Pelvic soft tissue sarcomas Sarre-Lazcano, Catherine; Dumitra, Sinziana; Fiore, Marco
European journal of surgical oncology,
June 2023, 2023-06-00, 20230601, Volume:
49, Issue:
6
Journal Article
Peer reviewed
Pelvic soft tissue sarcomas (PSTS) are a rare, heterogeneous group of tumors. They have been usually analyzed with retroperitoneal sarcomas (RPS), but actually have key differences. Due to their ...unique anatomic location, symptomatic presentation of PSTS may be more common than RPS. Adequate imaging approach is paramount for guiding differential diagnosis, while preoperative biopsy is mandatory, especially when preoperative treatment may be considered as initial approach. The most frequent histologic subtype is leiomyosarcoma, which is different as expected in the retroperitoneum where liposarcoma is the commonest histology. Also solitary fibrous tumor is commonly diagnosed in the pelvis. Surgical approach for PSTS differs from that for RPS mainly due to anatomic relations. Similarly, in the lack of definite evidence from specific trials about neoadjuvant and adjuvant treatments, the anatomic constraints to obtain wide margins in the pelvis as well as the expected functional outcome in case of organ resections should be factored into decision for individualized treatment offer. Vascular and genitourinary involvement are frequent, as well as herniation through pelvic foramina. For these reasons a multidisciplinary surgical team should always be considered. Early referral of these patients to high-volume centers is critical and may impact on survival, given that optimal initial resection is a major predictor of curative treatment. International consensus on PSTS treatment is advocated, similarly to the recent efforts realized for RPS.
-Adequate imaging and biopsy are crucial for diagnosis and planning surgical approach-Histologic subtypes are different in pelvic sarcomas compared to retroperitoneal-Multimodal treatment is frequently adopted at referral centers-Pelvic anatomy impacts functional outcome and decision for preoperative therapy-Benefit from referral to high volume centers and histology driven tailored approach
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background The operative dictation (OD) is the cornerstone of surgical communication, yet there appears to be a lack of formal education of this skill by training programs. We conducted a review of ...the literature to assess the teaching and quality of OD in surgical residency programs. Study Design Multiple databases were searched for studies pertaining to “OD,” “surgical education,” and “formal teaching.” Of 50 the studies, 13 were retained and assigned to one or more of the following categories: (1) surveys of the surgical community evaluating current perceptions of formal OD education ( n = 5), (2) studies assessing the quality of OD performed by residents ( n = 5), and (3) educational interventions for improving OD skills ( n = 4). Results (1) Between 12% and 25% of survey respondents reported formal teaching of OD skills in their surgical programs. Surveyed residents and program directors were in favor of the implementation of structured teaching 60% to 91% of the time. (2) Multiple studies demonstrated significant deficiencies in residents’ ODs, with key information missing in up to 76% of cases. The completeness of OD did not consistently correlate with level of training. (3) In one of the studies, a formal educational session was found to improve OD quality scores (p < 0.001). In 2 studies, the use of synoptic report maximized the completion rate of OD up to 92% from less than 70%. Synoptic reports were significantly more complete than conventional ODs with regard to general information (p < 0.001) and procedural aspects (p < 0.001). A single randomized trial demonstrated an improvement in junior residents’ ODs after the implementation of a template (p = 0.02). Conclusion Current evidence suggests that only a small proportion of residency programs offer formal OD instruction, despite a demonstrable need for improvement in residents’ OD skills. Educational interventions and synoptic reporting present possible solutions, although this continues to be an area of evolving interest.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
AIM:To evaluate the ability of the McGill Brisbane Symptom Score(MBSS)to predict survival in resectable pancreatic head adenocarcinoma(PHA)patients.METHODS:All PHA patients(n=83)undergoing ...pancreaticoduodenectomy at the McGill University Health Center,Quebec between 1/2001-1/2010 were evaluated.Data related to patient and cancer characteristics,MBSS variables,and treatment were collected;univariable and multivariable survival analyses were performed.We obtained complete follow-up until February 2011 in all patients through the database of the provincial health insurance plan of Quebec.The unique health insurance numbers of these patients were used to retrieve information from this database which captures all billable clinical encounters,and ensures 100%actual survival data.RESULTS:Median survival was 23 mo overall:45 mo for patients with low MBSS,17 mo for high MBSS(P=0.005).At twelve months survival was 83.3%(95%CI:66.6-92.1)vs 58.1%(95%CI:42.1-71.2)in those with low vs high MBSS,and24 mo survival was 63.8%(95%CI:45.9-77.1)and 34.0%(95%CI:20.2-48.2)respectively.In the multivariate Cox model(stratified by chemotherapy),after addition of clinically meaningful covariates,MBSS was the variable with the strongest association with survival(HR=2.63;P=0.001).Adjuvant chemotherapy interacted with MBSS category such that only high MBSS patients accrued a benefit.In univariate analysis we found a lower mortality in high MBSS but not low MBSS patients receiving adjuvant chemotherapy.This interaction variable,on Cox model,resulted in an adjusted mortality HR for the high MBSS(compared to low MBSS)of 4.14(95%CI:1.48-11.64)without chemotherapy and 2.11(95%CI:1.06-4.17)with chemotherapy.CONCLUSION:The MBSS is a simple prognostic tool for resectable PHA.Preoperative categorization of patients according to the MBSS allows effective stratification of patients to guide therapy.
Summary In 2012 Quebec limited continuous in-hospital duty to 16 consecutive hours for all residents regardless of postgraduate (PGY) level. The new restrictions in Quebec appeared to have a ...profound, negative effect on the quality of life of surgical residents at McGill University and a perceived detrimental effect on the delivery of surgical education and patient care. Here we discuss the results of a nationwide survey that we created and distributed to general surgery residents across Canada to capture and compare their perceptions of the changes to duty hour restrictions.
IMPORTANCE: A combined subjective and objective wireless monitoring program of patient-centered outcomes can be carried out in patients before and after major abdominal cancer surgery. OBJECTIVE: To ...conduct a proof-of-concept pilot study of a wireless, patient-centered outcomes monitoring program before and after major abdominal cancer surgery. DESIGN, SETTING, AND PARTICIPANTS: In this proof-of-concept pilot study, patients wore wristband pedometers and completed online patient-reported outcome surveys (symptoms and quality of life) 3 to 7 days before surgery, during hospitalization, and up to 2 weeks after discharge. Reminders via email were generated for all moderate to severe scores for symptoms and quality of life. Surgery-related data were collected via electronic medical records, and complications were calculated using the Clavien-Dindo classification. The study was carried out in the inpatient and outpatient surgical oncology unit of one National Cancer Institute–designated comprehensive cancer center. Eligible patients were scheduled to undergo curative resection for hepatobiliary and gastrointestinal cancers, were English speaking, and were 18 years or older. Twenty participants were enrolled over 4 months. The study dates were April 1, 2015, to July 31, 2016. MAIN OUTCOMES AND MEASURES: Outcomes included adherence to wearing the pedometer, adherence to completing the surveys (MD Anderson Symptom Inventory and EuroQol 5-dimensional descriptive system), and satisfaction with the monitoring program. RESULTS: This study included a final sample of 20 patients (median age, 55.5 years range, 22-74 years; 15 75% female) with evaluable data. Pedometer adherence (88% 17 of 20 before surgery vs 83% 16 of 20 after discharge) was higher than survey adherence (65% to 75% 13 of 20 and 15 of 20 completed). The median number of daily steps at day 7 was 1689 (19% of daily steps at baseline), which correlated with the Comprehensive Complication Index, for which the median was 15 of 100 (r = −0.64, P < .05). Postdischarge overall symptom severity (2.3 of 10) and symptom interference with activities (3.5 of 10) were mild. Pain (4.4 of 10), fatigue (4.7 of 10), and appetite loss (4.0 of 10) were moderate after surgery. Quality-of-life scores were lowest at discharge (66.6 of 100) but improved at week 2 (73.9 of 100). While patient-reported outcomes returned to baseline at 2 weeks, the number of daily steps was only one-third of preoperative baseline. CONCLUSIONS AND RELEVANCE: Wireless monitoring of combined subjective and objective patient-centered outcomes can be carried out in the surgical oncology setting. Preoperative and postoperative patient-centered outcomes have the potential of identifying high-risk populations who may need additional interventions to support postoperative functional and symptom recovery.
Breast cancer staging has been developed to quantify prognosis and guide treatment. The American Joint Committee on Cancer eighth edition manual (AJCC8) departed from traditional anatomic staging by ...incorporating biological factors such as grade, hormone and HER2 receptor status into a novel prognostic staging model. The aim of this study was to externally validate AJCC8 prognostic staging.
This retrospective cohort investigated patients diagnosed between 2010 and 2013 at the McGill University Health Center. Patients were classified using both anatomic and prognostic staging systems according AJCC8. Overall survival analysis using a multivariate Cox-proportional hazard model was performed and model accuracy was evaluated using the Harrell concordance index (C-index) and Akaike Information Criterion (AIC).
The cohort included 1703 women. Anatomic and prognostic stage assignments displayed discrepancies for 46.2% of patients, where 38.8% were downstaged and 7.5% were upstaged with prognostic staging. Patients with anatomic stages IB, IIA, IIB, IIIA and IIIC had high rates of downstaging (64.6–96.5%), as opposed to anatomic stages IA and IIIB where 93.1% and 75.0% of patients stage remained unchanged, respectively. The prognostic stage displayed increased prognostic accuracy with respect to overall survival, where the C-index was significantly higher compared to anatomic staging (0.810 vs 0.799, p < 0.05). In addition, prognostic staging displayed an improved model fit with a lower AIC (983.9) compared to anatomic staging (995.2).
Prognostic and anatomic staging differ in their classification of patients, where prognostic staging displays improved accuracy, supporting its use in informing patient prognosis and guiding treatment decisions.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract only
e22076
Background: The MSLT-II trial demonstrated no survival benefit of completion lymphadenectomy (CLND) compared to nodal observation (NO) and subsequent therapeutic lymphadenectomy ...(TLND) in the case of macroscopic nodal relapse in patients with melanoma and SLN metastases. NO avoids the upfront cost and morbidity of CLND. However, patients followed with NO must undergo intensive surveillance and if TLND is required, it is associated with a higher complication rate than CLND. The cost-effectiveness of NO versus CLND in light of data from MSLT-II has not been previously studied. Methods: A Markov model with a 10-year time horizon was constructed to simulate two hypothetical cohorts of patients with SLN metastases undergoing NO and subsequent TLND for nodal recurrence or upfront CLND. Transition probabilities between disease states were derived from the MSLT-II trial. Remaining parameters including complication rates and health state utilities were obtained from an extensive review of the literature. Direct health care system costs were obtained from published US Medicare cost data and the literature. Primary outcomes were cost and quality-adjusted life years (QALYs) saved. Incremental cost-effectiveness ratio (ICER) was used to compare treatment strategies. Sensitivity analysis was performed in order to evaluate model uncertainty. A threshold of acceptance of $100,000/QALY was used. Results: Total projected cost over the study period for CLND was $28,609.87, while that of NO was lower at $20,865.27, resulting in $7,744.60 saved for the NO treatment strategy. Ten-year utility was 4.840 for CLND compared to 5.379 for NO, resulting in a gain of 0.539 QALYs in the NO arm. The NO strategy is dominant in the model as it results in both cost-savings and a gain in health effects, with an average ICER of -$14,368.46/QALY gained. Conclusions: From the payer perspective, the strategy of NO compared to CLND in patients with melanoma and SLN metastases is associated with an improvement in health outcomes and reduction in cost. Taking into account MSLT-II trial data, this study demonstrates NO is more cost-effective than CLND.
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