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Primary cancers of the liver and biliary tract are rare and aggressive tumors that often present with locally advanced or metastatic disease. For patients with localized disease amenable to resection, surgery typically offers the best chance at curative-intent therapy. Unfortunately, the incidence of recurrence even after curative-intent surgery remains high. In turn, patients with hepatobiliary cancers commonly require multimodality therapy including a combination of resection, systemic therapy (i.e., targeted therapy, cytotoxic chemotherapy, immunotherapy), and/or loco-regional therapies. With advancements in the field, it is crucial for surgical oncologists to remain updated on the latest guidelines and recommendations for surgical management and optimal patient selection. Given the complex and evolving nature of treatment, this report highlights the latest practice guidelines for the surgical management of hepatobiliary cancers. [ABSTRACT FROM AUTHOR]

Background: Solid pseudopapillary neoplasms (SPN) are rare tumors of the pancreas, typically affecting young women. Resection is the mainstay of treatment but is associated with significant morbidity and potential mortality. We explore the idea that small, localized SPN could be safely observed. Methods: This retrospective review of the Pancreas National Cancer Database from 2004 to 2018 identified SPN via histology code 8452. Results: A total of 994 SPNs were identified. Mean age was 36.8 ± 0.5 years, 84.9% (n = 844) were female, and most had a Charlson–Deyo Comorbidity Coefficient (CDCC) of 0–1 (96.6%, n = 960). Patients were most often staged clinically as cT2 (69.5%, n = 457) followed by cT3 (17.6%, n = 116), cT1 (11.2%, n = 74), and cT4 (1.7%, n = 11). Clinical lymph node and distant metastasis rates were 3.0 and 4.0%, respectively. Surgical resection was performed in 96.6% of patients (n = 960), most commonly partial pancreatectomy (44.3%) followed by pancreatoduodenectomy (31.3%) and total pancreatectomy (8.1%). In patients clinically staged as node (N0) and distant metastasis (M0) negative, occult pathologic lymph node involvement was found in 0% (n = 28) of patients with stage cT1 and 0.5% (n = 185) of patients with cT2 disease. The risk of occult nodal metastasis significantly increased to 8.9% (n = 61) for patients with cT3 disease. The risk further increased to 50% (n = 2) in patients with cT4 disease. Conclusions: Herein, the specificity of excluding nodal involvement clinically is 99.5% in tumors ≤ 4 cm and 100% in tumors ≤ 2 cm. Therefore, there may be a role for close observation in patients with cT1N0 lesions to mitigate morbidity from major pancreatic resection. [ABSTRACT FROM AUTHOR]

Background: Racial/ethnic disparities in pancreatic adenocarcinoma (PDAC) outcomes may relate to receipt of National Comprehensive Cancer Network (NCCN) guideline-compliant care. We assessed the association between treatment at minority-serving hospitals (MSH) and receipt of NCCN-compliant care. Patients and Methods: Patients who underwent resection of early-stage PDAC between 2006 and 2019 were identified from the National Cancer Database (NCDB). MSH was defined as the top decile of facilities treating minority ethnicities (Black and/or Hispanic). Factors associated with receipt of NCCN-compliant care and its impact on overall survival (OS) were assessed. Results: Among 44,873 patients who underwent resection of PDAC, most were treated at non-MSH (n = 42,571, 94.9%), while a smaller subset were treated at MSH (n = 2302, 5.1%). Patients treated at MSH were more likely to be at a younger median age (MSH 66 years versus non-MSH 67 years), Black or Hispanic (MSH 58.4% versus non-MSH 12.0%), and not insured (MSH 7.8% versus non-MSH 1.6%). While 71.7% (n = 31,182) of patients were compliant with NCCN care, guideline-compliant care was lower at MSH (MSH 62.5% versus non-MSH 72.2%). On multivariable analysis, receiving care at MSH was associated with not receiving guideline-compliant care [odds ratio (OR) 0.63, 95% confidence interval (CI) 0.53–0.74]. At non-MSH, non-white patients had lower odds of receiving guideline-compliant PDCA care (OR 0.85, 95% CI 0.78–0.91). Failure to comply was associated with worse overall survival (OS) [hazard ratio (HR) 1.50, 95% CI 1.46–1.54, all p < 0.001]. Conclusions: Patients with PDAC treated at MSH and minorities treated at non-MSH were less likely to receive NCCN-compliant care. Failure to comply with guideline-based PDAC treatment was associated with worse OS. [ABSTRACT FROM AUTHOR]

Background: Ampullary neuroendocrine tumors (NETs) make up < 1% of all gastroenteropancreatic NETs, and information is limited to case series. This study compares patients with ampullary, duodenal, and pancreatic head NETs. Methods: The National Cancer Database (2004–2016) was queried for patients with ampullary, duodenal, and pancreatic head NETs. Survival was evaluated using Kaplan–Meier analysis and Cox regression. Results: Overall, 872, 9692, and 6561 patients were identified with ampullary, duodenal, and pancreatic head NETs, respectively. Patients with ampullary NETs had more grade 3 tumors (n = 149, 17%) than patients with duodenal (n = 197, 2%) or pancreatic head (n = 740, 11%) NETs. Patients with ampullary NETs had more positive lymph nodes (n = 297, 34%) than patients with duodenal (n = 950, 10%) or pancreatic head (n = 1513, 23%) NETs. On multivariable analysis for patients with ampullary NETs, age (hazard ratio [HR] 1.03, p < 0.0001), Charlson–Deyo score of 2 (HR 2.3, p = 0.001) or ≥3 (HR 2.9, p = 0.013), grade 2 (HR 1.9, p = 0.007) or grade 3 tumors (HR 4.0, p < 0.0001), and metastatic disease (HR 2.0, p = 0.001) were associated with decreased survival. At 5 years, the overall survival (OS) for patients with ampullary, duodenal, and pancreatic head NETs was 59%, 71%, and 50%, respectively (p < 0.0001), whereas the 5-year OS for patients with ampullary, duodenal, and pancreatic head NETs who underwent surgery was 62%, 78%, and 76%, respectively (p < 0.0001). Conclusions: Ampullary NETs were more likely to present with high-grade tumors and lymph node metastases. Based on the clinicopathologic and survival data, ampullary NETs have a unique underlying biology compared with duodenal and pancreatic head NETs. [ABSTRACT FROM AUTHOR]

Background: Fibrolamellar hepatocellular carcinoma (FLC) is a rare variant of hepatocellular carcinoma (HCC), with most clinical data stemming from single-institution series. The variability in the literature lends support for analysis using a large national dataset. In doing so, we sought to (1) define the characteristics and outcomes of patients with FLC; (2) determine factors associated with survival in patients undergoing resection; and (3) compare the overall survival (OS) of patients with FLC with a matched group of patients with HCC. Methods: The National Cancer Database was queried for patients with FLC, and their clinicopathologic features were recorded. Univariate and multivariate analyses were performed to delineate factors associated with survival. Results: Between 2004 and 2015, 496 patients were diagnosed with FLC, 229 of whom underwent a curative resection. The median OS for patients with FLC undergoing curative resection was 78.5 months. Factors associated with abbreviated OS in this surgical cohort include multiple tumors [hazard ratio (HR) 3.15, p = 0.025], positive regional lymph nodes (HR 2.83, p = 0.023), and elevated serum α-fetoprotein (AFP; HR 2.81, p = 0.034). When the OS of patients with FLC was compared with a matched group of patients with HCC, no difference was detected (p = 0.748); however, patients with FLC and elevated AFP had abbreviated OS compared with patients with HCC and elevated AFP (43 vs. 82 months, p ≤ 0.001). Conclusions: Elevations in serum AFP occur more frequently than previously documented for patients with FLC and are associated with abbreviated OS. AFP levels may help guide the decision for operative intervention in patients with FLC. [ABSTRACT FROM AUTHOR]

Background: There is significant demand for training in Complex General Surgical Oncology (CGSO) fellowships. Previous work has explored objective quantitative metrics of applicants that matriculated to CGSO fellowships; however, ambiguity remains concerning academic benchmarks and qualitative factors that impact matriculation. Study Design: A web-based survey was sent to each ACGME/SSO-approved CGSO fellowship training program. The survey was comprised of 24 questions in various forms, including dichotomous, ranked, and five-point Likert scale questions. Results: Twenty-nine of 30 program directors (97%) submitted complete survey responses, representing 64 of the 65 CGSO fellowship positions (99%) currently offered. Programs received a mean of 73 applications per cycle (range 50–125) and granted a mean of 26 interviews (range 2–45). Seventy-two percent of programs had an established benchmark for ABSITE score percentile before offering a candidate an interview, with 62% of those programs setting that benchmark above the 50th percentile. The majority of programs also had established benchmarks for quantity of first author publications (mean: 2.3) and all publications of any authorship (mean: 4.4). An applicant's interview was ranked as the most important factor in determining inclusion on the program's rank list. The ability to work as part of a team, interpersonal interaction/communication abilities, and operative skills were rated as most important applicant characteristics, whereas an applicant's personal statement was ranked as least important. Conclusions: After established academic benchmarks have been met, a multitude of factors influences ranking of applicants to the CGSO fellowship, most of which are assessed at the interview. [ABSTRACT FROM AUTHOR]

Patients with hepatopancreatobiliary (HPB) malignancies undergoing resection are prone to venous thromboembolism (VTE), and current guidelines recommend up to 28 days of chemoprophylaxis after major surgery. We sought to determine the practice patterns among HPB surgeons for use of chemoprophylaxis after discharge. A survey on VTE chemoprophylaxis after oncologic HPB operations was distributed to attending surgeons at the 18 HPB fellowship training programs in the United States and Canada. Of the HPB surgeons surveyed, 44 (44%) responded. VTE prophylaxis is used by 93% of respondants in the inpatient postoperative setting. Chemoprophylaxis after discharge for pancreaticoduodenenctomy and distal pancreatectomy is utilized by 45% and 39% of respondants, respectively. Of those who prescribe chemoprophylaxis after discharge, 79% and 88% prescribe it for the recommended 28 days after pancreaticoduodenectomy and distal pancreatectomy, respectively. Chemoprophylaxis after discharge for major and minor hepatectomy is utilized by 39% and 26% of respondents, respectively. Of those who prescribe chemoprophylaxis after discharge, 67% and 55% provide it for the recommended 28 days after major and minor hepatectomy, respectively. Despite documented prolonged postoperative thrombogenic risk, the use of chemoprophylaxis following discharge after pancreatic and liver resections for cancer was moderate among surveyed HPB surgeons. [ABSTRACT FROM AUTHOR]

Malignancy and surgery are both independent risk factors for venous thromboembolism (VTE) events. The current NCCN guidelines recommend VTE prophylaxis for up to 28 days after major abdominal or pelvic surgery for malignancy. We set out to evaluate the rate and timing of VTEs among patients with gastric, pancreatic, colorectal, and gynecologic malignancies who underwent surgery. We performed a retrospective review of the NSQIP database (2005-2013) focusing on patients with gastric, colorectal, pancreatic, and gynecologic malignancies. Our primary endpoint was a diagnosis of VTE within 30 days of surgery. We analyzed 128,864 patients in this study. On multivariable analysis, patients with pre-operative sepsis (OR 2.36, CI 2.04-2.76, p < 0.001), disseminated cancer (OR 1.73, CI 1.55-1.92, p < 0.001), congestive heart failure (OR 1.69, CI 1.25-2.28, p = 0.001), gastric cancer (OR 1.3, CI 1.09-1.56, p = 0.004), and pancreatic cancer (OR 1.2, CI 1.03-1.30, p = 0.021) were more likely to have a VTE. Of patients who had a VTE event, 34% occurred after discharge from surgery (gastric: 25%, colorectal 34%, pancreatic 31%, gynecologic malignancy 42%). Our study demonstrates that patients who undergo an operation for malignancy with pre-operative sepsis, disseminated cancer, congestive heart failure, gastric cancer, or pancreatic cancer are more likely to develop a VTE within 30 days of their operation. Of those patients who developed a VTE, approximately one-third occurred after discharge during a 30 day post-operative period. This data supports that further studies are needed to determine the appropriate length of post-operative VTE chemoprophylaxis in patients with cancer. [ABSTRACT FROM AUTHOR]

Background: The demand for training in complex general surgical oncology (CGSO) fellowships currently exceeds the number of positions offered; however, there are scarce data defining the applicant pool or characteristics associated with successful matriculation. Our study described the applicant population and to determine factors associated with acceptance into the fellowship.Study Design: Data were extracted from the Electronic Residency Application System for applicants in 2015 and 2016 and stratified based on matriculation status. Applicant demographics, including medical education, residency, and research achievements, were analyzed. Academic productivity was quantified using the number of peer-reviewed publications as well as the journal with the highest impact factor in which an applicant’s work was published.Results: Data were gathered on a total of 283 applicants, of which 105 matriculated. The overall population was primarily male (63.2%), Caucasian (40.6%), educated at a U.S. allopathic medical school (53.4%), and trained at a university-based General Surgery residency (55.5%). Education at a U.S. allopathic school (OR = 5.63, p < 0.0001), university-based classification of the applicant’s surgical residency (OR = 4.20, p < 0.0001), and a residency affiliation with a CGSO fellowship (OR = 2.61, p = 0.004) or National Cancer Institute designated Comprehensive Cancer Center (OR = 3.16, p < 0.001) were found to be associated with matriculation. Matriculants published a higher number of manuscripts than nonmatriculants (median of 10 vs. 4.5, p < 0.0001) and more frequently achieved publication in journals with higher impact factors (p < 0.0001).Conclusions: This study represents the first objective description of the CGSO fellowship applicant pool. Applicants’ medical school, residency, and research data points correlated with successful matriculation. [ABSTRACT FROM AUTHOR]

Ampullary neuroendocrine tumors (NETs) make up < 1% of all gastroenteropancreatic NETs. \Our study uses a national database to evaluate clinicopathologic factors and overall survival of this rare tumor (https://doi.org/10.1245/s10434-021-10371-w). It demonstrates that ampullary NETs likely have a different underlying biology than duodenal and pancreatic head NETs. [ABSTRACT FROM AUTHOR]