (1.4) days (range, 1-7 days). Patients ambulated by postoperative day 1 or 2. Most ECs were removed on postoperative day 4. There were no major complications from the EC. Fifty-two patients (44%) were treated with deep venous thrombosis prophylaxis on postoperative day 4 after removal of the EC. Lower extremity duplex studies showed 8 patients (6.7%) had an acute thrombus. One patient (0.8%) developed an asymptomatic proximal deep venous thrombosis and 7 patients (5.9%) developed distal superficial thrombi. No patient developed a pulmonary embolus. CONCLUSIONS Thromboembolic complications following major abdominal surgery for cancer may be reduced with the use of ECs. Epidural catheters may directly prevent deep venous thrombosis through sympathetic blockade, resulting in increased blood flow to the lower extremities. This effect may also be attributable to earlier ambulation. These results suggest that patients who have an EC and do not receive concurrent postoperative thromboprophylaxis do not have an increased risk for thromboembolic events.

Tumors at the aortoiliac/inferior vena cava bifurcation: preoperative, anesthetic, and intraoperative considerations.

Primary and recurrent retroperitoneal tumors can involve the aortoiliac vasculature. They are often considered inoperable or incurable because of the locally advanced nature of the disease or the technical aspects involved in safely resecting the lesion. Safe resection of these lesions requires experience and extensive preoperative planning for success. A retrospective database review of 76 patients with retroperitoneal tumors identified tumors involving major vascular structures in the abdomen and pelvis undergoing resection of tumor en bloc with the aortoiliac vasculature. Preoperative planning and intraoperative technical maneuvers are reviewed. Patients were followed until time of this report. Four patients with retroperitoneal tumors involving the aortoiliac vessels underwent surgery: two patients with sarcoma (one primary and one recurrent), one with metastatic renal cell carcinoma, and one with a paraganglioma. All patients had resection of the aorta and vena cava or the iliac artery and vein. Arterial reconstruction (anatomic or extra-anatomic) was performed in all cases. The patient with renal cell carcinoma also required venous reconstruction to support a renal autotransplant. Veno-venous bypass was required in one patient. Local control was achieved in 3 of 4 cases. Surgery for retroperitoneal tumors involving major vascular structures is technically feasible with appropriate planning and technique. Multiple disciplines are required, including general surgical oncology, vascular surgery, and possibly, cardiothoracic surgery.

Colorectal cancer metastasis presenting as a testicular mass: case report and review of the literature.

Metastatic lesions to the testicle are uncommon. The authors report a testicular mass as the initial manifestation of distant metastasis from colorectal cancer. This case describes a 51-year-old white man who presented with an enlarged right testicle 9 months after undergoing a right hemicolectomy for a stage IIIC colon adenocarcinoma. The diagnostic and management strategy is discussed. In addition, the literature is reviewed to characterize this uncommon entity further. Although rare, testicular metastasis must be considered in patients with previously resected colorectal carcinoma.

Comparative morbidity of axillary lymph node dissection and the sentinel lymph node technique: implications for patients with breast cancer.

OBJECTIVE: To assess our long-term complications from complete axillary lymph node dissection (AXLND) in patients with breast cancer. SUMMARY BACKGROUND DATA: Complete AXLND as part of the surgical therapy for breast cancer has come under increased scrutiny due the use of the sentinel lymph node (SLN) biopsy technique to assess the status of the axillary nodes. As the enthusiasm for the SLN technique has increased, our impression has been that the perceived complication rate from AXLND has increased dramatically while the negative aspects of the SLN technique have been underemphasized. METHODS: Female patients seen in routine follow-up over a 1-year period were eligible for our retrospective study of the long-term complications from AXLND if they were a minimum of 1 year out from all primary therapy; ie, surgery, radiation, and/or chemotherapy. All patients had previously undergone either a modified radical mastectomy (MRM) or a segmental mastectomy with axillary dissection and postoperative radiation (SegAx/XRT). All patients had a Level I-III dissection. Objective measurements, including upper and lower arm circumferences and body mass index (BMI), were obtained, and a subjective evaluation from the patients was conducted. RESULTS: Ninety-four patients were eligible for our study; 44 had undergone MRM, and 50 had undergone SegAx/XRT. The average number of nodes removed was 25.6 (standard deviation, 8). Thirty-three percent of the patients had positive nodal disease, 95% of the patients had an upper arm circumference within 2 cm of the unaffected side, and 93.3% had a lower arm circumference within 2 cm of the unaffected side. Subjectively, 90.4% of the patients had either no or minimal arm swelling, and 96.8% of the patients had "good" or "excellent" overall arm function. The most common long-term symptom was numbness involving the upper, inner aspect of the affected arm (25.5%). CONCLUSIONS: Our data indicate that a complete AXLND can be performed with minimal long-term morbidity. The lower the morbidity of AXLND, the less acceptable are the unique complications of the SLN technique.

Splenic infarction associated with anti-cardiolipin antibody: a report of two cases.

There are few cases of splenic infarction associated with antiphospholipid antibody reported in the literature. We present two cases of splenic infarction associated with anticardiolipin antibody, one complicated by the development of a splenic pseudocyst. Clinical diagnostic features of splenic infarction are described. In addition, a review of the literature on thrombotic manifestations of antiphospholipid syndrome is presented.