Value of a multidisciplinary geriatric oncology committee on patient care in a community-based, academic cancer center.

INTRODUCTION: The heterogeneity in health and functional ability among older patients makes the management of cancer a unique challenge. The Geriatric Oncology Program at the University of Maryland Baltimore Washington Medical Center (BWMC) was created to optimize cancer management for older patients. This study aimed to assess the benefits of the implementation of such a program at a community-based academic cancer center. MATERIALS AND METHODS: We analyzed patients aged ≥80 years presenting to the Geriatric Oncology Program between 2017 and 2022. A multidisciplinary team of specialists collectively reviewed each patient using geriatric-specific domains and stratified each patient into one of three management groups- Group 1: those deemed fit to receive standard oncologic care (SOC); Group 2: those recommended to receive optimization services prior to reassessment for SOC; and Group 3: those deemed to be best suited for supportive care and/or hospice care. RESULTS: The study cohort consisted of 233 patients, of which 76 (32.6%) received SOC, 43 (18.5%) were optimized, and 114 (49.0%) received supportive care or hospice referral. Among the optimized patients, 69.8% were deemed fit for SOC upon re-evaluation following their respective optimization services. The Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) score was implemented in 2019 (n = 90). Patients receiving supportive/hospice care only had an average score of 5.8, while the averages for those in the optimization and SOC groups were 4.6 and 4.1, respectively (p ≤0.001). Patients receiving SOC had the longest average survival of 2.71 years compared to the optimization (2.30 years) and supportive care groups (0.93 years) (p ≤0.001). For all patients that underwent surgical interventions post-operatively, 23 patients (85%) were discharged home and four (15%) were discharged to a rehabilitation facility. DISCUSSION: The present study demonstrates the profound impact that the complexities in health status and frailty among older individuals can have during cancer management. The Geriatric Oncology Program at BWMC maximized treatment outcomes for older adults through the provision of SOC therapies and optimization services, while also minimizing unnecessary interventions on an individual patient-centric level.

Analysis of 10 years of open, laparoscopic, and robotic rectal surgeries in the community setting.

Background: Colorectal cancer is the fourth most common cancer in the US. Many of these patients will require operations. Although there is significant data in the literature that supports minimally invasive colorectal operations in the academic setting, few studies have examined their performance in community hospitals. Methods: Data was collected from a high-volume, university-affiliated, community center. Our Cancer Registry Database was queried to include any patients that had rectal surgery at our institution from 2010 to 2020. One hundred-twenty-two patients were identified and reviewed retrospectively. Main outcome measures include estimated blood loss (EBL), blood transfusion, time to first bowel movement, oncologic resection, length of stay (LOS), survival, and cost analysis. Results: Both robotic and laparoscopic operations resulted in lower average EBL, less blood transfusions, and less time to first bowel movement (p = 0.003, 0.006, 0.003, respectively). There was no significant difference in ability to achieve R0 resection, adequate lymph node retrieval, and adequate total mesorectal excision (TME, p = 0.856, 0.489, 0.500, respectively). LOS was significantly shorter for minimally invasive operations, 4.35 vs 8.48 days, and average survival was longest for laparoscopic operations at 7.19 years as compared to 5.55 years for open operations (p < 0.001, 0.026, respectively). Cost was lowest for robotic operations (0.003). Conclusions: Minimally invasive rectal operations, especially robotic, lead to better short- and long-term outcomes, equivalent oncologic resection, and are more cost-effective as compared to open operations even in the community setting, supporting continued performance and growth of robotic colorectal operations in the community setting. Key message: Although there is significant data in the literature that supports minimally invasive colorectal operations in the academic setting, few studies have examined their performance in community hospitals as this study does. This study found that minimally invasive rectal operations, especially robotic, lead to better short- and long-term outcomes, equivalent oncologic resection, and are more cost-effective as compared to open operations even in the community setting, supporting continued performance and growth of robotic colorectal operations in the community setting.

Not just a GIST: an unclassifiable neoplasm in the genomics era.

Unclassifiable primary tumors despite adequate tissue for pathologic examination are quite rare. We present a case of a 72-year-old female who was found to have an abdominal mass after she reported to the emergency department with complaints of abdominal pain with spasms, bloating and nausea. Computed tomography scan demonstrated a 12.3 × 15.7 × 15.9 large multilobulated mass, abutting and compressing the stomach, compatible with neoplasm. She underwent esophagogastroduodenoscopy with findings concerning for gastrointestinal stromal tumor. The patient underwent en bloc resection of the mass. The neoplasm was unable to be classified on pathologic examination despite a comprehensive workup and multiple consultations with specialized pathologists from local institutions, as well as national specialists. Final pathology was unclassified malignant neoplasm displaying calretinin expression only. This presents a difficult clinical entity to treat. Even in the genomics era, there are tumors that cannot be even broadly classified on pathologic examination.

Enhancing recovery: Joining the Improving Surgical Care and Recovery programme to decrease colorectal surgical site infections.

AIM: Surgical site infections after colorectal surgery are a clinical and financial challenge in healthcare. The purpose of this project was to decrease the rate of surgical site infections in colorectal surgical patients in a community hospital with an academic cancer centre in the United States of America. METHOD: The Quality Improvement Department obtained data to measure the hospital's performance with colorectal surgical patients. The data examined the surgical site infection rate and the length of stay. A multidisciplinary team was established to implement protocols to improve compliance. RESULTS: More than 200 patients received a colorectal surgical resection at the hospital. The implemented protocols decreased both the surgical site infection rate and the length of stay (9.1-0% and median 6-4 days respectively). DISCUSSION: Challenges with implementation of the Improving Surgical Care and Recovery programme, in a community setting, are discussed. The challenges were worked through collaboratively to achieve the best outcomes for the patients. CONCLUSION: The interdisciplinary committee used evidence-based practices to enhance the care of the colorectal patients. Some of the protocols that emerged were: patient education, pain medication, mechanical bowel preparation and antibiotics, as well as early alimentation. The protocols are discussed in Tables 1 to 4.

Adjuvant therapy for pancreatic body or tail adenocarcinoma: a study of the National Cancer Database.

BACKGROUND: The optimal multimodality therapy for pancreatic ductal adenocarcinoma in the body or tail of the pancreas (PDAC-BT) is unclear. The purpose of this study was to compare overall 5-year survival between patients treated with adjuvant chemotherapy, adjuvant chemoradiation, and surgery alone. METHODS: Patients from the National Cancer Database (1998-2012) with resected stage I or II PDAC-BT were included. Overall survival between the three treatment groups was compared using Cox proportional-hazards regression, propensity-score matching, and the Kaplan-Meier method. RESULTS: Of the 700 patients included in the analysis, 189 (27%) were treated with chemotherapy, 226 (32%) were treated with chemoradiation, and 285 (41%) were treated with surgery alone. Chemoradiation was associated with higher survival than surgery alone [adjusted hazard ratio (HRadj): 0.67; 95% confidence interval (CI): 0.54, 0.84; p = 0.001], but there was no difference between chemotherapy and chemoradiation (HRadj: 0.82; 95% CI: 0.65, 1.05; p = 0.115). In propensity-score matched cohorts, median survival was 24.1 months (95% CI: 20.4, 28.4) with chemotherapy and 25.4 months (95% CI: 22.1, 31.7) with chemoradiation (log-rank p = 0.122). Among patients with positive resection margins, chemoradiation was associated with higher survival compared with chemotherapy (HRadj: 0.54; 95% CI: 0.32, 0.92; p = 0.022). In this subgroup of the propensity-score matched cohorts, median survival was 9.5 months (95% CI: 8.4, 16.0) with chemotherapy and 18.3 months (95% CI: 11.6, 26.3) with chemoradiation (log-rank p = 0.011). CONCLUSION: In patients with resected pancreatic body or tail adenocarcinoma, adjuvant chemoradiation was associated with higher survival compared with surgery alone. Among patients with positive resection margins, adjuvant chemoradiation was associated with higher survival compared with adjuvant chemotherapy.

Synergetic role of integrating the departments of cancer registry and clinical research at an academic comprehensive cancer center.

Integration of the cancer registry and clinical research departments can have a significant impact on the accreditation process of a Commission on Cancer (CoC) Program. Here in we demonstrate that the integration of both departments will benefit as there is increased knowledge, manpower and crossover in job responsibilities in our CoC-accredited Academic Comprehensive Cancer Center. In our model this integration has led to a more successful cooperative interaction among departments, which has in turn created an enhanced combined effect on overall output and productivity. More manpower for the cancer registry has led to increased caseloads, decreased time from date of first contact to abstraction, quality of data submissions, and timely follow-up of all patients from our reference date for accurate survival analysis along with completeness of data. In 2016, our Annual Facility report showed an additional 163 cases over prediction by the state of Maryland Cancer Registry and a 39% increase in case completeness. As proof of the synergetic effectiveness of our model within one year of its implementation, the cancer center was able to apply for, and was awarded membership from Alliance for Clinical Trials in Oncology, Central IRB, and in turn led to increased clinical trial accrual from 2.8% in 2014 compared to 13.2% currently. Our cancer registry in year one submitted over 150 more cases than predicted, improved quality outcome measures displayed by our Cancer Program Practice Profile reports and had more timely and complete data submissions to national and state registries. This synergetic integration has led to a better understanding, utilization and analysis of data by an integrated team with Clinical Research expertise.

Sarcina, a new threat in the bariatric era.

First identified in humans by Goodsir in 1842, Sarcina were already known to cause fatal abomasal bloat in animals. Their pathogenicity in humans has only recently been characterized. Sarcina is not inherently pathogenic but, with a gastric ulcer and delayed gastric emptying, can result in perforation. We present a case report of a 32-year-old woman status post-gastric banding presenting with epigastric pain. Upper endoscopy revealed a gastric ulcer near the band. After deflation, upper gastrointestinal series showed passage of contrast and no perforation. Ulcer biopsy showed gastric contents composed of Sarcina. Proton pump inhibitors and antibiotics were administered. Follow-up endoscopy at an outside institution resulted in perforation. This case report supports a growing body of literature that Sarcina organisms contribute to ulcers and perforation. This is the first report of Sarcina in elective bariatric surgery patients, highlighting the high suspicion needed among pathologists evaluating ulcers in this unique surgical population.

Biliary and gastric drainage in advanced pancreatic serous cystadenoma and portal hypertension in Von Hippel-Lindau syndrome.

Von Hippel-Lindau is a genetic syndrome, comprising several variant mutations on chromosome 3, that predisposes patients to the development of benign and malignant tumors. Tough relatively common, Von Hippel-Lindau syndrome (VHL) with associated hepato-biliary and gastric outlet obstruction, and portal hypertension consequent to the mass effect of a pancreatic serous cystadenoma is a rare scenario. This manuscript reports a 41-year-old female with the aforementioned presentation who successfully underwent a palliative cholecysto- and a gastro-jejunostomy. To the knowledge of the authors, this is the only report, describing a palliative biliary decompression for VHL-related pancreatic serous cystadenoma and portal hypertension.

Image findings in celiac artery stenosis due to median arcuate ligament compression: a crucial diagnosis when planning for pancreaticoduodenectomy.

Celiac axis stenosis caused by extrinsic compression by the median arcuate ligament (MAL) is present in up to 5% of patients undergoing pancreaticoduodenectomy. Failure to identify and manage MAL compression can lead to potentially devastating postoperative consequences that include frank liver necrosis and death. We report an incidental discovery of celiac axis stenosis by MAL in a patient prepared for pancreaticoduodenectomy. Image findings and operative management are discussed.

Assessment of clinical benefit and quality of life in patients undergoing cytoreduction and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for management of peritoneal metastases.

Peritoneal metastasis is a significant clinical challenge; life expectancy following diagnosis is usually very short. Surgical cytoreduction with HIPEC is being used with increasing frequency in selected patients; most outcome data have shown that prolonged median survivals can be observed in selected patients. This review summarizes the published data related to outcome and quality of life after cytoreduction and HIPEC to provide insights into its use in patients with peritoneal carcinomatosis.

Total laparoscopic distal pancreatectomy: beyond selected patients.

Laparoscopic distal pancreatectomy (LDP) has emerged as the procedure of choice for selected patients. This study is to evaluate the feasibility of LDP and procedural outcomes in a series of consecutive nonselected patients. All patients undergoing distal pancreatectomy over 18 months were identified from a prospectively maintained database, under institutional review board approval. A completely laparoscopic (non hand-assisted) procedure was performed using a 4-trocar technique. Conversion to an open procedure, operative time (OR), estimated blood loss (EBL), transfusion requirements, postoperative length of stay (LOS), and complications were assessed. Sixteen patients were identified; 2/16 patients had undergone distal pancreatectomy as a component of another multiorgan open procedure, and were thus excluded. The remaining 14 patients had consented for LDP. Conversion occurred in 4/14 cases. Converted patients trended towards increased OR, EBL, and LOS (P = not significant). No mortalities occurred, and overall morbidities included: pancreatic fistula (n = 2), splenic abscess (n = 1), and pneumonia (n = 1). LDP-splenectomy (n = 3/14) was associated with both increased EBL (683 mL ± 388 vs 168 ± 141, P < 0.002) and increased transfusion rate (3/3 vs 3/11, P = 0.05), as compared with LDP-splenic preservation. LDP with splenic artery preservation (LDP-SAP) was completed in 7 of 14 patients, with less OR (2 hours 29 minutes ± 53 minutes vs 3 hours 40 minutes ± 1 hour, P < 0.05), a decreased transfusion rate (14% vs 71%, P = 0.05), and decreased LOS (2.8 days vs 6.8 days, P = 0.002) compared with LDP without SAP. Pathology was intraductal papillary mucinous neoplasm (IPMN) (n = 5), ductal carcinoma (n = 3), high grade dysphasia (n = 2), neuroendocrine tumor (n = 2), and pancreatitis (n = 2). Patients undergoing LDP-SAP demonstrated superior peri-procedural outcomes. This series of nonselected consecutive patients supports that LDP is technically feasible with a comparable procedural outcome to the selected-patient literature, suggesting potentially expanded indications for LDP.

Early results on the use of biomaterials as adjuvant to abdominal wall closure following cytoreduction and hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Hyperthermic chemotherapy applies thermal energy to both abdominal wall as well as the intra-abdominal viscera. The combination of the hyperthemia, chemotherapy and cytoreductive surgery (CRS) is associated with a defined risk of abdominal wall and intestinal morbidity reported to be as high as 15%, respectively to date, no studies have evaluated the use of biomaterial mesh as adjuvant to abdominal wall closure in this group of patients. In the present report, we hypothesized that post HIPEC closure with a biomaterial can reduce abdominal wall morbidity after CRS and hyperthermic intraperitoneal chemotherapy. MATERIALS AND METHODS: All patients treated with HIPEC in a tertiary care center over 12 months (2008-2009) period were included. Eight patients received cytoreductive surgery followed by HIPEC for 90 minutes using Mitomycin C (15 mg q 45 minutes x 2). Abdominal wall closure was performed using Surgisis (Cook Biotech.) mesh in an underlay position with 3 cm fascial overlap-closure. Operative time, hospital length of stay (LOS) as well as postoperative outcome with special attention to abdominal wall and bowel morbidity were assessed. RESULTS: Eight patients, mean age 59.7 ys (36-80) were treated according to the above protocol. The primary pathology was appendiceal mucinous adenocarcinoma (n = 3) colorectal cancer (n = 3), and ovarian cancer (n = 2). Four patients (50%) presented initially with abdominal wall morbidity including incisional ventral hernia (n = 3) and excessive abdominal wall metastatic implants (n = 1). The mean peritoneal cancer index (PCI) was 8.75. Twenty eight CRS were performed (3.5 CRS/patient). The mean operating time was 6 hours. Seven patients had no abdominal wall or bowel morbidity, the mean LOS for these patients was 8 days. During the follow up period (mean 6.3 months), one patient required exploratory laparotomy 2 weeks after surgery and subsequently developed an incisional hernia and enterocutaneous fistula. CONCLUSION: The use of biomaterial mesh in concert with HIPEC enables the repair of concomitant abdominal wall hernia and facilitates abdominal wall closure following the liberal resection of abdominal wall tumors. Biomaterial mesh prevents evisceration on repeat laparotomy and resists infection in immunocompromised patients even when associated with bowel resection.

Management of an incidental liver mass.

The increased use of sensitive imaging modalities has led to increased identification of the incidental liver mass (ILM). A combination of careful consideration of patient factors and imaging characteristics of the ILM enables clinicians to recommend a safe and efficient course of action. Using an algorithmic approach, this article includes pertinent clinical factors and the specific radiologic criteria of ILMs and discusses the indications for potential procedures. It is the aim of this article to assist with the development of an individualized strategy for each patient with an ILM.

Omega-3 fatty acids: investigations from cytokine regulation to pancreatic cancer gene suppression.

Omega-3 (omega-3) fatty acids have been clinically and experimentally associated with the amelioration of chronic and acute inflammation; however, the mechanisms for these observations have not been well defined. During the past decade, laboratories of nutrition and inflammation have demonstrated that the anti-inflammatory activities of omega-3 fatty acids occur at least in part through the inhibition of macrophage-elaborated tumor necrosis factor production and through inactivation of the nuclear factor-kappaB signaling pathway subsequently altering proinflammatory cytokine transcription. These observations led to further experiments that support a role for omega-3 fatty acids in the restoration of apoptosis in various chemoresistant tumor models through a similar inactivation of the nuclear factor-kappaB signaling pathway. The potential for nutritional modulation of host inflammation has been an ongoing and expanding area of investigation. An increased emphasis has been placed on the potential for diet and dietary supplements to serve as modulators of host response to disease, injury, and infection.

Open cystogastrostomy, retroperitoneal drainage, and G-J enteral tube for complex pancreatitis-associated pseudocyst: 19 patients with no recurrence.

INTRODUCTION: Various techniques have been described to achieve definitive resolution of complex acute pancreatitis associated pseudocysts (PACs). Many of these strategies, inclusive of open, minimally invasive, and radiological procedures, are hampered by high recurrence or failed resolution, particularly for PAC near the pancreatic head. The present series describes a multimodal strategy combining a minilaparotomy for anterior gastrostomy for the creation of a stapled posterior cystogastrostomy, placement of an 8F secured silastic tube for intentional formation of a cystogastric fistula tract in combination with gastric drainage, and postduodenal enteral alimentation. MATERIALS AND METHODS: Using a prospectively maintained hepatobiliary database, patients with complex PAC undergoing the above procedures were identified. PAC location, postoperative length of stay (LOS), and time to start enteral feeding were identified. PAC were assessed by computed tomography (CT) scan prior to operation, 1 month after drainage, and patients with PAC resolution were started on oral diet, with the fistula silastic tube kept in place for an additional month. RESULTS: Over the interval 2003 to 2008, 19 patients were managed with the stated strategy. PACs were located at the pancreatic body/tail in 12 patients, and 7 patients had PAC at the level of the pancreatic head/neck area. In this cohort, prior to surgical drainage, 17/19 patients had undergone failed endoscopic retrograde cholangiopancreatography (ERCP) with decompressive stent placement and 13/19 had a failed percutaneous PAC drainage. There was no perioperative mortality after open surgical drainage. All patients started on jejunal tube feeding 24 h after surgical procedure. Median postoperative LOS was 7 days (4-13). At 1 month, 16/19 (84%) of patients showed complete resolution of the PAC on CT scan and were started on oral diet; 3/19 required additional month for complete resolution. After a mean follow-up of 31 months, there was no PAC recurrences in any of these patients demonstrated on follow-up. CONCLUSION: The described strategy is safe, efficient, and allows early restoration of enteral feeding with early hospital discharge. High resolution rates and absence of PAC recurrences in this series supports this approach for complex PAC.

Completely laparoscopic subtotal pancreatectomy with splenic artery preservation.

INTRODUCTION: Laparoscopic distal pancreatectomy has emerged as an attractive minimally invasive alternative for selected patients. Although technically challenging, distal pancreatectomy with splenic artery preservation has consistently been correlated with reduced blood loss and perioperative morbidity in multiple studies. Herein presented is our technique for completely laparoscopic (non-hand-assisted) subtotal pancreatectomy with splenic artery preservation (LSP-SAP). METHODS: An 87-year-old woman with an incidentally identified 3-cm cystic lesion in the pancreatic body-tail interface underwent EUS, which supported side-branch intraductal papillary mucinous neoplasm. The patient subsequently underwent laparoscopic resection. A completely laparoscopic procedure was performed using a four-trochar technique. The tail and body of the pancreas were dissected off of the retroperitoneum along the embryologic plane and separated from the colonic splenic flexure. Next, the splenic artery was dissected, isolated, and preserved, while the splenic vein was dissected off the ventral pancreas up to the level of the splenic-portal vein confluence. The technique employed a bipolar cutter-sealing device for dissection and hemostasis. Pancreatic parenchymal transection was performed with a standard vascular load endomechanical stapling device. RESULTS: Total procedure time was 210 min, and the estimated blood loss was 200 mL. Postoperatively, the patient was admitted, advanced to regular diet the next day, and discharged home on postoperative day 3. The pathological review of the specimen revealed high-grade dysplasia with a non-invasive malignant component, classified as intraductal carcinoma. Foci of PanIN 1-3 were identified with no high grade dysplasia at the surgical margin. Five lymph nodes were included in the specimen and were negative for malignancy. CONCLUSION: Completely LSP-SAP can be safely performed in selected patients. This procedure may be an optimal alternative to open surgery.