Soft tissue sarcomas are rarely associated with mutations of the MEN1 gene. We report a patient with a large retroperitoneal pleomorphic liposarcoma harboring a rare mutation of the MEN1 gene not previously reported to be associated with soft tissue sarcomas. This report expands the known spectrum of MEN1-associated cancers.

Background: Bilateral erector spinae fascial plane blocks (ESPB) offers a novel, alternative method of regional post-operative pain control to thoracic epidural analgesia (TEA). The aim of this study was to compare rates of postoperative hypotension, and other standard enhanced recovery after surgery (ERAS) endpoints, in patients receiving ESPB versus TEA for open hepatopancreaticobiliary (HPB) surgery. Materials and methods: This retrospective analysis compared historical controls of ERAS pa-tients undergoing open HPB surgery with TEA versus ESPB. The incidence of postoperative hypotension and clinical outcomes, including opioid requirements, were compared. Results: Forty patients receiving TEA were compared to 27 ESPB patients. Return of bowel function and length of stay (mean 7.2 versus7.4 days; P = 0.83) were similar. ESPB patients received less intraoperative colloid (142cc versus 340cc; P = 0.01) and had less postoperative hypotension versus TEA (22% versus 55%; P = 0.03). No ESPB patient required patient-controlled analgesia (versus 32.5% TEA; P < 0.001). ESPB MME requirements decreased over time, while TEA MME requirements increased over 72 hours (P = 0.019). Conclusions: ESPB is a novel method that shows promising outcomes in improving enhanced recovery parameters and minimizing opioid administration in open HPB surgery. (c) 2021 Elsevier Inc. All rights reserved.

Journal of the American College of Surgeons 229(4):p S173, October 2019. | DOI: 10.1016/j.jamcollsurg.2019.08.381

In this study, we examined the treatment and outcomes of pancreatic adenocarcinoma in New Mexico Native Americans (NA). Methods. A retrospective review of patients treated for pancreatic adenocarcinoma at a university cancer center from 2002-2016 comparing demographic characteristics, disease presentation, treatment, and outcomes among three main ethnic groups in New Mexico. Results. We identified 457 patients: 240 (52.5%) non-Hispanic Whites, 186 (40.7%) Hispanics, and 31 (6.8%) NA. Non-Hispanic Whites (OR 2.41; p=.026) and Hispanics (OR 2.37; p=.032) were more likely to receive or be offered chemotherapy than NA. More NA than non-Hispanic Whites died within one month of diagnosis (25.8% and 7.5%, respectively; p=.004). The NAs demonstrated a 26.2% one-year survival (CI 11.7-43.3), compared with 48.3% in non-Hispanic Whites (CI 40.9-55.2; p=.015). Conclusion. Significant disparities exist in the treatment and outcomes of pancreatic adenocarcinoma in New Mexico NA populations.

Gallbladder cancer is a rare malignancy of the biliary tract with a poor prognosis, frequently presenting at an advanced stage. While rare in the United States overall, gallbladder cancer has an elevated incidence in geographically distinct locations of the globe including Chile, North India, Korea, Japan and the state of New Mexico in the United States. People with Native American ancestry have a much elevated incidence of gallbladder cancer compared to Hispanic and non-Hispanic white populations of New Mexico. Gallbladder cancer is also one of the few bi-gendered cancers with an elevated female incidence compared to men. Similar to other gastrointestinal cancers, gallbladder cancer etiology is likely multi-factorial involving a combination of genomic, immunological, and environmental factors. Understanding the interplay of these unique epidemiological factors is crucial in improving the prevention, early detection, and treatment of this lethal disease. Previous studies have failed to identify a distinct genomic mutational profile in gallbladder cancers, however, work to identify promising clinically actionable targets is this form of cancer is ongoing. Examples include, interest in the HER2/Neu signaling pathway and the recognition that chronic inflammation plays a crucial role in gallbladder cancer pathogenesis. In this review, we provide a comprehensive overview of gallbladder cancer epidemiology, risk factors, pathogenesis, and treatment with a specific focus on the rural and Native American populations of New Mexico. We conclude this review by discussing future research directions with the goal of improving clinical outcomes for patients of this lethal malignancy.

Over 2.1 million Native Americans (NA) reside in the United States and 5.2 million people identify as NA in combination with other ethnicities. NA population numbers were noted to increase 18 per cent from 2000 to 2010. Recent studies have revealed significant health disparities and inferior surgical outcomes in this small but growing U.S ethnic minority.1 The high incidence of both benign and malignant gallbladder disease in NA populations, specifically those living in the southwest United States, is widely known. Studies performed before the laparoscopic era suggested that NA may experience increased postoperative complications after cholecystectomy compared to non-Hispanic Whites (NHW), though rates of bile duct injury (BDI) were not examined during this time.2 Major BDI presents a rare though devastating complication of laparoscopic cholecystectomy (LC). The presence of acute cholecystitis, male sex, aberrant biliary anatomy, and older age are associated with an increased risk of BDI during LC. One study to date has explored ethnicity as a possible risk factor for BDI.3 NA were not analyzed as a separated ethnic group and their BDI risk remains unknown. We observed a high number of NA patients referred to our academic center for major BDI after LC. New Mexico is a tricultural and mostly rural state with a high incidence of gallbladder disease, presenting a unique opportunity to study major BDI in NA, Hispanic, and NHW populations. We hypothesized that the risk of BDI is higher in NA populations compared to NHW and Hispanics. The Hospital Inpatient and Discharge Data (HIDD), a state database maintained by the New Mexico Department of Health, was queried to obtain the total number of LCs occurring from 2010 to 2014. LCs were identified by ICD-9 code and sorted by race/ethnicity (as defined by patient self-reporting). The HIDD did not yield any results in a query for ICD-9 codes for common BDI, though 18 patients had ICD-9 codes consistent with additional biliary procedures that may indicate the occurrence of BDI. Secondary to the small sample size, the Department of Health could not release the ethnicities of these patients due to confidentiality concerns. Therefore, we could not determine ethnic distribution of BDI solely through the HIDD. To estimate the incidence of major BDI occurring in the state by ethnicity, a retrospective cohort analysis of all patients referred to our institution during the study period was performed. We are the only tertiary referral center in the state with a hepatobiliary unit established in 2009, receiving transfers from all types of facilities, both public and private, metropolitan and rural, for major BDI after LC. We examined patient demographics, LC indications, injury characteristics, and subsequent interventions. Exact Wilcoxon rank sum tests were used to compare continuous variables. Chi-squared tests examined categorical variables and determined odds ratios with 95 per cent confidence intervals and P values (<0.05 considered significant). A total of 12,608 patients underwent LC in New Mexico from 2010 to 2014. NHW compromised 39.3 per cent of the cohort (n 4 4952), Hispanic patients 41.0 per cent (n 4 5105) and NA 10.5 per cent (n 4 1313). Other ethnicities (8.7%) were excluded from analysis. A retrospective chart review revealed 23 patients (10 NA, 9 Hispanic, and 4 NHW) were referred to our hepatobiliary surgeon. We compared NA to nonNative American (non-NA) patients including NHW and Hispanics. Patient cohort characteristics are shown in Table 1. NA were disproportionately represented in our BDI cohort compared to the New Mexico state population (43 vs 10.4%; P < 0.0001). NA had significantly higher BMIs than non-NA patients. NA underwent LC in a rural setting more often, had increased incidence of acute cholecystitis and experienced one Address correspondence and reprint requests to Alissa Greenbaum, M.D., Department of Surgery, University of New Mexico, MSC 10 5610, Albuquerque, NM 87131. E-mail: agreenbaum@salud.unm.edu.

Background Th ere have been few studies on the impact of viral etiology on the prognosis in patients with hepatocellular carcinoma (HCC).Th e aim of this study was to evaluate the clinical characteristics and survival of patients with viral hepatitis-associated HCC (V-HCC), compared to patients with HCC of non-hepatitis B, non-hepatitis C (NBNC-HCC) etiology. MethodsWe performed a retrospective analysis of all patients with HCC treated at our comprehensive cancer center from 2000 through 2014.Patients were divided into two groups according to their viral hepatitis status.Presentation patterns, treatments, and survival data were analyzed. ResultsWe evaluated 366 patients: 233 patients (63.7%) had V-HCC while 133 (36.3%) patients had NBNC-HCC.V-HCC patients were younger (P<0.0001) and more likely to be male (P=0.001).Decompensated cirrhosis was more prevalent in V-HCC patients (P=0.01).Th ere was no diff erence in the resectability rate or disease stage.In patients with resectable disease, those with V-HCC were less likely to undergo hepatectomy (23.7% vs. 38%; P=0.04) for more advanced liver disease.Th e estimated median survival for V-HCC was 13 months compared to 16 months in NBNC-HCC patients (P=0.57).On multivariate analysis, disease stage (P<0.0001)and Child-Pugh class (P<0.0001) were independent factors aff ecting survival, but viral status was not (P=0.75). ConclusionDespite presenting with more advanced cirrhosis and being less likely to undergo surgery, V-HCC patients had similar survival to patients with NBNC-HCC.

Background: Leiomyosarcoma of the inferior vena cava (IVC) is an exceedingly rare smooth muscle sarcoma. Approximately 300 cases have been described in the literature, and further research is needed to understand the disease and guide its management. Surgery remains the only potential curative measure.Methods: A retrospective chart review of patients who underwent surgical resection of IVC leiomyosarcoma at our institution over the past 3 years was performed. The patients were identified using a prospectively maintained database.Results: Three patients with leiomyosarcoma of the infrahepatic IVC underwent radical resection carried out by a team of surgical oncologists and vascular surgeons. There were 2 males (66.7%) and 1 female (33.3%). Mean age at diagnosis was 60.3 years (range 43-78). Mean tumor size was 12.2 cm (range 5.6-22). The mean operative time was 320 min (range 180-421), mean estimated blood loss was 1,300 mL (100-2,000) mL, and average length of stay 8.67 days (6-12). All patients achieved grossly negative margins (R1 or R0 resections) and are alive with a mean overall survival of 21 months (range 12-30). Patient 1 was a 60-year old man who presented with metachronous skin leiomyosarcomas at 2 different sites. He underwent PET/CT scan that revealed an IVC mass.,Resection of the middle segment of the IVC and right kidney was performed with reconstruction with polytetrafluorethylene (PTFE) graft. Patient 2 was a 78-year-old man with an incidentally found a 9-cm IVC tumor. Resection of the tumor was performed, and no reconstruction was needed since the tumor had a completely extraluminal growth pattern. Patient 3 was a 43-year-old woman who presented with abdominal pain. Her work-up showed a 15-cm IVC mass. She underwent resection of the middle segment of the IVC, right nephrectomy, and cholecystectomy with reconstruction of the IVC with PTFE graft.Conclusions: Surgical resection is the mainstay of treatment in patients with leiomyosarcoma of the IVC. A collaborative approach involving surgical oncologists and vascular surgeons ensures adequate resection with functional reconstruction to achieve the best patient outcomes.

BACKGROUND: We investigated if there were any differences in disease presentation and survival between the 3 major ethnicities in New Mexico; non-Hispanic whites (NHW), native Americans (NA), and Hispanics (H).METHODS: A retrospective analysis of patients with hepatocellular carcinoma treated at our institution between 2000 and 2014 was performed. Overall survival was analyzed using the Kaplan-Meier and Cox regression models.RESULTS: We identified 326 patients; 106 (32.5%) NHW, 183 (56.1%) H, and 37 (11.4%) NA. No difference in disease stage, resectability, rate of offering surgery, or chemotherapy was found. Advanced cirrhosis was more common in H and NA than NHW (P = .01). NA had a higher incidence of nonviral hepatocellular carcinoma (P - .0009). NHW were more likely to receive transarterial chemoembolization/radiofrequency than NA or H (P = .04). Median survivals for NA, NHW, H were 24, 14, and 11 months, respectively, (P = .01).CONCLUSIONS: Although there was no difference in disease stage or resectability, NA and H had more advanced cirrhosis and were less likely to undergo transarterial chemoembolization and/or radiofrequency than NHW. NA had the best survival, whereas H had the worst survival. (C) 2016 Elsevier Inc. All rights reserved.

Introduction: While trauma surgeons continue to manage complex hepatobiliary (HPB) injuries, HPB surgeons are increasingly consulted for recommendations regarding diagnosis and treatment. This is the first known study that describes the role of the HPB surgeon as a member of a multidisciplinary trauma team. Methods: The University of New Mexico Hospital Trauma Database was queried for patients sustaining HPB trauma from January 2008 to May 2015. A retrospective chart review was performed to determine patient demographics, injury grade, clinical presentation, and surgical management. Results: A total of 675 patients sustained HPB trauma at our institution between 2008 and 2015; 301 of whom underwent exploratory laparotomy. This operative cohort had a total of 340 HPB injuries, including liver (76.5%), pancreas (12.9%), duodenum (8.5%) and gallbladder (2.1%) injuries. An HPB surgeon was consulted in 13 cases (4.3%); 11 were grade 4 or 5 liver injuries and 2 were pancreatic head injuries with concern for major duct disruption. The HPB surgeon completed 4 diagnostic interventions including intraoperative cholangiogram, intraoperative ultrasound, and assessment of organ viability. Nine therapeutic interventions were performed by the HPB surgeon which included primary repair of the portal vein, repair versus ligation of the hepatic artery or perihepatic inferior vena cava, segmentectomy, or nonanatomic hepatic resection. Conclusion: Abdominal trauma resulting in HPB injuries is a highly morbid event. While trauma surgeons manage the majority of complex liver, duodenal and distal pancreatic trauma, HPB surgeons offer specialized diagnostic and therapeutic assistance in cases of high grade liver and pancreatic head trauma.

160 Background: Gallbladder cancer (GBCA) is a rare malignancy; however, within the U.S. incidence varies geographically. GBCA has a higher occurrence in the American Indian (AI) population versus non-Hispanic whites (NHW) and Hispanics (H). The goal of the study is to determine if clinicopathologic features correlate with ethnicity. Methods: Incident GBCA diagnosed in New Mexico from 1980-2009 were identified from the population-based New Mexico Tumor Registry. Average age-adjusted incidence rates were calculated by direct method using the United States 2000 standard population. Chi-squared statistic was used to assess ethnicity differences in case distribution at diagnosis by sex, age, stage and grade. Cause-specific survival was calculated by the Kaplan-Meier method and assessed with log-rank statistic. Results: GBCA incidence rates in New Mexico are highest for AI (7.6 per 100,000–95% confidence interval (CI)=6.5-8.9), followed by H (2.8 per 100,000 – 95% CI=2.5-3.2) and NHW (1.0 per 100,000 – 95% CI=0.9-1.1). Females are predominantly affected (Table). Median ages varied among NHW (74 years), H (71 years) and AI (69 years). There are no appreciable differences with respect to stage and tumor grade. Cause-specific survival at 60 months is also similar among NHW (20.25%), H (17.94%), and AI (22.43%) (log-rank p-value=0.7388). Conclusions: GBCA has a higher prevalence in AI. Regardless it shares similar characteristics in all evaluated ethnicities as it is predominantly a disease of older females, with similar tumor grade and stage and with equally poor survival. [Table: see text]

357 Background: Anal squamous cell carcinoma (SCC) is rare, but results in significant morbidity and mortality. The aim of this study was to characterize the trends of anal SCC in the U.S. between 1980-2009. Methods: Subjects were identified from records in the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program. The study included incident malignant squamous cell cancer of the anus, anal canal, and anorectum diagnosed among nine core areas of the SEER program from 1980-2009. Average annual age-adjusted incidence rates were calculated by the direct method with the U.S. 2000 standard population. 95% confidence intervals were calculated using the Tiwari adjustment. Temporal trends were assessed by joinpoint regression. Results: Incidence rates of anal cancer in the U.S. more than doubled during this period. A linear increase in anal cancer incidence rates was observed with an Annual Percent Change (APC) of 4.6 (p<0.01) for all races and both sexes-combined. Incidence rates were consistently greater for women than men, however, the increase in incidence rates was greater for men (APC=5.4, p<0.01) than for women (APC=4.3, p<0.01). Similar trends were seen for whites and blacks. Conclusions: Anal cancer is a relatively rare disease, yet incidence rates increased dramatically in the U.S. over the last three decades. Correlation of this increased incidence with HPV infection remains to be determined. [Table: see text]

421 Background: CRC is a leading cause of morbidity and mortality among NM’s American Indians, Hispanics, and non-Hispanic whites. Previous studies have shown that rural residents are more likely than urban dwellers to be diagnosed with late stage disease. Geographically New Mexico is the 5th largest state with a population of 2 million, many of whom reside in rural regions. This study was designed to characterize the association between distance-to-care and stage of disease at diagnosis in NM. Methods: The population-based NM Tumor Registry was used to identify records for all incident cases of CRC between 2001-2008. Latitude and longitude were determined for the place of residence for cancer cases and for the facility where each case was diagnosed. The “Great Circles” algorithm was used to estimate the distance from place of residence to the diagnosing facility. The percentage of cases diagnosed with early stage vs. other stages (i.e., regional, distant, and unknown stages-combined) was assessed by quartile of distance-to-care with the use of the chi-squared test for trend. Multiple logistic regression was used to characterize the association between stage and quartile of distance-to-care while controlling for other factors know to be associated with stage at diagnosis. Results: Analysis was based on 6,291 incident cases of CRC that were diagnosed among NM residents. Latitude and longitude for both place of residence at diagnosis and location of diagnosing facility were available for 4,385 (69.7%) of all incident cases. The percentage of cases diagnosed at early stage was inversely related to the distance between the place of residence at diagnosis and the facility where the cancer was diagnosed, as follows: 41.4% of cases in Quartile 1 (shortest distance-to-care); 39.9% in Quartile 2; 37.8% in Quartile 3; and 35.3% in Quartile 4 (p=0.002).By multiple logistic regression, distance-to-care was a significant predictor of stage at diagnosis after adjustment of sex, age and race/ethnicity. Conclusions: Rural residents of NM who must travel relatively long distances to receive medical care are at increased risk of being diagnosed at late stage colorectal cancer.