Treatment of locally advanced pancreatic cancer using localized trans-arterial micro perfusion of gemcitabine: combined analysis of RR1 and RR2.

BACKGROUND: Locally advanced pancreatic cancer (LAPC) comprises 40% of pancreatic cancer diagnoses and has a relatively poor prognosis. Trans-arterial micro perfusion (TAMP)-mediated chemotherapy delivery to the primary tumor is a novel approach worthy of investigation. The RR1 (dose escalation) and RR2 (observational) studies examined the safety and preliminary efficacy of TAMP-delivered gemcitabine for LAPC. PATIENTS AND METHODS: RR1 and RR2 data were pooled. Both studies enrolled patients with LAPC with histologically confirmed adenocarcinoma. Participant data, including age, sex, race, stage, previous treatments, toxicity, disease progression, and death, were collected. Median number of cycles and average treatment dosage were calculated. Overall survival (OS) was determined for the whole group and separately for patients who received and did not receive previous treatments. Aims of the analysis were to assess procedure safety, OS, and evaluate factors associated with OS. RESULTS: The median age of the 43 patients enrolled in RR1 and RR2 was 72 years (range, 51-88 years). Median OS for the 35 eligible patients with stage III disease was 12.6 months (95% CI, 2.1-54.2 months). Previous chemoradiation was associated with significantly longer OS [27.1 months (95% CI, 8.4-40.6 months)] compared to previous systemic chemotherapy [14.6 months (95% CI, 6.4-54.2 months)] or no prior treatment [7.0 months (95% CI, 2.1-35.4 months)] (P < .001). The most common adverse events were GI related (abdominal pain, emesis, and vomiting); the most common grade 3 toxicity was sepsis. CONCLUSION: Study results indicate that TAMP-mediated gemcitabine delivery in patients with LAPC is potentially safe, feasible, and provides potential clinical benefits. CLINICAL TRIAL REGISTRATION: NCT02237157 (RR1) and NCT02591082 (RR2).

Racial Differences in Patient-Reported Access to Telehealth: An Important and Unmeasured Social Determinant of Health.

PURPOSE: The COVID-19 pandemic expanded opportunities for remote oncology telehealth visits. However, reliable internet connectivity, digital literacy, and patient comfort with virtual medical visits may differ among patients, especially socially disadvantaged groups. The primary aim of this study was to identify barriers that might limit access to telehealth video services. METHODS: First, retrospective analysis was performed of composite administrative data of all patient visits to a large regional cancer center during the pandemic (March 2020 to April 2022). Second, a prospective, cross-sectional study was conducted of patients with known or suspected malignancy over a 6-month period (November 2021 to April 2022). A survey regarding video telehealth accessibility was verbally administered to patients at their clinic visit. RESULTS: Administrative data demonstrated that although Black patients comprised 43% (n = 9,021) of all patient visits (n = 20,953), the proportion of telehealth visits conducted among Black patients was significantly lower compared with White patients (29% v 71%; P < .0001). Of the prospective, cross-sectional study cohort (n = 148), 51.4% of patients (n = 76) were Black, 38.5% (n = 57) resided in a rural county, and 8.1% (n = 12) were Medicaid-insured. Black participants were more likely to self-report lack of internet access (73.7% v 90.4%; P < .01) and were less likely to report having access to or actively using a patient portal (29.0% v 47.2%; P < .001) compared with White patients. The independent association of race and internet access (P < .05) and patient portal use (P = .001) persisted after multivariable analysis. CONCLUSION: Black patients disproportionately underparticipated in telehealth visits, suggesting underlying structural disparities in access to digital care. A greater proportion of Black participants self-reported lack of internet access and access to a patient portal compared with White patients. Ensuring equal internet access and digital literacy will be critical to reduce disparities in cancer care among racial minorities.

Racial Disparity in the Surgical Management of Diverticular Disease.

INTRODUCTION: Although minimally invasive surgery (MIS) has clearly been associated with improved colorectal surgery outcomes, not all populations benefit from this approach. Using a national database, we analyzed both, the trend in the utilization of MIS for diverticulitis and differences in utilization by race. METHODS: Colon-targeted participant user files (PUFs) from 2012 to 18 were linked to respective PUFs in National Surgical Quality Improvement Project. Patients undergoing colectomy for acute diverticulitis or chronic diverticular disease were included. Surgical approach was stratified by race and year. To adjust for confounding and estimate the association of covariates with approach, data were fit using multivariable binary logistic regression main effects model. Using a joint effects model, we evaluated whether the odds of a particular approach over time was differentially affected by race. RESULTS: Of the 46 713 patients meeting inclusion criteria, 83% were white, with 7% black and 10% other. Over the study period, there was a decrease in the rate of open colectomy of about 5% P < .001, and increase in the rate of utilization of laparoscopic and robotic approaches (RC) P < .0001. After adjusting for confounders, black race was associated with open surgery P < .0001. CONCLUSION: There is disparity in the utilization of MIS for diverticulitis. Further research into the reasons for this disparity is critical to ensure known benefits of MIC are realized across all races.

Improvement in Surgical Quality Following Pancreaticoduodenectomy With Increasing Case Volume in a Rural Hospital.

BACKGROUND: The literature is replete with studies that define the nexus of quantity and quality in complex surgical operations. These observations have heralded a call for centralization of care to high-volume centers. The purpose of this study was to chronicle improvements in quality associated with pancreaticoduodenectomy (PD) as a rural hospital matures from a low- to very high-volume center. METHODS: A retrospective review of a prospective pancreatic surgery database was undertaken from July 2007 to June 2020. Annual periods were characterized as low (≤12/year), high (13-29/year), and very high volume (≥30/year). Data for the following quality benchmarks were aggregated and compared: length of stay (LOS), 30-day readmissions, 30-day mortality, and 1- and 3-year survival. A subgroup analysis was undertaken in those patients undergoing PD for adenocarcinoma detailing margin status and number of lymph nodes harvested. Outcomes were compared using the Fisher's exact and Student's t-test. RESULTS: 375 PD were completed over the 13-year period; 62.1% were undertaken for ductal adenocarcinoma. There was a significant decrease in LOS and 30-day readmissions as the institution matured toward very high volume. There were no significant differences in 30-day mortality, 1- and 3-year survival, or margin negativity rates associated with volume. Extent of lymph node harvest significantly improved as institutional experience increased. DISCUSSION: Our pancreatic surgery program matured rapidly from low to very high volume with institutional commitment and dedicated resources. As the institution matured, operational efficiencies and surgical quality improved. Not unexpectedly, biology trumped volume as reflected in 1- and 3-year survival rates.

When Is It Safe to Proceed With Pancreaticoduodenectomy Without Biliary Decompression?

BACKGROUND: An absolute bilirubin level where preoperative biliary decompression (PBD) is indicated before pancreaticoduodenectomy has been elusive. Our goal was to identify a total bilirubin level whereby biliary decompression provides clear benefit, despite associated expenses and potential complications. MATERIALS AND METHODS: We reviewed a prospectively collected database of patients undergoing pancreaticoduodenectomy at the Vidant Medical Center between 2007 and 2016. Patients were arbitrarily subdivided into 3 groups based on presenting bilirubin level (≤10 mg/dL, 10.1-14.9 mg/dL, and ≥15 mg/dL) to determine the presence of overall complications, severe complications (Clavien-Dindo classification ≥3), prolonged length of stay (>1 SD), readmissions, or mortality. RESULTS: Common bile duct stenting independently predicted a higher incidence of complications in patients presenting with bilirubin ≤10 mg/dL (P = .03) vs. those patients going directly to surgery. No differences were observed for patients with bilirubin between 10.1 mg/dL and 14.9 mg/dL. Biliary decompression in patients with bilirubin ≥15 mg/dL independently predicted fewer overall (73.8% vs. 100%, P = .0082) and less severe complications (14.3% vs. 44.5%, P = .03) and lower readmission rates (15.8% vs. 55.6%, P = .03) vs. those going directly to surgery. Patients not undergoing biliary decompression underwent pancreaticoduodenectomy sooner than those decompressed (4.7 days vs. 17.2 days, P = .01). DISCUSSION: All patients presenting with bilirubin ≥15 mg/dL should undergo PBD, while those with bilirubin ≤10 mg/dL should forego stent placement to avoid stent-related complications. The decision to stent between 10.1 and 14.9 mg/dL should be made on a case-by-case basis keeping in mind timeliness to definitive cancer treatment.

Thirty-Day Morbidity after Simultaneous Resection of Colorectal Cancer and Colorectal Liver Metastasis: American College of Surgeons NSQIP Analysis.

BACKGROUND: Approximately 20% of patients with colorectal cancer (CRC) present with synchronous liver metastases (CRLM). The decision to resect simultaneously or sequentially remains controversial. The primary aim of this study was to determine whether simultaneous resection of CRC and CRLM is associated with increased complications compared to isolated resection. STUDY DESIGN: Prospective data from the American College of Surgeons (ACS) NSQIP, including the ACS NSQIP procedure-specific colectomy and hepatectomy modules from 2014 to 2017, were reviewed in a retrospective cohort study. Primary study outcome was combined 30-day complication rates; secondary outcomes included colectomy and hepatectomy-specific complication. Multivariable logistic regression was performed to control for confounding factors associated with postoperative complication. RESULTS: A total of 23,643 patients underwent colectomy, 7,462 hepatectomy, and 592 simultaneous resection for CRC and CLRM. Overall morbidity was higher among patients treated with simultaneous resection (29.9%) compared with either isolated colorectal (22.2%) or hepatic resection (17.1%; p < 0.001). Additionally, postoperative ileus (36.4% vs 19.1%) and anastomotic failure (7.9% vs 3.8%) were more common after simultaneous resection compared with colorectal resection (p < 0.05). Similarly, rates of bile leak (8.3% vs 6.2%, p = 0.195) and post-hepatectomy liver failure (8.7% vs 3.8%, p < 0.001) were higher after simultaneous resection compared with isolated hepatectomy. By multivariable logistic regression, simultaneous resection was associated with increased overall complication compared with isolated colon (odds ratio 1.64 [95% CI 1.36 to 1.96]) or liver resection (odds ratio 2.11 [95% CI 1.75 to 2.55]), as well as increased procedure-specific complication. CONCLUSIONS: Although simultaneous resection offers definitive resection for patients with synchronous CRC and CRLM, it is associated with significantly increased 30-day overall and procedure-specific postoperative morbidity.

Predictive Value of Preoperative Serum CA19-9 on Margin Status.

Serum carbohydrate antigen (CA19-9) is known to correlate with stage, resectability, and prognosis of pancreatic cancer. The goal of pancreaticoduodenectomy is to achieve an R0 resection because worse outcomes are reported in the presence of positive margins. The purpose of this study was to evaluate the predictive utility of CA19-9 for pancreaticoduodenectomy margin status. A retrospective review of patients with pancreatic adenocarcinoma undergoing pancreaticoduodenectomy between October 2007 and November 2018 at our institution was performed. Patient demographics, preoperative CA19-9, and tumor characteristics were analyzed. Univariate and multivariate logistic regression was performed to determine factors associated with positive margins. A total of 184 patients were included. The mean age was 65 years; most patients were male and white. Majority had a positive preoperative CA19-9 (69%). There were nearly twice as many patients with negative as positive margins. Groups had similar demographics and preoperative CA19-9. A greater proportion of patients with negative margins had smaller tumors and early disease. On univariate and multivariate analysis, larger and higher stage tumors had greater odds of positive margins (P < 0.05). There was no significant association between margin status and preoperative CA19-9. Preoperative CA19-9 is not predictive of margin status. These results suggest that although preoperative CA19-9 values are associated with both resectability and prognosis, positive margins may not be a contributing mechanism.

A simple matrix to predict treatment success and long-term survival among patients undergoing pancreatectomy.

BACKGROUND: A more accurate measure of long-term survival among patients who have undergone a successful resection for pancreatic adenocarcinoma may be computed by accounting for time already survived during the initial treatment window. METHODS: Patients diagnosed with pancreatic adenocarcinoma, from 2004 through 2013, were identified from the American College of Surgeons National Cancer Database (NCDB). A risk-stratification matrix was constructed including age, histopathologic factors and the use of adjuvant therapy, given successful treatment and survival at 3-month following diagnosis. RESULTS: A total of 25,897 patients (50% male, 53% >65 years of age) presented with stage I-III pancreatic cancer. The majority of patients had tumors >2 cm size (82%), grade I/II (65%), lymphatic invasion (LI) (66%), and negative margins (76%). A survival advantage for adjuvant therapy was observed among all patients, independent of their risk-profile. For example, a patient ≤65 years of age, with early stage cancer (size ≤2 cm, grade I/II, -ve LI, -ve margins) who received adjuvant therapy had a 62% probability of being alive beyond three years (95%CI = 59%-66%). In contrast, the survival probability decreased to 53% (95%CI = 59%-66%) without adjuvant therapy. CONCLUSIONS: These results provide surgeons and patients with more accurate information regarding long-term survival, as well as the benefit of opting for adjuvant therapy after successful pancreatic surgery.

Emerging Role of Immune Checkpoint Blockade in Pancreatic Cancer.

Immune checkpoint blockade (ICB) with programmed cell death protein-1(PD-1)/programmed death ligand -1(PD-L1) antibodies has revolutionized the management of several cancers, especially non-small cell lung cancer, melanoma, urothelial, and renal cancer. Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive cancers associated with high morbidity and mortality. Based on available data, it's obvious that ICB has limited success in PDACs, which can be explained by the low immunogenicity and immunosuppressive tumor microenvironment of these tumors. In this review article, we focus on PD-L1 expression and microsatellite instability (MSI) in PDAC, and their roles as prognostic and predictive markers. We also discuss data supporting combination therapies to augment cancer immunity cycle. Combining anti-PD-1/PD-L1 agents with other modalities such as vaccines, chemotherapy, and radiation could potentially overcome resistance patterns and increase immune responsiveness in PDAC.

Development of improved therapeutic mesothelin-based vaccines for pancreatic cancer.

Pancreatic cancer is the 5th leading cause of cancer deaths, and there are no effective treatments. We developed a poxvirus platform vaccine with improved immunogenicity and inserted the mesothelin gene to create an anti-mesothelin cancer vaccine. Mesothelin expression is mostly restricted to tumors in adult mammals and thus may be a good target for cancer treatment. We show here that the modified vaccinia virus Ankara (MVA) virus expressing mesothelin and the enhanced MVA virus missing the immunosuppressive A35 gene and expressing mesothelin were both safe in mice and were able to induce IFN-gamma secreting T cells in response to mesothelin expressing tumor cells. In addition, the MVA virus has oncolytic properties in vitro as it can replicate in and kill Panc02 pancreatic adenocarcinoma cell line tumor cells, even though it is unable to replicate in most mammalian cells. Deletion of the A35 gene in MVA improved T cell responses as expected. However, we were unable to demonstrate inhibition of Panc02 tumor growth in immunocompetent mice with pre-vaccination of mice, boosts, or even intratumoral injections of the recombinant viruses. Vaccine efficacy may be limited by shedding of mesothelin from tumor cells thus creating a protective screen from the immune system.

Impact of malnutrition on gastrointestinal surgical patients.

BACKGROUND: The accurate diagnosis of malnutrition is imperative if we are to impact outcomes in the malnourished. The American Society of Parenteral and Enteral Nutrition (ASPEN) and Academy of Nutrition and Dietetics (AND), in an attempt to address this issue, have provided evidence-based criteria to diagnose malnutrition. The purpose of this study was to validate the ASPEN/AND criteria in a cohort of patients from a single high-volume surgical oncology unit. METHODS: Patients undergoing major abdominal surgery from June 2013 to March 2015 were classified by their nutritional status using the ASPEN/AND criteria. RESULTS: A total of 490 patients were included. Median age was 64 y, a majority were female (50.6%), white (60.2%), underwent elective procedures (77.6%), had a Charlson comorbidity score (CCS) of 3-5 (40.0%), and a Clavien-Dindo complication (CDC) grade of 0-II (81.2%). A total of 93 (19.0%) patients were classified as moderately/severely malnourished. On univariate analysis, malnourished patients were more likely to be older, undergo emergent procedures, and have a CCS >5 (P < 0.05). Malnutrition was also associated with a longer postoperative length of stay (LOS), higher cost, higher in-hospital mortality, more severe complications, and higher readmission rates (P < 0.05). Multivariate analysis reaffirmed the association between malnutrition, LOS (odds ratio [OR] = 1.67), and cost (OR = 2.49), P < 0.05. Complications (OR = 1.35), mortality rates (OR = 3.05), and readmission rates (OR = 1.34) P > 0.05 failed to reach significance. CONCLUSIONS: Malnutrition worsens LOS and cost. Utilization of standardized criteria consistently identifies patients at risk of negative outcomes who may benefit from perioperative nutritional support.

Enhanced Recovery after Surgery in a Single High-Volume Surgical Oncology Unit: Details Matter.

Benefits of ERAS protocol have been well documented; however, it is unclear whether the improvement stems from the protocol or shifts in expectations. Interdisciplinary educational seminars were conducted for all health professionals. However, one test surgeon adopted the protocol. 394 patients undergoing elective abdominal surgery from June 2013 to April 2015 with a median age of 63 years were included. The implementation of ERAS protocol resulted in a decrease in the length of stay (LOS) and mortality, whereas the difference in cost was found to be insignificant. For the test surgeon, ERAS was associated with decreased LOS, cost, and mortality. For the control providers, the LOS, cost, mortality, readmission rates, and complications remained similar both before and after the implementation of ERAS. An ERAS protocol on the single high-volume surgical unit decreased the cost, LOS, and mortality.

Discharge with Pancreatic Fistula after Pancreaticoduodenectomy Independently Predicts Hospital Readmission.

Readmission rates after pancreaticoduodenectomy (PD) are among the highest of any surgical procedure. The purpose of this study was to identify those factors present at discharge that may predict readmission after PD. All patients undergoing PD between 2010 and 2015 at a very high (>35 PD/year) volume center were entered into a prospective database. Twenty factors present at discharge from index admission identified on univariate analysis were subjected to multivariate analysis to identify those independently predictive of 30-day hospital readmission. A total of 220 patients underwent PD during the study period, 88 per cent of which had cancer. Mean age was 64.4 ± 11.7 years with slight male preponderance (54.5%) and significant African American representation (33.2%). Surgical complications occurred in 67.3 per cent of patients the most common of which included infectious/leak (30%), gastrointestinal (29%), cardiorespiratory (13%), other (13%), minor complications (7%), multi system failure (5%), and new onset diabetes (3%). The 30-day readmission rate was 27.3 per cent and was due to infection (89%), failure to thrive (32%), nausea/vomiting (15%), or other (15%). On multivariate analysis, presence of pancreatic leak/fistula at discharge was the only significant predictor of readmission, present in 62.5 per cent of all readmitted patients (P = 0.001). Comorbidities, length of stay, insurance status, obesity, smoking, and discharge to a care venue other than home did not predict readmission. Patients manifesting pancreatic fistula after PD are at high risk for hospital readmission. Enhanced scrutiny regarding suitability for discharge should be exercised in these patients and measures taken to minimize readmission whenever possible.

Indications for Surgical Resection in Low-Grade Pancreatic Neuroendocrine Tumors.

The role of surgical resection in low-grade pancreatic neuroendocrine tumors (P-NET) is unclear. The patients diagnosed with low-grade P-NET from 1988 to 2012 were identified in SEER. Five hundred and sixty-one patients met the inclusion criteria. A majority were white (82.9%), and node negative (69.9%). Univariate analysis revealed that tumor size (<2 cm 8.3%, 2-4 cm 38.5%, and >4 cm 40.3%; P < 0.0001) and surgery (30.9% vs 25.3%; P = 0.0014) were associated with the risk of lymph node metastases (LNM). In contrast, age (P = 0.8360), gender (P = 0.4903), and race (P = 0.4235) were not. Five-year disease-free survival was associated with size (<2 cm 89.4%, 2-4 cm 80.0%, and >4 cm 74.5%; P = 0.0089), LNM (72.4% vs 82.9%; P = 0.0025), and surgery (84.3% vs 47.5%; P < 0.0001). Cox regression model showed that the association with LNM (P = 0.0025) and surgery (P < 0.0001) was significant. Surgery was associated with an improved disease-free survival for tumors >2 cm (2-4 cm, 84.4% vs 26.0% at five years; P = 0.0003, and >4 cm, 80.5% vs 49.5% at five years; P < 0.0001) but not for those with tumor size <2 cm (P = 0.4525). In conclusions, low-grade P-NETs in patients with tumor size >2 cm showed an increased risk of LNM and improved survival with resection.

Molecular targeted therapy for pancreatic adenocarcinoma: A review of completed and ongoing late phase clinical trials.

Molecular targeted therapy is widely utilized and effective in a number of solid tumors. In pancreatic adenocarcinoma, targeted therapy has been extensively evaluated; however, survival improvement of this aggressive disease using a targeted strategy has been minimal. The purpose of this study is to review therapeutic molecular targets in completed and ongoing later phase (II and III) clinical trials to have a better understanding of the rationale and progress towards targeted molecular therapies for pancreatic cancer. The PubMed database and the NCDI clinical trial website (www.clinicaltrials.gov) were queried to identify phase II and III completed and published (PubMed) and ongoing (clinicaltrials.gov) trials using the keywords: pancreatic cancer and molecular targeted therapy. The search engines were further limited by adding Phase II or III, active enrollment and North American. A total of 14 completed and published phase II/III clinical trials and 17 ongoing trials were identified. Evaluated strategies included inhibition of growth factor receptors (EGFR, PDGFR, VGFR, IGF-1R), tyrosine kinase inhibitors, MEK1/2, mTOR blockade and PI3K and HER2-neu pathway inhibitors. Only one trial conducted by the National Cancer Institute of Canada and the PANTAR trial have demonstrated a survival improvement from EGFR inhibition using erlotinib. These trials ultimately led to FDA approval of erlotinib/Tarceva in advanced stage disease. It remains unclear whether new combinations of cytotoxic chemotherapy or immunotherapy plus molecular targeted therapy will be beneficial in management of pancreatic adenocarcinoma. Despite a number of phase II and III trials, to date, only erlotinib has emerged as an approved targeted therapy in pancreatic adenocarcinoma. There are several ongoing late phase trials evaluating a number of targets, the results of which will become available over the next 1 to 2 years.

Murine mesothelin: characterization, expression, and inhibition of tumor growth in a murine model of pancreatic cancer.

BACKGROUND: Mesothelin has attracted much interest as a tumor specific antigen; it has been reported to promote tumor development and to be a good target for cancer treatment. Most studies to date have used human mesothelin in immunocompromised mice. Since these models do not allow for study of the natural immune response to mesothelin expressing tumors, we have undertaken the characterization of mouse mesothelin so the effects of this protein can be assessed in immunocompetent mouse strains. METHODS: We analyzed mouse mesothelin expression, tissue distribution, shedding and biochemistry. In addition we constructed stable mesothelin overexpressing lines of the pancreatic cancer line Panc02 by two methods and tested them for growth and tumorigencity in vitro and in vivo. RESULTS: We show here that mouse mesothelin is similar to human mesothelin in biochemical characteristics, tumor expression and tissue distribution, suggesting the mouse may be a suitable model for study of mesothelin. Stable overexpression of mesothelin in a pancreatic cancer cell line did not increase cell proliferation or anchorage-independent growth in vitro, suggesting that mesothelin is not necessarily a tumor progression factor. Surprisingly overexpression of mesothelin inhibited tumor formation in vivo in immunocompetent mice. CONCLUSION: The mouse may be a good model for studying mesothelin in the context of an intact immune response. Mesothelin is not necessarily a tumor progression factor, and indeed mesothelin overexpression inhibited tumor growth in immunocompetent mice.

Patterns of node mapping differ for axial and extremity primary cutaneous melanoma: A case for a more selective use of pre-operative imaging.

PURPOSE: Preoperative lymphoscintigraphy for sentinel lymph node mapping in melanoma improves the ability to locate nodes. However, it still remains unclear whether this step is required for all patients. METHODS: Patients diagnosed with cutaneous melanoma from 1996 to 2012 were identified. Exclusion criteria were in situ disease, metastatic disease, or no SLN biopsy. RESULTS: 214 patients were evaluated. Median age was 57 years, the majority were male (59.8%), white (97.2%), and stage I (60.7%). SLN revealed metastatic disease in 14.5% of patients. The most common primary site was the trunk (43.4%) followed by head and neck (21%), upper extremity (19.2%), and lower extremity (16.4%). Multiple lymphatic basins were most common for head and neck lesions (66.7%) followed by those on the trunk (28.8%), with fewer identified when lower (11.4%), and upper extremities were involved (4.2%). When comparison was restricted to extremity vs. axial, a single basin was noted in 94.5% vs. 59.9% of patients, p < 0.0001. For all extremity lesions the SLN was located in the primary basin. Additional sites included in-transit (popliteal) and second tier basins. The only melanomas with bilateral or contralateral SLN were axial melanomas. CONCLUSIONS: Patients with axial melanomas benefit most from lymphoscintigraphy. This step may not be required for extremity melanoma.

Radiotherapy associated with improved survival for high-grade sarcoma of the extremity.

BACKGROUND: The impact of radiotherapy on local control in limb-preserving surgery for high-risk sarcoma has been well studied. However, the impact of the use and timing of radiation therapy on survival is unclear. METHODS: From 1988 to 2010, patients with Stage III extremity sarcoma were identified within the SEER registry and cohorts were created using propensity score matching between irradiated and non-irradiated groups. RESULTS: A total of 2,606 patients were identified, with a median age of 59 years a majority were white (81%), male (54%), received radiotherapy (78%), and had lower extremity (80%) sarcomas. The most common subtype was fibrohistiocytic (29.8%). Patients treated with radiotherapy were younger (57.2 vs. 60.3 years) and differed in subtype compared to those untreated. The matched cohorts were better balanced for all factors. Radiation therapy was associated with a 5% 5-year survival advantage on univariate analysis for both the unmatched (P = 0.002) and matched cohorts (P = 0.01). On multivariate analysis radiotherapy was associated with a 20% and 30% survival advantage for the matched and unmatched cohorts, respectively (P ≤ 0.02). The timing of radiotherapy did not affect survival. CONCLUSIONS: Radiotherapy, regardless of the timing, is associated with improved survival in high-risk sarcoma.