Audrey Choi

1031 Background: The treatment for patients with DCIS remains controversial. Current guidelines based upon best available evidence suggest that breast conserving surgery (BCS) followed by adjuvant radiation therapy (RT) result in acceptable local control and breast cancer specific survival. The purpose of this study was to analyze trends in patterns of care as well as identify factors associated with surgery type and use of adjuvant radiation therapy in a select cohort of patients enrolled into the SEER database. Methods: The study included females 18 years and older with focal DCIS and known tumor size of 5 cm or less diagnosed between 1996 and 2007. The Cochran-Armitage trend test was applied to identify trends in the use of BCS and RT over time. Multivariate logistic regression analyses were used to determine factors associated with receiving BCS vs. mastectomy and BCS plus RT vs. BCS alone. Cox proportional hazard model was used to determine associations with breast cancer-speci...

Adjuvant chemotherapy is recommended in patients with stage II colon cancer with high-risk features (HRF). However, there is no quantification of the amount of risk conferred by each HRF or the overall survival (OS) benefit gained by chemotherapy based on the risk factor. To assess survival benefits associated with adjuvant chemotherapy among stage II colon cancer patients having one or more HRF [T4 tumors, less than 12 lymph nodes examined (< 12LN), positive margins, high-grade tumor, perineural invasion (PNI), and lymphovascular invasion (LVI)]. Patients diagnosed with stage II colon cancer between 2010 and 2013 were identified from California Cancer Registry. Propensity score weighted all-cause mortality hazard ratios (HR) were calculated for combinations of HRF. A total of 5160 stage II colon cancer patients were identified, of which 2398 had at least one HRF and 510 of 2398 (21%) received adjuvant chemotherapy. Compared with patients with a single HRF, presence of any 2 or ≥...

Thyroid cancer is frequently difficult to diagnose due to an overlap of cytological features between malignant and benign nodules. This overlap leads to unnecessary removal of the thyroid in patients without cancer. While providing some improvement over cytopathologic diagnostics, molecular methods frequently fail to provide a correct diagnosis for thyroid nodules. These approaches are based on the difference between cancer and adjacent thyroid tissue and assume that adjacent tissues are the same as benign nodules. However, in contrast to adjacent tissues, benign thyroid nodules can contain genetic alterations that can be found in cancer. For the development of a new molecular diagnostic test for thyroid cancer, we evaluated DNA methylation in 109 thyroid tissues by using genome wide single base resolution DNA methylation analysis. The test was validated in a retrospective cohort containing 65 thyroid nodules. By conducting Reduced Representation Bisulfite Sequencing in 109 thyroid ...

Feeding jejunostomy tubes (FJT) in patients undergoing resection of gastroesophageal cancers facilitate perioperative nutrition. Data regarding FJT use and complications are limited. A single institution review was performed for patients who underwent perioperative FJT placement for gastrectomy or esophagogastrectomy from 2007 to 2015. FJT-related and unrelated complications were evaluated. FJTs were inserted for total/completion gastrectomy (n = 49/117, 41.9 %), proximal gastrectomy (n = 7/117, 6.0 %), or esophagogastrectomy (n = 61/117, 52.1 %). Ninety percent (n = 106/117) of patients used an FJT at some time point. Although the majority of patients (75.2 %) used FJTs after discharge, 8.5 % (n = 10/117) never used the FJT and 10.3 % (n = 12/117) used the FJT only during hospitalization. Overall, 44.4 % (n = 52/117) had FJT-related complications, including dislodgement (n = 22), clogging (n = 13), and leakage (n = 6). The majority of FJT complications were resolved by telephone triage (13.5 %) or bedside/clinic intervention (57.7 %), but 3.4 % required operative intervention for small bowel obstruction (n = 3) and hemorrhage (n = 1). FJT complications were more common with gastrectomy than esophagogastrectomy (53.6 vs. 36.0 %), perhaps related to longer FJT use in gastrectomy patients (71 vs. 38 days). FJT-related complications are common, occurring more frequently after gastrectomy than esophagogastrectomy. In most patients, complications can be managed by simple measures, rarely requiring operative intervention. Nevertheless, the need for FJTs should be carefully considered to balance nutritional benefits with the risks of insertion and usage.

Although the incidence of gastric cancer has been decreasing, recent reports suggest an increased rate in select populations. We sought to evaluate trends in gastric cancer incidence to identify high-risk populations. Gastric cancer incidence rates from 1992 to 2011 were computed with use of the Surveillance, Epidemiology, and End Results (SEER) registry. We evaluated trends in incidence rates by calculating the annual percent change (APC) across three age groups (20-49 years, 50-64 years, and 65 years or older) and four racial/ethnic groups (Hispanics, non-Hispanic whites, blacks, and Asian/Pacific Islanders). We identified 41,428 patients with gastric cancer. For the entire cohort during the study period, the APC was decreased. When patients were grouped according to sex, the APC was flat or decreased in women regardless of age or race/ethnicity. The APC was also flat or decreased for all men except young Hispanic men (20-49 years), who had an increased APC of nearly 1.6 % (1.55 %, 95 % confidence interval 0.26-2.86 %). Furthermore, young Hispanic men were the only group to have increased incidence of stage IV disease (APC 4.34 %, 95 % confidence interval 2.76-5.94 %) and poorly differentiated tumors (APC 2.08 %, 95 % confidence interval 0.48-3.70 %). The APC of the incidence of gastric cancer in young Hispanic men places it among the top cancers with rising incidence in the USA. This is concomitant with increased incidence of advanced disease at presentation. This major public health concern warrants additional research to determine the cause of the increasing incidence in this group.

Reports on outcomes after double-staple technique (DST) for total and proximal gastrectomy are limited, originating mostly from Asian centers. Our objective was to examine anastomotic leak and stricture with DST for esophagoenteric anastomosis in gastric cancer patients. A single institution review was performed for patients who underwent total/proximal gastrectomy with DST between 2006 and 2015. DST was performed using transoral anvil delivery (OrVil™) with end-to-end anastomosis. Clinical characteristics and outcomes, including anastomotic leak and stricture, were recorded. Overall, DST was performed in 60 patients [total gastrectomy (81.7 %, n = 49/60), proximal gastrectomy (10.0 %, n = 6/60), and completion gastrectomy (8.3 %, n = 5/60)]. Neoadjuvant chemotherapy was administered to 21 patients (35.0 %), and 6 patients (10.0 %) received external beam radiation therapy prior to completion gastrectomy. Operative approach was open (51.7 %, n = 31/60), laparoscopic (43.3 %, n = 26/6...

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are widely accepted in Asia for treatment of early gastric cancer (EGC). Few studies have examined lymph node (LN) metastasis for EGC in Western populations. We sought to examine EGC and LN metastasis in a heterogeneous Western population. Patients with surgically resected, histologically confirmed AJCC T1a gastric adenocarcinoma were identified in the Surveillance, Epidemiology, and End Results(SEER) database from 2002 to 2012. Patients were excluded if they had stage IV disease, had multiple primary cancers, or received neoadjuvant therapy. Rates of LN metastasis were calculated and survival analyses were performed. Of 923 patients in the cohort, 72 (7.8%) patients had at least one positive LN on final pathology. When stratified by race, Asian/Pacific Islanders (APIs) demonstrated the lowest rate of LN metastases (n = 17/327; 5.2%), followed by Hispanics (n = 12/171; 7.0%), whites (n = 27/278; 9.7%), and...

Based on the American College of Surgeons Oncology Group Z0011 trial exclusion criteria, patients with T1N0 or T2N0 breast cancer with 1 or 2 positive sentinel lymph nodes (SLNs) are recommended to undergo axillary lymph node dissection if extranodal extension (ENE) is present. To determine the effect of ENE size on residual axillary nodal burden, disease recurrence, and survival in patients meeting Z0011 criteria. Retrospective cohort study between January 1, 2000, and December 31, 2012, at a single tertiary cancer center. Patients had T1 or T2 breast cancer with 1 or 2 positive SLNs. The ENE was classified as 2 mm or smaller or as larger than 2 mm. Nodal burden, disease recurrence, and overall survival. Of 208 patients, 149 (71.6%) had no ENE, 21 (10.1%) had ENE 2 mm or smaller, and 38 (18.3%) had ENE larger than 2 mm on SLN dissection. The median follow-up time was 60 months (range, 1-158 months). The mean (SD) total number of positive lymph nodes differed significantly for the group with no ENE (1.72 [1.39]) vs the group with ENE 2 mm or smaller (3.22 [2.09]; P < .001) and vs the group with ENE larger than 2 mm (4.26 [5.01]; P < .001). Similar patterns were observed for mean (SD) nonsentinel lymph node metastases: 0.48 (1.30) for no ENE vs 1.91 (2.07) with ENE 2 mm or smaller (P = .02) and vs 2.95 (4.95) with ENE larger than 2 mm (P < .001). For the group without ENE vs the group with ENE 2 mm or smaller, there were no significant differences in recurrence (distant recurrence, 4 patients [2.7%] vs 1 patient [4.8%], respectively; P = .62) or in mortality (18 patients [12.1%] vs 4 patients [19.1%], respectively; P = .48). For the group without ENE vs the group with ENE larger than 2 mm, there were no significant differences in recurrence (distant recurrence, 4 patients [2.7%] vs 4 patients [10.5%], respectively; P = .19) or in mortality (18 patients [12.1%] vs 9 patients [23.7%], respectively; P = .07). Presence of ENE on SLN dissection is associated with N2 disease. Despite increased nodal burden, patients with 1 or 2 positive SLNs and ENE 2 mm or smaller demonstrated recurrence and survival rates similar to those of patients without ENE. Reporting of ENE size should be standardized and required.

To predict node-positive disease in colon cancer using computed tomography (CT). American Joint Committee on Cancer stage I-III colon cancer patients who underwent curavtive-intent colectomy between 2007-2010 were identified at a single comprehensive cancer center. All patients had preoperative CT scans with original radiology reports from referring institutions. CT images underwent blinded secondary review by a surgeon and a dedicated abdominal radiologist at our institution to identify pericolonic lymph nodes (LNs). Comparison of outside CT reports to our independent imaging review was performed in order to highlight differences in detection in actual clinical practice. CT reviews were compared with final pathology. Results of the outside radiologist review, secondary radiologist review, and surgeon review were compared with the final pathologic exam to determine sensitivity, specificity, positive and negative predictive values, false positive and negative rates, and accuracy of e...

Readmission rates after cancer surgery are infrequently reported, and better understanding of the etiologies for readmission is necessary. We sought to investigate the frequency, timing, and etiologies for hospital readmission after surgery for gastric cancer and whether readmission correlates with clinical outcomes. Hospital readmission was examined through linkage of the California Cancer Registry with the Office of Statewide Health Planning and Development database. Patients with gastric adenocarcinoma who had undergone curative intent surgery between 2000 and 2011 were identified. First readmission within 90 days of initial surgery was analyzed with respect to timing (0-30, 31-60, and 61-90 days) and etiology for readmission. Variables associated with readmission and impact on 5-year overall survival (OS) were examined. A total of 8887 (male, n = 5326; female, n = 3561) patients underwent curative intent surgery for gastric adenocarcinoma. Within 90 days of initial surgery, 2559 (28.8 %) patients had inpatient hospital readmission. The majority of readmissions occurred in the first 30 days [0-30, n = 1371 (53.6 %); 31-60, n = 773 (30.2 %); and 61-90, n = 415 (16.2 %)]. Readmission vs. no readmission within 90 days correlated with worse 5-year OS in patients with local (51.2 vs. 70.9 %, p < 0.0001) and regional (23.3 vs. 32.9 %, p < 0.0001) disease. On multivariate analysis, readmission within 90 days was associated with worse OS (HR 1.40, 95 % CI 1.32-1.49, p < 0.001). Hospital readmissions are high after surgery for gastric cancer and correlate with poor patient survival. A better understanding of these issues may allow health care providers to potentially lower readmission rates and improve gastric cancer outcomes.

Over the last 15 years, there have been major advances in the multimodal treatment of gastric cancer, in large part due to several phase III studies showing the treatment benefits of neoadjuvant and adjuvant chemotherapy and chemoradiation protocols. The objective of this editorial is to review the current high-level evidence supporting the use of chemotherapy, chemoradiation and anti-HER2 agents in both the neoadjuvant and adjuvant settings, as well as to provide a clinical framework for use of this data based on our own institutional protocol for gastric cancer. Major studies reviewed include the SWOG/INT 0116, Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC), CLASSIC, ACTS-GC, Adjuvant Chemoradiation Therapy in Stomach Cancer (ARTIST) and Trastuzumab for Gastric Cancer trials. Although these studies have demonstrated that multiple approaches in terms of the timing and therapy for gastric cancer are effective, no standard of care is widely accepted and que...

Hospital cancer registries are only required to report gastrointestinal stromal tumors (GISTs) if labeled malignant or metastatic, leading to potential loss of cases in national cancer registries. Our objective was to determine whether GISTs are underreported in the US. Retrospective review of pathology reports between 2010 and 2013 with diagnosis of GIST was performed at two academic medical centers. Recurrent GISTs were excluded. Pathology reports were cross-referenced to cases reported by each cancer registry. Risk for metastasis/death was determined according to National Comprehensive Cancer Network (NCCN) guidelines. Forty-nine cases of non-recurrent GIST were identified. Only 19/49 (38.8 %) cases were reported. None of the 30 non-reported cases were labeled malignant/metastatic on final pathology. To illustrate malignant potential, these tumors were risk stratified. Most (60 %) of the non-reported cases were low risk, but there were 4 (13.3 %) cases each in the intermediate, high, and unknown risk groups. Additionally, 7/30 (23.0 %) cases were treated with tyrosine kinase inhibitors, highlighting clinical concern of malignant GIST. Our results show that nearly two thirds of GIST cases have been underreported, suggesting that current reporting practices underestimate its true incidence. Revision of reporting guidelines may result in a more accurate estimation of the US disease burden of GIST.

Elevated levels of chemokine receptor CCR9 expression in solid tumors may contribute to poor patient prognosis. In this study, we characterized a novel CCR9-mediated pathway that promotes pancreatic cancer cell invasion and drug resistance, indicating that CCR9 may play a critical role in cancer progression through activation of β-catenin. We noted that the CCL25/CCR9 axis in pancreatic cancer cells induced the activation of β-catenin, which enhanced cell proliferation, invasion, and drug resistance. CCR9-mediated activation of β-catenin and the resulting downstream effects were effectively inhibited by blockade of the PI3K/AKT pathway, but not by antagonism of Wnt. Importantly, we discovered that CCR9/CCL25 increased the lethal dose of gemcitabine, suggesting decreased efficacy of anti-cancer drugs with CCR9 signaling. Through in silico computational modeling, we identified candidate CCR9 antagonists and tested their effects on CCR9/β-catenin regulation of cell signaling and drug sensitivity. When combined with gemcitabine, it resulted in synergistic cytotoxicity. Our results show that CCR9/β-catenin signaling enhances pancreatic cancer invasiveness and chemoresistance, and may be a highly novel therapeutic target.

Follicular fluid is an important environment for oocyte development, yet current knowledge regarding its in vivo oxidant and antioxidant levels remains limited. Examining follicular fluid oxidants and antioxidants will improve understanding of their changes in vivo and contribute to optimisation of in vitro maturation conditions. The aim of the present study was to consider selected markers, namely catalase (CAT) enzyme activity, total antioxidant capacity (TAC) and hydrogen peroxide (H(2)O(2)) in follicular fluid samples (n = 503) originating from bovine antral follicles. The dynamic changes in two relevant antioxidant measures and one reactive oxygen species (ROS) were measured through stages of bovine follicular development and the oestrous cycle. CAT activity and H(2)O(2) levels decreased significantly as follicle size increased, whereas TAC increased significantly as follicle size increased. Lower TAC and higher H(2)O(2) in small follicles suggest increased ROS in the initial s...