Regional differences in total hospital costs for radical cystectomy in the United States

ObjectivesTo test for regional differences in total hospital costs (THC) across the United States in bladder cancer patients treated with open radical cystectomy (ORC) or robotic-assisted radical cystectomy (RARC).MaterialsWe relied on the National Inpatient Sample (NIS) database (2016–2019) and stratified RC patients according to census region (Midwest, Northeast, South, West). Primary statistical analyses consisted of THC-trend analyses and multivariable log-link linear regression models, after adjustment for hospital clustering (Generalized Estimating Equation function) and discharge disposition weighting. Finally, sensitivity analysis, relying on most favorable patient cohort, was performed.ResultsOf 5280 eligible patients, 1441 (27%), 1031 (20%), 1854 (35%) and 954 (18%) underwent RC in the Midwest, Northeast, South and West, respectively. Median THC was 28,915$ and differed significantly between regions (Midwest: 28,105$; Northeast: 28,886$; South: 26,096$; West: 38,809$; p < 0.001). After stratification between ORC and RARC, highest THC was invariably recorded in the West: ORC 36,137$ vs 23,941–28,850$ and RARC 43,119$ vs 28,425–29,952$ (both p < 0.05). In multivariable log-link linear regression models, surgery in the West was independently associated with higher THC: ORC (Exponent beta [Exp[β]]: 1.39; 95%-CI: 1.32–1.47; p < 0.001) and RARC (Exp[β]: 1.46; 95%-CI: 1.38–1.55; p < 0.001). Results remained unchanged when analyses were refitted in most favorable patient subgroup.ConclusionsImportant regional differences in ORC and RARC THC distinguish the West from other United States regions. The THC discrepancy clearly requires closer examination to identify underlying processes that contribute to inflated costs in the West.     

A population-based study on incidence,treatment, and survival in ampullary cancer in the Netherlands

IntroductionAmpullary cancer is rare and as a result epidemiological data are scarce. The aim of this population-based study was to determine the trends in incidence, treatment and overall survival (OS) in patients with ampullary adenocarcinoma in the Netherlands between 1989 and 2016.MethodsPatients diagnosed with ampullary adenocarcinoma were identified from the Netherlands Cancer Registry. Incidence rates were age-adjusted to the European standard population. Trends in treatment and OS were studied over (7 years) period of diagnosis, using Kaplan-Meier and Cox regression analyses for OS and stratified by the presence of metastatic disease.ResultsIn total, 3840 patients with ampullary adenocarcinoma were diagnosed of whom, 55.0% were male and 87.1% had non-metastatic disease. The incidence increased from 0.59 per 100,000 in 1989–1995 to 0.68 per 100,000in 2010–2016. In non-metastatic disease, the resection rate increased from 49.5% in 1989–1995 to 63.9% in 2010–2016 (p < 0.001). The rate of adjuvant therapy increased from 3.1% to 7.9%. In non-metastatic disease, five-year OS (95% CI) increased from 19.8% (16.9–22.8) in 1989–1995 to 29.1% (26.0–31.2) in 2010–2016 (logrank p < 0.001). In patients with metastatic disease, median OS did not significantly improve (from 4.4 months (3.6–5.0) to 5.9 months (4.7–7.1); logrank p = 0.06). Cancer treatment was an independent prognostic factor for OS among all patients.ConclusionBoth incidence and OS of ampullary cancer increased from 1989 to 2016 which is most likely related to the observed increased resection rates and use of adjuvant therapy.     

Partial nephrectomy in frail patients: Benefits of robot-assisted surgery

BackgroundTo compare the effect of robot-assisted (RAPN) vs. open (OPN) partial nephrectomy on short-term postoperative outcomes and total hospital charges in frail patients with non-metastatic renal cell carcinoma (RCC).MethodsWithin the National Inpatient Sample database we identified 2745 RCC patients treated with either RAPN or OPN between 2008 and 2015, who met the Johns Hopkins Adjusted Clinical Groups frailty-defining indicator criteria. We examined the rates of RAPN vs. OPN over time. Moreover, we compared the effect of RAPN vs. OPN on short-term postoperative outcomes and total hospital charges. Time trends and multivariable logistic, Poisson and linear regression models were applied.ResultsOverall, 1109 (40.4%) frail patients were treated with RAPN. Rates of RAPN increased over time, from 16.3% to 54.7% (p < 0.001). Frail RAPN patients exhibited lower rates (all p < 0.001) of overall complications (35.3 vs. 48.3%), major complications (12.4 vs. 20.4%), blood transfusions (8.0 vs. 13.5%), non-home-based discharge (9.6 vs. 15.2%), shorter length of stay (3 vs. 4 days), but higher total hospital charges ($50,060 vs. $45,699). Moreover, RAPN independently predicted (all p < 0.001) lower risk of overall complications (OR: 0.58), major complications (OR: 0.55), blood transfusions (OR: 0.60) and non-home-based discharge (OR: 0.51), as well as shorter LOS (RR: 0.77) but also higher total hospital charges (RR: +$7682), relative to OPN.ConclusionsIn frail patients, RAPN is associated with lower rates of short-term postoperative complications, blood transfusions and non-home-based discharge, as well as with shorter LOS than OPN. However, RAPN use also results in higher total hospital charges.     

The effect of age and comorbidities on early postoperative complications after radical cystectomy: A contemporary population-based analysis

BackgroundAnalyzing the relationship between perioperative outcomes and age in urothelial carcinoma of the bladder (UCB) patients treated with radical cystectomy (RC) in a continuous fashion may provide detailed information on the increased risk of complications in older patients, even after accounting for different comorbidity profiles. Given the limited data available in the literature, we tested these relationships within a large scale, population-based database.Materials and MethodsWithin the NIS database (2003–2015), we identified patients who underwent RC for UCB. Multivariable logistic regression (MLoR) and Poisson regression (MPR) models were used after adjustment for clustering and stratification for comorbidity profiles.ResultsOverall, 20,144 patients underwent RC with a median age of 70 years (interquartile range: 62–77). In MLoR models, continuously coded age represented an independent predictor of overall (odds ratio [OR]: 1.008, 95%-confidence interval [CI]: 1.005–1.012), cardiac (OR: 1.042, 95%-CI: 1.035–1.049), vascular (OR: 1.024, 95%-CI: 1.014–1.034), respiratory (OR: 1.016, 95%-CI 1.009–1.022), miscellaneous medical (OR: 1.013, 95%-CI: 1.009–1.017), infectious (OR: 1.012, 95%-CI 1.004–1.019), transfusions (OR: 1.011, 95%-CI 1.007–1.015) and bowel obstruction (OR: 1.009, 95%-CI 1.004–1.013) complications, and in-hospital mortality (OR: 1.057, 95%-CI 1.039–1.075). Conversely, patients age did not predict intraoperative (p = 0.7), genitourinary (p = 0.9), operative wound (p = 0.2) and miscellaneous surgical complications (p = 0.1). In MPR models, patients age predicted longer LOS (relative risk [RR]: 1.002, 95%-CI 1.001–1.003). Finally, a decreasing effect of age was observed in patients low vs high comorbidity burden for cardiac, respiratory and overall complications.ConclusionsMost of early postoperative RC complications are related to patients age, but its impact varies according to comorbidity profile. Further studies are needed to validate our findings that may be then considered for individual counselling and informed consent, as well as for health expenditure planning.     

Tumour grade and stage are associated with specific body composition phenotypes with visceral obesity predisposing the host to a less aggressive tumour in colorectal cancer

BackgroundSarcopenia, myosteatosis and visceral obesity (VO) are known to negatively impact on outcomes from colorectal cancer (CRC). Little is known about tumour factors associated with these body composition (BC) phenotypes. We aimed to identify whether histopathological tumour characteristics were associated with various BC phenotypes.MethodsA prospectively collected database of patients undergoing surgery for primary CRC at a tertiary referral unit in the United Kingdom was analysed. Sarcopenia, myosteatosis and VO were identified on preoperative CT. Binary logistic regression modelling was performed to determine significant associations between tumour stage, grade and BC phenotype.ResultsFinal analysis included 795 patients; median age 69, 56% male, 65% were sarcopenic, 72% myosteatotic, 52% VO and 20% had sarcopenic obesity (SO). VO patients were significantly less likely to have advanced T Stage (T3-4) OR0.62(95%CI 0.44–0.86, p = 0.005); nodal metastases OR0.60(95%CI 0.44–0.82, p = 0.001); vascular invasion OR0.63(95%CI 0.46–0.88, p = 0.006) and poor tumour differentiation OR0.49(95%CI 0.28–0.86, p = 0.012). Myosteatotic patients were more likely to have metastatic disease OR2.31(95%CI 1.15–4.63, p = 0.018) but less likely to have poorly differentiated tumours OR0.48(95%CI 0.27–0.86, p = 0.013). SO patients were significantly more likely to have poorly differentiated tumours OR2.01(95%CI 1.04–3.87, p = 0.037).ConclusionVO predisposes to earlier stage tumours with a less aggressive tumour phenotype. The SO group have adverse tumour characteristics which may be explained by differences in fat distribution. Myosteatosis relates to increased likelihood of distant metastasis that may be related to a systemic inflammatory response, despite the association with better differentiated tumours.     

Outcomes of older adults aged 90 and over with cutaneous malignancies after electrochemotherapy with bleomycin: A matched cohort analysis from the InspECT registry

BackgroundWith extending life expectancy, more people are diagnosed with cutaneous malignancies at advanced ages and are offered nonsurgical treatment. We assessed outcomes of the oldest-old adults after electrochemotherapy (ECT).MethodsThe International Network for Sharing Practices of ECT (InspECT) registry was queried for adults aged ≥90 years (ys) with skin cancers/cutaneous metastases of any histotype who underwent bleomycin-ECT (2006–2019). These were subanalysed with patients aged <90 ys after matching 1:2 for tumor location, number, size, histotype, and previous treatments. We assessed ECT modalities, toxicity (CTCAE), response (RECIST), and patient perception (EQ-5D).ResultsSixty-one patients represented the study cohort (median 92 ys, range 92–104), 122 the control group (median 77 ys, range 23–89). Among the oldest-old, 44 patients (72%) had primary/recurrent skin cancers, 17 (28%) cutaneous metastases. Median tumour size was 15 mm (range, 5–450). The oldest-old adults underwent ECT mainly under local/regional anaesthesia (59% vs 39% p = .012). We observed no differences regarding dose and route of chemotherapy (intravenous vs intratumoral, p = .308), electrode geometry (linear vs hexagonal, p = .172) and procedural duration (18 vs 21 min, p = .378). Complete response (57.4 [95%-CI 44.1%–70.0%] vs 64.7% [95%-CI 55.6%–73.2%], p = .222) and 1-year local control (76.7% vs 81.7, p = .092) rates were comparable. Pain and skin hyperpigmentation were mild in both groups. Skin ulceration persisted longer in the oldest-old patients (4.4 vs 2.4 months, p = .008).ConclusionsThe oldest-old adults with cutaneous malignancies undergo ECT most commonly under local/regional anaesthesia with safety profiles and clinical effectiveness similar to their younger counterparts, except in case of ulcerated tumors.     

Meta-analysis on prognostic value of KRAS mutation in resected mass-forming cholangiocarcinoma

BackgroundDespite survival improvements for other cancers, the prognosis of resected mass-forming cholangiocellular carcinoma (MFCCC) remains dismal. As a possible background of that, biologic factors could play some role. KRAS mutation has been investigated in the present systematic review and meta-analysis.MethodsMEDLINE, Embase and Cochrane Library databases were searched for studies reporting overall survival (OS) following liver resection for MFCCC with known KRAS status. Secondary outcomes included completeness of resection (R1 vs R0), pathological lymph node (LN) rate, tumor burden (multiple vs single), perineural invasion (PI) rate.ResultsEight studies comprising 604 patients resected for MFCCC were eligible for analysis. Of these, 23% of patients were mKRAS. The mKRAS MFCCC showed lower 1-year OS [odd ratio (OR) 3.45, 95% confidence interval (CIs) 1.85–6.42; p < 0.001], 3-years OS (OR 4.82, 95% CI 2.63–8.84; p < 0.001), and 5-years OS (OR 10.60, 95% CI 3.12–36.03; p < 0.001) compared to wtKRAS. Pooled-R1 resection rate was 18% for mKRAS and 23% for those with wtKRAS (OR 1.71, 95%CIs 0.70–4.19; p = 0.239). The pooled-pathological LNs rate was 23% in mKRAS vs 17% (OR 2.36, 95%CIs 0.75–7.48; p = 0.144). The pooled-multifocality rate was 55% in mKRAS vs 19% (OR 5.38, 95%CIs 1.76–16.48; p = 0.003), while the pooled-PI was 77% vs 31% (OR 6.59, 95%CIs 2.13–20.37; p = 0.001).ConclusionThe KRAS mutation is relatively frequent in MFCCC. The mKRAS is strongly associated with a shortened survival and higher tumoral aggressiveness. Testing for KRAS mutations could be a valuable adjunct in opening a scenario to new treatments and improving prognosis of patients with MFCCC.     

The clinical impact of malnutrition on the postoperative outcomes of patients undergoing colorectal resection surgery for colon or rectal cancer: Propensity score matched analysis of 2011–2017 US hospitals

Background & aimsMalnutrition can be prevalently found in patients with significant-to-advanced colorectal cancer, who potential require colorectal resection procedures; to accurately describe the postoperative risks, we used a propensity-score matched comparison of national database to analyze the effects of malnutrition on post-colectomy outcomes.Methods2011–2017 National inpatient Sample was used to isolate inpatient ceases of colorectal resection procedures, which were stratified using malnutrition into malnutrition-present cohort and malnutrition-absent controls; the controls were propensity-score matched with the study cohort using 1:1 ratio and compared to the following endpoints: mortality, length of stay, costs, postoperative complications.ResultsAfter matching, there were 11357 with and without malnutrition who underwent colorectal resection surgery; in comparison, malnourished patients had higher rates of in-hospital mortality (6.14 vs 3.22% p < 0.001, OR 1.96 95%CI 1.73–2.23), length of stay (15.4 vs 9.61d p < 0.001), costs ($163, 962 vs $102,709 p < 0.001), and were more likely to be discharged to non-routine discharges, including short term hospitals, skilled nursing facilities, and home healthcare. In terms of complications, malnourished patients had higher bleeding (2.87 vs 1.68% p < 0.001, OR 1.73 95%CI 1.44–2.07), wound complications (4.31 vs 1.34% p < 0.001, OR 3.32 95%CI 2.76–3.99), infection (6 vs 2.62% p < 0.001, OR 2.38 95%CI 2.07–2.73), and postoperative respiratory failure (7.27 vs 3.37% p < 0.001, OR 2.25 95%CI 1.99–2.54).ConclusionThis study demonstrates the presence of malnutrition to be associated with adverse postoperative outcomes including mortality and complications in patients undergoing colorectal resection surgery for colon cancer.     

Laparoscopic versus open resection for rectal cancer: An individual patient data meta analysis of randomized controlled trials

Background and aimsThe role of laparoscopic rectal cancer resection remains controversial. Thus, we aimed to conduct a one-stage meta-analysis with reconstructed patient-level data using randomized trial data to compare long-term oncologic efficacy of laparoscopic and open surgical resection for rectal cancer.MethodsMedline, EMBASE and Scopus were searched for articles comparing laparoscopic with open surgery for rectal cancer. Primary outcome was disease free survival (DFS) while secondary outcome was overall survival (OS). One-stage meta-analysis was conducted using patient-level survival data reconstructed from Kaplan-Meier curves with Web Plot Digitizer. Shared-frailty and stratified Cox models were fitted to compare survival endpoints.ResultsSeven randomized trials involving 1767 laparoscopic and 1293 open resections for rectal cancer were included. There were no significant differences between both groups for DFS and OS with respective hazard ratio estimates of 0.91 (95% CI: 0.78–1.06, p = 0.241) and 0.86 (95% CI:0.73–1.02, p = 0.090). Sensitivity analysis for non-metastatic patients and patients with mid and lower rectal cancer showed no significant differences in OS and DFS between both surgical approaches. In the laparoscopic arm, improved DFS was noted for stage II (HR: 0.73, 95% CI:0.54–0.98, p = 0.036) and stage III rectal cancers (HR: 0.74, 95% CI:0.55–0.99, p = 0.041).ConclusionsThis meta-analysis concludes that laparoscopic rectal cancer resection does not compromise long-term oncologic outcomes compared with open surgery with potential survival benefits for a minimal access approach in patients with stage II and III rectal cancer.     

Chemotherapy for advanced non-pancreatic well-differentiated neuroendocrine tumours of the gastrointestinal tract,a systematic review and meta-analysis: A lost cause?

BackgroundChemotherapy is well-established in the treatment of patients with well-differentiated neuroendocrine tumours (NETs) arising from the pancreas (pNETs); however, its role in patients with gastrointestinal non-pancreatic NETs (non-pNETs) is uncertain. This systematic review assesses the evidence for the role of chemotherapy in well-differentiated non-pNET patients.MethodsEligible studies (identified using MEDLINE) were those reporting response and/or survival data for patients with well-differentiated non-pNETs receiving systemic chemotherapy. The primary end-point was overall-response (OR) rate; secondary end-points were progression-free survival (PFS), overall survival (OS), disease-stabilization (DS) and disease-control (DC) rates.ResultsOf 6434 studies screened, 20 were eligible: one randomised phase III trial, 2 randomised phase II studies, 10 single-arm phase II trials and 7 retrospective analyses including a total of 264 patients (median of 11 patients per study, range 6–49); and employing multiple chemotherapy schedules. The mean “median PFS” and “median OS” were 16.9 months (95%-confidence interval (CI) 3.8–30.04) and 32.2 months (95%-CI 10.4–54.2), respectively. The non-weighted mean OR, DS and DC rates were 11.5% (95%-CI 5.8–17.2), 56.5% (95%-CI 38.1–74.9) and 70.7% (95%-CI 54.9–86.5), respectively. In studies including both pNETs and non-pNET patients, meta-analysis showed a lower OR-rate in the non-pNET patients when compared to pNETs [odds ratio (OR) 0.35 (95% CI 0.18–0.66)]; however significance was lost when high-risk bias studies were excluded in a sensitivity analysis [OR 0.45 (95% CI 0.19–1.07); p-value 0.07].ConclusionStudies were of evidence level-C with heterogeneous populations and treatments; and small patient numbers. Well-designed, prospective studies are needed to adequately evaluate the role of chemotherapy in this setting.     

Retzius-sparing robot-assisted radical prostatectomy after previous trans-urethral resection of the prostate: Assessment of functional and oncological outcomes

Backgroundno data exist concerning functional and oncological outcomes of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP), in patients previously treated with trans-urethral resection of the prostate (p-TURP), for benign prostate obstruction. Our study addressed the impact of p-TURP on immediate and 12-months urinary continence recovery (UCR), as well as peri-operative outcomes and surgical margins, after RS-RARP.Methodsall patients treated with RS-RARP for prostate cancer at a single high-volume European institution, between 2010 and 2021, were identified and stratified according to p-TURP status. Logistic, Poisson and Cox regression models were performed.ResultsOf 1386 RS-RARP patients, 99 (7%) had history of p-TURP. Between p-TURP and no-TURP patients no differences were detected regarding both intra- and post-operative complications (p values = 0.9). The rates of immediate UCR were 40 vs 67% in p-TURP vs no-TURP patients (p < 0.001). At 12 months from RS-RARP, the rates of UCR were 68 vs 94% in p-TURP vs no-TURP patients (p < 0.001). At multivariable logistic and Cox regression models, p-TURP was independently associated, respectively, with lower immediate (odds ratio [OR]: 0.32, p < 0.001) and 12-months UCR (hazard ratio: 0.54, p < 0.001). At multivariable Poisson analyses, p-TURP predicted longer operative time (rate ratio: 1.08, p < 0.001) but not longer length of stay or time to catheter removal (p values > 0.05). Positive surgical margins rates were 23 vs 17% in p-TURP vs no-TURP patients (p = 0.1), which translated in a non-statistically significant multivariable OR of 1.14 (p = 0.6).Conclusionsp-TURP does not increase surgical morbidity but portends longer operative time and worse urinary continence after RS-RARP.     

Relevance of sentinel lymph node biopsy for thick melanoma in the era of immunotherapy

BackgroundSentinel lymph node biopsy provides prognostic information in patients with thick melanoma but is often underutilized. We examine regional lymph node evaluation (RLNE) in patients with thick melanoma and the effect on treatment and overall survival (OS).MethodsPatients with clinical T4N0M0 melanoma were selected from the National Cancer Database (2004–2015). Binary logistic regression analysis was used to identify factors associated with RLNE and treatment. Overall survival analysis was performed.ResultsA total of 14 286 patients with clinical T4N0M0 melanoma were identified; RLNE was performed in 70.2% of patients, and positive LNs were identified in 27.1%. RLNE was more likely in males (OR:1.44, 95%CI: 1.32–1.56, p < .001), and patients treated at academic centers (OR:1.58, 95%CI:1.46–1.71, p < .001). Immunotherapy was more commonly used in patients with RLNE (13.9% vs 3.4%, p < .001) and was associated with positive LNs (OR:2.50, 95%CI:2.19–2.86, p < .001). The 5-year OS for RLNE was 56.9% and for no RLNE was 32.7%. Independent factors associated with better OS were treatment at an academic center (HR:0.88, 95%CI:0.84–0.93, p < .001), and immunotherapy use (HR:0.86, 95%CI:0.76–0.96, p < .001).ConclusionThe use of RLNE in patients with thick melanoma is important for prognosis and to risk stratify patients for selection of adjuvant therapies and clinical trials.     

Multidisciplinary management of anal intraepithelial neoplasia and rate of progression to cancer: A retrospective cohort study

PurposeTo describe the regional burden of AIN and rate of progression to cancer in patients managed in specialist and non-specialist clinic settings.MethodsPatients with a histopathological diagnosis of AIN between 1994 and 2018 were retrospectively identified. Clinicopathological characteristics including high-risk status (chronic immunosuppressant use or HIV positive), number and type of biopsy (punch/excision) and histopathological findings were recorded. The relationship between clinicopathological characteristics and progression to cancer was assessed using logistic regression.ResultsOf 250 patients identified, 207 were eligible for inclusion: 144 from the specialist and 63 from the non-specialist clinic. Patients in the specialist clinic were younger (<40 years 31% vs 19%, p = 0.007), more likely to be male (34% vs 16%, p = 0.008) and HIV positive (15% vs 2%, p = 0.012). Patients in the non-specialist clinic were less likely to have AIN3 on initial pathology (68% vs 79%, p = 0.074) and were more often followed up for less than 36 months (46% vs 28%, p = 0.134). The rate of progression to cancer was 17% in the whole cohort (20% vs 10%, p = 0.061). On multivariate analysis, increasing age (OR 3.02, 95%CI 1.58–5.78, p < 0.001), high risk status (OR 3.53, 95% CI 1.43–8.74, p = 0.006) and increasing number of excisions (OR 4.88, 95%CI 2.15–11.07, p < 0.001) were related to progression to cancer.ConclusionThe specialist clinic provides a structured approach to the follow up of high-risk status patients with AIN. Frequent monitoring with specialist assessments including high resolution anoscopy in a higher volume clinic are required due to the increased risk of progression to anal cancer.     

The postoperative part of perioperative chemotherapy fails to provide a survival benefit in completely resected esophagogastric adenocarcinoma

BackgroundBased on two benchmark studies perioperative chemotherapy (CTx) has become standard treatment for locally advanced esophagogastric adenocarcinoma (EGA) in Europe. However, only half of the patients in both studies actually received postoperative CTx (aCTx). Thus, we evaluated the prognostic impact of preoperative CTx (nCTx) and aCTx combined versus nCTx alone. Furthermore, we aimed to identify subgroups potentially beneficial of aCTx and factors associated with its non-administration.MethodsWe retrospectively analyzed 299 consecutive patients with EGA, who underwent complete resection (all M0, R0) after nCTx in our institution and were eligible for aCTx. Patients with and without aCTx were compared regarding clinicopathological data, treatment, morbidity, and long-term prognosis.Results129 patients (43.1%) did not receive aCTx. Administration of aCTx did not significantly improve overall (OS) and recurrence free survival (RFS) (median OS: 78.2 months vs. not reached, p = 0.331; RFS: 43.3 vs. 41.1 months, p = 0.118), but was an independent positive predictor of RFS (HR 1.6 95%CI 1.1–2.5, p = 0.024). aCTx improved RFS in non-intestinal tumors (p = 0.023) and patients receiving FLOT regimen (p = 0.038). By logistic regression analysis factors predictive of non-administration of aCTx were older age (>65 years: OR 3.2, p = 0.028), longer hospital stay (15–28 days: OR 2.6, p = 0.001; >28 days: OR 5.2, p < 0.001), and histopathologic non-response (OR 1.9, p = 0.023).ConclusionAdvanced age, histopathologic non-response, and prolonged convalescence due to postoperative morbidity lead to omission of aCTx. However, this study could not provide evidence to support the beneficial role of aCTx in perioperative chemotherapy regimens for a selected patient collective with EGA and excellent prognosis.     

The effect of frailty on post-operative outcomes and health care expenditures in patients treated with partial nephrectomy

ObjectiveTo examine the effect of frailty on short-term post-operative outcomes and total hospital charges (THCs) in patients with non-metastatic renal cell carcinoma, treated with partial nephrectomy (PN).MethodsWithin the National Inpatient Sample (NIS) database we identified 25,545 patients treated with PN from 2000 to 2015. We used the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining indicator and we examined the rates of frailty over time, as well as its effect on overall complications, major complications, blood transfusions, non-home-based discharge, length of stay (LOS) and THCs. Time trends and multivariable logistic, Poisson and linear regression models were applied.ResultsOverall, 3574 (14.0%) patients were frail, 2677 (10.5%) were older than 75 years and 2888 (11.3%) had Charlson comorbidity index (CCI) ≥ 2. However, the vast majority of frail patients were neither elderly nor comorbid (83%). Rates of frail patients treated with PN increased over time, from 8.3 in 2000 to 18.1% in 2015 (all p < 0.001). Frail patients showed higher rates of overall complications (43.5 vs. 30.3%), major complications (16.6 vs. 9.8%), blood transfusions (11.6 vs 8.3%) and non-home-based discharge (9.9 vs. 5.4%). longer LOS [4 (IQR: 3–6) vs. 4 (IQR: 2–5) days] and higher THCs ($43,906 vs. $38,447 – all p < 0.001). Moreover, frailty status independently predicted overall complications (OR: 1.73), major complications (OR: 1.63), longer LOS (RR: 1.07) and higher THCs (RR: +$7506). Finally, a dose-response on the risk of suboptimal surgical outcomes was shown in patients with multiple risk factors.ConclusionsOne out of seven patients is frail at time of surgery and this rate is on the rise. Moreover, frailty is associated with adverse outcomes after PN. In consequence, preoperative assessment of frailty status should be implemented, to identify patients who may benefit from pre- or postoperative measures aimed at improving surgical outcomes in this patient population.     

Contemporary rates and predictors of open conversion during minimally invasive partial nephrectomy for kidney cancer

ObjectivesTo test contemporary rates and predictors of open conversion at minimally invasive partial nephrectomy (MIPN: laparoscopic or robotic partial nephrectomy).Materials and methodsWithin the National Inpatient Sample database (2008–2015) we identified all MIPN patients and patients that underwent open conversion at MIPN. First, estimated annual percentage changes (EAPC) tested temporal trends of open conversion. Second, univariable and multivariable logistic regression models predicted open conversion at MIPN. All models were weighted and adjusted for clustering, as well as all available patient and hospital characteristics.ResultsOf 7649 MIPN patients, 287 (3.8%) underwent open conversion. The rates of open conversion decreased over time (from 12 to 2.4%; EAPC: 24.8%; p = 0.004). In multivariable logistic regression models predicting open conversion, patient obesity achieved independent predictor status (OR:1.80; p < 0.001). Moreover, compared to high volume hospitals, medium volume (OR:1.48; p = 0.02) and low volume hospitals (OR:2.11; p < 0.001) were associated with higher rates of open conversion. Last but not least, when the effect of obesity was tested according to hospital volume, the rates of open conversion ranged from 2.2 (non obese patients treated at high volume hospitals) to 9.8% (obese patients treated at low volume hospitals).ConclusionOverall contemporary (2008–2015) rate of open conversion at MIPN was 3.8% and it was strongly associated with patient obesity and hospital surgical volume. In consequence, these two parameters should be taken into account during preoperative patients counselling, as well as in clinical and administrative decision making.     

Impact of neoadjuvant therapy on postoperative complications in non-small-cell lung cancer patients subjected to anatomic lung resection

ObjectiveTo study the impact of neoadjuvant therapies on postoperative complications and mortality among non-small-cell lung cancer (NSCLC) patients subjected to anatomic lung resection and included in the Spanish cohort of the video-assisted thoracic surgery (GE-VATS) multicenter database.MethodsThe study included a total of 3085 patients from 33 centers between December 2016 and March 2018. We performed a comparative analysis of the complications and mortality in patients who received neoadjuvant therapies (n = 263) versus those who did not (n = 2822). A propensity score-matched analysis was used to adjust for potential confounders. Association between exposure in two groups and outcomes were estimated by logistic regression weighted by inverse of probability of receiving the treatment that actually received.ResultsIn the unadjusted analysis, the chemotherapy (CT) and chemoradiotherapy (CRT) group presented a higher frequency of ICU readmissions, reinterventions, empyema, cardiovascular complications, a greater frequency of atrial fibrillation, and an increased need for blood product transfusions. In the adjusted group, CT and CRT patients had a higher rate of cardiovascular complications (CT p = 0.002; OR 2.29; 95% CI 1.34–3.94 and CRT p = 0.001; OR 2.90; 95% CI 1.52-5-52), arrhythmias (CT p = 0.013; OR 2.23; 95% CI 1.18–4.20 and CRT p = 0.046; OR 2.22; 95% CI 1.01–4.90) and transfussions (CT p = 0.042; OR 2.95; 95% CI 1.04–8.35 and CRT p < 0.001; OR 7.74; 95% CI 3.01-19-92).ConclusionsBased on our series, neoadjuvant CT and CRT were associated with a higher rate of cardiovascular complications, arrhythmias and transfussions in patients with NSCLC subjected to anatomic lung resection.     

The effect of delayed treatment in breast cancer patients: How much is too late? An experience of a single-center study effect of surgery delay in survival

Background and objectivesProper treatment is critical for control and curative intent in breast cancer. Delays in receiving treatment can influence patients' prognoses.MethodsRetrospective, observational, single-center study based on data from medical records of 747 patients with non-metastatic invasive ductal breast carcinoma (I-III) in the initial analysis, comprising 554 patients undergoing adjuvant and 193 neoadjuvant treatment. Kaplan-Meier, Cox regression and time-dependent Cox regression were performed to obtain the predictive value of time to surgery and time to first treatment. Immortal time bias was managed and only 721 patients were included in the multivariable analysis.ResultsDuring a median observation of 64.4 months, there were 140 death events and 177 disease progression events. Time to surgery (TTS) and time from completion of neoadjuvant chemotherapy to surgery (TNS) showed a significant impact on overall survival, associated with a 6% increased chance of death [HR: 1.06 (1.03–1.09), p < 0.001] and 4% [HR: 1.04 (1.00–1.09), p = 0.048] with a one-month increment, respectively. By multivariable analysis, continuous TTS had a different weight as a prognostic factor in stage IIIA/IIIB [adjusted HR: 1.249 (1.072–1.454), p = 0.004] compared to stage I/II [adjusted HR: 1.093 (1.048–1.141), p < 0.0005]. Likewise, TNS was significant after adjusting for other factors [adjusted HR: 1.092 (1.038–1.148), p = 0.001].ConclusionDelay in receiving surgery with curative intent impairs the survival of patients with breast cancer.     

Acute primary testicular failure due to radiotherapy increases risk of severe postoperative adverse events in rectal cancer patients

AimThe aim of this study is to analyze postoperative adverse events (AE) in relation to acute primary testicular failure after radiotherapy (RT) for rectal cancer.MethodThis relation was assessed in 104 men, included in a previous prospective cohort study of men treated with surgical resection of the rectum for rectal cancer stage I-III. Postoperative AE were graded according to Clavien-Dindo (2004). Grade 3 or more was set as cut-off for severe postoperative AE. The impact of primary testicular failure on postoperative AE was related to the cumulative mean testicular dose (TD) and the change in Testosterone (T) and Luteinizing hormone (LH) sampled at baseline and after RT.ResultsTwenty-six study participants (25%) had severe postoperative AE. Baseline characteristics and endocrine testicular function did not differ significantly between groups with (AE+) and without severe postoperative AE (AE-). After RT, the LH/T-ratio was higher in AE+, 0.603 (0.2–2.5) vs 0.452 (0.127–5.926) (p = 0.035). The longitudinal regression analysis showed that preoperative change in T (OR 0.844, 95% CI 0.720–0.990, p = 0.034), LH/T-ratio (OR 2.020, 95% CI 1.010–4.039, p = 0.047) and low T (<8 nmol/L, OR 2.605, 95 CI 0.951–7.139, p = 0.063) were related to severe postoperative AE.ConclusionPreoperative decline in T due to primary testicular failure induced by preoperative RT could be a risk factor regarding short-term outcome of surgery in men with rectal cancer.     

Radical cystectomy in non-metastatic sarcomatoid bladder cancer: A direct comparison vs urothelial bladder cancer

IntroductionThe effect of radical cystectomy (RC) on cancer-specific mortality (CSM) is unclear in non-metastatic sarcomatoid bladder cancer (SBC) patients. We aimed to test the benefit of RC in SBC, and to perform a direct comparison vs urothelial bladder cancer (UCB).Materials and methodsWithin the Surveillance, Epidemiology, and End Results database (SEER 2001–2018) all non-metastatic SBC and UBC patients were identified. Endpoint of interest was CSM. Propensity score matching (PSM), cumulative incidence plots, competing risks regression (CRR) analyses, three-months landmark analyses, and sensitivity analyses were performed. All results were stratified according to organ-confined (OC: T₂N₀M₀) vs non-organ-confined (NOC: T_3-4N₀M₀ or T_anyN_1-3M₀) stages.ResultsOf 554 SBC patients, 49 vs 51% harbored OC vs NOC stages. Of 47,741 UBC patients, 62 vs 38% harbored OC vs NOC stages. RC rates were 33 vs 67% in OC vs NOC-SBC patients, and 40 vs 60% in OC vs NOC-UBC patients. After 1:1 PSM, comparison between RC vs no-RC was performed in OC-SBC (67 patients per group), OC-UBC (7611 patients per group), NOC-SBC (63 patients per group), and NOC-UBC patients (4644 patients per group). CRR hazard ratios associated with RC vs no-RC were 0.37 (p < 0.001) in OC-SBC vs 0.45 (p < 0.001) in OC-UBC, and 0.56 (p = 0.01) in NOC-SBC vs 0.68 (p < 0.001) in NOC-UBC. These results were replicated in sensitivity and landmark analyses.ConclusionsThe protective effect of RC vs no-RC is stronger in SBC than UBC patients, regardless of OC vs NOC stages.