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One-third of micropapillary thyroid cancer found to be multifocal
LAS VEGAS – Micropapillary thyroid carcinoma may not be as indolent as generally thought, according to the findings of a retrospective study of thyroidectomy cases.
A review of 213 patients diagnosed with the cancer found that 34% of them had multifocal disease, and 14%, metastatic disease, Maggie Bosley reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Ms. Bosley presented a review of 213 consecutive patients who underwent thyroidectomy from 2007 to 2015, and were found to have micropapillary thyroid cancer. She reviewed the pathology reports for tumor size, presence or absence of metastases in the central and lateral node basins, and multifocality.
Most of the patients (88%) were women, with an average age of 56 years, although the range was wide (18-89 years).
About a third of the patients (73; 34%) had multifocal disease. This was bilateral in 21 (29%). Metastasis to the central nodes was present in 31 patients (14%); 4 of these patients also had positive lateral neck node metastases (2%).
“Approximately 13% of patients with node metastasis also required selective lateral neck dissections,” Ms. Bosley said.
She noted that, in 2015, the American Thyroid Association published a set of guidelines for diagnosing and treating micropapillary cancer. The guidelines suggest that most of these cancers can be safely followed with ultrasound exams, if there is no extrathyroid extension or nodal metastasis.
“However, ultrasound surveillance [quality] is very operator dependent,” Ms. Bosley said. Technician skill “could potentially impact the quality of surveillance.”
She had no relevant financial declarations.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Micropapillary thyroid carcinoma may not be as indolent as generally thought, according to the findings of a retrospective study of thyroidectomy cases.
A review of 213 patients diagnosed with the cancer found that 34% of them had multifocal disease, and 14%, metastatic disease, Maggie Bosley reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Ms. Bosley presented a review of 213 consecutive patients who underwent thyroidectomy from 2007 to 2015, and were found to have micropapillary thyroid cancer. She reviewed the pathology reports for tumor size, presence or absence of metastases in the central and lateral node basins, and multifocality.
Most of the patients (88%) were women, with an average age of 56 years, although the range was wide (18-89 years).
About a third of the patients (73; 34%) had multifocal disease. This was bilateral in 21 (29%). Metastasis to the central nodes was present in 31 patients (14%); 4 of these patients also had positive lateral neck node metastases (2%).
“Approximately 13% of patients with node metastasis also required selective lateral neck dissections,” Ms. Bosley said.
She noted that, in 2015, the American Thyroid Association published a set of guidelines for diagnosing and treating micropapillary cancer. The guidelines suggest that most of these cancers can be safely followed with ultrasound exams, if there is no extrathyroid extension or nodal metastasis.
“However, ultrasound surveillance [quality] is very operator dependent,” Ms. Bosley said. Technician skill “could potentially impact the quality of surveillance.”
She had no relevant financial declarations.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Micropapillary thyroid carcinoma may not be as indolent as generally thought, according to the findings of a retrospective study of thyroidectomy cases.
A review of 213 patients diagnosed with the cancer found that 34% of them had multifocal disease, and 14%, metastatic disease, Maggie Bosley reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Ms. Bosley presented a review of 213 consecutive patients who underwent thyroidectomy from 2007 to 2015, and were found to have micropapillary thyroid cancer. She reviewed the pathology reports for tumor size, presence or absence of metastases in the central and lateral node basins, and multifocality.
Most of the patients (88%) were women, with an average age of 56 years, although the range was wide (18-89 years).
About a third of the patients (73; 34%) had multifocal disease. This was bilateral in 21 (29%). Metastasis to the central nodes was present in 31 patients (14%); 4 of these patients also had positive lateral neck node metastases (2%).
“Approximately 13% of patients with node metastasis also required selective lateral neck dissections,” Ms. Bosley said.
She noted that, in 2015, the American Thyroid Association published a set of guidelines for diagnosing and treating micropapillary cancer. The guidelines suggest that most of these cancers can be safely followed with ultrasound exams, if there is no extrathyroid extension or nodal metastasis.
“However, ultrasound surveillance [quality] is very operator dependent,” Ms. Bosley said. Technician skill “could potentially impact the quality of surveillance.”
She had no relevant financial declarations.
[email protected]
On Twitter @Alz_Gal
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point:
Major finding: Micropapillary thyroid cancer was metastatic in 14% of cases.
Data source: A review involving 213 patients.
Disclosures: Ms. Bosley had no relevant financial disclosures.
Aortic repair in Loeys-Dietz syndrome requires close follow-up
The knowledge about Loeys-Dietz syndrome has evolved quickly since Hal Dietz, MD, and Bart Loeys, MD, at Johns Hopkins University, Baltimore, first reported on it in 2005. Now, another team of Johns Hopkins investigators have reported that an aggressive approach with aortic root replacement coupled with valve-sparing whenever possible produces favorable results, but that clinicians must follow these patients closely with cardiovascular imaging.
“Growing experience with Loeys-Dietz syndrome has confirmed early impressions of its aggressive nature and proclivity toward aortic catastrophe,” Nishant D. Patel, MD, and his coauthors said in the February issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:406-12). They reported on results of all 79 patients with Loeys-Dietz syndrome (LDS) who had cardiovascular surgery at Johns Hopkins. There were two (3%) deaths during surgery and eight (10%) late deaths.
Patients with LDS are at risk for dissection early when the aortic root reaches 4 cm. Despite what they termed “favorable” outcomes of surgery, Dr. Patel and his coauthors acknowledged that reintervention rates for this population are high – 19 patients (24%) had subsequent operations. That suggests cardiac surgeons must closely monitor these patients. “Meticulous follow-up with cardiovascular surveillance imaging remains important for management, particularly as clinical LDS subtypes are characterized and more tailored treatment is developed,” Dr. Patel and his coauthors reported.
They advise echocardiography every 3 to 6 months for the first year after surgery and then every 6 to 12 months afterward. Full-body imaging should occur at least every 2 years.
“In particular, patients with type B dissections should be monitored aggressively for aneurysm growth,” Dr. Patel and his coauthors said. They recommend imaging at seven to 14 days after dissection, then repeat imaging at 1, 3, 6, and 12 months, and then yearly thereafter.
They noted that four LDS subtypes have been identified. Although those with LDS1 and 2 subtypes are prone to aortic rupture at an earlier age and at smaller aortic diameters than other connective tissue disorders, the medical and surgical management for all subtypes are similar, Dr. Patel and his coauthors indicated.
“Certain congenital heart defects are more common among patients with LDS, compared with the normal population, including patent ductus arteriosus and mitral valve prolapse/insufficiency,” they said. Genotype is one factor that determines the need for surgery in LDS patients, Dr. Patel and his coauthors said. Others are growth rate, aortic valve function, family history, and severity of noncardiac phenotype.
The 79 patients in the study were divided almost evenly between gender, and the average age at first operation was 24.9 years; 38 were children younger than 18 years and 20 had a previous sternotomy.
Aortic root replacement represented the predominant operation in the group, accounting for 65 operations (82.3%), of which 52 (80%) were valve-sparing procedures and the remainder were composite valve-graft procedures. The other procedures the researchers performed were nine aortic arch replacements (11.4%), three open thoracoabdominal repairs (3.8%) and two ascending aorta replacements (2.5%).
“Valve-sparing root replacement has become a safe and reliable option for appropriately selected younger patients with LDS,” Dr. Patel and his coauthors wrote. Five patients needed a second operation on the aortic valve or root; three of them had a Florida sleeve procedure. “Based on these initial outcomes with the Florida sleeve at our institution, we have abandoned this procedure in favor of conventional valve-sparing root replacement,” Dr. Patel and his coauthors stated.
Dr. Patel and his coauthors had no financial relationships to disclose.
This report by Dr. Patel and his coauthors confirms the need for close surveillance of individuals with Loeys-Dietz syndrome who have had aortic operations, John S. Ikonomidis, MD, PhD, of the Medical University of South Carolina, Charleston, said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153:413-4).
Dr. Ikonomidis noted this study is important because of its population size. “This is probably the largest single-center surgical report of this kind in the world,” he said.
The study highlighted a number of issues germane to LDS patients who have cardiovascular surgery, among them a critical need for genetic testing to help cardiac surgeons determine the disease genotype and what operation to perform, Dr. Ikonomidis said.
But Dr. Ikonomidis also pointed out the variation in aortic root size in the study patients. The smallest root in the series was 2 cm and 21 of 65 patients with a maximum root diameter smaller than 4 cm had root surgery. “This is a testament to the fact that surgical decision making in this population is dependent not just on the known genotype and aortic dimensions, but also on the rate of growth, aortic valve function, severity of noncardiac phenotype, and family history,” Dr. Ikonomidis said.
Dr. Ikonomidis had no financial relationships to disclose.
This report by Dr. Patel and his coauthors confirms the need for close surveillance of individuals with Loeys-Dietz syndrome who have had aortic operations, John S. Ikonomidis, MD, PhD, of the Medical University of South Carolina, Charleston, said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153:413-4).
Dr. Ikonomidis noted this study is important because of its population size. “This is probably the largest single-center surgical report of this kind in the world,” he said.
The study highlighted a number of issues germane to LDS patients who have cardiovascular surgery, among them a critical need for genetic testing to help cardiac surgeons determine the disease genotype and what operation to perform, Dr. Ikonomidis said.
But Dr. Ikonomidis also pointed out the variation in aortic root size in the study patients. The smallest root in the series was 2 cm and 21 of 65 patients with a maximum root diameter smaller than 4 cm had root surgery. “This is a testament to the fact that surgical decision making in this population is dependent not just on the known genotype and aortic dimensions, but also on the rate of growth, aortic valve function, severity of noncardiac phenotype, and family history,” Dr. Ikonomidis said.
Dr. Ikonomidis had no financial relationships to disclose.
This report by Dr. Patel and his coauthors confirms the need for close surveillance of individuals with Loeys-Dietz syndrome who have had aortic operations, John S. Ikonomidis, MD, PhD, of the Medical University of South Carolina, Charleston, said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153:413-4).
Dr. Ikonomidis noted this study is important because of its population size. “This is probably the largest single-center surgical report of this kind in the world,” he said.
The study highlighted a number of issues germane to LDS patients who have cardiovascular surgery, among them a critical need for genetic testing to help cardiac surgeons determine the disease genotype and what operation to perform, Dr. Ikonomidis said.
But Dr. Ikonomidis also pointed out the variation in aortic root size in the study patients. The smallest root in the series was 2 cm and 21 of 65 patients with a maximum root diameter smaller than 4 cm had root surgery. “This is a testament to the fact that surgical decision making in this population is dependent not just on the known genotype and aortic dimensions, but also on the rate of growth, aortic valve function, severity of noncardiac phenotype, and family history,” Dr. Ikonomidis said.
Dr. Ikonomidis had no financial relationships to disclose.
The knowledge about Loeys-Dietz syndrome has evolved quickly since Hal Dietz, MD, and Bart Loeys, MD, at Johns Hopkins University, Baltimore, first reported on it in 2005. Now, another team of Johns Hopkins investigators have reported that an aggressive approach with aortic root replacement coupled with valve-sparing whenever possible produces favorable results, but that clinicians must follow these patients closely with cardiovascular imaging.
“Growing experience with Loeys-Dietz syndrome has confirmed early impressions of its aggressive nature and proclivity toward aortic catastrophe,” Nishant D. Patel, MD, and his coauthors said in the February issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:406-12). They reported on results of all 79 patients with Loeys-Dietz syndrome (LDS) who had cardiovascular surgery at Johns Hopkins. There were two (3%) deaths during surgery and eight (10%) late deaths.
Patients with LDS are at risk for dissection early when the aortic root reaches 4 cm. Despite what they termed “favorable” outcomes of surgery, Dr. Patel and his coauthors acknowledged that reintervention rates for this population are high – 19 patients (24%) had subsequent operations. That suggests cardiac surgeons must closely monitor these patients. “Meticulous follow-up with cardiovascular surveillance imaging remains important for management, particularly as clinical LDS subtypes are characterized and more tailored treatment is developed,” Dr. Patel and his coauthors reported.
They advise echocardiography every 3 to 6 months for the first year after surgery and then every 6 to 12 months afterward. Full-body imaging should occur at least every 2 years.
“In particular, patients with type B dissections should be monitored aggressively for aneurysm growth,” Dr. Patel and his coauthors said. They recommend imaging at seven to 14 days after dissection, then repeat imaging at 1, 3, 6, and 12 months, and then yearly thereafter.
They noted that four LDS subtypes have been identified. Although those with LDS1 and 2 subtypes are prone to aortic rupture at an earlier age and at smaller aortic diameters than other connective tissue disorders, the medical and surgical management for all subtypes are similar, Dr. Patel and his coauthors indicated.
“Certain congenital heart defects are more common among patients with LDS, compared with the normal population, including patent ductus arteriosus and mitral valve prolapse/insufficiency,” they said. Genotype is one factor that determines the need for surgery in LDS patients, Dr. Patel and his coauthors said. Others are growth rate, aortic valve function, family history, and severity of noncardiac phenotype.
The 79 patients in the study were divided almost evenly between gender, and the average age at first operation was 24.9 years; 38 were children younger than 18 years and 20 had a previous sternotomy.
Aortic root replacement represented the predominant operation in the group, accounting for 65 operations (82.3%), of which 52 (80%) were valve-sparing procedures and the remainder were composite valve-graft procedures. The other procedures the researchers performed were nine aortic arch replacements (11.4%), three open thoracoabdominal repairs (3.8%) and two ascending aorta replacements (2.5%).
“Valve-sparing root replacement has become a safe and reliable option for appropriately selected younger patients with LDS,” Dr. Patel and his coauthors wrote. Five patients needed a second operation on the aortic valve or root; three of them had a Florida sleeve procedure. “Based on these initial outcomes with the Florida sleeve at our institution, we have abandoned this procedure in favor of conventional valve-sparing root replacement,” Dr. Patel and his coauthors stated.
Dr. Patel and his coauthors had no financial relationships to disclose.
The knowledge about Loeys-Dietz syndrome has evolved quickly since Hal Dietz, MD, and Bart Loeys, MD, at Johns Hopkins University, Baltimore, first reported on it in 2005. Now, another team of Johns Hopkins investigators have reported that an aggressive approach with aortic root replacement coupled with valve-sparing whenever possible produces favorable results, but that clinicians must follow these patients closely with cardiovascular imaging.
“Growing experience with Loeys-Dietz syndrome has confirmed early impressions of its aggressive nature and proclivity toward aortic catastrophe,” Nishant D. Patel, MD, and his coauthors said in the February issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:406-12). They reported on results of all 79 patients with Loeys-Dietz syndrome (LDS) who had cardiovascular surgery at Johns Hopkins. There were two (3%) deaths during surgery and eight (10%) late deaths.
Patients with LDS are at risk for dissection early when the aortic root reaches 4 cm. Despite what they termed “favorable” outcomes of surgery, Dr. Patel and his coauthors acknowledged that reintervention rates for this population are high – 19 patients (24%) had subsequent operations. That suggests cardiac surgeons must closely monitor these patients. “Meticulous follow-up with cardiovascular surveillance imaging remains important for management, particularly as clinical LDS subtypes are characterized and more tailored treatment is developed,” Dr. Patel and his coauthors reported.
They advise echocardiography every 3 to 6 months for the first year after surgery and then every 6 to 12 months afterward. Full-body imaging should occur at least every 2 years.
“In particular, patients with type B dissections should be monitored aggressively for aneurysm growth,” Dr. Patel and his coauthors said. They recommend imaging at seven to 14 days after dissection, then repeat imaging at 1, 3, 6, and 12 months, and then yearly thereafter.
They noted that four LDS subtypes have been identified. Although those with LDS1 and 2 subtypes are prone to aortic rupture at an earlier age and at smaller aortic diameters than other connective tissue disorders, the medical and surgical management for all subtypes are similar, Dr. Patel and his coauthors indicated.
“Certain congenital heart defects are more common among patients with LDS, compared with the normal population, including patent ductus arteriosus and mitral valve prolapse/insufficiency,” they said. Genotype is one factor that determines the need for surgery in LDS patients, Dr. Patel and his coauthors said. Others are growth rate, aortic valve function, family history, and severity of noncardiac phenotype.
The 79 patients in the study were divided almost evenly between gender, and the average age at first operation was 24.9 years; 38 were children younger than 18 years and 20 had a previous sternotomy.
Aortic root replacement represented the predominant operation in the group, accounting for 65 operations (82.3%), of which 52 (80%) were valve-sparing procedures and the remainder were composite valve-graft procedures. The other procedures the researchers performed were nine aortic arch replacements (11.4%), three open thoracoabdominal repairs (3.8%) and two ascending aorta replacements (2.5%).
“Valve-sparing root replacement has become a safe and reliable option for appropriately selected younger patients with LDS,” Dr. Patel and his coauthors wrote. Five patients needed a second operation on the aortic valve or root; three of them had a Florida sleeve procedure. “Based on these initial outcomes with the Florida sleeve at our institution, we have abandoned this procedure in favor of conventional valve-sparing root replacement,” Dr. Patel and his coauthors stated.
Dr. Patel and his coauthors had no financial relationships to disclose.
Key clinical point: Outcomes for aortic surgery in Loeys-Dietz syndrome are favorable, but reintervention rates are high.
Major finding: Patients require close postoperative follow-up with cardiovascular imaging.
Data source: Retrospective review of 79 patients who had cardiovascular surgery for LDS over 26 years at Johns Hopkins University.
Disclosure: Dr. Patel and his coauthors reported having no relevant financial disclosures.
Intraoperative PTH spikes may mean multigland disease
SAN DIEGO – Intraoperative spikes of parathyroid hormone don’t predict a failed parathyroidectomy, according to a retrospective study of patients who had the surgery for hyperparathyroidism.
They should, however, raise the suspicion of multigland disease, Richard Teo said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Significantly more patients with intraoperative spikes didn’t achieve this drop, and they had a higher rate of multigland disease requiring bilateral neck exploration,” he said. “But although spikes did increase the suspicion of multigland disease, they did not affect the operative success rate in this study.”
He presented a retrospective analysis of 683 patients who underwent parathyroidectomy for hyperparathyroidism. These patients were largely female (76%). Those who had the intraoperative spikes were older (60 vs. 58 years) and had higher preoperative calcium than patients without spikes. There were no differences in parathyroid hormone (PTH) or creatinine levels.
Operative success – described as normocalcemia at least 6 months after surgery – occurred in 98% of the entire group. The operative failure rate was 0.9%, and the recurrence rate was 1%. About 5% of the entire group had multigland disease.
Intraoperative PTH spikes occurred in 224 patients (33%). Compared with those without spikes, patients with spikes were significantly less likely to achieve the PTH decrease of 50% or greater at 10 minutes after gland excision (70% vs. 90%).
Bilateral neck explorations were significantly more common among those with spikes (10% vs. 5%), as was multigland disease (8% vs. 3%). There was no significant difference in operative time (54 vs. 59 minutes).
Postoperative outcomes were similar. At last follow-up, calcium levels were identical (9.3 mg/dL) in the group with and the group without a spike in PTH. In addition, the PTH levels were not significantly different (47 vs. 57 pg/mL).
Operative success was achieved in 98% of both groups, with a 2% failure rate in both groups. Recurrence was slightly, though not significantly, less in the spike group (0.4% vs. 1.3%).
“We were able to show that intraoperative PTH spikes don’t predict a poor outcome of parathyroidectomy,” Mr. Teo said. “We also feel this study reaffirms the clinical utility of the 50% or greater intraoperative PTH drop as a predictor of the successful removal of all hypersecreting parathyroid tissue during parathyroidectomy guided by intraoperative PTH monitoring.”
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
SAN DIEGO – Intraoperative spikes of parathyroid hormone don’t predict a failed parathyroidectomy, according to a retrospective study of patients who had the surgery for hyperparathyroidism.
They should, however, raise the suspicion of multigland disease, Richard Teo said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Significantly more patients with intraoperative spikes didn’t achieve this drop, and they had a higher rate of multigland disease requiring bilateral neck exploration,” he said. “But although spikes did increase the suspicion of multigland disease, they did not affect the operative success rate in this study.”
He presented a retrospective analysis of 683 patients who underwent parathyroidectomy for hyperparathyroidism. These patients were largely female (76%). Those who had the intraoperative spikes were older (60 vs. 58 years) and had higher preoperative calcium than patients without spikes. There were no differences in parathyroid hormone (PTH) or creatinine levels.
Operative success – described as normocalcemia at least 6 months after surgery – occurred in 98% of the entire group. The operative failure rate was 0.9%, and the recurrence rate was 1%. About 5% of the entire group had multigland disease.
Intraoperative PTH spikes occurred in 224 patients (33%). Compared with those without spikes, patients with spikes were significantly less likely to achieve the PTH decrease of 50% or greater at 10 minutes after gland excision (70% vs. 90%).
Bilateral neck explorations were significantly more common among those with spikes (10% vs. 5%), as was multigland disease (8% vs. 3%). There was no significant difference in operative time (54 vs. 59 minutes).
Postoperative outcomes were similar. At last follow-up, calcium levels were identical (9.3 mg/dL) in the group with and the group without a spike in PTH. In addition, the PTH levels were not significantly different (47 vs. 57 pg/mL).
Operative success was achieved in 98% of both groups, with a 2% failure rate in both groups. Recurrence was slightly, though not significantly, less in the spike group (0.4% vs. 1.3%).
“We were able to show that intraoperative PTH spikes don’t predict a poor outcome of parathyroidectomy,” Mr. Teo said. “We also feel this study reaffirms the clinical utility of the 50% or greater intraoperative PTH drop as a predictor of the successful removal of all hypersecreting parathyroid tissue during parathyroidectomy guided by intraoperative PTH monitoring.”
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
SAN DIEGO – Intraoperative spikes of parathyroid hormone don’t predict a failed parathyroidectomy, according to a retrospective study of patients who had the surgery for hyperparathyroidism.
They should, however, raise the suspicion of multigland disease, Richard Teo said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Significantly more patients with intraoperative spikes didn’t achieve this drop, and they had a higher rate of multigland disease requiring bilateral neck exploration,” he said. “But although spikes did increase the suspicion of multigland disease, they did not affect the operative success rate in this study.”
He presented a retrospective analysis of 683 patients who underwent parathyroidectomy for hyperparathyroidism. These patients were largely female (76%). Those who had the intraoperative spikes were older (60 vs. 58 years) and had higher preoperative calcium than patients without spikes. There were no differences in parathyroid hormone (PTH) or creatinine levels.
Operative success – described as normocalcemia at least 6 months after surgery – occurred in 98% of the entire group. The operative failure rate was 0.9%, and the recurrence rate was 1%. About 5% of the entire group had multigland disease.
Intraoperative PTH spikes occurred in 224 patients (33%). Compared with those without spikes, patients with spikes were significantly less likely to achieve the PTH decrease of 50% or greater at 10 minutes after gland excision (70% vs. 90%).
Bilateral neck explorations were significantly more common among those with spikes (10% vs. 5%), as was multigland disease (8% vs. 3%). There was no significant difference in operative time (54 vs. 59 minutes).
Postoperative outcomes were similar. At last follow-up, calcium levels were identical (9.3 mg/dL) in the group with and the group without a spike in PTH. In addition, the PTH levels were not significantly different (47 vs. 57 pg/mL).
Operative success was achieved in 98% of both groups, with a 2% failure rate in both groups. Recurrence was slightly, though not significantly, less in the spike group (0.4% vs. 1.3%).
“We were able to show that intraoperative PTH spikes don’t predict a poor outcome of parathyroidectomy,” Mr. Teo said. “We also feel this study reaffirms the clinical utility of the 50% or greater intraoperative PTH drop as a predictor of the successful removal of all hypersecreting parathyroid tissue during parathyroidectomy guided by intraoperative PTH monitoring.”
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
Key clinical point: Major finding: Intraoperative PTH spikes occurred in 33% of parathyroidectomy patients, and 8% of patients with spikes had multigland disease.
Data source: The retrospective study comprised 683 patients.
Disclosures: He had no financial disclosures.
Can a nomogram foretell invasive pulmonary adenocarcinoma?
The diagnosis of solitary peripheral subsolid nodule carries with it an undefined risk of invasive pulmonary carcinoma, but clinicians have not had a tool that can help guide their planning for surgery. However, researchers in China have developed a nomogram that they said may aid clinicians to predict the risk of invasive pulmonary adenocarcinoma in these patients.
“Validation by the use of bootstrap resampling revealed optimal discrimination and calibration, indicating that the nomogram may have clinical utility,” said Chenghua Jin, MD, and Jinlin Cao, MD, of Zhejiang University, Hangzhou, China, and coauthors. They reported their findings in the February issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:42-9).
The nomogram accounts for the following factors: computed tomography attenuation; nodule size; spiculation; signs of vascular convergence; pleural tags; and solid proportion. “The nomogram showed a robust discrimination with an area under the receiver operating characteristic curve of 0.894,” Dr. Jin and coauthors reported. An area under the curve of 1 is equivalent to 100%, so the area under the curve this study reported shows close to 90% accuracy.
The study involved a retrospective analysis of 273 consecutive patients who had resection of a solitary peripheral subsolid nodule at Zhejiang University School of Medicine from January 2013 to December 2014. Subsolid pulmonary nodules include pure ground-glass nodules and part-solid nodules that feature both solid and ground-glass components. “The optimal management of patients with a subsolid nodule is of growing clinical concern, because the most common diagnosis for resected subsolid nodules is lung adenocarcinoma,” Dr. Jin and colleagues indicated.
Of the study population, 58% were diagnosed with invasive pulmonary adenocarcinoma. Other diagnoses within the group were benign (13%), atypical adenomatous hyperplasia (1%), adenocarcinoma in situ (6.5%) and minimally invasive adenocarcinoma (21%).
Results of the multivariable analyses showed that invasive pulmonary adenocarcinoma correlated with the following characteristics: lesion size; spiculation; vascular convergence; and pleural tag. Factors that were not significant included age, family history of lung cancer, CT attenuation, and solid proportion. However, the researchers did include CT attenuation, along with solid proportion, in the final regression analysis based on their contributions to the statistical analysis.
For the model, CT attenuation of –500 to –200 Hounsfield units carried an odds ratio of 1.690 (P = .228) while CT attenuation greater than –200 HU had an OR of 1.791 (P = .645). Positive spiculation had an OR of 3.312 (no P value given) and negative vascular convergence an OR of 0.300 (no P value given).
While a number of prediction models have been devised and validated to evaluate the likelihood of malignancy in pulmonary nodules, they have not given subsolid nodules “specific or detailed consideration,” Dr. Jin and and coauthors said. “To our knowledge, this study was the first to construct a quantitative nomogram to predict the probability of invasive pulmonary adenocarcinoma in patients with subsolid nodules,” the researchers wrote.
One limitation of the study is its selection bias toward patients with a greater probability of having a malignancy. Also, validation of the nomogram requires external analysis with additional databases from other countries and with more diverse ethnic groups. Another shortcoming is the retrospective nature of the study and a small number of patients who had positron emission tomography. “Further data collection, wider geographic recruitment, and incorporation of positron emission tomography results and some molecular factors could improve this model for future use,” Dr. Jin and coauthors concluded.
Dr. Jin and Dr. Cao had no relevant financial disclosures. The study received funding from the Zhejiang Province Science and Technology Plan.
The nomogram Dr. Jin and coauthors present can be a valuable tool for determining the extent of resection of subsolid pulmonary nodules and to distinguish invasive from preinvasive disease where preoperative needle biopsy and intraopertiave frozen section typically cannot, Bryan Burt, MD, of Baylor College of Medicine, Houston, said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153:460-1).
“However,” Dr. Burt added, “as the accuracy of frozen section for this disease improves, as it has in select centers, the clinical utility of such a nomogram will diminish.”
Use of the nomogram relies on experienced chest radiologists to aid in scoring variables and a validation methodology that a retrospective trial cannot meet, Dr. Burt said. “Of note, this nomogram was constructed from a dataset composed of only surgically resected lesions, and it will be imperative to validate these methods among a larger cohort of individuals with subsolid pulmonary nodules treated both surgically and nonsurgically, ideally in a prospective trial,” Dr. Burt concluded.
Dr. Burt had no relevant financial disclosures.
The nomogram Dr. Jin and coauthors present can be a valuable tool for determining the extent of resection of subsolid pulmonary nodules and to distinguish invasive from preinvasive disease where preoperative needle biopsy and intraopertiave frozen section typically cannot, Bryan Burt, MD, of Baylor College of Medicine, Houston, said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153:460-1).
“However,” Dr. Burt added, “as the accuracy of frozen section for this disease improves, as it has in select centers, the clinical utility of such a nomogram will diminish.”
Use of the nomogram relies on experienced chest radiologists to aid in scoring variables and a validation methodology that a retrospective trial cannot meet, Dr. Burt said. “Of note, this nomogram was constructed from a dataset composed of only surgically resected lesions, and it will be imperative to validate these methods among a larger cohort of individuals with subsolid pulmonary nodules treated both surgically and nonsurgically, ideally in a prospective trial,” Dr. Burt concluded.
Dr. Burt had no relevant financial disclosures.
The nomogram Dr. Jin and coauthors present can be a valuable tool for determining the extent of resection of subsolid pulmonary nodules and to distinguish invasive from preinvasive disease where preoperative needle biopsy and intraopertiave frozen section typically cannot, Bryan Burt, MD, of Baylor College of Medicine, Houston, said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153:460-1).
“However,” Dr. Burt added, “as the accuracy of frozen section for this disease improves, as it has in select centers, the clinical utility of such a nomogram will diminish.”
Use of the nomogram relies on experienced chest radiologists to aid in scoring variables and a validation methodology that a retrospective trial cannot meet, Dr. Burt said. “Of note, this nomogram was constructed from a dataset composed of only surgically resected lesions, and it will be imperative to validate these methods among a larger cohort of individuals with subsolid pulmonary nodules treated both surgically and nonsurgically, ideally in a prospective trial,” Dr. Burt concluded.
Dr. Burt had no relevant financial disclosures.
The diagnosis of solitary peripheral subsolid nodule carries with it an undefined risk of invasive pulmonary carcinoma, but clinicians have not had a tool that can help guide their planning for surgery. However, researchers in China have developed a nomogram that they said may aid clinicians to predict the risk of invasive pulmonary adenocarcinoma in these patients.
“Validation by the use of bootstrap resampling revealed optimal discrimination and calibration, indicating that the nomogram may have clinical utility,” said Chenghua Jin, MD, and Jinlin Cao, MD, of Zhejiang University, Hangzhou, China, and coauthors. They reported their findings in the February issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:42-9).
The nomogram accounts for the following factors: computed tomography attenuation; nodule size; spiculation; signs of vascular convergence; pleural tags; and solid proportion. “The nomogram showed a robust discrimination with an area under the receiver operating characteristic curve of 0.894,” Dr. Jin and coauthors reported. An area under the curve of 1 is equivalent to 100%, so the area under the curve this study reported shows close to 90% accuracy.
The study involved a retrospective analysis of 273 consecutive patients who had resection of a solitary peripheral subsolid nodule at Zhejiang University School of Medicine from January 2013 to December 2014. Subsolid pulmonary nodules include pure ground-glass nodules and part-solid nodules that feature both solid and ground-glass components. “The optimal management of patients with a subsolid nodule is of growing clinical concern, because the most common diagnosis for resected subsolid nodules is lung adenocarcinoma,” Dr. Jin and colleagues indicated.
Of the study population, 58% were diagnosed with invasive pulmonary adenocarcinoma. Other diagnoses within the group were benign (13%), atypical adenomatous hyperplasia (1%), adenocarcinoma in situ (6.5%) and minimally invasive adenocarcinoma (21%).
Results of the multivariable analyses showed that invasive pulmonary adenocarcinoma correlated with the following characteristics: lesion size; spiculation; vascular convergence; and pleural tag. Factors that were not significant included age, family history of lung cancer, CT attenuation, and solid proportion. However, the researchers did include CT attenuation, along with solid proportion, in the final regression analysis based on their contributions to the statistical analysis.
For the model, CT attenuation of –500 to –200 Hounsfield units carried an odds ratio of 1.690 (P = .228) while CT attenuation greater than –200 HU had an OR of 1.791 (P = .645). Positive spiculation had an OR of 3.312 (no P value given) and negative vascular convergence an OR of 0.300 (no P value given).
While a number of prediction models have been devised and validated to evaluate the likelihood of malignancy in pulmonary nodules, they have not given subsolid nodules “specific or detailed consideration,” Dr. Jin and and coauthors said. “To our knowledge, this study was the first to construct a quantitative nomogram to predict the probability of invasive pulmonary adenocarcinoma in patients with subsolid nodules,” the researchers wrote.
One limitation of the study is its selection bias toward patients with a greater probability of having a malignancy. Also, validation of the nomogram requires external analysis with additional databases from other countries and with more diverse ethnic groups. Another shortcoming is the retrospective nature of the study and a small number of patients who had positron emission tomography. “Further data collection, wider geographic recruitment, and incorporation of positron emission tomography results and some molecular factors could improve this model for future use,” Dr. Jin and coauthors concluded.
Dr. Jin and Dr. Cao had no relevant financial disclosures. The study received funding from the Zhejiang Province Science and Technology Plan.
The diagnosis of solitary peripheral subsolid nodule carries with it an undefined risk of invasive pulmonary carcinoma, but clinicians have not had a tool that can help guide their planning for surgery. However, researchers in China have developed a nomogram that they said may aid clinicians to predict the risk of invasive pulmonary adenocarcinoma in these patients.
“Validation by the use of bootstrap resampling revealed optimal discrimination and calibration, indicating that the nomogram may have clinical utility,” said Chenghua Jin, MD, and Jinlin Cao, MD, of Zhejiang University, Hangzhou, China, and coauthors. They reported their findings in the February issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:42-9).
The nomogram accounts for the following factors: computed tomography attenuation; nodule size; spiculation; signs of vascular convergence; pleural tags; and solid proportion. “The nomogram showed a robust discrimination with an area under the receiver operating characteristic curve of 0.894,” Dr. Jin and coauthors reported. An area under the curve of 1 is equivalent to 100%, so the area under the curve this study reported shows close to 90% accuracy.
The study involved a retrospective analysis of 273 consecutive patients who had resection of a solitary peripheral subsolid nodule at Zhejiang University School of Medicine from January 2013 to December 2014. Subsolid pulmonary nodules include pure ground-glass nodules and part-solid nodules that feature both solid and ground-glass components. “The optimal management of patients with a subsolid nodule is of growing clinical concern, because the most common diagnosis for resected subsolid nodules is lung adenocarcinoma,” Dr. Jin and colleagues indicated.
Of the study population, 58% were diagnosed with invasive pulmonary adenocarcinoma. Other diagnoses within the group were benign (13%), atypical adenomatous hyperplasia (1%), adenocarcinoma in situ (6.5%) and minimally invasive adenocarcinoma (21%).
Results of the multivariable analyses showed that invasive pulmonary adenocarcinoma correlated with the following characteristics: lesion size; spiculation; vascular convergence; and pleural tag. Factors that were not significant included age, family history of lung cancer, CT attenuation, and solid proportion. However, the researchers did include CT attenuation, along with solid proportion, in the final regression analysis based on their contributions to the statistical analysis.
For the model, CT attenuation of –500 to –200 Hounsfield units carried an odds ratio of 1.690 (P = .228) while CT attenuation greater than –200 HU had an OR of 1.791 (P = .645). Positive spiculation had an OR of 3.312 (no P value given) and negative vascular convergence an OR of 0.300 (no P value given).
While a number of prediction models have been devised and validated to evaluate the likelihood of malignancy in pulmonary nodules, they have not given subsolid nodules “specific or detailed consideration,” Dr. Jin and and coauthors said. “To our knowledge, this study was the first to construct a quantitative nomogram to predict the probability of invasive pulmonary adenocarcinoma in patients with subsolid nodules,” the researchers wrote.
One limitation of the study is its selection bias toward patients with a greater probability of having a malignancy. Also, validation of the nomogram requires external analysis with additional databases from other countries and with more diverse ethnic groups. Another shortcoming is the retrospective nature of the study and a small number of patients who had positron emission tomography. “Further data collection, wider geographic recruitment, and incorporation of positron emission tomography results and some molecular factors could improve this model for future use,” Dr. Jin and coauthors concluded.
Dr. Jin and Dr. Cao had no relevant financial disclosures. The study received funding from the Zhejiang Province Science and Technology Plan.
EXPERT ANALYSIS FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point: Investigators developed a nomogram that may help predict the risk of invasive pulmonary adenocarcinoma for patients with a solitary peripheral subsolid nodule.
Major finding: This nomogram may help clinicians individualize each patient’s prognosis for invasive pulmonary adenocarcinoma and develop treatment plans accordingly.
Data source: Retrospective analysis of 273 consecutive patients who had surgery to remove a solitary peripheral subsolid nodule at a single center.
Disclosure: The investigators received support from the Zhejiang Province Science and Technology Plan. Dr. Jin and Dr. Cao reported having no relevant financial disclosures.
CMS spending projections come with a caveat
The Centers for Medicare & Medicaid Services is predicting an average annual growth rate of 5.6% in health care expenditures over the next 10 years – but with a big asterisk.
The projections are based on current law and make no assumptions about potential repair, repeal, or replacement of the Affordable Care Act, leaving the projections to serve as a benchmark rather than a forecast.
In the short term, growth rates in 2016 and 2017 are the slowest in the forecast period, at 4.8% and 5.4%, respectively. For 2018 and beyond, the growth rate picks up, with both Medicare and Medicaid projected to grow faster and more rapidly, compared with private health insurance spending.
The CMS actuaries attribute this to the increase in Medicare spending over recent historic lows, a Medicaid population that is expected to become older and sicker, additional Baby Boomers entering the Medicare program, and decreased demand for health services as prices increase.
The percentage of population with either public or private health insurance coverage is expected to grow under current law from 90.9% in 2015 to 91.5% in 2025, “mainly a result of continued growth in enrollment in private health insurance – in particular, employer-sponsored health insurance – in the first year of the projection period, as well as enrollment growth in public programs throughout the period,” Mr. Keegan and colleagues wrote.
The Centers for Medicare & Medicaid Services is predicting an average annual growth rate of 5.6% in health care expenditures over the next 10 years – but with a big asterisk.
The projections are based on current law and make no assumptions about potential repair, repeal, or replacement of the Affordable Care Act, leaving the projections to serve as a benchmark rather than a forecast.
In the short term, growth rates in 2016 and 2017 are the slowest in the forecast period, at 4.8% and 5.4%, respectively. For 2018 and beyond, the growth rate picks up, with both Medicare and Medicaid projected to grow faster and more rapidly, compared with private health insurance spending.
The CMS actuaries attribute this to the increase in Medicare spending over recent historic lows, a Medicaid population that is expected to become older and sicker, additional Baby Boomers entering the Medicare program, and decreased demand for health services as prices increase.
The percentage of population with either public or private health insurance coverage is expected to grow under current law from 90.9% in 2015 to 91.5% in 2025, “mainly a result of continued growth in enrollment in private health insurance – in particular, employer-sponsored health insurance – in the first year of the projection period, as well as enrollment growth in public programs throughout the period,” Mr. Keegan and colleagues wrote.
The Centers for Medicare & Medicaid Services is predicting an average annual growth rate of 5.6% in health care expenditures over the next 10 years – but with a big asterisk.
The projections are based on current law and make no assumptions about potential repair, repeal, or replacement of the Affordable Care Act, leaving the projections to serve as a benchmark rather than a forecast.
In the short term, growth rates in 2016 and 2017 are the slowest in the forecast period, at 4.8% and 5.4%, respectively. For 2018 and beyond, the growth rate picks up, with both Medicare and Medicaid projected to grow faster and more rapidly, compared with private health insurance spending.
The CMS actuaries attribute this to the increase in Medicare spending over recent historic lows, a Medicaid population that is expected to become older and sicker, additional Baby Boomers entering the Medicare program, and decreased demand for health services as prices increase.
The percentage of population with either public or private health insurance coverage is expected to grow under current law from 90.9% in 2015 to 91.5% in 2025, “mainly a result of continued growth in enrollment in private health insurance – in particular, employer-sponsored health insurance – in the first year of the projection period, as well as enrollment growth in public programs throughout the period,” Mr. Keegan and colleagues wrote.
Will genome editing advance animal-to-human transplantation?
Advances in gene editing are pushing the possibility of raising pigs for organs that may be transplanted into humans with immunosuppression regimens comparable to those now used in human-to-human transplants, coauthors James Butler, MD, and A. Joseph Tector, MD, PhD, stated in an expert opinion in the February issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:488-92).
Developments in genome editing could bring new approaches to management of cardiopulmonary diseases, Dr. Butler and Dr. Tector noted. “Recently, cardiac-specific and lung-specific applications have been described, which will allow for the rapid creation of new models of heart and lung disease,” they said. Specifically, they noted gene targeting might eventually offer a way to treat challenging genetic problems “like the heterogeneous nature of nonsquamous cell lung cancer.”
Dr. Butler is with the department of surgery at Indiana University, Indianapolis, and Dr. Tector is with the department of surgery at the University of Alabama at Birmingham.
CRISPR technology has been used in developing multiple gene knockout pigs and neutralizing three separate porcine genes that encode human xenoantigens in a single reaction, leading to efficient methods for creating pigs with multiple genetic modifications.
According to the website of the Broad Institute of MIT and Harvard, Cambridge, Mass., where researchers perfected the system to work in eukaryotes, CRISPR works by using short RNA sequences designed by researchers to guide the system to matching sequences of DNA. When the target DNA is found, Cas9 – one of the enzymes produced by the CRISPR system – binds to the DNA and cuts it, shutting the targeted gene off.
“By facilitating high-throughput model creation, CRISPR has elucidated which modifications are necessary and which are not; despite the ability to alter many loci concurrently, recent evidence has implicated three porcine genes that are responsible for the majority of human-antiporcine humoral immunity,” Dr. Butler and Dr. Tector wrote.
Those genes are the Gal[alpha]1-3 epitope (Gal-alpha), CMAH and B4GaINT2 genes. “Each of these three genes is expressed in pigs but has been evolutionarily silenced in humans,” the coauthors added.
While CRISPR genome editing has yet to reach its full potential, researchers and clinicians should pay attention, according to Dr. Butler and Dr. Tector.
More recent modifications of CRISPR technology have shown promise in not just knocking out or turning off specific genes, but rather guiding directed replacement of genes with researcher-designed substitutes. This can enable permanent transformation of functional genes with altered behavior, according to the Broad Institute website.
Dr. Tector disclosed he has received funding from United Therapeutics and founded Xenobridge with patents for xenotransplantation. Dr. Butler has no relevant financial relationships to disclose.
CRISPR and CRISPR-associated proteins have emerged as effective genome editing techniques that may lead to cardiac and lung models and possibly xenotransplantation, Ari A. Mennander, MD, PhD, of the Tampere (Finland) University Heart Hospital, said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153:492).
The concept Dr. Butler and Dr. Tector discuss involves not using antibodies to ameliorate porcine antibodies that cause rejection in humans, but rather reengineering the genetic composition of pigs to eliminate those antibodies. “According to the wildest of dreams, these genes affecting porcine glycan expression may be silenced, and the human–antiporcine humoral immunity is controlled down to the level comparable with human allograft rejection,” Dr. Mennander said.
However, such a breakthrough carries with it consequences, Dr. Mennander said. “Should one worry about the induction of zoonosis, as well as the ethical aspects of transplanting the patient a whole organ of a pig? Would even a successful xenotransplant program seriously compete with artificial hearts or allografts?” Embracing the method too early would open its advocates to ridicule, he said.
“We are to applaud the researchers for ever-lasting and exemplary enthusiasm for a futuristic new surgical solution; the future may lie as much in current clinical solutions as in innovative discoveries based on persistent scientific experiments,” Dr. Mennander said.
Dr. Mennander had no relevant financial relationships to disclose.
CRISPR and CRISPR-associated proteins have emerged as effective genome editing techniques that may lead to cardiac and lung models and possibly xenotransplantation, Ari A. Mennander, MD, PhD, of the Tampere (Finland) University Heart Hospital, said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153:492).
The concept Dr. Butler and Dr. Tector discuss involves not using antibodies to ameliorate porcine antibodies that cause rejection in humans, but rather reengineering the genetic composition of pigs to eliminate those antibodies. “According to the wildest of dreams, these genes affecting porcine glycan expression may be silenced, and the human–antiporcine humoral immunity is controlled down to the level comparable with human allograft rejection,” Dr. Mennander said.
However, such a breakthrough carries with it consequences, Dr. Mennander said. “Should one worry about the induction of zoonosis, as well as the ethical aspects of transplanting the patient a whole organ of a pig? Would even a successful xenotransplant program seriously compete with artificial hearts or allografts?” Embracing the method too early would open its advocates to ridicule, he said.
“We are to applaud the researchers for ever-lasting and exemplary enthusiasm for a futuristic new surgical solution; the future may lie as much in current clinical solutions as in innovative discoveries based on persistent scientific experiments,” Dr. Mennander said.
Dr. Mennander had no relevant financial relationships to disclose.
CRISPR and CRISPR-associated proteins have emerged as effective genome editing techniques that may lead to cardiac and lung models and possibly xenotransplantation, Ari A. Mennander, MD, PhD, of the Tampere (Finland) University Heart Hospital, said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153:492).
The concept Dr. Butler and Dr. Tector discuss involves not using antibodies to ameliorate porcine antibodies that cause rejection in humans, but rather reengineering the genetic composition of pigs to eliminate those antibodies. “According to the wildest of dreams, these genes affecting porcine glycan expression may be silenced, and the human–antiporcine humoral immunity is controlled down to the level comparable with human allograft rejection,” Dr. Mennander said.
However, such a breakthrough carries with it consequences, Dr. Mennander said. “Should one worry about the induction of zoonosis, as well as the ethical aspects of transplanting the patient a whole organ of a pig? Would even a successful xenotransplant program seriously compete with artificial hearts or allografts?” Embracing the method too early would open its advocates to ridicule, he said.
“We are to applaud the researchers for ever-lasting and exemplary enthusiasm for a futuristic new surgical solution; the future may lie as much in current clinical solutions as in innovative discoveries based on persistent scientific experiments,” Dr. Mennander said.
Dr. Mennander had no relevant financial relationships to disclose.
Advances in gene editing are pushing the possibility of raising pigs for organs that may be transplanted into humans with immunosuppression regimens comparable to those now used in human-to-human transplants, coauthors James Butler, MD, and A. Joseph Tector, MD, PhD, stated in an expert opinion in the February issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:488-92).
Developments in genome editing could bring new approaches to management of cardiopulmonary diseases, Dr. Butler and Dr. Tector noted. “Recently, cardiac-specific and lung-specific applications have been described, which will allow for the rapid creation of new models of heart and lung disease,” they said. Specifically, they noted gene targeting might eventually offer a way to treat challenging genetic problems “like the heterogeneous nature of nonsquamous cell lung cancer.”
Dr. Butler is with the department of surgery at Indiana University, Indianapolis, and Dr. Tector is with the department of surgery at the University of Alabama at Birmingham.
CRISPR technology has been used in developing multiple gene knockout pigs and neutralizing three separate porcine genes that encode human xenoantigens in a single reaction, leading to efficient methods for creating pigs with multiple genetic modifications.
According to the website of the Broad Institute of MIT and Harvard, Cambridge, Mass., where researchers perfected the system to work in eukaryotes, CRISPR works by using short RNA sequences designed by researchers to guide the system to matching sequences of DNA. When the target DNA is found, Cas9 – one of the enzymes produced by the CRISPR system – binds to the DNA and cuts it, shutting the targeted gene off.
“By facilitating high-throughput model creation, CRISPR has elucidated which modifications are necessary and which are not; despite the ability to alter many loci concurrently, recent evidence has implicated three porcine genes that are responsible for the majority of human-antiporcine humoral immunity,” Dr. Butler and Dr. Tector wrote.
Those genes are the Gal[alpha]1-3 epitope (Gal-alpha), CMAH and B4GaINT2 genes. “Each of these three genes is expressed in pigs but has been evolutionarily silenced in humans,” the coauthors added.
While CRISPR genome editing has yet to reach its full potential, researchers and clinicians should pay attention, according to Dr. Butler and Dr. Tector.
More recent modifications of CRISPR technology have shown promise in not just knocking out or turning off specific genes, but rather guiding directed replacement of genes with researcher-designed substitutes. This can enable permanent transformation of functional genes with altered behavior, according to the Broad Institute website.
Dr. Tector disclosed he has received funding from United Therapeutics and founded Xenobridge with patents for xenotransplantation. Dr. Butler has no relevant financial relationships to disclose.
Advances in gene editing are pushing the possibility of raising pigs for organs that may be transplanted into humans with immunosuppression regimens comparable to those now used in human-to-human transplants, coauthors James Butler, MD, and A. Joseph Tector, MD, PhD, stated in an expert opinion in the February issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:488-92).
Developments in genome editing could bring new approaches to management of cardiopulmonary diseases, Dr. Butler and Dr. Tector noted. “Recently, cardiac-specific and lung-specific applications have been described, which will allow for the rapid creation of new models of heart and lung disease,” they said. Specifically, they noted gene targeting might eventually offer a way to treat challenging genetic problems “like the heterogeneous nature of nonsquamous cell lung cancer.”
Dr. Butler is with the department of surgery at Indiana University, Indianapolis, and Dr. Tector is with the department of surgery at the University of Alabama at Birmingham.
CRISPR technology has been used in developing multiple gene knockout pigs and neutralizing three separate porcine genes that encode human xenoantigens in a single reaction, leading to efficient methods for creating pigs with multiple genetic modifications.
According to the website of the Broad Institute of MIT and Harvard, Cambridge, Mass., where researchers perfected the system to work in eukaryotes, CRISPR works by using short RNA sequences designed by researchers to guide the system to matching sequences of DNA. When the target DNA is found, Cas9 – one of the enzymes produced by the CRISPR system – binds to the DNA and cuts it, shutting the targeted gene off.
“By facilitating high-throughput model creation, CRISPR has elucidated which modifications are necessary and which are not; despite the ability to alter many loci concurrently, recent evidence has implicated three porcine genes that are responsible for the majority of human-antiporcine humoral immunity,” Dr. Butler and Dr. Tector wrote.
Those genes are the Gal[alpha]1-3 epitope (Gal-alpha), CMAH and B4GaINT2 genes. “Each of these three genes is expressed in pigs but has been evolutionarily silenced in humans,” the coauthors added.
While CRISPR genome editing has yet to reach its full potential, researchers and clinicians should pay attention, according to Dr. Butler and Dr. Tector.
More recent modifications of CRISPR technology have shown promise in not just knocking out or turning off specific genes, but rather guiding directed replacement of genes with researcher-designed substitutes. This can enable permanent transformation of functional genes with altered behavior, according to the Broad Institute website.
Dr. Tector disclosed he has received funding from United Therapeutics and founded Xenobridge with patents for xenotransplantation. Dr. Butler has no relevant financial relationships to disclose.
Key clinical point: CRISPR/Cas9 genome editing is advancing the creation of animal models for xenotransplantation into humans.
Major finding: Genome editing tools are moving xenotransplantation models quickly toward potential treatments for cardiopulmonary disease.
Data source: Expert opinion with literature review.
Disclosures: Dr. Tector disclosed he has received funding from United Therapeutics and founded Xenobridge with patents for xenotransplantation. Dr. Butler reported having no relevant financial disclosures.
RNA-based biopsy test bests NCCN risk stratification for PC prognosis
ORLANDO – A genetic assay for prostate cancer typically used after radical prostatectomy could be used earlier, at the time of diagnostic biopsy testing, to classify patients as low, intermediate, and high risk for metastasis and disease-specific mortality, new research reveals.
Based on an approximately 1-mm biopsy sample, the Decipher Prostate Cancer Classifier assesses the activity of 22 genes relevant to prostate cancer. In a multicenter study of 175 patients, investigators found the 5-year risk for metastatic disease was 5.0% among patients classified as low risk by Decipher, 9.3% in the intermediate-risk group, and 23.4% in the high-risk patients.
“It turns out NCCN [National Comprehensive Cancer Network] risk groups can also provide this kind of risk stratification … so why do we need the extra test?” lead author Paul L. Nguyen, MD, of Dana-Farber Cancer Institute in Boston said here at the Genitourinary Cancers Symposium sponsored by the American Society of Clinical Oncology, ASTRO, and the Society of Urologic Oncology. Because, he added, Decipher provides “significant prognostic information for distant metastases beyond clinical variables alone,” even after controlling for prostate-specific antigen level, Gleason score, and treatment type, Dr. Nguyen said.
The Decipher RNA–based test also improved the c-index for predicting likelihood of distant metastases, with a 0.75 correlation, compared with 0.66 with NCCN risk stratification and 0.66 based on Cancer of the Prostate Risk Assessment score. “So this adds to what we already know, and it helps us decide which patients are going to develop metastases.”
Decipher’s prognostic value emerged regardless of first line therapy. A total 100 patients received radiation and androgen therapy at Dana-Farber and another 75 underwent radical prostatectomy at the Cleveland Clinic or Johns Hopkins University, Baltimore. Decipher classified 13% of patients as low risk, 51% as intermediate risk, and 34% as high risk. Because prostate tumors can be heterogeneous, researchers chose the highest-grade biopsy sample for each patient.
Local Therapy for High-Risk Patients?
A meeting attendee asked if a patient is “known to be high risk on biopsy, and has a 23% chance of metastasis after treatment, why treat with local treatment in the first place?”
“For these patients, we’re meeting them up front and they have a high risk of disease, a 23% chance of metastasis, I think we’re going to throw everything we can at them,” Dr. Nguyen said. Multiple randomized controlled trials indicate intensifying therapy can improve outcomes and that local therapy contributes to overall survival in these patients, he added. “For these patients who have very high risk disease, we have enough randomized data to show local therapy is still important. The next thing we need to do is work on personalizing their systemic therapy, and figuring out how to integrate these novel systemic therapies based on their genomic scores.”
Disease-Specific Survival
Eleven participants in the study died from prostate cancer. The only variable associated with prostate-specific disease mortality was the Decipher classification, with a hazard ratio of 1.57 for every 10% increase in the score on a univariate model (P = .02).
Dr. Nguyen and his coinvestigators also assessed 5-year prostate cancer specific mortality. They found a 9.4% rate in the Decipher high-risk group, compared with 0% in both the intermediate- and low-risk groups.
“Okay, we have this data. How do we incorporate this test into our practices?” Dr. Nguyen asked. Because the low-risk patients only comprised 13% of the study population, he was unable to state that this group could be directed to active surveillance based on the findings.
What about NCCN intermediate risk? Should these people treated with dose-escalated radiation therapy also be given short-course hormone therapy? “So far we have not seen a survival improvement, and we’re awaiting a definitive trial,” Dr. Nguyen said.
Prognostic, Not Predictive
Could the high-risk classification help physicians decide among prostatectomy, radiation, and long-course hormone therapy versus enrolling patients in a clinical trial to test a novel agent? “Perhaps, and there is some rationale for thinking in that direction,” Dr. Nguyen said. “But it is important to understand the difference between a prognostic and predictive biomarker. We’ve shown Decipher has prognostic value for identifying patients at risk for distant metastases and death.” In contrast, randomized controlled trials would be required to identify a predictive marker that ultimately could guide choice of treatment in an individual, he said.
“Robust markers are needed to see who needs treatment, and which treatment is best for primary and metastatic prostate cancer,” said study discussant Angelo DeMarzo, MD, PhD, of Johns Hopkins University. He asked Dr. Nguyen about the next best step in his research.
“Our paper was mostly intermediate- and high-risk patients; I would personally love to learn more about which patients need long-course, short-course, or no hormone treatment,” Dr. Nguyen said. He would also like to conduct randomized trials to assess any role of Decipher classification for active surveillance, and for guiding treatment intensification versus de-escalation for those patients who receive therapy.
ORLANDO – A genetic assay for prostate cancer typically used after radical prostatectomy could be used earlier, at the time of diagnostic biopsy testing, to classify patients as low, intermediate, and high risk for metastasis and disease-specific mortality, new research reveals.
Based on an approximately 1-mm biopsy sample, the Decipher Prostate Cancer Classifier assesses the activity of 22 genes relevant to prostate cancer. In a multicenter study of 175 patients, investigators found the 5-year risk for metastatic disease was 5.0% among patients classified as low risk by Decipher, 9.3% in the intermediate-risk group, and 23.4% in the high-risk patients.
“It turns out NCCN [National Comprehensive Cancer Network] risk groups can also provide this kind of risk stratification … so why do we need the extra test?” lead author Paul L. Nguyen, MD, of Dana-Farber Cancer Institute in Boston said here at the Genitourinary Cancers Symposium sponsored by the American Society of Clinical Oncology, ASTRO, and the Society of Urologic Oncology. Because, he added, Decipher provides “significant prognostic information for distant metastases beyond clinical variables alone,” even after controlling for prostate-specific antigen level, Gleason score, and treatment type, Dr. Nguyen said.
The Decipher RNA–based test also improved the c-index for predicting likelihood of distant metastases, with a 0.75 correlation, compared with 0.66 with NCCN risk stratification and 0.66 based on Cancer of the Prostate Risk Assessment score. “So this adds to what we already know, and it helps us decide which patients are going to develop metastases.”
Decipher’s prognostic value emerged regardless of first line therapy. A total 100 patients received radiation and androgen therapy at Dana-Farber and another 75 underwent radical prostatectomy at the Cleveland Clinic or Johns Hopkins University, Baltimore. Decipher classified 13% of patients as low risk, 51% as intermediate risk, and 34% as high risk. Because prostate tumors can be heterogeneous, researchers chose the highest-grade biopsy sample for each patient.
Local Therapy for High-Risk Patients?
A meeting attendee asked if a patient is “known to be high risk on biopsy, and has a 23% chance of metastasis after treatment, why treat with local treatment in the first place?”
“For these patients, we’re meeting them up front and they have a high risk of disease, a 23% chance of metastasis, I think we’re going to throw everything we can at them,” Dr. Nguyen said. Multiple randomized controlled trials indicate intensifying therapy can improve outcomes and that local therapy contributes to overall survival in these patients, he added. “For these patients who have very high risk disease, we have enough randomized data to show local therapy is still important. The next thing we need to do is work on personalizing their systemic therapy, and figuring out how to integrate these novel systemic therapies based on their genomic scores.”
Disease-Specific Survival
Eleven participants in the study died from prostate cancer. The only variable associated with prostate-specific disease mortality was the Decipher classification, with a hazard ratio of 1.57 for every 10% increase in the score on a univariate model (P = .02).
Dr. Nguyen and his coinvestigators also assessed 5-year prostate cancer specific mortality. They found a 9.4% rate in the Decipher high-risk group, compared with 0% in both the intermediate- and low-risk groups.
“Okay, we have this data. How do we incorporate this test into our practices?” Dr. Nguyen asked. Because the low-risk patients only comprised 13% of the study population, he was unable to state that this group could be directed to active surveillance based on the findings.
What about NCCN intermediate risk? Should these people treated with dose-escalated radiation therapy also be given short-course hormone therapy? “So far we have not seen a survival improvement, and we’re awaiting a definitive trial,” Dr. Nguyen said.
Prognostic, Not Predictive
Could the high-risk classification help physicians decide among prostatectomy, radiation, and long-course hormone therapy versus enrolling patients in a clinical trial to test a novel agent? “Perhaps, and there is some rationale for thinking in that direction,” Dr. Nguyen said. “But it is important to understand the difference between a prognostic and predictive biomarker. We’ve shown Decipher has prognostic value for identifying patients at risk for distant metastases and death.” In contrast, randomized controlled trials would be required to identify a predictive marker that ultimately could guide choice of treatment in an individual, he said.
“Robust markers are needed to see who needs treatment, and which treatment is best for primary and metastatic prostate cancer,” said study discussant Angelo DeMarzo, MD, PhD, of Johns Hopkins University. He asked Dr. Nguyen about the next best step in his research.
“Our paper was mostly intermediate- and high-risk patients; I would personally love to learn more about which patients need long-course, short-course, or no hormone treatment,” Dr. Nguyen said. He would also like to conduct randomized trials to assess any role of Decipher classification for active surveillance, and for guiding treatment intensification versus de-escalation for those patients who receive therapy.
ORLANDO – A genetic assay for prostate cancer typically used after radical prostatectomy could be used earlier, at the time of diagnostic biopsy testing, to classify patients as low, intermediate, and high risk for metastasis and disease-specific mortality, new research reveals.
Based on an approximately 1-mm biopsy sample, the Decipher Prostate Cancer Classifier assesses the activity of 22 genes relevant to prostate cancer. In a multicenter study of 175 patients, investigators found the 5-year risk for metastatic disease was 5.0% among patients classified as low risk by Decipher, 9.3% in the intermediate-risk group, and 23.4% in the high-risk patients.
“It turns out NCCN [National Comprehensive Cancer Network] risk groups can also provide this kind of risk stratification … so why do we need the extra test?” lead author Paul L. Nguyen, MD, of Dana-Farber Cancer Institute in Boston said here at the Genitourinary Cancers Symposium sponsored by the American Society of Clinical Oncology, ASTRO, and the Society of Urologic Oncology. Because, he added, Decipher provides “significant prognostic information for distant metastases beyond clinical variables alone,” even after controlling for prostate-specific antigen level, Gleason score, and treatment type, Dr. Nguyen said.
The Decipher RNA–based test also improved the c-index for predicting likelihood of distant metastases, with a 0.75 correlation, compared with 0.66 with NCCN risk stratification and 0.66 based on Cancer of the Prostate Risk Assessment score. “So this adds to what we already know, and it helps us decide which patients are going to develop metastases.”
Decipher’s prognostic value emerged regardless of first line therapy. A total 100 patients received radiation and androgen therapy at Dana-Farber and another 75 underwent radical prostatectomy at the Cleveland Clinic or Johns Hopkins University, Baltimore. Decipher classified 13% of patients as low risk, 51% as intermediate risk, and 34% as high risk. Because prostate tumors can be heterogeneous, researchers chose the highest-grade biopsy sample for each patient.
Local Therapy for High-Risk Patients?
A meeting attendee asked if a patient is “known to be high risk on biopsy, and has a 23% chance of metastasis after treatment, why treat with local treatment in the first place?”
“For these patients, we’re meeting them up front and they have a high risk of disease, a 23% chance of metastasis, I think we’re going to throw everything we can at them,” Dr. Nguyen said. Multiple randomized controlled trials indicate intensifying therapy can improve outcomes and that local therapy contributes to overall survival in these patients, he added. “For these patients who have very high risk disease, we have enough randomized data to show local therapy is still important. The next thing we need to do is work on personalizing their systemic therapy, and figuring out how to integrate these novel systemic therapies based on their genomic scores.”
Disease-Specific Survival
Eleven participants in the study died from prostate cancer. The only variable associated with prostate-specific disease mortality was the Decipher classification, with a hazard ratio of 1.57 for every 10% increase in the score on a univariate model (P = .02).
Dr. Nguyen and his coinvestigators also assessed 5-year prostate cancer specific mortality. They found a 9.4% rate in the Decipher high-risk group, compared with 0% in both the intermediate- and low-risk groups.
“Okay, we have this data. How do we incorporate this test into our practices?” Dr. Nguyen asked. Because the low-risk patients only comprised 13% of the study population, he was unable to state that this group could be directed to active surveillance based on the findings.
What about NCCN intermediate risk? Should these people treated with dose-escalated radiation therapy also be given short-course hormone therapy? “So far we have not seen a survival improvement, and we’re awaiting a definitive trial,” Dr. Nguyen said.
Prognostic, Not Predictive
Could the high-risk classification help physicians decide among prostatectomy, radiation, and long-course hormone therapy versus enrolling patients in a clinical trial to test a novel agent? “Perhaps, and there is some rationale for thinking in that direction,” Dr. Nguyen said. “But it is important to understand the difference between a prognostic and predictive biomarker. We’ve shown Decipher has prognostic value for identifying patients at risk for distant metastases and death.” In contrast, randomized controlled trials would be required to identify a predictive marker that ultimately could guide choice of treatment in an individual, he said.
“Robust markers are needed to see who needs treatment, and which treatment is best for primary and metastatic prostate cancer,” said study discussant Angelo DeMarzo, MD, PhD, of Johns Hopkins University. He asked Dr. Nguyen about the next best step in his research.
“Our paper was mostly intermediate- and high-risk patients; I would personally love to learn more about which patients need long-course, short-course, or no hormone treatment,” Dr. Nguyen said. He would also like to conduct randomized trials to assess any role of Decipher classification for active surveillance, and for guiding treatment intensification versus de-escalation for those patients who receive therapy.
AT THE GENITOURINARY CANCERS SYMPOSIUM
Key clinical point: A genomic test accurately risk stratifies patients with prostate cancer in study.
Major finding: Five-year risk of metastasis was 5.0% in a low-risk group, 9.3% in an intermediate-risk group, and 23.4% in a high-risk group.
Data source: A multicenter trial of needle biopsy samples taken from 175 people with prostate cancer.
Disclosures: Dr, Nguyen is a consultant/advisor for Ferring, GenomeDx, and Medivation, and also receives research funding from Astellas.
Study finds Roux-en-Y safe, effective for older patients
LAS VEGAS – Older obese patients shouldn’t be excluded from undergoing a Roux-en-Y gastric bypass based on concern for their long-term survival.
A 30-year review has determined that patients 60 years and older who had the surgery lost most of their excess body weight, and lived just as long as an age- and weight- matched cohort.
“We found a major weight loss benefit and no long-term differences in survival,” Taryn Hassinger, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “Our data support the use of this surgery in the elderly to achieve safe and effective weight loss.”
These subjects were matched for age and baseline weight to a group of 425 who did not have any bariatric surgery. Survival data in the univariate analysis came from Social Security death records.
The groups were similar at baseline, with a mean age of 62 and a mean body mass index of 47 kg/m2. About half of each group had obstructive sleep apnea. Other comorbidities were osteoarthritis (63%), chronic obstructive pulmonary disease (24%), type 2 diabetes (58%), gastroesophageal reflux (52%), congestive heart failure (8%), and hypertension (78%). About a quarter of each group smoked.
Patients were followed for up to 6 years. At the end of follow-up, those who had the surgery had lost a mean of 84% of their excess body weight. There was hardly any weight loss evident in the control group – a mean reduction of 4.6%. At the end of the follow-up period, 90% of surgical patients and 93% of the control patients were still alive.
The study provides reassuring data in an area that has not been well explored, Dr. Hassinger added. The only extant studies have compared older and younger cohorts. Peter Muscarella, MD, who moderated the session, agreed.
“This is very interesting, and good to know as we continue to expand the use of Roux-en-Y into different populations,” said Dr. Muscarella, a surgeon at Montefiore Medical Center, New York. “We have already expanded it into the pediatric population and now we are looking at its use in older individuals. But one question is, are there epidemiologic data on obesity in elderly patients? In my own practice, I just don’t see a lot of obese elderly patients. Is this really a problem in our country?”
A 2012 paper published by the National Center for Health Statistics addressed this issue. Data from the National Health and Nutrition Examination Survey, 2007-2010, found that nearly one-third of U.S. adults aged 65 years and older were obese. Other key findings:
• Obesity prevalence was higher among those aged 65-74, compared with those aged 75 and over in both men and women.
• The prevalence of obesity in women aged 65-74 was higher than in women aged 75 and over in all racial and ethnic groups except non-Hispanic black women, where approximately one in two were obese among both age groups.
• Between 1999-2002 and 2007-2010, the prevalence of obesity among older men increased.
As the proportion of older adults increases in the U.S. population, surgeons are likely to see older patients who are candidates for bariatric surgery, Dr. Hassinger said.
“We believe that surgery may be an option for people who are in the 60-70 year range,” she said. “We do operate on those patients not infrequently.”
The investigator had no disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Older obese patients shouldn’t be excluded from undergoing a Roux-en-Y gastric bypass based on concern for their long-term survival.
A 30-year review has determined that patients 60 years and older who had the surgery lost most of their excess body weight, and lived just as long as an age- and weight- matched cohort.
“We found a major weight loss benefit and no long-term differences in survival,” Taryn Hassinger, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “Our data support the use of this surgery in the elderly to achieve safe and effective weight loss.”
These subjects were matched for age and baseline weight to a group of 425 who did not have any bariatric surgery. Survival data in the univariate analysis came from Social Security death records.
The groups were similar at baseline, with a mean age of 62 and a mean body mass index of 47 kg/m2. About half of each group had obstructive sleep apnea. Other comorbidities were osteoarthritis (63%), chronic obstructive pulmonary disease (24%), type 2 diabetes (58%), gastroesophageal reflux (52%), congestive heart failure (8%), and hypertension (78%). About a quarter of each group smoked.
Patients were followed for up to 6 years. At the end of follow-up, those who had the surgery had lost a mean of 84% of their excess body weight. There was hardly any weight loss evident in the control group – a mean reduction of 4.6%. At the end of the follow-up period, 90% of surgical patients and 93% of the control patients were still alive.
The study provides reassuring data in an area that has not been well explored, Dr. Hassinger added. The only extant studies have compared older and younger cohorts. Peter Muscarella, MD, who moderated the session, agreed.
“This is very interesting, and good to know as we continue to expand the use of Roux-en-Y into different populations,” said Dr. Muscarella, a surgeon at Montefiore Medical Center, New York. “We have already expanded it into the pediatric population and now we are looking at its use in older individuals. But one question is, are there epidemiologic data on obesity in elderly patients? In my own practice, I just don’t see a lot of obese elderly patients. Is this really a problem in our country?”
A 2012 paper published by the National Center for Health Statistics addressed this issue. Data from the National Health and Nutrition Examination Survey, 2007-2010, found that nearly one-third of U.S. adults aged 65 years and older were obese. Other key findings:
• Obesity prevalence was higher among those aged 65-74, compared with those aged 75 and over in both men and women.
• The prevalence of obesity in women aged 65-74 was higher than in women aged 75 and over in all racial and ethnic groups except non-Hispanic black women, where approximately one in two were obese among both age groups.
• Between 1999-2002 and 2007-2010, the prevalence of obesity among older men increased.
As the proportion of older adults increases in the U.S. population, surgeons are likely to see older patients who are candidates for bariatric surgery, Dr. Hassinger said.
“We believe that surgery may be an option for people who are in the 60-70 year range,” she said. “We do operate on those patients not infrequently.”
The investigator had no disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Older obese patients shouldn’t be excluded from undergoing a Roux-en-Y gastric bypass based on concern for their long-term survival.
A 30-year review has determined that patients 60 years and older who had the surgery lost most of their excess body weight, and lived just as long as an age- and weight- matched cohort.
“We found a major weight loss benefit and no long-term differences in survival,” Taryn Hassinger, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “Our data support the use of this surgery in the elderly to achieve safe and effective weight loss.”
These subjects were matched for age and baseline weight to a group of 425 who did not have any bariatric surgery. Survival data in the univariate analysis came from Social Security death records.
The groups were similar at baseline, with a mean age of 62 and a mean body mass index of 47 kg/m2. About half of each group had obstructive sleep apnea. Other comorbidities were osteoarthritis (63%), chronic obstructive pulmonary disease (24%), type 2 diabetes (58%), gastroesophageal reflux (52%), congestive heart failure (8%), and hypertension (78%). About a quarter of each group smoked.
Patients were followed for up to 6 years. At the end of follow-up, those who had the surgery had lost a mean of 84% of their excess body weight. There was hardly any weight loss evident in the control group – a mean reduction of 4.6%. At the end of the follow-up period, 90% of surgical patients and 93% of the control patients were still alive.
The study provides reassuring data in an area that has not been well explored, Dr. Hassinger added. The only extant studies have compared older and younger cohorts. Peter Muscarella, MD, who moderated the session, agreed.
“This is very interesting, and good to know as we continue to expand the use of Roux-en-Y into different populations,” said Dr. Muscarella, a surgeon at Montefiore Medical Center, New York. “We have already expanded it into the pediatric population and now we are looking at its use in older individuals. But one question is, are there epidemiologic data on obesity in elderly patients? In my own practice, I just don’t see a lot of obese elderly patients. Is this really a problem in our country?”
A 2012 paper published by the National Center for Health Statistics addressed this issue. Data from the National Health and Nutrition Examination Survey, 2007-2010, found that nearly one-third of U.S. adults aged 65 years and older were obese. Other key findings:
• Obesity prevalence was higher among those aged 65-74, compared with those aged 75 and over in both men and women.
• The prevalence of obesity in women aged 65-74 was higher than in women aged 75 and over in all racial and ethnic groups except non-Hispanic black women, where approximately one in two were obese among both age groups.
• Between 1999-2002 and 2007-2010, the prevalence of obesity among older men increased.
As the proportion of older adults increases in the U.S. population, surgeons are likely to see older patients who are candidates for bariatric surgery, Dr. Hassinger said.
“We believe that surgery may be an option for people who are in the 60-70 year range,” she said. “We do operate on those patients not infrequently.”
The investigator had no disclosures.
[email protected]
On Twitter @Alz_Gal
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Older patients can safely lose weight after Roux-en-Y gastric bypass without excess mortality risk.
Major finding: At the end of follow-up, patients had lost a mean of 84% of their excess body weight, compared with 4.6% loss in controls. Survival was similar (90% of surgical patients and 93% of controls).
Data source: The retrospective study comprised 107 patients and 425 controls.
Disclosures: The investigator had no disclosures.
Strength in Community
No question about it, we are entering another uncertain time in health care.
Those of us of a “certain age” may yearn for a return to the days when we surgeons faced few restrictions on our practice or our decisions. Each of us has developed his/her own perspective on the state of U.S. health care and the best path forward, most frequently shaped by our background, geographical location, and practice environment. The tendency among a great many of us has been to erect walls rather than bridges and to view our own situation as unique and more threatened than that of others. Specialists and generalists, urbanites and rural dwellers, all tend to view their own worlds as uniquely challenging.
If there was ever a need to reach out and communicate with one another and understand that the overwhelming desire of every surgeon is to provide his/her patients with the best possible care, it is now. After all, we’re all surgeons who face the same sets of challenges in the OR. There is far more in our professional lives that unites us than separates us. It is critically important that surgeons maintain open lines of communication and solidarity, no matter what other characteristics of politics or place separate us. How do we accomplish this seemingly Herculean task in the midst of the dissension and disintegration occurring all around us?
One powerful tool that can help break down barriers to honest dialogue and reinforce solidarity among surgeons is the ACS Communities. This hugely successful communication platform, which grew out of the old ACS Rural List, is now an electronic meeting place and venue for dialogue for all members of the College. The Communities is a safe place where participants, despite their many differences in specialty, location, practice type, and political views, share the common goal of improving the care available to our patients. Postings range across a wide spectrum of topics – from clinical to fiscal, social, personal and philosophical, sometimes all in the same thread. All ACS Fellows are free to sign up and post on any subject that is of concern to them, as long as their postings adhere to a baseline respect for other members. The contributions are curated by Tyler G Hughes, MD, FACS, coeditor of ACS Surgery News, but they rarely stray from the boundaries of civil discourse.
The diversity of voices on the Communities is gratifying. Midcareer surgeons, recent grads, and retired specialists all converse with each other in this space. Surgeons from different practice types and locales, including from those who work in rural critical access hospitals and those in academic medical centers, all come to discuss, ask for opinions, exchange information, and debate. These colleagues offer opinions based on long years of practice and from article of the highest quality from the literature. The whole is somehow greater than the sum of its parts. Divergent opinions add depth and breadth to any conversation and lead to a greater understanding of the entirety of a subject. I always learn something from these dialogues.
Most threads involve questions about clinical issues that have arisen in the author’s practice. One recent topic was interval cholecystectomy in which the question was raised about whether the gallbladder needs to be removed after placement of a tube cholecystostomy (usually by Interventional Radiology) for acute cholecystitis, a practice that seems to be proliferating in many areas. Over a two-week period, responses poured in from a wide variety of practice sites and types and ranged from expert opinion to references from the literature. Other threads involve less commonly encountered conditions such as coccydynia or splenic cysts or offer opinions about such “hot-button” items” as attire in the OR or music in the OR. Almost every subject is interesting and provides the reader with food for thought.
Other topics stray from the purely clinical or surgical to the health care system itself. One current ongoing and timely subject of a thread on the ACS General Surgery community is entitled “Care for the Vulnerable vs. Cash for the Powerful.” Opinions have been expressed from many perspectives and have truly been educational and enlightening. While the general public discourse has been fraught and divisive, the Communities discussions have been respectful and collegial. This basic unity underlying our diversity is the foundation of the Communities and it is a source of strength for the surgical profession.
The ACS Communities is the work of many hands and hearts over many years, and I am truly grateful to those who made it happen and to the ACS for sponsoring this great platform for communication.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Coeditor of ACS Surgery News.
No question about it, we are entering another uncertain time in health care.
Those of us of a “certain age” may yearn for a return to the days when we surgeons faced few restrictions on our practice or our decisions. Each of us has developed his/her own perspective on the state of U.S. health care and the best path forward, most frequently shaped by our background, geographical location, and practice environment. The tendency among a great many of us has been to erect walls rather than bridges and to view our own situation as unique and more threatened than that of others. Specialists and generalists, urbanites and rural dwellers, all tend to view their own worlds as uniquely challenging.
If there was ever a need to reach out and communicate with one another and understand that the overwhelming desire of every surgeon is to provide his/her patients with the best possible care, it is now. After all, we’re all surgeons who face the same sets of challenges in the OR. There is far more in our professional lives that unites us than separates us. It is critically important that surgeons maintain open lines of communication and solidarity, no matter what other characteristics of politics or place separate us. How do we accomplish this seemingly Herculean task in the midst of the dissension and disintegration occurring all around us?
One powerful tool that can help break down barriers to honest dialogue and reinforce solidarity among surgeons is the ACS Communities. This hugely successful communication platform, which grew out of the old ACS Rural List, is now an electronic meeting place and venue for dialogue for all members of the College. The Communities is a safe place where participants, despite their many differences in specialty, location, practice type, and political views, share the common goal of improving the care available to our patients. Postings range across a wide spectrum of topics – from clinical to fiscal, social, personal and philosophical, sometimes all in the same thread. All ACS Fellows are free to sign up and post on any subject that is of concern to them, as long as their postings adhere to a baseline respect for other members. The contributions are curated by Tyler G Hughes, MD, FACS, coeditor of ACS Surgery News, but they rarely stray from the boundaries of civil discourse.
The diversity of voices on the Communities is gratifying. Midcareer surgeons, recent grads, and retired specialists all converse with each other in this space. Surgeons from different practice types and locales, including from those who work in rural critical access hospitals and those in academic medical centers, all come to discuss, ask for opinions, exchange information, and debate. These colleagues offer opinions based on long years of practice and from article of the highest quality from the literature. The whole is somehow greater than the sum of its parts. Divergent opinions add depth and breadth to any conversation and lead to a greater understanding of the entirety of a subject. I always learn something from these dialogues.
Most threads involve questions about clinical issues that have arisen in the author’s practice. One recent topic was interval cholecystectomy in which the question was raised about whether the gallbladder needs to be removed after placement of a tube cholecystostomy (usually by Interventional Radiology) for acute cholecystitis, a practice that seems to be proliferating in many areas. Over a two-week period, responses poured in from a wide variety of practice sites and types and ranged from expert opinion to references from the literature. Other threads involve less commonly encountered conditions such as coccydynia or splenic cysts or offer opinions about such “hot-button” items” as attire in the OR or music in the OR. Almost every subject is interesting and provides the reader with food for thought.
Other topics stray from the purely clinical or surgical to the health care system itself. One current ongoing and timely subject of a thread on the ACS General Surgery community is entitled “Care for the Vulnerable vs. Cash for the Powerful.” Opinions have been expressed from many perspectives and have truly been educational and enlightening. While the general public discourse has been fraught and divisive, the Communities discussions have been respectful and collegial. This basic unity underlying our diversity is the foundation of the Communities and it is a source of strength for the surgical profession.
The ACS Communities is the work of many hands and hearts over many years, and I am truly grateful to those who made it happen and to the ACS for sponsoring this great platform for communication.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Coeditor of ACS Surgery News.
No question about it, we are entering another uncertain time in health care.
Those of us of a “certain age” may yearn for a return to the days when we surgeons faced few restrictions on our practice or our decisions. Each of us has developed his/her own perspective on the state of U.S. health care and the best path forward, most frequently shaped by our background, geographical location, and practice environment. The tendency among a great many of us has been to erect walls rather than bridges and to view our own situation as unique and more threatened than that of others. Specialists and generalists, urbanites and rural dwellers, all tend to view their own worlds as uniquely challenging.
If there was ever a need to reach out and communicate with one another and understand that the overwhelming desire of every surgeon is to provide his/her patients with the best possible care, it is now. After all, we’re all surgeons who face the same sets of challenges in the OR. There is far more in our professional lives that unites us than separates us. It is critically important that surgeons maintain open lines of communication and solidarity, no matter what other characteristics of politics or place separate us. How do we accomplish this seemingly Herculean task in the midst of the dissension and disintegration occurring all around us?
One powerful tool that can help break down barriers to honest dialogue and reinforce solidarity among surgeons is the ACS Communities. This hugely successful communication platform, which grew out of the old ACS Rural List, is now an electronic meeting place and venue for dialogue for all members of the College. The Communities is a safe place where participants, despite their many differences in specialty, location, practice type, and political views, share the common goal of improving the care available to our patients. Postings range across a wide spectrum of topics – from clinical to fiscal, social, personal and philosophical, sometimes all in the same thread. All ACS Fellows are free to sign up and post on any subject that is of concern to them, as long as their postings adhere to a baseline respect for other members. The contributions are curated by Tyler G Hughes, MD, FACS, coeditor of ACS Surgery News, but they rarely stray from the boundaries of civil discourse.
The diversity of voices on the Communities is gratifying. Midcareer surgeons, recent grads, and retired specialists all converse with each other in this space. Surgeons from different practice types and locales, including from those who work in rural critical access hospitals and those in academic medical centers, all come to discuss, ask for opinions, exchange information, and debate. These colleagues offer opinions based on long years of practice and from article of the highest quality from the literature. The whole is somehow greater than the sum of its parts. Divergent opinions add depth and breadth to any conversation and lead to a greater understanding of the entirety of a subject. I always learn something from these dialogues.
Most threads involve questions about clinical issues that have arisen in the author’s practice. One recent topic was interval cholecystectomy in which the question was raised about whether the gallbladder needs to be removed after placement of a tube cholecystostomy (usually by Interventional Radiology) for acute cholecystitis, a practice that seems to be proliferating in many areas. Over a two-week period, responses poured in from a wide variety of practice sites and types and ranged from expert opinion to references from the literature. Other threads involve less commonly encountered conditions such as coccydynia or splenic cysts or offer opinions about such “hot-button” items” as attire in the OR or music in the OR. Almost every subject is interesting and provides the reader with food for thought.
Other topics stray from the purely clinical or surgical to the health care system itself. One current ongoing and timely subject of a thread on the ACS General Surgery community is entitled “Care for the Vulnerable vs. Cash for the Powerful.” Opinions have been expressed from many perspectives and have truly been educational and enlightening. While the general public discourse has been fraught and divisive, the Communities discussions have been respectful and collegial. This basic unity underlying our diversity is the foundation of the Communities and it is a source of strength for the surgical profession.
The ACS Communities is the work of many hands and hearts over many years, and I am truly grateful to those who made it happen and to the ACS for sponsoring this great platform for communication.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Coeditor of ACS Surgery News.
Initiating a surgical society within the ACS: The renewed Excelsior Surgical Society
At the end of World War II, surgeons who had served during the conflict gathered at the Excelsior Hotel in Rome, Italy, to discuss their experiences. This meeting was the first of what would be called the Excelsior Surgical Society. These meetings continued annually until the death of the last World War II member, Michael E. DeBakey, MD, FACS.
Visit the society’s web page for more information and to apply for membership.
Day-long meeting
In conjunction with Clinical Congress 2016, the Excelsior Surgical Society held a day-long meeting, with nearly 200 active and retired military surgeons, residents, and students in attendance. The meeting included discussion of the following topics:
• State of the Service addresses by the three General Surgery Consultants to the Army, Navy, and Air Force Surgeon Generals:
o COL Mary Edwards, MD, FACS (Army).
o CAPT Craig Shepps, MD, FACS (Navy).
o COL Gregory York, MD, FACS (Air Force).
• The John Pryor Annual Lectureship, delivered by retired Army COL Norman M. Rich, MD, FACS, department of surgery, Uniformed Services University of the Health Sciences (USUHS) and the Walter Reed National Military Medical Center (WRNMMC), Bethesda, Md.
• The Committee on Trauma Region 13 (Military Region) annual resident paper competition.
• Abstracts on various surgical topics submitted by surgeons from multiple military health care facilities across the country.
• Panel discussions on training and sustainment for surgeons in the military.
Election of Officers
At the business meeting, the following Excelsior Surgical Society Officers were elected:
• President: CAPT Eric Elster, MD, FACS, U.S. Navy, professor and chairman, department of surgery at USUHS and WRNMMC.
• Vice-President: COL Stacy Shackelford, MD, FACS, U.S. Air Force, deputy commander for clinical services/chief of the medical staff 455th Expeditionary Medical Dental Group, Craig Joint Theater Hospital Bagram Airfield, Afghanistan.
• Secretary: COL Robert B. Lim, MD, FACS, U.S. Army, chief, metabolic and advanced laparoscopic surgery, Tripler Army Medical Center, Honolulu, Hawaii.
• Treasurer: COL Kirby R. Gross, MD, FACS, U.S. Army, director, Army Trauma Training Center, University of Miami, Fla.
• Councilperson at Large, U.S. Army: COL Matthew Martin, MD, FACS, FASMBS, trauma medical director, Madigan Army Medical Center, Tacoma, Wash.
• Councilperson at Large, U.S. Navy: CPT Gordon Wisbach, MD, FACS, staff surgeon, department of general surgery, Naval Medical Center San Diego, Calif.
• Councilperson at Large, U.S. Air Force: Col Joe DuBose, MD, FACS, vascular and trauma surgeon, Travis Air Force Base, Calif.
• Councilperson at Large, Reserve/National Guard: COL Jay A. Johannigman, MD, FACS, director of the division of trauma and surgical critical care and professor of surgery at the University of Cincinnati, Ohio.
• Honorary Member: Dr. Rich, Leonard Heaton & David Packard Professor, founding chairman, department of surgery, USUHS and WRNMMC.
At the end of World War II, surgeons who had served during the conflict gathered at the Excelsior Hotel in Rome, Italy, to discuss their experiences. This meeting was the first of what would be called the Excelsior Surgical Society. These meetings continued annually until the death of the last World War II member, Michael E. DeBakey, MD, FACS.
Visit the society’s web page for more information and to apply for membership.
Day-long meeting
In conjunction with Clinical Congress 2016, the Excelsior Surgical Society held a day-long meeting, with nearly 200 active and retired military surgeons, residents, and students in attendance. The meeting included discussion of the following topics:
• State of the Service addresses by the three General Surgery Consultants to the Army, Navy, and Air Force Surgeon Generals:
o COL Mary Edwards, MD, FACS (Army).
o CAPT Craig Shepps, MD, FACS (Navy).
o COL Gregory York, MD, FACS (Air Force).
• The John Pryor Annual Lectureship, delivered by retired Army COL Norman M. Rich, MD, FACS, department of surgery, Uniformed Services University of the Health Sciences (USUHS) and the Walter Reed National Military Medical Center (WRNMMC), Bethesda, Md.
• The Committee on Trauma Region 13 (Military Region) annual resident paper competition.
• Abstracts on various surgical topics submitted by surgeons from multiple military health care facilities across the country.
• Panel discussions on training and sustainment for surgeons in the military.
Election of Officers
At the business meeting, the following Excelsior Surgical Society Officers were elected:
• President: CAPT Eric Elster, MD, FACS, U.S. Navy, professor and chairman, department of surgery at USUHS and WRNMMC.
• Vice-President: COL Stacy Shackelford, MD, FACS, U.S. Air Force, deputy commander for clinical services/chief of the medical staff 455th Expeditionary Medical Dental Group, Craig Joint Theater Hospital Bagram Airfield, Afghanistan.
• Secretary: COL Robert B. Lim, MD, FACS, U.S. Army, chief, metabolic and advanced laparoscopic surgery, Tripler Army Medical Center, Honolulu, Hawaii.
• Treasurer: COL Kirby R. Gross, MD, FACS, U.S. Army, director, Army Trauma Training Center, University of Miami, Fla.
• Councilperson at Large, U.S. Army: COL Matthew Martin, MD, FACS, FASMBS, trauma medical director, Madigan Army Medical Center, Tacoma, Wash.
• Councilperson at Large, U.S. Navy: CPT Gordon Wisbach, MD, FACS, staff surgeon, department of general surgery, Naval Medical Center San Diego, Calif.
• Councilperson at Large, U.S. Air Force: Col Joe DuBose, MD, FACS, vascular and trauma surgeon, Travis Air Force Base, Calif.
• Councilperson at Large, Reserve/National Guard: COL Jay A. Johannigman, MD, FACS, director of the division of trauma and surgical critical care and professor of surgery at the University of Cincinnati, Ohio.
• Honorary Member: Dr. Rich, Leonard Heaton & David Packard Professor, founding chairman, department of surgery, USUHS and WRNMMC.
At the end of World War II, surgeons who had served during the conflict gathered at the Excelsior Hotel in Rome, Italy, to discuss their experiences. This meeting was the first of what would be called the Excelsior Surgical Society. These meetings continued annually until the death of the last World War II member, Michael E. DeBakey, MD, FACS.
Visit the society’s web page for more information and to apply for membership.
Day-long meeting
In conjunction with Clinical Congress 2016, the Excelsior Surgical Society held a day-long meeting, with nearly 200 active and retired military surgeons, residents, and students in attendance. The meeting included discussion of the following topics:
• State of the Service addresses by the three General Surgery Consultants to the Army, Navy, and Air Force Surgeon Generals:
o COL Mary Edwards, MD, FACS (Army).
o CAPT Craig Shepps, MD, FACS (Navy).
o COL Gregory York, MD, FACS (Air Force).
• The John Pryor Annual Lectureship, delivered by retired Army COL Norman M. Rich, MD, FACS, department of surgery, Uniformed Services University of the Health Sciences (USUHS) and the Walter Reed National Military Medical Center (WRNMMC), Bethesda, Md.
• The Committee on Trauma Region 13 (Military Region) annual resident paper competition.
• Abstracts on various surgical topics submitted by surgeons from multiple military health care facilities across the country.
• Panel discussions on training and sustainment for surgeons in the military.
Election of Officers
At the business meeting, the following Excelsior Surgical Society Officers were elected:
• President: CAPT Eric Elster, MD, FACS, U.S. Navy, professor and chairman, department of surgery at USUHS and WRNMMC.
• Vice-President: COL Stacy Shackelford, MD, FACS, U.S. Air Force, deputy commander for clinical services/chief of the medical staff 455th Expeditionary Medical Dental Group, Craig Joint Theater Hospital Bagram Airfield, Afghanistan.
• Secretary: COL Robert B. Lim, MD, FACS, U.S. Army, chief, metabolic and advanced laparoscopic surgery, Tripler Army Medical Center, Honolulu, Hawaii.
• Treasurer: COL Kirby R. Gross, MD, FACS, U.S. Army, director, Army Trauma Training Center, University of Miami, Fla.
• Councilperson at Large, U.S. Army: COL Matthew Martin, MD, FACS, FASMBS, trauma medical director, Madigan Army Medical Center, Tacoma, Wash.
• Councilperson at Large, U.S. Navy: CPT Gordon Wisbach, MD, FACS, staff surgeon, department of general surgery, Naval Medical Center San Diego, Calif.
• Councilperson at Large, U.S. Air Force: Col Joe DuBose, MD, FACS, vascular and trauma surgeon, Travis Air Force Base, Calif.
• Councilperson at Large, Reserve/National Guard: COL Jay A. Johannigman, MD, FACS, director of the division of trauma and surgical critical care and professor of surgery at the University of Cincinnati, Ohio.
• Honorary Member: Dr. Rich, Leonard Heaton & David Packard Professor, founding chairman, department of surgery, USUHS and WRNMMC.