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‘Organoid technology’ poised to transform cancer care
BOSTON– Imagine being able to .
The implications are nearly endless. To start, chemotherapy and radiation options could be screened in vitro, much like culture and sensitivity testing of bacteria, to find a patient’s best option. Tumor cultures could be banked for mass screening of new cytotoxic candidates.
It’s already beginning to happen in a few research labs around the world, and it might foretell a breakthrough in cancer treatment.
After decades of failure, the trick to growing tumor cells in culture has finally been figured out. When stem cells are fished out of healthy tissue – from the crypts of the gastrointestinal lining, for instance – and put into a three-dimensional matrix culture with growth factors, they grow into little replications of the organs they came from, called “organoids;” when stem cells are pulled from cancers, they replicate the primary tumor, growing into “tumoroids” ready to be tested against cytotoxic drugs and radiation.
Philip B. Paty, MD, FACS, a colorectal surgeon and organoid researcher at Memorial Sloan Kettering Cancer Center, New York, said he is certain that the person who led the team that figured out the right culture condition – Hans Clevers, MD, PhD, a molecular genetics professor at the University of Utrecht (the Netherlands) – is destined for a Nobel Prize.
Dr. Paty took a few minutes at the annual clinical congress of the American College of Surgeons to explain in an interview why, and what ‘organoid technology’ will likely mean for cancer treatment in a few years.
“The ability to grow and sustain cancer means that we now can start doing real science on human tissues. We could never do this before. We’ve been treating cancer without being able to grow tumors and study them.” The breakthrough opens the door to “clinical trials in a dish,” and will likely take personalized cancer treatment to a new level, he said.
“It remains to be proven that “organoid technology “can change outcomes for patients, but those studies are likely coming,” said Dr. Paty, who investigates tumoroid response to radiation in his own lab work.
BOSTON– Imagine being able to .
The implications are nearly endless. To start, chemotherapy and radiation options could be screened in vitro, much like culture and sensitivity testing of bacteria, to find a patient’s best option. Tumor cultures could be banked for mass screening of new cytotoxic candidates.
It’s already beginning to happen in a few research labs around the world, and it might foretell a breakthrough in cancer treatment.
After decades of failure, the trick to growing tumor cells in culture has finally been figured out. When stem cells are fished out of healthy tissue – from the crypts of the gastrointestinal lining, for instance – and put into a three-dimensional matrix culture with growth factors, they grow into little replications of the organs they came from, called “organoids;” when stem cells are pulled from cancers, they replicate the primary tumor, growing into “tumoroids” ready to be tested against cytotoxic drugs and radiation.
Philip B. Paty, MD, FACS, a colorectal surgeon and organoid researcher at Memorial Sloan Kettering Cancer Center, New York, said he is certain that the person who led the team that figured out the right culture condition – Hans Clevers, MD, PhD, a molecular genetics professor at the University of Utrecht (the Netherlands) – is destined for a Nobel Prize.
Dr. Paty took a few minutes at the annual clinical congress of the American College of Surgeons to explain in an interview why, and what ‘organoid technology’ will likely mean for cancer treatment in a few years.
“The ability to grow and sustain cancer means that we now can start doing real science on human tissues. We could never do this before. We’ve been treating cancer without being able to grow tumors and study them.” The breakthrough opens the door to “clinical trials in a dish,” and will likely take personalized cancer treatment to a new level, he said.
“It remains to be proven that “organoid technology “can change outcomes for patients, but those studies are likely coming,” said Dr. Paty, who investigates tumoroid response to radiation in his own lab work.
BOSTON– Imagine being able to .
The implications are nearly endless. To start, chemotherapy and radiation options could be screened in vitro, much like culture and sensitivity testing of bacteria, to find a patient’s best option. Tumor cultures could be banked for mass screening of new cytotoxic candidates.
It’s already beginning to happen in a few research labs around the world, and it might foretell a breakthrough in cancer treatment.
After decades of failure, the trick to growing tumor cells in culture has finally been figured out. When stem cells are fished out of healthy tissue – from the crypts of the gastrointestinal lining, for instance – and put into a three-dimensional matrix culture with growth factors, they grow into little replications of the organs they came from, called “organoids;” when stem cells are pulled from cancers, they replicate the primary tumor, growing into “tumoroids” ready to be tested against cytotoxic drugs and radiation.
Philip B. Paty, MD, FACS, a colorectal surgeon and organoid researcher at Memorial Sloan Kettering Cancer Center, New York, said he is certain that the person who led the team that figured out the right culture condition – Hans Clevers, MD, PhD, a molecular genetics professor at the University of Utrecht (the Netherlands) – is destined for a Nobel Prize.
Dr. Paty took a few minutes at the annual clinical congress of the American College of Surgeons to explain in an interview why, and what ‘organoid technology’ will likely mean for cancer treatment in a few years.
“The ability to grow and sustain cancer means that we now can start doing real science on human tissues. We could never do this before. We’ve been treating cancer without being able to grow tumors and study them.” The breakthrough opens the door to “clinical trials in a dish,” and will likely take personalized cancer treatment to a new level, he said.
“It remains to be proven that “organoid technology “can change outcomes for patients, but those studies are likely coming,” said Dr. Paty, who investigates tumoroid response to radiation in his own lab work.
REPORTING FROM THE ACS CLINICAL CONGRESS
‘Watch and wait’ good for most – but not all – rectal cancers
BOSTON –
was established over a decade ago, and widely adopted since then. The idea is to hold off on surgery after a complete response to chemotherapy and radiation, to see if the patient really needs it.
While most do not, tumors regrow in 20%-30%, and when they come back, they tend to be aggressive, with poor outcomes. Patients in those situations would have been better off with upfront surgery.
The problem right now is that there’s no way to predict who will be cured by neoadjuvant therapy and whose tumor will come back, said Philip Paty, MD. FACS, a colorectal surgeon at Memorial Sloan Kettering Cancer Center, New York.
“There are some who are probably harmed by the watch-and-wait paradigm. The risk of local regrowth is hardbaked into [the model]; we haven’t been able to eliminate it,” he said at the annual clinical congress of the American College of Surgeons..
Dr. Paty is one of many investigators working to identify those at risk. In the meantime, watch-and-wait patients need to be followed closely, particularly in the first 2 years. Surgery is the best option at the first sign of regrowth. Dr. Paty explained his follow-up protocol, as well as the current state of watch and wait for low rectal cancer, in an interview at the meeting.
He also talked about overcoming hurdles. The risk of surgery, including permanent bowel and sexual dysfunction, is so great “that many patients latch onto watch and wait and won’t let go. They don’t come back for follow-up, or resist the idea of surgery even if it’s needed,” he said.
BOSTON –
was established over a decade ago, and widely adopted since then. The idea is to hold off on surgery after a complete response to chemotherapy and radiation, to see if the patient really needs it.
While most do not, tumors regrow in 20%-30%, and when they come back, they tend to be aggressive, with poor outcomes. Patients in those situations would have been better off with upfront surgery.
The problem right now is that there’s no way to predict who will be cured by neoadjuvant therapy and whose tumor will come back, said Philip Paty, MD. FACS, a colorectal surgeon at Memorial Sloan Kettering Cancer Center, New York.
“There are some who are probably harmed by the watch-and-wait paradigm. The risk of local regrowth is hardbaked into [the model]; we haven’t been able to eliminate it,” he said at the annual clinical congress of the American College of Surgeons..
Dr. Paty is one of many investigators working to identify those at risk. In the meantime, watch-and-wait patients need to be followed closely, particularly in the first 2 years. Surgery is the best option at the first sign of regrowth. Dr. Paty explained his follow-up protocol, as well as the current state of watch and wait for low rectal cancer, in an interview at the meeting.
He also talked about overcoming hurdles. The risk of surgery, including permanent bowel and sexual dysfunction, is so great “that many patients latch onto watch and wait and won’t let go. They don’t come back for follow-up, or resist the idea of surgery even if it’s needed,” he said.
BOSTON –
was established over a decade ago, and widely adopted since then. The idea is to hold off on surgery after a complete response to chemotherapy and radiation, to see if the patient really needs it.
While most do not, tumors regrow in 20%-30%, and when they come back, they tend to be aggressive, with poor outcomes. Patients in those situations would have been better off with upfront surgery.
The problem right now is that there’s no way to predict who will be cured by neoadjuvant therapy and whose tumor will come back, said Philip Paty, MD. FACS, a colorectal surgeon at Memorial Sloan Kettering Cancer Center, New York.
“There are some who are probably harmed by the watch-and-wait paradigm. The risk of local regrowth is hardbaked into [the model]; we haven’t been able to eliminate it,” he said at the annual clinical congress of the American College of Surgeons..
Dr. Paty is one of many investigators working to identify those at risk. In the meantime, watch-and-wait patients need to be followed closely, particularly in the first 2 years. Surgery is the best option at the first sign of regrowth. Dr. Paty explained his follow-up protocol, as well as the current state of watch and wait for low rectal cancer, in an interview at the meeting.
He also talked about overcoming hurdles. The risk of surgery, including permanent bowel and sexual dysfunction, is so great “that many patients latch onto watch and wait and won’t let go. They don’t come back for follow-up, or resist the idea of surgery even if it’s needed,” he said.
EXPERT ANALYSIS FROM THE ACS CLINICAL CONGRESS
How to slash colorectal surgery infection rates
BOSTON – driven mostly by a reduction in deep organ space infections from 5.5% to 1.7%.
It was a remarkable finding that got the attention of attendees at the annual clinical congress of the American College of Surgeons. The Cleveland Clinic had been an outlier, in the wrong direction, compared with other centers, and administrators wanted a solution.
I. Emre Gorgun, MD, FACS, a colorectal surgeon and quality improvement officer at Cleveland Clinic, led the search for evidence-based interventions. Eventually, big changes were made to perioperative antibiotics, mechanical bowel prep, preop shower routines, and intraoperative procedures. The efforts paid off (Dis Colon Rectum. 2018 Jan;61[1]:89-98).
To help surgeons lower their own infection rates, Dr. Gorgun agreed to an interview at the meeting to explain exactly what was done.
There was resistance at first from surgeons who wanted to stick with their routines, but they came around once they were shown the data backing the changes. Eventually, “everyone was on board. We believe in this,” Dr. Gorgun said.
BOSTON – driven mostly by a reduction in deep organ space infections from 5.5% to 1.7%.
It was a remarkable finding that got the attention of attendees at the annual clinical congress of the American College of Surgeons. The Cleveland Clinic had been an outlier, in the wrong direction, compared with other centers, and administrators wanted a solution.
I. Emre Gorgun, MD, FACS, a colorectal surgeon and quality improvement officer at Cleveland Clinic, led the search for evidence-based interventions. Eventually, big changes were made to perioperative antibiotics, mechanical bowel prep, preop shower routines, and intraoperative procedures. The efforts paid off (Dis Colon Rectum. 2018 Jan;61[1]:89-98).
To help surgeons lower their own infection rates, Dr. Gorgun agreed to an interview at the meeting to explain exactly what was done.
There was resistance at first from surgeons who wanted to stick with their routines, but they came around once they were shown the data backing the changes. Eventually, “everyone was on board. We believe in this,” Dr. Gorgun said.
BOSTON – driven mostly by a reduction in deep organ space infections from 5.5% to 1.7%.
It was a remarkable finding that got the attention of attendees at the annual clinical congress of the American College of Surgeons. The Cleveland Clinic had been an outlier, in the wrong direction, compared with other centers, and administrators wanted a solution.
I. Emre Gorgun, MD, FACS, a colorectal surgeon and quality improvement officer at Cleveland Clinic, led the search for evidence-based interventions. Eventually, big changes were made to perioperative antibiotics, mechanical bowel prep, preop shower routines, and intraoperative procedures. The efforts paid off (Dis Colon Rectum. 2018 Jan;61[1]:89-98).
To help surgeons lower their own infection rates, Dr. Gorgun agreed to an interview at the meeting to explain exactly what was done.
There was resistance at first from surgeons who wanted to stick with their routines, but they came around once they were shown the data backing the changes. Eventually, “everyone was on board. We believe in this,” Dr. Gorgun said.
REPORTING FROM THE ACS CLINICAL CONGRESS
Quality programs drive improvements in colorectal surgery outcomes
BOSTON – Rates of (ACS NSQIP), a recent analysis shows.
Reoperation rates have also decreased, while early-discharge rates have steadily increased, according to results of the analysis, presented at the annual clinical congress of the American College of Surgeons.
The findings underline the value of such ACS-led initiatives in improving patient care and surgical quality, said Ahmed M. Al-Mazrou, MD, a general surgery resident at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York.
“Over its first decade of introduction, ACS NSQIP was associated with improved outcomes after colorectal surgery, and also introduction of colectomy-targeted data was also associated with improved outcomes,” Dr. Al-Mazrou said in his presentation describing the results.
Prior to this study, the question of whether the introduction of ACS NSQIP has improved outcomes over time had not been well characterized, according to Dr. Al-Mazrou and his colleagues.
To evaluate the impact, the investigators looked at more than 310,000 nonemergency colorectal resections in ACS NSQIP, of which about 58% were done after the introduction of colectomy-targeted variables in 2013.
They found that, over time, incidence of most complications fell, including surgical site infections, urinary tract infections, sepsis and septic shock, and venous thromboembolism, while rates of early discharge increased.
For example, surgical site infections decreased from 13.7% to 4.7% over the 10-year period, while the number of patients discharged within 5 days or fewer increased from about 8% to 47%.
Introduction of colectomy-targeted data was associated with fewer surgical site infections (odds ratio, 0.78; 95% confidence interval, 0.77-0.80), multivariable analysis showed. Likewise, there were lower rates of systemic infections (OR, 0.94; 95% CI, 0.91-0.98) and urinary tract infections (OR, 0.70; 95% CI, 0.67-0.74) after introduction of the data.
Rates of reoperation also decreased (OR, 0.88; 95% CI, 0.85-0.91) while early-discharge rates increased (OR, 1.60; 95% CI, 1.57-1.63) after colectomy data was introduced, the multivariable analysis further showed.
Principal investigator P. Ravi Kiran, MD, FACS, professor of surgery at Columbia University and chief of the medical center’s division of colorectal surgery, said the improved outcomes were attributable to a few different factors.
First, the NSQIP national data allows participants to benchmark with peer hospitals and find areas for improvement, Dr. Kiran said in an ACS press release.
That benchmarking encourages participating centers to follow evidence-based recommendations, including ACS guidelines for preventing surgical site infections, he added.
The introduction of procedure-targeted datasets in NSQIP was done in response to user requests for more clinically detailed information, according to Clifford Y. Ko, MD, FACS, director of the ACS division of research and optimal patient care.
While the NSQIP data are important in improving surgical outcomes, credit also goes to the organizations that are leading the quality improvement efforts by effectively using the data, Dr. Ko said in the press release.
Dr. Ko was not involved in the study. Dr. Al-Mazrou and Dr. Kiran reported no disclosures relevant to the study.
SOURCE: Al-Mazrou AM et al. ACS Clinical Congress. Abstract SF330.
BOSTON – Rates of (ACS NSQIP), a recent analysis shows.
Reoperation rates have also decreased, while early-discharge rates have steadily increased, according to results of the analysis, presented at the annual clinical congress of the American College of Surgeons.
The findings underline the value of such ACS-led initiatives in improving patient care and surgical quality, said Ahmed M. Al-Mazrou, MD, a general surgery resident at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York.
“Over its first decade of introduction, ACS NSQIP was associated with improved outcomes after colorectal surgery, and also introduction of colectomy-targeted data was also associated with improved outcomes,” Dr. Al-Mazrou said in his presentation describing the results.
Prior to this study, the question of whether the introduction of ACS NSQIP has improved outcomes over time had not been well characterized, according to Dr. Al-Mazrou and his colleagues.
To evaluate the impact, the investigators looked at more than 310,000 nonemergency colorectal resections in ACS NSQIP, of which about 58% were done after the introduction of colectomy-targeted variables in 2013.
They found that, over time, incidence of most complications fell, including surgical site infections, urinary tract infections, sepsis and septic shock, and venous thromboembolism, while rates of early discharge increased.
For example, surgical site infections decreased from 13.7% to 4.7% over the 10-year period, while the number of patients discharged within 5 days or fewer increased from about 8% to 47%.
Introduction of colectomy-targeted data was associated with fewer surgical site infections (odds ratio, 0.78; 95% confidence interval, 0.77-0.80), multivariable analysis showed. Likewise, there were lower rates of systemic infections (OR, 0.94; 95% CI, 0.91-0.98) and urinary tract infections (OR, 0.70; 95% CI, 0.67-0.74) after introduction of the data.
Rates of reoperation also decreased (OR, 0.88; 95% CI, 0.85-0.91) while early-discharge rates increased (OR, 1.60; 95% CI, 1.57-1.63) after colectomy data was introduced, the multivariable analysis further showed.
Principal investigator P. Ravi Kiran, MD, FACS, professor of surgery at Columbia University and chief of the medical center’s division of colorectal surgery, said the improved outcomes were attributable to a few different factors.
First, the NSQIP national data allows participants to benchmark with peer hospitals and find areas for improvement, Dr. Kiran said in an ACS press release.
That benchmarking encourages participating centers to follow evidence-based recommendations, including ACS guidelines for preventing surgical site infections, he added.
The introduction of procedure-targeted datasets in NSQIP was done in response to user requests for more clinically detailed information, according to Clifford Y. Ko, MD, FACS, director of the ACS division of research and optimal patient care.
While the NSQIP data are important in improving surgical outcomes, credit also goes to the organizations that are leading the quality improvement efforts by effectively using the data, Dr. Ko said in the press release.
Dr. Ko was not involved in the study. Dr. Al-Mazrou and Dr. Kiran reported no disclosures relevant to the study.
SOURCE: Al-Mazrou AM et al. ACS Clinical Congress. Abstract SF330.
BOSTON – Rates of (ACS NSQIP), a recent analysis shows.
Reoperation rates have also decreased, while early-discharge rates have steadily increased, according to results of the analysis, presented at the annual clinical congress of the American College of Surgeons.
The findings underline the value of such ACS-led initiatives in improving patient care and surgical quality, said Ahmed M. Al-Mazrou, MD, a general surgery resident at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York.
“Over its first decade of introduction, ACS NSQIP was associated with improved outcomes after colorectal surgery, and also introduction of colectomy-targeted data was also associated with improved outcomes,” Dr. Al-Mazrou said in his presentation describing the results.
Prior to this study, the question of whether the introduction of ACS NSQIP has improved outcomes over time had not been well characterized, according to Dr. Al-Mazrou and his colleagues.
To evaluate the impact, the investigators looked at more than 310,000 nonemergency colorectal resections in ACS NSQIP, of which about 58% were done after the introduction of colectomy-targeted variables in 2013.
They found that, over time, incidence of most complications fell, including surgical site infections, urinary tract infections, sepsis and septic shock, and venous thromboembolism, while rates of early discharge increased.
For example, surgical site infections decreased from 13.7% to 4.7% over the 10-year period, while the number of patients discharged within 5 days or fewer increased from about 8% to 47%.
Introduction of colectomy-targeted data was associated with fewer surgical site infections (odds ratio, 0.78; 95% confidence interval, 0.77-0.80), multivariable analysis showed. Likewise, there were lower rates of systemic infections (OR, 0.94; 95% CI, 0.91-0.98) and urinary tract infections (OR, 0.70; 95% CI, 0.67-0.74) after introduction of the data.
Rates of reoperation also decreased (OR, 0.88; 95% CI, 0.85-0.91) while early-discharge rates increased (OR, 1.60; 95% CI, 1.57-1.63) after colectomy data was introduced, the multivariable analysis further showed.
Principal investigator P. Ravi Kiran, MD, FACS, professor of surgery at Columbia University and chief of the medical center’s division of colorectal surgery, said the improved outcomes were attributable to a few different factors.
First, the NSQIP national data allows participants to benchmark with peer hospitals and find areas for improvement, Dr. Kiran said in an ACS press release.
That benchmarking encourages participating centers to follow evidence-based recommendations, including ACS guidelines for preventing surgical site infections, he added.
The introduction of procedure-targeted datasets in NSQIP was done in response to user requests for more clinically detailed information, according to Clifford Y. Ko, MD, FACS, director of the ACS division of research and optimal patient care.
While the NSQIP data are important in improving surgical outcomes, credit also goes to the organizations that are leading the quality improvement efforts by effectively using the data, Dr. Ko said in the press release.
Dr. Ko was not involved in the study. Dr. Al-Mazrou and Dr. Kiran reported no disclosures relevant to the study.
SOURCE: Al-Mazrou AM et al. ACS Clinical Congress. Abstract SF330.
REPORTING FROM THE ACS CLINICAL CONGRESS
Key clinical point: Rates of colorectal procedure complications have steadily decreased since the introduction of the American College of Surgeons National Surgical Quality Improvement Program.
Major finding: Surgical site infections decreased from 13.7% to 4.7% over the 10-year period, while the number of patients discharged within 5 days or fewer increased from about 8% to 47%.
Study details: Retrospective review of more than 310,000 nonemergency colorectal resections in ACS NSQIP from 2007 to 2016.
Disclosures: Study authors reported no conflicts of interest.
Source: Al-Mazrou AM et al. ACS Clinical Congress, Abstract SF330.
'Liver first' for select stage IV colon cancer gaining traction
BOSTON –
It’s an alternative to usual care, meaning simultaneous bowel and liver resection or bowel resection with liver surgery later on.
Systemic chemotherapy comes first, followed by liver resection. If margins are microscopically negative, the patient gets another round of chemotherapy. If no additional lesions emerge, the primary tumor is taken out. The entire process can take up to a year.
The approach was developed in the Netherlands for rectal cancer with advanced liver metastases. The idea was to get the liver lesions out before they became unresectable, then remove the primary tumor later on. It’s gaining traction now for colon cancer, and beginning to trickle into the United States at a few academic medical centers.
It comes down to what’s more dangerous, the metastases or the primary tumor? Tumor science hasn’t answered that question yet. There’s general agreement that metastases are what kill people with cancer, but it’s not known if they come mostly from previous metastases or from the primary tumor. The liver-first approach assumes the former.
Liver-first is “extremely controversial. For older surgeons who are not in tertiary care centers, liver-first doesn’t make sense, and it doesn’t seem to make sense to patients. They wonder why you would go after the liver when they were diagnosed with a colon tumor,” said Janice Rafferty, MD, FACS, professor of surgery at the University of Cincinnati, at the annual clinical congress of the American College of Surgeons.
“Well, it’s because the primary tumor doesn’t limit your life,” she continued. “The life-limiting disease is in the liver, not the colon. If you explain it to them that way, it makes sense. If we cannot get an R0 resection on the liver, it doesn’t make sense to go after the primary, unless it’s symptomatic with obstruction, bleeding, or fistula.”
There have been about 10 attempts at a randomized trial of this approach versus usual care, but they were not successful because of the difficulty of recruiting patients. Patients – and no doubt, some surgeons – may have some resistance to the logic of going after metastases first.
Dr. Rafferty moderated a review of research from Yale University, New Haven, Conn., that attempted to plug the evidence gap. The Yale investigators “presented really interesting data that shows that liver-first has improved survival,” she said.
The Yale team used the National Cancer Database to compare 2010-2015 outcomes from liver-first patients with patients who had simultaneous or bowel-first resections, followed by later liver resections. The database didn’t allow them to tease out simultaneous from bowel-first cases, so they lumped them together as usual care. To avoid confounding, rectal carcinomas and metastases to the lung, brain, and other organs were excluded.
Median survival was 34 months among 358 liver-first patients versus 24 months among 18,042 usual care patients in an intention-to-treat analysis. Among patients who completed their resections, median survival was 57 months among 140 liver-first patients versus 36 months with usual care in 3,988.
The benefit held after adjustment for patient and tumor characteristics (hazard ratio for death 0.77 in favor of liver first). When further adjusted for chemotherapy timing, there was a strong trend for liver-first but it was not statistically significant, suggesting that up-front chemotherapy contributed to the results (HR, 0.88; 95% confidence interval, 0.75-1.01; P = .09).
There were many caveats. The liver-first patients were younger, with over half under the age of 60 years versus just over 40% in usual care. They were also healthier based on Charlson comorbidity scores and more likely to have upfront chemotherapy and be treated at an academic center.
So, what should surgeons make of these findings? Lead investigator Vadim Kurbatov, MD, a Yale surgery resident, argued that, at the very least, they suggest that liver-first is a viable option for stage IV colon cancer with isolated liver metastases. Going further, they suggest that liver first may be the right way to go for younger, healthier patients at academic centers.
For sicker stage IV patients, however, the role of liver-first is unclear. “We really do need a randomized trial,” he said.
Dr. Kurbatov and Dr. Rafferty had no relevant disclosures to report. The work was funded in part by the National Institutes of Health.
BOSTON –
It’s an alternative to usual care, meaning simultaneous bowel and liver resection or bowel resection with liver surgery later on.
Systemic chemotherapy comes first, followed by liver resection. If margins are microscopically negative, the patient gets another round of chemotherapy. If no additional lesions emerge, the primary tumor is taken out. The entire process can take up to a year.
The approach was developed in the Netherlands for rectal cancer with advanced liver metastases. The idea was to get the liver lesions out before they became unresectable, then remove the primary tumor later on. It’s gaining traction now for colon cancer, and beginning to trickle into the United States at a few academic medical centers.
It comes down to what’s more dangerous, the metastases or the primary tumor? Tumor science hasn’t answered that question yet. There’s general agreement that metastases are what kill people with cancer, but it’s not known if they come mostly from previous metastases or from the primary tumor. The liver-first approach assumes the former.
Liver-first is “extremely controversial. For older surgeons who are not in tertiary care centers, liver-first doesn’t make sense, and it doesn’t seem to make sense to patients. They wonder why you would go after the liver when they were diagnosed with a colon tumor,” said Janice Rafferty, MD, FACS, professor of surgery at the University of Cincinnati, at the annual clinical congress of the American College of Surgeons.
“Well, it’s because the primary tumor doesn’t limit your life,” she continued. “The life-limiting disease is in the liver, not the colon. If you explain it to them that way, it makes sense. If we cannot get an R0 resection on the liver, it doesn’t make sense to go after the primary, unless it’s symptomatic with obstruction, bleeding, or fistula.”
There have been about 10 attempts at a randomized trial of this approach versus usual care, but they were not successful because of the difficulty of recruiting patients. Patients – and no doubt, some surgeons – may have some resistance to the logic of going after metastases first.
Dr. Rafferty moderated a review of research from Yale University, New Haven, Conn., that attempted to plug the evidence gap. The Yale investigators “presented really interesting data that shows that liver-first has improved survival,” she said.
The Yale team used the National Cancer Database to compare 2010-2015 outcomes from liver-first patients with patients who had simultaneous or bowel-first resections, followed by later liver resections. The database didn’t allow them to tease out simultaneous from bowel-first cases, so they lumped them together as usual care. To avoid confounding, rectal carcinomas and metastases to the lung, brain, and other organs were excluded.
Median survival was 34 months among 358 liver-first patients versus 24 months among 18,042 usual care patients in an intention-to-treat analysis. Among patients who completed their resections, median survival was 57 months among 140 liver-first patients versus 36 months with usual care in 3,988.
The benefit held after adjustment for patient and tumor characteristics (hazard ratio for death 0.77 in favor of liver first). When further adjusted for chemotherapy timing, there was a strong trend for liver-first but it was not statistically significant, suggesting that up-front chemotherapy contributed to the results (HR, 0.88; 95% confidence interval, 0.75-1.01; P = .09).
There were many caveats. The liver-first patients were younger, with over half under the age of 60 years versus just over 40% in usual care. They were also healthier based on Charlson comorbidity scores and more likely to have upfront chemotherapy and be treated at an academic center.
So, what should surgeons make of these findings? Lead investigator Vadim Kurbatov, MD, a Yale surgery resident, argued that, at the very least, they suggest that liver-first is a viable option for stage IV colon cancer with isolated liver metastases. Going further, they suggest that liver first may be the right way to go for younger, healthier patients at academic centers.
For sicker stage IV patients, however, the role of liver-first is unclear. “We really do need a randomized trial,” he said.
Dr. Kurbatov and Dr. Rafferty had no relevant disclosures to report. The work was funded in part by the National Institutes of Health.
BOSTON –
It’s an alternative to usual care, meaning simultaneous bowel and liver resection or bowel resection with liver surgery later on.
Systemic chemotherapy comes first, followed by liver resection. If margins are microscopically negative, the patient gets another round of chemotherapy. If no additional lesions emerge, the primary tumor is taken out. The entire process can take up to a year.
The approach was developed in the Netherlands for rectal cancer with advanced liver metastases. The idea was to get the liver lesions out before they became unresectable, then remove the primary tumor later on. It’s gaining traction now for colon cancer, and beginning to trickle into the United States at a few academic medical centers.
It comes down to what’s more dangerous, the metastases or the primary tumor? Tumor science hasn’t answered that question yet. There’s general agreement that metastases are what kill people with cancer, but it’s not known if they come mostly from previous metastases or from the primary tumor. The liver-first approach assumes the former.
Liver-first is “extremely controversial. For older surgeons who are not in tertiary care centers, liver-first doesn’t make sense, and it doesn’t seem to make sense to patients. They wonder why you would go after the liver when they were diagnosed with a colon tumor,” said Janice Rafferty, MD, FACS, professor of surgery at the University of Cincinnati, at the annual clinical congress of the American College of Surgeons.
“Well, it’s because the primary tumor doesn’t limit your life,” she continued. “The life-limiting disease is in the liver, not the colon. If you explain it to them that way, it makes sense. If we cannot get an R0 resection on the liver, it doesn’t make sense to go after the primary, unless it’s symptomatic with obstruction, bleeding, or fistula.”
There have been about 10 attempts at a randomized trial of this approach versus usual care, but they were not successful because of the difficulty of recruiting patients. Patients – and no doubt, some surgeons – may have some resistance to the logic of going after metastases first.
Dr. Rafferty moderated a review of research from Yale University, New Haven, Conn., that attempted to plug the evidence gap. The Yale investigators “presented really interesting data that shows that liver-first has improved survival,” she said.
The Yale team used the National Cancer Database to compare 2010-2015 outcomes from liver-first patients with patients who had simultaneous or bowel-first resections, followed by later liver resections. The database didn’t allow them to tease out simultaneous from bowel-first cases, so they lumped them together as usual care. To avoid confounding, rectal carcinomas and metastases to the lung, brain, and other organs were excluded.
Median survival was 34 months among 358 liver-first patients versus 24 months among 18,042 usual care patients in an intention-to-treat analysis. Among patients who completed their resections, median survival was 57 months among 140 liver-first patients versus 36 months with usual care in 3,988.
The benefit held after adjustment for patient and tumor characteristics (hazard ratio for death 0.77 in favor of liver first). When further adjusted for chemotherapy timing, there was a strong trend for liver-first but it was not statistically significant, suggesting that up-front chemotherapy contributed to the results (HR, 0.88; 95% confidence interval, 0.75-1.01; P = .09).
There were many caveats. The liver-first patients were younger, with over half under the age of 60 years versus just over 40% in usual care. They were also healthier based on Charlson comorbidity scores and more likely to have upfront chemotherapy and be treated at an academic center.
So, what should surgeons make of these findings? Lead investigator Vadim Kurbatov, MD, a Yale surgery resident, argued that, at the very least, they suggest that liver-first is a viable option for stage IV colon cancer with isolated liver metastases. Going further, they suggest that liver first may be the right way to go for younger, healthier patients at academic centers.
For sicker stage IV patients, however, the role of liver-first is unclear. “We really do need a randomized trial,” he said.
Dr. Kurbatov and Dr. Rafferty had no relevant disclosures to report. The work was funded in part by the National Institutes of Health.
REPORTING FROM THE ACS CLINICAL CONGRESS
Key clinical point: The liver-first approach may be appropriate for younger, healthier patients at academic centers.
Major finding: Median survival was 34 months among 358 liver-first patients versus 24 months among 18,042 usual care patients in an intention-to-treat analysis.
Study details: A review of over 18,000 patients in the National Cancer Database
Disclosures: The lead investigator had no disclosures to report. The work was funded in part by the National Institutes of Health.
How to use transgastric necrosectomy for midline pancreatitis
BOSTON – When pancreatitis symptoms don’t resolve within a month, patients need some sort of surgical intervention, according to Steven Hughes, MD, FACS, professor and chief of surgical oncology at the University of Florida, Gainesville.
Pancreatitis management has been evolving in recent years. Prophylactic antibiotics and total parenteral nutrition are out; tube feeds are in, and there’s compelling evidence to take the gallbladder out, regardless of etiology, he said at the annual clinical congress of the American College of Surgeons.
However, too many patients get drains placed in the first 2 weeks; it’s the wrong move because it consigns to surgery a lot of patients who otherwise would have recovered on their own. “In the first 2 weeks, please do not place drains. Once you place the drain, you have committed the patient to a very different clinical course,” Dr. Hughes said.
Surgery generally comes a month or more after the initial presentation. Infection is inevitable at that point; the delay gives the lesion time to consolidate and wall itself off, making for a cleaner, safer operation.
It’s Dr. Hughes’s favored approach when the anatomy is appropriate; he shared his thoughts at the meeting.
Transgastric necrosectomy provides “single-stop shopping. You can get a thorough debridement in a single procedure,” and durable internal drainage. “Most importantly, from a patient’s perspective, it leaves them without external drains. You can transition a patient who’s been percutaneously drained to no external drainage at the time of this operation,” he said.
Additional pluses include cholecystectomy either before or after necrosectomy and the ability to place enteric feeding systems. “I like to use a combination G-J tube that allows drainage of the emptying stomach along with distal tube feeds,” he said.
Laparoscopic and endoscopic approaches are possible, but Dr. Hughes favors an open procedure “because the finger is the best debriding tool I have found.” There’s an anterior and then posterior gastric incision to dig out the necroma. The anterior incision is closed, but the posterior cut is sealed open to the necroma with a running hemostatic suture to allow for a “large cavity between the cavity and the stomach” for ongoing drainage.
“I have ultrasound on the field, but typically finding the necroma is like falling out of a canoe and finding water.” Even so, “I like to bring a 10-mm straight scope for direct viewing onto the field to explore the necrotic cavity and ensure I’ve done an adequate necrosectomy,” he said.
“I do think that this operation can be performed in patients who have some retrocolic extension even over into the pancreatic head and down the right paracolic gutter, but certainly if the collection extends down towards the pelvis, the notion that this is going to be adequate in and of itself requires further investigation,” he said.
In a cohort of 18 patients he and his colleagues followed for at least 2 years, “I was impressed that this operation is rather durable,” with rapid resolution of disease, Dr. Hughes said. Just a couple people needed additional operations. “The majority created persistent fistulas between the pancreatic body tail and the stomach.”
He cautioned that the procedure “is not for the faint of heart. The splenic vein and the splenic artery as well the celiac axis and portal vein are at risk during this procedure, and if you get into them, you have got a wolf by both ears. I would encourage you to consider referral for these patients.”
Dr. Hughes strongly encouraged surgeons to “ make sure your interventional radiologists and advanced endoscopists are on board, whether for the postop pseudoaneurysm bleeding or recurrent sepsis.”
Dr. Hughes had no relevant disclosures to report.
BOSTON – When pancreatitis symptoms don’t resolve within a month, patients need some sort of surgical intervention, according to Steven Hughes, MD, FACS, professor and chief of surgical oncology at the University of Florida, Gainesville.
Pancreatitis management has been evolving in recent years. Prophylactic antibiotics and total parenteral nutrition are out; tube feeds are in, and there’s compelling evidence to take the gallbladder out, regardless of etiology, he said at the annual clinical congress of the American College of Surgeons.
However, too many patients get drains placed in the first 2 weeks; it’s the wrong move because it consigns to surgery a lot of patients who otherwise would have recovered on their own. “In the first 2 weeks, please do not place drains. Once you place the drain, you have committed the patient to a very different clinical course,” Dr. Hughes said.
Surgery generally comes a month or more after the initial presentation. Infection is inevitable at that point; the delay gives the lesion time to consolidate and wall itself off, making for a cleaner, safer operation.
It’s Dr. Hughes’s favored approach when the anatomy is appropriate; he shared his thoughts at the meeting.
Transgastric necrosectomy provides “single-stop shopping. You can get a thorough debridement in a single procedure,” and durable internal drainage. “Most importantly, from a patient’s perspective, it leaves them without external drains. You can transition a patient who’s been percutaneously drained to no external drainage at the time of this operation,” he said.
Additional pluses include cholecystectomy either before or after necrosectomy and the ability to place enteric feeding systems. “I like to use a combination G-J tube that allows drainage of the emptying stomach along with distal tube feeds,” he said.
Laparoscopic and endoscopic approaches are possible, but Dr. Hughes favors an open procedure “because the finger is the best debriding tool I have found.” There’s an anterior and then posterior gastric incision to dig out the necroma. The anterior incision is closed, but the posterior cut is sealed open to the necroma with a running hemostatic suture to allow for a “large cavity between the cavity and the stomach” for ongoing drainage.
“I have ultrasound on the field, but typically finding the necroma is like falling out of a canoe and finding water.” Even so, “I like to bring a 10-mm straight scope for direct viewing onto the field to explore the necrotic cavity and ensure I’ve done an adequate necrosectomy,” he said.
“I do think that this operation can be performed in patients who have some retrocolic extension even over into the pancreatic head and down the right paracolic gutter, but certainly if the collection extends down towards the pelvis, the notion that this is going to be adequate in and of itself requires further investigation,” he said.
In a cohort of 18 patients he and his colleagues followed for at least 2 years, “I was impressed that this operation is rather durable,” with rapid resolution of disease, Dr. Hughes said. Just a couple people needed additional operations. “The majority created persistent fistulas between the pancreatic body tail and the stomach.”
He cautioned that the procedure “is not for the faint of heart. The splenic vein and the splenic artery as well the celiac axis and portal vein are at risk during this procedure, and if you get into them, you have got a wolf by both ears. I would encourage you to consider referral for these patients.”
Dr. Hughes strongly encouraged surgeons to “ make sure your interventional radiologists and advanced endoscopists are on board, whether for the postop pseudoaneurysm bleeding or recurrent sepsis.”
Dr. Hughes had no relevant disclosures to report.
BOSTON – When pancreatitis symptoms don’t resolve within a month, patients need some sort of surgical intervention, according to Steven Hughes, MD, FACS, professor and chief of surgical oncology at the University of Florida, Gainesville.
Pancreatitis management has been evolving in recent years. Prophylactic antibiotics and total parenteral nutrition are out; tube feeds are in, and there’s compelling evidence to take the gallbladder out, regardless of etiology, he said at the annual clinical congress of the American College of Surgeons.
However, too many patients get drains placed in the first 2 weeks; it’s the wrong move because it consigns to surgery a lot of patients who otherwise would have recovered on their own. “In the first 2 weeks, please do not place drains. Once you place the drain, you have committed the patient to a very different clinical course,” Dr. Hughes said.
Surgery generally comes a month or more after the initial presentation. Infection is inevitable at that point; the delay gives the lesion time to consolidate and wall itself off, making for a cleaner, safer operation.
It’s Dr. Hughes’s favored approach when the anatomy is appropriate; he shared his thoughts at the meeting.
Transgastric necrosectomy provides “single-stop shopping. You can get a thorough debridement in a single procedure,” and durable internal drainage. “Most importantly, from a patient’s perspective, it leaves them without external drains. You can transition a patient who’s been percutaneously drained to no external drainage at the time of this operation,” he said.
Additional pluses include cholecystectomy either before or after necrosectomy and the ability to place enteric feeding systems. “I like to use a combination G-J tube that allows drainage of the emptying stomach along with distal tube feeds,” he said.
Laparoscopic and endoscopic approaches are possible, but Dr. Hughes favors an open procedure “because the finger is the best debriding tool I have found.” There’s an anterior and then posterior gastric incision to dig out the necroma. The anterior incision is closed, but the posterior cut is sealed open to the necroma with a running hemostatic suture to allow for a “large cavity between the cavity and the stomach” for ongoing drainage.
“I have ultrasound on the field, but typically finding the necroma is like falling out of a canoe and finding water.” Even so, “I like to bring a 10-mm straight scope for direct viewing onto the field to explore the necrotic cavity and ensure I’ve done an adequate necrosectomy,” he said.
“I do think that this operation can be performed in patients who have some retrocolic extension even over into the pancreatic head and down the right paracolic gutter, but certainly if the collection extends down towards the pelvis, the notion that this is going to be adequate in and of itself requires further investigation,” he said.
In a cohort of 18 patients he and his colleagues followed for at least 2 years, “I was impressed that this operation is rather durable,” with rapid resolution of disease, Dr. Hughes said. Just a couple people needed additional operations. “The majority created persistent fistulas between the pancreatic body tail and the stomach.”
He cautioned that the procedure “is not for the faint of heart. The splenic vein and the splenic artery as well the celiac axis and portal vein are at risk during this procedure, and if you get into them, you have got a wolf by both ears. I would encourage you to consider referral for these patients.”
Dr. Hughes strongly encouraged surgeons to “ make sure your interventional radiologists and advanced endoscopists are on board, whether for the postop pseudoaneurysm bleeding or recurrent sepsis.”
Dr. Hughes had no relevant disclosures to report.
EXPERT ANALYSIS FROM THE ACS CLINICAL CONGRESS
Concurrent Capecitabine and Radiation to Treat End Stage Renal Disease Patients on Dialysis With Locally Advanced Unresectable Gastro-Intestinal Malignancies: A Veteran Population Experience
Background: Capecitabine is an oral precursor of 5-FU (5' deoxy-5-fluoridine), a commonly prescribed chemotherapeutic agent to treat gastrointestinal and breast cancers. Capecitabine is currently contraindicated in patients with severe renal failure with Glomerular filtration rate <
30 ml/min. Literature review shows limited evidence in safety and effectiveness of using capecitabine in patients undergoing hemodialysis.
Case Report 1: A 75-year-old old male with a history of end stage renal disease on hemodialysis, was diagnosed with a 10 cm duodenal mass on CT scan when presented with three months history of abdominal pain and 45 lb weight loss. esophagogastroduodenoscopy and biopsy confirmed
adenocarcinoma of duodenum/ampulla. Patient was deemed to be a high-risk candidate for Whipple’s procedure. The case was discussed in multidisciplinary tumor board and the patient was offered concurrent chemotherapy and radiation with capecitabine 500 mg BID. Posttreatment
CT scans suggested 60% shrinkage in tumor size. Patient was continued on capecitabine 300 mg BID two weeks on and one week off with continued response noted on restaging CT scans.
Case Report 2: A 76-year-old male with end stage renal disease on hemodialysis complained of bleeding per rectum for over 2 years. A colonoscopy showed a circumferential mass at 15 cm from anal verge, and biopsy was consistent with rectal adeno carcinoma. PET/CT scan confirmed primary lesion in rectum as well as abnormal retroperitoneal and left iliac adenopathy with high FDG uptake. EUS staged disease at uT3N0Mx. Given significant pain and bleeding patient was offered palliative radiation along with low dose capecitabine 500 mg BID. Two months after concurrent chemotherapy and radiation, restaging scans showed 50% shrinkage in primary tumor. The patient opted to continue treatment with capecitabine and completed two more cycles of 300 mg BID two weeks on and one week off. A repeat CT scan showed near complete resolution of rectal mass and lymphadenopathy.
Conclusions: Capecitabine is converted to active form 5-FU in liver by thymidine phosphorylase. Over 95% of the drug is excreted in urine. In the original phase II trial utilizing capecitabine at 1250 mg/m2 BID, four patients with GFR < 30 ml/min noted to have grade 3-4 toxicities. Jhaveri et al. in their retrospective analysis showed 12 patients tolerated reduced doses.
Background: Capecitabine is an oral precursor of 5-FU (5' deoxy-5-fluoridine), a commonly prescribed chemotherapeutic agent to treat gastrointestinal and breast cancers. Capecitabine is currently contraindicated in patients with severe renal failure with Glomerular filtration rate <
30 ml/min. Literature review shows limited evidence in safety and effectiveness of using capecitabine in patients undergoing hemodialysis.
Case Report 1: A 75-year-old old male with a history of end stage renal disease on hemodialysis, was diagnosed with a 10 cm duodenal mass on CT scan when presented with three months history of abdominal pain and 45 lb weight loss. esophagogastroduodenoscopy and biopsy confirmed
adenocarcinoma of duodenum/ampulla. Patient was deemed to be a high-risk candidate for Whipple’s procedure. The case was discussed in multidisciplinary tumor board and the patient was offered concurrent chemotherapy and radiation with capecitabine 500 mg BID. Posttreatment
CT scans suggested 60% shrinkage in tumor size. Patient was continued on capecitabine 300 mg BID two weeks on and one week off with continued response noted on restaging CT scans.
Case Report 2: A 76-year-old male with end stage renal disease on hemodialysis complained of bleeding per rectum for over 2 years. A colonoscopy showed a circumferential mass at 15 cm from anal verge, and biopsy was consistent with rectal adeno carcinoma. PET/CT scan confirmed primary lesion in rectum as well as abnormal retroperitoneal and left iliac adenopathy with high FDG uptake. EUS staged disease at uT3N0Mx. Given significant pain and bleeding patient was offered palliative radiation along with low dose capecitabine 500 mg BID. Two months after concurrent chemotherapy and radiation, restaging scans showed 50% shrinkage in primary tumor. The patient opted to continue treatment with capecitabine and completed two more cycles of 300 mg BID two weeks on and one week off. A repeat CT scan showed near complete resolution of rectal mass and lymphadenopathy.
Conclusions: Capecitabine is converted to active form 5-FU in liver by thymidine phosphorylase. Over 95% of the drug is excreted in urine. In the original phase II trial utilizing capecitabine at 1250 mg/m2 BID, four patients with GFR < 30 ml/min noted to have grade 3-4 toxicities. Jhaveri et al. in their retrospective analysis showed 12 patients tolerated reduced doses.
Background: Capecitabine is an oral precursor of 5-FU (5' deoxy-5-fluoridine), a commonly prescribed chemotherapeutic agent to treat gastrointestinal and breast cancers. Capecitabine is currently contraindicated in patients with severe renal failure with Glomerular filtration rate <
30 ml/min. Literature review shows limited evidence in safety and effectiveness of using capecitabine in patients undergoing hemodialysis.
Case Report 1: A 75-year-old old male with a history of end stage renal disease on hemodialysis, was diagnosed with a 10 cm duodenal mass on CT scan when presented with three months history of abdominal pain and 45 lb weight loss. esophagogastroduodenoscopy and biopsy confirmed
adenocarcinoma of duodenum/ampulla. Patient was deemed to be a high-risk candidate for Whipple’s procedure. The case was discussed in multidisciplinary tumor board and the patient was offered concurrent chemotherapy and radiation with capecitabine 500 mg BID. Posttreatment
CT scans suggested 60% shrinkage in tumor size. Patient was continued on capecitabine 300 mg BID two weeks on and one week off with continued response noted on restaging CT scans.
Case Report 2: A 76-year-old male with end stage renal disease on hemodialysis complained of bleeding per rectum for over 2 years. A colonoscopy showed a circumferential mass at 15 cm from anal verge, and biopsy was consistent with rectal adeno carcinoma. PET/CT scan confirmed primary lesion in rectum as well as abnormal retroperitoneal and left iliac adenopathy with high FDG uptake. EUS staged disease at uT3N0Mx. Given significant pain and bleeding patient was offered palliative radiation along with low dose capecitabine 500 mg BID. Two months after concurrent chemotherapy and radiation, restaging scans showed 50% shrinkage in primary tumor. The patient opted to continue treatment with capecitabine and completed two more cycles of 300 mg BID two weeks on and one week off. A repeat CT scan showed near complete resolution of rectal mass and lymphadenopathy.
Conclusions: Capecitabine is converted to active form 5-FU in liver by thymidine phosphorylase. Over 95% of the drug is excreted in urine. In the original phase II trial utilizing capecitabine at 1250 mg/m2 BID, four patients with GFR < 30 ml/min noted to have grade 3-4 toxicities. Jhaveri et al. in their retrospective analysis showed 12 patients tolerated reduced doses.
Findings at Baseline Colonoscopy Are Associated With Future Advanced Neoplasia Despite an Intervening Negative Colonoscopy
Background: Colorectal cancer (CRC) surveillance guidelines suggest that timing of a 3rd colonoscopy should be based on results of two prior exams. However, data are limited on whether baseline screening colonoscopy can inform the risk of advanced neoplasia (AN) at 3rd exam.
Methods: This study describes the risk of AN at 3rd colonoscopy stratified by findings on two previous exams in a prospective screening cohort and compares this risk over time from a negative 2nd exam between those with differing 1st exam findings.
The CSP #380 cohort included 3,121 Veterans aged 50-75 years who underwent screening colonoscopy from 1994-1997 and were followed for at least 10 years. Exclusion criteria included not having three colonoscopies more than one year apart, or having CRC at 1st or 2nd exam. The primary outcome was the proportion of AN at 3rd exam. Findings at 1st and 2nd exam were classified as high-risk adenoma (HRA), low-risk adenoma (LRA), or no adenoma. Chi-square tests compared proportions of AN on the 3rd exam between those with different baseline screening results but similar 2nd exam findings.
Results: This analysis included 891 participants: 58 (6.5%) had AN at 3rd exam. The proportion of AN at 3rd exam ranged from 3.2% to 21.4% when stratified by results of two previous exams. In participants with HRA or LRA on the 2nd exam, baseline screening colonoscopy was not associated with risk of AN at 3rd exam. However, for participants with no adenomas on the 2nd exam, baseline screening colonoscopy was associated with risk of AN at 3rd exam (P =.04). Furthermore, all AN was identified within about 5 years of the negative 2nd exam in those with HRA on the 1st exam.
Conclusions: Results of the 1st exam remain a risk factor for AN at 3rd exam in those with no adenomas at 2nd exam. This supports current guidelines which recommend a shortened surveillance interval in those with no adenomas at 2nd exam but HRA at 1st. Future work will combine CRC risk factors with genomic risk and colonoscopy outcomes over time to better identify individuals who might benefit from continued surveillance and to help inform appropriate surveillance intervals.
Background: Colorectal cancer (CRC) surveillance guidelines suggest that timing of a 3rd colonoscopy should be based on results of two prior exams. However, data are limited on whether baseline screening colonoscopy can inform the risk of advanced neoplasia (AN) at 3rd exam.
Methods: This study describes the risk of AN at 3rd colonoscopy stratified by findings on two previous exams in a prospective screening cohort and compares this risk over time from a negative 2nd exam between those with differing 1st exam findings.
The CSP #380 cohort included 3,121 Veterans aged 50-75 years who underwent screening colonoscopy from 1994-1997 and were followed for at least 10 years. Exclusion criteria included not having three colonoscopies more than one year apart, or having CRC at 1st or 2nd exam. The primary outcome was the proportion of AN at 3rd exam. Findings at 1st and 2nd exam were classified as high-risk adenoma (HRA), low-risk adenoma (LRA), or no adenoma. Chi-square tests compared proportions of AN on the 3rd exam between those with different baseline screening results but similar 2nd exam findings.
Results: This analysis included 891 participants: 58 (6.5%) had AN at 3rd exam. The proportion of AN at 3rd exam ranged from 3.2% to 21.4% when stratified by results of two previous exams. In participants with HRA or LRA on the 2nd exam, baseline screening colonoscopy was not associated with risk of AN at 3rd exam. However, for participants with no adenomas on the 2nd exam, baseline screening colonoscopy was associated with risk of AN at 3rd exam (P =.04). Furthermore, all AN was identified within about 5 years of the negative 2nd exam in those with HRA on the 1st exam.
Conclusions: Results of the 1st exam remain a risk factor for AN at 3rd exam in those with no adenomas at 2nd exam. This supports current guidelines which recommend a shortened surveillance interval in those with no adenomas at 2nd exam but HRA at 1st. Future work will combine CRC risk factors with genomic risk and colonoscopy outcomes over time to better identify individuals who might benefit from continued surveillance and to help inform appropriate surveillance intervals.
Background: Colorectal cancer (CRC) surveillance guidelines suggest that timing of a 3rd colonoscopy should be based on results of two prior exams. However, data are limited on whether baseline screening colonoscopy can inform the risk of advanced neoplasia (AN) at 3rd exam.
Methods: This study describes the risk of AN at 3rd colonoscopy stratified by findings on two previous exams in a prospective screening cohort and compares this risk over time from a negative 2nd exam between those with differing 1st exam findings.
The CSP #380 cohort included 3,121 Veterans aged 50-75 years who underwent screening colonoscopy from 1994-1997 and were followed for at least 10 years. Exclusion criteria included not having three colonoscopies more than one year apart, or having CRC at 1st or 2nd exam. The primary outcome was the proportion of AN at 3rd exam. Findings at 1st and 2nd exam were classified as high-risk adenoma (HRA), low-risk adenoma (LRA), or no adenoma. Chi-square tests compared proportions of AN on the 3rd exam between those with different baseline screening results but similar 2nd exam findings.
Results: This analysis included 891 participants: 58 (6.5%) had AN at 3rd exam. The proportion of AN at 3rd exam ranged from 3.2% to 21.4% when stratified by results of two previous exams. In participants with HRA or LRA on the 2nd exam, baseline screening colonoscopy was not associated with risk of AN at 3rd exam. However, for participants with no adenomas on the 2nd exam, baseline screening colonoscopy was associated with risk of AN at 3rd exam (P =.04). Furthermore, all AN was identified within about 5 years of the negative 2nd exam in those with HRA on the 1st exam.
Conclusions: Results of the 1st exam remain a risk factor for AN at 3rd exam in those with no adenomas at 2nd exam. This supports current guidelines which recommend a shortened surveillance interval in those with no adenomas at 2nd exam but HRA at 1st. Future work will combine CRC risk factors with genomic risk and colonoscopy outcomes over time to better identify individuals who might benefit from continued surveillance and to help inform appropriate surveillance intervals.
New Mexico Veteran Affairs Health Care System: Enhanced Recovery After Surgery: Concept to Practice for Colorectal Cancer Surgery
Purpose: The NMVAHCS is striving for innovation, with the implementation of an enhanced recovery after surgery (ERAS) protocol: best practice.
Background: Literature supports the reduction of intraoperative instability, post-operative ileus and complications, length of stay (LOS), readmission, and an increase in patient satisfaction. LOS is reduced by 2 days, complications decreased by 50%, readmissions reduced by 8%, with an average cost savings of $2,800-$5,900 per patient: depending on ERAS compliance.
Methods: Implementing an ERAS protocol requires engaging a multidisciplinary team comprised of the patient, surgeon, anesthesiologist, and support services. The surgeon/anesthesiologists attended ERAS educational conferences, ongoing seminars educated the teams. Updated patient instructions eased patient understanding. All colorectal cancer patients are enrolled. Ineligibility is due to severe renal dysfunction, or emergency procedure.
Protocols for each of the perioperative phases were created. Preoperative includes pre-habilitation, smoking cessation, pulmonary toilet, and low volume PEG-Gatorade bowel prep with modified Nichol’s prep. Patients drink a clear carbohydrate (CHO) drink 2 hours prior to induction of anesthesia. Intraoperative includes tight glucose and temperature control, goal-directed fluid therapy, pain management with regional and opioid sparing multimodal analgesia, as well as a minimally invasive approach. Postoperative includes avoidance of tubes and drains, early ambulation and pulmonary toilet, CHO drink, narcotics avoidance, and preemptive treatment for nausea and vomiting.
Outcomes are LOS, readmission, opioid use, complications, infection, return of bowel function, and patient satisfaction. Charts are reviewed for compliance and outcomes are recorded.
To sustain the practice, we have templated notes and orders sets to streamline each step of the process: alerting providers to educate patients and staff at each point of the process. Signage has been created to assist the patient and nursing staff in meeting milestones.
Results: From June 2017 to May 2018, 29 patients were enrolled ERAS protocol. PCAs were avoided, reducing ICU stay and overall cost. Patient satisfaction markedly improved with regional pain control, early CHO drink, early ambulation, and removal of Foley. LOS was not significantly affected due to long distance patients and ileostomy teaching, but did decrease by 1 day on average.
Conclusions: Successful ERAS implementation requires an engaged team.
Purpose: The NMVAHCS is striving for innovation, with the implementation of an enhanced recovery after surgery (ERAS) protocol: best practice.
Background: Literature supports the reduction of intraoperative instability, post-operative ileus and complications, length of stay (LOS), readmission, and an increase in patient satisfaction. LOS is reduced by 2 days, complications decreased by 50%, readmissions reduced by 8%, with an average cost savings of $2,800-$5,900 per patient: depending on ERAS compliance.
Methods: Implementing an ERAS protocol requires engaging a multidisciplinary team comprised of the patient, surgeon, anesthesiologist, and support services. The surgeon/anesthesiologists attended ERAS educational conferences, ongoing seminars educated the teams. Updated patient instructions eased patient understanding. All colorectal cancer patients are enrolled. Ineligibility is due to severe renal dysfunction, or emergency procedure.
Protocols for each of the perioperative phases were created. Preoperative includes pre-habilitation, smoking cessation, pulmonary toilet, and low volume PEG-Gatorade bowel prep with modified Nichol’s prep. Patients drink a clear carbohydrate (CHO) drink 2 hours prior to induction of anesthesia. Intraoperative includes tight glucose and temperature control, goal-directed fluid therapy, pain management with regional and opioid sparing multimodal analgesia, as well as a minimally invasive approach. Postoperative includes avoidance of tubes and drains, early ambulation and pulmonary toilet, CHO drink, narcotics avoidance, and preemptive treatment for nausea and vomiting.
Outcomes are LOS, readmission, opioid use, complications, infection, return of bowel function, and patient satisfaction. Charts are reviewed for compliance and outcomes are recorded.
To sustain the practice, we have templated notes and orders sets to streamline each step of the process: alerting providers to educate patients and staff at each point of the process. Signage has been created to assist the patient and nursing staff in meeting milestones.
Results: From June 2017 to May 2018, 29 patients were enrolled ERAS protocol. PCAs were avoided, reducing ICU stay and overall cost. Patient satisfaction markedly improved with regional pain control, early CHO drink, early ambulation, and removal of Foley. LOS was not significantly affected due to long distance patients and ileostomy teaching, but did decrease by 1 day on average.
Conclusions: Successful ERAS implementation requires an engaged team.
Purpose: The NMVAHCS is striving for innovation, with the implementation of an enhanced recovery after surgery (ERAS) protocol: best practice.
Background: Literature supports the reduction of intraoperative instability, post-operative ileus and complications, length of stay (LOS), readmission, and an increase in patient satisfaction. LOS is reduced by 2 days, complications decreased by 50%, readmissions reduced by 8%, with an average cost savings of $2,800-$5,900 per patient: depending on ERAS compliance.
Methods: Implementing an ERAS protocol requires engaging a multidisciplinary team comprised of the patient, surgeon, anesthesiologist, and support services. The surgeon/anesthesiologists attended ERAS educational conferences, ongoing seminars educated the teams. Updated patient instructions eased patient understanding. All colorectal cancer patients are enrolled. Ineligibility is due to severe renal dysfunction, or emergency procedure.
Protocols for each of the perioperative phases were created. Preoperative includes pre-habilitation, smoking cessation, pulmonary toilet, and low volume PEG-Gatorade bowel prep with modified Nichol’s prep. Patients drink a clear carbohydrate (CHO) drink 2 hours prior to induction of anesthesia. Intraoperative includes tight glucose and temperature control, goal-directed fluid therapy, pain management with regional and opioid sparing multimodal analgesia, as well as a minimally invasive approach. Postoperative includes avoidance of tubes and drains, early ambulation and pulmonary toilet, CHO drink, narcotics avoidance, and preemptive treatment for nausea and vomiting.
Outcomes are LOS, readmission, opioid use, complications, infection, return of bowel function, and patient satisfaction. Charts are reviewed for compliance and outcomes are recorded.
To sustain the practice, we have templated notes and orders sets to streamline each step of the process: alerting providers to educate patients and staff at each point of the process. Signage has been created to assist the patient and nursing staff in meeting milestones.
Results: From June 2017 to May 2018, 29 patients were enrolled ERAS protocol. PCAs were avoided, reducing ICU stay and overall cost. Patient satisfaction markedly improved with regional pain control, early CHO drink, early ambulation, and removal of Foley. LOS was not significantly affected due to long distance patients and ileostomy teaching, but did decrease by 1 day on average.
Conclusions: Successful ERAS implementation requires an engaged team.
Veterans With Colorectal Cancer Have a Higher Incidence of a Second Primary Malignancy Than the Colorectal Cancer Survivors in the General Population
Background: Compared to the general population, colorectal cancer (CRC) survivors are at higher risk for developing additional malignancies, with up to 11.5% of male CRC survivors diagnosed with a second distinct malignancy.
Methods: To determine if this trend is similar in CRC survivor veterans, a retrospective analysis of all veterans diagnosed with colorectal cancer (CRC) between 1995 and 2011 within a single Veterans Affairs Medical Center was performed.
Results: Of 1,496 veterans diagnosed with sporadic CRC, 22.6% had developed a second primary malignancy and 2.7% had a third primary malignancy. The most frequently diagnosed second primary malignancies within this cohort included cancer of the prostate (38.5%), lung and bronchus (15.3%), urinary bladder (11.5%), oral cavity and pharynx (6.3%), and kidney and renal pelvis (6.1%). Incidences of second primary malignancies were 24.8%, 27.3%, and 15.9% for veterans of World War II, the Korean War and Vietnam War, respectively.
Conclusions: Our findings indicated that cancer survivor veterans carried even a higher risk of developing a second primary malignancy regardless of their service eras as compared to the general population. Healthcare providers should remain vigilant regarding surveillance for the development of additional, distinct malignancy in this particular patient population.
Background: Compared to the general population, colorectal cancer (CRC) survivors are at higher risk for developing additional malignancies, with up to 11.5% of male CRC survivors diagnosed with a second distinct malignancy.
Methods: To determine if this trend is similar in CRC survivor veterans, a retrospective analysis of all veterans diagnosed with colorectal cancer (CRC) between 1995 and 2011 within a single Veterans Affairs Medical Center was performed.
Results: Of 1,496 veterans diagnosed with sporadic CRC, 22.6% had developed a second primary malignancy and 2.7% had a third primary malignancy. The most frequently diagnosed second primary malignancies within this cohort included cancer of the prostate (38.5%), lung and bronchus (15.3%), urinary bladder (11.5%), oral cavity and pharynx (6.3%), and kidney and renal pelvis (6.1%). Incidences of second primary malignancies were 24.8%, 27.3%, and 15.9% for veterans of World War II, the Korean War and Vietnam War, respectively.
Conclusions: Our findings indicated that cancer survivor veterans carried even a higher risk of developing a second primary malignancy regardless of their service eras as compared to the general population. Healthcare providers should remain vigilant regarding surveillance for the development of additional, distinct malignancy in this particular patient population.
Background: Compared to the general population, colorectal cancer (CRC) survivors are at higher risk for developing additional malignancies, with up to 11.5% of male CRC survivors diagnosed with a second distinct malignancy.
Methods: To determine if this trend is similar in CRC survivor veterans, a retrospective analysis of all veterans diagnosed with colorectal cancer (CRC) between 1995 and 2011 within a single Veterans Affairs Medical Center was performed.
Results: Of 1,496 veterans diagnosed with sporadic CRC, 22.6% had developed a second primary malignancy and 2.7% had a third primary malignancy. The most frequently diagnosed second primary malignancies within this cohort included cancer of the prostate (38.5%), lung and bronchus (15.3%), urinary bladder (11.5%), oral cavity and pharynx (6.3%), and kidney and renal pelvis (6.1%). Incidences of second primary malignancies were 24.8%, 27.3%, and 15.9% for veterans of World War II, the Korean War and Vietnam War, respectively.
Conclusions: Our findings indicated that cancer survivor veterans carried even a higher risk of developing a second primary malignancy regardless of their service eras as compared to the general population. Healthcare providers should remain vigilant regarding surveillance for the development of additional, distinct malignancy in this particular patient population.