Central Surgical Association (CSA): Annual Meeting

DETROIT – A simple formula that incorporates tumor area and percentage of positive lymph nodes helps predict 5-year disease-free survival in colorectal cancer, and may be used to guide treatment, a new study suggests.

"The formula is simple and inexpensive to apply," lead author Dr. Lisa Poritz said at the annual meeting of the Central Surgical Association. All the data are in the pathology report. "It does not require genetic or biologic tests that are expensive and not available throughout the country."

Although tumor size is not part of the widely used TNM (tumor, node, metastasis) staging system, Dr. Poritz and her colleagues hypothesized that it would be important in determining disease-free survival. To test that hypothesis, they used data from pathology reports to calculate the tumor area–to-node ratio (T:N) for 63 patients with stage III colorectal cancer (CRC) who underwent resection at the Hershey (Pa.) Medical Center from January 2000 to June 2008.

Specifically, tumor area is based on the two largest tumor measures multiplied together. The percentage of positive nodes is based on the number of nodes that are positive divided by the total number of nodes harvested, then multiplied by 100. The T:N ratio is based on the tumor area divided by the percentage of positive nodes.

In all, 35 patients remained disease free at 5 years and 28 developed metastatic disease at a mean of 16.4 months, said Dr. Poritz, a colorectal surgeon at Penn State Hershey.

The mean T:N ratio was significantly higher (2.76) in the disease-free group, compared with 0.50 in the metastatic group (P = .0009), meaning that a higher ratio is a better prognostic sign, she said.

In a receiver operating characteristic analysis, T:N ratio demonstrated the highest correlation with 5-year disease-free survival at an area under the curve of 0.86 vs. 0.79 for percentage of positive nodes, 0.75 for number of positive nodes, and just 0.61 for tumor volume.

When the data were applied to a logistic regression curve, the beta0 was 1.682 and beta1 was 2.274. From these values, the risk of distant metastasis can be calculated for a specific T:N ratio. For example, a patient with a T:N ratio of 1.22 would have a 25% risk of developing metastatic disease in 5 years, compared with a 50% risk for a patient with a T:N ratio of 0.77 and a 75% risk for a patient with a T:N ratio of 0.26, Dr. Poritz said.

Notably, even after controlling for the critical factor of nodal stage, researchers found that the T:N ratio remained significant in logistic regression analysis at a P value of .008.

Dr. Poritz also presented two hypothetical patients to illustrate how the formula could be used to influence clinical decision making. Patient A had a small tumor with an area of 1.52 and 2 of 17 positive nodes. This resulted in a T:N ratio of 0.25 and a 75% risk of developing metastatic disease in 5 years. Patient B had a large tumor with an area of 28.3 and also 2 of 17 positive nodes. The T:N ratio would be 2.4, and the patient would have only a 2% chance of developing metastatic disease within 5 years.

"If you only looked at the number of nodes or [percentage of positive nodes], you might consider treating these patients in exactly the same manner, or at least consider their risk of developing metastatic cancer to be exactly the same," she said. "However, when you use our calculations, you can see that tumor volume is very important, and it changes the risk of developing metastatic disease dramatically in these patients. In this context, you might want to treat patient A more aggressively than patient B."

Invited discussant Dr. Anthony Senagore of the University of Southern California in Los Angeles asked whether data were available on the relationship between T stage and the size of the tumor, because "you seem to imply that what we historically believe about depth of penetration seems to be less important, and that it’s the mass of the tumor that matters."

Dr. Poritz replied that depth of penetration – which is included in the TNM staging system – remains important, especially in stage II and node-negative disease when clinicians are trying to determine who should receive chemotherapy. However, the data would suggest that at least within stage III disease, tumor area may be more important than T stage, which has not been shown to correlate well with prognosis either in their study or others.

An audience member remarked that the researchers may be making too big a leap in suggesting that the formula could be used to guide therapy, and asked whether they have considered taking the findings to SWOG (formerly the Southwest Oncology Group) for further validation. Dr. Poritz said that they are in the process of applying the formula to a larger database, similar to that of SWOG.

Colon cancer was present in 21 patients in the disease-free group and in 19 patients in the metastatic group, with 14 cases of rectal cancer in each group. There were no differences between the two groups with regard to sex, age, tumor location, vascular or lymphatic invasion, or T stage. Perineural invasion was significantly more common in the metastatic group than in the disease-free group (11 cases vs. 2 cases), but Dr. Poritz urged caution in interpreting this because data on perineural invasion were not mentioned in 30 cases.

As expected, significantly more patients in the metastatic group than in the disease-free group had an N stage of 2 (18 cases vs. 6 cases) or N stage of 3 (1 case vs. 0). Similarly, the mean number of positive nodes was higher in the metastatic group than in the disease-free group at 6.1 vs. 2.3 (P = .0049), as was the percentage of positive nodes at 39.6% vs. 13% (P = .0006).

The study excluded patients who had inflammatory bowel disease, associated CRC, recurrent cancer, or perforated cancer, or who had received any neoadjuvant therapy or had died of unknown causes or causes other than cancer.

The authors reported no study support or conflicts of interest.

DETROIT – A simple formula that incorporates tumor area and percentage of positive lymph nodes helps predict 5-year disease-free survival in colorectal cancer, and may be used to guide treatment, a new study suggests.

"The formula is simple and inexpensive to apply," lead author Dr. Lisa Poritz said at the annual meeting of the Central Surgical Association. All the data are in the pathology report. "It does not require genetic or biologic tests that are expensive and not available throughout the country."

Although tumor size is not part of the widely used TNM (tumor, node, metastasis) staging system, Dr. Poritz and her colleagues hypothesized that it would be important in determining disease-free survival. To test that hypothesis, they used data from pathology reports to calculate the tumor area–to-node ratio (T:N) for 63 patients with stage III colorectal cancer (CRC) who underwent resection at the Hershey (Pa.) Medical Center from January 2000 to June 2008.

Specifically, tumor area is based on the two largest tumor measures multiplied together. The percentage of positive nodes is based on the number of nodes that are positive divided by the total number of nodes harvested, then multiplied by 100. The T:N ratio is based on the tumor area divided by the percentage of positive nodes.

In all, 35 patients remained disease free at 5 years and 28 developed metastatic disease at a mean of 16.4 months, said Dr. Poritz, a colorectal surgeon at Penn State Hershey.

The mean T:N ratio was significantly higher (2.76) in the disease-free group, compared with 0.50 in the metastatic group (P = .0009), meaning that a higher ratio is a better prognostic sign, she said.

In a receiver operating characteristic analysis, T:N ratio demonstrated the highest correlation with 5-year disease-free survival at an area under the curve of 0.86 vs. 0.79 for percentage of positive nodes, 0.75 for number of positive nodes, and just 0.61 for tumor volume.

When the data were applied to a logistic regression curve, the beta0 was 1.682 and beta1 was 2.274. From these values, the risk of distant metastasis can be calculated for a specific T:N ratio. For example, a patient with a T:N ratio of 1.22 would have a 25% risk of developing metastatic disease in 5 years, compared with a 50% risk for a patient with a T:N ratio of 0.77 and a 75% risk for a patient with a T:N ratio of 0.26, Dr. Poritz said.

Notably, even after controlling for the critical factor of nodal stage, researchers found that the T:N ratio remained significant in logistic regression analysis at a P value of .008.

Dr. Poritz also presented two hypothetical patients to illustrate how the formula could be used to influence clinical decision making. Patient A had a small tumor with an area of 1.52 and 2 of 17 positive nodes. This resulted in a T:N ratio of 0.25 and a 75% risk of developing metastatic disease in 5 years. Patient B had a large tumor with an area of 28.3 and also 2 of 17 positive nodes. The T:N ratio would be 2.4, and the patient would have only a 2% chance of developing metastatic disease within 5 years.

"If you only looked at the number of nodes or [percentage of positive nodes], you might consider treating these patients in exactly the same manner, or at least consider their risk of developing metastatic cancer to be exactly the same," she said. "However, when you use our calculations, you can see that tumor volume is very important, and it changes the risk of developing metastatic disease dramatically in these patients. In this context, you might want to treat patient A more aggressively than patient B."

Invited discussant Dr. Anthony Senagore of the University of Southern California in Los Angeles asked whether data were available on the relationship between T stage and the size of the tumor, because "you seem to imply that what we historically believe about depth of penetration seems to be less important, and that it’s the mass of the tumor that matters."

Dr. Poritz replied that depth of penetration – which is included in the TNM staging system – remains important, especially in stage II and node-negative disease when clinicians are trying to determine who should receive chemotherapy. However, the data would suggest that at least within stage III disease, tumor area may be more important than T stage, which has not been shown to correlate well with prognosis either in their study or others.

An audience member remarked that the researchers may be making too big a leap in suggesting that the formula could be used to guide therapy, and asked whether they have considered taking the findings to SWOG (formerly the Southwest Oncology Group) for further validation. Dr. Poritz said that they are in the process of applying the formula to a larger database, similar to that of SWOG.

Colon cancer was present in 21 patients in the disease-free group and in 19 patients in the metastatic group, with 14 cases of rectal cancer in each group. There were no differences between the two groups with regard to sex, age, tumor location, vascular or lymphatic invasion, or T stage. Perineural invasion was significantly more common in the metastatic group than in the disease-free group (11 cases vs. 2 cases), but Dr. Poritz urged caution in interpreting this because data on perineural invasion were not mentioned in 30 cases.

As expected, significantly more patients in the metastatic group than in the disease-free group had an N stage of 2 (18 cases vs. 6 cases) or N stage of 3 (1 case vs. 0). Similarly, the mean number of positive nodes was higher in the metastatic group than in the disease-free group at 6.1 vs. 2.3 (P = .0049), as was the percentage of positive nodes at 39.6% vs. 13% (P = .0006).

The study excluded patients who had inflammatory bowel disease, associated CRC, recurrent cancer, or perforated cancer, or who had received any neoadjuvant therapy or had died of unknown causes or causes other than cancer.

The authors reported no study support or conflicts of interest.

DETROIT – A simple formula that incorporates tumor area and percentage of positive lymph nodes helps predict 5-year disease-free survival in colorectal cancer, and may be used to guide treatment, a new study suggests.

"The formula is simple and inexpensive to apply," lead author Dr. Lisa Poritz said at the annual meeting of the Central Surgical Association. All the data are in the pathology report. "It does not require genetic or biologic tests that are expensive and not available throughout the country."

Although tumor size is not part of the widely used TNM (tumor, node, metastasis) staging system, Dr. Poritz and her colleagues hypothesized that it would be important in determining disease-free survival. To test that hypothesis, they used data from pathology reports to calculate the tumor area–to-node ratio (T:N) for 63 patients with stage III colorectal cancer (CRC) who underwent resection at the Hershey (Pa.) Medical Center from January 2000 to June 2008.

Specifically, tumor area is based on the two largest tumor measures multiplied together. The percentage of positive nodes is based on the number of nodes that are positive divided by the total number of nodes harvested, then multiplied by 100. The T:N ratio is based on the tumor area divided by the percentage of positive nodes.

In all, 35 patients remained disease free at 5 years and 28 developed metastatic disease at a mean of 16.4 months, said Dr. Poritz, a colorectal surgeon at Penn State Hershey.

The mean T:N ratio was significantly higher (2.76) in the disease-free group, compared with 0.50 in the metastatic group (P = .0009), meaning that a higher ratio is a better prognostic sign, she said.

In a receiver operating characteristic analysis, T:N ratio demonstrated the highest correlation with 5-year disease-free survival at an area under the curve of 0.86 vs. 0.79 for percentage of positive nodes, 0.75 for number of positive nodes, and just 0.61 for tumor volume.

When the data were applied to a logistic regression curve, the beta0 was 1.682 and beta1 was 2.274. From these values, the risk of distant metastasis can be calculated for a specific T:N ratio. For example, a patient with a T:N ratio of 1.22 would have a 25% risk of developing metastatic disease in 5 years, compared with a 50% risk for a patient with a T:N ratio of 0.77 and a 75% risk for a patient with a T:N ratio of 0.26, Dr. Poritz said.

Notably, even after controlling for the critical factor of nodal stage, researchers found that the T:N ratio remained significant in logistic regression analysis at a P value of .008.

Dr. Poritz also presented two hypothetical patients to illustrate how the formula could be used to influence clinical decision making. Patient A had a small tumor with an area of 1.52 and 2 of 17 positive nodes. This resulted in a T:N ratio of 0.25 and a 75% risk of developing metastatic disease in 5 years. Patient B had a large tumor with an area of 28.3 and also 2 of 17 positive nodes. The T:N ratio would be 2.4, and the patient would have only a 2% chance of developing metastatic disease within 5 years.

"If you only looked at the number of nodes or [percentage of positive nodes], you might consider treating these patients in exactly the same manner, or at least consider their risk of developing metastatic cancer to be exactly the same," she said. "However, when you use our calculations, you can see that tumor volume is very important, and it changes the risk of developing metastatic disease dramatically in these patients. In this context, you might want to treat patient A more aggressively than patient B."

Invited discussant Dr. Anthony Senagore of the University of Southern California in Los Angeles asked whether data were available on the relationship between T stage and the size of the tumor, because "you seem to imply that what we historically believe about depth of penetration seems to be less important, and that it’s the mass of the tumor that matters."

Dr. Poritz replied that depth of penetration – which is included in the TNM staging system – remains important, especially in stage II and node-negative disease when clinicians are trying to determine who should receive chemotherapy. However, the data would suggest that at least within stage III disease, tumor area may be more important than T stage, which has not been shown to correlate well with prognosis either in their study or others.

An audience member remarked that the researchers may be making too big a leap in suggesting that the formula could be used to guide therapy, and asked whether they have considered taking the findings to SWOG (formerly the Southwest Oncology Group) for further validation. Dr. Poritz said that they are in the process of applying the formula to a larger database, similar to that of SWOG.

Colon cancer was present in 21 patients in the disease-free group and in 19 patients in the metastatic group, with 14 cases of rectal cancer in each group. There were no differences between the two groups with regard to sex, age, tumor location, vascular or lymphatic invasion, or T stage. Perineural invasion was significantly more common in the metastatic group than in the disease-free group (11 cases vs. 2 cases), but Dr. Poritz urged caution in interpreting this because data on perineural invasion were not mentioned in 30 cases.

As expected, significantly more patients in the metastatic group than in the disease-free group had an N stage of 2 (18 cases vs. 6 cases) or N stage of 3 (1 case vs. 0). Similarly, the mean number of positive nodes was higher in the metastatic group than in the disease-free group at 6.1 vs. 2.3 (P = .0049), as was the percentage of positive nodes at 39.6% vs. 13% (P = .0006).

The study excluded patients who had inflammatory bowel disease, associated CRC, recurrent cancer, or perforated cancer, or who had received any neoadjuvant therapy or had died of unknown causes or causes other than cancer.

The authors reported no study support or conflicts of interest.

DETROIT – A simple formula that incorporates tumor area and percentage of positive lymph nodes helps predict 5-year disease-free survival in colorectal cancer, and may be used to guide treatment, a new study suggests.

"The formula is simple and inexpensive to apply," lead author Dr. Lisa Poritz said at the annual meeting of the Central Surgical Association. All the data are in the pathology report. "It does not require genetic or biologic tests that are expensive and not available throughout the country."

Although tumor size is not part of the widely used TNM (tumor, node, metastasis) staging system, Dr. Poritz and her colleagues hypothesized that it would be important in determining disease-free survival. To test that hypothesis, they used data from pathology reports to calculate the tumor area–to-node ratio (T:N) for 63 patients with stage III colorectal cancer (CRC) who underwent resection at the Hershey (Pa.) Medical Center from January 2000 to June 2008.

Specifically, tumor area is based on the two largest tumor measures multiplied together. The percentage of positive nodes is based on the number of nodes that are positive divided by the total number of nodes harvested, then multiplied by 100. The T:N ratio is based on the tumor area divided by the percentage of positive nodes.

In all, 35 patients remained disease free at 5 years and 28 developed metastatic disease at a mean of 16.4 months, said Dr. Poritz, a colorectal surgeon at Penn State Hershey.

The mean T:N ratio was significantly higher (2.76) in the disease-free group, compared with 0.50 in the metastatic group (P = .0009), meaning that a higher ratio is a better prognostic sign, she said.

In a receiver operating characteristic analysis, T:N ratio demonstrated the highest correlation with 5-year disease-free survival at an area under the curve of 0.86 vs. 0.79 for percentage of positive nodes, 0.75 for number of positive nodes, and just 0.61 for tumor volume.

When the data were applied to a logistic regression curve, the beta0 was 1.682 and beta1 was 2.274. From these values, the risk of distant metastasis can be calculated for a specific T:N ratio. For example, a patient with a T:N ratio of 1.22 would have a 25% risk of developing metastatic disease in 5 years, compared with a 50% risk for a patient with a T:N ratio of 0.77 and a 75% risk for a patient with a T:N ratio of 0.26, Dr. Poritz said.

Notably, even after controlling for the critical factor of nodal stage, researchers found that the T:N ratio remained significant in logistic regression analysis at a P value of .008.

Dr. Poritz also presented two hypothetical patients to illustrate how the formula could be used to influence clinical decision making. Patient A had a small tumor with an area of 1.52 and 2 of 17 positive nodes. This resulted in a T:N ratio of 0.25 and a 75% risk of developing metastatic disease in 5 years. Patient B had a large tumor with an area of 28.3 and also 2 of 17 positive nodes. The T:N ratio would be 2.4, and the patient would have only a 2% chance of developing metastatic disease within 5 years.

"If you only looked at the number of nodes or [percentage of positive nodes], you might consider treating these patients in exactly the same manner, or at least consider their risk of developing metastatic cancer to be exactly the same," she said. "However, when you use our calculations, you can see that tumor volume is very important, and it changes the risk of developing metastatic disease dramatically in these patients. In this context, you might want to treat patient A more aggressively than patient B."

Invited discussant Dr. Anthony Senagore of the University of Southern California in Los Angeles asked whether data were available on the relationship between T stage and the size of the tumor, because "you seem to imply that what we historically believe about depth of penetration seems to be less important, and that it’s the mass of the tumor that matters."

Dr. Poritz replied that depth of penetration – which is included in the TNM staging system – remains important, especially in stage II and node-negative disease when clinicians are trying to determine who should receive chemotherapy. However, the data would suggest that at least within stage III disease, tumor area may be more important than T stage, which has not been shown to correlate well with prognosis either in their study or others.

An audience member remarked that the researchers may be making too big a leap in suggesting that the formula could be used to guide therapy, and asked whether they have considered taking the findings to SWOG (formerly the Southwest Oncology Group) for further validation. Dr. Poritz said that they are in the process of applying the formula to a larger database, similar to that of SWOG.

Colon cancer was present in 21 patients in the disease-free group and in 19 patients in the metastatic group, with 14 cases of rectal cancer in each group. There were no differences between the two groups with regard to sex, age, tumor location, vascular or lymphatic invasion, or T stage. Perineural invasion was significantly more common in the metastatic group than in the disease-free group (11 cases vs. 2 cases), but Dr. Poritz urged caution in interpreting this because data on perineural invasion were not mentioned in 30 cases.

As expected, significantly more patients in the metastatic group than in the disease-free group had an N stage of 2 (18 cases vs. 6 cases) or N stage of 3 (1 case vs. 0). Similarly, the mean number of positive nodes was higher in the metastatic group than in the disease-free group at 6.1 vs. 2.3 (P = .0049), as was the percentage of positive nodes at 39.6% vs. 13% (P = .0006).

The study excluded patients who had inflammatory bowel disease, associated CRC, recurrent cancer, or perforated cancer, or who had received any neoadjuvant therapy or had died of unknown causes or causes other than cancer.

The authors reported no study support or conflicts of interest.

DETROIT – A simple formula that incorporates tumor area and percentage of positive lymph nodes helps predict 5-year disease-free survival in colorectal cancer, and may be used to guide treatment, a new study suggests.

"The formula is simple and inexpensive to apply," lead author Dr. Lisa Poritz said at the annual meeting of the Central Surgical Association. All the data are in the pathology report. "It does not require genetic or biologic tests that are expensive and not available throughout the country."

Although tumor size is not part of the widely used TNM (tumor, node, metastasis) staging system, Dr. Poritz and her colleagues hypothesized that it would be important in determining disease-free survival. To test that hypothesis, they used data from pathology reports to calculate the tumor area–to-node ratio (T:N) for 63 patients with stage III colorectal cancer (CRC) who underwent resection at the Hershey (Pa.) Medical Center from January 2000 to June 2008.

Specifically, tumor area is based on the two largest tumor measures multiplied together. The percentage of positive nodes is based on the number of nodes that are positive divided by the total number of nodes harvested, then multiplied by 100. The T:N ratio is based on the tumor area divided by the percentage of positive nodes.

In all, 35 patients remained disease free at 5 years and 28 developed metastatic disease at a mean of 16.4 months, said Dr. Poritz, a colorectal surgeon at Penn State Hershey.

The mean T:N ratio was significantly higher (2.76) in the disease-free group, compared with 0.50 in the metastatic group (P = .0009), meaning that a higher ratio is a better prognostic sign, she said.

In a receiver operating characteristic analysis, T:N ratio demonstrated the highest correlation with 5-year disease-free survival at an area under the curve of 0.86 vs. 0.79 for percentage of positive nodes, 0.75 for number of positive nodes, and just 0.61 for tumor volume.

When the data were applied to a logistic regression curve, the beta0 was 1.682 and beta1 was 2.274. From these values, the risk of distant metastasis can be calculated for a specific T:N ratio. For example, a patient with a T:N ratio of 1.22 would have a 25% risk of developing metastatic disease in 5 years, compared with a 50% risk for a patient with a T:N ratio of 0.77 and a 75% risk for a patient with a T:N ratio of 0.26, Dr. Poritz said.

Notably, even after controlling for the critical factor of nodal stage, researchers found that the T:N ratio remained significant in logistic regression analysis at a P value of .008.

Dr. Poritz also presented two hypothetical patients to illustrate how the formula could be used to influence clinical decision making. Patient A had a small tumor with an area of 1.52 and 2 of 17 positive nodes. This resulted in a T:N ratio of 0.25 and a 75% risk of developing metastatic disease in 5 years. Patient B had a large tumor with an area of 28.3 and also 2 of 17 positive nodes. The T:N ratio would be 2.4, and the patient would have only a 2% chance of developing metastatic disease within 5 years.

"If you only looked at the number of nodes or [percentage of positive nodes], you might consider treating these patients in exactly the same manner, or at least consider their risk of developing metastatic cancer to be exactly the same," she said. "However, when you use our calculations, you can see that tumor volume is very important, and it changes the risk of developing metastatic disease dramatically in these patients. In this context, you might want to treat patient A more aggressively than patient B."

Invited discussant Dr. Anthony Senagore of the University of Southern California in Los Angeles asked whether data were available on the relationship between T stage and the size of the tumor, because "you seem to imply that what we historically believe about depth of penetration seems to be less important, and that it’s the mass of the tumor that matters."

Dr. Poritz replied that depth of penetration – which is included in the TNM staging system – remains important, especially in stage II and node-negative disease when clinicians are trying to determine who should receive chemotherapy. However, the data would suggest that at least within stage III disease, tumor area may be more important than T stage, which has not been shown to correlate well with prognosis either in their study or others.

An audience member remarked that the researchers may be making too big a leap in suggesting that the formula could be used to guide therapy, and asked whether they have considered taking the findings to SWOG (formerly the Southwest Oncology Group) for further validation. Dr. Poritz said that they are in the process of applying the formula to a larger database, similar to that of SWOG.

Colon cancer was present in 21 patients in the disease-free group and in 19 patients in the metastatic group, with 14 cases of rectal cancer in each group. There were no differences between the two groups with regard to sex, age, tumor location, vascular or lymphatic invasion, or T stage. Perineural invasion was significantly more common in the metastatic group than in the disease-free group (11 cases vs. 2 cases), but Dr. Poritz urged caution in interpreting this because data on perineural invasion were not mentioned in 30 cases.

As expected, significantly more patients in the metastatic group than in the disease-free group had an N stage of 2 (18 cases vs. 6 cases) or N stage of 3 (1 case vs. 0). Similarly, the mean number of positive nodes was higher in the metastatic group than in the disease-free group at 6.1 vs. 2.3 (P = .0049), as was the percentage of positive nodes at 39.6% vs. 13% (P = .0006).

The study excluded patients who had inflammatory bowel disease, associated CRC, recurrent cancer, or perforated cancer, or who had received any neoadjuvant therapy or had died of unknown causes or causes other than cancer.

The authors reported no study support or conflicts of interest.

DETROIT – A simple formula that incorporates tumor area and percentage of positive lymph nodes helps predict 5-year disease-free survival in colorectal cancer, and may be used to guide treatment, a new study suggests.

"The formula is simple and inexpensive to apply," lead author Dr. Lisa Poritz said at the annual meeting of the Central Surgical Association. All the data are in the pathology report. "It does not require genetic or biologic tests that are expensive and not available throughout the country."

Although tumor size is not part of the widely used TNM (tumor, node, metastasis) staging system, Dr. Poritz and her colleagues hypothesized that it would be important in determining disease-free survival. To test that hypothesis, they used data from pathology reports to calculate the tumor area–to-node ratio (T:N) for 63 patients with stage III colorectal cancer (CRC) who underwent resection at the Hershey (Pa.) Medical Center from January 2000 to June 2008.

Specifically, tumor area is based on the two largest tumor measures multiplied together. The percentage of positive nodes is based on the number of nodes that are positive divided by the total number of nodes harvested, then multiplied by 100. The T:N ratio is based on the tumor area divided by the percentage of positive nodes.

In all, 35 patients remained disease free at 5 years and 28 developed metastatic disease at a mean of 16.4 months, said Dr. Poritz, a colorectal surgeon at Penn State Hershey.

The mean T:N ratio was significantly higher (2.76) in the disease-free group, compared with 0.50 in the metastatic group (P = .0009), meaning that a higher ratio is a better prognostic sign, she said.

In a receiver operating characteristic analysis, T:N ratio demonstrated the highest correlation with 5-year disease-free survival at an area under the curve of 0.86 vs. 0.79 for percentage of positive nodes, 0.75 for number of positive nodes, and just 0.61 for tumor volume.

When the data were applied to a logistic regression curve, the beta0 was 1.682 and beta1 was 2.274. From these values, the risk of distant metastasis can be calculated for a specific T:N ratio. For example, a patient with a T:N ratio of 1.22 would have a 25% risk of developing metastatic disease in 5 years, compared with a 50% risk for a patient with a T:N ratio of 0.77 and a 75% risk for a patient with a T:N ratio of 0.26, Dr. Poritz said.

Notably, even after controlling for the critical factor of nodal stage, researchers found that the T:N ratio remained significant in logistic regression analysis at a P value of .008.

Dr. Poritz also presented two hypothetical patients to illustrate how the formula could be used to influence clinical decision making. Patient A had a small tumor with an area of 1.52 and 2 of 17 positive nodes. This resulted in a T:N ratio of 0.25 and a 75% risk of developing metastatic disease in 5 years. Patient B had a large tumor with an area of 28.3 and also 2 of 17 positive nodes. The T:N ratio would be 2.4, and the patient would have only a 2% chance of developing metastatic disease within 5 years.

"If you only looked at the number of nodes or [percentage of positive nodes], you might consider treating these patients in exactly the same manner, or at least consider their risk of developing metastatic cancer to be exactly the same," she said. "However, when you use our calculations, you can see that tumor volume is very important, and it changes the risk of developing metastatic disease dramatically in these patients. In this context, you might want to treat patient A more aggressively than patient B."

Invited discussant Dr. Anthony Senagore of the University of Southern California in Los Angeles asked whether data were available on the relationship between T stage and the size of the tumor, because "you seem to imply that what we historically believe about depth of penetration seems to be less important, and that it’s the mass of the tumor that matters."

Dr. Poritz replied that depth of penetration – which is included in the TNM staging system – remains important, especially in stage II and node-negative disease when clinicians are trying to determine who should receive chemotherapy. However, the data would suggest that at least within stage III disease, tumor area may be more important than T stage, which has not been shown to correlate well with prognosis either in their study or others.

An audience member remarked that the researchers may be making too big a leap in suggesting that the formula could be used to guide therapy, and asked whether they have considered taking the findings to SWOG (formerly the Southwest Oncology Group) for further validation. Dr. Poritz said that they are in the process of applying the formula to a larger database, similar to that of SWOG.

Colon cancer was present in 21 patients in the disease-free group and in 19 patients in the metastatic group, with 14 cases of rectal cancer in each group. There were no differences between the two groups with regard to sex, age, tumor location, vascular or lymphatic invasion, or T stage. Perineural invasion was significantly more common in the metastatic group than in the disease-free group (11 cases vs. 2 cases), but Dr. Poritz urged caution in interpreting this because data on perineural invasion were not mentioned in 30 cases.

As expected, significantly more patients in the metastatic group than in the disease-free group had an N stage of 2 (18 cases vs. 6 cases) or N stage of 3 (1 case vs. 0). Similarly, the mean number of positive nodes was higher in the metastatic group than in the disease-free group at 6.1 vs. 2.3 (P = .0049), as was the percentage of positive nodes at 39.6% vs. 13% (P = .0006).

The study excluded patients who had inflammatory bowel disease, associated CRC, recurrent cancer, or perforated cancer, or who had received any neoadjuvant therapy or had died of unknown causes or causes other than cancer.

The authors reported no study support or conflicts of interest.

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

DETROIT – Incorporation of aspirin response testing can improve traumatic brain injury management algorithms, a small study suggests.

"It allows us to identify and thereby treat occult platelet inhibition, target platelet transfusion to those who are truly platelet inhibited, and assures adequate response to platelet therapy when it is given," Dr. Joshua Bautz said at the annual meeting of the Central Surgical Association.

The rising use of antiplatelet medications in America’s aging population has prompted many trauma centers to use empiric transfusion of platelet therapy in the setting of traumatic brain injury (TBI) when use of aspirin and other antiplatelet medications are suspected. But the approach is not without consequences.

Aspirin response testing (ART), which was originally designed for use in cardiac patients to assess the effectiveness of antiplatelet medication, has taken on a second role of objectively evaluating platelet inhibition in the setting of TBI when aspirin use is suspected.

Dr. Bautz reported on 84 patients, median age 78 years, who presented from 2008 to 2009 at the University of Pittsburgh Medical Center with a TBI confirmed on head computed tomography (CT). Of these, 45% had a subdural hematoma, 27% a subarachnoid hemorrhage, and 16.5% a combination of hemorrhages.

In all, 36 had a known aspirin history and 48 had no known history or an unobtainable history of aspirin use.

Platelet inhibition was defined by an aspirin response test of less than 550 aspirin response units (ARU) on the VerifyNow Aspirin Test (Accumetrics Inc., San Diego). Patients found to be inhibited received platelet transfusion and a repeat ART test was performed 1 hour following transfusion. If the follow-up ART test again showed platelet inhibition, additional platelets were transfused until the patient was no longer suppressed.

In all, 42% of patients with no known history of aspirin use were objectively shown to have aspirin inhibition, said Dr. Bautz, a second-year resident at the university. In contrast, only two patients with a known aspirin history had normal platelet function and 34 had aspirin inhibition.

As expected, patients with a known aspirin history had significantly lower ART results than did those with an unknown aspirin history (mean 471 ARUs vs. 564 ARUs), he said. All other outcomes were similar between groups including head CT progression (26.5% vs. 27%), craniotomy (5.6% vs. 8.5%) and mortality (11% vs. 6.4%).

When the researchers looked at the effect of platelet inhibition on follow-up ART testing, 64% of the 54 patients with an initial positive ART test showed reversal of platelet inhibition on their first follow-up ART test.

"This means that almost one-third of patients did not show a return to normal platelet functioning after a single transfusion of platelets," he said. Nine patients were taken urgently to the OR, died, or were given comfort medications only.

Of the 16 nonresponders, 12 (77%) ultimately showed reversal of their platelet inhibition on follow-up platelet administration and ART testing. Three patients, however, did not return to normal platelet functioning, despite more than three platelet transfusions. Dr. Bautz pointed out.

Initial responders received a significantly greater volume of platelets than did nonresponders (median eight platelet packs vs. six platelet packs), suggesting a dose-response relationship, he said. The mean increase was 70 ARUs per six-pack of platelets.

"A standard six-pack of platelets may not be sufficient, suggesting a benefit of post-transfusion ART," he said.

In all, 91% of patients were restored to normal platelet function.

In regression analysis, there was no significant association between aspirin history or ART results and CT progression, mortality, craniotomy or composite outcomes. Subgroup analysis, however, revealed a trend toward higher mortality for nonresponders, Dr. Bautz said.

"A significant number of traumatic brain injury patients may have occult aspirin inhibition, which is not revealed by history alone," he concluded. "This is in contrast to a rather small number of patients that were shown to have normal platelet functioning and a known history of aspirin, despite high levels of aspirin insensitivity in our population."

Overall, 25% of patients in the series showed progression on follow-up CT, 13% required a craniotomy, and 9.4% died.

The study excluded patients with a history of platelet inhibitors other than aspirin, ongoing use of warfarin (Coumadin), or an International Normalized Ratio of more than 1.5 and those with any epidural component to their TBI.

Invited discussant Dr. Maggie Brandt, with St. Joseph Mercy Hospital in Ann Arbor, Mich., said "the idea of testing for platelets is really spot on and really relevant, but I don’t know if its practical for this problem."

In particular, Dr. Brandt was troubled by the number of patients who did not have a history of aspirin therapy, but were aspirin inhibited, and said it is unclear whether this is a function of other comorbidities or of the test itself. She asked whether ADT testing should be conducted in all TBI patients and whether it is practical to do so based on cost and turnaround time.

Dr. Bautz explained that the high number of patients without an aspirin history in the study is likely because these patients were unable to provide a history upon presentation for TBI. "It is in this setting, that we feel our test is of the most value," he said.

The test typically takes 40 minutes, including laboratory and transport time, and costs about $40 per test, he said.

Audience member Dr. Jonathan Saxe, professor of surgery at Wright State University in Dayton, Ohio, said that brain injury itself has been known to cause issues with aspirin testing and asked whether the brain injuries in the cohort could be causing the platelet test to be abnormal rather than the aspirin. He also pointed out that his group published a similar study finding no impact on mortality with platelet transfusion in elderly TBI patients taking aspirin or clopidogrel (Am. Surg. 2009;75:1100-3). "So I’m wondering, if giving platelets really does anything," he said.

Dr. Bautz said that the ADT test has demonstrated a sensitivity of almost 100% and specificity of 88% at his institution for showing aspirin inhibition. "So it is our belief these patients are on aspirin and that is the cause of their platelet inhibition."

A randomized controlled trial using objective measures of platelet inhibition is necessary to quantify platelet administration in patients presenting with TBI, he said.

The authors reported no conflicts of interest.

DETROIT – Incorporation of aspirin response testing can improve traumatic brain injury management algorithms, a small study suggests.

"It allows us to identify and thereby treat occult platelet inhibition, target platelet transfusion to those who are truly platelet inhibited, and assures adequate response to platelet therapy when it is given," Dr. Joshua Bautz said at the annual meeting of the Central Surgical Association.

The rising use of antiplatelet medications in America’s aging population has prompted many trauma centers to use empiric transfusion of platelet therapy in the setting of traumatic brain injury (TBI) when use of aspirin and other antiplatelet medications are suspected. But the approach is not without consequences.

Aspirin response testing (ART), which was originally designed for use in cardiac patients to assess the effectiveness of antiplatelet medication, has taken on a second role of objectively evaluating platelet inhibition in the setting of TBI when aspirin use is suspected.

Dr. Bautz reported on 84 patients, median age 78 years, who presented from 2008 to 2009 at the University of Pittsburgh Medical Center with a TBI confirmed on head computed tomography (CT). Of these, 45% had a subdural hematoma, 27% a subarachnoid hemorrhage, and 16.5% a combination of hemorrhages.

In all, 36 had a known aspirin history and 48 had no known history or an unobtainable history of aspirin use.

Platelet inhibition was defined by an aspirin response test of less than 550 aspirin response units (ARU) on the VerifyNow Aspirin Test (Accumetrics Inc., San Diego). Patients found to be inhibited received platelet transfusion and a repeat ART test was performed 1 hour following transfusion. If the follow-up ART test again showed platelet inhibition, additional platelets were transfused until the patient was no longer suppressed.

In all, 42% of patients with no known history of aspirin use were objectively shown to have aspirin inhibition, said Dr. Bautz, a second-year resident at the university. In contrast, only two patients with a known aspirin history had normal platelet function and 34 had aspirin inhibition.

As expected, patients with a known aspirin history had significantly lower ART results than did those with an unknown aspirin history (mean 471 ARUs vs. 564 ARUs), he said. All other outcomes were similar between groups including head CT progression (26.5% vs. 27%), craniotomy (5.6% vs. 8.5%) and mortality (11% vs. 6.4%).

When the researchers looked at the effect of platelet inhibition on follow-up ART testing, 64% of the 54 patients with an initial positive ART test showed reversal of platelet inhibition on their first follow-up ART test.

"This means that almost one-third of patients did not show a return to normal platelet functioning after a single transfusion of platelets," he said. Nine patients were taken urgently to the OR, died, or were given comfort medications only.

Of the 16 nonresponders, 12 (77%) ultimately showed reversal of their platelet inhibition on follow-up platelet administration and ART testing. Three patients, however, did not return to normal platelet functioning, despite more than three platelet transfusions. Dr. Bautz pointed out.

Initial responders received a significantly greater volume of platelets than did nonresponders (median eight platelet packs vs. six platelet packs), suggesting a dose-response relationship, he said. The mean increase was 70 ARUs per six-pack of platelets.

"A standard six-pack of platelets may not be sufficient, suggesting a benefit of post-transfusion ART," he said.

In all, 91% of patients were restored to normal platelet function.

In regression analysis, there was no significant association between aspirin history or ART results and CT progression, mortality, craniotomy or composite outcomes. Subgroup analysis, however, revealed a trend toward higher mortality for nonresponders, Dr. Bautz said.

"A significant number of traumatic brain injury patients may have occult aspirin inhibition, which is not revealed by history alone," he concluded. "This is in contrast to a rather small number of patients that were shown to have normal platelet functioning and a known history of aspirin, despite high levels of aspirin insensitivity in our population."

Overall, 25% of patients in the series showed progression on follow-up CT, 13% required a craniotomy, and 9.4% died.

The study excluded patients with a history of platelet inhibitors other than aspirin, ongoing use of warfarin (Coumadin), or an International Normalized Ratio of more than 1.5 and those with any epidural component to their TBI.

Invited discussant Dr. Maggie Brandt, with St. Joseph Mercy Hospital in Ann Arbor, Mich., said "the idea of testing for platelets is really spot on and really relevant, but I don’t know if its practical for this problem."

In particular, Dr. Brandt was troubled by the number of patients who did not have a history of aspirin therapy, but were aspirin inhibited, and said it is unclear whether this is a function of other comorbidities or of the test itself. She asked whether ADT testing should be conducted in all TBI patients and whether it is practical to do so based on cost and turnaround time.

Dr. Bautz explained that the high number of patients without an aspirin history in the study is likely because these patients were unable to provide a history upon presentation for TBI. "It is in this setting, that we feel our test is of the most value," he said.

The test typically takes 40 minutes, including laboratory and transport time, and costs about $40 per test, he said.

Audience member Dr. Jonathan Saxe, professor of surgery at Wright State University in Dayton, Ohio, said that brain injury itself has been known to cause issues with aspirin testing and asked whether the brain injuries in the cohort could be causing the platelet test to be abnormal rather than the aspirin. He also pointed out that his group published a similar study finding no impact on mortality with platelet transfusion in elderly TBI patients taking aspirin or clopidogrel (Am. Surg. 2009;75:1100-3). "So I’m wondering, if giving platelets really does anything," he said.

Dr. Bautz said that the ADT test has demonstrated a sensitivity of almost 100% and specificity of 88% at his institution for showing aspirin inhibition. "So it is our belief these patients are on aspirin and that is the cause of their platelet inhibition."

A randomized controlled trial using objective measures of platelet inhibition is necessary to quantify platelet administration in patients presenting with TBI, he said.

The authors reported no conflicts of interest.

DETROIT – Incorporation of aspirin response testing can improve traumatic brain injury management algorithms, a small study suggests.

"It allows us to identify and thereby treat occult platelet inhibition, target platelet transfusion to those who are truly platelet inhibited, and assures adequate response to platelet therapy when it is given," Dr. Joshua Bautz said at the annual meeting of the Central Surgical Association.

The rising use of antiplatelet medications in America’s aging population has prompted many trauma centers to use empiric transfusion of platelet therapy in the setting of traumatic brain injury (TBI) when use of aspirin and other antiplatelet medications are suspected. But the approach is not without consequences.

Aspirin response testing (ART), which was originally designed for use in cardiac patients to assess the effectiveness of antiplatelet medication, has taken on a second role of objectively evaluating platelet inhibition in the setting of TBI when aspirin use is suspected.

Dr. Bautz reported on 84 patients, median age 78 years, who presented from 2008 to 2009 at the University of Pittsburgh Medical Center with a TBI confirmed on head computed tomography (CT). Of these, 45% had a subdural hematoma, 27% a subarachnoid hemorrhage, and 16.5% a combination of hemorrhages.

In all, 36 had a known aspirin history and 48 had no known history or an unobtainable history of aspirin use.

Platelet inhibition was defined by an aspirin response test of less than 550 aspirin response units (ARU) on the VerifyNow Aspirin Test (Accumetrics Inc., San Diego). Patients found to be inhibited received platelet transfusion and a repeat ART test was performed 1 hour following transfusion. If the follow-up ART test again showed platelet inhibition, additional platelets were transfused until the patient was no longer suppressed.

In all, 42% of patients with no known history of aspirin use were objectively shown to have aspirin inhibition, said Dr. Bautz, a second-year resident at the university. In contrast, only two patients with a known aspirin history had normal platelet function and 34 had aspirin inhibition.

As expected, patients with a known aspirin history had significantly lower ART results than did those with an unknown aspirin history (mean 471 ARUs vs. 564 ARUs), he said. All other outcomes were similar between groups including head CT progression (26.5% vs. 27%), craniotomy (5.6% vs. 8.5%) and mortality (11% vs. 6.4%).

When the researchers looked at the effect of platelet inhibition on follow-up ART testing, 64% of the 54 patients with an initial positive ART test showed reversal of platelet inhibition on their first follow-up ART test.

"This means that almost one-third of patients did not show a return to normal platelet functioning after a single transfusion of platelets," he said. Nine patients were taken urgently to the OR, died, or were given comfort medications only.

Of the 16 nonresponders, 12 (77%) ultimately showed reversal of their platelet inhibition on follow-up platelet administration and ART testing. Three patients, however, did not return to normal platelet functioning, despite more than three platelet transfusions. Dr. Bautz pointed out.

Initial responders received a significantly greater volume of platelets than did nonresponders (median eight platelet packs vs. six platelet packs), suggesting a dose-response relationship, he said. The mean increase was 70 ARUs per six-pack of platelets.

"A standard six-pack of platelets may not be sufficient, suggesting a benefit of post-transfusion ART," he said.

In all, 91% of patients were restored to normal platelet function.

In regression analysis, there was no significant association between aspirin history or ART results and CT progression, mortality, craniotomy or composite outcomes. Subgroup analysis, however, revealed a trend toward higher mortality for nonresponders, Dr. Bautz said.

"A significant number of traumatic brain injury patients may have occult aspirin inhibition, which is not revealed by history alone," he concluded. "This is in contrast to a rather small number of patients that were shown to have normal platelet functioning and a known history of aspirin, despite high levels of aspirin insensitivity in our population."

Overall, 25% of patients in the series showed progression on follow-up CT, 13% required a craniotomy, and 9.4% died.

The study excluded patients with a history of platelet inhibitors other than aspirin, ongoing use of warfarin (Coumadin), or an International Normalized Ratio of more than 1.5 and those with any epidural component to their TBI.

Invited discussant Dr. Maggie Brandt, with St. Joseph Mercy Hospital in Ann Arbor, Mich., said "the idea of testing for platelets is really spot on and really relevant, but I don’t know if its practical for this problem."

In particular, Dr. Brandt was troubled by the number of patients who did not have a history of aspirin therapy, but were aspirin inhibited, and said it is unclear whether this is a function of other comorbidities or of the test itself. She asked whether ADT testing should be conducted in all TBI patients and whether it is practical to do so based on cost and turnaround time.

Dr. Bautz explained that the high number of patients without an aspirin history in the study is likely because these patients were unable to provide a history upon presentation for TBI. "It is in this setting, that we feel our test is of the most value," he said.

The test typically takes 40 minutes, including laboratory and transport time, and costs about $40 per test, he said.

Audience member Dr. Jonathan Saxe, professor of surgery at Wright State University in Dayton, Ohio, said that brain injury itself has been known to cause issues with aspirin testing and asked whether the brain injuries in the cohort could be causing the platelet test to be abnormal rather than the aspirin. He also pointed out that his group published a similar study finding no impact on mortality with platelet transfusion in elderly TBI patients taking aspirin or clopidogrel (Am. Surg. 2009;75:1100-3). "So I’m wondering, if giving platelets really does anything," he said.

Dr. Bautz said that the ADT test has demonstrated a sensitivity of almost 100% and specificity of 88% at his institution for showing aspirin inhibition. "So it is our belief these patients are on aspirin and that is the cause of their platelet inhibition."

A randomized controlled trial using objective measures of platelet inhibition is necessary to quantify platelet administration in patients presenting with TBI, he said.

The authors reported no conflicts of interest.

DETROIT – Incorporation of aspirin response testing can improve traumatic brain injury management algorithms, a small study suggests.

"It allows us to identify and thereby treat occult platelet inhibition, target platelet transfusion to those who are truly platelet inhibited, and assures adequate response to platelet therapy when it is given," Dr. Joshua Bautz said at the annual meeting of the Central Surgical Association.

The rising use of antiplatelet medications in America’s aging population has prompted many trauma centers to use empiric transfusion of platelet therapy in the setting of traumatic brain injury (TBI) when use of aspirin and other antiplatelet medications are suspected. But the approach is not without consequences.

Aspirin response testing (ART), which was originally designed for use in cardiac patients to assess the effectiveness of antiplatelet medication, has taken on a second role of objectively evaluating platelet inhibition in the setting of TBI when aspirin use is suspected.

Dr. Bautz reported on 84 patients, median age 78 years, who presented from 2008 to 2009 at the University of Pittsburgh Medical Center with a TBI confirmed on head computed tomography (CT). Of these, 45% had a subdural hematoma, 27% a subarachnoid hemorrhage, and 16.5% a combination of hemorrhages.

In all, 36 had a known aspirin history and 48 had no known history or an unobtainable history of aspirin use.

Platelet inhibition was defined by an aspirin response test of less than 550 aspirin response units (ARU) on the VerifyNow Aspirin Test (Accumetrics Inc., San Diego). Patients found to be inhibited received platelet transfusion and a repeat ART test was performed 1 hour following transfusion. If the follow-up ART test again showed platelet inhibition, additional platelets were transfused until the patient was no longer suppressed.

In all, 42% of patients with no known history of aspirin use were objectively shown to have aspirin inhibition, said Dr. Bautz, a second-year resident at the university. In contrast, only two patients with a known aspirin history had normal platelet function and 34 had aspirin inhibition.

As expected, patients with a known aspirin history had significantly lower ART results than did those with an unknown aspirin history (mean 471 ARUs vs. 564 ARUs), he said. All other outcomes were similar between groups including head CT progression (26.5% vs. 27%), craniotomy (5.6% vs. 8.5%) and mortality (11% vs. 6.4%).

When the researchers looked at the effect of platelet inhibition on follow-up ART testing, 64% of the 54 patients with an initial positive ART test showed reversal of platelet inhibition on their first follow-up ART test.

"This means that almost one-third of patients did not show a return to normal platelet functioning after a single transfusion of platelets," he said. Nine patients were taken urgently to the OR, died, or were given comfort medications only.

Of the 16 nonresponders, 12 (77%) ultimately showed reversal of their platelet inhibition on follow-up platelet administration and ART testing. Three patients, however, did not return to normal platelet functioning, despite more than three platelet transfusions. Dr. Bautz pointed out.

Initial responders received a significantly greater volume of platelets than did nonresponders (median eight platelet packs vs. six platelet packs), suggesting a dose-response relationship, he said. The mean increase was 70 ARUs per six-pack of platelets.

"A standard six-pack of platelets may not be sufficient, suggesting a benefit of post-transfusion ART," he said.

In all, 91% of patients were restored to normal platelet function.

In regression analysis, there was no significant association between aspirin history or ART results and CT progression, mortality, craniotomy or composite outcomes. Subgroup analysis, however, revealed a trend toward higher mortality for nonresponders, Dr. Bautz said.

"A significant number of traumatic brain injury patients may have occult aspirin inhibition, which is not revealed by history alone," he concluded. "This is in contrast to a rather small number of patients that were shown to have normal platelet functioning and a known history of aspirin, despite high levels of aspirin insensitivity in our population."

Overall, 25% of patients in the series showed progression on follow-up CT, 13% required a craniotomy, and 9.4% died.

The study excluded patients with a history of platelet inhibitors other than aspirin, ongoing use of warfarin (Coumadin), or an International Normalized Ratio of more than 1.5 and those with any epidural component to their TBI.

Invited discussant Dr. Maggie Brandt, with St. Joseph Mercy Hospital in Ann Arbor, Mich., said "the idea of testing for platelets is really spot on and really relevant, but I don’t know if its practical for this problem."

In particular, Dr. Brandt was troubled by the number of patients who did not have a history of aspirin therapy, but were aspirin inhibited, and said it is unclear whether this is a function of other comorbidities or of the test itself. She asked whether ADT testing should be conducted in all TBI patients and whether it is practical to do so based on cost and turnaround time.

Dr. Bautz explained that the high number of patients without an aspirin history in the study is likely because these patients were unable to provide a history upon presentation for TBI. "It is in this setting, that we feel our test is of the most value," he said.

The test typically takes 40 minutes, including laboratory and transport time, and costs about $40 per test, he said.

Audience member Dr. Jonathan Saxe, professor of surgery at Wright State University in Dayton, Ohio, said that brain injury itself has been known to cause issues with aspirin testing and asked whether the brain injuries in the cohort could be causing the platelet test to be abnormal rather than the aspirin. He also pointed out that his group published a similar study finding no impact on mortality with platelet transfusion in elderly TBI patients taking aspirin or clopidogrel (Am. Surg. 2009;75:1100-3). "So I’m wondering, if giving platelets really does anything," he said.

Dr. Bautz said that the ADT test has demonstrated a sensitivity of almost 100% and specificity of 88% at his institution for showing aspirin inhibition. "So it is our belief these patients are on aspirin and that is the cause of their platelet inhibition."

A randomized controlled trial using objective measures of platelet inhibition is necessary to quantify platelet administration in patients presenting with TBI, he said.

The authors reported no conflicts of interest.

DETROIT – Incorporation of aspirin response testing can improve traumatic brain injury management algorithms, a small study suggests.

"It allows us to identify and thereby treat occult platelet inhibition, target platelet transfusion to those who are truly platelet inhibited, and assures adequate response to platelet therapy when it is given," Dr. Joshua Bautz said at the annual meeting of the Central Surgical Association.

The rising use of antiplatelet medications in America’s aging population has prompted many trauma centers to use empiric transfusion of platelet therapy in the setting of traumatic brain injury (TBI) when use of aspirin and other antiplatelet medications are suspected. But the approach is not without consequences.

Aspirin response testing (ART), which was originally designed for use in cardiac patients to assess the effectiveness of antiplatelet medication, has taken on a second role of objectively evaluating platelet inhibition in the setting of TBI when aspirin use is suspected.

Dr. Bautz reported on 84 patients, median age 78 years, who presented from 2008 to 2009 at the University of Pittsburgh Medical Center with a TBI confirmed on head computed tomography (CT). Of these, 45% had a subdural hematoma, 27% a subarachnoid hemorrhage, and 16.5% a combination of hemorrhages.

In all, 36 had a known aspirin history and 48 had no known history or an unobtainable history of aspirin use.

Platelet inhibition was defined by an aspirin response test of less than 550 aspirin response units (ARU) on the VerifyNow Aspirin Test (Accumetrics Inc., San Diego). Patients found to be inhibited received platelet transfusion and a repeat ART test was performed 1 hour following transfusion. If the follow-up ART test again showed platelet inhibition, additional platelets were transfused until the patient was no longer suppressed.

In all, 42% of patients with no known history of aspirin use were objectively shown to have aspirin inhibition, said Dr. Bautz, a second-year resident at the university. In contrast, only two patients with a known aspirin history had normal platelet function and 34 had aspirin inhibition.

As expected, patients with a known aspirin history had significantly lower ART results than did those with an unknown aspirin history (mean 471 ARUs vs. 564 ARUs), he said. All other outcomes were similar between groups including head CT progression (26.5% vs. 27%), craniotomy (5.6% vs. 8.5%) and mortality (11% vs. 6.4%).

When the researchers looked at the effect of platelet inhibition on follow-up ART testing, 64% of the 54 patients with an initial positive ART test showed reversal of platelet inhibition on their first follow-up ART test.

"This means that almost one-third of patients did not show a return to normal platelet functioning after a single transfusion of platelets," he said. Nine patients were taken urgently to the OR, died, or were given comfort medications only.

Of the 16 nonresponders, 12 (77%) ultimately showed reversal of their platelet inhibition on follow-up platelet administration and ART testing. Three patients, however, did not return to normal platelet functioning, despite more than three platelet transfusions. Dr. Bautz pointed out.

Initial responders received a significantly greater volume of platelets than did nonresponders (median eight platelet packs vs. six platelet packs), suggesting a dose-response relationship, he said. The mean increase was 70 ARUs per six-pack of platelets.

"A standard six-pack of platelets may not be sufficient, suggesting a benefit of post-transfusion ART," he said.

In all, 91% of patients were restored to normal platelet function.

In regression analysis, there was no significant association between aspirin history or ART results and CT progression, mortality, craniotomy or composite outcomes. Subgroup analysis, however, revealed a trend toward higher mortality for nonresponders, Dr. Bautz said.

"A significant number of traumatic brain injury patients may have occult aspirin inhibition, which is not revealed by history alone," he concluded. "This is in contrast to a rather small number of patients that were shown to have normal platelet functioning and a known history of aspirin, despite high levels of aspirin insensitivity in our population."

Overall, 25% of patients in the series showed progression on follow-up CT, 13% required a craniotomy, and 9.4% died.

The study excluded patients with a history of platelet inhibitors other than aspirin, ongoing use of warfarin (Coumadin), or an International Normalized Ratio of more than 1.5 and those with any epidural component to their TBI.

Invited discussant Dr. Maggie Brandt, with St. Joseph Mercy Hospital in Ann Arbor, Mich., said "the idea of testing for platelets is really spot on and really relevant, but I don’t know if its practical for this problem."

In particular, Dr. Brandt was troubled by the number of patients who did not have a history of aspirin therapy, but were aspirin inhibited, and said it is unclear whether this is a function of other comorbidities or of the test itself. She asked whether ADT testing should be conducted in all TBI patients and whether it is practical to do so based on cost and turnaround time.

Dr. Bautz explained that the high number of patients without an aspirin history in the study is likely because these patients were unable to provide a history upon presentation for TBI. "It is in this setting, that we feel our test is of the most value," he said.

The test typically takes 40 minutes, including laboratory and transport time, and costs about $40 per test, he said.

Audience member Dr. Jonathan Saxe, professor of surgery at Wright State University in Dayton, Ohio, said that brain injury itself has been known to cause issues with aspirin testing and asked whether the brain injuries in the cohort could be causing the platelet test to be abnormal rather than the aspirin. He also pointed out that his group published a similar study finding no impact on mortality with platelet transfusion in elderly TBI patients taking aspirin or clopidogrel (Am. Surg. 2009;75:1100-3). "So I’m wondering, if giving platelets really does anything," he said.

Dr. Bautz said that the ADT test has demonstrated a sensitivity of almost 100% and specificity of 88% at his institution for showing aspirin inhibition. "So it is our belief these patients are on aspirin and that is the cause of their platelet inhibition."

A randomized controlled trial using objective measures of platelet inhibition is necessary to quantify platelet administration in patients presenting with TBI, he said.

The authors reported no conflicts of interest.

DETROIT – Incorporation of aspirin response testing can improve traumatic brain injury management algorithms, a small study suggests.

"It allows us to identify and thereby treat occult platelet inhibition, target platelet transfusion to those who are truly platelet inhibited, and assures adequate response to platelet therapy when it is given," Dr. Joshua Bautz said at the annual meeting of the Central Surgical Association.

The rising use of antiplatelet medications in America’s aging population has prompted many trauma centers to use empiric transfusion of platelet therapy in the setting of traumatic brain injury (TBI) when use of aspirin and other antiplatelet medications are suspected. But the approach is not without consequences.

Aspirin response testing (ART), which was originally designed for use in cardiac patients to assess the effectiveness of antiplatelet medication, has taken on a second role of objectively evaluating platelet inhibition in the setting of TBI when aspirin use is suspected.

Dr. Bautz reported on 84 patients, median age 78 years, who presented from 2008 to 2009 at the University of Pittsburgh Medical Center with a TBI confirmed on head computed tomography (CT). Of these, 45% had a subdural hematoma, 27% a subarachnoid hemorrhage, and 16.5% a combination of hemorrhages.

In all, 36 had a known aspirin history and 48 had no known history or an unobtainable history of aspirin use.

Platelet inhibition was defined by an aspirin response test of less than 550 aspirin response units (ARU) on the VerifyNow Aspirin Test (Accumetrics Inc., San Diego). Patients found to be inhibited received platelet transfusion and a repeat ART test was performed 1 hour following transfusion. If the follow-up ART test again showed platelet inhibition, additional platelets were transfused until the patient was no longer suppressed.

In all, 42% of patients with no known history of aspirin use were objectively shown to have aspirin inhibition, said Dr. Bautz, a second-year resident at the university. In contrast, only two patients with a known aspirin history had normal platelet function and 34 had aspirin inhibition.

As expected, patients with a known aspirin history had significantly lower ART results than did those with an unknown aspirin history (mean 471 ARUs vs. 564 ARUs), he said. All other outcomes were similar between groups including head CT progression (26.5% vs. 27%), craniotomy (5.6% vs. 8.5%) and mortality (11% vs. 6.4%).

When the researchers looked at the effect of platelet inhibition on follow-up ART testing, 64% of the 54 patients with an initial positive ART test showed reversal of platelet inhibition on their first follow-up ART test.

"This means that almost one-third of patients did not show a return to normal platelet functioning after a single transfusion of platelets," he said. Nine patients were taken urgently to the OR, died, or were given comfort medications only.

Of the 16 nonresponders, 12 (77%) ultimately showed reversal of their platelet inhibition on follow-up platelet administration and ART testing. Three patients, however, did not return to normal platelet functioning, despite more than three platelet transfusions. Dr. Bautz pointed out.

Initial responders received a significantly greater volume of platelets than did nonresponders (median eight platelet packs vs. six platelet packs), suggesting a dose-response relationship, he said. The mean increase was 70 ARUs per six-pack of platelets.

"A standard six-pack of platelets may not be sufficient, suggesting a benefit of post-transfusion ART," he said.

In all, 91% of patients were restored to normal platelet function.

In regression analysis, there was no significant association between aspirin history or ART results and CT progression, mortality, craniotomy or composite outcomes. Subgroup analysis, however, revealed a trend toward higher mortality for nonresponders, Dr. Bautz said.

"A significant number of traumatic brain injury patients may have occult aspirin inhibition, which is not revealed by history alone," he concluded. "This is in contrast to a rather small number of patients that were shown to have normal platelet functioning and a known history of aspirin, despite high levels of aspirin insensitivity in our population."

Overall, 25% of patients in the series showed progression on follow-up CT, 13% required a craniotomy, and 9.4% died.

The study excluded patients with a history of platelet inhibitors other than aspirin, ongoing use of warfarin (Coumadin), or an International Normalized Ratio of more than 1.5 and those with any epidural component to their TBI.

Invited discussant Dr. Maggie Brandt, with St. Joseph Mercy Hospital in Ann Arbor, Mich., said "the idea of testing for platelets is really spot on and really relevant, but I don’t know if its practical for this problem."

In particular, Dr. Brandt was troubled by the number of patients who did not have a history of aspirin therapy, but were aspirin inhibited, and said it is unclear whether this is a function of other comorbidities or of the test itself. She asked whether ADT testing should be conducted in all TBI patients and whether it is practical to do so based on cost and turnaround time.

Dr. Bautz explained that the high number of patients without an aspirin history in the study is likely because these patients were unable to provide a history upon presentation for TBI. "It is in this setting, that we feel our test is of the most value," he said.

The test typically takes 40 minutes, including laboratory and transport time, and costs about $40 per test, he said.

Audience member Dr. Jonathan Saxe, professor of surgery at Wright State University in Dayton, Ohio, said that brain injury itself has been known to cause issues with aspirin testing and asked whether the brain injuries in the cohort could be causing the platelet test to be abnormal rather than the aspirin. He also pointed out that his group published a similar study finding no impact on mortality with platelet transfusion in elderly TBI patients taking aspirin or clopidogrel (Am. Surg. 2009;75:1100-3). "So I’m wondering, if giving platelets really does anything," he said.

Dr. Bautz said that the ADT test has demonstrated a sensitivity of almost 100% and specificity of 88% at his institution for showing aspirin inhibition. "So it is our belief these patients are on aspirin and that is the cause of their platelet inhibition."

A randomized controlled trial using objective measures of platelet inhibition is necessary to quantify platelet administration in patients presenting with TBI, he said.

The authors reported no conflicts of interest.

DETROIT – Incorporation of aspirin response testing can improve traumatic brain injury management algorithms, a small study suggests.

"It allows us to identify and thereby treat occult platelet inhibition, target platelet transfusion to those who are truly platelet inhibited, and assures adequate response to platelet therapy when it is given," Dr. Joshua Bautz said at the annual meeting of the Central Surgical Association.

The rising use of antiplatelet medications in America’s aging population has prompted many trauma centers to use empiric transfusion of platelet therapy in the setting of traumatic brain injury (TBI) when use of aspirin and other antiplatelet medications are suspected. But the approach is not without consequences.

Aspirin response testing (ART), which was originally designed for use in cardiac patients to assess the effectiveness of antiplatelet medication, has taken on a second role of objectively evaluating platelet inhibition in the setting of TBI when aspirin use is suspected.

Dr. Bautz reported on 84 patients, median age 78 years, who presented from 2008 to 2009 at the University of Pittsburgh Medical Center with a TBI confirmed on head computed tomography (CT). Of these, 45% had a subdural hematoma, 27% a subarachnoid hemorrhage, and 16.5% a combination of hemorrhages.

In all, 36 had a known aspirin history and 48 had no known history or an unobtainable history of aspirin use.

Platelet inhibition was defined by an aspirin response test of less than 550 aspirin response units (ARU) on the VerifyNow Aspirin Test (Accumetrics Inc., San Diego). Patients found to be inhibited received platelet transfusion and a repeat ART test was performed 1 hour following transfusion. If the follow-up ART test again showed platelet inhibition, additional platelets were transfused until the patient was no longer suppressed.

In all, 42% of patients with no known history of aspirin use were objectively shown to have aspirin inhibition, said Dr. Bautz, a second-year resident at the university. In contrast, only two patients with a known aspirin history had normal platelet function and 34 had aspirin inhibition.

As expected, patients with a known aspirin history had significantly lower ART results than did those with an unknown aspirin history (mean 471 ARUs vs. 564 ARUs), he said. All other outcomes were similar between groups including head CT progression (26.5% vs. 27%), craniotomy (5.6% vs. 8.5%) and mortality (11% vs. 6.4%).

When the researchers looked at the effect of platelet inhibition on follow-up ART testing, 64% of the 54 patients with an initial positive ART test showed reversal of platelet inhibition on their first follow-up ART test.

"This means that almost one-third of patients did not show a return to normal platelet functioning after a single transfusion of platelets," he said. Nine patients were taken urgently to the OR, died, or were given comfort medications only.

Of the 16 nonresponders, 12 (77%) ultimately showed reversal of their platelet inhibition on follow-up platelet administration and ART testing. Three patients, however, did not return to normal platelet functioning, despite more than three platelet transfusions. Dr. Bautz pointed out.

Initial responders received a significantly greater volume of platelets than did nonresponders (median eight platelet packs vs. six platelet packs), suggesting a dose-response relationship, he said. The mean increase was 70 ARUs per six-pack of platelets.

"A standard six-pack of platelets may not be sufficient, suggesting a benefit of post-transfusion ART," he said.

In all, 91% of patients were restored to normal platelet function.

In regression analysis, there was no significant association between aspirin history or ART results and CT progression, mortality, craniotomy or composite outcomes. Subgroup analysis, however, revealed a trend toward higher mortality for nonresponders, Dr. Bautz said.

"A significant number of traumatic brain injury patients may have occult aspirin inhibition, which is not revealed by history alone," he concluded. "This is in contrast to a rather small number of patients that were shown to have normal platelet functioning and a known history of aspirin, despite high levels of aspirin insensitivity in our population."

Overall, 25% of patients in the series showed progression on follow-up CT, 13% required a craniotomy, and 9.4% died.

The study excluded patients with a history of platelet inhibitors other than aspirin, ongoing use of warfarin (Coumadin), or an International Normalized Ratio of more than 1.5 and those with any epidural component to their TBI.

Invited discussant Dr. Maggie Brandt, with St. Joseph Mercy Hospital in Ann Arbor, Mich., said "the idea of testing for platelets is really spot on and really relevant, but I don’t know if its practical for this problem."

In particular, Dr. Brandt was troubled by the number of patients who did not have a history of aspirin therapy, but were aspirin inhibited, and said it is unclear whether this is a function of other comorbidities or of the test itself. She asked whether ADT testing should be conducted in all TBI patients and whether it is practical to do so based on cost and turnaround time.

Dr. Bautz explained that the high number of patients without an aspirin history in the study is likely because these patients were unable to provide a history upon presentation for TBI. "It is in this setting, that we feel our test is of the most value," he said.

The test typically takes 40 minutes, including laboratory and transport time, and costs about $40 per test, he said.

Audience member Dr. Jonathan Saxe, professor of surgery at Wright State University in Dayton, Ohio, said that brain injury itself has been known to cause issues with aspirin testing and asked whether the brain injuries in the cohort could be causing the platelet test to be abnormal rather than the aspirin. He also pointed out that his group published a similar study finding no impact on mortality with platelet transfusion in elderly TBI patients taking aspirin or clopidogrel (Am. Surg. 2009;75:1100-3). "So I’m wondering, if giving platelets really does anything," he said.

Dr. Bautz said that the ADT test has demonstrated a sensitivity of almost 100% and specificity of 88% at his institution for showing aspirin inhibition. "So it is our belief these patients are on aspirin and that is the cause of their platelet inhibition."

A randomized controlled trial using objective measures of platelet inhibition is necessary to quantify platelet administration in patients presenting with TBI, he said.

The authors reported no conflicts of interest.

DETROIT – Incorporation of aspirin response testing can improve traumatic brain injury management algorithms, a small study suggests.

"It allows us to identify and thereby treat occult platelet inhibition, target platelet transfusion to those who are truly platelet inhibited, and assures adequate response to platelet therapy when it is given," Dr. Joshua Bautz said at the annual meeting of the Central Surgical Association.

The rising use of antiplatelet medications in America’s aging population has prompted many trauma centers to use empiric transfusion of platelet therapy in the setting of traumatic brain injury (TBI) when use of aspirin and other antiplatelet medications are suspected. But the approach is not without consequences.

Aspirin response testing (ART), which was originally designed for use in cardiac patients to assess the effectiveness of antiplatelet medication, has taken on a second role of objectively evaluating platelet inhibition in the setting of TBI when aspirin use is suspected.

Dr. Bautz reported on 84 patients, median age 78 years, who presented from 2008 to 2009 at the University of Pittsburgh Medical Center with a TBI confirmed on head computed tomography (CT). Of these, 45% had a subdural hematoma, 27% a subarachnoid hemorrhage, and 16.5% a combination of hemorrhages.

In all, 36 had a known aspirin history and 48 had no known history or an unobtainable history of aspirin use.

Platelet inhibition was defined by an aspirin response test of less than 550 aspirin response units (ARU) on the VerifyNow Aspirin Test (Accumetrics Inc., San Diego). Patients found to be inhibited received platelet transfusion and a repeat ART test was performed 1 hour following transfusion. If the follow-up ART test again showed platelet inhibition, additional platelets were transfused until the patient was no longer suppressed.

In all, 42% of patients with no known history of aspirin use were objectively shown to have aspirin inhibition, said Dr. Bautz, a second-year resident at the university. In contrast, only two patients with a known aspirin history had normal platelet function and 34 had aspirin inhibition.

As expected, patients with a known aspirin history had significantly lower ART results than did those with an unknown aspirin history (mean 471 ARUs vs. 564 ARUs), he said. All other outcomes were similar between groups including head CT progression (26.5% vs. 27%), craniotomy (5.6% vs. 8.5%) and mortality (11% vs. 6.4%).

When the researchers looked at the effect of platelet inhibition on follow-up ART testing, 64% of the 54 patients with an initial positive ART test showed reversal of platelet inhibition on their first follow-up ART test.

"This means that almost one-third of patients did not show a return to normal platelet functioning after a single transfusion of platelets," he said. Nine patients were taken urgently to the OR, died, or were given comfort medications only.

Of the 16 nonresponders, 12 (77%) ultimately showed reversal of their platelet inhibition on follow-up platelet administration and ART testing. Three patients, however, did not return to normal platelet functioning, despite more than three platelet transfusions. Dr. Bautz pointed out.

Initial responders received a significantly greater volume of platelets than did nonresponders (median eight platelet packs vs. six platelet packs), suggesting a dose-response relationship, he said. The mean increase was 70 ARUs per six-pack of platelets.

"A standard six-pack of platelets may not be sufficient, suggesting a benefit of post-transfusion ART," he said.

In all, 91% of patients were restored to normal platelet function.

In regression analysis, there was no significant association between aspirin history or ART results and CT progression, mortality, craniotomy or composite outcomes. Subgroup analysis, however, revealed a trend toward higher mortality for nonresponders, Dr. Bautz said.

"A significant number of traumatic brain injury patients may have occult aspirin inhibition, which is not revealed by history alone," he concluded. "This is in contrast to a rather small number of patients that were shown to have normal platelet functioning and a known history of aspirin, despite high levels of aspirin insensitivity in our population."

Overall, 25% of patients in the series showed progression on follow-up CT, 13% required a craniotomy, and 9.4% died.

The study excluded patients with a history of platelet inhibitors other than aspirin, ongoing use of warfarin (Coumadin), or an International Normalized Ratio of more than 1.5 and those with any epidural component to their TBI.

Invited discussant Dr. Maggie Brandt, with St. Joseph Mercy Hospital in Ann Arbor, Mich., said "the idea of testing for platelets is really spot on and really relevant, but I don’t know if its practical for this problem."

In particular, Dr. Brandt was troubled by the number of patients who did not have a history of aspirin therapy, but were aspirin inhibited, and said it is unclear whether this is a function of other comorbidities or of the test itself. She asked whether ADT testing should be conducted in all TBI patients and whether it is practical to do so based on cost and turnaround time.

Dr. Bautz explained that the high number of patients without an aspirin history in the study is likely because these patients were unable to provide a history upon presentation for TBI. "It is in this setting, that we feel our test is of the most value," he said.

The test typically takes 40 minutes, including laboratory and transport time, and costs about $40 per test, he said.

Audience member Dr. Jonathan Saxe, professor of surgery at Wright State University in Dayton, Ohio, said that brain injury itself has been known to cause issues with aspirin testing and asked whether the brain injuries in the cohort could be causing the platelet test to be abnormal rather than the aspirin. He also pointed out that his group published a similar study finding no impact on mortality with platelet transfusion in elderly TBI patients taking aspirin or clopidogrel (Am. Surg. 2009;75:1100-3). "So I’m wondering, if giving platelets really does anything," he said.

Dr. Bautz said that the ADT test has demonstrated a sensitivity of almost 100% and specificity of 88% at his institution for showing aspirin inhibition. "So it is our belief these patients are on aspirin and that is the cause of their platelet inhibition."

A randomized controlled trial using objective measures of platelet inhibition is necessary to quantify platelet administration in patients presenting with TBI, he said.

The authors reported no conflicts of interest.

DETROIT – Incorporation of aspirin response testing can improve traumatic brain injury management algorithms, a small study suggests.

"It allows us to identify and thereby treat occult platelet inhibition, target platelet transfusion to those who are truly platelet inhibited, and assures adequate response to platelet therapy when it is given," Dr. Joshua Bautz said at the annual meeting of the Central Surgical Association.

The rising use of antiplatelet medications in America’s aging population has prompted many trauma centers to use empiric transfusion of platelet therapy in the setting of traumatic brain injury (TBI) when use of aspirin and other antiplatelet medications are suspected. But the approach is not without consequences.

Aspirin response testing (ART), which was originally designed for use in cardiac patients to assess the effectiveness of antiplatelet medication, has taken on a second role of objectively evaluating platelet inhibition in the setting of TBI when aspirin use is suspected.

Dr. Bautz reported on 84 patients, median age 78 years, who presented from 2008 to 2009 at the University of Pittsburgh Medical Center with a TBI confirmed on head computed tomography (CT). Of these, 45% had a subdural hematoma, 27% a subarachnoid hemorrhage, and 16.5% a combination of hemorrhages.

In all, 36 had a known aspirin history and 48 had no known history or an unobtainable history of aspirin use.

Platelet inhibition was defined by an aspirin response test of less than 550 aspirin response units (ARU) on the VerifyNow Aspirin Test (Accumetrics Inc., San Diego). Patients found to be inhibited received platelet transfusion and a repeat ART test was performed 1 hour following transfusion. If the follow-up ART test again showed platelet inhibition, additional platelets were transfused until the patient was no longer suppressed.

In all, 42% of patients with no known history of aspirin use were objectively shown to have aspirin inhibition, said Dr. Bautz, a second-year resident at the university. In contrast, only two patients with a known aspirin history had normal platelet function and 34 had aspirin inhibition.

As expected, patients with a known aspirin history had significantly lower ART results than did those with an unknown aspirin history (mean 471 ARUs vs. 564 ARUs), he said. All other outcomes were similar between groups including head CT progression (26.5% vs. 27%), craniotomy (5.6% vs. 8.5%) and mortality (11% vs. 6.4%).

When the researchers looked at the effect of platelet inhibition on follow-up ART testing, 64% of the 54 patients with an initial positive ART test showed reversal of platelet inhibition on their first follow-up ART test.

"This means that almost one-third of patients did not show a return to normal platelet functioning after a single transfusion of platelets," he said. Nine patients were taken urgently to the OR, died, or were given comfort medications only.

Of the 16 nonresponders, 12 (77%) ultimately showed reversal of their platelet inhibition on follow-up platelet administration and ART testing. Three patients, however, did not return to normal platelet functioning, despite more than three platelet transfusions. Dr. Bautz pointed out.

Initial responders received a significantly greater volume of platelets than did nonresponders (median eight platelet packs vs. six platelet packs), suggesting a dose-response relationship, he said. The mean increase was 70 ARUs per six-pack of platelets.

"A standard six-pack of platelets may not be sufficient, suggesting a benefit of post-transfusion ART," he said.

In all, 91% of patients were restored to normal platelet function.

In regression analysis, there was no significant association between aspirin history or ART results and CT progression, mortality, craniotomy or composite outcomes. Subgroup analysis, however, revealed a trend toward higher mortality for nonresponders, Dr. Bautz said.

"A significant number of traumatic brain injury patients may have occult aspirin inhibition, which is not revealed by history alone," he concluded. "This is in contrast to a rather small number of patients that were shown to have normal platelet functioning and a known history of aspirin, despite high levels of aspirin insensitivity in our population."

Overall, 25% of patients in the series showed progression on follow-up CT, 13% required a craniotomy, and 9.4% died.

The study excluded patients with a history of platelet inhibitors other than aspirin, ongoing use of warfarin (Coumadin), or an International Normalized Ratio of more than 1.5 and those with any epidural component to their TBI.

Invited discussant Dr. Maggie Brandt, with St. Joseph Mercy Hospital in Ann Arbor, Mich., said "the idea of testing for platelets is really spot on and really relevant, but I don’t know if its practical for this problem."

In particular, Dr. Brandt was troubled by the number of patients who did not have a history of aspirin therapy, but were aspirin inhibited, and said it is unclear whether this is a function of other comorbidities or of the test itself. She asked whether ADT testing should be conducted in all TBI patients and whether it is practical to do so based on cost and turnaround time.

Dr. Bautz explained that the high number of patients without an aspirin history in the study is likely because these patients were unable to provide a history upon presentation for TBI. "It is in this setting, that we feel our test is of the most value," he said.

The test typically takes 40 minutes, including laboratory and transport time, and costs about $40 per test, he said.

Audience member Dr. Jonathan Saxe, professor of surgery at Wright State University in Dayton, Ohio, said that brain injury itself has been known to cause issues with aspirin testing and asked whether the brain injuries in the cohort could be causing the platelet test to be abnormal rather than the aspirin. He also pointed out that his group published a similar study finding no impact on mortality with platelet transfusion in elderly TBI patients taking aspirin or clopidogrel (Am. Surg. 2009;75:1100-3). "So I’m wondering, if giving platelets really does anything," he said.

Dr. Bautz said that the ADT test has demonstrated a sensitivity of almost 100% and specificity of 88% at his institution for showing aspirin inhibition. "So it is our belief these patients are on aspirin and that is the cause of their platelet inhibition."

A randomized controlled trial using objective measures of platelet inhibition is necessary to quantify platelet administration in patients presenting with TBI, he said.

The authors reported no conflicts of interest.

DETROIT – Incorporation of aspirin response testing can improve traumatic brain injury management algorithms, a small study suggests.

"It allows us to identify and thereby treat occult platelet inhibition, target platelet transfusion to those who are truly platelet inhibited, and assures adequate response to platelet therapy when it is given," Dr. Joshua Bautz said at the annual meeting of the Central Surgical Association.

The rising use of antiplatelet medications in America’s aging population has prompted many trauma centers to use empiric transfusion of platelet therapy in the setting of traumatic brain injury (TBI) when use of aspirin and other antiplatelet medications are suspected. But the approach is not without consequences.

Aspirin response testing (ART), which was originally designed for use in cardiac patients to assess the effectiveness of antiplatelet medication, has taken on a second role of objectively evaluating platelet inhibition in the setting of TBI when aspirin use is suspected.

Dr. Bautz reported on 84 patients, median age 78 years, who presented from 2008 to 2009 at the University of Pittsburgh Medical Center with a TBI confirmed on head computed tomography (CT). Of these, 45% had a subdural hematoma, 27% a subarachnoid hemorrhage, and 16.5% a combination of hemorrhages.

In all, 36 had a known aspirin history and 48 had no known history or an unobtainable history of aspirin use.

Platelet inhibition was defined by an aspirin response test of less than 550 aspirin response units (ARU) on the VerifyNow Aspirin Test (Accumetrics Inc., San Diego). Patients found to be inhibited received platelet transfusion and a repeat ART test was performed 1 hour following transfusion. If the follow-up ART test again showed platelet inhibition, additional platelets were transfused until the patient was no longer suppressed.

In all, 42% of patients with no known history of aspirin use were objectively shown to have aspirin inhibition, said Dr. Bautz, a second-year resident at the university. In contrast, only two patients with a known aspirin history had normal platelet function and 34 had aspirin inhibition.

As expected, patients with a known aspirin history had significantly lower ART results than did those with an unknown aspirin history (mean 471 ARUs vs. 564 ARUs), he said. All other outcomes were similar between groups including head CT progression (26.5% vs. 27%), craniotomy (5.6% vs. 8.5%) and mortality (11% vs. 6.4%).

When the researchers looked at the effect of platelet inhibition on follow-up ART testing, 64% of the 54 patients with an initial positive ART test showed reversal of platelet inhibition on their first follow-up ART test.

"This means that almost one-third of patients did not show a return to normal platelet functioning after a single transfusion of platelets," he said. Nine patients were taken urgently to the OR, died, or were given comfort medications only.

Of the 16 nonresponders, 12 (77%) ultimately showed reversal of their platelet inhibition on follow-up platelet administration and ART testing. Three patients, however, did not return to normal platelet functioning, despite more than three platelet transfusions. Dr. Bautz pointed out.

Initial responders received a significantly greater volume of platelets than did nonresponders (median eight platelet packs vs. six platelet packs), suggesting a dose-response relationship, he said. The mean increase was 70 ARUs per six-pack of platelets.

"A standard six-pack of platelets may not be sufficient, suggesting a benefit of post-transfusion ART," he said.

In all, 91% of patients were restored to normal platelet function.

In regression analysis, there was no significant association between aspirin history or ART results and CT progression, mortality, craniotomy or composite outcomes. Subgroup analysis, however, revealed a trend toward higher mortality for nonresponders, Dr. Bautz said.

"A significant number of traumatic brain injury patients may have occult aspirin inhibition, which is not revealed by history alone," he concluded. "This is in contrast to a rather small number of patients that were shown to have normal platelet functioning and a known history of aspirin, despite high levels of aspirin insensitivity in our population."

Overall, 25% of patients in the series showed progression on follow-up CT, 13% required a craniotomy, and 9.4% died.

The study excluded patients with a history of platelet inhibitors other than aspirin, ongoing use of warfarin (Coumadin), or an International Normalized Ratio of more than 1.5 and those with any epidural component to their TBI.

Invited discussant Dr. Maggie Brandt, with St. Joseph Mercy Hospital in Ann Arbor, Mich., said "the idea of testing for platelets is really spot on and really relevant, but I don’t know if its practical for this problem."

In particular, Dr. Brandt was troubled by the number of patients who did not have a history of aspirin therapy, but were aspirin inhibited, and said it is unclear whether this is a function of other comorbidities or of the test itself. She asked whether ADT testing should be conducted in all TBI patients and whether it is practical to do so based on cost and turnaround time.

Dr. Bautz explained that the high number of patients without an aspirin history in the study is likely because these patients were unable to provide a history upon presentation for TBI. "It is in this setting, that we feel our test is of the most value," he said.

The test typically takes 40 minutes, including laboratory and transport time, and costs about $40 per test, he said.

Audience member Dr. Jonathan Saxe, professor of surgery at Wright State University in Dayton, Ohio, said that brain injury itself has been known to cause issues with aspirin testing and asked whether the brain injuries in the cohort could be causing the platelet test to be abnormal rather than the aspirin. He also pointed out that his group published a similar study finding no impact on mortality with platelet transfusion in elderly TBI patients taking aspirin or clopidogrel (Am. Surg. 2009;75:1100-3). "So I’m wondering, if giving platelets really does anything," he said.

Dr. Bautz said that the ADT test has demonstrated a sensitivity of almost 100% and specificity of 88% at his institution for showing aspirin inhibition. "So it is our belief these patients are on aspirin and that is the cause of their platelet inhibition."

A randomized controlled trial using objective measures of platelet inhibition is necessary to quantify platelet administration in patients presenting with TBI, he said.

The authors reported no conflicts of interest.

DETROIT – Incorporation of aspirin response testing can improve traumatic brain injury management algorithms, a small study suggests.

"It allows us to identify and thereby treat occult platelet inhibition, target platelet transfusion to those who are truly platelet inhibited, and assures adequate response to platelet therapy when it is given," Dr. Joshua Bautz said at the annual meeting of the Central Surgical Association.

The rising use of antiplatelet medications in America’s aging population has prompted many trauma centers to use empiric transfusion of platelet therapy in the setting of traumatic brain injury (TBI) when use of aspirin and other antiplatelet medications are suspected. But the approach is not without consequences.

Aspirin response testing (ART), which was originally designed for use in cardiac patients to assess the effectiveness of antiplatelet medication, has taken on a second role of objectively evaluating platelet inhibition in the setting of TBI when aspirin use is suspected.

Dr. Bautz reported on 84 patients, median age 78 years, who presented from 2008 to 2009 at the University of Pittsburgh Medical Center with a TBI confirmed on head computed tomography (CT). Of these, 45% had a subdural hematoma, 27% a subarachnoid hemorrhage, and 16.5% a combination of hemorrhages.

In all, 36 had a known aspirin history and 48 had no known history or an unobtainable history of aspirin use.

Platelet inhibition was defined by an aspirin response test of less than 550 aspirin response units (ARU) on the VerifyNow Aspirin Test (Accumetrics Inc., San Diego). Patients found to be inhibited received platelet transfusion and a repeat ART test was performed 1 hour following transfusion. If the follow-up ART test again showed platelet inhibition, additional platelets were transfused until the patient was no longer suppressed.

In all, 42% of patients with no known history of aspirin use were objectively shown to have aspirin inhibition, said Dr. Bautz, a second-year resident at the university. In contrast, only two patients with a known aspirin history had normal platelet function and 34 had aspirin inhibition.

As expected, patients with a known aspirin history had significantly lower ART results than did those with an unknown aspirin history (mean 471 ARUs vs. 564 ARUs), he said. All other outcomes were similar between groups including head CT progression (26.5% vs. 27%), craniotomy (5.6% vs. 8.5%) and mortality (11% vs. 6.4%).

When the researchers looked at the effect of platelet inhibition on follow-up ART testing, 64% of the 54 patients with an initial positive ART test showed reversal of platelet inhibition on their first follow-up ART test.

"This means that almost one-third of patients did not show a return to normal platelet functioning after a single transfusion of platelets," he said. Nine patients were taken urgently to the OR, died, or were given comfort medications only.

Of the 16 nonresponders, 12 (77%) ultimately showed reversal of their platelet inhibition on follow-up platelet administration and ART testing. Three patients, however, did not return to normal platelet functioning, despite more than three platelet transfusions. Dr. Bautz pointed out.

Initial responders received a significantly greater volume of platelets than did nonresponders (median eight platelet packs vs. six platelet packs), suggesting a dose-response relationship, he said. The mean increase was 70 ARUs per six-pack of platelets.

"A standard six-pack of platelets may not be sufficient, suggesting a benefit of post-transfusion ART," he said.

In all, 91% of patients were restored to normal platelet function.

In regression analysis, there was no significant association between aspirin history or ART results and CT progression, mortality, craniotomy or composite outcomes. Subgroup analysis, however, revealed a trend toward higher mortality for nonresponders, Dr. Bautz said.

"A significant number of traumatic brain injury patients may have occult aspirin inhibition, which is not revealed by history alone," he concluded. "This is in contrast to a rather small number of patients that were shown to have normal platelet functioning and a known history of aspirin, despite high levels of aspirin insensitivity in our population."

Overall, 25% of patients in the series showed progression on follow-up CT, 13% required a craniotomy, and 9.4% died.

The study excluded patients with a history of platelet inhibitors other than aspirin, ongoing use of warfarin (Coumadin), or an International Normalized Ratio of more than 1.5 and those with any epidural component to their TBI.

Invited discussant Dr. Maggie Brandt, with St. Joseph Mercy Hospital in Ann Arbor, Mich., said "the idea of testing for platelets is really spot on and really relevant, but I don’t know if its practical for this problem."

In particular, Dr. Brandt was troubled by the number of patients who did not have a history of aspirin therapy, but were aspirin inhibited, and said it is unclear whether this is a function of other comorbidities or of the test itself. She asked whether ADT testing should be conducted in all TBI patients and whether it is practical to do so based on cost and turnaround time.

Dr. Bautz explained that the high number of patients without an aspirin history in the study is likely because these patients were unable to provide a history upon presentation for TBI. "It is in this setting, that we feel our test is of the most value," he said.

The test typically takes 40 minutes, including laboratory and transport time, and costs about $40 per test, he said.

Audience member Dr. Jonathan Saxe, professor of surgery at Wright State University in Dayton, Ohio, said that brain injury itself has been known to cause issues with aspirin testing and asked whether the brain injuries in the cohort could be causing the platelet test to be abnormal rather than the aspirin. He also pointed out that his group published a similar study finding no impact on mortality with platelet transfusion in elderly TBI patients taking aspirin or clopidogrel (Am. Surg. 2009;75:1100-3). "So I’m wondering, if giving platelets really does anything," he said.

Dr. Bautz said that the ADT test has demonstrated a sensitivity of almost 100% and specificity of 88% at his institution for showing aspirin inhibition. "So it is our belief these patients are on aspirin and that is the cause of their platelet inhibition."

A randomized controlled trial using objective measures of platelet inhibition is necessary to quantify platelet administration in patients presenting with TBI, he said.

The authors reported no conflicts of interest.

DETROIT – Incorporation of aspirin response testing can improve traumatic brain injury management algorithms, a small study suggests.

"It allows us to identify and thereby treat occult platelet inhibition, target platelet transfusion to those who are truly platelet inhibited, and assures adequate response to platelet therapy when it is given," Dr. Joshua Bautz said at the annual meeting of the Central Surgical Association.

The rising use of antiplatelet medications in America’s aging population has prompted many trauma centers to use empiric transfusion of platelet therapy in the setting of traumatic brain injury (TBI) when use of aspirin and other antiplatelet medications are suspected. But the approach is not without consequences.

Aspirin response testing (ART), which was originally designed for use in cardiac patients to assess the effectiveness of antiplatelet medication, has taken on a second role of objectively evaluating platelet inhibition in the setting of TBI when aspirin use is suspected.

Dr. Bautz reported on 84 patients, median age 78 years, who presented from 2008 to 2009 at the University of Pittsburgh Medical Center with a TBI confirmed on head computed tomography (CT). Of these, 45% had a subdural hematoma, 27% a subarachnoid hemorrhage, and 16.5% a combination of hemorrhages.

In all, 36 had a known aspirin history and 48 had no known history or an unobtainable history of aspirin use.

Platelet inhibition was defined by an aspirin response test of less than 550 aspirin response units (ARU) on the VerifyNow Aspirin Test (Accumetrics Inc., San Diego). Patients found to be inhibited received platelet transfusion and a repeat ART test was performed 1 hour following transfusion. If the follow-up ART test again showed platelet inhibition, additional platelets were transfused until the patient was no longer suppressed.

In all, 42% of patients with no known history of aspirin use were objectively shown to have aspirin inhibition, said Dr. Bautz, a second-year resident at the university. In contrast, only two patients with a known aspirin history had normal platelet function and 34 had aspirin inhibition.

As expected, patients with a known aspirin history had significantly lower ART results than did those with an unknown aspirin history (mean 471 ARUs vs. 564 ARUs), he said. All other outcomes were similar between groups including head CT progression (26.5% vs. 27%), craniotomy (5.6% vs. 8.5%) and mortality (11% vs. 6.4%).

When the researchers looked at the effect of platelet inhibition on follow-up ART testing, 64% of the 54 patients with an initial positive ART test showed reversal of platelet inhibition on their first follow-up ART test.

"This means that almost one-third of patients did not show a return to normal platelet functioning after a single transfusion of platelets," he said. Nine patients were taken urgently to the OR, died, or were given comfort medications only.

Of the 16 nonresponders, 12 (77%) ultimately showed reversal of their platelet inhibition on follow-up platelet administration and ART testing. Three patients, however, did not return to normal platelet functioning, despite more than three platelet transfusions. Dr. Bautz pointed out.

Initial responders received a significantly greater volume of platelets than did nonresponders (median eight platelet packs vs. six platelet packs), suggesting a dose-response relationship, he said. The mean increase was 70 ARUs per six-pack of platelets.

"A standard six-pack of platelets may not be sufficient, suggesting a benefit of post-transfusion ART," he said.

In all, 91% of patients were restored to normal platelet function.

In regression analysis, there was no significant association between aspirin history or ART results and CT progression, mortality, craniotomy or composite outcomes. Subgroup analysis, however, revealed a trend toward higher mortality for nonresponders, Dr. Bautz said.

"A significant number of traumatic brain injury patients may have occult aspirin inhibition, which is not revealed by history alone," he concluded. "This is in contrast to a rather small number of patients that were shown to have normal platelet functioning and a known history of aspirin, despite high levels of aspirin insensitivity in our population."

Overall, 25% of patients in the series showed progression on follow-up CT, 13% required a craniotomy, and 9.4% died.

The study excluded patients with a history of platelet inhibitors other than aspirin, ongoing use of warfarin (Coumadin), or an International Normalized Ratio of more than 1.5 and those with any epidural component to their TBI.

Invited discussant Dr. Maggie Brandt, with St. Joseph Mercy Hospital in Ann Arbor, Mich., said "the idea of testing for platelets is really spot on and really relevant, but I don’t know if its practical for this problem."

In particular, Dr. Brandt was troubled by the number of patients who did not have a history of aspirin therapy, but were aspirin inhibited, and said it is unclear whether this is a function of other comorbidities or of the test itself. She asked whether ADT testing should be conducted in all TBI patients and whether it is practical to do so based on cost and turnaround time.

Dr. Bautz explained that the high number of patients without an aspirin history in the study is likely because these patients were unable to provide a history upon presentation for TBI. "It is in this setting, that we feel our test is of the most value," he said.

The test typically takes 40 minutes, including laboratory and transport time, and costs about $40 per test, he said.

Audience member Dr. Jonathan Saxe, professor of surgery at Wright State University in Dayton, Ohio, said that brain injury itself has been known to cause issues with aspirin testing and asked whether the brain injuries in the cohort could be causing the platelet test to be abnormal rather than the aspirin. He also pointed out that his group published a similar study finding no impact on mortality with platelet transfusion in elderly TBI patients taking aspirin or clopidogrel (Am. Surg. 2009;75:1100-3). "So I’m wondering, if giving platelets really does anything," he said.

Dr. Bautz said that the ADT test has demonstrated a sensitivity of almost 100% and specificity of 88% at his institution for showing aspirin inhibition. "So it is our belief these patients are on aspirin and that is the cause of their platelet inhibition."

A randomized controlled trial using objective measures of platelet inhibition is necessary to quantify platelet administration in patients presenting with TBI, he said.

The authors reported no conflicts of interest.

DETROIT - Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 surgeons over the next 20 years.

"We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bidding wars," Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

"In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today."

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical specialties: obstetrics and gynecology, orthopedic surgery, general surgery, otolaryngology, urology, neurosurgery, and thoracic surgery (Ann. Surg. 2009;250:590-7)

The current analysis went one step further, focusing on the average recruitment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population receiving care at urban and rural hospitals will remain constant, Dr. Williams explained.

Currently, the American Hospital Association estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hospitals serving 18% or 56 million Americans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and retain 4,175 surgeons per year or 27.7 surgeons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dramatic loss of general surgeons.

"In rural hospitals, general surgery is essential," he said. "[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their administrators of retiring or leaving in 2 years. Thirty-three percent of rural hospitals are recruiting now."

Factors that might make rural recruitment more difficult include professional and social isolation, cross coverage, insufficient training for the variety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, independence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon toward a rural hospital is doing a residency in a rural training program. The researchers estimate that half of general surgery residents who rotate through such a program will go on to practice in rural towns.

"It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals," Dr. Williams said.

Consideration of the needs of the surgeon’s family is another factor. Typically, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician couple. Thus, educational loan repayment could be a potential "trump card" for rural hospitals in the future, he said.

Rural hospitals are already throwing out the welcome mat. Most offer hiring incentives such as a relocation allowance; signing bonus; health, disability, and life insurance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hospitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

"In many general surgery programs in the United States, senior residents are receiving as many as 50 offers for employment today," he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an orthopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full benefits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Soper, chair of the department of surgery at Northwestern University in Chicago, said, "It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done."

Dr. Sober suggested that the basic problem is not so much the division between rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhagwan Satiani replied that the analysis included a simplified version of the federal model used to calculate supply and demand, but added that every projection in the last 50-75 years has been wrong. "You have to look at this model and say, ‘This is the best we can do right now," he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive medical school rural program (MSRP). "If you took 10 medical students out of the class and put them into the MSRP program, you could double the number of rural surgeons. That’s how important that is," said Dr. Satiani, medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia provides a similar calculation for rural physicians and reports that 79%-87% of graduates from the two MSRPs with long-range rural outcomes – the PSAP and University of Minnesota at Duluth – remained in rural practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Affordable Care Act authorized a new Rural Physician Training Grants program to provide grants to medical schools to develop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be considered programs that attract rural surgeons, according to Dr. Satiani. "I think American surgery is going to have to give this a separate tract within residency programs."

Audience member Dr. Mark Malangoni, associate executive director of the American Board of Surgery in Philadelphia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Washington state. He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural areas.

Finally, several audience members suggested that efforts need to be made to eliminate the perception among residents that surgical specialists are somehow better than general surgeons.

"It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists," Dr. Satiani said. "I think it has to come from the programs and the leadership; defining general surgery better, even going as far as changing the name, if that becomes an important issue."

When asked in an interview what that new name might be, Dr. Satiani said the terms "master surgeon" and "omni surgeon" have been floated, with master surgeon more likely to resonate with the general public.

The authors reported no conflicts of interest.

DETROIT - Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 surgeons over the next 20 years.

"We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bidding wars," Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

"In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today."

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical specialties: obstetrics and gynecology, orthopedic surgery, general surgery, otolaryngology, urology, neurosurgery, and thoracic surgery (Ann. Surg. 2009;250:590-7)

The current analysis went one step further, focusing on the average recruitment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population receiving care at urban and rural hospitals will remain constant, Dr. Williams explained.

Currently, the American Hospital Association estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hospitals serving 18% or 56 million Americans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and retain 4,175 surgeons per year or 27.7 surgeons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dramatic loss of general surgeons.

"In rural hospitals, general surgery is essential," he said. "[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their administrators of retiring or leaving in 2 years. Thirty-three percent of rural hospitals are recruiting now."

Factors that might make rural recruitment more difficult include professional and social isolation, cross coverage, insufficient training for the variety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, independence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon toward a rural hospital is doing a residency in a rural training program. The researchers estimate that half of general surgery residents who rotate through such a program will go on to practice in rural towns.

"It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals," Dr. Williams said.

Consideration of the needs of the surgeon’s family is another factor. Typically, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician couple. Thus, educational loan repayment could be a potential "trump card" for rural hospitals in the future, he said.

Rural hospitals are already throwing out the welcome mat. Most offer hiring incentives such as a relocation allowance; signing bonus; health, disability, and life insurance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hospitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

"In many general surgery programs in the United States, senior residents are receiving as many as 50 offers for employment today," he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an orthopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full benefits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Soper, chair of the department of surgery at Northwestern University in Chicago, said, "It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done."

Dr. Sober suggested that the basic problem is not so much the division between rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhagwan Satiani replied that the analysis included a simplified version of the federal model used to calculate supply and demand, but added that every projection in the last 50-75 years has been wrong. "You have to look at this model and say, ‘This is the best we can do right now," he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive medical school rural program (MSRP). "If you took 10 medical students out of the class and put them into the MSRP program, you could double the number of rural surgeons. That’s how important that is," said Dr. Satiani, medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia provides a similar calculation for rural physicians and reports that 79%-87% of graduates from the two MSRPs with long-range rural outcomes – the PSAP and University of Minnesota at Duluth – remained in rural practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Affordable Care Act authorized a new Rural Physician Training Grants program to provide grants to medical schools to develop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be considered programs that attract rural surgeons, according to Dr. Satiani. "I think American surgery is going to have to give this a separate tract within residency programs."

Audience member Dr. Mark Malangoni, associate executive director of the American Board of Surgery in Philadelphia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Washington state. He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural areas.

Finally, several audience members suggested that efforts need to be made to eliminate the perception among residents that surgical specialists are somehow better than general surgeons.

"It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists," Dr. Satiani said. "I think it has to come from the programs and the leadership; defining general surgery better, even going as far as changing the name, if that becomes an important issue."

When asked in an interview what that new name might be, Dr. Satiani said the terms "master surgeon" and "omni surgeon" have been floated, with master surgeon more likely to resonate with the general public.

The authors reported no conflicts of interest.

DETROIT - Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 surgeons over the next 20 years.

"We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bidding wars," Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

"In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today."

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical specialties: obstetrics and gynecology, orthopedic surgery, general surgery, otolaryngology, urology, neurosurgery, and thoracic surgery (Ann. Surg. 2009;250:590-7)

The current analysis went one step further, focusing on the average recruitment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population receiving care at urban and rural hospitals will remain constant, Dr. Williams explained.

Currently, the American Hospital Association estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hospitals serving 18% or 56 million Americans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and retain 4,175 surgeons per year or 27.7 surgeons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dramatic loss of general surgeons.

"In rural hospitals, general surgery is essential," he said. "[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their administrators of retiring or leaving in 2 years. Thirty-three percent of rural hospitals are recruiting now."

Factors that might make rural recruitment more difficult include professional and social isolation, cross coverage, insufficient training for the variety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, independence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon toward a rural hospital is doing a residency in a rural training program. The researchers estimate that half of general surgery residents who rotate through such a program will go on to practice in rural towns.

"It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals," Dr. Williams said.

Consideration of the needs of the surgeon’s family is another factor. Typically, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician couple. Thus, educational loan repayment could be a potential "trump card" for rural hospitals in the future, he said.

Rural hospitals are already throwing out the welcome mat. Most offer hiring incentives such as a relocation allowance; signing bonus; health, disability, and life insurance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hospitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

"In many general surgery programs in the United States, senior residents are receiving as many as 50 offers for employment today," he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an orthopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full benefits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Soper, chair of the department of surgery at Northwestern University in Chicago, said, "It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done."

Dr. Sober suggested that the basic problem is not so much the division between rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhagwan Satiani replied that the analysis included a simplified version of the federal model used to calculate supply and demand, but added that every projection in the last 50-75 years has been wrong. "You have to look at this model and say, ‘This is the best we can do right now," he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive medical school rural program (MSRP). "If you took 10 medical students out of the class and put them into the MSRP program, you could double the number of rural surgeons. That’s how important that is," said Dr. Satiani, medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia provides a similar calculation for rural physicians and reports that 79%-87% of graduates from the two MSRPs with long-range rural outcomes – the PSAP and University of Minnesota at Duluth – remained in rural practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Affordable Care Act authorized a new Rural Physician Training Grants program to provide grants to medical schools to develop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be considered programs that attract rural surgeons, according to Dr. Satiani. "I think American surgery is going to have to give this a separate tract within residency programs."

Audience member Dr. Mark Malangoni, associate executive director of the American Board of Surgery in Philadelphia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Washington state. He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural areas.

Finally, several audience members suggested that efforts need to be made to eliminate the perception among residents that surgical specialists are somehow better than general surgeons.

"It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists," Dr. Satiani said. "I think it has to come from the programs and the leadership; defining general surgery better, even going as far as changing the name, if that becomes an important issue."

When asked in an interview what that new name might be, Dr. Satiani said the terms "master surgeon" and "omni surgeon" have been floated, with master surgeon more likely to resonate with the general public.

The authors reported no conflicts of interest.