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1.
Curr Oncol ; 31(7): 3657-3668, 2024 Jun 25.
Article in English | MEDLINE | ID: mdl-39057141

ABSTRACT

BACKGROUND: Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a major treatment of colorectal peritoneal carcinomatosis (CPC). The aim was to determine the disease-free survival (DFS) and overall survival (OS) of patients undergoing CRS-HIPEC for CPC and factors associated with long-term survival (LTS). METHODS: consecutive CPC patients who underwent CRS-HIPEC at a HIPEC center between 2007 and 2021 were included. Actual survival was calculated, and Cox proportional hazards models were used to identify factors associated with OS, DFS and LTS. RESULTS: there were 125 patients with CPC who underwent primary CRS-HIPEC, with mean age of 54.5 years. Median follow-up was 31 months. Average intraoperative PCI was 11, and complete cytoreduction (CC-0) was achieved in 96.8%. Median OS was 41.6 months (6-196). The 2-year and 5-year OS were 68% and 24.8%, respectively, and the 2-year DFS was 28.8%. Factors associated with worse OS included pre-HIPEC systemic therapy, synchronous extraperitoneal metastasis, and PCI ≥ 20 (p < 0.05). Progression prior to CRS-HIPEC was associated with worse DFS (p < 0.05). Lower PCI, fewer complications, lower recurrence and longer DFS were associated with LTS (p < 0.05). CONCLUSION: CRS and HIPEC improve OS in CPC patients but they have high disease recurrence. Outcomes depend on preoperative therapy response, extraperitoneal metastasis, and peritoneal disease burden.


Subject(s)
Colorectal Neoplasms , Cytoreduction Surgical Procedures , Hyperthermic Intraperitoneal Chemotherapy , Peritoneal Neoplasms , Humans , Cytoreduction Surgical Procedures/methods , Peritoneal Neoplasms/therapy , Peritoneal Neoplasms/secondary , Colorectal Neoplasms/pathology , Colorectal Neoplasms/therapy , Female , Hyperthermic Intraperitoneal Chemotherapy/methods , Male , Middle Aged , Aged , Adult , Treatment Outcome , Combined Modality Therapy , Retrospective Studies
2.
Ann Diagn Pathol ; 48: 151606, 2020 Oct.
Article in English | MEDLINE | ID: mdl-32889392

ABSTRACT

Low grade appendiceal mucinous neoplasm (LAMN) is the primary source of pseudomyxoma peritonei (PMP). PMP may develop after seemingly complete resection of primary tumor by appendectomy, which is unpredictable due to lack of reliable prognostic indicators. We retrospectively reviewed 154 surgically resected LAMNs to explore if any of the macroscopic and microscopic characteristics may be associated with increasing risk of PMP development. Our major findings include: (1) As compared to those without PMP, the cases that developed PMP were more frequent to have (a) smaller luminal diameter (<1 cm) and thicker wall, separate mucin aggregations, and microscopic perforation/rupture, all suggestive of luminal mucin leakage; (b) microscopic acellular mucin presenting on serosal surface and not being confined to mucosa; and (c) neoplastic epithelium dissecting outward beyond mucosa, however, with similar frequency of neoplastic cells being present in muscularis propria. (2) Involvement of neoplastic cells or/and acellular mucin at surgical margin did not necessarily lead to tumor recurrence or subsequent PMP, and clear margin did not absolutely prevent PMP development. (3) Coexisting diverticulum, resulted from neoplastic or non-neoplastic mucosa being herniated through muscle-lacking vascular hiatus of appendiceal wall, was seen in a quarter of LAMN cases, regardless of PMP. The diverticular portion of tumor involvement was often the weakest point where rupture occurred. In conclusion, proper evaluation of surgical specimens with search for mucin and neoplastic cells on serosa and for microscopic perforation, which are of prognostic significance, should be emphasized.


Subject(s)
Adenocarcinoma, Mucinous/pathology , Adenocarcinoma, Mucinous/surgery , Appendectomy/methods , Appendiceal Neoplasms/pathology , Pseudomyxoma Peritonei/pathology , Adenocarcinoma, Mucinous/complications , Adenocarcinoma, Mucinous/ultrastructure , Adolescent , Adult , Aged , Aged, 80 and over , Case-Control Studies , Diverticulum/etiology , Diverticulum/pathology , Female , Humans , Male , Middle Aged , Mucins/ultrastructure , Neoplasm Grading/methods , Neoplasm Recurrence, Local/prevention & control , Pathology, Surgical/methods , Prognosis , Pseudomyxoma Peritonei/diagnosis , Pseudomyxoma Peritonei/etiology , Retrospective Studies , Risk Management , Serous Membrane/pathology , Serous Membrane/ultrastructure , Young Adult
3.
Can J Surg ; 63(1): E71-E79, 2020 02 21.
Article in English | MEDLINE | ID: mdl-32080999

ABSTRACT

Background: Peritoneal recurrences after cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) for appendiceal and colorectal cancers are frequent. This study aimed to evaluate the safety, technical feasibility and perioperative and long-term outcomes of repeat CRS/HIPEC in patients with recurrent peritoneal carcinomatosis of colorectal and appendiceal origin. Methods: Data were collected from patients treated from 2000 to 2016 for recurrent peritoneal carcinomatosis from appendiceal or colorectal cancer with CRS/HIPEC at 2 specialist centres. Data on demographics, procedure details, morbidity and survival were recorded. Analyses compared the iterations of CRS/HIPEC to assess the safety and effectiveness of repeat surgery. Results: Of all patients who underwent CRS/HIPEC in the 2 centres, 37 patients underwent a repeat procedure. Operative time was similar for the first and second surgeries (412.1 v. 412.5 min, p = 0.74) but patients had a significantly lower peritoneal carcinoma index score with the second surgery (21.8 in the first iteration v. 9.53 in the second iteration, p < 0.001) and significantly less blood loss (1762 mL in the first iteration v. 790 mL in the second iteration, p = 0.001). There was a nonsignificant decrease in grade III­IV complications and there was no 30-day mortality associated with repeat procedures. For patients with colorectal cancer, median disease-free survival was 9.6 months and median overall survival was 40 months. For patients with appendiceal cancer, median disease-free survival was 15 months and overall survival was 64.4 months. Conclusion: Repeat CRS/HIPEC procedures for recurrent appendiceal and colorectal peritoneal carcinomatosis are safe in well-selected patients, without increased morbidity or mortality, and they are associated with significant long-term survival, particularly for patients with appendiceal cancers. These results support the use of repeat CRS/HIPEC in these patients.


Contexte: Les récurrences péritonéales après une chirurgie cytoréductrice (CCR) et une chimiothérapie hyperthermique intrapéritonéale (CHIP) pour les cancers de l'appendice et colorectaux sont fréquentes. Cette étude visait à évaluer l'innocuité, la faisabilité technique et les résultats périopératoires et à long terme d'une reprise de CCR/CHIP chez les patients qui présentent une récurrence de carcinomatose péritonéale ayant son origine au niveau colorectal ou de l'appendice. Méthodes: Des données ont été recueillies sur des patients traités entre 2000 et 2016 pour une récurrence de carcinomatose péritonéale ayant son origine au niveau colorectal ou de l'appendice par CCR/CHIP dans 2 centres spécialisés. On a tenu compte des données démographiques, des détails des interventions, ainsi que de la morbidité et de la survie. Des analyses ont permis de comparer les premières et deuxièmes CCR/CHIP pour évaluer l'innocuité et l'efficacité des chirurgies répétées. Résultats: De tous les patients soumis à des CCR/CHIP dans les 2 centres, 37 ont subi l'intervention de nouveau. Le temps opératoire a été similaire pour les premières et les deuxièmes chirurgies (412,1 c. 412,5 min, p = 0,74), mais les patients présentaient un score de carcinomatose péritonéale beaucoup plus bas lors de la deuxième chirurgie (21,8 pour la première intervention c. 9,53 pour la seconde, p < 0,001) et des pertes sanguines significativement moindres (1762 mL pour la première intervention c. 790 mL pour la seconde, p = 0,001). On a noté une diminution non significative des complications de grades III­IV et on n'a déploré aucune mortalité à 30 jours en lien avec la reprise de l'intervention. Pour les patients atteints d'un cancer colorectal, la survie médiane sans maladie a été de 9,6 mois et la survie médiane globale a été de 40 mois. Pour les patients atteints d'un cancer de l'appendice, la survie médiane sans maladie a été de 15 mois et la survie médiane globale a été de 64,4 mois. Conclusion: La reprise des CCR/CHIP pour les récurrences de carcinomatose péritonéale ayant leur origine au niveau colorectal ou de l'appendice est sécuritaire chez les patients soigneusement sélectionnés, sans accroissement de la morbidité ou de la mortalité, et elles sont associées à une survie à long terme significative, particulièrement chez les patients ayant un cancer de l'appendice. Ces résultats appuient la reprise des CCR/CHIP chez ces patients.


Subject(s)
Antineoplastic Combined Chemotherapy Protocols , Appendiceal Neoplasms/therapy , Carcinoma/therapy , Colorectal Neoplasms/therapy , Cytoreduction Surgical Procedures , Hyperthermia, Induced , Neoplasm Recurrence, Local/therapy , Outcome Assessment, Health Care , Peritoneal Neoplasms/therapy , Reoperation , Adult , Antineoplastic Combined Chemotherapy Protocols/adverse effects , Appendiceal Neoplasms/mortality , Appendiceal Neoplasms/pathology , Canada/epidemiology , Carcinoma/mortality , Carcinoma/secondary , Colorectal Neoplasms/mortality , Colorectal Neoplasms/pathology , Combined Modality Therapy , Cross-Sectional Studies , Cytoreduction Surgical Procedures/adverse effects , Cytoreduction Surgical Procedures/mortality , Feasibility Studies , Female , Humans , Hyperthermia, Induced/adverse effects , Male , Middle Aged , Neoplasm Recurrence, Local/mortality , Peritoneal Neoplasms/mortality , Peritoneal Neoplasms/secondary , Reoperation/adverse effects , Reoperation/mortality , Retrospective Studies
4.
Curr Oncol ; 28(1): 40-51, 2020 12 01.
Article in English | MEDLINE | ID: mdl-33704173

ABSTRACT

Background: The COVID-19 pandemic has put enormous pressure on hospital resources, and has affected all aspects of patient care. As operative volumes decrease, cancer surgeries must be triaged and prioritized with careful thought and attention to ensure maximal benefit for the maximum number of patients. Peritoneal malignancies present a unique challenge, as surgical management can be resource intensive, but patients have limited non-surgical treatment options. This review summarizes current data on outcomes and resource utilization to help inform decision-making and case prioritization in times of constrained health care resources. Methods: A rapid literature review was performed, examining surgical and non-surgical outcomes data for peritoneal malignancies. Narrative data synthesis was cross-referenced with relevant societal guidelines. Peritoneal malignancy surgeons and medical oncologists reviewed recommendations to establish a national perspective on case triage and mitigating treatment strategies. Results and Conclusions: Triage of peritoneal malignancies during this time of restricted health care resource is nuanced and requires multidisciplinary discussion with consideration of individual patient factors. Prioritization should be given to patients where delay may compromise resectability of disease, and where alternative treatment options are lacking. Mitigating strategies such as systemic chemotherapy and/or surgical deferral may be utilized with close surveillance for disease stability or progression, which may affect surgical urgency. Unique hospital capacity, and ability to manage the complex post-operative course for these patients must also be considered to ensure patient and system needs are aligned.


Subject(s)
COVID-19/prevention & control , Cytoreduction Surgical Procedures/methods , Health Resources/statistics & numerical data , Peritoneal Neoplasms/surgery , SARS-CoV-2/isolation & purification , Triage/methods , COVID-19/epidemiology , COVID-19/virology , Combined Modality Therapy , Evidence-Based Medicine/methods , Humans , Pandemics , Patient Selection , Peritoneal Neoplasms/therapy , SARS-CoV-2/physiology , Surgical Oncology/methods
5.
J Surg Oncol ; 117(4): 545-550, 2018 Mar.
Article in English | MEDLINE | ID: mdl-29127696

ABSTRACT

Giving hope to patients is our responsibility. It is the essence of a meaningful practice in medicine. Science now allows us to understand this complex and multidimensional human dynamic, and translate it into clinical practice. Quantitative research has shown hope is strong even in terminal illness. Through qualitative methodology hope fostering strategies and hope hindering behaviors have been identified. This exciting new knowledge facilitates the challenging task of disclosure of bad news while enabling hope.


Subject(s)
Hope , Neoplasms/prevention & control , Oncologists/psychology , Physician-Patient Relations , Translational Research, Biomedical/methods , Humans , Neoplasms/therapy
6.
Can J Anaesth ; 64(11): 1144-1152, 2017 Nov.
Article in English | MEDLINE | ID: mdl-28853010

ABSTRACT

PURPOSE: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) benefit patients with peritoneal carcinomatosis. Nevertheless, this therapy is associated with considerable postoperative pain due to the extensive abdominal incision. While epidural analgesia offers efficacious pain control, CRS and HIPEC therapy is associated with perioperative coagulopathy that may impact its use. The purpose of this retrospective study is to characterize the postoperative coagulopathy in this patient subset and to develop a model that will help predict those at risk. METHODS: Our database of patients treated with CRS and HIPEC (n = 171) was reviewed to assess perioperative changes in platelet count, international normalized ratio (INR), and partial thromboplastin time (PTT). Abnormal coagulation was defined by platelet count < 100 × 10-9·L-1, INR ≥ 1.5, or PTT ≥ 45 sec. Severe abnormality in coagulation was defined by platelet count < 50 ×10-9·L-1, INR > 2.0, and/or PTT > 60 sec. A logistic regression model was developed to determine if patient, disease, and/or surgical factor(s) were associated with the development of postoperative coagulopathy. Epidural catheter management in this patient population was also reviewed. RESULTS: Significant differences (adjusted P < 0.007) were noted between median preoperative and postoperative platelet and INR values on postoperative days (POD) 0 through 6 and days 0 through 3, respectively. Highest observed median differences between preoperative and postoperative values showed a decrease in platelet count of 94 × 10-9·L-1 (POD 2 and POD 3), an increase in INR of 0.2 (POD 0 to POD 2), and a decrease in PTT of 3.1 sec (POD 5). Coagulopathy and severe coagulopathy occurred in 38% and 4.7% of patients, respectively. Predictors of coagulopathy included intraoperative transfusion of packed red blood cells (PRBCs) and perhaps the peritoneal carcinomatosis index (PCI). Epidural catheters were inserted in 26 patients for a median [IQR] duration of 7.0 [5.0-7.0] days without complication. At the time of their removal, no blood products were required to correct abnormal coagulation values. CONCLUSIONS: Altered coagulation may appear during the postoperative period in approximately 40% of our patients treated with CRS and HIPEC. Intraoperative transfusion of RBCs and possibly increased PCI are associated with abnormal postoperative coagulation. Close monitoring of coagulation parameters is required to help ensure safe removal of an epidural catheter.


Subject(s)
Blood Coagulation Disorders/etiology , Cytoreduction Surgical Procedures/methods , Hyperthermia, Induced/methods , Peritoneal Neoplasms/therapy , Analgesia, Epidural/methods , Blood Coagulation , Blood Coagulation Disorders/epidemiology , Cohort Studies , Combined Modality Therapy , Databases, Factual , Erythrocyte Transfusion/methods , Female , Humans , International Normalized Ratio , Logistic Models , Male , Middle Aged , Pain, Postoperative/epidemiology , Platelet Count , Postoperative Complications/epidemiology , Retrospective Studies , Risk
7.
J Clin Pathol ; 70(1): 40-50, 2017 Jan.
Article in English | MEDLINE | ID: mdl-27371613

ABSTRACT

BACKGROUND: Tumours of appendix, including classic carcinoid tumour (CCT), goblet cell carcinoid (GCC), low-grade appendiceal mucinous neoplasm, high-grade appendiceal mucinous neoplasm/mucinous carcinoma (MCA) and non-mucinous adenocarcinoma (NMA), show different and sometimes mixed morphological features. It was hypothesised that these tumours originate from common tumour stem cell(s) with potential of various cell lineage differentiation. In normal intestinal epithelium, absorptive lineage (enterocytes) differentiation is driven by Notch-Hes1 pathway, while secretory lineage is driven by Wnt-Math1 pathway and further separated by different downstream signallings into three sublineages (Gfi1-Klf4/Elf3 for goblet cells, Gfi1-Sox9 for Paneth cells and Ngn3-Pdx1/Beta2/Pax4 for enteroendocrine cells). METHODS: The expressions of various signalling proteins in different appendiceal tumours were detected by immunohistochemistry on tumour tissue microarray. RESULTS: CCT showed reduced Hes1/Elf3 and Sox9/Klf4 coupled with elevated Math1, in keeping with endocrine phenotype. As compared with CCT, GCC showed higher Klf4 and similar Ngn3/Pax4, indicative of a shift of differentiation towards goblet cells as well as endocrine cells. GCC displayed a Notch signalling similar to adenocarcinoma. Mucinous tumours showed lower Elf3 than normal appendiceal epithelium and higher Math1/Gfi1/Klf4, suggestive of a differentiation towards less enterocytes but more goblet cells. NMA showed Notch signalling similar to other glandular tumours, but lower Klf4. However, some seemingly paradoxical changes were also observed, probably suggesting gene mutations and/or our incomplete understanding of the intestinal cell differentiation. CONCLUSIONS: Wnt/secretory lineage protein and Notch/absorptive lineage protein expression profiles are generally associated with the tumour cell differentiation and morphological diversity of common appendiceal tumours.


Subject(s)
Adenocarcinoma, Mucinous/metabolism , Appendiceal Neoplasms/metabolism , Carcinoid Tumor/metabolism , Enterocytes/metabolism , Intestinal Mucosa/metabolism , Receptors, Notch/metabolism , Wnt Signaling Pathway/physiology , Adenocarcinoma, Mucinous/genetics , Adenocarcinoma, Mucinous/pathology , Appendiceal Neoplasms/genetics , Appendiceal Neoplasms/pathology , Carcinoid Tumor/genetics , Carcinoid Tumor/pathology , Cell Differentiation/physiology , Cell Lineage , Enterocytes/pathology , Humans , Intestinal Mucosa/pathology , Kruppel-Like Factor 4 , Receptors, Notch/genetics
8.
J Surg Oncol ; 113(1): 108-13, 2016 Jan.
Article in English | MEDLINE | ID: mdl-26661586

ABSTRACT

BACKGROUND AND OBJECTIVES: Currently, standard treatment of soft tissue sarcoma (STS) is wide local excision and adjuvant radiation, but radiation may be unnecessary in superficial STS. The primary objective is to assess local recurrence rates in patients treated with surgical management alone for superficial STS. METHODS: A retrospective cancer registry review of patients treated with surgery alone for superficial STS at the Tom Baker Cancer Center (TBCC) was performed. Patient and tumor characteristics as well as recurrence data were collected. RESULTS: Sixty-one patients met study criteria. Local and overall recurrence rates were 7/61 (11.5%) and 12/61 (19.7%), respectively. The proportion with a T2 tumor was 38.8% versus 33.3% (P = 0.69), with Grade 2 or 3 tumors was 59.2% versus 83.3% (P = 0.14), and with resection margins <1 cm was 28.6% versus 75.0% (P = 0.008) for patients without and with recurrence, respectively. Median time to recurrence was 1.7 (0.4-5.2) years. CONCLUSIONS: Surgical resection alone appears to be a viable option for superficial STS that can save patients from potential side effects of radiation. The association between recurrence and inadequate margins (<1 cm) requires additional treatment be offered to this subset of patients.


Subject(s)
Sarcoma/pathology , Sarcoma/surgery , Adult , Aged , Alberta/epidemiology , Disease-Free Survival , Female , Humans , Kaplan-Meier Estimate , Male , Medical Records , Middle Aged , Neoplasm Grading , Neoplasm Recurrence, Local/epidemiology , Patient Selection , Registries , Retrospective Studies , Sarcoma/epidemiology , Sarcoma/mortality , Treatment Outcome
9.
Ann Surg Oncol ; 22(10): 3376-82, 2015 Oct.
Article in English | MEDLINE | ID: mdl-26202561

ABSTRACT

INTRODUCTION: Neoadjuvant chemotherapy in breast cancer is used to downstage locally advanced and inoperable tumors. Expanded benefits of neoadjuvant chemotherapy include downstaging of tumors to allow breast-conserving surgery (BCS) and assessment of in vivo tumor response. We sought to identify patterns and predictors of neoadjuvant chemotherapy use to determine if this has translated into population-level clinical practice. METHODS: All patients undergoing surgery for invasive breast cancer between January 2012 and June 2014 were identified from our provincial synoptic operating room database. Data regarding patient demographics, hospital, operating surgeon, preoperative tumor characteristics, neoadjuvant treatment, and type of surgery performed were collected. Descriptive statistics and multivariable analysis were used to identify predictors of neoadjuvant chemotherapy. RESULTS: A total of 4186 patients were identified, 363 (8.53%) of whom underwent neoadjuvant chemotherapy. A significant increase was seen in the use of neoadjuvant chemotherapy over time. In multivariable analysis, neoadjuvant chemotherapy was associated with prechemotherapy tumor size, multicentricity, lymph node positivity, and decreasing patient age. In addition, there was significant variability in neoadjuvant chemotherapy use between operating surgeons. Of those patients who underwent neoadjuvant chemotherapy, 68.9% were not pretreatment candidates for BCS. At the time of definitive surgery, 72.1% had mastectomy, with 18.7% opting for contralateral prophylactic mastectomy. As reported, this was due to the tumor being advanced/too large (50.4%), patient preference (12.6%), multicentricity (8.8%) and margins, genetics, and previous radiotherapy (4%). CONCLUSIONS: A significant increase in the use of neoadjuvant chemotherapy over time was identified, and treatment with mastectomy as definitive surgical management remained high. There was significant variability in neoadjuvant chemotherapy use by the operating surgeons, in addition to factors generally associated with more locally advanced/aggressive tumors.


Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Breast Neoplasms/drug therapy , Breast Neoplasms/surgery , Mastectomy, Segmental , Neoadjuvant Therapy , Adult , Aged , Aged, 80 and over , Breast Neoplasms/epidemiology , Breast Neoplasms/pathology , Chemotherapy, Adjuvant , Combined Modality Therapy , Female , Follow-Up Studies , Humans , Middle Aged , Neoplasm Staging , Prognosis , Prospective Studies , Receptor, ErbB-2/metabolism , Receptors, Estrogen/metabolism , Receptors, Progesterone/metabolism , Young Adult
10.
Am J Surg ; 210(3): 424-30, 2015 Sep.
Article in English | MEDLINE | ID: mdl-26051744

ABSTRACT

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have improved survival for colorectal and high-grade appendiceal carcinomatosis. We compared the overall and recurrence-free survival (OS and RFS) of patients treated with HIPEC with mitomycin c and early postoperative intraperitoneal chemotherapy (EPIC) with fluorouracil versus HIPEC alone using oxaliplatin and simultaneous IV infusion of fluorouracil. METHODS: Ninety-three patients with colorectal or high-grade appendiceal carcinomatosis were treated with CRS and HIPEC + EPIC or HIPEC alone. OS and RFS were analyzed using Kaplan-Meier curves and log-rank testing. RESULTS: Survival did not differ between HIPEC regimens. The 3-year OS and RFS rates were 50% and 21% for HIPEC + EPIC and 46% and 6% for HIPEC alone (P = .72 and P = .89, respectively). HIPEC + EPIC patients experienced more grade III/IV complications (43.2% vs 19.6%, P = .01). CONCLUSIONS: There was no difference in OS and RFS between colorectal and high-grade appendiceal adenocarcinoma patients treated with CRS and HIPEC + EPIC versus HIPEC alone. However, HIPEC + EPIC patients suffered greater morbidity, making HIPEC alone the preferable regimen.


Subject(s)
Chemotherapy, Cancer, Regional Perfusion , Colorectal Neoplasms/mortality , Colorectal Neoplasms/therapy , Cytoreduction Surgical Procedures , Hyperthermia, Induced , Peritoneal Neoplasms/mortality , Peritoneal Neoplasms/therapy , Adenocarcinoma/mortality , Adenocarcinoma/therapy , Adenocarcinoma, Mucinous/mortality , Adenocarcinoma, Mucinous/therapy , Adult , Aged , Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Appendiceal Neoplasms/mortality , Appendiceal Neoplasms/therapy , Chemotherapy, Adjuvant , Female , Fluorouracil/administration & dosage , Humans , Male , Middle Aged , Neoplasm Recurrence, Local , Organoplatinum Compounds/administration & dosage , Oxaliplatin
11.
Ann Surg Oncol ; 22(9): 2869-75, 2015 Sep.
Article in English | MEDLINE | ID: mdl-25783679

ABSTRACT

BACKGROUND: Preoperative irradiation reduces local recurrence of soft tissue sarcomas (STSs), but major wound complication rates approach 25-35 %. Using a novel neoadjuvant chemoradiation protocol, we prospectively documented functional outcomes and quality of life (QOL) and hypothesized a lower major wound complication rate. METHODS: Patients with STS deep to muscular fascia were treated with 3 days of doxorubicin (30 mg/day) and 10 days of irradiation (300 cGy/day) followed by limb-sparing surgery. Wound complications were assessed, and functional assessment and QOL were followed prospectively using the Toronto Extremity Salvage Score (TESS), Musculoskeletal Tumor Society (MSTS), and Short Form (SF)-36 questionnaires preoperatively and 6 and 12 months postoperatively. RESULTS: Altogether, 52 consecutive patients were accrued during 2006-2011. Overall, 80.8 % of STSs were >5 cm, and 67.3 % involved the lower extremity. Seven (13.5 %) major wound complications occurred, all requiring reoperation. Preoperative scores for TESS, MSTS, and SF-36 physical (PCS) and mental (MCS) health components were 83.3, 86.7, 40.6, and 49.4, respectively. There were no differences seen 6 months postoperatively. By 12 months, however, patients showed improved functional scores (TESS 93.0, p = 0.02; MSTS 93.3, p < 0.01) and QOL scores (PCS 45.1, p = 0.02; MCS = 52.9, p = 0.05). No differences in scores were seen between patients with or without wound complications. CONCLUSIONS: Patients treated with our neoadjuvant chemoradiation protocol had stable QOL and functional scores 6 months postoperatively and showed improvement by 12 months. Importantly, the major wound complication rate was low.


Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Chemoradiotherapy , Neoadjuvant Therapy , Quality of Life , Sarcoma/complications , Wounds and Injuries/etiology , Adult , Aged , Aged, 80 and over , Female , Follow-Up Studies , Humans , Limb Salvage , Male , Middle Aged , Neoplasm Grading , Neoplasm Staging , Preoperative Care , Prognosis , Prospective Studies , Young Adult
12.
Am J Surg ; 207(5): 760-4; discussion 764-5, 2014 May.
Article in English | MEDLINE | ID: mdl-24791641

ABSTRACT

BACKGROUND: Obtaining a complete cytoreduction in patients with peritoneal carcinomatosis (PC) is one of the most significant prognostic variables for long-term survival. This study explored features on preoperative computed tomography (CT) to predict unresectability. METHODS: A retrospective case-control study was conducted of 15 patients with unresectable PC and 15 patients with completely resected PC matched by intraoperative peritoneal cancer index (PCI) and pathology type. Two surgical oncologists blindly analyzed all abdominopelvic CT scans. RESULTS: PCI estimated on imaging was not higher in unresectable patients (P = .851) and significantly underestimated intraoperative PCI measurement (P = .003). No single concerning feature was associated with unresectability. However, patients with 2 or more concerning features were more likely to be unresectable (87.5% vs 36.4%, P = .035). CONCLUSIONS: Two or more concerning CT imaging features appear to be associated with a higher risk of unresectability in patients with PC. However, no specific imaging feature should exclude a patient from an attempted cytoreduction.


Subject(s)
Carcinoma/diagnostic imaging , Carcinoma/secondary , Patient Selection , Peritoneal Neoplasms/diagnostic imaging , Peritoneal Neoplasms/secondary , Preoperative Care/methods , Tomography, X-Ray Computed , Appendiceal Neoplasms/pathology , Carcinoma/surgery , Case-Control Studies , Colorectal Neoplasms/pathology , Decision Support Techniques , Female , Humans , Male , Matched-Pair Analysis , Mesothelioma/pathology , Middle Aged , Peritoneal Neoplasms/surgery , Retrospective Studies , Severity of Illness Index
13.
Am J Surg ; 207(5): 693-6; discussion 696-7, 2014 May.
Article in English | MEDLINE | ID: mdl-24576583

ABSTRACT

BACKGROUND: A Web-based synoptic operative reporting system (WebSMR) incorporates implicit guidelines and real-time feedback of a surgeon's practice compared with provincial data. This study compares rates of total mastectomy (TM) between the overall provincial and WebSMR patients and examines decision-making factors in WebSMR patients. METHODS: Patients treated for invasive breast cancer (2007 to 2011) were identified from WebSMR and the Alberta Cancer Registry. Reports include surgery type and reasons for TM. RESULTS: Among 5,787 patients in WebSMR (2007 to 2011), TM rate decreased from 48% to 42% (P < .001). In 2011, the provincial cancer registry recorded a 56% TM rate compared to 42% in WebSMR patients. Patient preference accounted for 36% in the latter group. CONCLUSIONS: In WebSMR patients, TM rates were lower than the overall provincial rate and decreased significantly during the study period. Reasons are unclear, but guidelines and real-time feedback likely plays a role.


Subject(s)
Breast Neoplasms/surgery , Carcinoma, Ductal, Breast/surgery , Guideline Adherence/statistics & numerical data , Internet , Mastectomy, Simple/statistics & numerical data , Medical Records Systems, Computerized , Practice Patterns, Physicians'/statistics & numerical data , Alberta , Decision Support Techniques , Female , Guideline Adherence/trends , Humans , Mastectomy, Segmental/statistics & numerical data , Mastectomy, Segmental/trends , Mastectomy, Simple/trends , Patient Preference , Practice Guidelines as Topic , Practice Patterns, Physicians'/trends , Registries
14.
Ann Surg Oncol ; 21(6): 1975-82, 2014 Jun.
Article in English | MEDLINE | ID: mdl-24398544

ABSTRACT

BACKGROUND: The debate remains whether appendiceal goblet cell cancers behave as classical carcinoid or adenocarcinoma. Treatment options are unclear and reports of outcomes are scarce. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS+HIPEC) is considered optimal treatment for peritoneal involvement of other epithelial appendiceal tumors. METHODS: Prospective cohorts of patients treated for advanced appendiceal tumors from three peritoneal malignancy centres were collected (1994-2011). All patients underwent complete CRS+HIPEC, when possible, or tumor debulking. Demographic and outcome data for patients with goblet cell cancers were compared to patients with low- or high-grade epithelial appendiceal tumors treated during the same time period. RESULTS: Details on 45 goblet cell cancer patients were compared to 708 patients with epithelial appendix lesions. In the goblet cell group, 57.8 % were female, median age was 53 years, median peritoneal cancer index (PCI) was 24, and CRS+HIPEC was achieved in 71.1 %. These details were similar in patients with low- or high-grade epithelial tumors. Lymph nodes were involved in 52 % of goblet cell patients, similar to rates in high-grade cancers, but significantly higher than in low-grade lesions (6.4 %; p < 0.001). At 3 years, overall survival (OS) was 63.4 % for goblet cell patients, intermediate between that for high-grade (40.4-52.2 %) and low-grade (80.6 %) tumors. On multivariate analysis, tumor histology, PCI, and achievement of CRS+HIPEC were independently associated with OS. CONCLUSIONS: This data supports the concept that appendiceal goblet cell cancers behave more as high-grade adenocarcinomas than as low-grade lesions. These patients have reasonable long-term survival when treated using CRS+HIPEC, and this strategy should be considered.


Subject(s)
Adenocarcinoma/therapy , Appendiceal Neoplasms/pathology , Appendiceal Neoplasms/therapy , Carcinoid Tumor/pathology , Carcinoid Tumor/therapy , Cytoreduction Surgical Procedures , Hyperthermia, Induced , Adenocarcinoma/chemistry , Adenocarcinoma/pathology , Antibiotics, Antineoplastic/administration & dosage , Appendiceal Neoplasms/chemistry , Carcinoembryonic Antigen/analysis , Carcinoid Tumor/chemistry , Disease-Free Survival , Female , Humans , Keratin-20/analysis , Keratin-7/analysis , Male , Middle Aged , Mitomycin/administration & dosage , Neoplasm Grading , Retrospective Studies , Survival Rate
15.
J Surg Oncol ; 109(2): 104-9, 2014 Feb.
Article in English | MEDLINE | ID: mdl-24449172

ABSTRACT

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are increasingly used to treat peritoneal carcinomatosis from colorectal cancer. It is still relatively unknown which poor prognostic factors to avoid in order to optimize patient selection for CRS + HIPEC. METHODS: Between February 2003 and October 2011, 68 consecutive colorectal cancer patients who underwent CRS + HIPEC with a complete cytoreduction were identified from a prospective database. Survival analysis was performed using the Kaplan-Meier method, with log rank testing of differences between groups. Multivariate analysis was conducted using Cox proportional hazard regression. RESULTS: Median follow-up was 30.3 (range, 2-88) months amongst survivors. Patients with a peritoneal cancer index (PCI) of 10 or less showed improved survival over those with a PCI of 11 or higher (P = 0.03). No difference in survival was seen for the other potentially poor prognostic variables including lymph node status, synchronous peritoneal disease, peri-operative systemic chemotherapy, and rectal cancer primary. CONCLUSIONS: A low PCI was associated with improved survival. Complete CRS + HIPEC appears to result in similar survival outcomes regardless of delivery of peri-operative systemic chemotherapy. Rectal origin, lymph node status, and synchronous peritoneal disease should not be used as an absolute exclusion criteria for CRS + HIPEC based on current data.


Subject(s)
Colorectal Neoplasms/mortality , Patient Selection , Peritoneal Neoplasms/secondary , Peritoneal Neoplasms/therapy , Adult , Aged , Chemotherapy, Cancer, Regional Perfusion , Colorectal Neoplasms/pathology , Colorectal Neoplasms/therapy , Combined Modality Therapy , Disease-Free Survival , Female , Follow-Up Studies , Humans , Hyperthermia, Induced , Kaplan-Meier Estimate , Male , Middle Aged , Multivariate Analysis , Peritoneal Neoplasms/mortality
16.
Ann Surg Oncol ; 21(1): 66-73, 2014 Jan.
Article in English | MEDLINE | ID: mdl-24046105

ABSTRACT

BACKGROUND: There are few established indications for sentinel lymph node biopsy (SLNB) in breast ductal carcinoma in situ (DCIS). This study examines factors contributing to the high rate of SLNB in DCIS in Alberta, Canada. METHODS: Patients who underwent definitive surgery from January 2009 to July 2011 for DCIS diagnosed on preoperative core-needle biopsy were identified using a provincial synoptic operative report database (WebSMR). The relationship between baseline patient and tumor characteristics and treatment with total mastectomy (TM), use of SLNB, and upstaging were examined. RESULTS: There were 394 patients identified in the study cohort. Mean age was 57 years, and average preoperative tumor size was 3 cm. Overall, 148 patients (37.6 %) underwent TM; predictors were preoperative tumor size [odds ratio (OR), 1.92 per 1-cm increase in size; 95 % CI 1.65-2.24] and surgeon. Upstaging to invasive cancer at surgery occurred in 23 %, predicted only by preoperative tumor size (OR 1.14 per 1 cm; 95 % CI 1.03-1.27). SLNB was performed in 306 patients overall (77 %) and 140 of those treated with BCS (61 %). Predictors of SLNB were larger preoperative tumor size (OR 1.55 per 1 cm; 95 % CI 1.18-2.04) and the surgeon. In patients treated with BCS, 3 patients who were upstaged had positive SLNs (>0.2 mm), and no patients with DCIS had a positive SLN. CONCLUSIONS: SLNB use is high in patients undergoing BCS for DCIS. Tumor size and the operating surgeon predicted SLNB use. Despite a 23 % upstaging rate, the rate of clinically significant positive SLNs in patients treated with BCS is low, supporting omission of upfront SLNB.


Subject(s)
Breast Neoplasms/pathology , Carcinoma, Ductal, Breast/secondary , Carcinoma, Intraductal, Noninfiltrating/secondary , Lymph Nodes/pathology , Mastectomy , Biopsy, Large-Core Needle , Breast Neoplasms/surgery , Carcinoma, Ductal, Breast/surgery , Carcinoma, Intraductal, Noninfiltrating/surgery , Female , Follow-Up Studies , Humans , Lymph Nodes/surgery , Lymphatic Metastasis , Middle Aged , Neoplasm Invasiveness , Neoplasm Staging , Predictive Value of Tests , Sentinel Lymph Node Biopsy
17.
J Surg Oncol ; 109(6): 548-55, 2014 May.
Article in English | MEDLINE | ID: mdl-24374723

ABSTRACT

BACKGROUND: Goblet cell carcinoid (GCC) and appendiceal mucinous neoplasms (AMNs) are considered as different appendiceal tumors. Coexistence of both tumors was occasionally noted. We further observed the concurrence in both primary tumors and their peritoneal dissemination, that is, peritoneal carcinomatosis (PC) including pseudomyxoma peritonei (PMP). METHODS: Review of our 10-year file identified two subgroups of cases with such concurrence. Group 1 is 14 cases of PC/PMP treated by surgical cytoreduction. Morphologic components of GCC, low-grade mucinous neoplasm (LMN), mucinous adenocarcinoma (MCA), and non-mucinous adenocarcinoma (NMCA) were identified separately in different organs/tissues. Group 2 is eight cases of localized primary tumors of appendix and ileocecal junction. RESULTS: In Group 1, primary tumors (11 GCC, 1 GCC + LMN, 1 MCA, 1 NMCA) were identified in appendix (13) and in rectum (1). Further review identified mixed morphologic components in 7/12 GCC cases, including GCC + LMN (2), GCC + MCA (2), GCC + NMCA (1), and GCC + MCA + NMCA (2). Over peritoneal dissemination, GCC and/or other components were coexistent at different sites and in variable combinations. In Group 2, primary tumors were initially diagnosed as GCC (7) and MCA (1). Further review identified mixed components in all cases, including GCC + LMN (3), GCC + LMN + MCA (3), GCC + MCA + NMCA (2). CONCLUSIONS: GCC may present as a component mixed with AMNs and even with conventional adenocarcinoma in both primary tumors and metastatic lesions. AMN in any given single case may show a wide morphologic spectrum. GCC and AMN may share a common tumor stem cell with potential of multiple lineage differentiations.


Subject(s)
Adenocarcinoma, Mucinous/pathology , Appendiceal Neoplasms/pathology , Carcinoid Tumor/pathology , Neoplasms, Multiple Primary/pathology , Adenocarcinoma, Mucinous/surgery , Adult , Aged , Appendectomy , Appendiceal Neoplasms/surgery , Carcinoid Tumor/surgery , Cecum/pathology , Cecum/surgery , Female , Humans , Ileum/pathology , Ileum/surgery , Male , Middle Aged , Neoplasms, Multiple Primary/surgery , Peritoneal Neoplasms/pathology , Peritoneal Neoplasms/surgery , Pseudomyxoma Peritonei/pathology , Pseudomyxoma Peritonei/surgery , Rectal Neoplasms/pathology , Rectal Neoplasms/surgery
18.
J Surg Oncol ; 108(6): 348-51, 2013 Nov.
Article in English | MEDLINE | ID: mdl-24038038

ABSTRACT

BACKGROUND AND OBJECTIVES: Evaluation of the management of DCIS poses challenges, as standard breast cancer outcome measures such as mortality do not apply. We have developed quality indicators (QIs) to measure the quality of DCIS treatment in Alberta, Canada. METHODS: A modified Delphi process was used to determine QIs in the treatment of DCIS after review of evidence-based clinical practice guidelines. Patients diagnosed with DCIS from 2000 to 2001 (cohort 1) and 2009-2010 (cohort 2) were identified from the Alberta Cancer Registry and QIs were retrospectively abstracted. RESULTS: The expert panel developed eight QIs to assess the overall quality of care for DCIS patients. Five hundred eighty eligible patients were identified in the two cohorts. There was significant improvement in radiation oncology referral, radiation post lumpectomy and complete pathology reporting. Axillary staging significantly increased from 20% (axillary dissection in cohort 1) to 60% (sentinel node biopsy in cohort 2). Other QIs did not differ significantly. CONCLUSIONS: By developing QIs, performance measures for DCIS may assessed and compared over time. Although there have been significant improvements with pathology reporting and radiation oncology assessment and treatment, axillary staging rates are unexpectedly high, necessitating further investigation.


Subject(s)
Breast Neoplasms/therapy , Carcinoma, Intraductal, Noninfiltrating/therapy , Delphi Technique , Quality Indicators, Health Care , Adult , Aged , Alberta , Antineoplastic Agents, Hormonal/administration & dosage , Biopsy, Large-Core Needle , Breast Neoplasms/pathology , Carcinoma, Intraductal, Noninfiltrating/pathology , Female , Humans , Interdisciplinary Communication , Lymph Node Excision , Mastectomy, Segmental , Middle Aged , Neoplasm Staging , Radiotherapy, Adjuvant , Retrospective Studies , Sentinel Lymph Node Biopsy , Survival Analysis , Tamoxifen/administration & dosage
19.
J Surg Oncol ; 107(6): 591-6, 2013 May.
Article in English | MEDLINE | ID: mdl-23129533

ABSTRACT

INTRODUCTION: Peritoneal metastases (PM) can be treated with cytoreduction surgery (CRS) with intraoperative heated intraperitoneal chemotherapy (HIPEC) plus or minus early postoperative intraperitoneal chemotherapy (EPIC). HIPEC + EPIC may be associated with more complications than HIPEC alone. METHODS: A prospective database of consecutive patients undergoing CRS + HIPEC ± EPIC at the University of Calgary between February 2000 and May 2011 was reviewed. Patient, tumor, and perioperative variables included peritoneal cancer index (PCI), completeness of cytoreduction (CCR) score, HIPEC ± EPIC type, and grade III/IV complications. RESULTS: 198 patients had a CCR score of 0/1 and received: (1) HIPEC mitomycin C + EPIC 5-fluorouracil for 5 days (n = 85; February 2000-January 2008); or (2) HIPEC oxaliplatin with IV 5-fluorouracil + no EPIC (n = 113; February 2008-May 2011). Clinicodemographics were similar except PCI was higher in the HIPEC-alone group (mean PCI 22 vs. 17; P = 0.02). The rate of grade III/IV complications was higher in the HIPEC + EPIC group (44.7% vs. 31.0%; P = 0.05). On multivariate logistic regression only HIPEC + EPIC and PCI > 26 were associated with an increased rate of complications. CONCLUSION: In patients with PM, the use of EPIC, in combination with CRS and HIPEC, is associated with an increased rate of complications. Surgeons should consider using HIPEC only (without EPIC).


Subject(s)
Adenocarcinoma/secondary , Antineoplastic Combined Chemotherapy Protocols/adverse effects , Chemotherapy, Cancer, Regional Perfusion/adverse effects , Hyperthermia, Induced , Peritoneal Neoplasms/secondary , Peritoneum/surgery , Postoperative Complications/etiology , Adenocarcinoma/drug therapy , Adenocarcinoma/surgery , Adult , Aged , Antineoplastic Agents/administration & dosage , Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Chemotherapy, Adjuvant , Chemotherapy, Cancer, Regional Perfusion/methods , Colorectal Neoplasms/pathology , Female , Fluorouracil/administration & dosage , Humans , Infusions, Parenteral , Logistic Models , Male , Middle Aged , Mitomycin/administration & dosage , Multivariate Analysis , Organoplatinum Compounds/administration & dosage , Oxaliplatin , Peritoneal Neoplasms/drug therapy , Peritoneal Neoplasms/surgery , Postoperative Complications/epidemiology , Retrospective Studies , Treatment Outcome
20.
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