Journal of the American College of Surgeons
-
Multicenter Study
Are Current National Review Board Downstaging Protocols for Hepatocellular Carcinoma Too Restrictive?
Liver transplantation (LT) is an effective strategy for patients with unresectable hepatocellular carcinoma (HCC). To qualify for standardized LT model for end-stage liver disease exception points, the United Network for Organ Sharing National Liver Review Board (NLRB) requires that the presenting and final HCC tumor burden be within the University of California San Francisco criteria, which were recently expanded (within expanded UCSF [W-eUCSF]). Current NLRB criteria may be too restrictive because it has been shown previously that the initial burden does not predict LT failure when tumors downstage to UCSF. This study aims to assess LT outcomes for HCC initially presenting beyond expanded UCSF (B-eUCSF) criteria in a large multicenter collaboration. ⋯ Transplantation for patients initially presenting with HCC B-eUSCF criteria offers a survival advantage similar to those with tumors meeting W-eUCSF criteria at presentation. The current NLRB policy is too stringent, and considerations to expand criteria should be discussed.
-
Recent large retrospective studies suggest that breast-conserving therapy (BCT) plus radiation yielded better outcomes than mastectomy (MST) for women with early-stage breast cancer (ESBC). Whether this is applicable to the different subtypes is unknown. We hypothesize that BCT yielded better outcomes than MST, regardless of subtypes of ESBC. ⋯ BCT yielded better survival rates than mastectomy for women with all subtypes of ESBC. The role of mastectomy for women with ESBC should be reassessed in future clinical trials.
-
The introduction of more effective chemotherapy a decade ago has led to increased use of neoadjuvant therapy (NAT) in patients with pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to assess the evolving use of NAT in individuals with PDAC undergoing pancreatoduodenectomy (PD) and to compare their outcomes with patients undergoing upfront operation. ⋯ NAT before pancreatoduodenectomy increased more than 3-fold over the past decade and was associated with improved optimal operative outcomes.
-
Pancreatic neuroendocrine tumor (PNET) survival outcomes differ by race. Current recommendations for surveillance of PNETs less than 2 cm in size are based on low malignant potential and low rates of lymph node metastases (LNM). We investigated whether these guidelines are universally applicable regardless of race. ⋯ The current recommendation for surveillance of PNETs of less than 2 cm in size is likely based on a low rate of LNM seen in a predominantly White population. The incidence of LNM in Black patients with tumors less than 2 cm in size is clinically relevant and concerning. Current guidelines may not be universally applicable, and a more aggressive approach to resection in Black patients with small PNETs may be warranted.
-
The American College of Surgeons (ACS) NSQIP risk calculator helps guide operative decision making. In patients with significant surgical risk, it may be unclear whether to proceed with "Hail Mary"-type interventions. To refine predictions, a local interpretable model-agnostic explanations machine (LIME) learning algorithm was explored to determine weighted patient-specific factors' contribution to mortality. ⋯ Through the application of machine learning algorithms (GBM and LIME), our model individualized predicted mortality and contributing factors with substantial ACS-NSQIP predicted mortality. USE of machine learning techniques may better inform operative decisions and family conversations in cases of significant surgical risk.