ASCRS Annual Meeting 2016

LOS ANGELES – In the clinical experience of Dr. Ian C. Lavery, prevention efforts are the best defense against local recurrence of rectal cancer.

“This means adjuvant treatment, if necessary, neoadjuvant treatment, and a meticulous surgical operation,” Dr. Lavery of the department of colorectal surgery at the Cleveland Clinic said at the annual meeting of the American Society of Colon and Rectal Surgeons. “If the circumferential resection margin is negative, the local recurrence rate is 10% or less. If it’s positive, local recurrence goes up to 78%. Even when we attempt to do the perfect total mesorectal excision, local recurrence is in the order of 4%.”

Selective use of radiotherapy in the neoadjuvant setting appears to be reducing the incidence of local recurrence, “certainly in the short term,” he added. “In the long term, I’m not sure we know the true answer to that yet. Using other techniques like washing the rectal stump out, the use of stapling, and en-bloc resection if necessary [can help prevention efforts].”

The incidence of local rectal cancer recurrence is reported to be between 3% and 50%, but neither curative nor palliative treatment is standardized. “When you get local recurrence after a rectal cancer operation, it’s a disaster,” Dr. Lavery said. “It may cause intractable pain, bleeding, perforation, obstruction, and sepsis – all incredibly difficult things to manage.”

Patients who develop a local recurrence of rectal cancer are often asymptomatic. A digital rectal exam (DRE) may or may not identify a recurrence and carcinoembryonic antigen levels are helpful on some occasions. According to Dr. Lavery, optimal surveillance consists of a clinical examination including DRE, endoscopy, blood tests, CT scans, MRI, and PET scans. “If they were all to be done routinely it would increase the detection earlier rather than later,” he said.

CT and MRI appear to be about 85% accurate but both modalities are “very poor at detecting peritoneal disease,” he said. PET scans for recurrent carcinoma have been shown to change the management in 20%-56% of cases (Ann Surg Oncol. 1997 Dec; 4:613-20).

While follow-up of patients who have undergone surgery for local rectal cancer is generally favored, there is no consensus on what the ideal follow-up timeline should be. “In my opinion, the more intensive follow-up is going to be better than the cursory conventional follow-up examination,” Dr. Lavery said. “One of the big reasons for that is the vast majority of recurrences are extraluminal so they may be difficult to feel. Doing endoscopy, you can’t see them if they’re extraluminal.”

The goal in treating recurrent rectal cancer is to improve quality of life, he continued, as the common symptoms include obstruction, pain, bleeding, bowel discharge, or perforation/abscess. Optimal treatment involves striving for tumor-free margins after the operation. “This may require en bloc resection of an adjacent prostate, bladder, lateral pelvic wall,” he said. “But clinically and radiologically, it’s very difficult to identify those patients that have a potentially R0 resection.”

Curative treatment is possible if the recurrence is locally resectable and the patient has minimal comorbidities. “The potential morbidity after the surgery has to be acceptable, considering the severity of the problem that we’re dealing with,” Dr. Lavery noted. “Distant disease also complicates the issue.”

Reasons to avoid resection include rigid tumor fixation, leg lymphedema, major vessel encasement, bilateral ureteric involvement, extensive para-aortic lymph node involvement, and radicular pain. “If you embark on one of these cases, you want to make it at least the first if not the only case of the day,” Dr. Lavery advised. “Anticipate the need for assistance during the operation, but above all, make sure you have optimal exposure to do the surgery.” He reported having no financial disclosures.

[email protected]

LOS ANGELES – In the clinical experience of Dr. Ian C. Lavery, prevention efforts are the best defense against local recurrence of rectal cancer.

“This means adjuvant treatment, if necessary, neoadjuvant treatment, and a meticulous surgical operation,” Dr. Lavery of the department of colorectal surgery at the Cleveland Clinic said at the annual meeting of the American Society of Colon and Rectal Surgeons. “If the circumferential resection margin is negative, the local recurrence rate is 10% or less. If it’s positive, local recurrence goes up to 78%. Even when we attempt to do the perfect total mesorectal excision, local recurrence is in the order of 4%.”

Selective use of radiotherapy in the neoadjuvant setting appears to be reducing the incidence of local recurrence, “certainly in the short term,” he added. “In the long term, I’m not sure we know the true answer to that yet. Using other techniques like washing the rectal stump out, the use of stapling, and en-bloc resection if necessary [can help prevention efforts].”

The incidence of local rectal cancer recurrence is reported to be between 3% and 50%, but neither curative nor palliative treatment is standardized. “When you get local recurrence after a rectal cancer operation, it’s a disaster,” Dr. Lavery said. “It may cause intractable pain, bleeding, perforation, obstruction, and sepsis – all incredibly difficult things to manage.”

Patients who develop a local recurrence of rectal cancer are often asymptomatic. A digital rectal exam (DRE) may or may not identify a recurrence and carcinoembryonic antigen levels are helpful on some occasions. According to Dr. Lavery, optimal surveillance consists of a clinical examination including DRE, endoscopy, blood tests, CT scans, MRI, and PET scans. “If they were all to be done routinely it would increase the detection earlier rather than later,” he said.

CT and MRI appear to be about 85% accurate but both modalities are “very poor at detecting peritoneal disease,” he said. PET scans for recurrent carcinoma have been shown to change the management in 20%-56% of cases (Ann Surg Oncol. 1997 Dec; 4:613-20).

While follow-up of patients who have undergone surgery for local rectal cancer is generally favored, there is no consensus on what the ideal follow-up timeline should be. “In my opinion, the more intensive follow-up is going to be better than the cursory conventional follow-up examination,” Dr. Lavery said. “One of the big reasons for that is the vast majority of recurrences are extraluminal so they may be difficult to feel. Doing endoscopy, you can’t see them if they’re extraluminal.”

The goal in treating recurrent rectal cancer is to improve quality of life, he continued, as the common symptoms include obstruction, pain, bleeding, bowel discharge, or perforation/abscess. Optimal treatment involves striving for tumor-free margins after the operation. “This may require en bloc resection of an adjacent prostate, bladder, lateral pelvic wall,” he said. “But clinically and radiologically, it’s very difficult to identify those patients that have a potentially R0 resection.”

Curative treatment is possible if the recurrence is locally resectable and the patient has minimal comorbidities. “The potential morbidity after the surgery has to be acceptable, considering the severity of the problem that we’re dealing with,” Dr. Lavery noted. “Distant disease also complicates the issue.”

Reasons to avoid resection include rigid tumor fixation, leg lymphedema, major vessel encasement, bilateral ureteric involvement, extensive para-aortic lymph node involvement, and radicular pain. “If you embark on one of these cases, you want to make it at least the first if not the only case of the day,” Dr. Lavery advised. “Anticipate the need for assistance during the operation, but above all, make sure you have optimal exposure to do the surgery.” He reported having no financial disclosures.

[email protected]

LOS ANGELES – In the clinical experience of Dr. Ian C. Lavery, prevention efforts are the best defense against local recurrence of rectal cancer.

“This means adjuvant treatment, if necessary, neoadjuvant treatment, and a meticulous surgical operation,” Dr. Lavery of the department of colorectal surgery at the Cleveland Clinic said at the annual meeting of the American Society of Colon and Rectal Surgeons. “If the circumferential resection margin is negative, the local recurrence rate is 10% or less. If it’s positive, local recurrence goes up to 78%. Even when we attempt to do the perfect total mesorectal excision, local recurrence is in the order of 4%.”

Selective use of radiotherapy in the neoadjuvant setting appears to be reducing the incidence of local recurrence, “certainly in the short term,” he added. “In the long term, I’m not sure we know the true answer to that yet. Using other techniques like washing the rectal stump out, the use of stapling, and en-bloc resection if necessary [can help prevention efforts].”

The incidence of local rectal cancer recurrence is reported to be between 3% and 50%, but neither curative nor palliative treatment is standardized. “When you get local recurrence after a rectal cancer operation, it’s a disaster,” Dr. Lavery said. “It may cause intractable pain, bleeding, perforation, obstruction, and sepsis – all incredibly difficult things to manage.”

Patients who develop a local recurrence of rectal cancer are often asymptomatic. A digital rectal exam (DRE) may or may not identify a recurrence and carcinoembryonic antigen levels are helpful on some occasions. According to Dr. Lavery, optimal surveillance consists of a clinical examination including DRE, endoscopy, blood tests, CT scans, MRI, and PET scans. “If they were all to be done routinely it would increase the detection earlier rather than later,” he said.

CT and MRI appear to be about 85% accurate but both modalities are “very poor at detecting peritoneal disease,” he said. PET scans for recurrent carcinoma have been shown to change the management in 20%-56% of cases (Ann Surg Oncol. 1997 Dec; 4:613-20).

While follow-up of patients who have undergone surgery for local rectal cancer is generally favored, there is no consensus on what the ideal follow-up timeline should be. “In my opinion, the more intensive follow-up is going to be better than the cursory conventional follow-up examination,” Dr. Lavery said. “One of the big reasons for that is the vast majority of recurrences are extraluminal so they may be difficult to feel. Doing endoscopy, you can’t see them if they’re extraluminal.”

The goal in treating recurrent rectal cancer is to improve quality of life, he continued, as the common symptoms include obstruction, pain, bleeding, bowel discharge, or perforation/abscess. Optimal treatment involves striving for tumor-free margins after the operation. “This may require en bloc resection of an adjacent prostate, bladder, lateral pelvic wall,” he said. “But clinically and radiologically, it’s very difficult to identify those patients that have a potentially R0 resection.”

Curative treatment is possible if the recurrence is locally resectable and the patient has minimal comorbidities. “The potential morbidity after the surgery has to be acceptable, considering the severity of the problem that we’re dealing with,” Dr. Lavery noted. “Distant disease also complicates the issue.”

Reasons to avoid resection include rigid tumor fixation, leg lymphedema, major vessel encasement, bilateral ureteric involvement, extensive para-aortic lymph node involvement, and radicular pain. “If you embark on one of these cases, you want to make it at least the first if not the only case of the day,” Dr. Lavery advised. “Anticipate the need for assistance during the operation, but above all, make sure you have optimal exposure to do the surgery.” He reported having no financial disclosures.

[email protected]

LOS ANGELES – The use of locoregional tissue flaps in combination with abdominoperineal resection was associated with higher rates of perioperative complications, longer hospital stays, and higher total hospital charges, compared with patients who did not undergo tissue flap reconstruction, an analysis of national data showed.

The findings come at a time when closure of perineal wounds with tissue flaps is an increasingly common approach, especially in academic institutions, Dr. Nicole Lopez said at the annual meeting of the American Society of Colon and Rectal Surgeons. “The role of selection bias in this [study] is difficult to determine, but I think it’s important that we clarify the utility of this technique before more widespread adoption of the approach,” she said.

According to Dr. Lopez of the department of surgery at the University of North Carolina, Chapel Hill, perineal wound complications can occur in 16%-49% of patients undergoing abdominoperineal resection. Contributing factors include noncollapsible dead space, bacterial contamination, wound characteristics, and patient comorbidities.

In an effort to identify national trends in the use of tissue flaps in patients undergoing abdominoperineal resection for rectal or anal cancer, as well as the effect of this approach on perioperative complications, length of stay, and total hospital charges, Dr. Lopez and her associates used the National Inpatient Sample to identify patients aged 18-80 years who were treated between 2000 and 2013. They excluded patients undergoing nonelective procedures or additional pelvic organ resections. Patients who received a tissue flap were compared with those who did not.

Dr. Lopez reported results from 298 patients who received a tissue flap graft and 12,107 who did not. Variables significantly associated with receiving a tissue flap, compared with not receiving one, were being male (73% vs. 66%, respectively; P =. 01), having anal cancer (32% vs. 11%; P less than .0001), being a smoker (34% vs. 23%; P less than .0001), undergoing the procedure in a large hospital (75% vs. 67%; P = .003), and undergoing the procedure in an urban teaching hospital (89% vs. 53%; P less than .0001).

The researchers also found that the number of concurrent tissue flaps performed rose significantly during the study period, from 0.4% in 2000 to 6% in 2013 (P less than .0001). “This was most noted in teaching institutions, compared with nonteaching institutions,” Dr. Lopez said.

Bivariate analysis revealed that, compared with patients who did not receive tissue flaps, those who did had higher rates of postoperative complications (43% vs. 33%, respectively; P less than .0001), a longer hospital stay (mean of 9 vs. 7 days; P less than .001), and higher total hospital charges (mean of $67,200 vs. $42,300; P less than .001). These trends persisted on multivariate analysis. Specifically, patients who received tissue flaps were 4.14 times more likely to have wound complications, had a length of stay that averaged an additional 2.78 days, and had $28,000 more in total hospital charges.

“The extended duration of the study enables evaluation of trends over time, and this is the first study that analyzes the costs associated with these procedures,” Dr. Lopez said. She acknowledged certain limitations of the study, including its retrospective, nonrandomized design and the potential for selection bias. In addition, the National Inpatient Sample “is susceptible to coding errors, a lack of patient-specific oncologic history, and the inability to assess postdischarge occurrences, since this only looks at inpatient stays.”

Dr. Lopez reported having no financial disclosures.

[email protected]

LOS ANGELES – The use of locoregional tissue flaps in combination with abdominoperineal resection was associated with higher rates of perioperative complications, longer hospital stays, and higher total hospital charges, compared with patients who did not undergo tissue flap reconstruction, an analysis of national data showed.

The findings come at a time when closure of perineal wounds with tissue flaps is an increasingly common approach, especially in academic institutions, Dr. Nicole Lopez said at the annual meeting of the American Society of Colon and Rectal Surgeons. “The role of selection bias in this [study] is difficult to determine, but I think it’s important that we clarify the utility of this technique before more widespread adoption of the approach,” she said.

According to Dr. Lopez of the department of surgery at the University of North Carolina, Chapel Hill, perineal wound complications can occur in 16%-49% of patients undergoing abdominoperineal resection. Contributing factors include noncollapsible dead space, bacterial contamination, wound characteristics, and patient comorbidities.

In an effort to identify national trends in the use of tissue flaps in patients undergoing abdominoperineal resection for rectal or anal cancer, as well as the effect of this approach on perioperative complications, length of stay, and total hospital charges, Dr. Lopez and her associates used the National Inpatient Sample to identify patients aged 18-80 years who were treated between 2000 and 2013. They excluded patients undergoing nonelective procedures or additional pelvic organ resections. Patients who received a tissue flap were compared with those who did not.

Dr. Lopez reported results from 298 patients who received a tissue flap graft and 12,107 who did not. Variables significantly associated with receiving a tissue flap, compared with not receiving one, were being male (73% vs. 66%, respectively; P =. 01), having anal cancer (32% vs. 11%; P less than .0001), being a smoker (34% vs. 23%; P less than .0001), undergoing the procedure in a large hospital (75% vs. 67%; P = .003), and undergoing the procedure in an urban teaching hospital (89% vs. 53%; P less than .0001).

The researchers also found that the number of concurrent tissue flaps performed rose significantly during the study period, from 0.4% in 2000 to 6% in 2013 (P less than .0001). “This was most noted in teaching institutions, compared with nonteaching institutions,” Dr. Lopez said.

Bivariate analysis revealed that, compared with patients who did not receive tissue flaps, those who did had higher rates of postoperative complications (43% vs. 33%, respectively; P less than .0001), a longer hospital stay (mean of 9 vs. 7 days; P less than .001), and higher total hospital charges (mean of $67,200 vs. $42,300; P less than .001). These trends persisted on multivariate analysis. Specifically, patients who received tissue flaps were 4.14 times more likely to have wound complications, had a length of stay that averaged an additional 2.78 days, and had $28,000 more in total hospital charges.

“The extended duration of the study enables evaluation of trends over time, and this is the first study that analyzes the costs associated with these procedures,” Dr. Lopez said. She acknowledged certain limitations of the study, including its retrospective, nonrandomized design and the potential for selection bias. In addition, the National Inpatient Sample “is susceptible to coding errors, a lack of patient-specific oncologic history, and the inability to assess postdischarge occurrences, since this only looks at inpatient stays.”

Dr. Lopez reported having no financial disclosures.

[email protected]

LOS ANGELES – The use of locoregional tissue flaps in combination with abdominoperineal resection was associated with higher rates of perioperative complications, longer hospital stays, and higher total hospital charges, compared with patients who did not undergo tissue flap reconstruction, an analysis of national data showed.

The findings come at a time when closure of perineal wounds with tissue flaps is an increasingly common approach, especially in academic institutions, Dr. Nicole Lopez said at the annual meeting of the American Society of Colon and Rectal Surgeons. “The role of selection bias in this [study] is difficult to determine, but I think it’s important that we clarify the utility of this technique before more widespread adoption of the approach,” she said.

According to Dr. Lopez of the department of surgery at the University of North Carolina, Chapel Hill, perineal wound complications can occur in 16%-49% of patients undergoing abdominoperineal resection. Contributing factors include noncollapsible dead space, bacterial contamination, wound characteristics, and patient comorbidities.

In an effort to identify national trends in the use of tissue flaps in patients undergoing abdominoperineal resection for rectal or anal cancer, as well as the effect of this approach on perioperative complications, length of stay, and total hospital charges, Dr. Lopez and her associates used the National Inpatient Sample to identify patients aged 18-80 years who were treated between 2000 and 2013. They excluded patients undergoing nonelective procedures or additional pelvic organ resections. Patients who received a tissue flap were compared with those who did not.

Dr. Lopez reported results from 298 patients who received a tissue flap graft and 12,107 who did not. Variables significantly associated with receiving a tissue flap, compared with not receiving one, were being male (73% vs. 66%, respectively; P =. 01), having anal cancer (32% vs. 11%; P less than .0001), being a smoker (34% vs. 23%; P less than .0001), undergoing the procedure in a large hospital (75% vs. 67%; P = .003), and undergoing the procedure in an urban teaching hospital (89% vs. 53%; P less than .0001).

The researchers also found that the number of concurrent tissue flaps performed rose significantly during the study period, from 0.4% in 2000 to 6% in 2013 (P less than .0001). “This was most noted in teaching institutions, compared with nonteaching institutions,” Dr. Lopez said.

Bivariate analysis revealed that, compared with patients who did not receive tissue flaps, those who did had higher rates of postoperative complications (43% vs. 33%, respectively; P less than .0001), a longer hospital stay (mean of 9 vs. 7 days; P less than .001), and higher total hospital charges (mean of $67,200 vs. $42,300; P less than .001). These trends persisted on multivariate analysis. Specifically, patients who received tissue flaps were 4.14 times more likely to have wound complications, had a length of stay that averaged an additional 2.78 days, and had $28,000 more in total hospital charges.

“The extended duration of the study enables evaluation of trends over time, and this is the first study that analyzes the costs associated with these procedures,” Dr. Lopez said. She acknowledged certain limitations of the study, including its retrospective, nonrandomized design and the potential for selection bias. In addition, the National Inpatient Sample “is susceptible to coding errors, a lack of patient-specific oncologic history, and the inability to assess postdischarge occurrences, since this only looks at inpatient stays.”

Dr. Lopez reported having no financial disclosures.

[email protected]

LOS ANGELES – The size of anorectal gastrointestinal stroma tumors is the most important determinant of survival following resection, results from an analysis of national data showed.

In addition, preoperative chemotherapy appears to improve survival rate in patients with tumors 5 cm in size or greater.

Anorectal gastrointestinal stromal tumors (GISTs) are rare, making up about 3% of all GIST cases, lead study author Dr. Alexander T. Hawkins reported at the annual meeting of the American Society of Colon and Rectal Surgeons. However, “optimal management remains elusive with questions regarding the role of local excision and the use of preoperative chemotherapy,” said Dr. Hawkins of the section of colon and rectal surgery at Washington University in St. Louis.

In an effort to determine the impact of tumor size, the benefits of using neoadjuvant imatinib, and the impact of a surgical approach, the researchers used the National Cancer Database (NCD) to identify 333 cases of anorectal GIST from 1998 through 2012. The NCD collects data from more than 1,500 cancer centers in the United States, and it’s estimated to account for 70% of all newly diagnosed cases of cancer.

Dr. Alexander Hawkins

The mean age of patients was 62 years, the median tumor size was 4 cm, 47% had a high-grade tumor, six presented with metastatic disease, and the overall 5-year survival rate was 78%. Of the 333 cases, 163 underwent local excision, 158 underwent radical excision, and 12 had no resection data. Of the radical excision cases, 89 had tumors of 5 cm in size or larger, while 69 had tumors of less than 5 cm in size.

Tumors treated with local resection tended to be smaller, compared with those treated by radical resection (a median of 2.5 cm vs. a median of 6.2 cm, respectively; P less than .001). Bivariate analysis revealed that patients who underwent treatment with local resection had a shorter hospital length of stay (a median of 0 vs. 7 days; P less than .001), but similar rates of 30-day readmission (5.5% vs. 4.4%, P = .65), 30-day mortality (0.6% vs. 1.3%, P = .54) and 90-day mortality (1.2% vs. 2.5%, P = .38). The rates of 5-year survival were higher in the local resection group (80.1% vs. 74.1%, P = .04).

Multivariable survival analysis revealed that advanced age (HR, 2.41) and tumor size greater than 5 cm (HR 2.48; P = .004) were associated with increased mortality. When Dr. Hawkins and his associates evaluated the role of chemotherapy, patients who received preoperative chemotherapy had a 5-year survival of 76.7%, compared with 50.4% in those who did not (P = .04). However, in this same group, chemotherapy did not improve the rate of margin-negative resection (80% vs. 78.6%, P = .88).

Dr. Hawkins also reported that, compared with patients who underwent radical resection, those who underwent local resection had lower rates of preoperative chemotherapy (9.2% vs. 25.3%, respectively; P = .0001) and smaller median tumor size (2.5 cm vs. 6.2 cm, P less than .0001). For tumors smaller than 5 cm in size, there was no difference in 5-year survival by surgical approach (82.3% vs. 82.6%, P = .71).

“Size in the most important determinant of survival after resection of anorectal GIST,” Dr. Hawkins concluded. “For smaller tumors, local excision may be an adequate therapy. Perhaps our most important finding is that preoperative chemotherapy appears to result in improved survival for large tumors treated with radical resection.”

Dr. Hawkins reported having no relevant financial disclosures.

[email protected]

LOS ANGELES – The size of anorectal gastrointestinal stroma tumors is the most important determinant of survival following resection, results from an analysis of national data showed.

In addition, preoperative chemotherapy appears to improve survival rate in patients with tumors 5 cm in size or greater.

Anorectal gastrointestinal stromal tumors (GISTs) are rare, making up about 3% of all GIST cases, lead study author Dr. Alexander T. Hawkins reported at the annual meeting of the American Society of Colon and Rectal Surgeons. However, “optimal management remains elusive with questions regarding the role of local excision and the use of preoperative chemotherapy,” said Dr. Hawkins of the section of colon and rectal surgery at Washington University in St. Louis.

In an effort to determine the impact of tumor size, the benefits of using neoadjuvant imatinib, and the impact of a surgical approach, the researchers used the National Cancer Database (NCD) to identify 333 cases of anorectal GIST from 1998 through 2012. The NCD collects data from more than 1,500 cancer centers in the United States, and it’s estimated to account for 70% of all newly diagnosed cases of cancer.

Dr. Alexander Hawkins

The mean age of patients was 62 years, the median tumor size was 4 cm, 47% had a high-grade tumor, six presented with metastatic disease, and the overall 5-year survival rate was 78%. Of the 333 cases, 163 underwent local excision, 158 underwent radical excision, and 12 had no resection data. Of the radical excision cases, 89 had tumors of 5 cm in size or larger, while 69 had tumors of less than 5 cm in size.

Tumors treated with local resection tended to be smaller, compared with those treated by radical resection (a median of 2.5 cm vs. a median of 6.2 cm, respectively; P less than .001). Bivariate analysis revealed that patients who underwent treatment with local resection had a shorter hospital length of stay (a median of 0 vs. 7 days; P less than .001), but similar rates of 30-day readmission (5.5% vs. 4.4%, P = .65), 30-day mortality (0.6% vs. 1.3%, P = .54) and 90-day mortality (1.2% vs. 2.5%, P = .38). The rates of 5-year survival were higher in the local resection group (80.1% vs. 74.1%, P = .04).

Multivariable survival analysis revealed that advanced age (HR, 2.41) and tumor size greater than 5 cm (HR 2.48; P = .004) were associated with increased mortality. When Dr. Hawkins and his associates evaluated the role of chemotherapy, patients who received preoperative chemotherapy had a 5-year survival of 76.7%, compared with 50.4% in those who did not (P = .04). However, in this same group, chemotherapy did not improve the rate of margin-negative resection (80% vs. 78.6%, P = .88).

Dr. Hawkins also reported that, compared with patients who underwent radical resection, those who underwent local resection had lower rates of preoperative chemotherapy (9.2% vs. 25.3%, respectively; P = .0001) and smaller median tumor size (2.5 cm vs. 6.2 cm, P less than .0001). For tumors smaller than 5 cm in size, there was no difference in 5-year survival by surgical approach (82.3% vs. 82.6%, P = .71).

“Size in the most important determinant of survival after resection of anorectal GIST,” Dr. Hawkins concluded. “For smaller tumors, local excision may be an adequate therapy. Perhaps our most important finding is that preoperative chemotherapy appears to result in improved survival for large tumors treated with radical resection.”

Dr. Hawkins reported having no relevant financial disclosures.

[email protected]

LOS ANGELES – The size of anorectal gastrointestinal stroma tumors is the most important determinant of survival following resection, results from an analysis of national data showed.

In addition, preoperative chemotherapy appears to improve survival rate in patients with tumors 5 cm in size or greater.

Anorectal gastrointestinal stromal tumors (GISTs) are rare, making up about 3% of all GIST cases, lead study author Dr. Alexander T. Hawkins reported at the annual meeting of the American Society of Colon and Rectal Surgeons. However, “optimal management remains elusive with questions regarding the role of local excision and the use of preoperative chemotherapy,” said Dr. Hawkins of the section of colon and rectal surgery at Washington University in St. Louis.

In an effort to determine the impact of tumor size, the benefits of using neoadjuvant imatinib, and the impact of a surgical approach, the researchers used the National Cancer Database (NCD) to identify 333 cases of anorectal GIST from 1998 through 2012. The NCD collects data from more than 1,500 cancer centers in the United States, and it’s estimated to account for 70% of all newly diagnosed cases of cancer.

Dr. Alexander Hawkins

The mean age of patients was 62 years, the median tumor size was 4 cm, 47% had a high-grade tumor, six presented with metastatic disease, and the overall 5-year survival rate was 78%. Of the 333 cases, 163 underwent local excision, 158 underwent radical excision, and 12 had no resection data. Of the radical excision cases, 89 had tumors of 5 cm in size or larger, while 69 had tumors of less than 5 cm in size.

Tumors treated with local resection tended to be smaller, compared with those treated by radical resection (a median of 2.5 cm vs. a median of 6.2 cm, respectively; P less than .001). Bivariate analysis revealed that patients who underwent treatment with local resection had a shorter hospital length of stay (a median of 0 vs. 7 days; P less than .001), but similar rates of 30-day readmission (5.5% vs. 4.4%, P = .65), 30-day mortality (0.6% vs. 1.3%, P = .54) and 90-day mortality (1.2% vs. 2.5%, P = .38). The rates of 5-year survival were higher in the local resection group (80.1% vs. 74.1%, P = .04).

Multivariable survival analysis revealed that advanced age (HR, 2.41) and tumor size greater than 5 cm (HR 2.48; P = .004) were associated with increased mortality. When Dr. Hawkins and his associates evaluated the role of chemotherapy, patients who received preoperative chemotherapy had a 5-year survival of 76.7%, compared with 50.4% in those who did not (P = .04). However, in this same group, chemotherapy did not improve the rate of margin-negative resection (80% vs. 78.6%, P = .88).

Dr. Hawkins also reported that, compared with patients who underwent radical resection, those who underwent local resection had lower rates of preoperative chemotherapy (9.2% vs. 25.3%, respectively; P = .0001) and smaller median tumor size (2.5 cm vs. 6.2 cm, P less than .0001). For tumors smaller than 5 cm in size, there was no difference in 5-year survival by surgical approach (82.3% vs. 82.6%, P = .71).

“Size in the most important determinant of survival after resection of anorectal GIST,” Dr. Hawkins concluded. “For smaller tumors, local excision may be an adequate therapy. Perhaps our most important finding is that preoperative chemotherapy appears to result in improved survival for large tumors treated with radical resection.”

Dr. Hawkins reported having no relevant financial disclosures.

[email protected]

LOS ANGELES – The inpatient use of infliximab for severe ulcerative colitis does not avoid the need for colectomy in patients who fail steroid therapy, results from a single-center study demonstrated.

In an interview at the annual meeting of the American Society of Colon and Rectal Surgeons, lead study author Dr. Rachel E. Andrew, a third-year resident in the department of surgery at Penn State Hershey Medical Center in Hershey, Pa., said that despite recent interest in providing inpatient infliximab as an alternative to surgery for those with steroid-refractory disease, 82% of those who received salvage infliximab went on to undergo a total abdominal colectomy during the same admission.

“Our findings suggest that inpatient infliximab was not effective at improving the severity of colitis in these patients,” she said. “Further, infliximab was unreliable in avoiding the need for a total colectomy in this population of ulcerative colitis patients. One difference between our study and those previously published on this subject is that our study focuses on patients with a severity of colitis that resulted in their admission to a surgery service. In terms of evaluating the benefit of infliximab and providing a reliable avoidance of colectomy, we feel that this population of ulcerative colitis patients would be most appropriate to evaluate this issue. This possible difference in patient population may explain the difference in our study findings and those previously published.”

The researchers compared colectomy rates in 173 patients with severe ulcerative colitis who were admitted to the colorectal surgery service at Penn State Hershey Medical Center. Their mean age was 41 years, with 155 (90%) treated with high-dose steroids alone, and with 18 (10%) having received inpatient infliximab as salvage therapy due to a lack of response to steroids alone. Of the patients who received high-dose steroids alone, 81 (52%) required total colectomy, compared with 14 (82%) who received infliximab salvage therapy (P = .046).

The researchers observed no statistically significant differences between the two groups regarding rates of hospital readmission, superficial, deep and organ space surgical-site infections, unplanned return to the operating room, and all complication rates (P greater than .05). Among patients who required total colectomy, hospital costs were 27% higher among those who received infliximab compared with those who received high-dose steroids alone (a mean of $19,880 vs. $14,492, respectively), but because of the small sample size of the infliximab cohort this difference did not reach statistical significance.

“In our institution, salvage infliximab has not been shown to be effective,” Dr. Andrew said. “One key difference between our findings and other studies is that our study population had a high colectomy rate; 82% is much higher than the approximately 30% colectomy rate described in many reports from colleagues in gastroenterology. While there are several potential explanations for our higher rate of colectomy, including the potential concerns that surgeons might be inclined to opt for surgery more readily than non-surgical providers, it is likely that the patients in our study had more severe forms of colitis. It might be the case that there are certain severities of colitis that are beyond the ability of infliximab to salvage, which would be an important issue in selecting which patients to provide inpatient infliximab, so as to not unnecessarily delay surgery, increase hospital costs and to avoid escalating the degree of immunosuppression without a reasonable likelihood of clinical improvement.”

Dr. Andrew reported having no financial disclosures.

[email protected]

LOS ANGELES – The inpatient use of infliximab for severe ulcerative colitis does not avoid the need for colectomy in patients who fail steroid therapy, results from a single-center study demonstrated.

In an interview at the annual meeting of the American Society of Colon and Rectal Surgeons, lead study author Dr. Rachel E. Andrew, a third-year resident in the department of surgery at Penn State Hershey Medical Center in Hershey, Pa., said that despite recent interest in providing inpatient infliximab as an alternative to surgery for those with steroid-refractory disease, 82% of those who received salvage infliximab went on to undergo a total abdominal colectomy during the same admission.

“Our findings suggest that inpatient infliximab was not effective at improving the severity of colitis in these patients,” she said. “Further, infliximab was unreliable in avoiding the need for a total colectomy in this population of ulcerative colitis patients. One difference between our study and those previously published on this subject is that our study focuses on patients with a severity of colitis that resulted in their admission to a surgery service. In terms of evaluating the benefit of infliximab and providing a reliable avoidance of colectomy, we feel that this population of ulcerative colitis patients would be most appropriate to evaluate this issue. This possible difference in patient population may explain the difference in our study findings and those previously published.”

The researchers compared colectomy rates in 173 patients with severe ulcerative colitis who were admitted to the colorectal surgery service at Penn State Hershey Medical Center. Their mean age was 41 years, with 155 (90%) treated with high-dose steroids alone, and with 18 (10%) having received inpatient infliximab as salvage therapy due to a lack of response to steroids alone. Of the patients who received high-dose steroids alone, 81 (52%) required total colectomy, compared with 14 (82%) who received infliximab salvage therapy (P = .046).

The researchers observed no statistically significant differences between the two groups regarding rates of hospital readmission, superficial, deep and organ space surgical-site infections, unplanned return to the operating room, and all complication rates (P greater than .05). Among patients who required total colectomy, hospital costs were 27% higher among those who received infliximab compared with those who received high-dose steroids alone (a mean of $19,880 vs. $14,492, respectively), but because of the small sample size of the infliximab cohort this difference did not reach statistical significance.

“In our institution, salvage infliximab has not been shown to be effective,” Dr. Andrew said. “One key difference between our findings and other studies is that our study population had a high colectomy rate; 82% is much higher than the approximately 30% colectomy rate described in many reports from colleagues in gastroenterology. While there are several potential explanations for our higher rate of colectomy, including the potential concerns that surgeons might be inclined to opt for surgery more readily than non-surgical providers, it is likely that the patients in our study had more severe forms of colitis. It might be the case that there are certain severities of colitis that are beyond the ability of infliximab to salvage, which would be an important issue in selecting which patients to provide inpatient infliximab, so as to not unnecessarily delay surgery, increase hospital costs and to avoid escalating the degree of immunosuppression without a reasonable likelihood of clinical improvement.”

Dr. Andrew reported having no financial disclosures.

[email protected]

LOS ANGELES – The inpatient use of infliximab for severe ulcerative colitis does not avoid the need for colectomy in patients who fail steroid therapy, results from a single-center study demonstrated.

In an interview at the annual meeting of the American Society of Colon and Rectal Surgeons, lead study author Dr. Rachel E. Andrew, a third-year resident in the department of surgery at Penn State Hershey Medical Center in Hershey, Pa., said that despite recent interest in providing inpatient infliximab as an alternative to surgery for those with steroid-refractory disease, 82% of those who received salvage infliximab went on to undergo a total abdominal colectomy during the same admission.

“Our findings suggest that inpatient infliximab was not effective at improving the severity of colitis in these patients,” she said. “Further, infliximab was unreliable in avoiding the need for a total colectomy in this population of ulcerative colitis patients. One difference between our study and those previously published on this subject is that our study focuses on patients with a severity of colitis that resulted in their admission to a surgery service. In terms of evaluating the benefit of infliximab and providing a reliable avoidance of colectomy, we feel that this population of ulcerative colitis patients would be most appropriate to evaluate this issue. This possible difference in patient population may explain the difference in our study findings and those previously published.”

The researchers compared colectomy rates in 173 patients with severe ulcerative colitis who were admitted to the colorectal surgery service at Penn State Hershey Medical Center. Their mean age was 41 years, with 155 (90%) treated with high-dose steroids alone, and with 18 (10%) having received inpatient infliximab as salvage therapy due to a lack of response to steroids alone. Of the patients who received high-dose steroids alone, 81 (52%) required total colectomy, compared with 14 (82%) who received infliximab salvage therapy (P = .046).

The researchers observed no statistically significant differences between the two groups regarding rates of hospital readmission, superficial, deep and organ space surgical-site infections, unplanned return to the operating room, and all complication rates (P greater than .05). Among patients who required total colectomy, hospital costs were 27% higher among those who received infliximab compared with those who received high-dose steroids alone (a mean of $19,880 vs. $14,492, respectively), but because of the small sample size of the infliximab cohort this difference did not reach statistical significance.

“In our institution, salvage infliximab has not been shown to be effective,” Dr. Andrew said. “One key difference between our findings and other studies is that our study population had a high colectomy rate; 82% is much higher than the approximately 30% colectomy rate described in many reports from colleagues in gastroenterology. While there are several potential explanations for our higher rate of colectomy, including the potential concerns that surgeons might be inclined to opt for surgery more readily than non-surgical providers, it is likely that the patients in our study had more severe forms of colitis. It might be the case that there are certain severities of colitis that are beyond the ability of infliximab to salvage, which would be an important issue in selecting which patients to provide inpatient infliximab, so as to not unnecessarily delay surgery, increase hospital costs and to avoid escalating the degree of immunosuppression without a reasonable likelihood of clinical improvement.”

Dr. Andrew reported having no financial disclosures.

[email protected]

LOS ANGELES – Treatment with neoadjuvant chemotherapy leads to significant downstaging in a selected group of patients with advanced colon cancer, results from a large registry study showed.

“Neoadjuvant chemotherapy is already established as a treatment strategy in several other types of cancers, such as breast cancer, gastric cancer, and rectal cancer,” lead study author Dr. Moniek Verstegen said at the annual meeting of the American Society of Colon and Rectal Surgeons. “It reduces tumor size and promotes resectability. In colon cancer, however, this treatment strategy is relatively new and not applied very often.”

©BluePlanetEarth/thinkstockphotos.com

Preliminary results from the ongoing FOxTROT trial in the United Kingdom showed that preoperative chemotherapy for radiologically staged, locally advanced, operable primary colon cancer is feasible, with acceptable toxicity and perioperative morbidity, but long-term results are not yet available. The aim of the current study was to see how often neoadjuvant chemotherapy is used in the Netherlands for stage II and III colon cancer and to assess the tumor and nodal downsizing effects. Moreover, perioperative results and long-term outcomes were compared between those treated with neoadjuvant chemotherapy and those who were treated with adjuvant chemotherapy for locally advanced colon cancer.

The researchers searched the Netherlands Cancer Registry from 2008-2012 to identify 24,944 patients diagnosed with stage II and III colon cancer. Dr. Verstegen, a researcher in the department of surgery at Radboud University Medical Center, Nijmegen, Netherlands, reported results from 85 patients who received neoadjuvant chemotherapy and 2,216 who received adjuvant chemotherapy (the control group). Both groups were similar in terms of age (a median of about 65 years), gender, localization of the primary tumor, differentiation grade, morphology, and clinical T and N stage. Multivisceral resections were performed significantly more often in the neoadjuvant group, compared with the control group (21% vs. 5%, respectively; P less than .001). There were no differences between groups in the number of complete resections, nor in the rate of complications. Furthermore, no patient died within 30 days of neoadjuvant chemotherapy after surgery.

Tumor downstaging was observed in 47% of patients treated with neoadjuvant chemotherapy and there were three complete responses. At the same time, nodal downstaging was observed in 50% of patients treated with neoadjuvant chemotherapy. The 3-year overall survival was 73% in both groups.

Dr. Verstegen acknowledged certain limitations of the study, including its retrospective design and the lack of data on recurrences and disease-free survival. “Neoadjuvant chemotherapy seems to be a safe treatment strategy, since we have low postoperative morbidity and mortality rates,” she concluded. “We see comparable outcomes compared to the control group. Prospective trials are needed to confirm the safety and value of neoadjuvant chemotherapy.”

Dr. Verstegen reported having no financial disclosures.

[email protected]

LOS ANGELES – Treatment with neoadjuvant chemotherapy leads to significant downstaging in a selected group of patients with advanced colon cancer, results from a large registry study showed.

“Neoadjuvant chemotherapy is already established as a treatment strategy in several other types of cancers, such as breast cancer, gastric cancer, and rectal cancer,” lead study author Dr. Moniek Verstegen said at the annual meeting of the American Society of Colon and Rectal Surgeons. “It reduces tumor size and promotes resectability. In colon cancer, however, this treatment strategy is relatively new and not applied very often.”

©BluePlanetEarth/thinkstockphotos.com

Preliminary results from the ongoing FOxTROT trial in the United Kingdom showed that preoperative chemotherapy for radiologically staged, locally advanced, operable primary colon cancer is feasible, with acceptable toxicity and perioperative morbidity, but long-term results are not yet available. The aim of the current study was to see how often neoadjuvant chemotherapy is used in the Netherlands for stage II and III colon cancer and to assess the tumor and nodal downsizing effects. Moreover, perioperative results and long-term outcomes were compared between those treated with neoadjuvant chemotherapy and those who were treated with adjuvant chemotherapy for locally advanced colon cancer.

The researchers searched the Netherlands Cancer Registry from 2008-2012 to identify 24,944 patients diagnosed with stage II and III colon cancer. Dr. Verstegen, a researcher in the department of surgery at Radboud University Medical Center, Nijmegen, Netherlands, reported results from 85 patients who received neoadjuvant chemotherapy and 2,216 who received adjuvant chemotherapy (the control group). Both groups were similar in terms of age (a median of about 65 years), gender, localization of the primary tumor, differentiation grade, morphology, and clinical T and N stage. Multivisceral resections were performed significantly more often in the neoadjuvant group, compared with the control group (21% vs. 5%, respectively; P less than .001). There were no differences between groups in the number of complete resections, nor in the rate of complications. Furthermore, no patient died within 30 days of neoadjuvant chemotherapy after surgery.

Tumor downstaging was observed in 47% of patients treated with neoadjuvant chemotherapy and there were three complete responses. At the same time, nodal downstaging was observed in 50% of patients treated with neoadjuvant chemotherapy. The 3-year overall survival was 73% in both groups.

Dr. Verstegen acknowledged certain limitations of the study, including its retrospective design and the lack of data on recurrences and disease-free survival. “Neoadjuvant chemotherapy seems to be a safe treatment strategy, since we have low postoperative morbidity and mortality rates,” she concluded. “We see comparable outcomes compared to the control group. Prospective trials are needed to confirm the safety and value of neoadjuvant chemotherapy.”

Dr. Verstegen reported having no financial disclosures.

[email protected]

LOS ANGELES – Treatment with neoadjuvant chemotherapy leads to significant downstaging in a selected group of patients with advanced colon cancer, results from a large registry study showed.

“Neoadjuvant chemotherapy is already established as a treatment strategy in several other types of cancers, such as breast cancer, gastric cancer, and rectal cancer,” lead study author Dr. Moniek Verstegen said at the annual meeting of the American Society of Colon and Rectal Surgeons. “It reduces tumor size and promotes resectability. In colon cancer, however, this treatment strategy is relatively new and not applied very often.”

©BluePlanetEarth/thinkstockphotos.com

Preliminary results from the ongoing FOxTROT trial in the United Kingdom showed that preoperative chemotherapy for radiologically staged, locally advanced, operable primary colon cancer is feasible, with acceptable toxicity and perioperative morbidity, but long-term results are not yet available. The aim of the current study was to see how often neoadjuvant chemotherapy is used in the Netherlands for stage II and III colon cancer and to assess the tumor and nodal downsizing effects. Moreover, perioperative results and long-term outcomes were compared between those treated with neoadjuvant chemotherapy and those who were treated with adjuvant chemotherapy for locally advanced colon cancer.

The researchers searched the Netherlands Cancer Registry from 2008-2012 to identify 24,944 patients diagnosed with stage II and III colon cancer. Dr. Verstegen, a researcher in the department of surgery at Radboud University Medical Center, Nijmegen, Netherlands, reported results from 85 patients who received neoadjuvant chemotherapy and 2,216 who received adjuvant chemotherapy (the control group). Both groups were similar in terms of age (a median of about 65 years), gender, localization of the primary tumor, differentiation grade, morphology, and clinical T and N stage. Multivisceral resections were performed significantly more often in the neoadjuvant group, compared with the control group (21% vs. 5%, respectively; P less than .001). There were no differences between groups in the number of complete resections, nor in the rate of complications. Furthermore, no patient died within 30 days of neoadjuvant chemotherapy after surgery.

Tumor downstaging was observed in 47% of patients treated with neoadjuvant chemotherapy and there were three complete responses. At the same time, nodal downstaging was observed in 50% of patients treated with neoadjuvant chemotherapy. The 3-year overall survival was 73% in both groups.

Dr. Verstegen acknowledged certain limitations of the study, including its retrospective design and the lack of data on recurrences and disease-free survival. “Neoadjuvant chemotherapy seems to be a safe treatment strategy, since we have low postoperative morbidity and mortality rates,” she concluded. “We see comparable outcomes compared to the control group. Prospective trials are needed to confirm the safety and value of neoadjuvant chemotherapy.”

Dr. Verstegen reported having no financial disclosures.

[email protected]

LOS ANGELES – A multicenter of patients who had low anterior resection with stapled anastomosis for rectal cancer found no clinical or economic benefit in routinely sending anastomotic doughnuts for histopathological evaluation.

“Several small studies outside the United States have found no benefit in histologic examination of anastomotic stapler doughnuts,” lead study author Dr. Jeremy Sugrue said at the annual meeting of the American Society of Colon and Rectal Surgeons. “We wanted to see if this held true in our population.”

Dr. Sugrue, of the division of colon and rectal surgery in the department of surgery at the University of Illinois at Chicago, and his associates performed a retrospective review of 486 patients who underwent a low anterior resection with stapled anastomosis for rectal cancer between 2002 and 2015 at three medical institutions. The primary outcome was pathologic findings in the doughnuts and their impact on patient management. Secondary outcomes included tumor characteristics that may influence how often a surgeon may send a doughnut to pathology, along with approximate cost.

The mean age of the 486 patients was 60 years, 55% were male, and the mean gross distal margin of the primary tumor specimen was 2.9 cm. “The majority of tumors were located in the middle rectum, and the rest were evenly distributed between the lower rectum, upper rectum, and rectosigmoid regions,” said Dr. Sugrue, who is a general surgery resident. About half of the patients received neoadjuvant radiation or chemotherapy.

Benign findings were found in 33 patients. Among these, 16 had inflammatory changes, including 12 who had nonspecific changes, 3 who had changes from radiation, and 1 had inflammatory bowel disease changes. In addition, 13 patients with benign findings had polyps in their doughnuts (10 hyperplastic and 3 adenomatous), while 4 patients had miscellaneous changes including two cases of vessel micro calcification, one case of diverticuli, and one case of melanosis coli.

Among the 412 patients with malignant findings, 410 (99.5%) had no cancer in the doughnuts and no cancer at the distal resection margin in the primary tumor specimens. “In the two patients where we found cancer in the doughnuts, these patients also had a positive distal margin,” Dr. Sugrue said. “We did not find any patients with a positive distal margin and a negative doughnut. Likewise, we did not find any patients with a negative distal margin or an unexpectedly positive doughnut.”

The researchers also found that patients with low rectal tumors were significantly more likely to have their doughnut sent to pathology, compared with those with rectosigmoid tumors. “However, when we looked at distal margin comparing patients who had doughnuts reported on pathology with those who did not, there was no statistically significant difference,” Dr. Sugrue said. After averaging pathology professional fees and technical fees across all three institutions, he and his associates determined that doughnuts add $643 in cost when processed by pathology as a unique specimen.

Limitations of the study, he said, include its retrospective design, “which inherently introduces selection bias, and we did not perform a precise cost-benefit analysis.”

Dr. Sugrue reported having no financial disclosures.

[email protected]

LOS ANGELES – A multicenter of patients who had low anterior resection with stapled anastomosis for rectal cancer found no clinical or economic benefit in routinely sending anastomotic doughnuts for histopathological evaluation.

“Several small studies outside the United States have found no benefit in histologic examination of anastomotic stapler doughnuts,” lead study author Dr. Jeremy Sugrue said at the annual meeting of the American Society of Colon and Rectal Surgeons. “We wanted to see if this held true in our population.”

Dr. Sugrue, of the division of colon and rectal surgery in the department of surgery at the University of Illinois at Chicago, and his associates performed a retrospective review of 486 patients who underwent a low anterior resection with stapled anastomosis for rectal cancer between 2002 and 2015 at three medical institutions. The primary outcome was pathologic findings in the doughnuts and their impact on patient management. Secondary outcomes included tumor characteristics that may influence how often a surgeon may send a doughnut to pathology, along with approximate cost.

The mean age of the 486 patients was 60 years, 55% were male, and the mean gross distal margin of the primary tumor specimen was 2.9 cm. “The majority of tumors were located in the middle rectum, and the rest were evenly distributed between the lower rectum, upper rectum, and rectosigmoid regions,” said Dr. Sugrue, who is a general surgery resident. About half of the patients received neoadjuvant radiation or chemotherapy.

Benign findings were found in 33 patients. Among these, 16 had inflammatory changes, including 12 who had nonspecific changes, 3 who had changes from radiation, and 1 had inflammatory bowel disease changes. In addition, 13 patients with benign findings had polyps in their doughnuts (10 hyperplastic and 3 adenomatous), while 4 patients had miscellaneous changes including two cases of vessel micro calcification, one case of diverticuli, and one case of melanosis coli.

Among the 412 patients with malignant findings, 410 (99.5%) had no cancer in the doughnuts and no cancer at the distal resection margin in the primary tumor specimens. “In the two patients where we found cancer in the doughnuts, these patients also had a positive distal margin,” Dr. Sugrue said. “We did not find any patients with a positive distal margin and a negative doughnut. Likewise, we did not find any patients with a negative distal margin or an unexpectedly positive doughnut.”

The researchers also found that patients with low rectal tumors were significantly more likely to have their doughnut sent to pathology, compared with those with rectosigmoid tumors. “However, when we looked at distal margin comparing patients who had doughnuts reported on pathology with those who did not, there was no statistically significant difference,” Dr. Sugrue said. After averaging pathology professional fees and technical fees across all three institutions, he and his associates determined that doughnuts add $643 in cost when processed by pathology as a unique specimen.

Limitations of the study, he said, include its retrospective design, “which inherently introduces selection bias, and we did not perform a precise cost-benefit analysis.”

Dr. Sugrue reported having no financial disclosures.

[email protected]

LOS ANGELES – A multicenter of patients who had low anterior resection with stapled anastomosis for rectal cancer found no clinical or economic benefit in routinely sending anastomotic doughnuts for histopathological evaluation.

“Several small studies outside the United States have found no benefit in histologic examination of anastomotic stapler doughnuts,” lead study author Dr. Jeremy Sugrue said at the annual meeting of the American Society of Colon and Rectal Surgeons. “We wanted to see if this held true in our population.”

Dr. Sugrue, of the division of colon and rectal surgery in the department of surgery at the University of Illinois at Chicago, and his associates performed a retrospective review of 486 patients who underwent a low anterior resection with stapled anastomosis for rectal cancer between 2002 and 2015 at three medical institutions. The primary outcome was pathologic findings in the doughnuts and their impact on patient management. Secondary outcomes included tumor characteristics that may influence how often a surgeon may send a doughnut to pathology, along with approximate cost.

The mean age of the 486 patients was 60 years, 55% were male, and the mean gross distal margin of the primary tumor specimen was 2.9 cm. “The majority of tumors were located in the middle rectum, and the rest were evenly distributed between the lower rectum, upper rectum, and rectosigmoid regions,” said Dr. Sugrue, who is a general surgery resident. About half of the patients received neoadjuvant radiation or chemotherapy.

Benign findings were found in 33 patients. Among these, 16 had inflammatory changes, including 12 who had nonspecific changes, 3 who had changes from radiation, and 1 had inflammatory bowel disease changes. In addition, 13 patients with benign findings had polyps in their doughnuts (10 hyperplastic and 3 adenomatous), while 4 patients had miscellaneous changes including two cases of vessel micro calcification, one case of diverticuli, and one case of melanosis coli.

Among the 412 patients with malignant findings, 410 (99.5%) had no cancer in the doughnuts and no cancer at the distal resection margin in the primary tumor specimens. “In the two patients where we found cancer in the doughnuts, these patients also had a positive distal margin,” Dr. Sugrue said. “We did not find any patients with a positive distal margin and a negative doughnut. Likewise, we did not find any patients with a negative distal margin or an unexpectedly positive doughnut.”

The researchers also found that patients with low rectal tumors were significantly more likely to have their doughnut sent to pathology, compared with those with rectosigmoid tumors. “However, when we looked at distal margin comparing patients who had doughnuts reported on pathology with those who did not, there was no statistically significant difference,” Dr. Sugrue said. After averaging pathology professional fees and technical fees across all three institutions, he and his associates determined that doughnuts add $643 in cost when processed by pathology as a unique specimen.

Limitations of the study, he said, include its retrospective design, “which inherently introduces selection bias, and we did not perform a precise cost-benefit analysis.”

Dr. Sugrue reported having no financial disclosures.

[email protected]

LOS ANGELES – Primary small cell cancer of the anus is a rare but devastating condition and overall survival may not be improved with surgical treatment.

Those are key findings from what is believed to be the largest analysis of its kind to date.

“There are very limited data for patients with anal small cell cancers who need preoperative counseling and risk stratification,” study author Dr. Cornelius A. Thiels said in an interview at the annual meeting of the American Society of Colon and Rectal Surgeons. “There are also no data to guide treatment, so, until now, management was based on the treatment of small cell of the lung, and other anal cancers.”

Cancers of the anal canal are estimated to represent about 2.5% of all gastrointestinal neoplasms, while primary small cell cancer of the anus is believed to account for less than 1% of all anal neoplasms, according to Dr. Thiels, who is a third-year general surgery resident in the department of surgery and a surgical outcomes fellow in the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery at the Mayo Clinic, Rochester, Minn.

In an effort to evaluate the outcomes of patients with primary small cell cancer of the anus, the researchers reviewed their own institutional experience in treating nine patients with this condition between from 1994-2014, as well as National Cancer Data Base (NCDB) records of 174 patients from 1998-2014. The NCDB is maintained by collecting data prospectively from more than 1,500 facilities across the United States and is estimated to capture approximately 70% of all newly diagnosed cases of cancer annually. Institutional data allowed the researchers to identify details, including how these patients presented and what type of chemotherapy they received. However, analysis of a national database was necessary given the rarity of the diagnosis.

In the analysis of NCDB records, the mean patient age was 59 years and 74% were female. Most of the tumors (95%) were high grade and the majority of patients presented with advanced disease (50 with stage IV disease, 49 with stage III disease, 29 with stage II disease, 25 with stage I disease, and 21 with unknown stage). Overall survival was 66% at 12 months and 29% at 36 months. Among patients with stage I-III disease, survival was 72% at 12 months and 39% at 36 months.

Of the 103 patients with stage I-III disease, 95% received medical therapy, 70% underwent medical management alone, while 30% underwent surgery with curative intent. Patients who did not undergo surgery tended to have a higher stage of disease, compared with those who did (57% vs. 26%: P = .005). Overall survival at 36 months was similar between the two groups (33.9% in the surgery group vs. 35.8% in the no surgery group; P = .87).

“Unfortunately, it seems from our own experience and from national data that additional research is needed to determine how best to treat these patients and that surgery may not prolong survival in many of these patients,” Dr. Thiels said. “Although additional research is needed to optimize outcomes for these patients, harnessing the power of a national cancer database like the NCDB allows us to improve our understanding of these otherwise extremely rare, and difficult to study, tumors.”

Dr. Thiels reported having no financial disclosures.

[email protected]

LOS ANGELES – Primary small cell cancer of the anus is a rare but devastating condition and overall survival may not be improved with surgical treatment.

Those are key findings from what is believed to be the largest analysis of its kind to date.

“There are very limited data for patients with anal small cell cancers who need preoperative counseling and risk stratification,” study author Dr. Cornelius A. Thiels said in an interview at the annual meeting of the American Society of Colon and Rectal Surgeons. “There are also no data to guide treatment, so, until now, management was based on the treatment of small cell of the lung, and other anal cancers.”

Cancers of the anal canal are estimated to represent about 2.5% of all gastrointestinal neoplasms, while primary small cell cancer of the anus is believed to account for less than 1% of all anal neoplasms, according to Dr. Thiels, who is a third-year general surgery resident in the department of surgery and a surgical outcomes fellow in the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery at the Mayo Clinic, Rochester, Minn.

In an effort to evaluate the outcomes of patients with primary small cell cancer of the anus, the researchers reviewed their own institutional experience in treating nine patients with this condition between from 1994-2014, as well as National Cancer Data Base (NCDB) records of 174 patients from 1998-2014. The NCDB is maintained by collecting data prospectively from more than 1,500 facilities across the United States and is estimated to capture approximately 70% of all newly diagnosed cases of cancer annually. Institutional data allowed the researchers to identify details, including how these patients presented and what type of chemotherapy they received. However, analysis of a national database was necessary given the rarity of the diagnosis.

In the analysis of NCDB records, the mean patient age was 59 years and 74% were female. Most of the tumors (95%) were high grade and the majority of patients presented with advanced disease (50 with stage IV disease, 49 with stage III disease, 29 with stage II disease, 25 with stage I disease, and 21 with unknown stage). Overall survival was 66% at 12 months and 29% at 36 months. Among patients with stage I-III disease, survival was 72% at 12 months and 39% at 36 months.

Of the 103 patients with stage I-III disease, 95% received medical therapy, 70% underwent medical management alone, while 30% underwent surgery with curative intent. Patients who did not undergo surgery tended to have a higher stage of disease, compared with those who did (57% vs. 26%: P = .005). Overall survival at 36 months was similar between the two groups (33.9% in the surgery group vs. 35.8% in the no surgery group; P = .87).

“Unfortunately, it seems from our own experience and from national data that additional research is needed to determine how best to treat these patients and that surgery may not prolong survival in many of these patients,” Dr. Thiels said. “Although additional research is needed to optimize outcomes for these patients, harnessing the power of a national cancer database like the NCDB allows us to improve our understanding of these otherwise extremely rare, and difficult to study, tumors.”

Dr. Thiels reported having no financial disclosures.

[email protected]

LOS ANGELES – Primary small cell cancer of the anus is a rare but devastating condition and overall survival may not be improved with surgical treatment.

Those are key findings from what is believed to be the largest analysis of its kind to date.

“There are very limited data for patients with anal small cell cancers who need preoperative counseling and risk stratification,” study author Dr. Cornelius A. Thiels said in an interview at the annual meeting of the American Society of Colon and Rectal Surgeons. “There are also no data to guide treatment, so, until now, management was based on the treatment of small cell of the lung, and other anal cancers.”

Cancers of the anal canal are estimated to represent about 2.5% of all gastrointestinal neoplasms, while primary small cell cancer of the anus is believed to account for less than 1% of all anal neoplasms, according to Dr. Thiels, who is a third-year general surgery resident in the department of surgery and a surgical outcomes fellow in the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery at the Mayo Clinic, Rochester, Minn.

In an effort to evaluate the outcomes of patients with primary small cell cancer of the anus, the researchers reviewed their own institutional experience in treating nine patients with this condition between from 1994-2014, as well as National Cancer Data Base (NCDB) records of 174 patients from 1998-2014. The NCDB is maintained by collecting data prospectively from more than 1,500 facilities across the United States and is estimated to capture approximately 70% of all newly diagnosed cases of cancer annually. Institutional data allowed the researchers to identify details, including how these patients presented and what type of chemotherapy they received. However, analysis of a national database was necessary given the rarity of the diagnosis.

In the analysis of NCDB records, the mean patient age was 59 years and 74% were female. Most of the tumors (95%) were high grade and the majority of patients presented with advanced disease (50 with stage IV disease, 49 with stage III disease, 29 with stage II disease, 25 with stage I disease, and 21 with unknown stage). Overall survival was 66% at 12 months and 29% at 36 months. Among patients with stage I-III disease, survival was 72% at 12 months and 39% at 36 months.

Of the 103 patients with stage I-III disease, 95% received medical therapy, 70% underwent medical management alone, while 30% underwent surgery with curative intent. Patients who did not undergo surgery tended to have a higher stage of disease, compared with those who did (57% vs. 26%: P = .005). Overall survival at 36 months was similar between the two groups (33.9% in the surgery group vs. 35.8% in the no surgery group; P = .87).

“Unfortunately, it seems from our own experience and from national data that additional research is needed to determine how best to treat these patients and that surgery may not prolong survival in many of these patients,” Dr. Thiels said. “Although additional research is needed to optimize outcomes for these patients, harnessing the power of a national cancer database like the NCDB allows us to improve our understanding of these otherwise extremely rare, and difficult to study, tumors.”

Dr. Thiels reported having no financial disclosures.

[email protected]

LOS ANGELES – The detection rate of significant polyps was highest for the first postoperative surveillance colonoscopies performed at 1 year following curative resection for colorectal cancer, results from a single-center study demonstrated.

“There’s no consensus on when to perform the first surveillance colonoscopy post curative resection for colorectal cancer,” lead study author Dr. Noura Alhassan said at the annual meeting of the American Society of Colon and Rectal Surgeons. For example, the American Society of Colon and Rectal Surgeons and National Carcinoma Comprehensive Network guidelines recommend a colonoscopy at 1 year, while the Canadian Association of Gastroenterology recommends surveillance at 3 years postoperatively.

Doug Brunk/Frontline Medical News

In an effort to determine the optimal timing of the first surveillance colonoscopy following curative colorectal carcinoma resection, Dr. Alhassan and her associates retrospectively reviewed the charts of all patients who underwent colorectal resection from 2007 to 2012 at Jewish General Hospital, a tertiary care center affiliated with McGill University, Montreal. The study included patients who had a complete preoperative colonoscopy, those who had a complete postoperative colonoscopy performed by one of the Jewish General Hospital colorectal surgeons, and those who had colorectal cancer resection with curative intent. Excluded from the study were patients with stage IV colorectal cancer, those with a prior history of colorectal cancer, those who underwent total abdominal colectomies or proctocolectomies, those who underwent local excision, and those with familial cancer syndromes and inflammatory bowel disease.

Dr. Alhassan, a fourth-year resident in the division of general surgery at McGill University, said that the researchers classified the colonoscopic findings as normal, nonsignificant polyps, significant polyps, and recurrence. Significant polyps consisted of adenomas 1 cm or greater in size, villous or tubulovillous adenoma, adenoma with high-grade dysplasia, three or more adenomas, or sessile serrated polyps at least 1 cm in size or with dysplasia. Of the 857 colorectal resections performed during the study period, 181 met inclusion criteria. The tumor stage was evenly distributed among study participants and 57% of the resections were colon operations, while the remaining 43% were proctectomies.

The preoperative colonoscopy was done by one of the Jewish General Hospital gastroenterologists 43% of the time, by one of the Jewish General Hospital colorectal surgeons 41% of the time, and by an outside hospital 16% of the time. The median time to postoperative colonoscopy was 421 days (1.1 years). Specifically, 25.90% of patients underwent their first surveillance colonoscopy in the first postoperative year, 48.10% in the second year, 14.40% in the third year, 8.5% in the fourth year, and 2.7% in the fifth year.

Dr. Alhassan reported that the all-polyp detection rate was 30.1%; 21.3% were detected in postoperative year 1, 33.3% in year 2, and 34.6% in year 3.

The overall significant polyp detection rate was 10.5%, but the detection rate was 12.8% in postoperative year 1, 8% in postoperative year 2, and 7.7% in postoperative year 3. There were two anastomotic recurrences: one in year 1 (2.1%) and one in year 3 (3.8%).

On univariate analysis, factors associated with significant polyp detection were male gender, poor bowel preparation on preoperative colonoscopy, and concomitant use of metformin, while having stage III disease was associated with a lower significant polyp detection rate.

On multivariate analysis only male gender was associated with a higher significant polyp detection rate, while stage III disease was associated with a lower significant polyp detection rate.

“Significant polyp detection rate of 12.8% at postoperative year 1 justifies surveillance colonoscopy at 1 year post curative colon cancer resection,” Dr. Alhassan concluded. She reported having no financial disclosures.

[email protected]

LOS ANGELES – The detection rate of significant polyps was highest for the first postoperative surveillance colonoscopies performed at 1 year following curative resection for colorectal cancer, results from a single-center study demonstrated.

“There’s no consensus on when to perform the first surveillance colonoscopy post curative resection for colorectal cancer,” lead study author Dr. Noura Alhassan said at the annual meeting of the American Society of Colon and Rectal Surgeons. For example, the American Society of Colon and Rectal Surgeons and National Carcinoma Comprehensive Network guidelines recommend a colonoscopy at 1 year, while the Canadian Association of Gastroenterology recommends surveillance at 3 years postoperatively.

Doug Brunk/Frontline Medical News

In an effort to determine the optimal timing of the first surveillance colonoscopy following curative colorectal carcinoma resection, Dr. Alhassan and her associates retrospectively reviewed the charts of all patients who underwent colorectal resection from 2007 to 2012 at Jewish General Hospital, a tertiary care center affiliated with McGill University, Montreal. The study included patients who had a complete preoperative colonoscopy, those who had a complete postoperative colonoscopy performed by one of the Jewish General Hospital colorectal surgeons, and those who had colorectal cancer resection with curative intent. Excluded from the study were patients with stage IV colorectal cancer, those with a prior history of colorectal cancer, those who underwent total abdominal colectomies or proctocolectomies, those who underwent local excision, and those with familial cancer syndromes and inflammatory bowel disease.

Dr. Alhassan, a fourth-year resident in the division of general surgery at McGill University, said that the researchers classified the colonoscopic findings as normal, nonsignificant polyps, significant polyps, and recurrence. Significant polyps consisted of adenomas 1 cm or greater in size, villous or tubulovillous adenoma, adenoma with high-grade dysplasia, three or more adenomas, or sessile serrated polyps at least 1 cm in size or with dysplasia. Of the 857 colorectal resections performed during the study period, 181 met inclusion criteria. The tumor stage was evenly distributed among study participants and 57% of the resections were colon operations, while the remaining 43% were proctectomies.

The preoperative colonoscopy was done by one of the Jewish General Hospital gastroenterologists 43% of the time, by one of the Jewish General Hospital colorectal surgeons 41% of the time, and by an outside hospital 16% of the time. The median time to postoperative colonoscopy was 421 days (1.1 years). Specifically, 25.90% of patients underwent their first surveillance colonoscopy in the first postoperative year, 48.10% in the second year, 14.40% in the third year, 8.5% in the fourth year, and 2.7% in the fifth year.

Dr. Alhassan reported that the all-polyp detection rate was 30.1%; 21.3% were detected in postoperative year 1, 33.3% in year 2, and 34.6% in year 3.

The overall significant polyp detection rate was 10.5%, but the detection rate was 12.8% in postoperative year 1, 8% in postoperative year 2, and 7.7% in postoperative year 3. There were two anastomotic recurrences: one in year 1 (2.1%) and one in year 3 (3.8%).

On univariate analysis, factors associated with significant polyp detection were male gender, poor bowel preparation on preoperative colonoscopy, and concomitant use of metformin, while having stage III disease was associated with a lower significant polyp detection rate.

On multivariate analysis only male gender was associated with a higher significant polyp detection rate, while stage III disease was associated with a lower significant polyp detection rate.

“Significant polyp detection rate of 12.8% at postoperative year 1 justifies surveillance colonoscopy at 1 year post curative colon cancer resection,” Dr. Alhassan concluded. She reported having no financial disclosures.

[email protected]

LOS ANGELES – The detection rate of significant polyps was highest for the first postoperative surveillance colonoscopies performed at 1 year following curative resection for colorectal cancer, results from a single-center study demonstrated.

“There’s no consensus on when to perform the first surveillance colonoscopy post curative resection for colorectal cancer,” lead study author Dr. Noura Alhassan said at the annual meeting of the American Society of Colon and Rectal Surgeons. For example, the American Society of Colon and Rectal Surgeons and National Carcinoma Comprehensive Network guidelines recommend a colonoscopy at 1 year, while the Canadian Association of Gastroenterology recommends surveillance at 3 years postoperatively.

Doug Brunk/Frontline Medical News

In an effort to determine the optimal timing of the first surveillance colonoscopy following curative colorectal carcinoma resection, Dr. Alhassan and her associates retrospectively reviewed the charts of all patients who underwent colorectal resection from 2007 to 2012 at Jewish General Hospital, a tertiary care center affiliated with McGill University, Montreal. The study included patients who had a complete preoperative colonoscopy, those who had a complete postoperative colonoscopy performed by one of the Jewish General Hospital colorectal surgeons, and those who had colorectal cancer resection with curative intent. Excluded from the study were patients with stage IV colorectal cancer, those with a prior history of colorectal cancer, those who underwent total abdominal colectomies or proctocolectomies, those who underwent local excision, and those with familial cancer syndromes and inflammatory bowel disease.

Dr. Alhassan, a fourth-year resident in the division of general surgery at McGill University, said that the researchers classified the colonoscopic findings as normal, nonsignificant polyps, significant polyps, and recurrence. Significant polyps consisted of adenomas 1 cm or greater in size, villous or tubulovillous adenoma, adenoma with high-grade dysplasia, three or more adenomas, or sessile serrated polyps at least 1 cm in size or with dysplasia. Of the 857 colorectal resections performed during the study period, 181 met inclusion criteria. The tumor stage was evenly distributed among study participants and 57% of the resections were colon operations, while the remaining 43% were proctectomies.

The preoperative colonoscopy was done by one of the Jewish General Hospital gastroenterologists 43% of the time, by one of the Jewish General Hospital colorectal surgeons 41% of the time, and by an outside hospital 16% of the time. The median time to postoperative colonoscopy was 421 days (1.1 years). Specifically, 25.90% of patients underwent their first surveillance colonoscopy in the first postoperative year, 48.10% in the second year, 14.40% in the third year, 8.5% in the fourth year, and 2.7% in the fifth year.

Dr. Alhassan reported that the all-polyp detection rate was 30.1%; 21.3% were detected in postoperative year 1, 33.3% in year 2, and 34.6% in year 3.

The overall significant polyp detection rate was 10.5%, but the detection rate was 12.8% in postoperative year 1, 8% in postoperative year 2, and 7.7% in postoperative year 3. There were two anastomotic recurrences: one in year 1 (2.1%) and one in year 3 (3.8%).

On univariate analysis, factors associated with significant polyp detection were male gender, poor bowel preparation on preoperative colonoscopy, and concomitant use of metformin, while having stage III disease was associated with a lower significant polyp detection rate.

On multivariate analysis only male gender was associated with a higher significant polyp detection rate, while stage III disease was associated with a lower significant polyp detection rate.

“Significant polyp detection rate of 12.8% at postoperative year 1 justifies surveillance colonoscopy at 1 year post curative colon cancer resection,” Dr. Alhassan concluded. She reported having no financial disclosures.

[email protected]

LOS ANGELES – Overall 5-year survival rates for anal cancer in the United States have steadily improved since the 1970s, but the incidence of disease continues to rise. In addition, African Americans with anal cancer have significantly and disproportionally lower 5-year survival rates, compared with whites.

Those are key findings from an analysis of Surveillance, Epidemiology and End Results (SEER) data that primary study author Dr. Marco Ferrara presented at the annual meeting of the American Society of Colon and Rectal Surgeons.

“Disparities in health-related outcomes for diseases such as cancer are unfortunately commonly observed,” Dr. Ferrara’s mentor and the senior study author Dr. Daniel I. Chu said in an interview in advance of the meeting. “African Americans in particular have higher cancer-specific death rates, higher rates of advanced cancer on initial diagnosis, and less frequent use of cancer screening tests. While our understanding of disparities continues to progress for the more common cancers (lung, breast, prostate, colorectal), comparatively fewer data are available for anal cancer. This gap in knowledge is important because anal cancer incidence has actually been increasing in the U.S. population over the past decades. While effective treatment is available, we asked if disparities exist in anal cancer.”

To find out, the researchers used the national SEER database to identify all patients with cancer of the anus, anal canal, and anorectum from 1973 to 1999 (Period 1; a total of 6,755 cases) and 2000 to 2012 (Period 2; a total of 18,027 cases) and stratified them by race. They determined the incidence, staging, and treatment provided for each group and used 2000 Census data to calculate the age-adjusted annual incidence of anal cancer. The primary outcome was 5-year survival.

More than half of patients (61%) were female, 86% were white, 10% were African American, and the remaining 4% were from other ethnic groups. Dr. Ferrara, who is a fourth-year surgery resident at Baptist Health System in Birmingham, Ala., reported that between Periods 1 and 2, the overall incidence of anal cancer increased from 1.1 to 1.8 cases per 100,000 individuals. The overall incidence was higher among African Americans, compared with whites (1.6 vs. 1.3 cases per 100,000 individuals, respectively). The incidence among African-American males was slightly higher, at 1.9 cases per 100,000 individuals.

The researchers found that nearly half of patients (48%) presented with localized disease, while 31% had regional disease. Between Periods 1 and 2 the proportion of patients who received any treatment for anal cancer increased from 63% to 74%. The use of radiation therapy increased from 61% to 72%, while the use of local excisions and abdominoperineal resections decreased from 60% to 45%. Overall, African Americans were more likely than whites to not undergo recommended surgery (9.8% vs. 8.7%, respectively) or to refuse recommended surgery (1.8% vs. 1.1%; P less than .05 for both associations).

Overall 5-year survival for anal cancer improved from 63% in Period 1 to 70% in Period 2 (P less than .05). However, African Americans had significantly lower 5-year survival rates, compared with whites in both time periods (53% vs. 64% in Period 1, and 62% vs. 71% in Period 2; P less than .05 for both associations).

“Health disparities exist in anal cancer with African Americans faring worse than Caucasian patients,” said Dr. Chu, who is a gastrointestinal surgeon at the University of Alabama at Birmingham. “While the etiologies for these disparities are unclear, anal cancer is a very treatable disease when caught early, regardless of race. Screening should be done for those at higher risk, such as patients with a family history of anal cancer, HIV, or HPV [human papillomavirus]. Ultimately, more research is needed to understand the factors driving these disparities at the patient, provider, and health care system level.”

He acknowledged certain limitations of the study, including its retrospective nature, the inability to assess the potential impact of education status and other social factors, and the generalizability of its findings, since SEER is limited to major cancer hospitals.

The researchers reported having no financial disclosures.

[email protected]

LOS ANGELES – Overall 5-year survival rates for anal cancer in the United States have steadily improved since the 1970s, but the incidence of disease continues to rise. In addition, African Americans with anal cancer have significantly and disproportionally lower 5-year survival rates, compared with whites.

Those are key findings from an analysis of Surveillance, Epidemiology and End Results (SEER) data that primary study author Dr. Marco Ferrara presented at the annual meeting of the American Society of Colon and Rectal Surgeons.

“Disparities in health-related outcomes for diseases such as cancer are unfortunately commonly observed,” Dr. Ferrara’s mentor and the senior study author Dr. Daniel I. Chu said in an interview in advance of the meeting. “African Americans in particular have higher cancer-specific death rates, higher rates of advanced cancer on initial diagnosis, and less frequent use of cancer screening tests. While our understanding of disparities continues to progress for the more common cancers (lung, breast, prostate, colorectal), comparatively fewer data are available for anal cancer. This gap in knowledge is important because anal cancer incidence has actually been increasing in the U.S. population over the past decades. While effective treatment is available, we asked if disparities exist in anal cancer.”

To find out, the researchers used the national SEER database to identify all patients with cancer of the anus, anal canal, and anorectum from 1973 to 1999 (Period 1; a total of 6,755 cases) and 2000 to 2012 (Period 2; a total of 18,027 cases) and stratified them by race. They determined the incidence, staging, and treatment provided for each group and used 2000 Census data to calculate the age-adjusted annual incidence of anal cancer. The primary outcome was 5-year survival.

More than half of patients (61%) were female, 86% were white, 10% were African American, and the remaining 4% were from other ethnic groups. Dr. Ferrara, who is a fourth-year surgery resident at Baptist Health System in Birmingham, Ala., reported that between Periods 1 and 2, the overall incidence of anal cancer increased from 1.1 to 1.8 cases per 100,000 individuals. The overall incidence was higher among African Americans, compared with whites (1.6 vs. 1.3 cases per 100,000 individuals, respectively). The incidence among African-American males was slightly higher, at 1.9 cases per 100,000 individuals.

The researchers found that nearly half of patients (48%) presented with localized disease, while 31% had regional disease. Between Periods 1 and 2 the proportion of patients who received any treatment for anal cancer increased from 63% to 74%. The use of radiation therapy increased from 61% to 72%, while the use of local excisions and abdominoperineal resections decreased from 60% to 45%. Overall, African Americans were more likely than whites to not undergo recommended surgery (9.8% vs. 8.7%, respectively) or to refuse recommended surgery (1.8% vs. 1.1%; P less than .05 for both associations).

Overall 5-year survival for anal cancer improved from 63% in Period 1 to 70% in Period 2 (P less than .05). However, African Americans had significantly lower 5-year survival rates, compared with whites in both time periods (53% vs. 64% in Period 1, and 62% vs. 71% in Period 2; P less than .05 for both associations).

“Health disparities exist in anal cancer with African Americans faring worse than Caucasian patients,” said Dr. Chu, who is a gastrointestinal surgeon at the University of Alabama at Birmingham. “While the etiologies for these disparities are unclear, anal cancer is a very treatable disease when caught early, regardless of race. Screening should be done for those at higher risk, such as patients with a family history of anal cancer, HIV, or HPV [human papillomavirus]. Ultimately, more research is needed to understand the factors driving these disparities at the patient, provider, and health care system level.”

He acknowledged certain limitations of the study, including its retrospective nature, the inability to assess the potential impact of education status and other social factors, and the generalizability of its findings, since SEER is limited to major cancer hospitals.

The researchers reported having no financial disclosures.

[email protected]

LOS ANGELES – Overall 5-year survival rates for anal cancer in the United States have steadily improved since the 1970s, but the incidence of disease continues to rise. In addition, African Americans with anal cancer have significantly and disproportionally lower 5-year survival rates, compared with whites.

Those are key findings from an analysis of Surveillance, Epidemiology and End Results (SEER) data that primary study author Dr. Marco Ferrara presented at the annual meeting of the American Society of Colon and Rectal Surgeons.

“Disparities in health-related outcomes for diseases such as cancer are unfortunately commonly observed,” Dr. Ferrara’s mentor and the senior study author Dr. Daniel I. Chu said in an interview in advance of the meeting. “African Americans in particular have higher cancer-specific death rates, higher rates of advanced cancer on initial diagnosis, and less frequent use of cancer screening tests. While our understanding of disparities continues to progress for the more common cancers (lung, breast, prostate, colorectal), comparatively fewer data are available for anal cancer. This gap in knowledge is important because anal cancer incidence has actually been increasing in the U.S. population over the past decades. While effective treatment is available, we asked if disparities exist in anal cancer.”

To find out, the researchers used the national SEER database to identify all patients with cancer of the anus, anal canal, and anorectum from 1973 to 1999 (Period 1; a total of 6,755 cases) and 2000 to 2012 (Period 2; a total of 18,027 cases) and stratified them by race. They determined the incidence, staging, and treatment provided for each group and used 2000 Census data to calculate the age-adjusted annual incidence of anal cancer. The primary outcome was 5-year survival.

More than half of patients (61%) were female, 86% were white, 10% were African American, and the remaining 4% were from other ethnic groups. Dr. Ferrara, who is a fourth-year surgery resident at Baptist Health System in Birmingham, Ala., reported that between Periods 1 and 2, the overall incidence of anal cancer increased from 1.1 to 1.8 cases per 100,000 individuals. The overall incidence was higher among African Americans, compared with whites (1.6 vs. 1.3 cases per 100,000 individuals, respectively). The incidence among African-American males was slightly higher, at 1.9 cases per 100,000 individuals.

The researchers found that nearly half of patients (48%) presented with localized disease, while 31% had regional disease. Between Periods 1 and 2 the proportion of patients who received any treatment for anal cancer increased from 63% to 74%. The use of radiation therapy increased from 61% to 72%, while the use of local excisions and abdominoperineal resections decreased from 60% to 45%. Overall, African Americans were more likely than whites to not undergo recommended surgery (9.8% vs. 8.7%, respectively) or to refuse recommended surgery (1.8% vs. 1.1%; P less than .05 for both associations).

Overall 5-year survival for anal cancer improved from 63% in Period 1 to 70% in Period 2 (P less than .05). However, African Americans had significantly lower 5-year survival rates, compared with whites in both time periods (53% vs. 64% in Period 1, and 62% vs. 71% in Period 2; P less than .05 for both associations).

“Health disparities exist in anal cancer with African Americans faring worse than Caucasian patients,” said Dr. Chu, who is a gastrointestinal surgeon at the University of Alabama at Birmingham. “While the etiologies for these disparities are unclear, anal cancer is a very treatable disease when caught early, regardless of race. Screening should be done for those at higher risk, such as patients with a family history of anal cancer, HIV, or HPV [human papillomavirus]. Ultimately, more research is needed to understand the factors driving these disparities at the patient, provider, and health care system level.”

He acknowledged certain limitations of the study, including its retrospective nature, the inability to assess the potential impact of education status and other social factors, and the generalizability of its findings, since SEER is limited to major cancer hospitals.

The researchers reported having no financial disclosures.

[email protected]

LOS ANGELES – Overall, 44% of inflammatory bowel disease (IBD) patients on vedolizumab had some form of infectious complication following intra-abdominal or anorectal surgery, results from a small single-center study suggest.

According to lead study author Dr. Samuel Eisenstein, there are currently no published surgical outcomes of patients receiving vedolizumab, an integrin receptor antagonist which was approved in May 2014 for the treatment of adults with moderate to severe ulcerative colitis as well as those with moderate to severe Crohn’s disease. “We’re not trying to alienate people who are proponents of the medication,” Dr. Eisenstein said in an interview in advance of the annual meeting of the American Society of Colon and Rectal Surgeons. “It’s an effective medication for treating Crohn’s and ulcerative colitis. We need to have a high index of suspicion that patients may have complications after these surgeries and to treat them with caution until we have better data.”

Dr. Eisenstein and his associates in the section of colon and rectal surgery at Moores Cancer Center, University of California, San Diego, Health System, retrospectively analyzed the medical records of 26 patients with IBD who underwent intra-abdominal or anorectal surgery at the center following treatment with vedolizumab. The patients underwent a total of 36 operations: 27 that were intra-abdominal and 9 that were anorectal. Their mean age was 31 years and 46% were female.

Dr. Eisenstein reported that 17 of the 26 patients (65%) had a Clavien-Dindo grade II or greater complication following 19 operations. In all, 26 complications occurred following these 19 operations, and 53% were infectious in nature. The overall rate of infectious complications following any operation was 44%. In addition, the rate of anastomotic leak was 15%, and two patients died from culture-negative sepsis following abdominal surgery, for an overall mortality rate of 7.7%.

The researchers also observed that there were 23 visits to the emergency room following surgery and 10 hospital readmissions. The only preoperative characteristics that differed significantly between patients who had complications and those who did not were level of hemoglobin (10.6 g/dL vs. 11.9 g/dL, respectively; P = .02) and platelet count (349 vs. 287 K/mm³; P = .025). No differences in the rate of complications were observed based on the number of biologic medications each patient failed prior to the initiation of vedolizumab (P = .718). Compared with patients who had no postoperative complications, those who did were more likely to have undergone intra-abdominal surgery (17 vs. 10 patients; P = .034), require postoperative transfusion (4 vs. none; P = .045), visit the emergency department (10 vs. none; P less than .001), or require hospital readmission (10 vs. none; P less than .001).

Dr. Eisenstein acknowledged certain limitations of the study including its small sample size, single-center, retrospective design, and the potential for selection bias. “The patients who were getting vedolizumab are the patients who failed all of the anti-TNFs, so we’re really selecting patients with the worst, most medically refractory disease,” he noted. “Because of that we can’t say for sure [if the complications] are due to their severity of disease or due to the medication itself.”

The data are “preliminary and retrospectively analyzed, but there is some concern that patients on these types of medications may have an increased risk of postoperative complications,” he concluded. “What we really need are bigger studies. To that end, we are actually starting an IBD collaborative based on some of the findings we have here, because we really want to analyze these data over a much larger population of patients.”

The researchers reported having no financial disclosures.

[email protected]

LOS ANGELES – Overall, 44% of inflammatory bowel disease (IBD) patients on vedolizumab had some form of infectious complication following intra-abdominal or anorectal surgery, results from a small single-center study suggest.

According to lead study author Dr. Samuel Eisenstein, there are currently no published surgical outcomes of patients receiving vedolizumab, an integrin receptor antagonist which was approved in May 2014 for the treatment of adults with moderate to severe ulcerative colitis as well as those with moderate to severe Crohn’s disease. “We’re not trying to alienate people who are proponents of the medication,” Dr. Eisenstein said in an interview in advance of the annual meeting of the American Society of Colon and Rectal Surgeons. “It’s an effective medication for treating Crohn’s and ulcerative colitis. We need to have a high index of suspicion that patients may have complications after these surgeries and to treat them with caution until we have better data.”

Dr. Eisenstein and his associates in the section of colon and rectal surgery at Moores Cancer Center, University of California, San Diego, Health System, retrospectively analyzed the medical records of 26 patients with IBD who underwent intra-abdominal or anorectal surgery at the center following treatment with vedolizumab. The patients underwent a total of 36 operations: 27 that were intra-abdominal and 9 that were anorectal. Their mean age was 31 years and 46% were female.

Dr. Eisenstein reported that 17 of the 26 patients (65%) had a Clavien-Dindo grade II or greater complication following 19 operations. In all, 26 complications occurred following these 19 operations, and 53% were infectious in nature. The overall rate of infectious complications following any operation was 44%. In addition, the rate of anastomotic leak was 15%, and two patients died from culture-negative sepsis following abdominal surgery, for an overall mortality rate of 7.7%.

The researchers also observed that there were 23 visits to the emergency room following surgery and 10 hospital readmissions. The only preoperative characteristics that differed significantly between patients who had complications and those who did not were level of hemoglobin (10.6 g/dL vs. 11.9 g/dL, respectively; P = .02) and platelet count (349 vs. 287 K/mm³; P = .025). No differences in the rate of complications were observed based on the number of biologic medications each patient failed prior to the initiation of vedolizumab (P = .718). Compared with patients who had no postoperative complications, those who did were more likely to have undergone intra-abdominal surgery (17 vs. 10 patients; P = .034), require postoperative transfusion (4 vs. none; P = .045), visit the emergency department (10 vs. none; P less than .001), or require hospital readmission (10 vs. none; P less than .001).

Dr. Eisenstein acknowledged certain limitations of the study including its small sample size, single-center, retrospective design, and the potential for selection bias. “The patients who were getting vedolizumab are the patients who failed all of the anti-TNFs, so we’re really selecting patients with the worst, most medically refractory disease,” he noted. “Because of that we can’t say for sure [if the complications] are due to their severity of disease or due to the medication itself.”

The data are “preliminary and retrospectively analyzed, but there is some concern that patients on these types of medications may have an increased risk of postoperative complications,” he concluded. “What we really need are bigger studies. To that end, we are actually starting an IBD collaborative based on some of the findings we have here, because we really want to analyze these data over a much larger population of patients.”

The researchers reported having no financial disclosures.

[email protected]

LOS ANGELES – Overall, 44% of inflammatory bowel disease (IBD) patients on vedolizumab had some form of infectious complication following intra-abdominal or anorectal surgery, results from a small single-center study suggest.

According to lead study author Dr. Samuel Eisenstein, there are currently no published surgical outcomes of patients receiving vedolizumab, an integrin receptor antagonist which was approved in May 2014 for the treatment of adults with moderate to severe ulcerative colitis as well as those with moderate to severe Crohn’s disease. “We’re not trying to alienate people who are proponents of the medication,” Dr. Eisenstein said in an interview in advance of the annual meeting of the American Society of Colon and Rectal Surgeons. “It’s an effective medication for treating Crohn’s and ulcerative colitis. We need to have a high index of suspicion that patients may have complications after these surgeries and to treat them with caution until we have better data.”

Dr. Eisenstein and his associates in the section of colon and rectal surgery at Moores Cancer Center, University of California, San Diego, Health System, retrospectively analyzed the medical records of 26 patients with IBD who underwent intra-abdominal or anorectal surgery at the center following treatment with vedolizumab. The patients underwent a total of 36 operations: 27 that were intra-abdominal and 9 that were anorectal. Their mean age was 31 years and 46% were female.

Dr. Eisenstein reported that 17 of the 26 patients (65%) had a Clavien-Dindo grade II or greater complication following 19 operations. In all, 26 complications occurred following these 19 operations, and 53% were infectious in nature. The overall rate of infectious complications following any operation was 44%. In addition, the rate of anastomotic leak was 15%, and two patients died from culture-negative sepsis following abdominal surgery, for an overall mortality rate of 7.7%.

The researchers also observed that there were 23 visits to the emergency room following surgery and 10 hospital readmissions. The only preoperative characteristics that differed significantly between patients who had complications and those who did not were level of hemoglobin (10.6 g/dL vs. 11.9 g/dL, respectively; P = .02) and platelet count (349 vs. 287 K/mm³; P = .025). No differences in the rate of complications were observed based on the number of biologic medications each patient failed prior to the initiation of vedolizumab (P = .718). Compared with patients who had no postoperative complications, those who did were more likely to have undergone intra-abdominal surgery (17 vs. 10 patients; P = .034), require postoperative transfusion (4 vs. none; P = .045), visit the emergency department (10 vs. none; P less than .001), or require hospital readmission (10 vs. none; P less than .001).

Dr. Eisenstein acknowledged certain limitations of the study including its small sample size, single-center, retrospective design, and the potential for selection bias. “The patients who were getting vedolizumab are the patients who failed all of the anti-TNFs, so we’re really selecting patients with the worst, most medically refractory disease,” he noted. “Because of that we can’t say for sure [if the complications] are due to their severity of disease or due to the medication itself.”

The data are “preliminary and retrospectively analyzed, but there is some concern that patients on these types of medications may have an increased risk of postoperative complications,” he concluded. “What we really need are bigger studies. To that end, we are actually starting an IBD collaborative based on some of the findings we have here, because we really want to analyze these data over a much larger population of patients.”

The researchers reported having no financial disclosures.

[email protected]