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Pancreatic Neoplasms: HELP
Articles by Syed Arif Ahmad
Based on 53 articles published since 2009
(Why 53 articles?)
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Between 2009 and 2019, Syed Ahmad wrote the following 53 articles about Pancreatic Neoplasms.
 
+ Citations + Abstracts
Pages: 1 · 2 · 3
1 Editorial Comparison of the sendai and fukuoka consensus guidelines for the management of mucinous cystic lesions of the pancreas: are we making progress? 2014

Abbott, Daniel E / Ahmad, Syed A. ·Division of Surgical Oncology, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA. ·Ann Surg Oncol · Pubmed #24496603.

ABSTRACT: -- No abstract --

2 Review The Surgeon's Role in Treating Chronic Pancreatitis and Incidentally Discovered Pancreatic Lesions. 2017

Dhar, Vikrom K / Xia, Brent T / Ahmad, Syed A. ·Division of Surgical Oncology, Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA. · Division of Surgical Oncology, Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA. ahmadsy@uc.edu. ·J Gastrointest Surg · Pubmed #28808857.

ABSTRACT: Chronic pancreatitis and incidentally discovered pancreatic lesions present significant diagnostic and therapeutic challenges for surgeons. While both decompressive and resection procedures have been described for treatment of chronic pancreatitis, optimal management must be tailored to each patient's individual disease characteristics, parenchymal morphology, and ductal anatomy. Surgeons should strive to achieve long-lasting pain relief while preserving native pancreatic function. For patients with incidentally discovered pancreatic lesions, differentiating benign, pre-malignant, and malignant lesions is critical as earlier treatment is thought to result in improved survival. The purpose of this evidence-based manuscript is to review the presentation, workup, surgical management, and associated outcomes for patients with chronic pancreatitis or incidentally discovered solid and cystic lesions of the pancreas.

3 Review Knowing Your Boundaries: A Review of the Definitions and Imaging Features of Borderline Resectable Pancreatic Carcinoma. 2016

McDonald, Nicholas / Ahmad, Syed / Ann Choe, Kyuran. ·Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH. · Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH. · Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH. Electronic address: Kyuran.Choe@UCHealth.com. ·Semin Roentgenol · Pubmed #27105962.

ABSTRACT: -- No abstract --

4 Review Clinical Considerations for Pancreatic Cancer. 2016

Xia, Brent T / Ahmad, Syed A. ·Department of Surgery, University of Cincinnati College of Medicine, University of Cincinnati, Cincinnati, OH 45267. · Department of Surgery, University of Cincinnati College of Medicine, University of Cincinnati, Cincinnati, OH 45267. Electronic address: ahmadsy@uc.edu. ·Semin Roentgenol · Pubmed #27105961.

ABSTRACT: -- No abstract --

5 Review A systematic review of the role of periadventitial dissection of the superior mesenteric artery in affecting margin status after pancreatoduodenectomy for pancreatic adenocarcinoma. 2016

Butler, James R / Ahmad, Syed A / Katz, Matthew H / Cioffi, Jessica L / Zyromski, Nicholas J. ·Indiana University School of Medicine, Department of Surgery, Indianapolis IN, USA. · The University of Cincinnati Cancer Institute, Cincinnati OH, USA. · Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. · Indiana University School of Medicine, Department of Surgery, Indianapolis IN, USA. Electronic address: nzyromsk@iupui.edu. ·HPB (Oxford) · Pubmed #27037198.

ABSTRACT: BACKGROUND: Resectable pancreatic ductal adenocarcinoma continues to carry a poor prognosis. Of the controllable clinical variables known to affect outcome, margin status is paramount. Though the importance of a R0 resection is generally accepted, not all margins are easily managed. The superior mesenteric artery [SMA] in particular is the most challenging to clear. The aim of this study was to systematically review the literature with specific focus on the role of a SMA periadventitial dissection during PD and it's effect on margin status in pancreatic adenocarcinoma. STUDY DESIGN: The MEDLINE, EMBASE and Cochrane databases were searched for abstracts that addressed the effect of margin status on survival and recurrence following pancreaticoduodenectomy [PD]. Quantitative analysis was performed. RESULTS: The overall incidence of a R1 resection ranged from 16% to 79%. The margin that was most often positive following PD was the SMA margin, which was positive in 15-45% of resected specimens. Most studies suggested that a positive margin was associated with decreased survival. No consistent definition of R0 resection was observed. CONCLUSIONS: Margin positivity in resectable pancreatic adenocarcinoma is associated with poor survival. Inability to clear the SMA margin is the most common cause of incomplete resection. More complete and consistently reported data are needed to evaluate the potential effect of periadventitial SMA dissection on margin status, local recurrence, or survival.

6 Review Factors affecting readmission after pancreaticoduodenectomy. 2013

Clarke, Callisia N / Sussman, Jeffrey J / Abbott, Daniel E / Ahmad, Syed A. ·Pancreatic Disease Center, Department of Surgery, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH 45219, USA. ·Adv Surg · Pubmed #24298846.

ABSTRACT: PD continues to be associated with a high rate of failed discharges, despite significant improvements in techniques and postoperative care at high-volume centers. Even in the best hands, 1 in 5 patients undergoing PD can be expected to require readmission in the early postoperative period. Efforts to minimize readmissions must be aimed at identifying high-risk patients, addressing patient expectations, establishing patient care plans, and using outpatient resources to address anticipated problems and complications.

7 Review Borderline resectable pancreatic cancer: need for standardization and methods for optimal clinical trial design. 2013

Katz, Matthew H G / Marsh, Robert / Herman, Joseph M / Shi, Qian / Collison, Eric / Venook, Alan P / Kindler, Hedy L / Alberts, Steven R / Philip, Philip / Lowy, Andrew M / Pisters, Peter W T / Posner, Mitchell C / Berlin, Jordan D / Ahmad, Syed A. ·Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA. mhgkatz@mdanderson.org ·Ann Surg Oncol · Pubmed #23435609.

ABSTRACT: BACKGROUND: Methodological limitations of prior studies have prevented progress in the treatment of patients with borderline resectable pancreatic adenocarcinoma. Shortcomings have included an absence of staging and treatment standards and pre-existing biases with regard to the use of neoadjuvant therapy and the role of vascular resection at pancreatectomy. METHODS: In this manuscript, we review limitations of studies of borderline resectable PDAC reported to date, highlight important controversies related to this disease stage, emphasize the research infrastructure necessary for its future study, and present a recently-approved Intergroup pilot study (Alliance A021101) that will provide a foundation upon which subsequent well-designed clinical trials can be performed. RESULTS: We identified twenty-three studies published since 2001 which report outcomes of patients with tumors labeled as borderline resectable and who were treated with neoadjuvant therapy prior to planned pancreatectomy. These studies were heterogeneous in terms of the populations studied, the metrics used to characterize therapeutic response, and the indications used to select patients for surgery. Mechanisms used to standardize these and other issues that are incorporated into Alliance A021101 are reviewed. CONCLUSIONS: Rigorous standards of clinical trial design incorporated into trials of other disease stages must be adopted in all future studies of borderline resectable pancreatic cancer. The Intergroup trial should serve as a paradigm for such investigations.

8 Review Current concepts in the surgical management of pancreatic cancer. 2010

Thomas, Ryan M / Ahmad, Syed A. ·Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA. ·Surg Oncol Clin N Am · Pubmed #20159518.

ABSTRACT: Pancreatic ductal adenocarcinoma (PDA) is the most common pancreatic malignancy comprising approximately 85% of cases. Many aspects of surgical resection of pancreatic cancer have been evaluated as to their effects on morbidity and mortality, including evaluation of anastomotic techniques, the role of extended lymphadenectomies, and the use of vascular reconstruction. Progress in the perioperative care of those undergoing pancreatic resection for PDA has resulted in improved outcomes. This review discusses the preoperative evaluation of a patient with pancreatic cancer and addresses the surgical management of these patients, with special attention to recent areas of progress and controversy.

9 Clinical Trial A Phase II Clinical Trial of Molecular Profiled Neoadjuvant Therapy for Localized Pancreatic Ductal Adenocarcinoma. 2018

Tsai, Susan / Christians, Kathleen K / George, Ben / Ritch, Paul S / Dua, Kulwinder / Khan, Abdul / Mackinnon, A Craig / Tolat, Parag / Ahmad, Syed A / Hall, William A / Erickson, Beth A / Evans, Douglas B. ·Department of Surgery, Division of Surgical Oncology, The Medical College of Wisconsin, Milwaukee, WI. · Department of Medicine, Division of Hematology/Oncology, The Medical College of Wisconsin, Milwaukee, WI. · Division of Gastroenterology, The Medical College of Wisconsin, Milwaukee, WI. · Department of Pathology, The Medical College of Wisconsin, Milwaukee, WI. · Department of Radiology, The Medical College of Wisconsin, Milwaukee, WI. · Department of Radiation Oncology, The Medical College of Wisconsin, Milwaukee, WI. · Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, Cincinnati, OH. ·Ann Surg · Pubmed #30080723.

ABSTRACT: OBJECTIVES: One facet of precision medicine is the use of tumor molecular profiling to guide chemotherapeutic selection. We conducted the first prospective clinical trial of molecular profiling to guide neoadjuvant therapy in patients with operable pancreatic ductal adenocarcinoma (PDAC). We hypothesized that more effective systemic therapy would prevent disease progression during neoadjuvant therapy and, therefore, allow more patients to undergo surgery. METHODS: In patients with resectable and borderline resectable (BLR) PDAC, molecular profiling consisted of immunocytochemical staining of pretreatment endoscopic ultrasound-guided fine needle aspiration tumor biopsies using 6 biomarkers. Neoadjuvant systemic therapy was selected based on the molecular profiling results. The primary endpoint was the completion of all intended neoadjuvant therapy and surgery. RESULTS: The trial enrolled 130 patients; 61 (47%) resectable and 69 (53%) BLR. Molecular profiling was reported within a median of 5 business days (IQR: 3). Of the 130 patient samples, 95 (73%) had adequate cellularity for molecular profiling and 92 (71%) patients received molecular profile-directed therapy. Of the 92 patients who had predictive profiling, 74 (80%) received fluoropyrimidine-based therapy and 18 (20%) received gemcitabine-based therapies. Of the 130 patients, 107 (82%) completed all intended neoadjuvant therapy and surgery; 56 (92%) of the 61 with resectable PDAC and 51 (74%) of 69 with BLR PDAC. CONCLUSIONS: We report the first prospective clinical trial that utilized molecular profiling to select neoadjuvant therapy in patients with operable PDAC. Such high resectability rates have not been observed in prior neoadjuvant trials, suggesting that molecular profiling may improve the efficacy of chemotherapy in these patients.

10 Clinical Trial Preoperative Modified FOLFIRINOX Treatment Followed by Capecitabine-Based Chemoradiation for Borderline Resectable Pancreatic Cancer: Alliance for Clinical Trials in Oncology Trial A021101. 2016

Katz, Matthew H G / Shi, Qian / Ahmad, Syed A / Herman, Joseph M / Marsh, Robert de W / Collisson, Eric / Schwartz, Lawrence / Frankel, Wendy / Martin, Robert / Conway, William / Truty, Mark / Kindler, Hedy / Lowy, Andrew M / Bekaii-Saab, Tanios / Philip, Philip / Talamonti, Mark / Cardin, Dana / LoConte, Noelle / Shen, Perry / Hoffman, John P / Venook, Alan P. ·Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston. · Alliance for Clinical Trials in Oncology Statistics and Data Center, Mayo Clinic, Rochester, Minnesota. · Department of Surgery, University of Cincinnati, Cincinnati, Ohio. · Department of Radiation Oncology, Johns Hopkins University, Baltimore, Maryland. · Department of Medical Oncology, NorthShore University HealthSystem, University of Chicago, Chicago, Illinois. · Department of Medical Oncology, University of California-San Francisco, San Francisco. · Department of Radiology, Columbia University, New York, New York. · Department of Pathology, Ohio State University, Columbus. · Department of Surgery, University of Louisville, Louisville, Kentucky. · Department of Surgery, Ochsner Medical Center, New Orleans, Louisiana. · Department of Surgery, Mayo Clinic, Rochester, Minnesota. · Department of Medical Oncology, University of Chicago, Chicago, Illinois. · Department of Surgery, University of California, San Diego. · Department of Medical Oncology, Ohio State University, Columbus. · Department of Medical Oncology, Karmanos Cancer Center, Detroit, Michigan. · Department of Surgery, NorthShore University HealthSystem, University of Chicago, Chicago, Illinois. · Department of Medical Oncology, Vanderbilt University, Nashville, Tennessee. · Department of Medical Oncology, University of Wisconsin-Madison, Madison, Wisconsin. · Department of Surgery, Wake Forest University, Winston Salem, North Carolina. · Department of Surgery, Fox Chase Cancer Center, Philadelphia, Pennsylvania. ·JAMA Surg · Pubmed #27275632.

ABSTRACT: IMPORTANCE: Although consensus statements support the preoperative treatment of borderline resectable pancreatic cancer, no prospective, quality-controlled, multicenter studies of this strategy have been conducted. Existing studies are retrospective and confounded by heterogeneity in patients studied, therapeutic algorithms used, and outcomes reported. OBJECTIVE: To determine the feasibility of conducting studies of multimodality therapy for borderline resectable pancreatic cancer in the cooperative group setting. DESIGN, SETTING, AND PARTICIPANTS: A prospective, multicenter, single-arm trial of a multimodality treatment regimen administered within a study framework using centralized quality control with the cooperation of 14 member institutions of the National Clinical Trials Network. Twenty-nine patients with biopsy-confirmed pancreatic cancer preregistered, and 23 patients with tumors who met centrally reviewed radiographic criteria registered. Twenty-two patients initiated therapy (median age, 64 years [range, 50-76 years]; 55% female). Patients registered between May 29, 2013, and February 7, 2014. INTERVENTIONS: Patients received modified FOLFIRINOX treatment (85 mg/m2 of oxaliplatin, 180 mg/m2 of irinotecan hydrochloride, 400 mg/m2 of leucovorin calcium, and then 2400 mg/m2 of 5-fluorouracil for 4 cycles) followed by 5.5 weeks of external-beam radiation (50.4 Gy delivered in 28 daily fractions) with capecitabine (825 mg/m2 orally twice daily) prior to pancreatectomy. MAIN OUTCOMES AND MEASURES: Feasibility, defined by the accrual rate, the safety of the preoperative regimen, and the pancreatectomy rate. RESULTS: The accrual rate of 2.6 patients per month was superior to the anticipated rate. Although 14 of the 22 patients (64% [95% CI, 41%-83%]) had grade 3 or higher adverse events, 15 of the 22 patients (68% [95% CI, 49%-88%]) underwent pancreatectomy. Of these 15 patients, 12 (80%) required vascular resection, 14 (93%) had microscopically negative margins, 5 (33%) had specimens that had less than 5% residual cancer cells, and 2 (13%) had specimens that had pathologic complete responses. The median overall survival of all patients was 21.7 months (95% CI, 15.7 to not reached) from registration. CONCLUSIONS AND RELEVANCE: The successful completion of this collaborative study demonstrates the feasibility of conducting quality-controlled trials for this disease stage in the multi-institutional setting. The data generated by this study and the logistical elements that facilitated the trial's completion are currently being used to develop cooperative group trials with the goal of improving outcomes for this subset of patients. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01821612.

11 Article Does Surgical Margin Impact Recurrence in Noninvasive Intraductal Papillary Mucinous Neoplasms?: A Multi-institutional Study. 2018

Dhar, Vikrom K / Merchant, Nipun B / Patel, Sameer H / Edwards, Michael J / Wima, Koffi / Imbus, Joseph / Abbott, Daniel E / Weber, Sharon M / Louie, Raphael / Kim, Hong J / Martin, Robert C G / Scoggins, Charles R / Bentrem, David J / LeCompte, Michael T / Idrees, Kamran / Lopez-Aguiar, Alexandra G / Maithel, Shishir K / Kooby, David A / Franco, Daniel A / Yakoub, Danny / Ahmad, Syed A. ·Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH. · Division of Surgical Oncology, Department of Surgery, University of Miami Leonard M Miller School of Medicine, Miami, FL. · Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI. · Division of Surgical Oncology, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC. · Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, KY. · Division of Surgical Oncology, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. · Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN. · Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA. ·Ann Surg · Pubmed #30063495.

ABSTRACT: OBJECTIVE: The relevance of margin positivity on recurrence after resection of intraductal papillary mucinous neoplasms (IPMNs) is poorly defined and represents one reason controversy remains regarding optimal surveillance recommendations. METHODS: Patients undergoing surgery for noninvasive IPMN at 8 academic medical centers from the Central Pancreas Consortium were analyzed. A positive margin was defined as presence of IPMN or pancreatic intraepithelial neoplasia. RESULTS: Five hundred two patients underwent surgery for IPMN; 330 (66%) did not have invasive cancer on final pathology and form the study cohort. Of these, 20% harbored high grade dysplasia. A positive margin was found in 20% of cases and was associated with multifocal disease (P = 0.02). The majority of positive margins were associated with low grade dysplasia. At a median follow-up of 36 months, 34 (10.3%) patients recurred, with 6.7% developing recurrent cystic disease and 3.6% developing invasive cancer. On multivariate analysis, margin positivity was not associated with recurrence of either IPMN or invasive cancer (P > 0.05). No association between margin status and development of recurrence at the margin was found. Only 6% of recurrences developed at the resection margin and median time to recurrence was 22 months. Of note, 18% of recurrences occurred > 5 years following surgery. CONCLUSION: Margin positivity after resection for noninvasive IPMNs is primarily due to low grade dysplasia and is not associated with developing recurrence in the remnant pancreas or at the resection margin. Long-term surveillance is required for all patients, as a significant number of recurrences developed over 5 years after the index operation.

12 Article The Hand-Assisted Laparoscopic Approach to Resection of Pancreatic Mucinous Cystic Neoplasms: An Underused Technique? 2018

Postlewait, Lauren M / Ethun, Cecilia G / McInnis, Mia R / Merchant, Nipun / Parikh, Alexander / Idrees, Kamran / Isom, Chelsea A / Hawkins, William / Fields, Ryan C / Strand, Matthew / Weber, Sharon M / Cho, Clifford S / Salem, Ahmed / Martin, Robert C G / Scoggins, Charles / Bentrem, David / Kim, Hong J / Carr, Jacquelyn / Ahmad, Syed / Abbott, Daniel / Wilson, Gregory C / Kooby, David A / Maithel, Shishir K. · ·Am Surg · Pubmed #29428029.

ABSTRACT: Pancreatic mucinous cystic neoplasms (MCNs) are rare tumors typically of the distal pancreas that harbor malignant potential. Although resection is recommended, data are limited on optimal operative approaches to distal pancreatectomy for MCN. MCN resections (2000-2014; eight institutions) were included. Outcomes of minimally invasive and open MCN resections were compared. A total of 289 patients underwent distal pancreatectomy for MCN: 136(47%) minimally invasive and 153(53%) open. Minimally invasive procedures were associated with smaller MCN size (3.9 vs 6.8 cm; P = 0.001), lower operative blood loss (192 vs 392 mL; P = 0.001), and shorter hospital stay(5 vs 7 days; P = 0.001) compared with open. Despite higher American Society of Anesthesiologists class, hand-assisted (n = 46) had similar advantages as laparoscopic/robotic (n = 76). When comparing hand-assisted to open, although MCN size was slightly smaller (4.1 vs 6.8 cm; P = 0.001), specimen length, operative time, and nodal yield were identical. Similar to laparoscopic/robotic, hand-assisted had lower operative blood loss (161 vs 392 mL; P = 0.001) and shorter hospital stay (5 vs 7 days; P = 0.03) compared with open, without increased complications. Hand-assisted laparoscopic technique is a useful approach for MCN resection because specimen length, lymph node yield, operative time, and complication profiles are similar to open procedures, but it still offers the advantages of a minimally invasive approach. Hand-assisted laparoscopy should be considered as an alternative to open technique or as a successive step before converting from total laparoscopic to open distal pancreatectomy for MCN.

13 Article Grading Using Ki-67 Index and Mitotic Rate Increases the Prognostic Accuracy of Pancreatic Neuroendocrine Tumors. 2018

Philips, Prejesh / Kooby, David A / Maithel, Shishir / Merchant, Nipun B / Weber, Sharon M / Winslow, Emily R / Ahmad, Syed / Kim, Hong J / Scoggins, Charles R / McMasters, Kelly M / Martin, Robert C G. · ·Pancreas · Pubmed #29351120.

ABSTRACT: OBJECTIVES: To measure the usefulness of Ki-67 proliferative index (Ki-67 index) as a prognostic variable for grading pancreatic neuroendocrine tumors. METHODS: A multi-institutional prospective database comprising 350 patients. Grading based on mitotic activity (<2 mitoses/10 high-power fields, 2-20 and >20) and Ki-67 index (<3% per 10 high-power fields, 3%-20% and >20%). Final grade selected based on higher grade of either variable. RESULTS: Most patients were in the less than 3% (n = 158) and 3% to 20% Ki-67 category (n = 107), with a minority being high-grade (Ki-67 > 20%, n = 27). Discordance between Ki-67 and mitotic rate was noted in 58 patients. On multivariate analysis, final-grade (grade 2: P = 0.010, hazard ratio [HR], 1.2; grade 3: P = 0.002; HR, 2.8), Ki-67, mitotic rate, and lymph node status were significant prognostic markers for overall survival (OS). For disease-free survival (DFS), only final-grade (grade 2: P = 0.05; HR, 1.4; grade 3: P = 0.009; HR, 2.3), Ki-67, mitotic rate, and margin status significantly predicted DFS. Ki-67 was a better model for OS and mitotic rate for DFS. Overall combined final grade was the best model based on HR. CONCLUSION: Ki-67 is a strong prognostic factor for OS and DFS and should be included in all pancreatic neuroendocrine tumor pathology.

14 Article Equivalent Treatment and Survival after Resection of Pancreatic Cancer at Safety-Net Hospitals. 2018

Dhar, Vikrom K / Hoehn, Richard S / Kim, Young / Xia, Brent T / Jung, Andrew D / Hanseman, Dennis J / Ahmad, Syed A / Shah, Shimul A. ·Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA. · Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA. Shimul.shah@uc.edu. · Division of Transplant Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, MSB 2006C, Cincinnati, OH, 45267-0558, USA. Shimul.shah@uc.edu. ·J Gastrointest Surg · Pubmed #28849353.

ABSTRACT: BACKGROUND: Due to disparities in access to care, patients with Medicaid or no health insurance are at risk of not receiving appropriate adjuvant treatment following resection of pancreatic cancer. We have previously shown inferior short-term outcomes following surgery at safety-net hospitals. Subsequently, we hypothesized that safety-net hospitals caring for these vulnerable populations utilize less adjuvant chemoradiation, resulting in inferior long-term outcomes. METHODS: The American College of Surgeons National Cancer Data Base was queried for patients diagnosed with pancreatic adenocarcinoma (n = 32,296) from 1998 to 2010. Hospitals were grouped according to safety-net burden, defined as the proportion of patients with Medicaid or no insurance. The highest quartile, representing safety-net hospitals, was compared to lower-burden hospitals with regard to patient demographics, disease characteristics, surgical management, delivery of multimodal systemic therapy, and survival. RESULTS: Patients at safety-net hospitals were less often white, had lower income, and were less educated. Safety-net hospital patients were just as likely to undergo surgical resection (OR 1.03, p = 0.73), achieving similar rates of negative surgical margins when compared to patients at medium and low burden hospitals (70% vs. 73% vs. 66%). Thirty-day mortality rates were 5.6% for high burden hospitals, 5.2% for medium burden hospitals, and 4.3% for low burden hospitals. No clinically significant differences were noted in the proportion of surgical patients receiving either chemotherapy (48% vs. 52% vs. 52%) or radiation therapy (26% vs. 30% vs. 29%) or the time between diagnosis and start of systemic therapy (58 days vs. 61 days vs. 53 days). Across safety-net burden groups, no difference was noted in stage-specific median survival (all p > 0.05) or receipt of adjuvant as opposed to neoadjuvant systemic therapy (82% vs. 85% vs. 85%). Multivariate analysis adjusting for cancer stage revealed no difference in survival for safety-net hospital patients who had surgery and survived > 30 days (HR 1.02, p = 0.63). CONCLUSION: For patients surviving the perioperative setting following pancreatic cancer surgery, safety-net hospitals achieve equivalent long-term survival outcomes potentially due to equivalent delivery of multimodal therapy at non-safety-net hospitals. Safety-net hospitals are a crucial resource that provides quality long-term cancer treatment for vulnerable populations.

15 Article Alliance for clinical trials in oncology (ALLIANCE) trial A021501: preoperative extended chemotherapy vs. chemotherapy plus hypofractionated radiation therapy for borderline resectable adenocarcinoma of the head of the pancreas. 2017

Katz, Matthew H G / Ou, Fang-Shu / Herman, Joseph M / Ahmad, Syed A / Wolpin, Brian / Marsh, Robert / Behr, Spencer / Shi, Qian / Chuong, Michael / Schwartz, Lawrence H / Frankel, Wendy / Collisson, Eric / Koay, Eugene J / Hubbard, JoLeen M / Leenstra, James L / Meyerhardt, Jeffrey / O'Reilly, Eileen / Anonymous3600914. ·The University of Texas MD Anderson Cancer Center, University of Texas, 1400 Pressler Street FCT 17.6058, Unit #1484, Houston, TX, 77030-4009, USA. mhgkatz@mdanderson.org. · Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, USA. · The University of Texas MD Anderson Cancer Center, University of Texas, 1400 Pressler Street FCT 17.6058, Unit #1484, Houston, TX, 77030-4009, USA. · University of Cincinnati, Cincinnati, OH, USA. · Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA. · NorthShore Evanston Hospital, Evanston, IL, USA. · The University of California at San Francisco, San Francisco, CA, USA. · University of Maryland/Greenebaum Cancer Center, Baltimore, MD, USA. · New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA. · The Ohio State University, Columbus, OH, USA. · Mayo Clinic, Rochester, MN, USA. · Memorial Sloan Kettering Cancer Center, New York, NY, USA. ·BMC Cancer · Pubmed #28750659.

ABSTRACT: BACKGROUND: Borderline resectable pancreatic cancers infiltrate into adjacent vascular structures to an extent that makes an R0 resection unlikely when pancreatectomy is performed de novo. In a pilot study, Alliance for Clinical Trials in Oncology Trial A021101, the median survival of patients who received chemotherapy and radiation prior to anticipated pancreatectomy was 22 months, and 64% of operations achieved an R0 resection. However, the individual contributions of preoperative chemotherapy and radiation therapy to therapeutic outcome remain poorly defined. METHODS: In Alliance for Clinical Oncology Trial A021501, a recently activated randomized phase II trial, patients (N = 134) with a CT or MRI showing a biopsy-confirmed pancreatic ductal adenocarcinoma that meets centrally-reviewed anatomic criteria for borderline resectable disease will be randomized to receive either 8 cycles of modified FOLFIRINOX (oxaliplatin 85 mg/m DISCUSSION: This study will help define standard preoperative treatment regimens for borderline resectable pancreatic cancer and position the superior arm for further evaluation in future phase III trials. TRIAL REGISTRATION: ClinicalTrials.gov : NCT02839343 , registered July 14, 2016.

16 Article Time to Initiation of Adjuvant Chemotherapy in Pancreas Cancer: A Multi-Institutional Experience. 2017

Xia, Brent T / Ahmad, Syed A / Al Humaidi, Ali H / Hanseman, Dennis J / Ethun, Cecilia G / Maithel, Shishir K / Kooby, David A / Salem, Ahmed / Cho, Clifford S / Weber, Sharon M / Stocker, Susan J / Talamonti, Mark S / Bentrem, David J / Abbott, Daniel E. ·Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA. · Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA. · Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA. · Division of Surgical Oncology, Department of Surgery, University of Michigan, Ann Arbor, MI, USA. · Department of Surgery, Northwestern University, Chicago, IL, USA. · Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA. · Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA. abbott@surgery.wisc.edu. ·Ann Surg Oncol · Pubmed #28600732.

ABSTRACT: BACKGROUND: Despite randomized trials addressing adjuvant therapy (AT) for pancreas cancer, the ideal time to initiate therapy remains undefined. Retrospective analyses of the ESPAC-3 trial demonstrated that time to initiation of AT did not impact overall survival (OS). Given the absence of confirmatory data outside of a clinical trial, we sought to determine if AT timing in routine clinical practice is associated with OS differences. METHODS: Perioperative data of pancreatectomies for ductal adenocarcinoma from five institutions (2005-2015) were assessed. Delay in AT was defined as initiation >12 weeks after surgery. Multivariate analysis was performed to identify predictors of mortality. RESULTS: Of 867 patients, 172 (19.8%) experienced omission of AT. Improved OS was observed in patients who received AT compared with patients who did not (24.8 vs. 19.1 months, p < 0.01). Information on time to initiation of AT was available in 488 patients, of whom 407 (83.4%) and 81 (16.6%) received chemotherapy ≤12 and >12 weeks after surgery, respectively. There were no differences in recurrence-free survival or OS (all p > 0.05) between the timely and delayed AT groups. After controlling for perioperative characteristics and tumor pathology, patients who initiated AT ≤ 12 or > 12 weeks after surgery had a 50% lower odds of mortality than patients who only underwent resection (p < 0.01). CONCLUSIONS: In a multi-institutional experience of resected pancreas cancer, delayed initiation of AT was not associated with poorer survival. Patients who do not receive AT within 12 weeks after surgery are still appropriate candidates for multimodal therapy and its associated survival benefit.

17 Article The diagnosis of pancreatic mucinous cystic neoplasm and associated adenocarcinoma in males: An eight-institution study of 349 patients over 15 years. 2017

Ethun, Cecilia G / Postlewait, Lauren M / McInnis, Mia R / Merchant, Nipun / Parikh, Alexander / Idrees, Kamran / Isom, Chelsea A / Hawkins, William / Fields, Ryan C / Strand, Matthew / Weber, Sharon M / Cho, Clifford S / Salem, Ahmed / Martin, Robert C G / Scoggins, Charles R / Bentrem, David / Kim, Hong J / Carr, Jacquelyn / Ahmad, Syed A / Abbott, Daniel E / Wilson, Gregory / Kooby, David A / Maithel, Shishir K. ·Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia. · Division of Surgical Oncology, Department of Surgery, University of Miami, Miami, Florida. · Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee. · Department of Surgery, Washington University School of Medicine, St Louis, Missouri. · Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. · Department of Surgery, University of Michigan, Ann Arbor, Michigan. · Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky. · Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois. · Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina. · Division of Surgical Oncology, Department of Surgery, University of Cincinnati Cancer Institute, Cincinnati, Ohio. ·J Surg Oncol · Pubmed #28211072.

ABSTRACT: BACKGROUND: Per WHO, 2000 classification, pancreatic mucinous cystic neoplasms (MCN) are defined by presence of ovarian stroma, and are primarily located in the pancreatic body/tail of females. The incidence of MCN and associated malignancy in males, since, standardization of MCN diagnostic-criteria is unknown. METHODS: MCN resections from 2000 to 2014 at eight institutions of the Central-Pancreas-Consortium were included, and divided into early (2000-2007) and late (2008-2014) time-periods. Primary aim was to characterize MCN and associated adenocarcinoma/high-grade-dysplasia (AC/HGD) in males versus females over time. RESULTS: Of 1667 resections for pancreatic cystic lesions, 349 pts (21%) had MCNs: 310 (89%) female, 39 (11%) male. Patients were equally divided between early (n = 173) and late (n = 176) time-periods. MCN in male-patients decreased over time (early: 15%, late: 7%; P = 0.036), as did pancreatic head/neck location (early: 22%, late: 11%; P = 0.01). MCN-associated AC/HGD was more frequent in males versus females (39 vs. 12%; P < 0.001). The overall rate of MCN-associated AC/HGD remained stable (early: 17%, late: 13%; P = 0.4), and was identical in males (39%) over both time-periods. Males with AC/HGD had more LN-positive disease versus females (57 vs. 22%; P = 0.039). CONCLUSIONS: As the diagnostic-criteria of MCN have standardized over time, MCN diagnosis has decreased in males and head/neck location. Despite this, MCN-associated adenocarcinoma/high-grade dysplasia has been stable and remains high in males. Any male with suspected MCN, regardless of location, should undergo resection.

18 Article Does radiologic response correlate to pathologic response in patients undergoing neoadjuvant therapy for borderline resectable pancreatic malignancy? 2017

Xia, Brent T / Fu, Baojin / Wang, Jiang / Kim, Young / Ahmad, S Ameen / Dhar, Vikrom K / Levinsky, Nick C / Hanseman, Dennis J / Habib, David A / Wilson, Gregory C / Smith, Milton / Olowokure, Olugbenga O / Kharofa, Jordan / Al Humaidi, Ali H / Choe, Kyuran A / Abbott, Daniel E / Ahmad, Syed A. ·Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, Ohio. · Department of Pathology, University of Cincinnati, Cincinnati, Ohio. · Division of Gastroenterology, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio. · Division of Medical Oncology, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio. · Department of Radiation Oncology, University of Cincinnati, Cincinnati, Ohio. · Department of Radiology, University of Cincinnati, Cincinnati, Ohio. · Division of Surgical Oncology, Department of Surgery, Univesity of Wisconsin, Madison, Wisconsin. ·J Surg Oncol · Pubmed #28105634.

ABSTRACT: BACKGROUND AND OBJECTIVES: In patients with borderline resectable pancreas cancers, clinicians frequently consider radiographic response as the primary driver of whether patients should be offered surgical intervention following neoadjuvant therapy (NT). We sought to determine any correlation between radiographic and pathologic response rates following NT. METHODS: Between 2005 and 2015, 38 patients at a tertiary care referral center underwent NT followed by pancreaticoduodenectomy for borderline resectable pancreas cancer. Radiographic response after the completion of NT and pathologic response after surgery were graded according to RECIST and Evans' criteria, respectively. RESULTS: Preoperatively, 50% of patients underwent chemotherapy alone and 50% underwent chemotherapy and chemoradiation. Radiographically, one patient demonstrated a complete radiologic response, 68.4% (n = 26) of patients had stable disease (SD), 26.3% (n = 10) demonstrated a partial response, and one patient had progressive. Among patients without radiographic response, 77.7% (n = 21) achieved a R0 resection. Of patients with SD on imaging, 26.9% (n = 7) had Evans grade IIB or greater pathologic response. CONCLUSIONS: Our data indicate that approximately one-fourth of patients who did not have a radiologic response had a grade IIB or greater pathologic response. In the absence of metastatic progression, lack of radiographic down-staging following NT should not preclude surgery.

19 Article Are the Current Guidelines for the Surgical Management of Intraductal Papillary Mucinous Neoplasms of the Pancreas Adequate? A Multi-Institutional Study. 2017

Wilson, Gregory C / Maithel, Shishir K / Bentrem, David / Abbott, Daniel E / Weber, Sharon / Cho, Clifford / Martin, Robert C G / Scoggins, Charles R / Kim, Hong Jin / Merchant, Nipun B / Kooby, David A / Edwards, Michael J / Ahmad, Syed A. ·Division of Surgical Oncology, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH. · Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA. · Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. · Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI. · Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY. · Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, NC. · Division of Surgical Oncology, Department of Surgery, University of Miami, Miami, FL. · Division of Surgical Oncology, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH. Electronic address: ahmadsy@uc.edu. ·J Am Coll Surg · Pubmed #28088598.

ABSTRACT: BACKGROUND: Controversy persists regarding the management of patients with intraductal papillary mucinous neoplasms (IPMN). International consensus guidelines stratify patients into high-risk, worrisome, and low risk categories. STUDY DESIGN: The medical records of 7 institutions were reviewed for patients who underwent surgical management of IPMN between 2000 and 2015. RESULTS: There were 324 patients included in the analysis; 60.4% of patients had main-duct/mixed type, and 39.7% had branch-duct IPMN. The median cyst size was 2.65 cm, invasive cancer (IC) or high-grade dysplasia (HGD) was present in 42% (n = 136); 68.9% of patients with high-risk, 40.0% of patients with worrisome, and 24.6% of patients with low risk features exhibited HGD/IC. Multivariate analysis demonstrated that only 1 of 3 high-risk features and 2 of 7 worrisome features predicted the presence of HGD/IC. Positive predictive values for HGD/ IC in patients with obstructive jaundice and lymphadenopathy were 0.83 (95% CI 0.65 to 0.94) and 0.69 (95% CI 0.39 to 0.91), respectively. In the absence of high-risk features, HGD/IC was still present in 57.4% of patients with 2 or more worrisome features. Regression analysis demonstrated that each additional worrisome factor present was additive in predicting HGD/IC in a linear fashion (odds ratio 1.39; 95% CI 1.08 to 1.80; p < 0.01). CONCLUSIONS: These data demonstrate that the current consensus guidelines for surgical resection of IPMN may not adequately stratify and identify patients at risk for having HGD or invasive cancer. Patients with multiple worrisome features, in the absence of high-risk factors, should be considered for resection.

20 Article Distal Cholangiocarcinoma and Pancreas Adenocarcinoma: Are They Really the Same Disease? A 13-Institution Study from the US Extrahepatic Biliary Malignancy Consortium and the Central Pancreas Consortium. 2017

Ethun, Cecilia G / Lopez-Aguiar, Alexandra G / Pawlik, Timothy M / Poultsides, George / Idrees, Kamran / Fields, Ryan C / Weber, Sharon M / Cho, Clifford / Martin, Robert C / Scoggins, Charles R / Shen, Perry / Schmidt, Carl / Hatzaras, Ioannis / Bentrem, David / Ahmad, Syed / Abbott, Daniel / Kim, Hong Jin / Merchant, Nipun / Staley, Charles A / Kooby, David A / Maithel, Shishir K. ·Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA. · Division of Surgical Oncology, Department of Surgery, Johns Hopkins University, Baltimore, MD; Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH. · Department of Surgery, Stanford University, Stanford, CA. · Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, TN. · Department of Surgery, Washington University, St Louis, MO. · Department of Surgery, University of Wisconsin, Madison, WI. · Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY. · Department of Surgery, Wake Forest University, Winston-Salem, NC. · Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH. · Department of Surgery, New York University, New York, NY. · Department of Surgery, Northwestern University, Chicago, IL. · Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH. · Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH; Department of Surgery, University of Wisconsin, Madison, WI. · Division of Surgical Oncology, Department of Surgery, University of North Carolina, Raleigh, NC. · Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, TN; Division of Surgical Oncology, Department of Surgery, University of Miami, Miami, FL. · Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA. Electronic address: smaithe@emory.edu. ·J Am Coll Surg · Pubmed #28017812.

ABSTRACT: BACKGROUND: Distal cholangiocarcinoma (DC) and pancreatic ductal adenocarcinoma (PDAC) are often managed as 1 entity, yet direct comparisons are lacking. Our aim was to use 2 large multi-institutional databases to assess treatment, pathologic, and survival differences between these diseases. STUDY DESIGN: This study included patients with DC and PDAC who underwent curative-intent pancreaticoduodenectomy from 2000 to 2015 at 13 institutions comprising the US Extrahepatic Biliary Malignancy and Central Pancreas Consortiums. Primary endpoint was disease-specific survival (DSS). RESULTS: Of 1,463 patients, 224 (15%) had DC and 1,239 (85%) had PDAC. Compared with PDAC, DC patients were less likely to be margin-positive (19% vs 25%; p = 0.005), lymph node (LN)-positive (55% vs 69%; p < 0.001), and receive adjuvant therapy (57% vs 71%; p < 0.001). Of DC patients treated with adjuvant therapy, 62% got gemcitabine alone and 16% got gemcitabine/cisplatin. Distal cholangiocarcinoma was associated with improved median DSS (40 months) compared with PDAC (22 months; p < 0.001), which persisted on multivariable analysis (hazard ratio 0.65; 95% CI 0.50 to 0.84; p = 0.001). Lymph node involvement was the only factor independently associated with decreased DSS for both DC and PDAC. The DC/LN-positive patients had similar DSS as PDAC/LN-negative patients (p = 0.74). Adjuvant therapy (chemotherapy ± radiation) was associated with improved median DSS for PDAC/LN-positive patients (21 vs 13 months; p = 0.001), but not for DC patients (38 vs 40 months; p = 0.62), regardless of LN status. CONCLUSIONS: Distal cholangiocarcinoma and pancreatic ductal adenocarcinoma are distinct entities. Distal cholangiocarcinoma has a favorable prognosis compared with PDAC, yet current adjuvant therapy regimens are only associated with improved survival in PDAC, not DC. Therefore, treatment paradigms used for PDAC should not be extrapolated to DC, despite similar operative approaches, and novel therapies for DC should be explored.

21 Article Association of Preoperative Risk Factors With Malignancy in Pancreatic Mucinous Cystic Neoplasms: A Multicenter Study. 2017

Postlewait, Lauren M / Ethun, Cecilia G / McInnis, Mia R / Merchant, Nipun / Parikh, Alexander / Idrees, Kamran / Isom, Chelsea A / Hawkins, William / Fields, Ryan C / Strand, Matthew / Weber, Sharon M / Cho, Clifford S / Salem, Ahmed / Martin, Robert C G / Scoggins, Charles / Bentrem, David / Kim, Hong J / Carr, Jacquelyn / Ahmad, Syed / Abbott, Daniel E / Wilson, Gregory C / Kooby, David A / Maithel, Shishir K. ·Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia. · Division of Surgical Oncology, Department of Surgery, University of Miami, Miami, Florida. · Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee. · Department of Surgery, Washington University School of Medicine, St Louis, Missouri. · Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison. · Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky. · Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois. · Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill. · Division of Surgical Oncology, Department of Surgery, University of Cincinnati Cancer Institute, Cincinnati, Ohio. ·JAMA Surg · Pubmed #27760255.

ABSTRACT: Importance: Pancreatic mucinous cystic neoplasms (MCNs) harbor malignant potential, and current guidelines recommend resection. However, data are limited on preoperative risk factors for malignancy (adenocarcinoma or high-grade dysplasia) occurring in the setting of an MCN. Objectives: To examine the preoperative risk factors for malignancy in resected MCNs and to assess outcomes of MCN-associated adenocarcinoma. Design, Setting, and Participants: Patients who underwent pancreatic resection of MCNs at the 8 academic centers of the Central Pancreas Consortium from January 1, 2000, through December 31, 2014, were retrospectively identified. Preoperative factors of patients with and without malignant tumors were compared. Survival analyses were conducted for patients with adenocarcinoma. Main Outcomes and Measures: Binary logistic regression models were used to determine the association of preoperative factors with the presence of MCN-associated malignancy. Results: A total of 1667 patients underwent resection of pancreatic cystic lesions, and 349 (20.9%) had an MCN (310 women [88.8%]; mean (SD) age, 53.3 [14.7] years). Male sex (odds ratio [OR], 3.72; 95% CI, 1.21-11.44; P = .02), pancreatic head and neck location (OR, 3.93; 95% CI, 1.43-10.81; P = .01), increased radiographic size of the MCN (OR, 1.17; 95% CI, 1.08-1.27; P < .001), presence of a solid component or mural nodule (OR, 4.54; 95% CI, 1.95-10.57; P < .001), and duct dilation (OR, 4.17; 95% CI, 1.63-10.64; P = .003) were independently associated with malignancy. Malignancy was not associated with presence of radiographic septations or preoperative cyst fluid analysis (carcinoembryonic antigen, amylase, or mucin presence). The median serum CA19-9 level for patients with malignant neoplasms was 210 vs 15 U/mL for those without (P = .001). In the 44 patients with adenocarcinoma, 41 (93.2%) had lymph nodes harvested, with nodal metastases in only 14 (34.1%). Median follow-up for patients with adenocarcinoma was 27 months. Adenocarcinoma recurred in 11 patients (25%), with a 64% recurrence-free survival and 59% overall survival at 3 years. Conclusions and Relevance: Adenocarcinoma or high-grade dysplasia is present in 14.9% of resected pancreatic MCNs for which risks include male sex, pancreatic head and neck location, larger MCN, solid component or mural nodule, and duct dilation. Mucinous cystic neoplasm-associated adenocarcinoma appears to have decreased nodal involvement at the time of resection and increased survival compared with typical pancreatic ductal adenocarcinoma. Indications for resection of MCNs should be revisited.

22 Article Two studies pave the way for preoperative therapy in pancreatic cancer patients. 2016

Katz, Matthew H / Ahmad, Syed A / Boughey, Judy C. · ·Bull Am Coll Surg · Pubmed #28941435.

ABSTRACT: The delivery of chemotherapy and/or radiation in the preoperative setting (before surgical resection, instead of after it) has been hypothesized to improve both rates of margin-negative resection and survival.

23 Article Variability in postoperative resource utilization after pancreaticoduodenectomy: Who is responsible. 2016

Ertel, Audrey E / Wima, Koffi / Hoehn, Richard S / Chang, Alex L / Hohmann, Samuel F / Ahmad, Syed A / Sussman, Jeffrey J / Shah, Shimul A / Abbott, Daniel E. ·Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH. · Vizient, Chicago, IL. · Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI. Electronic address: abbott@surgery.wisc.edu. ·Surgery · Pubmed #27712874.

ABSTRACT: BACKGROUND: We aimed to quantify and predict variability that exists in resource utilization after pancreaticoduodenectomy and determine how such variability impacts postoperative outcomes. METHODS: The University HealthSystems Consortium database was queried for all pancreaticoduodenectomies performed between 2011-2013 (n = 9,737). A composite resource utilization score was created using z-scores of 8 clinically significant postoperative care delivery variables including number of laboratory tests, imaging tests, computed tomographic scans, days on antibiotics, anticoagulation, antiemetics, promotility agents, and total number of blood products transfused per patient. Logistic, Poisson, and gamma regression models were used to determine predictors of increased variability in care between patients. RESULTS: Having a high (versus low) resource utilization score after pancreaticoduodenectomy correlated with increased duration of stay; (odds ratio 2.28), cost (odds ratio 1.89), readmission rate (odds ratio 1.46), and mortality (odds ratio 7.54). Patient-specific factors were the strongest predictors and included extreme severity of illness (odds ratio 114), major comorbidities/complications (odds ratio 5.99), and admission prior to procedure (odds ratio 2.72; all P < .01). Surgeon and center volume were not associated with resource utilization. CONCLUSION: Public reporting of patient outcomes and resource utilization, invariably tied to reimbursement in the near future, should consider that much of the postoperative variability after complex pancreatic operation is related to patient-specific risk factors.

24 Article Early Recurrence and Omission of Adjuvant Therapy after Pancreaticoduodenectomy Argue against a Surgery-First Approach. 2016

Xia, Brent T / Habib, David A / Dhar, Vikrom K / Levinsky, Nick C / Kim, Young / Hanseman, Dennis J / Sutton, Jeffrey M / Wilson, Gregory C / Smith, Milton / Choe, Kyuran Ann / Sussman, Jeffrey J / Ahmad, Syed A / Abbott, Daniel E. ·Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA. · College of Medicine, University of Cincinnati, Cincinnati, OH, USA. · Department of Medicine, Division of Gastroenterology, University of Cincinnati, Cincinnati, OH, USA. · Department of Radiology, University of Cincinnati, Cincinnati, OH, USA. · Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, WI, USA. abbott@surgery.wisc.edu. ·Ann Surg Oncol · Pubmed #27459987.

ABSTRACT: BACKGROUND: Sequencing therapy for patients with periampullary malignancy is controversial. Clinical trial data report high rates of adjuvant therapy completion, though contemporary, real-world rates remain incomplete. We sought to identify patients who failed to receive adjuvant therapy and those at risk for early recurrence (ER) who might benefit most from neoadjuvant therapy (NT). METHODS: We retrospectively reviewed medical records of 201 patients who underwent pancreaticoduodenectomy for periampullary malignancies between 1999 and 2015; patients receiving NT were excluded. Univariate and multivariate analyses were performed to identify predictors of failure to receive adjuvant therapy and ER (within 6 months) as the primary end points. RESULTS: The median age at the time of surgery was 65.5 years (interquartile range 57-74 years). The majority of tumors were pancreatic ductal adenocarcinoma (76.6 %), and 71.6 % of patients received adjuvant therapy after resection. Univariate predictors of failure to undergo adjuvant therapy were advanced age, age-adjusted Charlson comorbidity index, operative transfusion, reoperation, length of stay, and 30- to 90-day readmissions (all p < 0.05). Advanced age, specifically among patients >70 years, persisted as a significant preoperative predictor on multivariate analysis (p < 0.01). Patients who failed to receive adjuvant therapy and/or developed ER had significantly worse overall survival rates compared to all other patients (27.8 vs. 9.7 months; p < 0.01). CONCLUSIONS: Approximately one-third of surgery-first patients undergoing pancreaticoduodenectomy at our institution did not receive adjuvant therapy and/or demonstrated ER. This substantial subset of patients may particularly benefit from NT, ensuring completion of multimodal therapy and/or avoiding futile surgical intervention.

25 Article A Multi-institutional Comparison of Perioperative Outcomes of Robotic and Open Pancreaticoduodenectomy. 2016

Zureikat, Amer H / Postlewait, Lauren M / Liu, Yuan / Gillespie, Theresa W / Weber, Sharon M / Abbott, Daniel E / Ahmad, Syed A / Maithel, Shishir K / Hogg, Melissa E / Zenati, Mazen / Cho, Clifford S / Salem, Ahmed / Xia, Brent / Steve, Jennifer / Nguyen, Trang K / Keshava, Hari B / Chalikonda, Sricharan / Walsh, R Matthew / Talamonti, Mark S / Stocker, Susan J / Bentrem, David J / Lumpkin, Stephanie / Kim, Hong J / Zeh, Herbert J / Kooby, David A. ·*Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA †Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute ‡Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA §Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison ¶Department of Surgery, University of Cincinnati, Cincinnati ||Department of Surgery, Cleveland Clinic Foundation, Cleveland, OH **Department of Surgery, NorthShore University Health System, Evanston ††Department of Surgery, Northwestern Memorial Hospital, Chicago, IL ‡‡Department of Surgery, University of North Carolina, Chapel Hill. ·Ann Surg · Pubmed #27433907.

ABSTRACT: OBJECTIVES: Limited data exist comparing robotic and open approaches to pancreaticoduodenectomy (PD). We performed a multicenter comparison of perioperative outcomes of robotic PD (RPD) and open PD (OPD). METHODS: Perioperative data for patients who underwent postlearning curve PD at 8 centers (8/2011-1/2015) were assessed. Univariate analyses of clinicopathologic and treatment factors were performed, and multivariable models were constructed to determine associations of operative approach (RPD or OPD) with perioperative outcomes. RESULTS: Of the 1028 patients, 211 (20.5%) underwent RPD (4.7% conversions) and 817 (79.5%) underwent OPD. As compared with OPD, RPD patients had higher body mass index, rates of prior abdominal surgery, and softer pancreatic remnants, whereas OPD patients had a higher percentage of pancreatic ductal adenocarcinoma cases, and greater proportion of nondilated (<3 mm) pancreatic ducts. On multivariable analysis, as compared with OPD, RPD was associated with longer operative times [mean difference = 75.4 minutes, 95% confidence interval (CI) 17.5-133.3, P = 0.01], reduced blood loss (mean difference = -181 mL, 95% CI -355-(-7.7), P = 0.04) and reductions in major complications (odds ratio = 0.64, 95% CI 0.47-0.85, P = 0.003). No associations were demonstrated between operative approach and 90-day mortality, clinically relevant postoperative pancreatic fistula and wound infection, length of stay, or 90-day readmission. In the subset of 522 (51%) pancreatic ductal adenocarcinomas, operative approach was not a significant independent predictor of margin status or suboptimal lymphadenectomy (<12 lymph nodes harvested). CONCLUSIONS: Postlearning curve RPD can be performed with similar perioperative outcomes achieved with OPD. Further studies of cost, quality of life, and long-term oncologic outcomes are needed.

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