1,720,991 research outputs found
Intraoperative Surgical Margin Re-resection for Colorectal Liver Metastasis: Is It Worth the Effort?
No full textThis study was conducted to evaluate recurrence and survival among patients who underwent intraoperative margin re-resection for colorectal cancer liver metastases (CRLM). Among patients who receive intraoperative margin re-resection, the relation between final margin status, pattern of recurrence, and survival is largely unknown. Three hundred thirty-two patients who underwent hepatic resection for CRLM between 2000 and 2013 were identified. Demographics, operative data, pathologic margin status, site of recurrence, and long-term survival data were collected and analyzed. Patients were stratified in three groups based on their margin status: R0, R1, and R1 -> aEuro parts per thousand R0. R0 resections were achieved in 247 (74.4 %) patients, 61 (18.4 %) patients had an R1 resection, whereas 24 (7.2 %) had an R1 -> aEuro parts per thousand R0. Median survival for patients undergoing R0 resections was 50.2 (95 % confidence interval (CI) 49.2-66.2) months versus 63.0 (95 % CI 50.3-70.5) months for patients undergoing R1 resections versus 49.2 (95 % CI 29.9-NA) months for patients undergoing intraoperative margin re-resection (P > 0.05). Differences in recurrence rate and pattern were not significant between the three groups (P > 0.05). In the era of modern systemic chemotherapy, it seems that the impact of margin status on outcomes may be minimal compared to that of patient and tumor factors. In this scenario, margin re-resection to achieve R0 status does not improve long-term outcomes
Benign Solid Tumors of the Liver: Management in the Modern Era
No full textRecently, there has been a growing interest in solid benign liver tumors as the understanding of the pathogenesis and molecular underpinning of these lesions continues to evolve. We herein provide an evidence-based review of benign solid liver tumors with particular emphasis on the diagnosis and management of such tumors. A search of all available literature on benign hepatic tumors through a search of the MEDLINE/PubMed electronic database was conducted. New diagnostic and management protocols for benign liver tumors have emerged, as well as new insights into the molecular pathogenesis. In turn, these data have spawned a number of new studies seeking to correlate molecular, clinicopathological, and clinical outcomes for benign liver tumors. In addition, significant advances in surgical techniques and perioperative care have reduced the morbidity and mortality of liver surgery. Despite current data that supports conservative management for many patients with benign liver tumors, patients with severe preoperative symptomatic disease seem to benefit substantially from surgical treatment based on quality of life data. Future studies should seek to further advance our understanding of the underlying pathogenesis and natural history of benign liver tumors in order to provide clinicians with evidence-based guidelines to optimize treatment of patients with these lesions
Surgical Management of Intrahepatic Cholangiocarcinoma: Defining an Optimal Prognostic Lymph Node Stratification Schema
No full textMetastatic disease to the regional lymph node (LN) is a strong predictor of worse long-term outcome after curative-intent resection of intrahepatic cholangiocarcinoma (ICC). The objectives of this study were to assess the prognostic performance of American Joint Committee on Cancer (AJCC)/International Union Against Cancer, 7th edition, N stage, LN ratio (LNR), and log odds of metastatic LN (LODDS) staging criteria in patients with ICC. The surveillance, epidemiology, and end results cancer registry was queried to identify 749 patients who underwent surgical resection of ICC during 1988-2011. The Kaplan-Meier method and Cox proportional hazards regression models were used to analyze survival. The relative discriminative abilities of the different LN staging systems were assessed by the Harrell concordance index (c statistic). Of the 749 patients, 477 (63.7 %) had no LN metastasis, while 272 (36.3 %) had LN metastasis. Patients with LN metastasis had an increased risk of death (hazard ratio 2.42, 95 % confidence interval 1.98-2.95; P < 0.001). When assessed using categorical values, LNR (C index 0.620) and LODDS (C index = 0.630) showed a better prognostic performance than the AJCC 7th edition staging system (C index = 0.607). When assessed using continuous values, the LODDS staging system (C index = 0.626) slightly outperformed LNR (C index = 0.621). There was heterogeneity of outcomes among patients with no LN involved (LNR = 0) or all LN involved (LNR = 1), indicating that LODDS may better characterize and stratify outcomes among these groups. LODDS and LNR showed better prognostic performance than the AJCC 7th edition staging system. When assessed as categorical and continuous variables, LODDS outperformed LNR, especially among those patients with either very low or high LNR
Impact of Blood Transfusions and Transfusion Practices on Long-Term Outcome Following Hepatopancreaticobiliary Surgery
No full textThe long-term impact of transfusions with packed red blood cells (PRBC) among patients undergoing hepatopancreaticobiliary (HPB) surgery remains ill-defined. We sought to determine the impact of overall blood utilization, as well as a restrictive transfusion strategy, on long-term outcomes among patients undergoing an HPB resection for a malignancy. Data on overall blood utilization and hemoglobin (Hb) levels that triggered a transfusion were obtained for patients with cancer undergoing pancreas or liver surgery between 2009 and 2013. Risk-adjusted recurrence-free (RFS) and overall survival (OS) were assessed based on receipt of PRBC and whether the patient received a transfusion using a restrictive transfusion strategy (intraoperative: Hb < 10 g/dL; postoperative: Hb < 8 g/dL). Four hundred forty-two patients underwent either a pancreas (58.1 %) or liver (41.9 %) resection. Most tumors were pancreatic in origin (41.8 %), while a subset were primary (23.1 %) or secondary (18.8 %) liver tumors. One hundred seventy-five (39.6 %) patients received a parts per thousand yen1 PRBC transfusion either intraoperatively (16.7 %), postoperatively (12.7 %), or both (10.2 %). There was a higher incidence of PRBC transfusion among patients undergoing a pancreas resection, those with higher comorbidities, and those with lower preoperative Hb levels. Perioperative morbidity was higher among patients receiving either 1-2 units (OR 3.14) or 3 or more units of PRBC (OR 8.54). Median OS was 31.9 months. Receipt of a blood transfusion was associated with a worse OS (1-2 units: HR 1.76; 3 + units: HR 2.50; both P < 0.05), and RFS (3 + units: HR 2.91; P = 0.02). Utilization of a restrictive transfusion strategy did not impact perioperative morbidity or long-term RFS or OS. Adoption of a more restrictive transfusion strategy in patients undergoing resection for cancer may preserve a limited resource, reduce costs, as well as avoid exposing oncology patients to the unnecessary risks associated with a transfusion
Lymph Node Status After Resection for Gallbladder Adenocarcinoma: Prognostic Implications of Different Nodal Staging/Scoring Systems
No full textBackground and ObjectivesSeveral lymph node (LN) staging/scoring systems have been proposed to stratify the prognosis of patients with gallbladder adenocarcinoma (GBA). We sought to define the prognostic performance of the most commonly utilized LN staging/scoring systems including AJCC/UICC N stage, lymph node ratio (LNR), log odds (LODDS), and N score, among patients with GBA. MethodBetween 2004 and 2010, 1,124 patients with GBA were identified from the Surveillance Epidemiology and End Results (SEER) database. The discriminative ability of each LN staging/scoring system was assessed using the Akaike's Information Criterion (AIC) and the Harrell's concordance index. ResultsWhen assessed using categorical values, LNR had a modest, improved ability to discriminate patients with regard to prognosis (C-index: 0.615; AIC: 2118.2) compared with AJCC/UICC N stage or N score and a prognostic discrimination comparable to LODDS. Among patients who had a total number of LN examined (TNLE) of 1 or 2, all the staging/scoring systems performed comparably. In contrast, among patients who had 4 TNLE, LODDS performed the best (C-index: 0.613; AIC: 303.2). ConclusionThe performance of the different LN staging/scoring systems varied based on the TNLE. In particular, for patients who had 4 TNLE, LODDS out-performed the other staging/scoring systems. J. Surg. Oncol. 2015 111:299-305. (c) 2014 Wiley Periodicals, Inc
Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratio in Patients After Resection for Hepato-Pancreatico-Biliary Malignancies
No full textBackground and ObjectivesWe sought to determine whether Neutrophil-lymphocyte ratio (NLR) or platelet-lymphocyte ratio (PLR) were associated with outcomes of patients undergoing surgery for a hepatopancreatico-biliary (HPB) malignancy. MethodBetween 2000 and 2013, 452 patients who underwent an HPB procedure for a malignant indication were identified. Clinicopathological characteristics, NLR, and PLR, as well as short- and long-term outcomes were analyzed. High NLR and PLR were classified using a cut-off value of 5 and 190, respectively, based on ROC curve analysis. ResultsPatients with low versus high NLR and PLR had similar baseline characteristics with regard to performance status and tumor stage (all P>0.05). Elevated PLR (HR=1.40) tends to be association with shorter recurrence-free survival (RFS) (P=0.05), whereas NLR was not a predictor of shorter RFS. Differently, both elevated NLR (HR=1.94) and PLR (HR=1.79) were associated with worse overall survival (OS) (both P<0.05). Patients with NLR 5 and those with PLR 190 had a significantly shorter OS compared to patients with NLR <5 and PLR <190, respectively (log-rank test, both P<0.05). Moreover, patients who had both NLR and PLR elevated had worse OS compared to patients with either one or none inflammatory markers elevated (log-rank P=0.02). ConclusionElevated NLR and PLR were predictors of worse long-term outcome among patients with HPB malignancy undergoing resection. J. Surg. Oncol. 2015 111:868-874. (c) 2014 Wiley Periodicals, Inc
Effect of KRAS Mutation on Long-term Outcomes of Patients undergoing Hepatic Resection for Colorectal Liver Metastases
No full textTo investigate the prognostic value of KRAS in a large cohort of patients undergoing liver resection for colorectal liver metastases (CRLM). Between 2003 and 2013, 334 patients underwent hepatic resection for CRLM at Johns Hopkins Hospital and met the inclusion criteria. Clinicopathologic characteristics, perioperative details, and outcomes were stratified by KRAS status-mutant KRAS (mtKRAS) versus wild-type KRAS (wtKRAS)-and analyzed. mtKRAS was identified in 115 (34.4 %) patients. At a median follow-up of 28.2 months, recurrence was observed in 59 (51.3 %) patients with mtKRAS and 117 (53.4 %) patients with wtKRAS (P = 0.79); there was no difference in the pattern of recurrence (liver: mtKRAS 39.0 % vs. wtKRAS 52.1 %; lung: mtKRAS 55.6 % vs. wtKRAS 64.3 %; both P > 0.05). Although 5-year log-rank overall survival (OS) was comparable among mtKRAS (41.6 %) vs. wtKRAS (48.5 %), on multivariable Cox survival analysis and after adjusting for known predictors of OS mtKRAS was associated with worse OS (hazard ratio 1.65; 95 % confidence interval 1.07-2.54; P = 0.02). Among patients who experienced a recurrence, 5-year OS was worse among those patients who had mtKRAS (mtKRAS 28.1 % vs. wtKRAS 44.5 %; P = 0.004). After controlling for tumor factors and receipt of chemotherapy, mtKRAS status remained independently associated with a worse outcome among patients who experienced recurrence (hazard ratio 2.07; 95 % confidence interval 1.31-3.27; P = 0.002). mtKRAS was noted in one-third of patients with CRLM. Although KRAS status did not affect the pattern of recurrence and recurrence-free survival, mtKRAS was an independent predictor of worse OS. The effect was more pronounced among patients who experienced a recurrence after resection of CRLM
National trends in the use of surgery for benign hepatic tumors in the United States
No full textBackground. The widespread use of diagnostic imaging has led to an increase in the incidence and diagnosis of benign liver tumors. The objective of this study was to define the overall use and temporal trends of operative procedures for benign liver tumors using a nationally representative cohort. Methods. All patients who underwent liver surgery for benign liver tumors between 2000 and 2011 were identified from the Nationwide Inpatient Sample database. Trends in annual volume of liver procedures were analyzed using the average annual percent change (AAPC) assessed by joinpoint analysis. Results. There were 2,489 open (94.5%) and 144 (5.5%) minimally invasive surgical (MIS) procedures. Partial hepatectomy accounted for 43.8% of all cases (n = 1,153). Surgery for patients with benign liver tumors increased from 156 in 2000 to 272 in 2011 (AAPC, 5.8%; 95% CI, 3.2-8.6%). There was decline in the relative use of open operative procedures from 98.1% in 2000 to 92.3% in 2011 (AAPC, 0.4%; 95% CI, 0.7 to 0.1%). In contrast, the proportion of MIS procedures increased from 1.9% in 2000 to 7.7% in 2011 (AAPC, 7.4%; 95% CI, 1.9-13.3 %). The median duration of stay among all patients was 5 days (interquartile range, 4-7; 5 days [open] vs 3 days [MIS]; P .05). Conclusion. Overall volume of surgical management of benign liver tumors has increased substantially over the past decade. There has been a relative shift away from open procedures toward MIS procedures
Association Between Specific Mutations in KRAS Codon 12 and Colorectal Liver Metastasis
No full textIMPORTANCE Currently, one of the most commonly available biomarkers in the treatment of patients with colorectal liver metastases (CRLM) is the Kirsten rat sarcoma viral oncogene homolog (KRAS); however, the prognostic implications of specific mutations of the KRAS gene are still not well defined. OBJECTIVE To investigate the prognostic impact of specific KRAS mutations on patients undergoing liver resection for CRLM. DESIGN, SETTING, AND PARTICIPANTS This retrospective single-center study was conducted from January 1, 2003, to December 31, 2013. Data about specific KRAS mutations for 331 patients who underwent hepatic resection for CRLM at Johns Hopkins Hospital between 2003 and 2013 were analyzed. Clinicopathological characteristics, perioperative details, and outcomes were stratified by specific KRAS mutation at codons 12 and 13. INTERVENTION Resection of CRLM. MAIN OUTCOMES AND MEASURES Overall survival (OS) and recurrence-free survival. RESULTS A mutated KRAS (mtKRAS) was identified in 91 patients (27.5%). At a median follow-up of 27.4 months, recurrence was observed in 48 patients (52.7%) with mtKRAS and 130 patients (54.2%) with wild-type KRAS (wtKRAS) (P = .82). Median and 5-year survival among patients with mtKRAS was 32.4 months and 32.7%, respectively, vs 58.5 months and 46.9%, respectively, for patients with wtKRAS (P = .02). Patients with KRAS codon 12 mutations had worse OS (hazard ratio [HR], 1.54; 95% CI, 1.05-2.27; P = .03) vs those with wtKRAS, whereas a KRAS codon 13 mutation was not associated with prognosis (HR, 1.47; 95% CI, 0.83-2.62; P = .19). Among the 6 most common mutations in codons 12 and 13, only G12V (HR, 1.78; 95% CI, 1.00-3.17; P = .05) and G12S (HR, 3.33; 95% CI, 1.22-9.10; P = .02) were associated with worse OS compared with patients with wtKRAS (both P < .05). Among patients who recurred, G12V (HR, 2.96; 95% CI, 1.32-6.61; P = .01), G12C (HR, 6.74; 95% CI, 2.05-22.2; P = .002), and G12S mutations (HR, 4.91; 95% CI, 1.52-15.8; P = .01) were associated with worse OS (both P < .05). CONCLUSIONS AND RELEVANCE G12V and G12S mutations of codon 12 were independent prognostic factors of worse OS. Among patients who recurred after resection of CRLM, G12V, G12C, and G12S mutations were associated with worse OS. Information on specific KRAS mutations may help individualize therapeutic and surveillance strategies for patients with resected CRLM
Neutrophil-lymphocyte and platelet-lymphocyte ratio in patients after resection for hepato-pancreatico-biliary cancers
No full textBackground and Objectives We sought to determine whether Neutrophil-lymphocyte ratio (NLR) or platelet-lymphocyte ratio (PLR) were associated with outcomes of patients undergoing surgery for a hepatopancreatico-biliary (HPB) malignancy. Method Between 2000 and 2013, 452 patients who underwent an HPB procedure for a malignant indication were identified. Clinicopathological characteristics, NLR, and PLR, as well as short- and long-term outcomes were analyzed. High NLR and PLR were classified using a cut-off value of 5 and 190, respectively, based on ROC curve analysis. Results Patients with low versus high NLR and PLR had similar baseline characteristics with regard to performance status and tumor stage (all P>0.05). Elevated PLR (HR=1.40) tends to be association with shorter recurrence-free survival (RFS) (P=0.05), whereas NLR was not a predictor of shorter RFS. Differently, both elevated NLR (HR=1.94) and PLR (HR=1.79) were associated with worse overall survival (OS) (both P<0.05). Patients with NLR ≥5 and those with PLR ≥190 had a significantly shorter OS compared to patients with NLR <5 and PLR <190, respectively (log-rank test, both P<0.05). Moreover, patients who had both NLR and PLR elevated had worse OS compared to patients with either one or none inflammatory markers elevated (log-rank P=0.02). Conclusion Elevated NLR and PLR were predictors of worse long-term outcome among patients with HPB malignancy undergoing resection. © 2015 Wiley Periodicals, In
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