Background: Readmission is considered as a surgical quality indicator. More data regarding predictors of readmission and outcomes after surgery for colorectal liver metastasis are needed. Using a propensity score match to create a 1:2 match of cases:controls for 90-day. Readmission, the matching variables used for balance included age, tumor size, estimated blood loss, and type of resection (minor or major). T-tests were used for continuous measures, Fisher's exact test was used for categorical data, and the Kaplan-Meier method was used to estimate survival. p < 0.05 was considered significant. Methods: Retrospectively examined 935 patients with CLM from 2000 to 2018. Using a propensity score match to create a 1:2 match of cases:controls for 90-day. Readmission, the matching variables used for balance included age, tumor size, estimated blood loss, and type of resection (minor or major). T-tests were used for continuous measures, Fisher's exact test was used for categorical data, and the Kaplan-Meier method was used to estimate survival. p < 0.05 was considered significant. Results: 935 patients were included in the initial sample with 896 eligible for inclusion in the propensity matching. The average age of the population was 59% and 59% male. Overall readmission rate was 8.0%. Median time to readmission was 14 days. In the propensity score matched sample, readmitted patients had higher rates of organ space infection (28% vs 2% and p < 0.0001), bile leak (26% vs 1% and p < 0.0001), and liver failure (9% vs 2% and p = 0.042). There was no difference in LOS (7 days versus six days and p = 0.40), overall survival (median 39.7 vs 41.0 months and p = 0.79), or rate of adjuvant therapy (68% for both and p > 0.99). Conclusion: Patients readmitted for intermediate and late complications after surgery for CLM can recover and receive adjuvant therapy with no adverse effect on overall survival. Organ space infection, bile leak, and liver failure are highly associated with readmission.

BACKGROUND:The survival benefit of neoadjuvant chemotherapy (NAC) in early-stage pancreatic ductal adenocarcinoma (PDAC) remains uncertain. Although retrospective studies often suggest improved outcomes, these findings may be confounded by immortal time bias (ITB), the interval between diagnosis and treatment during which patients must survive to receive therapy, potentially inflating survival estimates. This study applied multiple bias-adjusted analytic methods to re-evaluate the association between NAC and overall survival in early-stage PDAC. METHODS:Using the National Cancer Database (2012-2017), we identified adults with resectable clinical T1 and T2 PDAC who underwent pancreatectomy. Overall survival was compared between multiagent NAC and upfront surgery by using Kaplan-Meier and multivariable Cox models. We used three statistical approaches to adjust for immortal time bias: 1) a 9-month landmark analysis; 2) a time-varying Cox regression model; and 3) a propensity-matched time-varying Cox model. RESULTS:Among 13,466 patients, 15.8% received NAC. Before bias adjustment, NAC was associated with longer median survival (33.4 vs. 25.7 months; HR 0.78, p < 0.001). However, after correcting for immortal time bias, this apparent survival advantage disappeared: landmark analysis (HR 0.94, p = 0.072), time-varying model (HR 1.06, p = 0.2), and matched cohort (HR 0.94, p = 0.2). CONCLUSIONS:This study shows that ITB significantly influences survival estimates in retrospective analyses of NAC for early-stage resectable PDAC. When appropriately adjusted, NAC was not associated with a survival advantage compared to upfront surgery. These findings underscore the need for methodological rigor in retrospective studies and caution against overinterpreting unadjusted survival advantages.

Small intestine neuroendocrine tumors (SI-NETs) frequently present as multifocal primaries. We commonly observe microscopic lesions in the superficial layer of the small intestine of SI-NET patients. We aimed to define them as small intestinal neuroendocrine tumorlets (SINTs) and explore their clinical and biological significance. Twenty multifocal and twenty unifocal SI-NETs patients who received resection at a single institution were retrospectively reviewed. Four hundred and forty six archived pathological slides were examined for microscopic lesions located in the lamina propria, muscularis mucosa, and superficial submucosa. Clinicopathological associations and progression-free survival were analyzed. Previously published genomic data were re-analyzed. SINTs were identified in 50% of multifocal and 30% of unifocal SI-NET patients. Median SINT size was 95 μm, with a median distance of 2.2 mm from the nearest mass. Compared to the ‘true unifocal’ group (unifocal without SINT), the ‘multifocal-spectrum’ group (multifocal or unifocal with SINT) had higher BMI (median: 27.6 vs 22.8, P = 0.0060), higher rates of perineural invasion (OR: 5.5, P = 0.044), larger mesenteric mass (median: 2.6 vs 1.6 cm, P = 0.034), and more advanced pT stage (pT3 or pT4, OR: 7.2, P = 0.018). Genomic re-analysis suggested that 13% of cells in multifocal primary tumors could share clonal origins, possibly indicating clonal spread via SINTs. SINTs may serve as a new biomarker for multifocal spectrum with local aggressiveness. The actual frequency of multifocal SI-NET may be higher than currently recognized in clinical practice. Further studies are needed to validate their prognostic and biological significance.

(1) Background: Comprehensive evaluation of guideline-concordant care (GCC) across all PDAC stages has yet to be thoroughly conducted. This study aimed to characterize treatment patterns and assess factors associated with receiving GCC among patients with pancreatic ductal adenocarcinoma (PDAC) in California. (2) Methods: Data on adult patients with PDAC were extracted from the California Cancer Registry (2004-2020). GCC is defined according to the recommendations provided by the National Comprehensive Cancer Network. We used multivariable logistic regression to identify factors associated with receiving GCC. A Cox model was used to examine the association of GCC with overall survival. (3) Results: A total of 50,346 PDAC patients were included (stage 1: 10%; stage 2: 25%; stage 3: 11%; stage 4: 54%). Only 46.7% of all patients received GCC (stage 1: 20%; stage 2: 40%; stage 3: 69%; stage 4: 50%). Only 31% of stage 1 patients underwent surgery. Factors inversely associated with receiving GCC were Hispanic ethnicity (OR 0.78; p < 0.001), Black race (OR 0.74; p < 0.001), having no insurance (OR 0.40; p < 0.001]), and a Charlson-Deyo score of ≥2 (OR 0.68; p < 0.001). Adherence to GCC was associated with improved survival (Hazard Ratio 0.39; p < 0.001). Notably, patients with stage 1 PDAC who received GCC had a median survival of 47 months vs. 8 months for those who did not. (4) Conclusions: Although stage 1 PDAC patients have the greatest potential for survival with GCC, only 20% of patients received such treatment. Thus, it is crucial to identify and address the modifiable factors contributing to these suboptimal care patterns.

BACKGROUND AND OBJECTIVES:Solid pseudopapillary tumors (SPTs) of the pancreas occur predominantly in young females and possess low malignant potential. In this study, clinicopathologic, perioperative, and long-term outcomes are compared in SPT patients that received open or minimally invasive (MIS) resection. METHODS:The National Cancer Database (2010-2020) was queried to identify all patients with SPTs that underwent an open or MIS surgical resection. Propensity score matching analysis was conducted through 1:1 matching based on the nearest neighbor method. RESULTS:Of 835 patients, 59.7% received an open approach and 40.3% were performed MIS. Over the decade, MIS approach increased from 7.7% to 60.0% for distal pancreatectomy (DP) and 15.4% to 30.2% for pancreaticoduodenectomy (PD) (both p < 0.05). There were no differences in lymphadenectomy (>15 nodes) or resection margin positivity. Shorter length of stay was noted for MIS resections (PD: 5 vs. 8 days, p < 0.001; DP: 5 vs. 6 days, p = 0.022), and no difference was appreciated in 30-day readmission rates. There was no difference in overall survival between open and MIS approaches for PD and DP. CONCLUSIONS:Minimally invasive resections for SPTs have increased by ~40% over a decade and may offer a safe and feasible alternative to open resection that provides similar perioperative and long-term oncologic outcomes.

Supplementary Table S3. Univariate analysis by pre-operative ctDNA status. Depicted are multiple clinicopathologic variables analyzed by ctDNA status.

Introduction: Pancreatic neuroendocrine tumors (PNETs) are typically diagnosed using endoscopic ultrasoundguided (EUS) biopsy, which can be associated with complications. Since 2016, DOTATATE PET/CT has emerged as an effective tool to localize and stage PNETs. Methods: Patients with PNETs who underwent R0 resections were identified from the 2004-2019 National Cancer Database PUF. Joinpoint regression and multivariable logistic regression were used to analyze trends in the use of biopsy. Results: Of 16,746 R0 resected PNET patients, 44 % underwent diagnostic biopsy. Joinpoint regression showed a significant increase in the use of biopsy from 2004 to 2019 (APC 1.80, p < 0.001). A higher percentage of patients diagnosed after DOTATATE approval underwent biopsy compared to those diagnosed before (48 % vs. 42 %, p < 0.001). Adjusted analysis showed diagnosis after 2016 was associated with increased odds of biopsy (OR 1/4 1.67, p < 0.001). Conclusions: Despite technologic advancement with DOTATATE PET/CT, there has been a significant increase in the proportion of resectable PNETs undergoing preoperative biopsy.

BACKGROUND:Despite significant advancements in the treatment of patients with colorectal liver metastases (CRLMs), only a minority will experience long-term survival. This study aimed to determine the effect of chemotherapy (CT) and immunotherapy (IT) compared with that of CT alone on patient survival after surgical resection. METHODS:Patients undergoing curative-intent liver resection followed by adjuvant systemic therapy for stage IV colon cancer were identified using the National Cancer Database. Patients were stratified into type of therapy (CT alone vs CT + IT) and microsatellite status. Propensity score-weighted analysis was performed through 1:1 matching based on the nearest neighbor method. RESULTS:Of 9943 patients who underwent resection of CRLMs, 7971 (80%) received systemic adjuvant therapy. Of 7971 patients, 1432 (18%) received a combination of CT and IT. Microsatellite status was not associated with overall survival (OS). Adjuvant CT + IT was associated with increased 3-year OS compared with that of CT alone in both the unmatched cohort (55% vs 48%, respectively; P < .001) and matched cohort (52% vs 48%, respectively; P = .050). On multivariate analysis, older age, positive resection margins, and KRAS mutation were independent predictors of poor survival, whereas the administration of adjuvant CT + IT was an independent predictor of improved survival. CONCLUSION:IT combined with CT was associated with improved survival compared with that of CT alone after curative-intent resection of CRLMs, regardless of microsatellite instability status. Clinical trials to determine optimal patient selection, IT regimen, and long-term efficacy to improve outcomes of patients with CRLMs are warranted.

Supplementary Figure S3. ctDNA dynamic changes for patients pre-and post-curative intent therapy (CI) (left) or adjuvant chemotherapy (ACT) (right).

Supplementary Figure S4. Survival outcomes and recurrence rates stratified by CEA status.

Supplementary Table S2. Demographics, clinicopathologic and procedure-related features table. Table depicts study participants in primary timepoint analysis.

BackgroundThis study investigates the impact of margin status after colorectal liver metastasis (CLM) resection on outcomes of patients after neoadjuvant treatment versus those who underwent upfront resection.MethodsAn international collaborative database of CLM patients who underwent surgical resection was used. Proportional hazard regression models were created for single and multivariable models to assess the relationship between independent measures and median overall survival (mOS).ResultsR1 was associated with worse OS in the neoadjuvant group (mOS: 51.8 m for R0 vs. 26.0 m for R1; HR: 2.18). In the patients who underwent upfront surgery, R1 was not associated with OS. (mOS: 46.7 m for R0 vs. 42.6 m for R1). When patients with R1 in each group were stratified by adjuvant treatment, there was no significant difference in the neoadjuvant group, while in the upfront surgery group with R1, adjuvant treatment was associated with significant improvement in OS (mOS: 42.6 m for adjuvant vs. 25.0 m for no adjuvant treatment; HR: 0.21).ConclusionR1 is associated with worse outcomes in the patients who receive neoadjuvant treatment with no significant improvement with the addition of adjuvant therapy, likely representing an aggressive tumor biology. R1 did not impact OS in patients with upfront surgery who received postoperative chemotherapy.