Non-curative Surgery Research Articles

Efficacy of pasireotide LAR for acromegaly: a prolonged real-world monocentric study.

Acromegaly is caused by excessive growth hormone (GH) and insulin-like growth factor 1 (IGF1). Medical therapy plays a role as a treatment option for persistent disease after non-curative surgery or as a first-line therapy when surgery is not feasible. Pasireotide-LAR (Pas-LAR) is recommended for patients with acromegaly as second-line treatment. To evaluate the patients characteristics predictive of an adequate response to Pas-LAR and the long-term efficacy and safety of the Pas-LAR treatment. Data from 19 patients with active acromegaly, who were and resistant or intolerant to first-line medical therapy and were switched to pas-LAR have been retrospectively collected. We compared the baseline clinical and biochemical characteristics of patients who were found to respond to Pas-LAR therapy (responders, n=14) with those of patients who did not respond (non-responders, n=5). We then evaluated the Pas-LAR efficacy and safety during long-term follow-up in responders. IGF1 normalization occurred in 71.4% of responders after one injection. IGF1 levels, [median(interquartile range) of the upper limit of the normal range (ULN) fold increase] were higher in non-responders compared to responders within the initial month of therapy [1.40(1.30-2.34) vs 0.70(0.55-1.25), respectively, p=0.009] and after three [1.77(1.74-2.29) vs 0.94(0.82-1.13), respectively, p=0.029] and six months [1.68(1.33-1.72) vs 1.00(0.65 -1.28), respectively, p=0.002]. Out of 6 patients with symptomatic headache (all in responder group), 5 and 1 reported the resolution and improvement of headache, respectively, already after the first injection. Median HbA1c levels tended to increase from baseline to 6 months both in responder (36 mMol/Mol to 42 mMol/Mol) and non-responder patients (45 mMol/Mol to 48 mMol/Mol). During long term follow up, in the responder group 2 new patients developed diabetes. Tumor shrinkage was observed in 6 out of 7 evaluated responders, with no cases of size increase during the long-term follow-up. Pas-LAR is effective and safe and the early identification of responders is possible just after the first administration.

Laparoscopic surgery for adrenocortical carcinoma: Estimating the risk of margin-positive resection.

Over recent years, there has been increasing adoption of minimally invasive surgery (MIS) in the treatment of adrenocortical carcinoma (ACC). However, MIS has been associated with noncurative resection and locoregional recurrence. We aimed to identify risk factors for margin-positivity among patients who undergo MIS resection for ACC. We hypothesized that a simple nomogram can accurately identify patients most suitable for curative MIS resection. Curative-intent resections for ACC were identified through the National Cancer Database spanning 2010-2018. Trends in MIS utilization were reported using Pearson correlation coefficients. Factors associated with margin-positive resection were identified among preoperatively available variables using multivariable logistic regression, then incorporated into a predictive model. Model quality was cross validated using an 80% training data set and 20% test data set. Among 1260 ACC cases, 38.6% (486) underwent MIS resection. MIS utilization increased over time at nonacademic centers (R = 0.818, p = 0.007), but not at academic centers (R = 0.009, p = 0.982). Factors associated with margin-positive MIS resection were increasing age, nonacademic center (odds ratio [OR]: 1.8, p = 0.006), cT3 (OR: 4.7, p < 0.001) or cT4 tumors (OR: 14.6, p < 0.001), and right-sided tumors (OR: 2.0, p = 0.006). A predictive model incorporating these four factors produced favorable c-statistics of 0.75 in the training data set and 0.72 in the test data set. A pragmatic nomogram was created to enable bedside risk stratification. An increasing proportion of ACC are resected via minimally invasive operations, particularly at nonacademic centers. Patient selection based on a few key factors can minimize the risk of noncurative surgery.

Clinicopathological Characteristics and Survival Outcomes in Patients with Advanced Esophageal Squamous Cell Carcinoma Who Were Intraoperatively Diagnosed Non-Curative

Introduction: Curative esophagectomy is not always possible in patients with locally advanced esophageal cancer. However, few studies have investigated patients who underwent non-curative surgery with intraoperative judgment. This study aimed to investigate patient characteristics and clinical outcomes for patients undergoing non-curative surgery and compare them between non-resectional and non-radical surgery. Methods: Among 989 consecutive patients with thoracic esophageal squamous cell carcinoma who were preoperatively expected for curative esophagectomy, 66 who were eligible for non-curative surgery were included in this study. Results: Intraoperative diagnosis of T4b accounted for 93% of the reasons for the failure of curative surgery. In those patients, esophageal cancer locally invaded into the aortobronchial constriction (70%), trachea (25%), or pulmonary vein (5%). Lymph node metastasis mainly invaded into the trachea (50%) or bronchus (28%). The overall survival of patients with non-curative surgery was 51.5%, 25.7%, and 10.4% at 6, 12, and 24 months after surgery, respectively. Although there were no differences in preoperative patient characteristics between non-resectional and non-radical surgery, distant metastasis, especially pleural dissemination, was significantly observed in T4b patients due to esophageal cancer with non-radical surgery than those with non-resectional surgery (35% vs. 15%, p = 0.002). Even in patients with non-curative surgery, R1 resection and postoperative chemoradiotherapy were identified as independent factors for survival 1 year after surgery (p = 0.047, and 0.019). Conclusions: T4b tumor located in aortobronchial constriction or trachea/bronchus makes it difficult to diagnose whether it is resectable or unresectable. Moreover, surgical procedures and perioperative treatment were deeply associated with the clinical outcomes.

Survey of Palliative Care Use in Primary Malignant Bone Tumors: A National Cancer Database Review.

Background/Objectives: Palliative care (PC) has been associated with reduced patient symptom burden, improved physician satisfaction, and reduced cost of care. However, its use in primary bone tumors has not been well classified. Design/Setting and Subjects: Patients diagnosed with primary malignant bone tumors (osteosarcoma, chondrosarcoma, Ewing sarcoma, and chordoma) between 2004 and 2018 were identified in the National Cancer Database. Cross tabulations with chi-square analysis were performed to evaluate frequencies of PC use by patient, facility, and tumor characteristics. Multivariate logistic binary regression was performed to evaluate relationships between patient, treatment facility, and tumor characteristics and the use of PC. Results: Around 24,401 patients were identified. Overall, 2.52% had any form of PC utilization. Of those receiving PC, 55.5-65.1% were treated with only noncurative surgery, radiation, chemotherapy, or any combination of these modalities. Odds of PC utilization were decreased for patients with chordomas, patients living >24 miles from the treatment facility, or patients with private insurance, Medicare, or unknown insurance status. Odds of PC utilization were increased in patients with greater tumor diameter or unknown tumor size, tumors in midline, increased tumor grade, stage IV tumors, or living in urban areas. Conclusion: PC use in patients with primary bone tumors increases with tumor stage, tumor grade, tumor size, and if the tumor is midline, and in patients living in urban areas. However, overall utilization remains markedly low. Future studies should be done to investigate these patterns of care and help expand the utilization of PC.

Survival and Prognostic Factors Predicting Outcomes of Patients with Primary Non-Metastatic Colorectal Cancer who have not had Curative Intervention

Abstract Background: The natural progression and life expectancy of patients following a diagnosis of treatable colorectal cancer who receive only symptomatic treatment, nonoperative palliative therapy, or noncurative surgical interventions are relatively unknown. Objectives: The objective of this retrospective study was to examine the survival of patients following a diagnosis of primary nonmetastatic colorectal cancer who did not undergo major surgery for the purpose of curative treatment. Design: A retrospective observational study. Study Settings: Department of Colorectal Surgery, King’s College Hospital, London. Patient and Methods: A retrospective study of patients with stages I–III colorectal cancer who had not undergone noncurative surgery, palliative chemotherapy, or radiotherapy between 2012 and 2019 was conducted. Multivariate and univariate analyses were used to evaluate the prognostic factors associated with overall survival (OS). Main Outcome Measure: OS. Sample Size: A total of 78 patients. Results: A total of 78 patients were enrolled in this study. The median survival rate was 296 days or 9.7 months, and the mean survival rate was 385 days (15–1894 days). The 1- and 2-year OS rates were 37.2% and 3.8%, respectively. Univariate analysis revealed that three parameters were statistically significant for OS with a significant correlation with performance status (PS) (P = 0.004), tumor stage (pT) (P = 0.030), and lymph node metastasis (pN) (P = 0.001). Multivariate analysis revealed that pN2 (hazard ratio: 2.19, 95% confidence index: -1.1–4.4) and PS 3 and 4 (hazard ratio: 0.525, 95% confidence index: 0.3–1.0, P = 0.026) were prognostic factors associated with OS. Conclusion: Operable colorectal cancer patients without surgical resection have an OS rate of &lt;1 year; a higher T and N stage is associated with adverse prognosis. Limitations: Our study is limited by its retrospective nature and small sample size. In addition, patients underwent various palliative interventions based on their unique clinical, pathological, and social needs. Conflict of Interest: The authors have no conflict of interest to declare.

Racial and ethnic inequities of palliative care use among advanced Non-Small cell lung cancer patients in the US.

With early intervention, palliative care (PC) can improve quality of life and increase survival among advanced-stage non-small cell lung cancer (aNCSLC) patients. However, PC is often offered late in the cancer treatment course and is underused. We characterized racial/ethnic inequities and the role of healthcare access in PC use among patients with aNSCLC. We used data from the 2004-2016 National Cancer Database, including adults aged 18-90 years with aNSCLC (stage 3 or 4 at diagnosis; n=803,618). Based on the NCCN guidelines, PC includes non-curative surgery, radiation, chemotherapy, pain management, or any combination of non-curative care. We examined PC use by sociodemographic and health care-level characteristics. To evaluate the independent associations of race/ethnicity and health care access characteristics with PC, we estimated adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). Covariate adjustment sets varied by exposure determined using directed acyclic graphs. Our population was 55% male and 77% non-Hispanic/Latinx (NH)-White, with a mean age of 68 years. Overall, 19% of patients with aNSCLC used PC. Compared to NH-White patients, NH-Black (aOR:0.91,95% CI:0.89-0.93) and Hispanic/Latinx (aOR:0.80,95% CI:0.77-0.83) patients were less likely to use PC, whereas Indigenous (AI/AN) (aOR:1.18,95% CI:1.06-1.31) and Native Hawaiian/Pacific Islander (aOR:2.08,95% CI:1.83-2.36) patients were more likely. Overall, compared to the privately-insured, uninsured (aOR:1.19,95% CI:1.11-1.28) and Medicaid-insured patients (aOR:1.19,95% CI:1.14-1.25) were more likely to use PC. PC is underutilized among NH-Black and Hispanic/Latinx patients with aNSCLC. Insurance type may play a role in PC use among patients with aNSCLC.

Use of non-curative oncological care in osteosarcoma.

78 Background: Osteosarcoma is the most common form of bone cancer, but the utilization of palliative care (PC) in patients with this cancer has not previously been investigated in the NCDB. Methods: This study retrospectively evaluated the use of palliative care in osteosarcoma patients diagnosed and recorded in the National Cancer Database (NCDB) between 2004 and 2017. Patients were identified by the International Classification of Diseases for Oncology, Third Edition (ICD-O-3) coding, and patients with other malignancies or missing follow-up data were excluded. Cross tabulations with Chi-square analysis were performed to evaluate frequencies of different patient and tumor characteristics. Multivariable logistic binary regression was performed to evaluate relationships between patient and tumor characteristics and the use of palliative care. Results: A total of 7498 patients were analyzed with 2.8% of all patients diagnosed having any form of palliative care utilization. Of this group, 53.37% received PC within the first 12 months after diagnosis. Those receiving PC were most likely to be treated with non-curative surgery, radiation, chemotherapy, or any combination of these modalities (56.7%). No significant increase in PC utilization was noted over the 13-year duration of this study. Palliative care usage was increased in patients with greater tumor diameter, tumors in the bones of the trunk &amp; skull, or stage IV tumors. Palliative care usage was decreased in patients living 25-49 miles of their treatment facility, those living in pacific states, those with chondroblastic osteosarcoma, or those with private insurance. Conclusions: Palliative care use in patients with osteosarcoma increases with tumor stage, tumor size, or more proximal tumors, but overall utilization remains markedly low. Future studies should further define these patterns of care and help expand the utilization of PC.

Utilization of Palliative Care in Osteosarcoma: A National Cancer Database Review.

Background: Osteosarcoma is the most common form of bone cancer, but the utilization of palliative care (PC) in patients with this cancer has not previously been investigated in the National Cancer Database (NCDB). Methods: Patients diagnosed with osteosarcoma (2004-2017) were identified within the NCDB. Cross tabulations with Chi-square analysis were performed to evaluate frequencies of palliative care use by patient, facility, and tumor characteristics. Multivariate logistic binary regression was performed to evaluate relationships between patient, treatment facility, and tumor characteristics and the use of palliative care. Results: A total of 7498 patients were analyzed with 2.8% of patients diagnosed having any form of palliative care utilization. Of this group, 53.37% received PC within the first 12 months after diagnosis. Of the 2.8% of patients receiving PC the most common forms of PC utilized were non-curative symptom-directed surgery, radiation, or chemotherapy, or a combination of these modalities (56.7%). Palliative care usage was increased in patients with greater tumor diameter, tumors in the bones of the midline, or stage IV tumors. Palliative care usage was decreased in patients living within 25-49 miles of their treatment facility, those living in pacific states, those with chondroblastic osteosarcoma, or those with private insurance. Conclusion: Palliative care use in patients with osteosarcoma increases with tumor stage, tumor size, or more proximal tumors, but overall utilization remains markedly low. Future studies should further define these patterns of care and help expand the utilization of PC.

Noncurative microsurgery for cerebral aneurysms: a systematic review and meta-analysis of wrapping, residual, and recurrence rates.

Microsurgery for cerebral aneurysms is called definitive, yet some patients undergo a craniotomy that results in noncurative treatment. Furthermore, the overall rate of noncurative microsurgery for cerebral aneurysms is unclear. The objective of this study was to complete a systematic review and meta-analysis to quantify three scenarios of noncurative treatment: aneurysm wrapping, postclipping remnants, and late regrowth of completely obliterated aneurysms. A PRISMA-guided systematic literature review of the MEDLINE and Cochrane Library databases and meta-analysis was completed. Studies were included that detailed rates of aneurysm wrapping, residua confirmed with imaging, and regrowth after confirmed total occlusion. Pooled rates were subsequently calculated using a random-effects model. An assessment of statistical heterogeneity and publication bias among the included studies was also completed for each analysis, with resultant I2 values and p values determined with Egger's test. Sixty-four studies met the inclusion criteria for final analysis. In 41 studies, 573/15,715 aneurysms were wrapped, for a rate of 3.5% (95% CI 2.7%-4.2%, I2 = 88%). In 43 studies, 906/13,902 aneurysms had residual neck or dome filling, for a rate of 6.4% (95% CI 5.2%-7.6%, I2 = 93%). In 15 studies, 71/2568 originally fully occluded aneurysms showed regrowth, for a rate of 2.1% (95% CI 1.2%-3.1%, I2 = 58%). Together, there was a total rate of noncurative surgery of 12.0% (95% CI 11.5%-12.5%). Egger's test suggested no significant publication bias among the studies. Meta-regression analysis revealed that the reported rate of aneurysm wrapping has significantly declined over time, whereas the rates of aneurysm residua and recurrence have not significantly changed. Open microsurgery for cerebral aneurysm results in noncurative treatment approximately 12% of the time. This metric may be used to counsel patients and as a benchmark for other treatment modalities. This investigation is limited by the high degree of heterogeneity among the included studies.

Risk Factors and Timing of Additional Surgery after Noncurative ESD for Early Gastric Cancer.

Background Patients with early gastric cancer undergoing noncurative endoscopic submucosal dissection (ESD) have a risk of tumor recurrence and metastasis, and some patients need additional surgery. The purpose of this study was to explore the risk factors of cancer residue and lymph node (LN) metastasis after noncurative ESD for early gastric cancer and to compare the short outcome of early and delayed additional surgery. Methods The clinicopathological characteristics of 30 early gastric cancer patients who received noncurative ESD and additional surgery were studied retrospectively. Multivariable regression was utilized to examine the independent risk factors for residual cancer and LN metastasis. Receiver operating characteristic curve was used to analyze the multivariable model's predictive performance. Furthermore, the perioperative safety and radical tumor performance of early surgery (≤30 days, n = 11), delayed surgery (>30 days, n = 11) after ESD, and upfront surgery (n = 59) were compared. Results Multivariable regression showed that diffuse type of Lauren classification, submucosal invasion, and positive human epidermal growth factor receptor-2 (HER-2) were risk factors for residual cancer. Undifferentiated carcinoma, vascular invasion, and positive vertical margin were risk factors for LN metastasis. The area under the curve (AUC) of the multifactor model predicting cancer residue and LN metastasis was 0.761 and 0.792, respectively. The early surgery group experienced higher intraoperative blood loss and a longer operation time than the delayed surgery and upfront surgery groups. There was no significant difference in the number of LN dissections, LN metastasis rate, and postoperative complications among the three groups. Conclusion Diffuse type of Lauren classification, submucosal invasion, and positive HER-2 are risk factors for residual cancer, while undifferentiated carcinoma, vascular invasion, and positive vertical margin are risk factors for LN metastasis. Delayed additional surgery after ESD (>30 days) has higher intraoperative safety, without affecting the radical resection in early gastric cancer patients.

Adipocytes contribute to tumor progression and invasion of peritoneal metastasis by interacting with gastric cancer cells as cancer associated fibroblasts.

Peritoneal metastasis (PM) is one of the most common causes of noncurative surgery and the most frequent recurrence pattern in gastric cancer (GC). During the process of PM, GC cells detached from primary tumor interact with human peritoneal mesothelial cells (HPMC) overlapped with adipose tissues such as the omentum or mesentery. Although the interaction with HPMC promotes the malignancy of GC, the role of adipose tissues remains unclear. We aimed to clarify how adipose tissue are affected by adjacent primary tumors during the expression of adipokines and to elucidate whether GC cells transform adipocytes into CAFs in vitro. In addition, we investigated whether GC cells are affected by adipocytes in their ability to infiltrate. We investigated the phenotypic conversion of adipocytes during the malignant process of GC cells in vivo and in vitro. We evaluated the expression levels of adiponectin in the omental adipose tissue of gastric cancer patients by western blotting. Following adipocytes/gastric cancer cells coculture, adipocyte markers, adiponectin receptors, and inflammatory cytokine markers were detected by real-time PCR and/or western blotting in the single-cultured and co-cultured adipocytes; cancer-associated fibroblast (CAF) markers were detected by immunofluorescence and western blotting in the single-cultured and co-cultured adipocytes; invasion assays were performed in single cultured and co-cultured MKN45 and OCUM. In omental adipose tissues that are situated close to the primary tumors, the expression of adiponectin tended to decrease in patients with subserosal or serosal invasion. By co-culturing with GC cells, adipocytes were dedifferentiated and the expression levels of CAF marker FSP1 and inflammatory cytokines, PAI-1 and IL-6, significantly increased (p < 0.05). Furthermore, GC cells co-cultured with adipocytes showed enhanced invasion ability. Our findings suggest that the phenotypic conversion of adipocytes may promote the malignancy of GC in the construction of the cancer microenvironment of PM.

Survey of palliative care use in primary malignant bone tumors: An NCDB review.

e23514 Background: Palliative care has been associated with reduced patient symptom burden, improved physician satisfaction, and reduced cost of care. However, its use in primary bone tumors has not been well classified. Methods: This study retrospectively evaluated the use of palliative care in patients with primary malignant bone tumors (osteosarcoma, chondrosarcoma, Ewing sarcoma &amp; chordoma) diagnosed and recorded in the National Cancer Database (NCDB) between 2004 and 2018. Patients were identified by ICD-O-3 coding and patients with other malignancies were excluded. Cross Tabulations with Chi-square analysis was performed to evaluate frequencies of different patient and tumor characteristics. Multivariable logistic binary logistic regression was performed to evaluate relationships between patient and tumor characteristics and the use of palliative care. Results: 24,401 patients with primary malignant bone tumors were identified. Overall, only 2.52% had any form of palliative care utilization. Of those receiving palliative care, 55.5-65.1% were treated with only non-curative surgery, radiation, chemotherapy, or any combination of these modalities. Odds of palliative care were decreased for patients with chordomas, patients living more than 24 miles from the treatment facility, patients living in west-south-central or pacific states, or patients with private insurance, medicare, or unknown insurance status. Odds of palliative care were increased in patients with greater tumor diameter or unknown tumor size, tumors in the midline, increased tumor grade, stage 4 tumors, or patients living in urban areas. Conclusions: Palliative care use in patients with primary bone tumors increases with tumor stage, tumor grade, tumor size, midline tumors, or in patients living in urban areas, but overall utilization remains markedly low. Future studies should be done to investigate these patterns of care and help expand the utilization of palliative care.

Transanal minimally invasive surgery using laparoscopic instruments of the rectum: A review.

Transanal minimally invasive surgery (TAMIS) was first described in 2010 as an alternative to transanal endoscopic microsurgery (TEM). The TAMIS technique can be access to the proximal and mid-rectum for resection of benign and early-stage malignant rectal lesions and also used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery. TAMIS has a shorter learning curve, reduced device setup time, flexibility in instrument use, and versatility in application than TEM. Also, TAMIS shows similar results in a view of the operation time, conversion rate, reoperation rate, and complication to TEM. For these reasons, TAMIS is an easily accessible, technically feasible, and cost-effective alternative to TEM. Overall, TAMIS has enabled the performance of high-quality local excision of rectal lesions by many colorectal surgeons. As TAMIS becomes more broadly utilized such as pelvic abscess drainage, rectal stenosis, and treatment of anastomotic dehiscence, the acquisition of appropriate training must be ensured, and the continued assessment and assurance of outcome must be maintained.

Prognostic factors of minimally invasive surgery for gastric cancer: Does robotic gastrectomy bring oncological benefit?

BACKGROUNDGastric cancer is the third leading cause of cancer-related death worldwide and surgical resection remains the sole curative treatment for gastric cancer. Minimally invasive gastrectomy including laparoscopic and robotic approaches has been increasingly used in a few decades. Thus far, only a few reports have investigated the oncological outcomes following minimally invasive gastrectomy. AIMTo determine the 5-year survival following minimally invasive gastrectomy for gastric cancer and identify prognostic predictors.METHODSThis retrospective cohort study identified 939 patients who underwent gastrectomy for gastric cancer during the study period. After excluding 125 patients with non-curative surgery (n = 77), other synchronous cancer (n = 2), remnant gastric cancer (n = 25), insufficient physical function (n = 13), and open gastrectomy (n = 8), a total of 814 consecutive patients with primary gastric cancer who underwent minimally invasive R0 gastrectomy at our institution between 2009 and 2014 were retrospectively examined. Accordingly, 5-year overall and recurrence-free survival were analyzed using the Kaplan–Meier method with the log-rank test and Cox regression analyses, while factors associated with survival were determined using multivariate analysis.RESULTSOur analysis showed that age > 65 years, American Society of Anesthesiologists (ASA) physical status 3, total or proximal gastrectomy, and pathological T4 and N positive status were independent predictors of both 5-year overall and recurrence-free survival. Accordingly, the included patients had a 5-year overall and recurrence-free survival of 80.3% and 78.2%, respectively. Among the 814 patients, 157 (19.3%) underwent robotic gastrectomy, while 308 (37.2%) were diagnosed with pathological stage II or III disease. Notably, our findings showed that robotic gastrectomy was an independent positive predictor for recurrence-free survival in patients with pathological stage II/III [hazard ratio: 0.56 (0.33-0.96), P = 0.035]. Comparison of recurrence-free survival between the robotic and laparoscopic approach using propensity score matching analysis verified that the robotic group had less morbidity (P = 0.005).CONCLUSIONAge, ASA status, gastrectomy type, and pathological T and N status were prognostic factors of minimally invasive gastrectomy, with the robot approach possibly improving long-term outcomes of advanced gastric cancer.

A Possible Definition of Oligometastasis in Pancreatic Cancer and Associated Survival Outcomes.

Oligometastatic cancer (OM) is possibly associated with relatively better survival outcomes. We attempted to identify cases in line with this OM concept. A total of 130 cases with unresectable metastatic pancreatic cancer underwent non-curative surgery from April 2001 to December 2019. Sites of metastasis, clinicopathological information, and surgical outcomes were collected to formulate a better definition of OM. OM criteria were defined as having metastasis to a single organ, few countable lesions and low serum cancer antigen 19-9 level. The median overall survival after non-curative surgery of OM cases was 13.0 months and was significantly better than that of non-OM cases (8.4 months, p=0.003). We propose single-organ metastasis of limited tumor volume (H1 or P1/2 by the Japanese Society of Cancer of the Colon and Rectum classification) and low serum cancer antigen 19-9 level (<2,000 U/ml) as new criteria for defining OM pancreatic cancer.

EUS-guided verteporfin photodynamic therapy for pancreatic cancer

Locally advanced pancreatic cancer (LAPC) often causes obstruction. Verteporfin photodynamic therapy (PDT) can feasibly "debulk" the tumor more safely than noncurative surgery and has multiple advantages over older PDT agents. We aimed to assess the feasibility of EUS-guided verteporfin PDT in ablating nonresectable LAPC. Adults with LAPC with adequate biliary drainage were prospectively enrolled. Exclusion criteria were significant metastatic disease burden, disease involving >50% duodenal or major artery circumference, and recent treatment with curative intent. CT was obtained between days -28 to 0. On day 0, verteporfin .4 mg/kg was infused 60 to 90 minutes before EUS, during which a diffuser was positioned in the tumor and delivered light at 50 J/cm for 333 seconds. CT was obtained on day 2, with adverse event monitoring occurring on days 1, 2, and 14. The primary outcome was presence of necrosis. Of 8 patients (62.5% men, mean age 65 ± 7.9 years) included in the study, 5 were staged at T3, 2 at T2, and 1 at T1. Most (n= 4) had primary lesions in the pancreatic head. Mean pretrial tumor diameter was 33.3 ± 13.4mm. On day 2 CT, 5 lesions demonstrated a zone of necrosis measuring a mean diameter of 15.7 ± 5.5mm; 3 cases did not develop necrosis. No adverse events were noted during the procedure or postprocedure observation period (days 1-3), and no changes in patient-reported outcomes were noted. In this pilot study, EUS-guided verteporfin PDT is feasible and shows promise as a minimally invasive ablative therapy for LAPC in select patients. Tumor necrosis is visible within 48 hours after treatment. Patient enrollment and data collection are ongoing. (Clinical trial registration number: NCT03033225.).

Optimal treatment and complications of patients with the perforated upper gastrointestinal tract.

The perforation of the upper gastrointestinal tract is still associated with a high risk of complications and mortality. We aimed to evaluate the optimal treatment and post-treatment complications for this condition. This was a retrospective, single-center study conducted between 2010 and 2019. We analyzed 50 patients with intraperitoneal free air caused by peptic ulcer (44 cases) or cancer (six cases). All patients initially received either conservative therapy (n = 7) or surgery (n = 43). The nonsurgically cured patients were significantly younger and had mild peritonitis and also had a shorter hospital stay. Two patients were converted to surgery due to worsening symptoms, and one of them was elderly and had a long perforation-to-treatment time. Regarding postoperative complications, patients with Grade II-V (n = 21) were significantly older and had a poorer physical status, longer perforation-to-surgery time, and higher preoperative CRP and lactate than those with Grade 0-I (n = 24). Multivariable analyses identified elevated preoperative lactate as an independent risk factor for postoperative complications. The patients with noncurative surgery for perforated advanced gastric cancer all died within 1year after surgery. Consideration should be given to the nonsurgical indications in elderly and delayed treatment patients and the postoperative outcomes of patients with preoperatively elevated lactate levels.

The Contribution of Intensity-Modulated Radiotherapy after Non-curative Intent Surgery for Head and Neck Adenoid Cystic Carcinoma

Incomplete surgery (gross total resection, near total resection, and subtotal resection) of head and neck adenoid cystic carcinoma (HNACC) is controversially considered as an unfavorable prognostic factor as to curative intent surgery (CIS). However, in Intensity-Modulated Radiotherapy (RT) era, after planed incomplete surgery (PIS), intensified RT or RT with concurrent chemotherapy (CCT) may contribute to tumor control and survival. Thus, we investigated the contribution of IMRT after PIS on local control and survival in HNACC. Retrospective review was performed for 170 consecutive patients with HNACC treated with curative postoperative IMRT with or without concurrent chemotherapy, between 2015 and 2018, after PIS (n = 102) or CIS (n = 68). All plan target volumes were designed to including the primary tumor and related cranial nerve pathway. Patients with other malignant tumors or distant metastasis were excluded. Among the 170 patients (98 women and 72 men; median age, 53 years), the median follow-up time was 27.8 (range, 9.6-59.1) months. The estimated 3-year local-regional recurrence-free survival (LRRFS) rate, progression-free survival (PFS) rate, overall survival (OS) rate, and distant metastasis-free survival (DMFS) rate were 92.4% (95%CI: 87.3-95.9), 74.7% (95%CI: 67.5-81.0), 98.5% (95%CI: 94.9-99.6), and 76.0% (95%CI: 68.7-82.1), respectively. Patients with high grade, Ki-67≥10%, Stage III-IV, extra-nodal extension (ENE), perineural invasion (PNI) and positive margin was associated with worse PFS (p<0.0001, p = 0.002, p = 0.003, and p = 0.0004, p = 0.042, and p = 0.021, respectively). The baseline and treatment characteristics were equally distributed between PIS and CIS group, except that there were more patients with positive margin and received RT dose≥66 Gy in PIS group (p = 0.000 and p = 0.000). There was no difference in LRRFS, DFS, OS, and DMFS between two groups, both in stage I-II and Stage III-IV (p = 0.280, p = 0.371, p = 0.752, and p = 0.549, respectively). Among patients with high grade, Ki-67≥10%, ENE or PNI, there was also no difference in PFS between two groups. Among patients received radiation dose<66Gy, PIS group patients had significant worse PFS (p = 0.029), while among patients without any CCT, PIS group patients had marginal significant worse PFS (p = 0.067). In IMRT era, PIS does not compromise oncologic treatment, even in patients with worse prognostic factors; however, Doses of ≥66 Gy or CCT might be essential. This strategy warrants further evaluation in prospective randomized trials with longer follow-up.

SUN-416 Fatigue and Quality of Life Among Thyroid Cancer Survivors

BACKGROUND Fatigue among thyroid cancer survivors is an important issue that needs to be appreciated and managed appropriately. Although several studies have reported potential factors that might be related to postoperative fatigue, the associations have yet to be inconclusive. The purpose of the present study was to estimate the prevalence of clinical fatigue in patients with papillary thyroid carcinoma and to reveal predictive factors, including their quality of life. METHODS A cross-sectional survey was conducted on patients with papillary thyroid carcinoma. Patients who underwent non-curative surgery, or those with recurrent or metastatic PTC, or those with other malignancies were excluded. The primary outcome was fatigue measured by the Cancer Fatigue Scale (CFS), and the secondary outcome was quality of life (QoL) quantified using the SF-36 v2. The following explanatory variables were collected; gender, age, employment status, marital status, co-morbidities, time since initial surgery, types of surgery, replacement of thyroid hormone, use of radioactive iodine, and the level of thyrotropin. The prevalence of clinical fatigue was estimated with the cut-off value of 18/19 of the CFS score. Correlations between the CFS score and the explanatory variables were examined using uni-variable analyses as well as multi-variable analysis. RESULTS Three hundred twenty-one patients participated in the survey. Of them, 258 respondents (80%) were female. The median age was 58 years, and the median time from initial surgery was 6.4 years. The mean and the standard deviation of the CFS score were 17.9 and 9.3, respectively (range: 0-48). The prevalence of clinical fatigue was 42% [95%CI: 36-47%]. Among the variables explored, having a job and scores of the mental component summary, the physical component summary, and the role/social component summary of the SF-36 were inversely associated with the CFS score in both uni- and multivariable analyses. CONCLUSION Postoperative fatigue was common in thyroid cancer survivors. Patients with a job and better QoL, in particular, those with good mental health, maybe at low-risk of developing the burden.

SAT-248 Cushing’s Disease with Two ACTH-Producing Pituitary Tumors

Objective: The objective of this case report is to discuss a case of Cushing’s disease with two ACTH-producing pituitary tumors and emphasize consideration of repeat surgery as a treatment modality for unsuccessful initial surgery. Methods: We present a case of a patient with Cushing’s disease with two ACTH-producing pituitary tumors and a literature review. Results: A 36 year-old female found to have left supraclavicular fossa swelling was screened for Cushing’s syndrome. Midnight salivary cortisol levels elevated at 0.636 ug/dL and 0.316 ug/dL (<0.010–0.090 ug/dL). 24-hour urine cortisol 162 ug/24 hr (0–50 ug/24 hr). 1-mg dexamethasone suppression test 14.0 ug/dL. Serum morning cortisol 26.4 ug/dL with corresponding ACTH 66.7 pg/mL (7.2–63.3 pg/mL). MRI brain with and without contrast showed a 7-mm relatively hypoenhancing lesion of the anterior pituitary gland. 8-mg dexamethasone suppression test 2.7 ug/dL. She underwent transsphenoidal surgery (TSS) and pathology was consistent with a pituitary adenoma staining positive for ACTH. No residual tumor was seen. Postoperative morning serum cortisol 17.0 ug/dL and ACTH 79 pg/mL (9–46 pg/mL). She had repeat TSS and the area of resection was clean with no residual tumor but a second adenoma was found that was not visualized on MRI and was distinct from the initial lesion. Postoperative morning cortisol 0.7 ug/dL and ACTH <9 pg/mL (9–46 pg/mL). Pathology was consistent with pituitary adenoma staining positive for ACTH. She is now on steroids for central adrenal insufficiency. Discussion: First-line treatment for Cushing’s disease is surgical resection of the primary lesion (Nieman LK, Biller BMK, et al. Treatment of Cushing’s syndrome: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2015; 100(8):2807–2831). Remission rates are 73–76% for selectively resected microadenomas but 43% for macroadenomas (Nieman et al. 2015). For patients who undergo a noncurative surgery, second-line therapies include repeat TSS, radiotherapy, medical therapy, and bilateral adrenalectomy. Repeat TSS is recommended particularly in patients who had evidence of incomplete resection or a pituitary lesion on imaging although this was not the case with our patient. Repeat TSS is cited to be successful in about 50–60% of cases (Patil CG, Veeravagu A, et al. Outcomes after repeat transsphenoidal surgery for recurrent Cushing’s disease. Neurosurgery. 2008;63(2):266–270) but carries an increased risk of hypopituitarism and lower likelihood of remission compared to initial surgery. Remission can be achieved more rapidly compared to other second-line treatments. Conclusion: In Cushing’s Disease with unsuccessful initial surgery, consideration for repeat TSS may be considered when there is access to an expert pituitary surgeon.