Subsequent Surveillance Research Articles

Clinical outcomes of positive resection margins after endoscopic resection of early colorectal cancer.

688 Background: The management of patients with a positive resection margin after endoscopic resection of early colorectal cancer (ECC) depends on various clinical factors, including the pathology. There is little information on the clinical outcomes according to the subsequent management of a positive resection margin in patients with ECC treated by endoscopic resection. We assessed the management according to the pathology of the positive margin and evaluated the clinical outcomes. Methods: Consecutive patients with ECC who underwent endoscopic resection from January 2004 to December 2014 were reviewed. This study retrospectively analyzed 363 lesions from 338 patients (mean age, 60.1 years; 68% [230/338] male). Results: The resection margin was positive in 29.2% of patients, including cancer cells in 9.9%, adenoma in 16.5%, and high-grade dysplasia (HGD) in 2.8%. Subsequent surgery was performed on 11.8% of patients, 72.2% (26/43) of whom were cancer cell–positive, while 23.3% (10/43) were resection margin–negative but had deep submucosal (SM) or lymphatic invasion. Remnant cancer cells were identified in 25.6% (11/43) of the operated group and 81.8% (9/11) of the cancer cell–positive group. On early follow-up surveillance colonoscopy (mean interval, 3.57 months) in 88.2% of patients (320/363), including 95.7% (67/70) of the adenoma and HGD-positive group, only one (0.3%, 1/320) case of remnant adenoma was found. In the multivariate analysis, deep SM invasion ( p=0.026), number of pieces of piecemeal resection (p=0.03) and cancer cell positivity ( p=0.001) predicted subsequent surgery. In the multivariate analysis, an endoscopic appearance of incomplete resection ( p=0.002) and cancer cell positivity (p=0.041) were related to the identification of remnant cancer cells after subsequent surgery. Conclusions: Patients with an adenoma-positive resection margin had favorable clinical outcomes during subsequent surveillance. The choice of subsequent surgery was related to deep SM invasion and cancer cell–positive resection margins, and subsequent surgery group showed a high rate of remnant cancer cells.

Outbreak of Hospital Infection from Biofilm-embedded Pan Drug-resistant Pseudomonas aeroginosa, Due to a Contaminated Bronchoscope.

Colistin-resistant Pseudomonas aeruginosa (P. aeruginosa) has been defined as pandrug-resistant (PDR) strain. Outbreaks of PDR P. aeruginosa especially in pulmonary tract infections due to contaminated bronchoscopes have rarely been reported. The emergence of pandrug-resistant strains in both CF (Cystic Fibrosis) and non-CF clinical isolates over recent years remains of a great concern. Hospital wards contaminated with PDR P. aeruginosa infection, must be shot down until their eradication. Health Authorities must be informed immediately and infection control strategies must be implemented. To report such an outbreak and modify the infection control strategy in an academic hospital in Ankara Turkey. From October to December 2013, PDR-Pseudomonas aerogionsa were identified from bronchial cultures of 15 patients who had undergone bronchoscopy prior to the infection. Three batches of surveillance cultures were obtained from the environmental objects and healthcare workers related to the procedures. Pulsed-field gel electrophoresis (PFGE) was used for bacterial typing. Antimicrobial susceptibility was assessed by disc diffusion and E-test methods. A total of 70 specimens were obtained during the first surveillance operation. One Colistin-resistant P. aeroginosa was isolated from a bronchoscope. Although the disinfection protocols for bronchoscope were revised and implemented, seven additional bronchial cases were identified thereafter. The pathogen was identified from two subsequent surveillance cultures and was not eliminated until Ethylene oxide sterilization was added to the disinfection protocol. PFGE revealed that all 15 isolates from the patients and the three isolates from the bronchoscope shared a common pattern with minor variance. XbaI restriction enzyme turned out better than SpeI in interpreting bacterial pulse types with BioNumerics 6.0. The most suitable cut off value for SpeI was above 80% Dice similarity while for XbaI above 95%Dice similarity with BioNumerics 6.0. The outbreak of "Colistin" pan drug-resistant Pseudomonas aeroginosa was caused by a contaminated bronchoscope and was terminated by the implementation of a revised disinfection protocol for bronchoscope.

Local recurrence and subsequent endoscopic treatment after endoscopic piecemeal mucosal resection with or without precutting in the colorectum.

Background/AimsPrecutting before endoscopic piecemeal mucosal resection (EPMR) may increase colorectal polyp resection effectiveness. We aimed to identify risk factors for recurrence after conventional EPMR (CEPMR) and precut EPMR (PEPMR) and investigated endoscopic treatment outcomes for recurrent cases.MethodsThe medical records of patients with colorectal polyps treated by EPMR were analyzed. Patients without follow-up surveillance colonoscopies were excluded.ResultsAmong 359 lesions, the local recurrence rate on the first surveillance colonoscopy was 5.8% (18/312) and 6.4% (3/47) after CEPMR and PEPMR, respectively. Among lesions without recurrence at the first surveillance colonoscopy, the rates of late recurrence on subsequent surveillance colonoscopy were 3.9% (6/152) and 0% after CEPMR and PEPMR, respectively. Larger tumor size was the only independent risk factor for recurrence (odds ratio, 7.93; 95% confidence interval, 1.95–32.30; P<0.001). Endoscopic treatment was performed for all 27 recurrences. A combination of ≥2 endoscopic treatment modalities was used in 19 of 27 recurrences (70.4%). Surveillance colonoscopies were performed in 20 of 27 recurrences after endoscopic treatment. One (5.0%) had a re-recurrence and was treated by surgical resection because recurrence occurred at the appendiceal orifice. Nineteen of 20 lesions (95.0%) could be cured endoscopically, although 3 of the 19 showed second or third recurrences and were treated by repeat endoscopic resection.ConclusionsThe local recurrence rates after CEPMR and PEPMR were similar. Larger tumor size was an independent risk factor for local recurrence after EPMR. Endoscopic treatment of recurrences resulted in high cure rates, although combination methods were necessary in many cases.

Vancomycin-Resistant Enterococcus Colonization and Bacteremia and Hematopoietic Stem Cell Transplantation Outcomes

The association between pre–hematopoietic stem cell transplantation (HSCT) vancomycin-resistant Enterococcus (VRE) colonization, HSCT-associated VRE bacteremia, and HSCT mortality is disputed. We studied 161 consecutive patients with acute leukemia who underwent HSCT at our hospital between 2006 and 2014, of whom 109 also received leukemia induction/consolidation on our unit. All inpatients had weekly VRE stool surveillance. Pre-HSCT colonization was not associated with increases in HSCT mortality but did identify a subgroup of HSCT recipients with a higher risk for VRE bacteremia and possibly bacteremia from other organisms. The major risk factor for pre-HSCT colonization was the number of hospital inpatient days between initial admission for leukemia and HSCT. One-third of evaluable patients colonized before HSCT were VRE-culture negative on admission for HSCT; these patients had an increased risk for subsequent VRE stool surveillance positivity but not VRE bacteremia. Molecular typing of VRE isolates obtained before and after HSCT showed that VRE strains frequently change. Postengraftment VRE bacteremia was associated with a much higher mortality than pre-engraftment VRE bacteremia. Pre-engraftment bacteremia from any organism was associated with an alternative donor and resulted in an increase in hospital length of stay and cost. Mortality was similar for pre-engraftment VRE bacteremia and pre-engraftment bacteremia due to other organisms, but mortality associated with post-engraftment VRE bacteremia was higher and largely explained by associated severe graft-versus-host disease and relapsed leukemia. These data emphasize the importance of distinguishing between VRE colonization before HSCT and at HSCT, between pre-engraftment and postengraftment VRE bacteremia, and between VRE bacteremia and bacteremia from other organisms.

Evaluating the Four Kallikrein Panel of the 4Kscore for Prediction of High-grade Prostate Cancer in Men in the Canary Prostate Active Surveillance Study

BackgroundDiagnosis of Gleason 6 prostate cancer can leave uncertainty about the presence of undetected aggressive disease. ObjectiveTo evaluate the utility of a four kallikrein (4K) panel in predicting the presence of high-grade cancer in men on active surveillance. Design, setting, and participantsPlasma collected before the first and subsequent surveillance biopsies was assessed for 718 men prospectively enrolled in the multi-institutional Canary PASS trial. Biopsy data were split 2:1 into training and test sets. We developed statistical models that included clinical information and either the 4Kpanel or serum prostate-specific antigen (PSA). Outcome measurements and statistical analysisThe endpoint was reclassification to Gleason ≥7. We used receiver operating characteristic (ROC) curve analyses and area under the curve (AUC) to assess discriminatory capacity, and decision curve analysis (DCA) to report clinical net benefit. Results and limitationsSignificant predictors for reclassification were 4Kpanel (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.31–1.81) or PSA (OR 2.11, 95% CI 1.53–2.91), ≥20% cores positive (OR 2.10, 95% CI 1.33–3.32), two or more prior negative biopsies (OR 0.19, 95% CI 0.04–0.85), prostate volume (OR 0.47, 95% CI 0.31–0.70), and body mass index (OR 1.09, 95% CI 1.04–1.14). ROC curve analysis comparing 4K and base models indicated that the 4Kpanel improved accuracy for predicting reclassification (AUC 0.78 vs 0.74) at the first surveillance biopsy. Both models performed comparably for prediction of reclassification at subsequent biopsies (AUC 0.75 vs 0.76). In DCA, both models showed higher net benefit compared to biopsy-all and biopsy-none strategies. Limitations include the single cohort nature of the study and the small numbers; results should be validated in another cohort before clinical use. ConclusionsThe 4Kpanel provided incremental value over routine clinical information in predicting high-grade cancer in the first biopsy after diagnosis. The 4Kpanel did not add predictive value to the base model at subsequent surveillance biopsies. Patient summaryActive surveillance is a management strategy for many low-grade prostate cancers. Repeat biopsies monitor for previously undetected high-grade cancer. We show that a model with clinical variables, including a panel of four kallikreins, indicates the presence of high-grade cancer before a biopsy is performed.

Colonic Polyps: Treatment.

Colonic polyps are considered to be precursors of colon cancer based on several different molecular pathway models and should be resected with a principle of complete excisional biopsy. Several techniques are available for excisional biopsy, ranging from endoscopic techniques such as snare polypectomy, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD) to surgical colonic resection and colonic endolaparoscopic surgery (CELS). This article focuses on these modalities with contemporary recommendations for choice of modality based on the size and features of the polyp encountered upon endoscopy. In addition, the morphologically apparent risk factors for polyps harboring invasive malignancy are discussed along with implications for management. Current literature on the comparative risks and benefits of EMR, ESD, CELS, and surgical resection is reviewed, as well as recommendations regarding cancer risk and subsequent surveillance.

Clinical Outcomes Following Recurrence of Intestinal Metaplasia After Successful Treatment of Barrett's Esophagus With Radiofrequency Ablation.

Radiofrequency ablation (RFA) is an effective treatment for Barrett's esophagus (BE). However, recurrence of BE after initially successful RFA is common, and outcomes following recurrence not well described. We report the outcomes associated with recurrence following initially successful RFA. We performed a retrospective cohort study of 306 patients treated with RFA for dysplastic BE. Complete eradication of intestinal metaplasia (CE-IM) was defined as complete histological and endoscopic remission of IM. Recurrence was defined as any presence of IM or dysplasia in the tubular esophagus or dysplasia in the gastric cardia subsequent to CE-IM. We examined rates and risk factors for recurrence, dysplastic recurrence, and invasive adenocarcinoma after CE-IM. We also describe the clinical course of patients following recurrence. Of the 306 eligible patients undergoing RFA, 218 achieved CE-IM and also had subsequent surveillance endoscopy. Of these, 52 (24%) experienced recurrence of IM or Barrett's-associated neoplasia over 540.6 person-years (incidence rate 9.6%/year). Thirty (58%) of these achieved second CE-IM; 4 (1.8% of total, 7.7% of recurrences) ultimately progressed to invasive adenocarcinoma (incidence rate 0.65%/year). Longer Prague M was a strong risk factor for invasive adenocarcinoma (rate ratio of 1.34/cm). Most dysplastic recurrences were in the cardia, and the majority were not visible but detected on random biopsies. Most patients with recurrent BE after initially successful RFA achieve second CE-IM; however, 1.8% progressed to invasive adenocarcinoma. Longer Prague M was predictive of invasive adenocarcinoma. Four-quadrant random biopsy of the cardia is advisable during surveillance endoscopy after CE-IM.

Autism spectrum disorder reporting in lower socioeconomic neighborhoods.

Utilizing surveillance data from five sites participating in the Autism and Developmental Disabilities Monitoring Network, we investigated contributions of surveillance subject and census tract population sociodemographic characteristics on variation in autism spectrum disorder ascertainment and prevalence estimates from 2000 to 2008 using ordinal hierarchical models for 2489 tracts. Multivariable analyses showed a significant increase in ascertainment of autism spectrum disorder cases through both school and health sources, the optimal ascertainment scenario, for cases with college-educated mothers (adjusted odds ratio = 1.06, 95% confidence interval = 1.02-1.09). Results from our examination of sociodemographic factors of tract populations from which cases were drawn also showed that after controlling for other covariates, statistical significance remained for associations between optimal ascertainment and percentage of Hispanic residents (adjusted odds ratio = 0.93, 95% confidence interval = 0.88-0.99) and percentage of residents with at least a bachelor's degree (adjusted odds ratio = 1.06, 95% confidence interval = 1.01-1.11). We identified sociodemographic factors associated with autism spectrum disorder prevalence estimates including race, ethnicity, education, and income. Determining which specific factors influence disparities is complicated; however, it appears that even in the presence of education, racial and ethnic disparities are still apparent. These results suggest disparities in access to autism spectrum disorder assessments and special education for autism spectrum disorder among ethnic groups may impact subsequent surveillance.

Findings at surveillance colonoscopy following surgery for colorectal cancer.

Colonoscopic surveillance following potentially curative surgery for colorectal cancer aims to detect treatable metachronous neoplasia. The timing and findings of colonoscopies for patients enrolled in an endoscopic surveillance programme were examined in this study. A retrospective clinical audit was undertaken of 174 consecutive patients undergoing surgery for first-presentation colorectal cancer, looking at the findings of subsequent surveillance colonoscopies. Sixty-nine patients were fit for ongoing surveillance, with the median time to first colonoscopy being 14 months, and significant metachronous pathology was identified in 25%, comprising low-risk adenomas, high-risk adenomas, sessile serrated adenomas and one Dukes A carcinoma. Twenty-seven patients underwent a second colonoscopy, with a median interval of 34 months between the investigations, and adenomas were identified in 30% of patients at the second surveillance colonoscopy. All polyps were colonoscopically resectable. Colonoscopy at 1 and 4 years following bowel cancer resection may detect treatable pathology in a significant proportion of those patients fit for ongoing surveillance.

How Many Lymph Nodes Are Enough? Assessing the Adequacy of Lymph Node Yield for Papillary Thyroid Cancer

Patients who undergo surgery for papillary thyroid cancer with only a limited lymph node examination are thought to be at risk for potentially harboring occult disease. However, this risk has not been objectively quantified and may have implications for subsequent management and surveillance. Data from the National Cancer Database (1998 to 2012) were used to characterize the distribution of nodal positivity of adult patients diagnosed with localized ≥ 1-cm papillary thyroid cancer who underwent thyroidectomy with one or more lymph nodes (LNs) examined. A β-binomial distribution was used to estimate the probability of occult nodal disease as a function of total number of LNs examined and pathologic tumor stage. A total of 78,724 patients met study criteria; 38,653 patients had node-positive disease. The probability of falsely identifying a patient as node negative was estimated to be 53% for patients with a single node examined and decreased to less than 10% when more than six LNs were examined. To rule out occult nodal disease with 90% confidence, six, nine, and 18 nodes would need to be examined for patients with T1b, T2, and T3 disease, respectively. Sensitivity analyses limited to patients likely undergoing prophylactic central neck dissection resulted in three, four, and eight nodes needed to provide comparable adequacy of LN evaluation. To our knowledge, our study provides the first empirically based estimates of occult nodal disease risk in patients after surgery for papillary thyroid cancer as a function of primary tumor stage and number of LNs examined. Our estimates provide an objective guideline for evaluating adequacy of LN yield for surgeons and pathologists in the treatment of papillary thyroid cancer, and especially intermediate-risk disease, for which use of adjuvant radioactive iodine and surveillance intensity are not currently standardized.

Interventional Radiology: Interventions and Techniques in Trauma

The purpose of the review was to describe how interventional radiology procedure contribute in the management of the trauma patient, distinguish the situations where evidence has demonstrated improved outcomes with its use, acknowledge the limitations and controversies of the techniques and their place on management algorithms, and mention some particular situations where, despite lack of evidence, the procedures are commonly employed. CT seems to be a better indicator of significant vascular injury with the associated high risks when compared to a discordant negative conventional angiogram. Empiric embolization of the injured segments might improve outcomes in these settings. Finding a subcapsular splenic hematoma in CT is an independent risk factor associated with high rates of NOM failure. Prophylactic interventions are recommended, even in low grade splenic injuries, when a subcapsular splenic hematoma is present. In liver trauma, the injured liver is more susceptible to ischemic injury from arterial embolization with subsequent infarct, biloma, and abscess formation. When needed, angio-embolization should be performed as selective as possible. Subsequent surveillance for ischemic liver injury complications should be instated and, if required, timely therapeutic interventions considered. The initial CT scan findings of “contrast blush” and high-grade solid organ injury are some of the best early predictors for failure of the non-operative management (NOM) in the trauma patient. Endovascular interventions improve the outcomes of NOM when clinical or imaging findings indicate a high risk for continued or delayed hemorrhage. Angio-embolization improves the outcomes of unstable hemorrhagic pelvic fractures and is useful as complement of damage control surgeries or when the surgical interventions fail to control vascular injuries.

Is tapentadol different from classical opioids? A review of the evidence.

Tapentadol is a single molecule able to deliver analgesia by two distinct mechanisms, a feature which differentiates it from many other analgesics. Pre-clinical data demonstrate two mechanisms of action: mu-opioid receptor agonist activity and noradrenaline re-uptake inhibition. From these, one may predict that tapentadol would be applicable across a broad spectrum of pain from nociceptive to neuropathic. The evidence in animal models suggests that norepinephrine re-uptake inhibition (NRI) is a key mechanism and may even predominate over opioid actions in chronic (and especially neuropathic) pain states, reinforcing that tapentadol is different to classical opioids and may, therefore, be an a priori choice for the treatment of neuropathic and mixed pain. The clinical studies and subsequent practice experience and surveillance support the concept of opioid and non-opioid mechanisms of action. The reduced incidence of some of the typical opioid-induced side effects, compared to equianalgesic doses of classical opioids, supports the hypothesis that tapentadol analgesia is only partially mediated by opioid agonist mechanisms. Both the pre-clinical and clinical profiles appear to be differentiated from those of classical opioids.

Outcomes of Active Surveillance after Initial Surveillance Prostate Biopsy

We analyzed the rates of disease reclassification at initial and subsequent surveillance prostate biopsy as well as the treatment outcomes of deferred therapy among men on active surveillance for prostate cancer. From a prospective database we identified 300 men on active surveillance who had undergone initial surveillance prostate biopsy, with or without confirmatory biopsy, within 1 year of diagnosis. Of these men 261 (87%) were classified as having NCCN very low or low risk disease at diagnosis. Disease reclassification on active surveillance was defined as the presence of 50% or more positive cores and/or surveillance prostate biopsy Gleason score upgrading. Patients with type I disease reclassification included those with any surveillance prostate biopsy Gleason score upgrading, while patients with type II reclassification had to have primary Gleason pattern 4-5 disease on surveillance prostate biopsy. Outcomes after initial surveillance prostate biopsy were evaluated using actuarial analyses. At the time of initial surveillance prostate biopsy 49 (16%) and 19 (6%) patients had type I and type II disease reclassification, respectively. Those who underwent confirmatory biopsy had significantly reduced rates of type I (9% vs 23%, p=0.001) and type II (3% vs 9%, p=0.01) reclassification at initial surveillance prostate biopsy. For the 251 patients without disease reclassification at initial surveillance prostate biopsy the 2-year rates of subsequent type I and II reclassification were 17% (95% CI 0-24) and 3% (95% CI 0.1-7), respectively. For the 93 patients who received deferred therapy the 5-year biochemical progression-free probability was 89% (95% CI 79-98), including 95%, 82% and 70% among those without, and those with type I and type II disease reclassification, respectively. Patients on active surveillance with stable disease at the time of initial surveillance prostate biopsy may be appropriate candidates for less intensive surveillance prostate biopsy schedules.

A case of multiple recurrence of Clostridium difficile infection with severe hematochezia in an immunocompromised host

Clostridium difficile infection (CDI) is increasing in incidence and severity. Clinically, diarrhea frequently occurs, but severe hematochezia is rarely seen with CDI. We describe here a hematopoietic stem cell transplantation (HSCT) recipient who experienced life-threatening gastrointestinal bleeding due to severe CDI. Subsequent stool surveillance and molecular typing observed the patient who had two episodes of recurrence with a new strain of C. difficile distinct from the initial infection. We analyze C. difficile strains obtained from the patient, and also discuss the diagnosis and treatment of this case.

PTU-093a An Audit of Primary Prophylaxis Against Variceal Bleeding Amongst Patients with Cirrhosis

Introduction Variceal bleeding occurs in 30–50% of patients with portal hypertension with early mortality (within 6 weeks) after a first variceal bleed approaching 20%. 1 In 2015, the updated BSG guidelines recommend that all patients with cirrhosis should be screened for varices at diagnosis. 1 Primary prophylaxis with non-selective beta-blockers (NSBB) or variceal band ligation (VBL) should be offered to those with grade 2–3 oesophageal varices, or any varices with red signs. Appropriate endoscopic surveillance intervals are recommended for the others. Here, we aim to audit the implementation of these recommendations in our patient cohort. Methods Between January and March 2015, consecutive patients with cirrhosis who attended specialist liver clinics at our institution were included. Clinical, demographic and endoscopic data was collected retrospectively. Results 111 patients (50 alcohol-related liver disease [ARLD], 25 non-alcoholic steatohepatitis [NASH], 25 viral hepatitis and 11 others) were studied. The mean age was 61±12 and 68 (61%) were male. The Child’s-Pugh score was A: 93 (84%), B: 15 (14%) and C: 3 (2%). Upon diagnosis of cirrhosis, 64 (58%) patients underwent endoscopic variceal screening; varices were detected in 37 (34%). Variceal screening at diagnosis was higher amongst NASH (80%) and viral hepatitis (64%) than ARLD (43%). Amongst those with varices (n = 37), primary prophylaxis was warranted in 28 and given in 27 (96%). After initiation, NSBB were rarely titrated according to clinical response. Amongst those requiring interval variceal screening or surveillance (n = 70), 40 (57%) underwent correctly-timed endoscopy. This was higher amongst NASH (71%) and viral hepatitis (69%) than ARLD (24%). Variceal haemorrhage occurred in 7 (6%) patients, 3 (43%) of whom had never undergone any endoscopic screening. Conclusion Our results demonstrate room for greater adherence to the guidelines with regards to initial screening and subsequent surveillance endoscopy. Once varices are identified, primary prophylaxis is initiated in the majority of patients, though with little evidence of subsequent titration to clinical response. Varices screening and appropriate primary prophylaxis is a proposed quality indicator in cirrhosis care. In order to improve quality of care, we highlight the need to perform screening endoscopy at diagnosis, and to titrate primary prophylaxis after initiation. Reference 1 Tripathi D, et al . UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2015; 0 :1–25. Disclosure of Interest None Declared

Patient and Clinician Characteristics Associated with Adherence. A Cohort Study of Veterans with Incidental Pulmonary Nodules.

Many patients are diagnosed with small pulmonary nodules for which professional societies recommend subsequent imaging surveillance. Adherence to these guidelines involves many steps from both clinicians and patients but has not been well studied. In a health care setting with a nodule tracking system, we evaluated the association of communication processes and distress with patient and clinician adherence to recommended follow up and Fleischner Society guidelines, respectively. We conducted a prospective, longitudinally assessed, cohort study of patients with incidentally detected nodules who received care at one Veterans Affairs Medical Center. We measured patient-centered communication with the Consultation Care Measure and distress with the Impact of Event Scale. We abstracted data regarding participant adherence to clinician recommendations (defined as receiving the follow-up scan within 30 d of the recommended date) and clinician adherence to Fleischner guidelines (defined as planning the follow-up scan within 30 d of the recommended interval) from the electronic medical record. We measured associations of communication and distress with adherence using multivariable-adjusted generalized estimating equations. Among 138 veterans, 39% were nonadherent at least once during follow up. Clinicians were nonadherent to Fleischner guidelines for 27% of follow-up scans. High-quality communication (adjusted odds ratio, 3.65; P = 0.02) and distress (adjusted odds ratio, 0.38; P = 0.02) were associated with increased and decreased participant adherence, respectively. Neither was associated with clinician adherence. Patients and clinicians often do not adhere to nodule follow-up recommendations. Interventions designed to improve communication quality and decrease distress may also improve patient adherence to nodule follow-up recommendations.

Overdiagnosis of HSIL on cervical biopsy: errors in p16 immunohistochemistry implementation

In 2012, the lower anogenital squamous terminology (LAST) project introduced new nomenclature for human papillomavirus-related squamous lesions of the lower genital tract: low-grade and high-grade squamous intraepithelial lesion (LSIL and HSIL). Biomarker p16(INK4a) immunohistochemistry (IHC) was also recommended to assist classification: block-like positive staining supports the diagnosis of HSIL. We aim to assess the impact of LAST recommendations on our practice as well as to identify challenges and errors in p16 IHC implementation. We studied 262 cervical biopsies meeting 3 criteria: (1) HSIL diagnosis; (2) p16 IHC performed at time of diagnosis; and (3) patient's follow-up more than 12 months, including cervical cytology, biopsy, and excision. Among these patients, subsequent loop electrosurgical excision procedure and surveillance revealed 163 HSILs (62%), 28 LSILs (11%), and 71 "nondysplastic changes" (27%). We reviewed the latter 2 groups' original hematoxylin and eosin and p16 IHC slides. The diagnosis of HSIL was confirmed in 49 cases (49%), whereas 50 (51%) were reclassified as LSIL (n=46) or negative for dysplasia (n=4). These cases were initially overdiagnosed as HSIL because pathologists (1) overused p16 IHC on unequivocal LSIL (n=27) or (2) upgraded questionable lesions to HSIL based on nonblock p16 staining patterns (patchy or focal, n=23). To implement LAST recommendations successfully, we advocate judicious use of p16 in the designated circumstances and careful interpretation of staining patterns in the context of morphology. A standardized threshold for p16 positivity and supplementary guidance will help clarify the biomarker's utility and will facilitate LAST implementation in routine practice.

Ovarian-Sparing Surgery in Pediatric Benign Ovarian Tumors

Study ObjectiveTo evaluate outcomes of children after ovarian-sparing surgery (OSS) for non-neoplastic and benign neoplastic ovarian lesions. DesignRetrospective cohort study from January 2003 to January 2012. SettingSingle, high-volume, tertiary care hospital. ParticipantsChildren 18 years of age and younger. InterventionsNone. Main Outcome MeasuresPostoperative complications and tumor recurrence after OSS. ResultsOne hundred nine patients underwent OSS with a median age of 13.3 years (interquartile range [IQR], 11.4-15.1 years). Eighty-two patients were treated laparoscopically with 4 conversions to an open procedure. Postoperative complications included surgical site infections in 7 patients (6%). Pathology most commonly revealed functional ovarian cysts (n = 57) and mature teratomas (n = 37). Ninety-four patients (86%) were followed for a median of 10.4 months (IQR, 0.72-30.8 months). Fifty-five patients (60%) had subsequent imaging surveillance a median of 7.6 months postoperatively (IQR, 3.9-13 months). Ten patients (10%) developed a second ipsilateral lesion within a median time of 11 months (IQR, 7.7-24 months), of whom 5 girls had repeated surgery for mass enlargement or persistent abdominal pain at a median time of 10.5 months (IQR, 8.0-12.65 months). Fifty-eight patients (63%) began or resumed menses at their most recent follow-up. Three girls became pregnant after OSS at a median follow-up of 5 years (range, 2.4-6.7 years). ConclusionBenign ovarian lesions in children can be treated successfully with OSS with low recurrence and repeat surgery rates.

Association between adenoma location and risk of recurrence

The biological environment varies across the colorectum and may therefore affect neoplastic growth differently in the proximal and distal colon. The aim of the study was to evaluate the risk for recurrent adenomas and their anatomic location based on adenoma location at baseline colonoscopy. Data were extracted from 3 adenoma prevention trials (n= 2430). Participants had at least 1 adenoma at baseline colonoscopy and underwent subsequent surveillance colonoscopy, at which time metachronous adenomas could be detected. We calculated the risk ratio (RR) and the 95% confidence interval (CI) for metachronous adenomas by location of the baseline lesion and considered the impact of advanced neoplasia and multiplicity. At baseline, 522 patients (21.5%) had adenomas only in the proximal colon, 1266 patients (52.1%) had adenomas only in the distal colorectum, and 642 (26.4%) had adenomas in both regions. Overall, 877 patients (36.5%) had metachronous adenomas during the follow-up period. Those with only proximal adenomas at baseline had a higher risk of metachronous adenomas compared with patients with only distal adenomas (RR, 1.17; 95% CI, 1.01-1.35). A greater proximal risk was found after restricting the analysis to patients with multiple proximal adenomas versus multiple distal adenomas (RR, 1.35; 95% CI, 1.10-1.67). The risk of recurrent adenomas on the same side was 48% higher for patients with only proximal adenomas at baseline compared with those with only distal adenomas at baseline (RR, 1.48; 95% CI, 1.22-1.80). Patients with proximal adenomas only have a modestly greater risk of adenoma recurrence than patients with adenomas limited to the distal colon, and have a greater likelihood of adenoma recurrence on the same side compared with patients with distal adenomas. This observation suggests that biological factors may differentially affect neoplasia growth across the colon.

Abstract B64: Hepatocellular carcinoma characteristics and outcomes among Somali immigrants

Abstract Background: Hepatocellular Carcinoma (HCC) is the 6th most common cancer and the 2nd leading cause of cancer-related mortality in the world. Sub-Saharan Africa and Eastern Asia are regions endemic for viral hepatitis, accounting for 80% of all HCC cases worldwide. A recent hospital-based study assessing the frequency of hepatitis B (HBV), hepatitis C (HCV), and HCC among Somali immigrants seen at Mayo Clinic determined the adjusted frequency for HBsAg positivity was 10-fold higher and anti-HCV positivity was 3-fold higher as compared to non-Somali residents of Olmsted County, Minnesota. Furthermore, HCV infection was identified as the leading contributor to HCC development among Somalis. The overall goal of this study is to determine the risk factors, surveillance, treatment options, and outcomes of Somalis with HCC seen at Mayo Clinic. Methods: The Mayo Clinic Unified Data Platform Advanced Cohort Explorer (ACE) query tool was used to identify Somali patients seen at Mayo Clinic from March 1, 1998 to March 31, 2015. Clinical notes were searched in ACE using conjunction and disjunction combinations: the terms Somali, Somalia or Somalian were linked with the terms HCC, Hepatocellular Carcinoma or Liver Cancer. Diagnosis was validated using histopathology and/or imaging reports from the electronic medical record (EMR). To confirm the ethnicity of identified patients, names were screened by author HMA who is of Somali heritage. Variables abstracted from the EMR include demographics, etiology of HCC, diagnosis date, date of death or last contact, Child-Turcotte-Pugh class, Barcelona Clinic Liver Cancer (BCLC) stage, comorbid conditions, initial and subsequent treatments, HCC surveillance, cirrhosis and other malignancies. Results: 54 Somali patients diagnosed with HCC were seen at Mayo Clinic from March 1, 1998 to March 31, 2015. The mean age was 63±16.3 and 36 (67%) individuals were male. Thirty-eight (70%) of the 54 HCC patients had HCV, 14 (26%) had HBV, 1 (2%) had non-alcoholic steatohepatitis (NASH), and 1 (2%) had unknown etiology for HCC. Of those with known HCV genotypes, the most common were genotype 4 (45%) and 3 (35%). At the time of HCC diagnosis, 16 (32%) presented with BCLC stage A, 5 (10%) with stage B, 17 (34%) with stage C, and 12 (24%) with stage D. Of the 54 patients, 43 (80%) had cirrhosis, 15 (28%) had vascular invasion, and 10 (19%) had metastatic HCC. Regarding treatment, 12 (22%) patients received curative treatment while 42 (78%) received palliative treatment. Orthotopic liver transplantation (OLT) was received by 3 (6%) of Somali patients compared to 19% of non-Somali HCC patients seen at Mayo Clinic between 2007 and 2009. HCC was detected during surveillance in 11 (20%) Somali HCC patients; of the 11, 2 (4%) received semiannual surveillance. Conclusions: These findings provide a starting point to address liver cancer disparities among Somalis. HCV genotype 4 was most commonly associated with HCC development among the study population. Due to low surveillance rates, more Somalis presented with end-stage liver disease. Furthermore, advanced stage HCC was disproportionately found among Somalis compared to the general North American population. A recent study demonstrated that 11% of North American HCC patients seen at 4 major medical centers presented with stage D. By contrast, our study found 25% of Somalis had Stage D HCC. As a result, Somalis are more likely to receive palliative rather than curative treatments. Improving the identification of individuals with chronic HBV or HCV who are at increased risk for HCC and implementing more comprehensive HCC surveillance is likely to reduce the burden of HCC among this population. Citation Format: Hawa M. Ali, Nasra H. Giama, Hager Ahmed Mohammed, Essa A. Mohamed, Ju Dong Yang, Abdirashid M. Shire, Lewis R. Roberts. Hepatocellular carcinoma characteristics and outcomes among Somali immigrants. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B64.