New perspectives on robotic pancreaticoduodenectomy:An analysis of the National Cancer Database

BACKGROUND Pancreatic ductal adenocarcinoma is a common malignancy.Despite all advancements,the prognosis remains,poor with an overall 5-year survival of only 10.8%.Recently,a robotic platform has become an attractive tool for treating pancreatic cancer(PC).While recent studies indicated improved lymph node(LN)harvest during robotic pancreaticoduodenectomy(PD),data on long-term outcomes are insufficient.AIM To evaluate absolute LN harvest during PD.Secondary outcomes included evaluating the association between LN harvest and short-and long-term oncological outcomes for three different surgical approaches.METHODS We conducted an analysis of the National Cancer Database,including patients diagnosed with PC who underwent open,laparoscopic,or robotic PD in 2010-2018.One-way analysis of variance was used to compare continuous variables,chi-square test-for categorical.Overall survival was defined as the time between surgery and death.Median survival time was estimated with the Kaplan-Meier method,and groups were compared with the Wilcoxon test.A Cox proportional hazards model was used to assess the association of covariates with survival after controlling for patient characteristics and procedure type.RESULTS 17169 patients were included,8859(52%)males;mean age 65;14509(85%)white.13816(80.5%)patients had an open PD,2677(15.6%)and 676(3.9%)-laparoscopic and robotic PD respectively.Mean comorbidity index(Charlson-Deyo Score)0.50.On average,18.84 LNs were harvested.Mean LN harvest during open,laparoscopic and robotic PD was 18.59,19.65 and 20.70 respectively(P<0.001).On average 2.49 LNs were positive for cancer and did not differ by the procedure type(P=0.26).Vascular invasion was noted in 42.6%of LNs and did differ by the approach:42.1%for open,44.0%for laparoscopic and 47.2%for robotic PD(P=0.015).Median survival for open PD was 26.1 mo,laparoscopic-27.2 mo,robotic-29.1 mo(P=0.064).Survival was associated with higher LN harvest,while higher number of positive LNs was associated with higher mortality.CONCLUSION Our study suggests that robotic PD is associated with increased intraoperative LN harvest and has comparable short-term oncological outcomes and survival compared to open and laparoscopic approaches.

Predictors of nodal metastasis in sinonasal squamous cell carcinoma:A national cancer database analysis

Objective:We present the largest population based study of sinonasal squamous cell carcinoma(SCC)to identify risk factors for presentation with nodal metastasis.Methods:The National Cancer Database(NCDB)was used for this study.Location codes corresponding to the nasal cavity and paranasal sinuses and histology codes representing SCC malignancy were queried.Logistic regression analysis was performed to identify factors associated with presentation with nodal metastasis.Results:6448 cases met inclusion criteria.Nodal metastasis at presentation was seen in 13.2%of patients,with the sinus subsite(19.3%)being a significant risk factor for nodal metastasis at presentation when compared to the nasal cavity(7.9%).Logistic regression analysis showed black,uninsured and Medicaid patients were more likely than white and privately insured patients,respectively,to present with nodal metastasis.Conclusions:In sinonasal SCC,the sinus subsite has a significantly increased risk of nodal metastasis compared to the nasal cavity.Black race,uninsured and Medicaid patients are more likely to have nodal metastasis at presentation.

Carcinosarcoma of the nasal cavity and paranasal sinuses:Review of the national cancer database

Background:Carcinosarcomas are rare,aggressive malignancies that can arise in the nasal cavity and paranasal sinuses.There are limited outcome data available.Accordingly,we sought to use the National Cancer Database(NCDB)to characterize patient demographics and outcomes.Method:A retrospective analysis of the NCDB from 2004 to 2016 for patients with sinonasal carcinosarcoma was conducted.Results:Thirty patients were included.The patients were predominantly male(n=20),white(n=23),and privately insured(n=15),with an average age of 62.4 years.The nasal cavity was the most common subsite(n=14),followed by the maxillary sinus(n=8).Most patient were treated with surgery followed by radiation(n=23),with the remaining undergoing surgery alone(n=4),radiation alone(n=2),or no treatment(n=1).One-third(n=10)received adjuvant chemotherapy.The 1-and 5-year overall survival(OS)in the cohort were 79.2%and 43.3%,respectively.Univariate log-rank testing showed OS varied based on intervention(P<0.029),sex(P<0.042),and age(P<0.025),while on multivariate analysis none of these factors independently predicted OS.Conclusions:We describe the demographics and presenting features of a national cohort of sinonasal carcinosarcoma patients.Future research is needed to identify predictors of overall survival,and to assess the optimal roles for radiation and systemic chemotherapy.

Comparative effectiveness of immunotherapy and chemotherapy in patients with metastatic colorectal cancer stratified by microsatellite instability status

BACKGROUND Immunotherapy have demonstrated promising outcomes in patients with high microsatellite instability(MSI)(MSI-H)metastatic colorectal cancer.However,the comparative effectiveness of Immunotherapy and chemotherapy for patients with low MSI(MSI-L),and microsatellite stable(MSS)metastatic colorectal cancer remains unclear.AIM To investigate immunotherapy vs chemotherapy for treatment of MSI-L/MSS metastatic colorectal cancer,and to evaluate the success of immunotherapy against chemotherapy in managing MSI-H metastatic colorectal cancer during a follow-up of 50 months.METHODS We conducted a retrospective cohort study using the National Cancer Database(NCDB)to evaluate the overall survival(OS)of patients with metastatic colorectal cancer treated with immunotherapy or chemotherapy.The study population was stratified by MSI status(MSI-H,MSI-L,and MSS).Multivariable Cox proportional hazard models were used to assess the association between treatment modality and OS,adjusting for potential confounders.RESULTS A total of 21951 patients with metastatic colorectal cancer were included in the analysis,of which 2358 were MSI-H,and 19593 were MSI-L/MSS.In the MSI-H cohort,immunotherapy treatment(n=142)was associated with a significantly improved median OS compared to chemotherapy(n=860).After adjusting for potential confounders,immunotherapy treatment remained significantly associated with better OS in the MSI-H cohort[adjusted hazard ratio(aHR):0.57,95%confidence interval(95%CI):0.43-0.77,P<0.001].In the MSS cohort,no significant difference in median OS was observed between immunotherapy treatment and chemotherapy(aHR:0.94,95%CI:0.69-1.29,P=0.715).CONCLUSION In this population-based study using the NCDB,immunotherapy treatment was associated with significantly improved OS compared to chemotherapy in patients with MSI-H metastatic colorectal cancer,but not in those with MSI-L/MSS metastatic colorectal cancer.Further studies are warranted to determine the optimal therapeutic approach for patients with MSI-L/MSS metastatic colorectal cancer.

Improving the quality of gastric cancer surgery:factors associated with positive resection margins for gastrectomy

Purpose:Positive margins after gastrectomy have been associated with poor patient prognosis.This study aimed to identify risk factors associated with margin-positive resections.Methods:The National Cancer Database was queried from 2004 to 2014 for all patients with gastric adenocarcinoma who underwent resection with curative intent and had known margin status.Univariable and multivariable logistic regression analysis was performed to identify variables associated with positive margins.Results:A total of 32,193 patients were identified who met study inclusion criteria,of which 11.8%(3786 patients)had a margin-positive resection.Tumor size>6 cm,T3 or T4 tumors,tumor location in the body of stomach or in multiple regions,signet ring cell histology,presence of lymphovascular invasion,positive lymph node involvement,and lack of neoadjuvant therapy were independently associated with an increased risk of positive margins.Conclusions:Advanced disease characteristics,aggressive tumor pathology,and absence of neoadjuvant therapy were associated with margin-positive resections.