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Objective To summarize the multi-specialty strategy and initial guidelines of a Case Review Committee in triaging oncologic surgery procedures in a large Comprehensive Cancer Center and to outline current steps moving forward after the initial wave. Summary of background data The impetus for strategic rescheduling of operations is multifactorial and includes our societal responsibility to minimize COVID-19 exposure risk and propagation among patients, the healthcare workforce, and our community at large. Strategic rescheduling is also driven by the need to preserve limited resources. As many states have already or are considering to re-open and relax stay-at-home orders, there remains a continued need for careful surgical scheduling because we must face the reality that we will need to co-exist with COVID-19 for months, if not years. Methods The quality officers, chairs, and leadership of the 9 surgical departments in our Division of Surgery provide specialty-specific approaches to appropriately triage patients. Results We present the strategic approach for surgical rescheduling during and immediately after the COVID-19 first wave for the 9 departments in the Division of Surgery at The University of Texas MD Anderson Cancer Center in Houston, Texas. Conclusions Cancer surgeons should continue to use their oncologic knowledge to determine the window of opportunity for each surgical procedure, based on tumor biology, preoperative treatment sequencing, and response to systemic therapy, to safely guide patients through this cautious recovery phase.

OBJECTIVES: Neoadjuvant therapy (NT) is used for advanced pancreatic ductal adenocarcinoma (PDAC). No clear guidelines exist for switching therapies when patients do not respond to initial NT. We sought to characterize patients who underwent early switch from FOLFIRINOX to gemcitabine/nab-paclitaxel (GA) as NT for PDAC. METHODS: We identified patients at a single institution switched from FFX to GA within the first 4 months of NT for PDAC during 2012–2017. We compared clinicopathologic data and oncologic outcomes. RESULTS: Of 25 patients who met criteria, 21 showed a serologic or radiographic response to GA; 11 (52%) reached resection. Responders had decreased carbohydrate antigen (CA) 19-9 levels from pre-treatment to post-GA (P = 0.036). Resected responders had significantly decreased CA 19-9 comparing pre-switch to post-GA (P = 0.048). The only predictor of GA response was pre-chemotherapy CA 19-9

OBJECTIVE: To assess the impact of somatic gene mutations on survival among patients undergoing resection of colorectal liver metastases (CLM). SUMMARY BACKGROUND DATA: Patients undergoing CLM resection have heterogeneous outcomes, and accurate risk stratification is necessary to optimize patient selection for surgery. METHODS: Next-generation sequencing of 50 cancer-related genes was performed from primary tumors and/or liver metastases in 401 patients undergoing CLM resection. Missense TP53 mutations were classified by the Evolutionary Action Score (EAp53), a novel approach that dichotomizes mutations as low or high risk. RESULTS: The most frequent somatic gene mutations were TP53 (65.6%), followed by KRAS (48.1%) and APC (47.4%). Double mutation in RAS/TP53, identified in 31.4% of patients, was correlated with primary tumor location in the right colon (P = 0.006). On multivariable analysis, RAS/TP53 double mutation was an independent predictor of shorter overall survival (hazard ratio, 2.62; 95% confidence interval 1.41 to 4.87; P = 0.002). In patients with co-mutated RAS, EAp53 high risk mutations were associated with shorter 5-year overall survival of 12.2%, compared with 55.7% for TP53 wild-type (P < 0.001). The negative prognostic effects of RAS and TP53 mutations were limited to tumors harboring mutations in both genes. CONCLUSIONS: Concomitant RAS and TP53 mutations are associated with decreased survival after CLM resection. A high EAp53 predicts a subset of patients with worse prognosis. These preliminary analyses suggest that surgical resection of liver metastases should be carefully considered in this subset of patients.

Although the use of neoadjuvant therapy for resectable pancreatic ductal adenocarcinoma is increasing, the optimal preoperative treatment regimen remains poorly defined.All patients with resectable pancreatic ductal adenocarcinoma who received preoperative chemotherapy alone (12%) or chemoradiation therapy (CRT) alone (88%) before pancreatectomy between 1999 and 2014 were included. Propensity score matching with inverse probability weighting was conducted based on age, baseline carbohydrate antigen 19-9, and procedure type.Patients who received preoperative CRT were more likely to undergo a margin negative (91% vs 79%, P0.01) and node negative (53% vs 23%, P0.01) resection and experience less locoregional recurrence (LR; 16% vs 33%, P0.01) but similar median overall survival (OS; 33.6 vs 26.4 months, P = 0.09). On multivariate analysis, carbohydrate antigen 19-9 (hazard ratio, 1.2; 95% confidence interval [CI], 1.1-1.3) and positive lymph nodes (hazard ratio, 1.5; 95% CI, 1.0-2.2) were associated with OS, whereas tumor size (odds ratio [OR], 1.5; 95% CI, 1.3-1.8), positive lymph nodes (OR, 3.1; 95% CI, 1.8-5.6), and preoperative chemotherapy (OR, 1.8; 95% CI, 1.1-2.9) were associated with LR.Preoperative CRT is associated with less margin and lymph node positivity, reduced LR, and similar OS compared with preoperative chemotherapy.

Objective To determine if tumor genetics are associated with overall survival (OS) after concurrent resection of colorectal liver metastases (CLM) and extrahepatic disease (EHD). Summary background data The prognosis for patients who undergo concurrent resection of CLM/EHD is unclear and the impact of somatic mutations has not been reported. Methods Patients undergoing concurrent resection of CLM and EHD from 2007-2017 were identified from two academic centers. From 1 center, patients were selected from a pre-existing database of patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). The Kaplan-Meier method was used to construct survival curves, compared using the log-rank test. Multivariable Cox analysis for OS was performed. Results One hundred nine patients were included. Most common EHD sites included lung (33 patients), peritoneum (32), and portal lymph nodes (14). TP53 mutation was the most common mutation, identified in 75 patients (69%), and RAS/TP53 co-mutation was identified in 31 patients (28%). The median OS was 49 months (IQR, 24-125), and 3- and 5-year OS rates were 66% and 44%, respectively. Compared to patients without RAS/TP53 co-mutation, patients with RAS/TP53 co-mutation had lower median OS: 39 vs. 51 months (P = .02). On multivariable analysis, lung EHD (hazard ratio [HR], 0.7; 95% CI, 0.3-1.4), peritoneal EHD (HR, 2.2; 95% CI, 1.1-4.2) and RAS/TP53 co-mutation (HR, 2.8; 95% CI, 1.1-7.2) were independently associated with OS. Conclusions RAS/TP53 co-mutation is associated with worse OS after concurrent CLM/EHD resection. Mutational status and site of EHD should be included in the evaluation of patients considered for concurrent resection.

Situs inversus totalis (SIT) is a rare anomaly characterized by the transposition of organs. We present a case of a 67-year-old White woman with a history of SIT, who presented with fatigue, jaundice, and abnormal liver enzymes. Endoscopic ultrasound demonstrated a solid lesion at the distal common bile duct (CBD). Subsequent endoscopic retrograde cholangiopancreatography displayed severe stenosis in the CBD. A plastic stent was placed into the CBD, resulting in successful biliary decompression. Biliary brushings and biopsy showed atypical cells, suspicious for carcinoma. Ensuing pancreaticoduodenectomy confirmed cholangiocarcinoma. Although challenging, endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in SIT can be successfully performed in preoperative evaluation for possible pancreaticobiliary cancers.

Category 1 guidelines emphasize multimodality therapy (MMT) for patients with gastric cardia cancer (GCC). These patients are often referred to thoracic surgeons for "esophagogastric junction" cancers rather than to abdominal surgeons for "proximal gastric" cancers. This study sought to determine the ideal surgical approach using national datasets evaluating morbidity/mortality (M/M) and overall survival (OS).Patients with resected GCC were identified from the 2005 to 2012 ACS-NSQIP dataset and the 1998 to 2010 SEER dataset. Multivariate 30-day M/M analyses were performed using NSQIP. Survival analyses were derived from SEER and stratified by surgical approach.There were 1,181 NSQIP patients with GCC included; 81.8% had esophagectomies and 18.1% had gastrectomies. Major postoperative M/M occurred in 33.2%/3.7% patients after gastrectomy vs 35.0%/2.4% after esophagectomy (p = 0.260). Although a major postoperative complication (odds ratio 12.8, p0.001) was an independent predictor of mortality on multivariate analysis, surgical approach was not. Of the 3,815 SEER patients included, 71.1% had esophagectomies and 28.9% had gastrectomies. Radiation use (surrogate for MMT) was administered more often with esophagectomy vs gastrectomy (42.9% vs 29.6%, p0.001). Unadjusted median overall survival (OS) favored esophagectomy (26.0 vs 21.0 months, p = 0.025). However, multivariate analysis confirmed age (hazard ratio [HR] 1.01), T/N stages (HR 1.12/1.91), and radiation use (HR 0.83, all p ≤ 0.018), but not surgical approach (HR 0.95, p = 0.259), as independent predictors of OS.Tumor biology and MMT, rather than surgical approach, dictate oncologic outcomes for GCC. Therefore, the decision of esophagectomy vs gastrectomy for GCC should be based on proximal and distal tumor extent and the multidisciplinary strategy with the lower rate of complications and the higher rate of MMT completion.

BACKGROUND: Conditional recurrence-free survival (RFS) probability, i.e., recurrence probability after a given interval without recurrence, has not been reported after resection of colorectal liver metastases (CLM). We aimed to estimate conditional RFS and identify factors affecting conditional RFS. STUDY DESIGN: Patients undergoing initial resection of CLM during 2000-2016 with mutation data were identified. RFS and risk factors for recurrence were evaluated at the time of resection for all patients and at 1 year and 2 years after resection for patients who remained recurrence-free. RESULTS: Of 2118 patients, 485 met the inclusion criteria, of whom 225 were recurrence-free at 1 year and 109 were recurrence-free at 2 years. The 5-year RFS rates were 17.3%, 36.8%, and 70.7% for all patients and the 1-year and 2-year recurrence-free groups, respectively, when assessed from the time of initial CLM resection. RAS/TP53 co-mutation was the only factor independently associated with increased risk of recurrence for all groups (all patients, hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.19–1.82, P

INTRODUCTION: Traumatic brain injury (TBI) affects over 1.7 million patients per year according to Centers for Disease Control estimates. Post-concussive syndrome (PCS) is a poorly defined constellation of heterogeneous symptoms with reported incidence ranging from 15 to 80% after mild TBI. Our objective is to examine the incidence of self-reported PCS symptoms in patients with mild TBI within three to six months post-injury with particular focus on psychological impairment.

Mechanisms of aberrant epidermal growth factor receptor signaling in the absence of EGFR gene activating mutations in pancreatic cancer patients Ching-Wei D Tzeng MD, Andrey Frolov MD, PhD, Natalya Frolova MD, Nirag C Jhala MD, Andra R Frost MD, J Harrison Howard MD, Kyle W Schuller BE, Donald J Buchsbaum PhD, Selwyn M Vickers MD, Martin J Heslin MD, J Pablo Arnoletti MD University of Alabama at Birmingham, Birmingham, AL