Welcome to the Surg Onc Files! We are two Washington University general surgery residents with an interest in surgical oncology. This is us trying to digest the latest research and trends in surg onc and often enlisting a lot of help to get us all the way there. Check out the episodes and please let us know if there's a topic you'd like to hear about!
On this episode of the SO files, we interview Dr. Andrea Wang-Gillam MD/PhD, associate professor in the division of oncology at Wash U School of medicine and clinical director of the GI oncology, about systemic options for treating pancreatic adenocarcinoma. As much as we all love a good Whipple, this really is a systemic disease, and unlike other cancers 100% of patients regardless of stage will need some form of systemic treatment. Good thing we have great options to choose from! …Right?
Daniel D. Von Hoff, M.D., Thomas Ervin, M.D., Francis P. Arena, M.D., E. Gabriela Chiorean, M.D., Jeffrey Infante, M.D., Malcolm Moore, M.D., Thomas Seay, M.D., Sergei A. Tjulandin, M.D., Wen Wee Ma, M.D., Mansoor N. Saleh, M.D., Marion Harris, M.D., Michele Reni, M.D., Scot Dowden, M.D., Daniel Laheru, M.D., Nathan Bahary, M.D., Ramesh K. Ramanathan, M.D., Josep Tabernero, M.D., Manuel Hidalgo, M.D., Ph.D., David Goldstein, M.D., Eric Van Cutsem, M.D., Xinyu Wei, Ph.D., Jose Iglesias, M.D., and Markus F. Renschler, M.D.
Take away: nab-Paclitaxel (Abraxane) added to gemcitabine improved survival when compared to gemcitabine alone (median OS 8.5 pos vs 6.7 mos, ORR 23% vs 7%).
Thierry Conroy, M.D., Françoise Desseigne, M.D., Marc Ychou, M.D., Ph.D., Olivier Bouché, M.D., Ph.D., Rosine Guimbaud, M.D., Ph.D., Yves Bécouarn, M.D., Antoine Adenis, M.D., Ph.D., Jean-Luc Raoul, M.D., Ph.D., Sophie Gourgou-Bourgade, M.Sc., Christelle de la Fouchardière, M.D., Jaafar Bennouna, M.D., Ph.D., Jean-Baptiste Bachet, M.D., Faiza Khemissa-Akouz, M.D., Denis Péré-Vergé, M.D., Catherine Delbaldo, M.D., Eric Assenat, M.D., Ph.D., Bruno Chauffert, M.D., Ph.D., Pierre Michel, M.D., Ph.D., Christine Montoto-Grillot, M.Chem., and Michel Ducreux, M.D., Ph.D. for the Groupe Tumeurs Digestives of Unicancer and the PRODIGE Intergroup
FOLFIRINOX (oxaliplatin, irinotecan, leucovorin, fluorouracil) is a much more effective regimen than gemcitabine alone (median OS 11.1 mos vs 6.8 mos; ORR 32% vs 9%), but is a more toxic regimen with higher rate of adverse events.
Helmut Oettle, MD, PhD; Peter Neuhaus, MD, PhD; Andreas Hochhaus, MD, PhD; Jörg Thomas Hartmann, MD, PhD; Klaus Gellert, MD, PhD; Karsten Ridwelski, MD, PhD; Marco Niedergethmann, MD, PhD; Carl Zülke, MD, PhD; Jörg Fahlke, MD, PhD; Michael B. Arning, MD, PhD; Marianne Sinn, MD; Axel Hinke, PhD; Hanno Riess, MD, PhD
Take away: 6 months of gemcitabine treatment after complete resection was better for OS than no treatment (13.4 mos vs 6.7 mos).
Hingorani SR, Zheng L, Bullock AJ, Seery TE, Harris WP, Sigal DS, Braiteh F, Ritch PS, Zalupski MM, Bahary N, Oberstein PE, Wang-Gillam A, Wu W, Chondros D, Jiang P, Khelifa S, Pu J, Aldrich C, Hendifar AE.
Take away: The addition of PEGPH20 (pegvorhyaluronidase alfa) to gem/abraxane improved PFS and OS compared to gem/abraxane alone in patients with untreated metastatic disease, especially in patients with hyaluron high tumors. Phase III study ongoing!!
Ongoing phase Ib dose escalation study of BBI608 (Napabucasin), STAT3/cancer stem cell inhibitor, in combination with other standard chemotherapy regimens (gem/abraxane, FOLFIRINOX, FOLFIRI). Accrual slated to complete June 2018.
Nywening TM, Wang-Gillam A, Sanford DE, Belt BA, Panni RZ, Cusworth BM, Toriola AT, Nieman RK, Worley LA, Yano M, Fowler KJ, Lockhart AC, Suresh R, Tan BR, Lim KH, Fields RC, Strasberg SM, Hawkins WG, DeNardo DG, Goedegebuure SP, Linehan DC.
Blockade of CCR2, as a means to suppress tumor infiltration of immunosuppressive tumor associated macrophages, in combination with FOLFIRINOX chemotherapy for borderline resectable or locally advanced PDAC resulted in a 49% objective tumor response rate.
CCR2 inhibition decreases tumor-associated macrophages and Treg cells, and increases CD8+ and CD4+ T cells in pancreatic tumors. In preliminary data presented at ASCO, CX872-B plus FOLFIRINOX resulted in a TCR of 78% and an ORR of 30 to 37% with no safety issues ascribed to CCX872-B use. Estimated study completion date December 2018.
On this episode of SO Files, Alston, Brad and Linda take a closer look at the recently published TAILORx Clinical Trial Published in NEJM by Sparano and colleagues. The study expands the existing clinical application of the Oncotype DX score. If that score sounds familiar its because it has been quickly making its way into clinical practice over the past few years (see our last episode on the new AJCC guidelines!). We explain the origin of the score, how it has been incorporated into clinical practice thus far, and how this trial addresses a large gap in the existing literature.
A randomized controlled trial, designed to assess the utility of the Oncotype DX Score in predicting the need for chemotherapy, in addition to anti endocrine therapy, for hormone receptor +, Her2 -, node negative breast cancer. Bottom Line: Patients with an intermediate Oncotype DX Score of 11-25 can forgo chemotherapy, especially those patients >50 y/o.
On this episode of SO Files, Brad and Linda cover the updated staging guidelines for breast cancer that have been in practice (theoretically) since Jan 1, 2018. The possibilities for stage groups now cover a full six pages in the AJCC manual and you can hear Brad and Linda read through each one right here…. just kidding. We will however cover the major changes, the reasoning behind them, and talk about how they are fitting into practice with podcast favorite Dr. Cyr.
BONUS: listen to Brad, Alston and Linda survive a tornado during the live taping of this show!
0-14 minutes: Background information with Brad, Linda and Alston
Today we will be discussing the modern management of colorectal liver metastases. For today’s episode, we are excited to be welcoming on Dr. Yuman Fong, Sangiacomo Family Chair in Surgical Oncology and Surgical chair at City of Hope Cancer Center in California. Dr. Fong previously held the Murray F. Brennan Chair of Surgery at Memorial Sloan Kettering Cancer center, and is an international expert in both liver and pancreatic surgery.
2017 review article in The Journal of Surgical Oncology, outlining the surgical and medical management of colorectal liver metastases. Figure depicting the utilization of the colorectal liver metastasis clinical risk score in order to guide chemotherapy and surgical strategy.
Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH
Classic article depicting a clinical risk score that predicts survival in patients with resected colorectal liver metastasis. 5 preoperative factors, with each factor contributing to 1 point on the score, with more points = worse prognosis. At time of initial publication in 1998: 5 pts led to 14% 5 year survival vs. 60% for someone with 0 points. The 5 factors are: >1 liver metastasis, node positive primary, <12 months between primary colorectal tumor and liver met, >5cm liver tumor, preop CEA >200.
House MG, Ito H, Gönen M, Fong Y, Allen PJ, DeMatteo RP, Brennan MF, Blumgart LH, Jarnagin WR, D’Angelica MI
Data from Memorial Sloan Kettering that compared survival after resection for colorectal liver metastases for patients during 2 different eras: 1985-1998, and 1999-2004. Many of the patients in the more modern era were offered therapy with oxaliplatin or irinotecan, which likely led to the improved survival in these patients. Recurrence free survival in both generations were similar, suggesting that chemotherapy regimens and possibly patient selection differences led to differences in overall survival.
On this episode of the SO files, Brad and Linda welcome Assistant Professor of Surgery at Washington University in St. Louis/ Siteman Cancer Center, and co-author of the NCCN Clinical Practice Guidelines for Breast Cancer, Dr. Amy Cyr . We will take you through both benign, pre-malignant, and malignant breast oncology, with a focus on ABSITE relevant information.
Kevin C. Oeffinger, Elizabeth T. H. Fontham, Ruth Etzioni, Abbe Herzig, James S. Michaelson, Ya-Chen Tina Shih, Louise C. Walter, Timothy R. Church, Christopher R. Flowers, Samuel J. LaMonte, Andrew M. D. Wolf, Carol DeSantis, Joannie Lortet-Tieulent, Kimberly Andrews, Deana Manassaram-Baptiste, Debbie Saslow, Robert A. Smith, Otis W. Brawley, Richard Wender.
ACS updated recommendations for breast cancer screening for average risk women. Recommendations: Annual screening from 45-54, 55+ biennial screening or have the opportunity to continue annual screening. Screening should continue as long as the women has good overall health, and a life expectancy of 10+ years.
Giuliano AE, Hunt KK, Ballman KV, Beitsch PD, Whitworth PW, Blumencranz PW, Leitch AM, Saha S, McCall LM, Morrow M.
A practice changing article that established that for patients with clinical T1-2 N0 breast cancer with <3 SLN metastases found on SLN biopsy, there is no benefit of completion axillary lymph node dissection over no further surgical treatment of the axilla. This is high yield for the ABSITE, and a good thing to know for any medical student scrubbing in on a breast cancer operation during their surgical rotation.
Donker M, van Tienhoven G, Straver ME, Meijnen P, van de Velde CJ, Mansel RE, Cataliotti L, Westenberg AH, Klinkenbijl JH, Orzalesi L, Bouma WH, van der Mijle HC, Nieuwenhuijzen GA, Veltkamp SC, Slaets L, Duez NJ, de Graaf PW, van Dalen T, Marinelli A, Rijna H, Snoj M, Bundred NJ, Merkus JW, Belkacemi Y, Petignat P, Schinagl DA, Coens C, Messina CG, Bogaerts J, Rutgers EJ.
AMAROS Phase III Trial: For patients with clinical T1-2 N0 breast cancer and 1 or more positive SLNs identified during surgery, axillary radiotherapy results in statistically equivalent axillary recurrence at 5 years vs. completion axillary lymph node dissection (1.19% and 0.43%, respectively, at 5 years). No significant differences in disease free or overall survival. Of note, at 5 years significantly more patients in the completion axillary lymph node dissection group had ipsilateral arm lymphedema than the axillary radiotherapy group (23% vs. 11%, respectively, p<0.0001).
A commonly used model to predict future breast cancer risk for patients with no history of invasive breast cancer, DCIS or LCIS. Patients with a 5 year risk of >1.7% are candidates for chemoprevention.
Happy new years from SO Files! Ring in 2018 with an algorithm based review of gastric cancer management! We released this all out of order so excuse our Thanksgiving banter but the great news is that bad jokes never go out of style, so enjoy some useful review while adhering to your gym goals for at least the first week of January.
Songun I, Putter H, Kranenbarg EM, Sasako M, van de Velde CJ.
15 year follow-up data from the Dutch D1D2 trial for gastric cancer. D2 lymphadenectomy resulted in a 29% overall survival for the D2 group vs. 21% for the D1 group (p=0.34). Gastric cancer related death was higher in the D1 group than the D2 group (48% vs. 37%, respectively, p=0.01). In this trial a D2 gastrectomy included a splenectomy as standard protocol.