Bagaria, Sanjay P.

Retroperitoneal liposarcomas (RPLPS) are rare tumors that represent at least 50% of all retroperitoneal sarcomas. Surgical resection remains the standard of care. Unfortunately, many RPLPS patients will develop a local recurrence and subsequently die in the absence of distant metastasis. This review outlines the factors that predict local recurrence and influence the management of first and subsequent multiply recurrent RPLPS.

Background and ObjectivesSurgical resection of retroperitoneal sarcomas (RPS) often involves removal of the ipsilateral kidney. We evaluated the long‐term post‐operative renal function in patients who underwent a nephrectomy as part of their en‐bloc resection of RPS.MethodsRetrospective review of an institutional database identified RPS patients who underwent nephrectomy for curative intent from 1990 to 2014. The primary outcome measured was chronic kidney disease (CKD) calculated by the glomerular filtration rate (GFR).ResultsOf the 47 patients in our study, 19 (40%), 18 (38%), and 10 (21%) patients had a preoperative CKD stage 1, 2, and 3, respectively. The GFR decreased by an average of 33.4 mL/min/1.73 m2 with 66% of patients demonstrating mild progression of their renal impairment. Only three (6%) patients progressed to CKD stage 4 or 5, one of which required life‐long dialysis.ConclusionNephrectomy as part of an en‐bloc resection is associated with a decrease in GFR that is not clinically significant. Fear of kidney failure should not prevent a surgeon from performing a nephrectomy in the treatment of RPS.

94 Background: Octogenarian breast cancer (BrCa) patients accept less aggressive BrCa treatment due to decreased life expectancy, increased comorbidities, and high likelihood of death from other causes. Unfortunately little data exist stratifying octogenarian outcomes by disease risk. We sought to characterize treatment and recurrence patterns in patients >80yo. Methods: Retrospective review identified 432 women >80yo treated surgically for stage 0-3 BrCa between 11/99-8/11. We gathered clinicopathologic data and classified patients by disease risk as DCIS only, low risk (<2cm and ER positive and node negative), or high risk (>2cm or ER negative or node positive). We compared recurrence rates and estimated survival by Kaplan-Meier curves. Results: Among the 432 women, disease was found by mammogram in 86%, treated with BCT in 64%, and predominantly ER-positive (87%). We classified patients as having DCIS only (N=61), low risk (N=205), or high risk (N=166) disease. We identified the following deviations from standard treatment guidelines: 68% DCIS BCT and 38% high risk BCT patients did not have radiation therapy, 25% low risk BCT patients had surgery only, 51% low risk patients did not take adjuvant hormonal therapy, and 40% high risk patients had no adjuvant chemo/hormonal therapy. At 5 and 10 years the overall estimated survival was 63% and 31%, respectively. Overall, 19/432 (5%) patients developed recurrence (table 1). Patients needing mastectomy for high risk disease had significantly higher risk of recurrence than high or low risk BCT patients (p=0.02). Of the 19 recurrence patients, 7/19 (37%; 1 DCIS, 1 low risk, 5 high risk) occurred despite standard multimodality treatment, while12 (63%; 3 low risk, 9 high risk) had the initial tumor treated less aggressively due to patient choice (n=9) or medical co-morbidities (n=3). Conclusions: Significant deviations from treatment guidelines occur in women >80yo. Those with high risk disease should be counseled accordingly and encouraged to receive adjuvant treatment as two thirds of women >80yo will live at least 5 years. [Table: see text]

541 Background: A long wait-time for colectomy for colon cancer should theoretically affect survival but, to date, the association between delay to colectomy and survival remains unresolved. Methods: We studied 4,692 patients who underwent colectomy for colon cancer between 1990 and 2012. Wait-time was defined as the number of days between diagnosis and colectomy. Cox regression models were used to estimate all-cause mortality across wait-time categories. Multivariable analyses were controlled for clinicopathologic variables and Charlson comorbidity index. Results: The number of patients in the wait-time group of 1-28 days was 3,950 (84.2%), 29-84 days was 681 (22.7%), and >84 days was 61 (1.3%). A wait-time of 29-84 days was not associated with an increased risk of death (HR=1.13; p=0.056) when compared to a wait-time of 1-28 days. Though a wait-time >84 days represented a small group, it was associated with an increased risk of death (HR=1.60; p=0.013). For patients with stage I and II disease, wait-times of 29-84 days (HR =1.44; p=0.0001) and >84 days (adjusted HR=2.24; p=0.0007) were associated with an increased risk of mortality. Conclusions: A wait-time for colon cancer surgery of up to 12 weeks is likely safe for most patients. However, those suspected to have early-stage colon cancer may benefit from less of delay. These data provide a framework to address concerns over prolonged wait-times and can direct efforts for timely surgical intervention in patients with colon cancer. [Table: see text]

178 Background: Soft tissue sarcoma is a rare disease requiring multidisciplinary care for effective treatment. The National Comprehensive Cancer Network has developed guidelines for surgical resection and adjuvant therapy based on best available evidence. We sought to examine variance from these guidelines in treatment across the United States. Methods: The Surveillance, Epidemiology and End Results cancer registry was queried to identify patients undergoing surgery for extra-abdominal soft tissue sarcoma from 2004-2009. Coded variables signifying radical excision (RE) and the use of radiation therapy (RT) were correlated with stage of the primary tumor. Patients with metastatic disease, unknown size and unknown grade were excluded. Results: A total of 5,600 patients were identified with a median age of 61. Median tumor size was 8cm and most tumors were high grade (57% G3). Stage specific breakdown was as follows; Stage I 24%, Stage II 37% and Stage III 39%. Overall, 54% of patients underwent RE and 50% received RT, mostly in the post-operative setting (83%). The amputation rate was 4%. Although routine radiation therapy is not recommended for Stage IA and IB patients, 24% still underwent RT, whereas only 49% of Stage I patients were noted to have undergone a RE. Even though routine RT is recommended for Stage II and III tumors, 42% of patients did not undergo any RT, and only 58% underwent RE. On multivariate analysis predictors of RE were age <50 (OR 1.3, 95% CI 1.1-1.6), lower extremity tumor (OR 2.2, 95% CI 1.6- 2.8), Stage III, (OR 2.1, 95% CI 1.7- 2.6), and white race (OR 1.4, 95% CI 1.2- 1.8). Variance from guidelines was seen in 64% of patients. Conclusions: Significant heterogeneity and variation in the contemporary treatment for soft tissue sarcoma in the United States exists. Although low rates of RE may be related to coding discrepancies, rates as low as 54% are still a cause for concern. Overuse, and more importantly, underuse of RT is seen for a significant proportion of patients. If these trends are confirmed by further study, more effort will have to be directed towards compliance with appropriate treatment recommendations, perhaps by regionalizing sarcoma care.

13 Background: A Memorial Sloan Kettering Cancer Center (MSKCC) nomogram predicts disease−specific survival (DSS) following R0 resection for gastric adenocarcinoma using patient and tumor factors, with predictive ability superior to that of the current AJCC staging system. However, validation has only been performed in high−volume, specialized institutions. The goal of this study is to compare nomogram-predicted survival with actual survival by using a population database with the largest sample size reported to date. Methods: A retrospective review of all gastric cancer patients from Surveillance, Epidemiology and End Results (SEER) registry data from 1988 to 2000 was conducted. Data for patient age, tumor size, gender, primary location of tumor, Lauren histology, depth of tumor invasion, and % (+) and (-) lymph nodes was entered into the nomogram calculator for each patient. Nomogram-derived 5−year DSS was compared with actual DSS survival using Cox proportional hazards regression and Kaplan-Meier estimates. Results: 4,700 patients were identified. Mean patient age was 68.7 years (SD 12.3), and mean tumor size was 4.8 cm (SD 2.7). The commonest tumor location was the body/middle third of stomach (1519, 32%), followed by the gastro−esophageal junction (1381, 29%) and the antrum (1376, 29%). The majority of patients (76%) had intestinal histology. The estimated proportion of patients surviving 5 years was 23%, 48%, 58%, and 82% for survival groups defined by nomogram likelihoods of 5−year DSS of 0−25%, 26−50%, 51−75%, and 76−100%, respectively. Relative to patients in the 76−100% 5−year nomogram group, patients in the 0−25%, 26−50%, and 51−75% group had significantly higher likelihood of death with hazard ratios of 7.0 (95% CI 6.1−8.0), 3.3 (95% CI 2.8−4.0), and 2.6 (95% CI 2.2−3.0), respectively (all p<0.001). Median follow-up was 9.1 years (range, 0−18). The concordance index (c−index) for the 5−year nomogram score was 0.68 (95% CI 0.67−0.69). Conclusions: There is good discrimination of survival between nomogram-predicted survival groups. Our results validate the use of the MSKCC nomogram in the setting of the general population, outside of specialized institutions, for predicting DSS following resection of gastric adenocarcinoma.

Checkpoint blockade inhibitors have revolutionized the treatment of metastatic melanoma. Despite the success of these agents in improving the overall survival of patients with metastatic melanoma, not all patients achieve clinical benefit, leaving room for improvement. The presence of cutaneous metastases in patients with metastatic melanoma provides the unique opportunity to treat the cutaneous lesions with a local modality while simultaneously treating systemic disease with systemic therapy. Herein, we describe the treatment of two patients with both in-transit and metastatic melanoma with the combination of the topical toll-like receptor 7 agonist imiquimod with systemic ipilimumab. Both patients appeared to have progressed and developed new cutaneous and systemic metastases while on single agent ipilimumab only to respond when started on topical imiquimod. Both patients tolerated the combination of imiquimod and ipilimumab without serious adverse events, and both patients had excellent clinical responses. These cases provide a proof of principle of the possibility of the combination of toll-like receptor 7 agonists with immune checkpoint blockade inhibitors.

BackgroundA Memorial Sloan Kettering (MSKCC) nomogram predicts disease specific survival (DSS) for gastric adenocarcinoma. The goal of this study is to use a cancer registry to compare nomogram predicted survival with actual survival in the general population.MethodsAll patients undergoing surgery for gastric adenocarcinoma from the Surveillance, Epidemiology, and End Results (SEER) database (1988–2012) were studied.Results6954 patients were identified. Majority of cancers were in the antrum (30.2%), and had intestinal histology (73.7%). Median follow‐up was 8.2 years. Five year DSS for nomogram risk groups (0–25%, 26–50%, 51–75%, and 76–100%) was 23%, 48%, 57%, and 81% respectively. Actual DSS was 7–15% lower than nomogram predicted DSS. Relative to patients in the 76–100% 5‐year DSS risk group, patients in the 0–25%, 26–50%, and 51–75% groups had significantly higher risks of death with hazard ratios of 6.84 (95%CI 6.12–7.65), 3.30 (95%CI 2.83–3.86), and 2.64 (95%CI 2.30–3.03), respectively (all P < 0.001). The concordance index for 5‐year nomogram predicted DSS was 0.68 (95%CI 0.67–0.69).ConclusionsThe MSKCC gastric cancer nomogram over‐estimates DSS from gastric cancer in the general population and has a moderate concordance index. Predictive tools generated at specialized institutions may not perform as well in the general population. J. Surg. Oncol. 2015; 112:377–380. © 2015 Wiley Periodicals, Inc.