Abstract Background Lymph node positivity is a strong prognostic indicator in many cancers including gastric cancer. The extent of surgical resection directly influences the number of lymph nodes ...available for staging, with the lesser D1 resection that is standard practice in non-Asian countries typically providing fewer nodes for analysis. The widely used AJCC TNM staging system has been criticized for under-staging and stage migration where fewer than 15 nodes are resected, which is often the case in these populations. The ratio of positive to total nodes harvested – Lymph Node Ration (LNR) – has been proposed as an improved and more widely applicable prognostic indicator. Hypothesis The LNR is a reliable and accurate prognostic indicator of survival in a Western gastric cancer population. Methods 9357 patients were acquired via a SEER case listing session with 2004–2011 gastric adenocarcinoma diagnoses. AJCC 7th edition nodal staging (N0: 0, N1:1–2, N2:3–6, N3:≥7 positive lymph nodes) and LNR positive nodal staging (PN0: 0%, PN1: 1–20%, PN2: 21–50%, PN3: 51–100% of examined nodes positive) were compared as respects seven year survivorship. Results Adjusted survival time ratios for AJCC nodal curves were less evenly distributed than were the percent positive nodal curves. Results of multiple regression reflected that survival time ratios of the percent positive nodal schema being more evenly spaced than those of the AJCC schema. Because BIC for AJCC, 41071.48, was larger than that for percent positive nodes, 41024.25, the LNR nodal system better explained survival than the AJCC nodal classification system. Conclusion LNR produced reliable and internally consistent survival curves for this population. LNR is an effective tool to predict survival in a western gastric cancer patient population, where the majority of the patients have limited lymph node dissection.
Introduction
While minimally invasive surgery (MIS) is frequently utilized to remove small gastric gastrointestinal stromal tumors (GIST), MIS surgery for tumors ≥ 5 cm is currently not endorsed by ...national guidelines as standard of care due to concerns of safety and inferior oncologic outcomes. Hence this study investigates the perioperative and long-term outcomes of MIS for T3 gastric GIST measuring 5–10 cm.
Methods
The National Cancer Database (NCDB) 2017 was queried for gastric GIST measuring 5–10 cm or T3 category. Inclusion criteria were known: stage, size, comorbidities, grade, lymphovascular invasion, type of surgery, approach, conversion info, margin status, mitotic rate, neoadjuvant and adjuvant treatment, hospital stay, readmission, 30- and 90-day mortality, complete follow-up, type of institution, and hospital gastric surgery case volume. Binary logistic regression, linear regression models, and Kaplan–Meier survival analysis were used.
Results
In 3765 patients, mean tumor size was 67.3 mm; 26.3% MIS; and 73.8% open. Median hospital stay was shorter for MIS (4.77 vs 7.04 days,
p
< 0.001). There was no significant difference in incidence of R1 margins 2.9% MIS vs. 3.1% open (
p
= 0.143), unplanned readmission 2.9% MIS and 4.1% open (OR 0.474
p
= 0.025), 30-day mortality 0.5% MIS vs 1.2% open (OR 0.325,
p
= 0.031), and 90-day mortality 0.9% MIS vs 2.1% open (OR 0.478
p
= 0.036). Cox regression models for OS showed no difference in survival (
p
= 0.137, HR 0.808).
Conclusion
This analysis provides substantial evidence that MIS for gastric GIST ≥ 5–10 cm may not only offer improved postoperative morbidity but also oncologic safety. Moreover, as both approaches lead to similar long-term survival, national guidelines may need to incorporate this new information.
Graphical abstract
Background
While it has been shown that neoadjuvant chemotherapy (NCT) for pancreatic cancer (PDAC) undergoing pancreaticoduodenectomy (PD) is critical for optimal oncologic management, NCT is (A) ...not universally practiced and (B) the reasons ill-defined. This study investigates national rates, trends, and factors affecting NCT utilization.
Patients and Methods
Using the National Cancer Database, patients who underwent PD for PDAC between 2006 and 2017 were identified. Changes in chemotherapy sequence over time were identified. For patients diagnosed after 2010, multivariable logistic regression models for factors affecting NCT were created.
Results
A total of 128,980 patients were diagnosed and 23,206 underwent surgery. Three thousand five (12.9%) received NCT with a preoperative chemotherapy (NCT + PCT) utilization rate of 7.3% in 2004 that increased to 36.8% in 2017. Factors affecting utilization of preoperative chemotherapy were age (OR 0.972), academic and integrated network institutions (OR 1.916, OR 1.559), institutional case volume (OR 1.007), distance from the hospital (OR 1.002), stage (IB OR 3.108, IIA OR 3.133, IIB OR 3.775, III OR 3.782), grade IV (OR 1.977), and insurance status (private OR 2.371, Medicaid OR 1.811, and Medicare OR 2.191, government OR 2.645).
Conclusion
Even though more than 3/5 of patients receive no preoperative chemotherapy (NCT + PCT) and nearly 1/5 of patients still receive no chemotherapy at all, utilization of NCT is increasing. Moreover, since this study demonstrates that omission of NCT is associated with modifiable factors such as type of institution and health care disparity, mechanisms (reimbursement, policy) geared to change current national practice patterns may most immediately affect optimal oncologic management.
Background
While preoperative chemotherapy for patients with stage II-III pancreatic adenocarcinoma (PDAC) is frequently practiced, its impact on very early PDAC (stage I) remains unclear today.
...Material and Methods
Patients undergoing pancreatectomy for PDAC between 2010 and 2016 were identified in the National Cancer Database. Early-stage patients (IA-IB) with complete oncologic and clinical information and more than 30-day survival were included. The effect of preoperative chemotherapy on margin status was assessed with binary logistic regression. Following correction for confounders, the effect of therapy sequencing was assessed via comparison of preoperative, postoperative, perioperative (pre- and post-operative) chemotherapy, and surgery only using Cox regression.
Results
Of 4785 patients, 688 (14.4%) were stage IA, and 4197 (87.7%) IB. The rate of preoperative chemotherapy was only 8.8%. Rate of margin positivity was lower for preoperative chemotherapy (12.3% vs 19.7%). After correcting for confounders, the risk of a positive margin was lower in preoperative chemotherapy (odd ratio OR 0.703,
p
= 0.042). Cox regression showed a significant overall survival advantage for preoperative (hazard ratio HR 0.784,
p
= 0.002), postoperative (HR 0.618,
p
< 0.001), and perioperative (HR 0.601,
p
< 0.001) chemotherapy compared with surgery alone. There was no significant difference in survival between chemotherapy groups but a trend towards optimal survival for preoperative chemotherapy.
Conclusion
Despite preoperative chemotherapy vs surgery alone resulting in improved R0 rates and overall survival even in stage I PDAC, it is rarely practiced. The results presented here suggest that preoperative chemotherapy should be strongly considered in all patients with resectable PDAC, including very early PDAC.
To determine if laparoscopic pancreaticoduodenectomy (LPD) is safe and offers benefits over open pancreaticoduodenectomy (OPD) at institutions with lower pancreaticoduodenectomy (PD) volume.
Although ...a hospital-based case volume-outcome relationship for morbidity, mortality, and oncologic quality has been reported for OPD, comparative trends for LPD have yet to be investigated.
A total of 4739 patients with complete data were identified in National Cancer Data Base between 2010 and 2011; 4309 patients had OPD and 430 patients had LPD. Institutions were categorized into quartiles based on PD case volume. For the entire cohort and within each quartile, LPD and OPD were compared for 30-day and 90-day mortality, length of hospital stay, 30-day unplanned readmission rate, and margin status. Binary logistic regression, linear regression, and propensity score matching was performed.
Hospitals with low PD case volume (≤25 PDs per year; 91% of all hospitals in the US and 25% of cases) had the highest 30- and 90-day mortality, highest margin positivity rates, and lowest lymph node counts. These trends were more pronounced in the LPD group. Only in the highest-volume hospitals was LPD associated with shorter hospital stay and lower readmission compared with OPD.
These findings confirm that risks of postoperative mortality and suboptimal oncologic surgical quality following PD are higher in low-volume hospitals. Furthermore, these risks are more profound with LPD compared with OPD. These data suggest that the putative benefits of LPD are unlikely to be observed in institutions performing ≤25 PDs per year.
Background
While minimally invasive liver resection (MILR) vs. open approach (OLR) has been shown to be safe, the perioperative and oncologic safety for intrahepatic cholangiocarcinoma (ICC) ...specifically, necessitating often complex hepatectomy and extended lymphadenectomy, remains ill-defined.
Methods
The National Cancer Database was queried for patients with ICC undergoing liver resection from 2010 to 2016. After 1:1 Propensity Score Matching (PSM), Kruskal–Wallis and
χ
2
tests were applied to compare short-term outcomes. Kaplan–Meier survival analyses and Cox multivariable regression were performed.
Results
988 patients met inclusion criteria: 140 (14.2%) MILR and 848 (85.8%) OLR resulting in 115 patients MILR and OLR after 1:1 PSM with c-index of 0.733. MILR had lower unplanned 30-day readmission OR 0.075,
P
= 0.014 and positive margin rates OR 0.361,
P
= 0.011 and shorter hospital length of stay (LOS) OR 0.941,
P
= 0.026, but worse lymph node yield 1.52 vs 2.07,
P
= 0.001. No difference was found for 30/90-day mortality. Moreover, multivariate analysis revealed that MILR was associated with poorer overall survival compared to OLR HR 2.454,
P
= 0.001. Subgroup analysis revealed that survival differences from approach were dependent on major hepatectomy, tumor size > 4 cm, or negative margins.
Conclusion
MILR vs. OLR is associated with worse lymphadenectomy and survival in patients with ICC greater than 4 cm requiring major hepatectomy. Hence, MILR major hepatectomy for ICC should only be approached selectively and if surgeons are able to perform an appropriate lymphadenectomy.
Background
The safety and oncologic outcomes of patients with advanced cirrhosis undergoing laparoscopic liver resection (LLR) compared to open resection (OLR) for hepatocellular carcinoma (HCC) ...remain unclear.
Methods
Patients with HCC resection during 2010–2014 were identified from the National Cancer Database. Patients with severe fibrosis; single lesions; M0; and known grade, margin status, tumor size, length of hospital stay, 30- and 90-day mortality, 30-day readmission, surgical approach, and complete follow-up were included. A 1:1 propensity score matching analysis of LLR:OLR was performed. Prognostic effect of LLR was assessed by multivariable Cox proportional hazards model.
Results
A total of 1799 hepatectomy patients (minor (
n
= 491, 27.3%); major (
n
= 1308, 72.7%)) were included. Of 193 (10.7%) LLR patients, 190 were eligible for matching. The LLR vs OLR did not differ for patient characteristics, resection margin status, and 30-day (
p
= 0.141), 90-day mortality (
p
= 0.121), or 30-day readmission (
p
= 0.784). Median hospital stay was shorter for LLR (6 vs 8 days,
p
= 0.001). Median overall survival (OS) was similar for LLR vs OLR (44.2 and 39.5 months, respectively,
p
= 0.064). Predictors of worse OS were older age (hazard ratio (HR) 1.04,
p
= 0.034), > 2 comorbidities (HR 1.29,
p
= 0.012), grade 3–4 disease (HR 1.81,
p
= 0.025), N1 disease (HR 1.04,
p
= 0.048), and R1 margins (HR 1.34,
p
= 0.002). After adjustment for confounders, LLR vs OLR was not a significant risk factor for OS (HR 1.14, 95% CI 0.76–1.71,
p
= 0.522).
Conclusion
While LLR in advanced cirrhosis for patients with HCC proved safe, optimal patient selection based on the preoperatively available factors comorbidities, age, degree of underlying liver disease, and high-quality oncologic surgery will determine long-term survival.
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