Attaining a successful career in cancer surgery depends on many choices. In this paper based on the Letton Lecture from the 2023 Southeastern Surgical Conference, Dr. Jennifer Tseng reflects on the ...choices that enabled her current work.
2023 A. Hamblin Letton Lecture Tseng, Jennifer F.
The American surgeon,
07/2023, Letnik:
89, Številka:
7
Journal Article
Recenzirano
Odprti dostop
For this lecture, I was inspired by Dr. Bryan Richmond’s Southeastern Surgical Congress presidential address, “Finding your own unique place in the house of surgery.” I struggled to find my own place ...in cancer surgery. The choices available to me and those who came before me enabled the wonderful career I am blessed to enjoy. What I share as part of my own story. My words do not represent those of my institutions or any organizations of which I am privileged to belong.
This manuscript is the result of the North American Neuroendocrine Tumor Society consensus conference on the surgical management of pancreatic neuroendocrine tumors from July 19 to 20, 2018. The ...group reviewed a series of questions of specific interest to surgeons taking care of patients with pancreatic neuroendocrine tumors, and for each, the available literature was reviewed. What follows are these reviews for each question followed by recommendations of the panel.
This 2019 Presidential Address for the Society of Asian Academic Surgeons was delivered on September 27, 2019. Using anecdotes from her upbringing, Dr. Jennifer Tseng offers a visionary perspective ...on belonging and inclusivity in academic surgery. She concludes with practical strategies for success drawn from these experiences.
Background Neoadjuvant therapy is an emerging paradigm in pancreatic cancer care; however, its role for resectable disease remains controversial in the absence of conclusive randomized controlled ...trials. The purpose of the present study is to assess the impact of neoadjuvant therapy on survival in resected pancreatic cancer patients by clinical stage. Methods A retrospective cohort study using the National Cancer Data Base from 2004 to 2012 including nonmetastatic pancreatic adenocarcinoma patients who underwent pancreatectomy and initiated chemotherapy. Propensity score matching within each stage was used to account for potential selection bias between patients undergoing neoadjuvant therapy and upfront surgery. Overall survival was compared by the Kaplan-Meier method. Results In the study, 1,541 and 7,159 patients received neoadjuvant therapy followed by surgery and upfront surgery succeeded by adjuvant therapy, respectively. In clinical stage III pancreatic cancer ( n = 486), neoadjuvant therapy was associated with significant survival benefit after matching (median survival 22.9 vs 17.3 months; log-rank P < .0001) compared with conventional upfront surgery followed by adjuvant therapy; however, no survival difference was found between the 2 treatment sequences in patients with clinical stage I ( n = 3,149; median survival, 26.2 vs 25.7 months; P = .4418) and II ( n = 5,065; median survival, 23.5 vs 23.0 months; P = .7751) disease after matching. Conclusion The survival impact of neoadjuvant therapy is stage-dependent. Neoadjuvant therapy does not disadvantage survival compared with conventional upfront surgery followed by adjuvant therapy in any stage, and is associated with a significant survival advantage in stage III pancreatic cancer.
Introduction
Pancreaticoduodenectomy is one of the more complicated operations that exists in surgery, and is fraught with potential morbidity, the most well-known, and dreaded, of which is the ...pancreatic leak. While much of the risk associated with pancreatic leak is inherent to the operation, there have been no shortage of techniques employed by surgeons to try to mitigate that risk.
Methods
We focused on four topics of greatest conjecture with regard to reconstruction after pancreaticoduodenectomy: (1) the type of anastomosis, (2) the enteral organ to which the pancreas is sewn, (3) whether to preserve the pylorus and (4) whether or not to use anastomotic silastic stents. We identified the most relevant randomized control trials on each topic, which were appropriately powered.
Results
We identified a total of 15 studies for evaluation, (type of anastomosis:
n
= 4; enteral organ to which the pancreas is sewn:
n
= 4; whether to preserve the pylorus, n=3; and whether or not to use anastomotic silastic stents,
n
= 4). In each group of comparisons, there was no definitive conclusion to be made on superiority of reconstruction.
Conclusion
While clear consensus on how best to reconstruct the anatomy after pancreaticoduodenectomy has not yet been reached, we present the following review in the hope of providing some understanding of the literature for the pancreatic surgeon.
IMPORTANCE: The recently released eighth edition of the American Joint Committee on Cancer TNM staging system for pancreatic cancer seeks to improve prognostic accuracy but lacks international ...validation. OBJECTIVE: To validate the eighth edition of the American Joint Committee on Cancer TNM staging system in an international cohort of patients with resected pancreatic ductal adenocarcinoma. DESIGN, SETTING, AND PARTICIPANTS: This international multicenter cohort study took place in 5 tertiary centers in Europe and the United States from 2000 to 2015. Patients who underwent pancreatoduodenectomy for nonmetastatic pancreatic ductal adenocarcinoma were eligible. Data analysis took place from December 2017 to April 2018. EXPOSURES: Patients were retrospectively staged according to the seventh and eighth editions of the TNM staging system. MAIN OUTCOMES AND MEASURES: Prognostic accuracy on survival rates, assessed by Kaplan-Meier and multivariate Cox proportional hazards analyses and concordance statistics. RESULTS: A total of 1525 consecutive patients were included (median IQR age, 66 (58-72) years; 802 (52.6%) male). Distribution among stages via the seventh edition was stage IA in 41 patients (2.7%), stage IB in 42 (2.8%), stage IIA in 200 (13.1%), stage IIB in 1229 (80.6%), and stage III in 12 (0.8%); this changed with use of the eighth edition to stage IA in 118 patients (7.7%), stage IB in 144 (9.4%), stage IIA in 22 (1.4%), stage IIB in 643 (42.2%), and stage III in 598 (39.2%). With the eighth edition, 774 patients (50.8%) migrated to a different stage; 183 (12.0%) were reclassified to a lower stage and 591 (38.8%) to a higher stage. Median overall survival for the entire cohort was 24.4 months (95% CI, 23.4-26.2 months). On Kaplan-Meier analysis, 5-year survival rates changed from 38.2% for patients in stage IA, 34.7% in IB, 35.3% in IIA, 16.5% in IIB, and 0% in stage III (log-rank P < .001) via classification with the seventh edition to 39.2% for patients in stage IA, 33.9% in IB, 27.6% in IIA, 21.0% in IIB, and 10.8% in stage III (log-rank P < .001) with the eighth edition. For patients who were node negative, the T stage was not associated with prognostication of survival in either edition. In the eighth edition, the N stage was associated with 5-year survival rates of 35.6% in N0, 20.8% in N1, and 10.9% in N2 (log-rank P < .001). The C statistic improved from 0.55 (95% CI, 0.53-0.57) for the seventh edition to 0.57 (95% CI, 0.55-0.60) for the eighth edition. CONCLUSIONS AND RELEVANCE: The eighth edition of the TNM staging system demonstrated a more equal distribution among stages and a modestly increased prognostic accuracy in patients with resected pancreatic ductal adenocarcinoma compared with the seventh edition. The revised T stage remains poorly associated with survival, whereas the revised N stage is highly prognostic.
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