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BACKGROUND Merkel cell polyomavirus (MCPyV) is associated with the development of Merkel cell carcinoma (MCC). Antibody (MCPyV-Ab) titers may have prognostic implications. This study evaluated the impact of the presence or absence of MCPyV-Ab on the 2-year overall survival (OS) and disease-free survival (DFS) of MCC patients. METHODS This single-center, IRB-approved, retrospective cohort study evaluated 51 adult patients with MCC from 2014 to 2021 using a prospectively maintained database. Patients were compared by MCPyV-Ab status, and Kaplan-Meier analysis was used to evaluate 2-year OS and DFS. RESULTS Of the 51 patients, 13 (25.4%) were seropositive, 41 (80.4%) underwent wide excision, 40 (80.0%) received radiotherapy, and 43 (84.3%) received multimodal therapy. The median follow-up period was 15.5 months (range 1-69.5 months). The median 2-year OS of the entire cohort was not reached. The median 2-year OS was not reached for either the seronegative or the seropositive patients. The difference in 2-year OS between the groups was not statistically significant (p = 0.37). Eight patients, all seronegative, were never rendered disease-free and were removed from recurrence analysis. The seropositive patients experienced no recurrences. Of the 30 seronegative patients, 9 (30.0%) experienced recurrence. The median 2-year DFS of the entire cohort was not reached. The median 2-year DFS of the seronegative group was 22.2 months. The 2-year DFS was not reached for the seropositive cohort. Seropositivity conferred a significantly better 2-year DFS than seronegativity (p = 0.04). CONCLUSION The MCPyV-Ab seropositive patients demonstrated improved 2-year DFS. The seropositive patients showed a strong trend toward improved 2-year OS, although the difference not statistically significant. This study substantiated the value of MCPyV-Ab assessment for MCC.

Background Enhanced recovery after surgery (ERAS) protocols are widely utilized for elective colorectal surgery to improve outcomes and decrease costs, but few studies have evaluated the impact of ERAS protocols on cost with respect to anatomic site of resection. This study evaluated the impact of ERAS protocol on elective colon resections by site and longitudinal impact over time. Methods A single-center retrospective cohort study of 598 consecutive patients undergoing elective colorectal resection before and after implementation of ERAS protocol from 2013 to 2017 was performed. The primary outcomes were length of stay (LOS) and cost. Comparative and multivariate inferential statistics were used to assess additional outcomes. Results A total of 598 patients (100 pre-ERAS vs 498 post-ERAS) were evaluated with an overall median LOS of 4 days for right and left colectomies and 3 days for transverse colectomies. When comparing type of resection before and after ERAS protocol introduction, an increased LOS for left hemicolectomies from 3.09 to 4.03 days ( P = .047) was noted, with all other comparisons failing to reach statistical significance. Over time, an initial decrease in LOS for MIS approach after protocol introduction was observed; however, this effect diminished in the ensuing years and had no significant effect overall. Total cost of care was significantly increased post-ERAS for all cohorts except transverse colectomies. No further statistically significant differences were found. Conclusion After an initial improvement in outcomes, continued utilization of ERAS protocols demonstrated no improvement in LOS compared to pre-ERAS data and increased cost overall for patients regardless of site of resection.

Postoperative pain managed with opioids has contributed to the opioid crisis through over-prescribing practices. We assessed opioid-prescribing habits and their use by patients undergoing surgery for cutaneous malignancies. An Institutional Review Board–approved retrospective analysis was conducted for patients who underwent skin cancer resection between January 2018 and June 2018. Data were collected from the electronic medical record, and opioid-related data were collected from patient interviews and state registries. There were 120 study participants (42 females and 78 males) with a median age of 67 years (range, 21–94 years). All received preincision local anesthetic: 64 had liposomal bupivacaine (LB) (53%) and 56 had non-LB bupivacaine (47%). Most participants (n = 88) used 0 opioids (73%), including 43 LB-anesthetic (67%) and 45 non–LB-anesthetic (80%). No significance was seen between those with a diagnosis of chronic pain, narcotic tolerance, an area of resection, and nodal sampling groups in opioid use. Four patients (3%) requested a refill. Of 105 prescriptions written for opioids, 99 had leftover opioids for an over-prescribing rate of 94 per cent. This study suggests pain after skin cancer surgery is manageable with very limited opioid requirements. Our results support prescribing no more than five opioid tablets for postoperative pain control in patients undergoing resection for skin malignancies.

Background Early ambulation after surgery is demonstrated to reduce complications and decreases patient length of stay (LOS) as part of an enhanced recovery after surgery (ERAS) program. This study hypothesizes that missed and refused ambulation attempts prolong patient LOS. Methods From January 2014 to December 2016, all patients admitted to one ward who had undergone bowel resection surgery were assigned a dedicated ambulation team with the goal of ambulating 3 times per day. Clinical data was collected prospectively. Statistical analysis of ambulation frequency, percentage of ambulation sessions completed and overall LOS was performed to test the hypothesis. Results A total of 127 patients were analyzed for mean age, breakdown of laparoscopic/open procedures/pre-surgery ambulation status. The median LOS (mLOS) for all patients was 4.3 days. When ambulation was not offered for a 24-hour period, the mLOS increased from 3.6 to 6.6 days (P

The influence of preoperative hemoglobin levels on outcomes of patients undergoing esophagectomy for cancer is not clearly defined. The goal of this article was to explore the association between combined modality therapy, preoperative anemia status, and perioperative blood transfusion and risk of postoperative complications among patients undergoing esophageal resection.From a retrospective esophageal database, 413 patients were identified. Anemia was defined according to the World Health Organization classification of13 g/dL or12 g/dL for men or women, respectively. Statistical analysis was performed with analysis of variance, Pearson's chi(2), or Fisher exact test as appropriate. The independent association of anemia, blood transfusion, and combined modality treatment on risk of postoperative complications were examined using multiple logistic regression.Information on combined modality treatment, preoperative hemoglobin levels, and blood transfusion was available for 413 patients, of whom 57% received combined modality treatment. Overall 197 (47.6%) patients were preoperatively found to be anemic, and those who had received combined modality treatment were more likely to be anemic (60.6% versus 30.7%, P0.001). Anemic patients required more blood transfusions than nonanemic patients (46.7% versus 29.6%, P0.001). Seventy-five percent of patients who required transfusion during the hospital stay had received combined modality treatment (P = 0.01). Combined modality treatment and anemia were not associated with increased risk of complications. Patients with any perioperative complication and surgical site infections were more likely to have received blood transfusion compared to patients without complications (OR = 1.73; 95% CI 1.04-2.87 and OR = 2.98; 95% CI 1.04-8.55; respectively).Overall, we determined that administration of neoadjuvant treatment to esophageal cancer patients was not associated with an increased rate of perioperative complications. Preoperative anemia did not predict worsened short-term outcomes, but increased the chances of red blood cell transfusion, which were significantly associated with higher overall complications and increased risk of surgical site infections. These data confirm previous studies that allogenic red blood cell transfusions are independent risk factors for increased morbidity and mortality and should be minimized during surgery for esophageal cancer.

Background Esophageal cancer continues to increase in incidence. Many patients are presenting with stage II or greater disease and proceeding to neoadjuvant chemoradiation therapy before resection. Approximately 30% of patients will achieve a complete response and might not benefit from proceeding to resection. This study will examine the ability of PET to predict patients with a complete pathologic response. Study Design A query of our IRB-approved esophageal database revealed 81 patients who underwent a pre- and postchemoradiation PET scan and then proceeded to esophageal resection. Statistical analysis was performed to determine the ability of PET to predict a complete pathologic response. Results When comparing posttherapy PET with final pathology, it was determined that PET could not consistently differentiate a complete pathologic response from patients who still had persistent disease. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 61.8%, 43.8%, 70%, 35%, and 56%, respectively, for patients with a complete PET response after neoadjuvant therapy. Conclusions A complete PET response after neoadjuvant chemoradiation is not substantially predictive of a complete pathologic response. Patients should still be referred for resection unless distant metastases are identified.

Given the increasing rate of obesity, the effects of excessive body weight on surgical outcomes constitute a relevant quality of care concern. Our aim was to determine the relationship between preoperative body mass index (BMI) on perioperative complications after esophagectomy for cancer.From our comprehensive esophageal cancer database consisting of 510 patients, we identified 166 obese (BMI ≥30), 176 overweight (BMI 25-29), and 148 normal-weight (BMI 20-24) patients. Malnourished patients (BMI of20) were excluded. Incidence of preoperative risk factors and perioperative complications in each group were analyzed.The patient group consists of 420 men and 70 women with a mean age at time of surgery were 64 years (range 28-86 years). The categories of patients (obese, overweight, and normal-weight) were similar in terms of demographics and comorbidities, with the exception of a younger age (62.5 years vs 66.2 years vs 65.3 years, P = 0.002), and a higher incidence of diabetes (23.5% vs 11.4% vs 10.1%, P = 0.001) and hiatal hernia (28.3% vs 14.8% vs 20.3%, P = 0.01) for obese patients. More patients with BMI24 were found with adenocarcinoma, compared with the normal-weight group (90.8% vs 90.9% vs 82.5%, P = 0.03). Despite similar preoperative stage, obese patients were less likely to receive neoadjuvant treatment (47.6% vs 54.5% vs 66.2%, P = 0.004). The type of surgery performed, overall blood loss, extent of lymphadenectomy, rate of resections with negative margins, and postoperative complications were not influenced by BMI on univariate and multivariate analysis.In our experience, BMI did not affect number of harvested lymph-nodes, rates of negative margins, and morbidity and mortality after esophagectomy for cancer. In our experience, esophagectomy could be performed safely and efficiently in mildly obese patients.

Cytoreductive therapy for metastatic carcinoid provides symptomatic relief and improvement in overall survival. We evaluated whether CgA and 5HIAA could predict symptomatic relief and control of disease progression after cytoreductive surgery.We retrospectively reviewed 70 patients who underwent cytoreductive surgery for neuroendocrine hepatic metastases between 1996 and 2005. Twenty-two patients had pre and post-operative CgA and/or 5HIAA levels measured. Reduction of biomarkers following cytoreduction was correlated with patient symptoms and progression of disease following surgery.Our study consisted of 14 males and 8 females with a mean age of 55 (+/-12 years). Median follow-up was 18 months (range 5-64 months). Six patients (26.1%) had complete (R0) cytoreduction, while 4 (17.4%) and 13 (56.5%) had microscopic (R1) and gross (R2) disease remaining. All patients reported improvements in their symptoms, with 12 (54.5%) reporting complete resolution (CR) and 10 (45.5%) reporting partial resolution (PR). Reduction of CgA ofor= 80% was highly predictive of complete resolution of symptoms (P = 0.007) and stabilization of disease (P = 0.034). Reduction of 5HIAA levels ofor= 80% (or normalization) was predictive of symptomatic relief, but not progression of disease (P = 0.026 and P = 0.725). Five of six patients who had R0 resections had CR and were free of disease at last follow-up (median 24.5 months, range: 11-48, P = 0.002).We conclude thator= 80% reduction in CgA level following cytoreductive surgery for carcinoid tumors is predictive of subsequent symptom relief and disease control. Substantial reduction in CgA is associated with improved patient outcomes, even after incomplete cytoreduction.

Background In patients with esophageal cancer, treatment decisions often involve a balance between a high-risk procedure and the chance for long-term benefit. The decision can be additionally challenging for elderly patients since some studies have reported an increased incidence of morbidity and mortality in this age group, and data are not clear on the overall benefit of multimodality therapy. Methods To investigate the management and outcomes associated with esophagectomy in elderly patients with esophageal cancer, we performed a review of the literature as well as an analysis of our own institutional data, with a focus on the impact of age on surgical outcomes. We examined type of surgery, neoadjuvant and adjuvant therapy, postoperative complications, length of hospitalization, and mortality as variables in elderly patients with esophageal cancer. Results When assessing the impact of age on the success of esophagectomy, several studies have concluded that advanced age itself is not a predictor of outcomes as much as associated comorbidities are. Our own experience suggests that age is not associated with adverse outcomes when controlling for patient comorbidities. This finding is similar to data reported elsewhere. Conclusions When considering treatment for patients of advanced age, the risks of treatment should be compared with the survival benefits of the therapy prescribed, taking into account additional factors such as poor performance status, existing comorbidities, and residual tumor following neoadjuvant therapy. Many reports, as well as our own experience, have concluded that when adjusted for comorbidities, patient age does not significantly affect outcomes.

Neoadjuvant chemoradiation (NCRT) has become the preferred treatment for patients with locally advanced esophageal cancer. Survival often is correlated to degree of pathologic response; however, outcomes in patients who are found to be pathologic nonresponders (pNR) remain uninvestigated. This study was designed to evaluate survival in pNR to NCRT compared with patients treated with primary esophagectomy (PE). Using our comprehensive esophageal cancer database, we identified patients treated with NCRT and deemed pNR along with patients who proceeded to PE. Clinical and pathologic data were compared using Fisher’s exact and χ2, whereas Kaplan–Meier estimates were used for survival analysis. We identified 63 patients treated with NCRT and were found to have a pNR, and 81 patients who underwent PE. Disease-free (DFS) and overall survival (OS) were significantly decreased in the pNR group compared with those treated with PE (10 vs. 50 months (0–152), P

Incidences of esophageal cancer and obesity are both rising in the United States. The aim of this study was to determine the influence of elevated body mass index on outcomes after esophagectomy for cancer.Overall and disease-free survivals in obese (BMI ≥ 30), overweight (BMI 25-29), and normal-weight (BMI 20-24) patients undergoing esophagectomy constituted the study end points. Survivals were calculated by the Kaplan-Meier method, and differences were analyzed by log rank method.The study included 166 obese, 176 overweight, and 148 normal-weight patients. These three groups were similar in terms of demographics and comorbidities, with the exception of younger age (62.5 vs. 66.2 vs. 65.3 years, P = 0.002), and higher incidence of diabetes (23.5 vs. 11.4 vs. 10.1%, P = 0.001) and hiatal hernia (28.3 vs. 14.8 vs. 20.3%, P = 0.01) in obese patients. Rates of adenocarcinoma histology were higher in obese patients (90.8 vs. 90.9 vs. 82.5%, P = 0.03). Despite similar preoperative stage, obese patients were less likely to receive neoadjuvant treatment (47.6 vs. 54.5 vs. 66.2%, P = 0.004). Response to neoadjuvant treatment, type of surgery performed, extent of lymphadenectomy, rate of R0 resections, perioperative complications, and administration of adjuvant chemotherapy were not influenced by BMI. At a median follow-up of 25 months, 5-year overall and disease-free survivals were longer in obese patients (respectively, 48, 41, 34%, P = 0.01 and 48, 44, 34%, P = 0.01).In our experience, an elevated BMI did not reduce overall and disease-free survivals after esophagectomy for cancer.

Esophageal cancer remains a malignancy with high morbidity and mortality despite improvements to diagnosis, staging, chemotherapy, radiation, and surgery. Neoadjuvant therapy (NT) may improve oncologic outcome in many patients, however the degree to which patients benefit remains unclear. We examined the relationship between pathologic response to NT and magnitude of benefit in patients with esophageal cancer.Using a comprehensive esophageal cancer database, we identified patients who underwent esophagectomy between 1994 and 2008. Pathologic response was denoted as complete (pCR), partial (pPR), and nonresponse (NR). Clinical and pathologic data were compared using Fisher's exact and chi-square when appropriate, while Kaplan-Meier estimates were used for survival analysis.We identified 347 patients who underwent esophagectomy, and 262 (75.5%) were treated with NT. The median age was 66 years (28-86 years) with median follow-up of 20 months (1-177 months). There were 106 (40.5%) patients exhibiting pCR, 95 (36.3%) with pPR, and 61 (23.3%) with NR. The rate of R0 resections was higher amongst pCR (100%) compared with 94.7% in pPR (P = 0.02) and 87.5% in NR (P = 0.0007). There were 15 (14.2%) recurrences in pCR, 22 (23.7%) in pPR, and 17 (28.8%) in NR (P = 0.04). Patients achieving pCR had 5-year disease-free survival (DFS) and overall survival (OS) of 52% and 52%, respectively, compared with 36% and 38% in pPR and 22% and 19% in NR (P0.0001, P0.0001).Esophageal cancer patients frequently succumb to their disease. However, patients treated with neoadjuvant therapy who achieve pCR have a higher rate of R0 resections, fewer recurrences, and improved 5-year OS and DFS.

Background Patients who develop metastatic melanoma often have limited effective treatment options. However, a select group of patients will benefit from aggressive surgery or a multidisciplinary approach, depending on the site of metastasis. Methods The current literature was reviewed and summarized regarding the collective recommendations for staging and treating patients with metastatic melanoma. Results A thorough preoperative staging includes positron-emission tomography, MRI of the brain, and CT of the chest, abdomen, and pelvis. Tumor biology ultimately determines the success of intervention. A long disease-free interval is a good indicator of potential benefit from resection of metastatic disease. If surgery is performed, no less than a complete resection will affect the overall survival of the patient. Surgery and other multimodality treatment options can be used for symptomatic palliation but will not affect survival. Chemotherapy and radiation are often used to control the symptoms of brain and bony metastases but have limited if any impact on survival. Conclusions A select group of patients with metastatic melanoma will benefit from aggressive surgery. Identifying which patients will benefit from treatment requires good clinical judgment and a thorough radiologic evaluation to identify the true extent of disease.

Cytoreductive surgery represents a therapeutic attempt to improve patient outcomes by reducing overall tumor burden to render postsurgical therapy effective or at least increase its effectiveness. The intent of cytoreduction differs from palliative or curative-intent surgery for oligometastatic melanoma. Both palliative surgery and attempted curative resection have important roles to play in the management of patients with melanoma that has spread beyond the regional nodes or recurred "in transit" between the primary and the regional nodal basin. To date, however, no evidence shows that cytoreductive surgery offers any meaningful benefit to patients with metastatic melanoma, and, outside of a clinical trial, there is no role for cytoreductive surgery in melanoma. To date, adjuvant vaccine therapy after complete resection of metastatic melanoma has not proved to be efficacious in clinical trials, so there is little reason to believe that the use of currently available immunotherapy strategies will be enhanced after incomplete tumor resections.

CONTEXT Patients with peritoneal carcinomatosis have a dismal prognosis despite systemic chemotherapy or palliative surgery. A novel strategy of complete tumor debulking with intraoperative hyperthermia with chemotherapy has been proposed to provide prolonged survival. OBJECTIVE To retrospectively analyze the preliminary experience with this technique at Baylor University Medical Center. METHODS All patients underwent attempted tumor debulking followed by intraperitoneal hyperthermia with 40 mg mitomycin-C over 2 hours. RESULTS Patient diagnoses included nonmucinous colorectal carcinomatosis (n = 9), diffuse peritoneal adenomucinosis (n = 1), peritoneal mucinous carcinomatosis (n = 2), and gastric carcinomatosis (n = 3). Tumors in most patients (13/15) were resected to < or = 5 mm, and those in 10 of 15 were resected to no gross disease. Complications included ileus (n = 9), bowel leak (n = 2), infection (n = 1), and fistula (n = 1). One patient died of progressive gastric cancer at 1 month. Within a median follow-up of 4 months, 8 patients had no tumor by radiologic or tumor marker analysis. CONCLUSION Intraoperative hyperthermia with chemotherapy is a viable treatment for patients with isolated peritoneal carcinomatosis from colorectal or gastric origin.

130 Background: Esophageal cancer often presents as locally advanced disease with 15% of patients having T4 tumors upon diagnosis. Esophagectomy was often reserved for palliation given the dismal survival rates and high rates of R1/R2 resections. However, neoadjuvant therapy (NT) has the potential to significantly downstage esophageal cancers and thus increase complete resection rates. We report our experience with surgically resected T4 cancers of the esophagus. Methods: Using a comprehensive esophageal cancer database, we identified patients who underwent an esophagectomy for T4 tumors between 1994 and 2008. Neoadjuvant therapy and pathologic response were recorded and denoted as complete (pCR), partial (pPR), and non-response (NR). Clinical and pathologic data were compared using Fisher's exact and chi-square when appropriate while Kaplan Meier estimates were used for survival analysis. Results: We identified 39 patients with T4 tumors who underwent esophagectomy of which 38 (97%) underwent NT. The median age was 61 (31-79) years with a median follow-up of 32 (5-97) months. There were 3 (7.9%) pCR, 17 (44.7%) pPR, and 18 (47.4%) NR. R0 resections were accomplished in 37 (94.9%). Two patients had incomplete resections. One patient had a R2 resection after NT and was deemed as NR. An additional patient had a R1 resection after NT and was a pPR with a residual 0.2 cm tumor on permanent pathology. There were 14 (35.9%) recurrences with a median time to recurrence of 19.5 (4-71) months. Complete pathologic response represented 1 (7.1%), whereas pPR and NR represented 6 (42.9%), and 7 (50%) respectively of all recurrences. The overall and disease free survival for all patients with T4 tumors was 28% and 34% respectively. Patients achieving a pCR had a 5-year overall and disease free survival of (43% and 47%), compared to pPR (30% and 21%) while there were no 5-year survivors in the NR cohort. Conclusions: T4 esophageal cancer often portends a dismal prognosis even after surgical resection. Historical incomplete resections and dismal survival rates often make surgery palliative rather then curative. However, we have demonstrated that neoadjuvant therapy and down staging of T4 tumors leads to increased R0 resections and improvements in overall and disease free survival. No significant financial relationships to disclose.

Skin substitutes have shown success in complex wound reconstruction. We evaluate the use of a human acellular dermal matrix (ADM) as a viable alternative to autologous skin grafting for defects secondary to skin cancer excision. An institutional review board–approved, retrospective review of ADM-reconstructed defects secondary to skin cancer excision between 2012 and 2018 was conducted. ADM was indicated in patients with preclusive factors for general anesthesia, protracted procedure time, reluctance for additional donor site wound, and personal choice. We reviewed defect characteristics, healing time, postoperative outcomes, and patient demographics. The 228 participants (151 males, 77 females) had a median age of 72 years (range, 29–95 years), with melanoma diagnosed in 113 (49.6%), squamous cell carcinoma in 61 (26.8%), and basal cell carcinoma in 28 (12.2%) patients. The median interval to complete epidermal coverage was 42 days, with graft failure evident in six patients (2.6%). ADM is a viable, low-morbid alternative for reconstruction of defects secondary to skin cancer excision, with no donor site morbidity. With exception to complete healing time, outcomes are similar to those of autologous grafting.