BACKGROUND:The clinical utility of [18F]-fluorodeoxyglucose positron emission tomography in well-differentiated pancreatic neuroendocrine tumors remains unclear. While its prognostic role is established in high-grade disease, its value in grade 1 and grade 2 pancreatic neuroendocrine tumors, particularly in guiding systemic therapy, requires further evaluation. METHODS:We retrospectively analyzed 140 consecutive patients with histologically confirmed grade 1 (n = 44, 31.4%) or grade 2 (n = 96, 68.6%) pancreatic neuroendocrine tumors (per the 2022 World Health Organization Classification of Tumors, Fifth Edition) who underwent baseline dual-tracer positron emission tomography/computed tomography (68Ga-DOTA-(Tyr3)-octreotate and [18F]-fluorodeoxyglucose) between 2018 and 2023 at a tertiary cancer center. The cohort represents 15.6% of all gastroenteropancreatic neuroendocrine tumors evaluated during the study period and was selected for dual-tracer imaging based on predefined clinical indications. Primary end points were overall survival and progression-free survival. RESULTS:[18F]-Fluorodeoxyglucose avidity was observed in 97 of 140 patients (69.3%), with significantly higher prevalence in grade 2 tumors (73/96, 76.0%) compared with grade 1 (24/44, 54.5%; χ2 = 5.58; P = .018). On multivariate analysis, [18F]-fluorodeoxyglucose avidity (hazard ratio, 9.74; P = .026) and skeletal metastases (22/140, 15.7%; hazard ratio, 3.62; P = .002) were independently associated with inferior overall survival. In grade 1 pancreatic neuroendocrine tumors, [18F]-fluorodeoxyglucose avidity did not influence prognosis, with 5-year overall survival of 90.7% and progression-free survival of 67.1% irrespective of [18F]-fluorodeoxyglucose uptake. In contrast, grade 2 [18F]-fluorodeoxyglucose-avid tumors (n = 73) demonstrated significantly worse outcomes compared with [18F]-fluorodeoxyglucose-negative counterparts (n = 23), with 5-year overall survival 61.5% versus not reached (P = .003) and median progression-free survival 41.2 months ([18F]-fluorodeoxyglucose avid) versus 94.8 months ([18F]-fluorodeoxyglucose negative); P = .006. Systemic chemotherapy (52/140, 37.1%) did not improve survival in [18F]-fluorodeoxyglucose-avid patients. Completion of ≥4 peptide receptor radionuclide therapy cycles (22/73, 30.1%) was associated with improved survival (5-year overall survival 72.6% vs 40.6%; P = .020); landmark analysis confirmed a directional progression-free survival benefit. CONCLUSION:[18F]-Fluorodeoxyglucose avidity is prognostically significant in grade 2 well-differentiated pancreatic neuroendocrine tumors but was not associated with improved outcomes following systemic chemotherapy in this retrospective cohort. In grade 1 tumors, [18F]-fluorodeoxyglucose avidity had no prognostic or therapeutic consequence. These findings support the prognostic rather than predictive role of [18F]-fluorodeoxyglucose positron emission tomography and requires prospective validation.
BACKGROUND:The proliferation of acronyms in abdominal wall surgery has fragmented procedural language, limiting comparability across studies, registries, and operative reports. The Muysoms A-H-M-T-F nomenclature was proposed to standardize hernia repair description across 5 key dimensions; however, its inter-rater reproducibility among independent surgeons has not previously been evaluated. METHODS:An international cross-sectional survey was conducted among surgeons with hernia repair experience, who were invited to independently code 15 clinical scenarios using the A-H-M-T-F system. For each case, respondents rated their confidence, assigned a classic nomenclature label, and provided qualitative feedback. Percentage agreement and Fleiss' kappa were calculated for each nomenclature component and for the full 5-component code. Variability in classic terminology was compared with Muysoms coding variability before and after format normalization. RESULTS:Seventy-two surgeons from 4 continents completed the survey; 83% had not previously used the nomenclature. Mean percentage agreement on the modal response was highest for mesh position (99.0%) and hernia type (95.3%), followed by mesh type (93.5%), fixation (89.4%), and approach (87.2%). Fleiss' kappa was substantial for mesh position (0.735), hernia type (0.726), and fixation (0.672), and moderate for approach (0.591), mesh type (0.559), and the full code (0.484). After format normalization, the Muysoms system reduced procedural naming variability by 72% compared with classic free-text terminology. CONCLUSION:The Muysoms nomenclature demonstrated moderate-to-substantial inter-rater reproducibility, even among predominantly first-time users, and reduced procedural naming variability. These findings support its potential role in standardized operative reporting, registry-based research, and comparative studies in abdominal wall surgery.
Rural settings can be challenging with regard to the level of resources and general support of surgery. Effective advocacy is the means to deal with barriers to good surgical care. While advocating for more support for rural health care can appear daunting, it can be accomplished. This article gives concrete examples of tools for rural surgeons to participate in strong advocacy as well as success stories. This article can serve as a primer to begin or amplify a surgeon's advocacy journey.
Significant research has occurred over the last 2 decades outlining the disparities that female residents and residents who are underrepresented in medicine face. While there is an increasing number of institutional protocols and initiatives published in the literature attempting to improve these disparities, enrollment and retention of minority residents remain lower than expected. Designing and implementing measures to improve the recruitment, retention, and daily experience of women and underrepresented in medicine residents involves significant challenges because of the complex nature of the disparities that these residents experience. We describe our own experience with The Pregnancy Curriculum, an initiative that created sweeping culture changes and initially disruptive policies in our own institution to support pregnant residents. As we reflect on our own experience, we find that honoring the individuality of residents and their unique goals creates sustainable and effective changes to support residents. Herein, we outline the disparities residents face, current research in institutional protocols, and our own response to the challenges that residents experience.
