Dataset Information

Association Between Pancreatic Fistula and Long-term Survival in the Era of Neoadjuvant Chemotherapy.

ABSTRACT: Importance:In the past decade, the use of neoadjuvant therapy (NAT) has increased for patients with borderline and locally advanced pancreatic ductal adenocarcinoma (PDAC). Data on pancreatic fistula and related overall survival (OS) in this setting are limited. Objective:To compare postoperative complications in patients undergoing either upfront resection or pancreatectomy following NAT, focusing on clinically relevant postoperative pancreatic fistula (CR-POPF) and potential associations with OS. Design, Setting, and Participants:This retrospective cohort study was conducted on data from patients who underwent pancreatic resection for PDAC at the Massachusetts General Hospital from January 1, 2007, to December 31, 2017. Exposures:Pancreatic cancer surgery with or without NAT. Main Outcomes and Measures:Overall morbidity and CR-POPF rates were compared between NAT and upfront resection. Factors associated with CR-POPF were assessed with univariate and multivariate analysis. Survival data were analyzed by Kaplan-Meier curves and a Cox proportional hazards regression model. Results:Of 753 patients, 364 were men (48.3%); median (interquartile range) age was 68 (61-75) years. A total of 346 patients (45.9%) received NAT and 407 patients (54.1%) underwent upfront resection. At pathologic examination, NAT was associated with smaller tumor size (mean [SD], 26.0 [15.3] mm vs 32.7 [14.4] mm; P?

SUBMITTER: Hank T

PROVIDER: S-EPMC6694396 | biostudies-literature | 2019 Oct

REPOSITORIES: biostudies-literature

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Association Between Pancreatic Fistula and Long-term Survival in the Era of Neoadjuvant Chemotherapy.

Hank Thomas T Sandini Marta M Ferrone Cristina R CR Rodrigues Clifton C Weniger Maximilian M Qadan Motaz M Warshaw Andrew L AL Lillemoe Keith D KD Fernández-Del Castillo Carlos C

JAMA surgery 20191001 10

<h4>Importance</h4>In the past decade, the use of neoadjuvant therapy (NAT) has increased for patients with borderline and locally advanced pancreatic ductal adenocarcinoma (PDAC). Data on pancreatic fistula and related overall survival (OS) in this setting are limited.<h4>Objective</h4>To compare postoperative complications in patients undergoing either upfront resection or pancreatectomy following NAT, focusing on clinically relevant postoperative pancreatic fistula (CR-POPF) and potential ass ...[more]

PMID: 31411659

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Project description:Recent studies have indicated the prognostic value of tumour subtype and pathological complete response (pCR) after neoadjuvant chemotherapy (NAC). However these results were reported after a short follow-up and using a standard Cox model which could be unsatisfactory for time-dependent factors. In the present study, we identified the prognostic factors for long-term outcome after NAC, considering that they could have an inconstant impact over time.Prognostic factors from 956 consecutive breast cancer patients treated with NAC were identified and associated with long-term outcomes. We estimated survival by a time function multivariate Cox model regression and stratified by follow-up length.The prognostic value of tumour histological grade and hormone receptors status varied as distant recurrence-free interval (DRFI) increased. The multivariate analysis identified the following significant prognostic factors: tumour size, N stage, clinical and pathological response to NAC, hormone receptors (HR) status and histological tumour grade. The 'prognostic benefit' of low-grade and positive-HR status decreased over the years. Thus, in the early years after cancer diagnosis, the hazard ratio of distant recurrences in patients with positive-HR status increased from 0.26 (95% CI 0.1-0.4) at 6 months to 2.2 (95% CI 1.3-3.7) at 120 months. The histological tumour grade followed a similar trend. The hazard ratio of grade III patients compared with grade I was 1.83 (95% CI 1.1-2.8) at 36 months and diminished over time to 0.70 (95% CI 0.4-1.3) at 120 months. This indicates that the risk of recurrence for positive-HR patients was 74% lower at 6 months compared with the negative-hormone receptor group, but 30% higher at 5 years and more than double at 10 years. High-grade tumours presented a risk of 83% in the earlier years decreasing to 30% at 10 years versus the low-grade group.From the present study, we conclude the importance of identifying time-dependent prognostic factors. Distant recurrence-free interval within women who receive NAC are influenced by achieving pCR and breast cancer subtype. Tumours with more aggressive biology have poorer survival during the first 5 years, but if they exceed this point their prognostic impact is no longer significant. Conversely, positive-HR patients remain at risk for distant recurrence for many years.

Project description:To determine the risk-adjusted mortality of intentionally injured patients within 7 to 9 years postinjury, compared with unintentionally injured patients.Violent injury contributes significantly to trauma mortality in the United States. Homicide is the second leading killer of American youth, aged 15 to 24 years. Long-term survival among intentionally injured patients has not been well studied. It is also unknown whether intentionally injured patients have worse long-term survival compared with unintentionally or accidentally injured patients with equivalent injuries.Adult trauma patients admitted for 24 hours or more and discharged alive from the Johns Hopkins Hospital from January 1, 1998, to December 31, 2000, were included. The primary outcome was mortality within 7 to 9 years postinjury. Long-term patient survival was determined using the National Death Index. The association between injury intentionality and mortality was investigated using a Cox proportional hazard regression model, adjusted for confounders such as injury severity and patient race, socioeconomic status, and comorbid conditions. Overall differences in survival between those with intentional versus unintentional injury were also determined by comparing adjusted Kaplan-Meier survival curves.A total of 2062 patients met inclusion criteria. Of these, 56.4% were intentionally injured and 43.6% were unintentionally injured. Compared with unintentionally injured patients, intentionally injured patients were younger and more often male and from a zip code with low median household income. Approximately 15% of all patients had died within 7 to 9 years of follow-up. Older age and presence of comorbidities were associated with this outcome; however, intentional injury was not found to be significantly associated with long-term mortality rates. There was also no significant difference in survival curves between groups; intentionally injured patients were much more likely to die of a subsequent injury, whereas those with unintentional injury commonly died of noninjury causes.There was no significant difference in mortality between intentionally injured and unintentionally injured patients within 7 to 9 years postinjury. These results confirm the long-term effectiveness of lifesaving trauma care for those with intentional injury. However, given that patients with intentional injuries were more likely to suffer a subsequent violent death, interventions focused on breaking the cycle of violence are needed.

Project description:Importance:Although American guidelines recommend use of adjuvant chemotherapy in patients with locally advanced rectal cancer, individuals who achieve a pathological complete response (pCR) following neoadjuvant chemoradiotherapy are less likely to receive adjuvant treatment than incomplete responders. The association and resection of adjuvant chemotherapy with survival in patients with pCR is unclear. Objective:To determine whether patients with locally advanced rectal cancer who achieve pCR after neoadjuvant chemoradiation therapy and resection benefit from the administration of adjuvant chemotherapy. Design, Setting, and Participants:This retrospective propensity score-matched cohort study identified patients with locally advanced rectal cancer from the National Cancer Database from 2006 through 2012. We selected patients with nonmetastatic invasive rectal cancer who achieved pCR after neoadjuvant chemoradiation therapy and resection. Exposures:We matched patients who received adjuvant chemotherapy to patients who did not receive adjuvant treatment in a 1:1 ratio. We separately matched subgroups of patients with node-positive disease before treatment and node-negative disease before treatment to investigate for effect modification by pretreatment nodal status. Main Outcome and Measures:We compared overall survival between groups using Kaplan-Meier survival methods and Cox proportional hazards models. Results:We identified 2455 patients (mean age, 59.5 years; 59.8% men) with rectal cancer with pCR after neoadjuvant chemoradiation therapy and resection. We matched 667 patients with pCR who received adjuvant chemotherapy and at least 8 weeks of follow-up after surgery to patients with pCR who did not receive adjuvant treatment. Over a median follow-up of 3.1 years (interquartile range, 1.94-4.40 years), patients treated with adjuvant chemotherapy demonstrated better overall survival than those who did not receive adjuvant treatment (hazard ratio, 0.44; 95% CI, 0.28-0.70). When stratified by pretreatment nodal status, only those patients with pretreatment node-positive disease exhibited improved overall survival with administration of adjuvant chemotherapy (hazard ratio, 0.24; 95% CI, 0.10-0.58). Conclusions and Relevance:The administration of adjuvant chemotherapy in patients with rectal cancer with pCR is associated with improved overall survival, particularly in patients with pretreatment node-positive disease. Although this study suggests a beneficial effect of adjuvant treatment on survival in patients with pCR, these results are limited by the presence of potential unmeasured confounding in this nonrandomized study.

Dataset Information

Association Between Pancreatic Fistula and Long-term Survival in the Era of Neoadjuvant Chemotherapy.

Publications

Association Between Pancreatic Fistula and Long-term Survival in the Era of Neoadjuvant Chemotherapy.

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