High-volume Cancer Center Research Articles

Do Fellowship-educated Military Orthopaedic Oncologists Who Practice in Military Settings Treat a Sufficient Volume of Patients to Maintain Their Oncologic Expertise?

Fellowship-trained orthopaedic oncologists in the US military provide routine clinical care and also must maintain readiness to provide combat casualty care. However, low oncologic procedure volume may hinder the ability of these surgeons to maintain relevant surgical expertise. Other low-volume specialties within the Military Health System (MHS) have established partnerships with neighboring civilian centers to increase procedure volume, but the need for similar partnerships for orthopaedic oncologists has not been examined. The purpose of this study was to characterize the practice patterns of US military fellowship-trained orthopaedic oncologists. We asked the following questions: (1) What are the diagnoses treated by US military fellowship-trained orthopaedic oncologists? (2) What are the procedures performed by US military fellowship-trained orthopaedic oncologists? We queried the Military Data Repository, a centralized repository for healthcare data for all healthcare beneficiaries (active duty, dependents, and retirees) within the Defense Health Agency using the MHS's Management and Reporting Tool for all international common procedure taxonomy (CPT) codes and ICD-9 and ICD-10 codes associated with National Provider Identifier (NPI) numbers of active duty, military fellowship-trained orthopaedic oncologists. Fellowship-trained orthopaedic oncologists were identified by military specialty leaders. Then, we identified all procedures performed by the orthopaedic oncologist based on NPI numbers for fiscal years 2013 to 2022. We stratified the CPT codes by top orthopaedic procedure categories (such as amputation [performed for oncologic and nononcologic reasons], fracture, arthroplasty, oncologic) based on associated ICD codes. These were then tabulated by the most common diagnoses treated. Thirteen percent (796 of 5996) of the diagnoses were oncologic, of which 45% (357 of 796) were malignant. Forty-four percent (158 of 357) of the malignancies were primary and 56% (199 of 357) were secondary; this translates to an average of 2 patients with primary and 2.5 patients with secondary malignancies treated per surgeon per year. During the study period, nine orthopaedic oncologists performed 5996 orthopaedic procedures, or 74 procedures per surgeon per year. Twenty-one percent (1252 of 5996) of the procedures were oncologic; the remaining procedures included 897 arthroplasties, 502 fracture-related, 275 amputations for a nononcologic indication, 204 infections, 142 arthroscopic, and 2724 other procedures. Although military orthopaedic oncologists possess expert skills that are directly translatable to combat casualty care and operational readiness, within MHS hospitals they treat relatively few patients with oncologic diagnoses, and less than one-half of those involve malignancies. Despite postgraduation procedure volume raining stable over the last decade, it is unknown how many new patient visits for oncologic diagnoses and how many corresponding tumor procedures are necessary to maintain competence or build confidence after musculoskeletal oncology fellowship training. It is important to note that there are no military orthopaedic oncology fellowships, and all active duty orthopaedic oncologists undergo training at civilian institutions. Military-civilian partnerships with high-volume cancer centers may enable military orthopaedic oncologists to work at civilian cancer centers to increase their oncologic volume to ensure sustainment of operationally relevant knowledge, skills, and abilities and improve patient care and outcomes.

The effect of PSMA PET/CT on clinical decision-making of radical prostatectomy and pelvic lymph node dissection

Objective To evaluate the effect of prostate-specific membrane antigen (PSMA) PET/computed tomography (CT) on clinical decision-making of radical prostatectomy (RP) and pelvic lymph node dissection (PLND) after its utilization in daily clinical practice at an European high-volume cancer center. Materials and methods Patients who had unfavorable intermediate- and high-risk prostate cancer between 2017 and 2021 were included retrospectively and divided into two groups; those who staged using PSMA PET/CT (group 1) and those who staged using conventional modalities (group 2). Clinical decision-making of RP over nonsurgical treatments and f PLND were primary endpoints and evaluated using regression models. Results PSMA PET/CT claimed significantly more N1 (24.2% vs. 11.3%; P = 0.01; OR, 1.97; 95% CI, 1.18–3.28) but insignificantly more M1 disease (9.9% vs. 5.7%; P = 0.42; OR, 1.91; 95% CI, 0.39–9.23), compared with the conventional imaging modalities. miN0 stage was related to more RP decisions compared with cN0 stage (P < 0.001; OR, 1.91; 95% CI, 1.48–2.46). PLND decision-making was significantly driven by positive c\miN stage findings, which were more reliable when it was reported after a PSMA PET/CT examination (P < 0.001; OR, 35.55; 95% CI, 6.74–187.45 for conventional imaging modalities vs. P < 0.001; OR, 91.72; 95% CI, 11.25–747.56 for PSMA PET/CT). Conclusions Patients with no suspicion of lymph node invasion on molecular imaging (PSMA PET/CT) tended to be referred to RP more compared to radiological imaging. Also, the PLND decision was strongly driven by staging findings. Compared with conventional imaging, PSMA PET/CT findings were more reliable during PLND decision-making.

High-dose chemotherapy as initial salvage chemotherapy in patients with relapsed or refractory testicular cancer: a systematic review and meta-analysis.

The role of high-dose chemotherapy followed by autologous hematopoietic cell transplantation in the management of patients with relapsed/refractory germ-cell tumors has not been established in prospective studies. Our aim was to estimate the benefits and harm of this treatment in men with relapsed/refractory germ-cell tumors. Electronic databases, conference proceedings, and trial registers until April 30, 2023, were searched. Randomized and non-randomized prospective controlled trials were included. Risk of bias assessments were performed using either RoB2 or ROBINS-I tools. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. Time-to-event data were analyzed using the hazard ratio. The primary outcome was overall survival, and a meta-analysis was not conducted to assess it because non-randomized trials were judged to have a critical risk of bias. Categorical data were analyzed using a risk ratio. All results are presented with the corresponding 95% confidence interval. Four out of 3,824 records met the inclusion criteria, and three out of four were used to assess primary and secondary outcomes. Based on the IT94 study (N = 263 participants), single high-dose chemotherapy followed by autologous hematopoietic cell transplantation may have little to no effect on overall survival [hazard ratio (HR) 0.98, 95%CI 0.68 to 1.42; p = 0.916]. Non-randomized trials (N = 43 participants) showed contrasting results, which may be explained by the number of cycles of high-dose chemotherapy administered in each study. Regarding secondary outcomes, information was only provided for event-free survival, response rate, and acute toxicities. Based on prospective data, there is insufficient evidence to support or refute the proposal that high-dose chemotherapy with autologous hematopoietic cell transplantation improves survival in men with relapsed/refractory germ-cell tumors. If this treatment is considered essential, the choice should be made by experienced clinicians at high-volume cancer centers.

Impact of a remote second opinion program on changes in recommended treatment plans for patients with cancer across the U.S.

386 Background: Second opinion consultations are a promising strategy to identify errors in diagnosis and recommend the optimal course of treatment for the patient. Yet, there are several barriers to patients accessing second opinions, including geographic barriers. By bringing high-level care to patients where they live, remote second opinion programs might benefit populations without access to subspecialty cancer centers, including those from underserved communities. While meaningful changes from in-person second opinions have been observed at several institutions, little is known about how often remote second opinions lead to similar improvements in treatment plans. Thus, our objective was to examine the extent to which the Memorial Sloan Kettering Cancer Center (MSK) remote second opinion program led to changes in treatment plans for cancer patients residing across the U.S. Methods: MSK is a high-volume cancer center based in NYC. MSK’s remote second opinion program was developed and rolled out as part of a national cancer benefits solution in 2016. Each second opinion review process is conducted by an MSK subspecialist and enabled by a customized digital platform. The process is asynchronous. To capture subspecialists’ perceptions of the importance of any changes to diagnosis or treatment recommended, we designed and administered a questionnaire starting in December 2023 that subspecialists completed after each case. Here, we report summary findings from the first 100 second opinion cases with complete information from this questionnaire. Results: These 100 case reviews were completed between December 2023 and April 2024. Spanning cancer types, the cases were reviewed by 49 unique subspecialists. There were 17 patients with breast cancer, 9 with colon cancer, 9 with lymphoma, 9 with prostate cancer, 7 with endometrial cancer, 7 with squamous cell carcinoma, 6 with myeloma, 5 with ovarian cancer, and 31 with one of 18 other cancer types. Patients had a mean age of 57 years (median 58) and 61% were female. Patients were from 27 different U.S. states. Of the 100 cases reviewed, subspecialists made a “meaningful change” (expected to affect patient outcomes) in recommended treatment, in 39 cases (39%). These meaningful changes included better prognosis / survival (n=26, 67%), reduced short-term morbidity / quality of life / toxicity (n=17, 44%), or improved long-term morbidity / quality of life / toxicity (n=29, 74%). There was a higher percent of recommended changes for liquid tumor cases compared to solid tumor cases (11/17, 65% for liquid; 28/83, 34% for solid). Conclusions: Findings are crucial for understanding potential opportunities to grow remote second opinion programs to benefit patients. This information is also essential for identifying the most effective strategies to reach underserved communities with geographic access barriers to high-quality subspecialty cancer care.

30 Cumulative Incidence of Sarcoma Brain Metastases: Report from a High-Volume Cancer Centre

30 Cumulative Incidence of Sarcoma Brain Metastases: Report from a High-Volume Cancer Centre

Long-term Survival in Esophageal Cancer: Comparison of Minimally Invasive and Open Esophagectomy

BackgroundThoracoscopic esophagectomy is a less invasive surgical procedure; however, evidence of its effect on long-term survival is limited. We evaluated long-term survival after the procedure in patients with esophageal carcinoma. MethodsThis retrospective multicenter study involved 1559 consecutive patients with esophageal carcinoma who underwent thoracoscopic esophagectomy or open esophagectomy between 2012 and 2019 at 2 Japanese high-volume cancer centers. Propensity score matching analysis was performed to compare short- and long-term outcomes. In addition, stage-specific survival rates were compared between the groups. ResultsThere were 313 patients who were matched and analyzed. The 1-, 3-, and 5-year overall survival rates were 84.5%, 60.5%, and 52.1%, respectively, in the matched open esophagectomy group; and 87.2%, 68.6%, and 61.8%, respectively, in the matched thoracoscopic esophagectomy group. The weighted Cox regression model showed significantly better survival in the thoracoscopic esophagectomy group than in the open esophagectomy group (hazard ratio, 0.74; 95% CI, 0.582-0.941). Deaths from other causes occurred more frequently in the open esophagectomy group than in the thoracoscopic esophagectomy group. Stratified analysis showed no significant survival differences between clinical stage I or II and pathologic stage 0 or I subgroups. However, the thoracoscopic esophagectomy groups with clinical stage III or IV and pathologic stage II, III, or IV had significantly better overall survival. ConclusionsThis study demonstrated the survival benefits of thoracoscopic esophagectomy, particularly for highly advanced esophageal carcinoma.

Ovarian Mesonephric-like Adenocarcinoma: Its Prevalence in a Japanese High-Volume Cancer Center and a Literature Review on Therapeutic Targets.

Ovarian mesonephric-like adenocarcinoma (MLA) is a newly described histological type known for its aggressive behavior. This study aims to determine the frequency of ovarian MLA, review the existing literature, and elucidate its clinicopathological characteristics, including the potential therapeutic targets. We retrospectively reviewed the pathological diagnoses of 501 primary ovarian cancer surgical cases at our institution from 2010 to 2023. MLAs exhibiting typical morphological and immunohistochemical features were included. The frequency and clinicopathological characteristics of these cases were summarized. Additionally, we conducted a literature search using PubMed to collect and summarize previously reported cases of ovarian MLAs. Among the 501 primary ovarian cancer cases, we identified 3 cases (0.6%) of MLA. The patients were 52-76 years old, and the initial FIGO stages were IC1 (two cases) and IIIB (one case). All the cases exhibited HRP, pMMR, PD-L1 negativity (CPS < 1), and low HER2 expression. Two cases experienced metastatic recurrence. A literature review identified 97 cases of MLA. The MLAs frequently exhibited KRAS mutations (90%, 38/42), with a recurrence rate of 39% (26/67). MLAs accounted for 0.6% of malignant ovarian tumors at our institution, all of which were advanced or recurrent cases. These cases showed HRP, pMMR, and PD-L1 negativity, indicating a lack of current therapeutic targets. The literature also reported a high incidence of advanced and recurrent cases, highlighting the need for accurate diagnosis and the development of new treatments. The frequent KRAS mutations suggest a potential therapeutic target for recurrent or metastatic MLA.

Unilateral Post-Chemotherapy Robot-Assisted Retroperitoneal Lymph Node Dissection for Stage II Non-Seminomatous Germ Cell Tumors: Sexual and Reproductive Outcomes.

We aimed to report sexual and reproductive outcomes following post-chemotherapy robot-assisted retroperitoneal unilateral lymph node dissection (PC-rRPLND) for non-seminomatous germ cell tumors (NSGCTs) at a high-volume cancer center. We collected records regarding sexual and reproductive outcomes of patients undergoing unilateral PC-rRPLND for stage II NSGCTs from January 2018 to November 2021. Preoperative and postoperative (at 12 months) ejaculatory function as well as erectile function, based on the International Index of Erectile Function-5 (IIEF-5) and Erection Hardness Score (EHS), were assessed. Only patients with a pre-operative IIEF-5 of ≥22 and EHS of ≥3 were included in this analysis. Overall, 22 patients undergoing unilateral PC-rRPLND met the inclusion criteria. Of these, seven (31.8%) patients presented an andrological disorder of any type after PC-rRPLND. Specifically, retrograde ejaculation was present in three (13.6%) patients and hypospermia was present in one (4.5%) patient. Moreover, three (13.6%) patients yielded erectile dysfunction (IIEF-5 < 22 and/or EHS < 3). Lastly, two (9.1%) succeeded in naturally conceiving a child after PC-rRPLND. Retrograde ejaculation is confirmed to be one of the most common complications of PC-rRPLND. Moreover, a non-negligible number of patients experience erectile dysfunction.

C-reactive protein as robust laboratory value associated with prognosis in patients with stage III non-small cell lung cancer (NSCLC) treated with definitive radiochemotherapy

To evaluate the prognostic value of biomarkers from peripheral blood obtained as routine laboratory assessment for overall survival in a cohort of stage III non-small cell lung cancer (NSCLC) patients treated with definitive radiochemotherapy at a high-volume cancer center. Seven blood biomarkers from 160 patients treated with definitive radiochemotherapy for stage III NSCLC were analyzed throughout the course treatment. Parameters were preselected using univariable and multivariable proportional hazards analysis and were assessed for internal validity using leave-one-out cross validation. Cross validated classifiers including biomarkers in addition to important clinical parameters were compared with classifiers containing the clinical parameters alone. An increased C-reactive protein (CRP) value in the final week of radiotherapy was found as a prognostic factor for overall survival, both as a continuous (HR 1.099 (1.038–1.164), p < 0.0012) as well as categorical variable splitting data at the median value of 1.2 mg/dl (HR 2.214 (1.388–3.531), p < 0.0008). In the multivariable analysis, the CRP value-maintained significance with an HR of 1.105 (1.040–1.173) and p-value of 0.0012. The cross validated classifier using CRP at the end of radiotherapy in addition to clinical parameters separated equally sized high and low risk groups more distinctly than a classifier containing the clinical parameters alone (HR = 2.786 (95% CI 1.686–4.605) vs. HR = 2.287 (95% CI 1.407–3.718)). Thus, the CRP value at the end of radiation therapy has successfully passed the crucial cross-validation test. The presented data on CRP levels suggests that inflammatory markers may become increasingly important during definitive radiochemotherapy, particularly with the growing utilization of immunotherapy as a consolidation therapy for stage III NSCLC.

Lung cancer in females from nonsmoker families in India: Observations and inferences in 5 years.

e20610 Background: Incidence in lung cancer in last two decades has been changing drastically in terms of gender, age, smoking behaviour of patients, stage at presentation, histopathology, genetic abnormalities, operability at presentation and survival. More perplexing is the increase in its occurrence in females from non smoker families, mitigating the sole importance of the traditional risk factors of tobacco and smoking in the recent times. This highlights the need to investigate other risk factors like radon exposure from indoor pollution where females stay most of the time, exposure to arsenic and other chemicals in daily life, particle pollution, physical inactivity and inflammatory diseases of airways. Methods: It was an observational study of patients who were diagnosed and treated at a high volume cancer centre in Karnataka state of India. 89 never smoker female patients under 50 years of age from non smoker families with no obvious exposure to second hand or third hand smoke were enrolled from October, 2018 to June, 2023. It was a longitudinal prospective cohort study where the demographic data, symptoms with duration, histopathology including genetic abnormalities, treatment details and survival were noted. Results: 89 never smoker females from non smoker families with ages ranging from 36 to 50 years had a median age of 46 years. About 70% of the ladies were from houses closely associated with farm in past or present. 55% of them had overweight and obese body habitus. Most common presenting symptom was dry cough with median duration of about 3 months in about 89%. Other symptoms were pleuritic chest pain(39%), breathlessness (19%), generalized body ache(9%) and jaundice(2%). Stage of disease was IV(69%), IIIC(12.3%), IIIB(11.2%), IIIA(5.6%) and II in just one patient. Most common sites of metastasis were contralateral lung(45%), bone(20%), liver(20%), adrenal glands(10%) and brain (15%). Most common histopathology was adenocarcinoma(87.6%), adenosquamous carcinoma(7.8%), squamous cell carcinoma(3.3%), large cell neuroendocrine carcinoma in just one patient. EGFR was mutated in 56(62.9%) with deletion 19( 33%) and L858R(21%) being the most common abnormalities. ALK rearrangements and ROS1 fusion were seen in about 9(3.3%) and 3(3.3%) patients respectively. Surgery was done in only 3 patients and chemoradiation after neoadjuvant chemotherapy was given in 8(8.9%) patients. Median overall survival was about 42 months in stage IV patients. Conclusions: Changing demographic profile of lung cancer warrants more research into the other causes of lung cancer. More stage IV disease highlights the emphasis on prevention and screening for the disease.

MSK Engage: A comprehensive program for collection of patient reported outcomes at scale.

e13666 Background: Collecting patient-reported outcomes (PROs) yields high value data for clinical care and research and is associated with improved survival in oncology. However, collection of PROs at scale requires a multifaceted program that in most institutions is not available. This study describes a comprehensive PRO program to support research and standard clinical care at scale. Methods: Memorial Sloan Kettering Cancer Center is a high-volume cancer center in New York. Beginning in 2016, we developed a comprehensive PRO program, MSK Engage, with the following capabilities: (i) A governance process to oversee the creation of questionnaires for both research and clinical care. This process includes alignment with the IRB and standardization of questions presented to patients. (ii) Technology to determine which patients should get an assessment (i.e., instance of a questionnaire) at what point in time. (iii) An interactive module in our patient portal that would present the assessment to the patient. (iv) Various methods to present the PRO data to providers to support clinical decision making. These methods included (a) alerts based on threshold logic that would send secure messages to the clinical team, (b) integration of the PRO data into the EHR to be viewed with other clinical data, and (c) the creation of specialized workflows. The results of assessments are also stored in an analytics database to support operations, research, and the creation of smart reports that compare a patient’s responses with other similar patients. Results: We analyzed the use of the program from 2016 to 2023 (Table). 189 questionnaires have been implemented, generating 3,098,574 completed assessments from 314,685 distinct patients. Completion rates varied. The median completion time for all questionnaires was 2 minutes. Examples of programs enabled by patient-reported outcomes include post-operative symptom monitoring, family history questionnaires to support clinical genetics decision making and operations, intake and follow up questionnaires that support clinical documentation and quality of life questionnaires to support goal concordant care. Conclusions: Adoption of PROs at scale for both research and standard of care in oncology is feasible and innovative programs of care can be supported while maintaining a centralized and acceptable patient experience. This model can be applied across institutions seeking to develop or scale PRO programs to assure patient data are meaningfully incorporated into decision-making. [Table: see text]

Recurrence of rectal cancer on the pelvic sidewall after lateral lymph node dissection

PurposeAlthough lateral lymph node dissection has been performed to prevent lateral pelvic recurrence in locally advanced lower rectal cancer, the incidence of lateral pelvic recurrence after this procedure has not been investigated. Therefore, this study aimed to investigate the long-term outcomes of patients who underwent lateral pelvic lymph node dissection, with a particular focus on recurrence patterns.MethodsThis was a retrospective study conducted at a single high-volume cancer center in Japan. A total of 493 consecutive patients with stage II-III rectal cancer who underwent lateral lymph node dissection between January 2005 and August 2022 were included. The primary outcome measures included patterns of recurrence, overall survival, and relapse-free survival. Patterns of recurrence were categorized as lateral or central pelvic.ResultsAmong patients who underwent lateral lymph node dissection, 18.1% had pathologically positive lateral lymph node metastasis. Lateral pelvic recurrence occurred in 5.5% of patients after surgery. Multivariate analysis identified age > 75 years, lateral lymph node metastasis, and adjuvant chemotherapy as independent risk factors for lateral pelvic recurrence. Evaluation of the recurrence rate by dissection area revealed approximately 1% of recurrences in each area after dissection.ConclusionWe demonstrated the prognostic outcome and limitations of lateral lymph node dissection for patients with advanced lower rectal cancer, focusing on the incidence of recurrence in the lateral area after the dissection. Our study emphasizes the clinical importance of lateral lymph node dissection, which is an essential technique that surgeons should acquire.

Radiotherapy Improves Survival in NSCLC After Oligoprogression on Immunotherapy: A Cohort Study

IntroductionThe patterns of oligoprogression after first-line immune checkpoint inhibitors (ICIs) for metastatic NSCLC are yet to be well established. An increasing volume of data suggests that directed radiotherapy improves survival outcomes in patients with progression after ICIs. MethodsA retrospective cohort study was performed on patients with metastatic NSCLC who had completed first-line programmed death-(ligand) 1 inhibitor therapy with or without chemotherapy at two high-volume cancer centers. We sought to characterize the frequency and location of oligoprogression and determine the overall survival (OS) after radiotherapy in this population. ResultsA total of 159 patients were included in the study. At first progression, 62 (39.0%) were classified as undergoing oligoprogression. Multivariate analysis confirmed the presence of brain metastases was associated with an increased likelihood of oligoprogression (OR = 2.44, p = 0.04) with most (63.2%) of these patients experiencing progression intracranially. The presence of liver metastases was associated with a decreased likelihood of oligoprogression (OR = 0.17, p < 0.01). For patients with oligoprogression, those who received radiotherapy had a longer median progression-free survival-2 (PFS2) (17 versus 11.5 mo, HR = 0.51, p = 0.02) and a longer median OS (23 versus 13 mo, HR = 0.40, p < 0.001) compared with those who did not receive radiotherapy. No difference in PFS2 or OS outcomes was observed between patients who received radiotherapy versus those who did not for systemic progression. ConclusionsIn patients with oligoprogressive metastatic NSCLC after treatment with first-line ICIs, radiotherapy significantly improves OS and PFS2 outcomes. Patients with baseline brain metastases are more likely to experience oligoprogression. Further prospective studies in directed, less heterogeneous populations of patients with metastatic NSCLC will be fundamental to optimize management.

Reconstructive Head and Neck Microsurgery in a High-Volume Cancer Center—Long-Term Impact of an Early Experience

Objectives The aim of this study was to evaluate a 16-year-long outcome of an evolving practical approach to reconstructive microsurgery in a high volume, resource-constrained, head and neck cancer care setting. Patients and Methods Seventy-three consecutive cases of free flap reconstruction done by the Head and Neck Surgical Oncology team of Regional Cancer Centre, Thiruvananthapuram, from October 2004 to May 2020 were prospectively studied for flap viability, cosmesis, morbidity, and oncologic safety. The cases were selected based on their “emphatic” superiority to the conventional alternative as determined by two or more surgeons of the head and neck team or the recommendations of the head and neck tumor board. Results With the long-term results, this article discusses and validates our strategy for controlled patient recruitment for reconstructive microsurgery to ensure the best resource utilization in a tertiary cancer care center. Conclusions Adequate training and optimal application are the key factors determining success in microvascular reconstructive surgery in resource-constrained, high-volume cancer care facilities.

Radioactive seed localization is a safe and effective tool for breast cancer surgery: an evaluation of over 25,000 cases.

Radioactive seed localization (RSL) provides a precise and efficient method for removing non-palpable breast lesions. It has proven to be a valuable addition to breast surgery, improving perioperative logistics and patient satisfaction. This retrospective review examines the lessons learned from a high-volume cancer center's RSL program after 10 years of practice and over 25 000 cases. We provide an updated model for assessing the patient's radiation dose from RSL seed implantation and demonstrate the safety of RSL to staff members. Additionally, we emphasize the importance of various aspects of presurgical evaluation, surgical techniques, post-surgical management, and regulatory compliance for a successful RSL program. Notably, the program has reduced radiation exposure for patients and medical staff.

Fast-track anesthesia and outcomes in hepatopancreatic cancer surgery: a retrospective analysis

AimTo assess the feasibility of a fast-track anesthesia protocol for hepatopancreatobiliary cancer surgery.MethodsRetrospective analysis of consecutive sample of patients who underwent hepatopancreatic surgery for cancer for a period of 12 months in a high volume cancer center. Blended anesthesia was performed for most patients who were then observed in a recovery room area until achieving a safety score.ResultsData of 163 patients were examined. Fifty-six and 107 patients underwent surgery for pancreatic cancer and liver surgery for primary tumor or metastases, respectively. Most patients were ASA 3. The mean durations of anesthesia and surgery were 322 min (SD 320) and 296 min (SD 133), respectively. Extubation was performed in the operating room in 125 patients. Post-operatory invasive ventilation was maintained in the recovery room in fifteen patients for a mean duration of 72.7 min (SD148.2). Only one patient was admitted to intensive care for 15 h. NIV was performed in three patients for a mean duration of 73.3 min (SD 15.3). The mean recovery room staying was 79 min (SD 80). The mean hospital postoperative stay was a mean of 8.1 days (SD 5.7). No complications were found in 144 patients. Globally, mortality rate was 3%.ConclusionA program of fast-track anesthesia with a short stay in recovery room allowed to achieve a good outcome, limiting the costs of intensive care admission.

Oncological risk of proximal gastrectomy for proximal advanced gastric cancer after neoadjuvant chemotherapy

PurposeThis study assesses the metastasis rate of the key distal lymph nodes (KDLN) that are not routinely dissected in proximal gastrectomy, aiming to explore the oncological safety of proximal gastrectomy for upper gastric cancer who underwent neoadjuvant chemotherapy.MethodsWe analyzed a cohort of 150 patients with proximal locally advanced gastric cancer (cT3/4 before chemotherapy) from two high-volume cancer centers in China who received preoperative neoadjuvant chemotherapy (NAC) and total gastrectomy with lymph node dissection. Metastasis rate of the KDLN (No.5/6/12a) and the risk factors were analyzed.ResultsKey distal lymph node metastasis was detected in 10% (15/150) of patients, with a metastasis rate of 6% (9/150) in No. 5 lymph nodes, 6.7% (10/150) in No. 6 lymph nodes, and 2.7% (2/75) in No. 12a lymph nodes. The therapeutic value index of KDLN as one entity is 5.8. Tumor length showed no correlation with KDLN metastasis, while tumor regression grade (TRG) emerged as an independent risk factor (OR: 1.47; p-value: 0.04). Of those with TRG3 (no response to NAC), 80% (12/15) was found with KDLN metastasis.ConclusionFor cT3/4 proximal locally advanced gastric cancer patients, the risk of KDLN metastasis remains notably high even after NAC. Therefore, proximal gastrectomy is not recommended; instead, total gastrectomy with thorough distal lymphadenectomy is the preferred surgical approach.

Evaluation of Different Regimens of Palliative Radiation Therapy for Symptomatic Bone Metastases: An Audit From a Tertiary Care Hospital in Jharkhand, India.

Background This study aimed to assess the efficacy of different radiation therapy regimens in treating patients with symptomatic bone metastases. Methodology A retrospective study was conducted by assigning patients with symptomatic bone metastases from different primary cancers into three groups, namely, Arms A, B, and C. The radiation dose delivered in each arm was as follows: 8 Gray (Gy) in a single fraction for Arm A, 20 Gy in five fractions at the rate of 4 Gy per fraction for Arm B, and 30 Gy in 10 fractions at the rate of 3 Gy per fraction for Arm C. Each arm consisted of 15 patients. A comparison was conducted across all three arms to evaluate pain relief based on the Visual Analog Scale (VAS), performance score improvement based on the Eastern Cooperative Oncology Group (ECOG), and analgesic requirement based on the World Health Organization (WHO) step ladder at one week, one month, and three months. Results The pain relief was measured using the VAS in three different arms, i.e., Arm A, B, and C. After one week, the pain relief was 66.67%, 60%, and 60%, respectively. After one month, it was 73.33% in all three arms. At three months, it was 80%, 86.67%, and 86.67%, respectively. The study also measured the improvement in the ECOG performance score. The improvement in all three arms was 60% after one week and 66.67% in Arm A and 73.33% in Arms B and C after one month. After three months, the improvement was 73.33%, 80%, and 80% in Arms A, B, and C, respectively. The decrease in analgesic usage was also measured in all three arms. After one week, it was 60% in all three arms. After one month, it was 66.67%, 73.33%, and 73.33% in Arms A, B, and C, respectively. At three months, it was 73.33%, 80%, and 80% in Arms A, B, and C, respectively. No significant statistical difference was found between the three arms. Conclusions The efficacy of a single 8 Gy arm was almost equivalent to that of other arms of multifractionated regimens in terms of improvement in pain and performance score and decreased use of analgesics for a short duration of follow-up. For high-volume cancer centers and patients with economic constraints, a single-fraction regime provides effective palliation for painful bone metastases.

Vascular resection for pancreas cancer: Ten-year real-world experience from a single high-volume center.

638 Background: In pancreatic ductal adenocarcinoma (PDAC), to identify prognostic factors for surgically treated patients, including vascular resections. Methods: Retrospective review (2011 – 2023) of pathologically proven PDAC treated with curative-intent surgery (n = 715) at a high-volume cancer center. We tested associations between clinicopathological and radiological data, perioperative therapy, time to recurrence (TTR) and overall survival (OS). Results: Demographic and clinicopathological variables were comparable to published surgical cohorts. Initial NCCN radiological staging was 533 (74.5%) resectable, 98 (13.7%) borderline, and 84 (11.7%) locally advanced PDAC. There were 467(65.3%) pancreaticoduodenectomies, 104 (14.5%) distal pancreatectomies, 31 (4.3%) total pancreatectomies and 112 (15.7%) aborted procedures, mostly due to metastatic disease (82.1%). Of the 603 resected cases, 351 (58.2%) were non-vascular resections (NVR), 181 (30.0%) venous-only resections (VR), and 70 (11.8%) were arterial ± venous resections (AR). Median length of stay was 8 days, ICU admission rate was 6.1% (n = 37), readmissions occurred in 114 (18.9%) cases and reoperations in 47 (7.8%) cases. The 90-day mortality rate was 3.2% (n = 19) and the 5-year OS was 20.7%. Perioperative chemotherapy was given to 258 (78.4%) NVR, 129 (75.9%) VR and 60 (93.8%) AR. Perioperative chemoradiation was given to 20 (6.8%) NVR, 34 (21.0%) VR and 43 (66.1%) AR. Median TTR and OS did not significantly differ by initial NCCN staging or type of pancreas resection. Median TTR and OS were significantly shorter for VR (14.5 and 22.7 months) compared to NVR (18.6 and 30.5 months, p&lt;0.001) and AR (20.6 months, p = 0.004 and 30.9 months, p = 0.017). Patients who received chemotherapy or chemoradiation had significantly longer TTR (20.1 vs. 10.2 months, p&lt;0.001 and 25.3 vs. 16.4 months, p&lt;0.001) and OS (31.5 vs. 17.2 months, p&lt;0.001 and 35.5 vs. 27.5 months, p=0.030) compared to patients not receiving any therapy. In multivariate analysis, when controlling for perioperative therapy and usual clinicopathological factors, vascular resection was not associated with TTR and OS. Perioperative chemotherapy, chemoradiation, pathological N0 status, and absence of perineural invasion were significant independent predictors of longer TTR and OS. For VR specifically, patients who received chemotherapy and chemoradiation had significantly longer median TTR and OS (41.9 and 35.3 months) compared to patients receiving chemotherapy alone (14.3 and 24.6 months, p&lt;0.001 and p=0.017) or receiving no perioperative therapy (9.5 and 12.8 months, p &lt;0.001 and p = 0.004). Conclusions: In this cohort of patients with PDAC treated with surgical resection at a high-volume cancer center, vascular resection was not associated with oncological outcomes when controlling for administration of perioperative therapy.

Clinical risk factors for splenic hilar nodal metastasis in remnant gastric cancer after distal gastrectomy.

270 Background: Splenectomy is usually considered to be required for complete dissection of splenic hilar lymph node (#10 LN) in gastric cancer (GC). Although spleen-preserving D2 was established for the advanced GC not invading the grater coverture based on the JCOG0110 clinical trial, D2 gastrectomy with splenectomy remains the standard procedure for the advanced GC involving grater coverture in Japan. However, the applicability of this treatment for remnant gastric cancer (RGC) is unclear because the lymphatic flow and lymphatic metastatic pattern may have been changed after initial gastrectomy. There are no guidelines for splenic hilar nodal dissection for RGC. In this study we evaluated risk factors for #10 nodal metastasis in RGC. Methods: This study retrospectively examined RGC patients who received gastrectomy with #10 nodal dissection after distal gastrectomy at two high-volume cancer centers in Japan between 1998 and 2015. Results: 99 patients were entered in this study. The #10 nodal metastatic rate was 12.1% (12/99). Initial gastrectomy was performed for benign in 42 patients and for malignant in 52 patients. The median duration from the initial gastrectomy was 20 (1-55) years. Main tumor location was lesser curvature in 46 patients, anterior wall in 11, greater curvature in 19, posterior wall in 11, and the whole in 12. Large type 3(≥8cm) and type 4 were found in 18 cases. The median tumor size was 50 (10-232) mm. The depth of invasion was cT1 in 31 patients, cT2 in 19, cT3 in 11, cT4a in 28, and cT4b in 10. Histology was differentiated type in 46 patients and undifferentiated type in 56. Completion gastrectomy was performed in 98 patients and partial gastrectomy in 1. 89 patients underwent splenectomy. The univariate analysis showed that tumor location (lesser curvature vs others, p=0.027) and depth of invasion (cT1-3 vs cT4, p=0.032) were significant risk factors for #10 nodal metastasis. By multivariate analysis, these two factors remained significant. Metastasis to #10 nodal metastasis was 0% (0/28) in patients without both risk factors, 11-12% in those with at least one risk factor, and 30% (6/20) in those with both risk factors. Conclusions: The tumors not confined to the lesser curvature and cT4 were significant risk factors for #10 nodal metastasis of RGC after distal gastrectomy. Splenectomy should be considered for complete splenic hilar nodal dissection when these risk factors are positive.