Introduction Robotic surgery has expanded rapidly in the United States despite high financial commitments of a robotic surgery program. Factors that drive uneven robotic surgery adoption has not been adequately explored at the populational level. Methods A retrospective analysis was performed using the National Cancer Database to evaluate facility-level adoption of robotic colorectal surgery. Facilities were stratified by the timing of the first robotic colorectal case into adoption quartiles (1st: earliest to 4th: latest) and nonadopters. A multivariable ordinal logistic regression model with mixed-methods approach with clustering at the facility level was performed to evaluate the association between the timing of robotic surgery adoption and region, institution-type, and patient socioeconomic demographic variables. Results A total of 1182 facilities were identified as robotic surgery adopters between 2010 and 2021. Early adopting facilities were more likely to be academic facilities (OR 0.34, 95% CI: 0.24-0.47) that treated high-income patients (OR 0.81, 95% CI: 0.70-0.94) with access to insurance (OR 0.71, 95% CI: 0.61-0.81). Early adopting facilities were less likely to treat patients from urban (OR 1.41, 95% CI: 1.18-1.69) and rural regions (OR 1.34, 95% CI: 1.01-1.78) compared to metropolitan areas. Conclusions Robotic colorectal surgery adoption is influenced by academic status of the facility and socioeconomic make-up of patients treated at the facility. Ensuring equitable access to advanced surgical technology remains an essential systems-level priority to reduce differences in surgical care delivery.

BACKGROUND:The Surgery With or Without Neoadjuvant Chemotherapy in High Risk RetroPeritoneal Sarcoma (STRASS 2) trial is evaluating the impact of neoadjuvant chemotherapy versus surgery in patients with high-risk, resectable retroperitoneal sarcoma. To evaluate the real-world effectiveness of this approach, we performed a target trial emulation using the STRASS 2 trial as the foundation. METHODS:Using the national cancer database (2010-2022), we identified patients with dedifferentiated liposarcoma and leiomyosarcoma within the STRASS 2 trial eligibility criteria who underwent definitive surgery. We compared those undergoing neoadjuvant chemotherapy followed by surgery to upfront surgery. Multivariable-adjusted and inverse probability of treatment-weighted Cox proportional hazards regression models were used to estimate the impact on overall survival. RESULTS:Among 2,215 eligible patients, 209 (9.4%) received neoadjuvant chemotherapy followed by surgery, and 2,006 (90.6%) underwent upfront surgery. Neoadjuvant chemotherapy patients were younger, more often privately insured, and more likely treated at academic centers. Compared with upfront surgery, neoadjuvant chemotherapy approach did not improve overall survival in routine multivariable Cox regression (hazard ratio 0.73, 95% confidence interval 0.48-1.10), regression with inverse probability of treatment-weighting (0.74, 0.49-1.11), or target trial emulation analyses (0.75, 0.50-1.12). Neoadjuvant chemotherapy was also not associated with improved R0/R1 resection rates (odds ratio 1.96, 95% confidence interval 0.82-4.74). CONCLUSIONS:The neoadjuvant chemotherapy approach did not confer overall survival advantage in patients with resectable retroperitoneal sarcoma. Target trial emulation offers a valuable framework for generating real-world evidence to complement ongoing randomized trials, particularly in rare and heterogeneous cancers.

BACKGROUND:Endoscopic resection (ER) is increasingly utilized for early gastric cancer (EGC) due to its minimally invasive profile and comparable survival to gastrectomy (GR). However, concerns regarding oncologic efficacy and institutional volume impact persist. This study evaluates how ER volume quartiles impact outcomes and guideline adherence in EGC management. METHODS:A retrospective analysis of the NCDB from 2010 to 2021 for patients with cT1aN0M0 gastric adenocarcinoma was performed comparing ER and GR. Primary outcomes were oncologic outcomes, rates of guideline adherence, and survival stratified by institutional ER volume tertiles (high, mid, low). Multivariable logistic, linear regression, and Cox proportional hazards models were used. RESULTS:A total of 1461 patients were analyzed; 937 (61.4%) undergoing ER and 524 (35.7%) GR. 57.5% of ER occurred in the latter half of the study time period, and increasing proportional ER utilization in EGC was observed over time. When stratified by ER volume tertiles, margin positivity (14.6% high volume vs. 13.7% mid vs. 15.5% low, p = 0.85), LVI rates (6.3% high vs. 9.5% mid vs. 9.7% low, p = 0.32), guideline discordant care (22.6% high vs. 22.3% mid vs. 24.3% low, p = 0.82), and survival (vs. low volume: high HR 1.04, p = 0.87; mid HR 1.27, p = 0.39) did not differ by institutional ER volume. High-volume centers preferentially used ER (OR 1.76, p < 0.01) compared to low and mid-volume centers. Guideline-discordant ER correlated with earlier years (OR 0.69, p = 0.03) but not institutional volume (vs. low volume: high OR 0.94, p = 0.76; mid OR 0.90, p = 0.61). CONCLUSION:ER for EGC is rapidly expanding across US institutions at all volume levels. ER achieves comparable oncological outcomes and survival independent of ER volume when guideline-concordant criteria are met, suggesting centralization may be unnecessary for EGC. The guideline discordant care rate of ~24% across all institutions highlights the need for adherence to ER criteria for EGC.

BACKGROUND:The optimal sequencing for resection of primary and liver metastases in stage IV colorectal cancer (CRC) remains debated. This study evaluated utilization trends and outcomes of liver resection before colon/rectal resections. METHODS:A retrospective analysis was performed using the National Cancer Database (2010-2020) for patients with stage IV CRC and isolated liver metastases who underwent resection of primary CRC and liver metastases. The study identified two cohort groups: a group that underwent liver resection before colon/rectal resection (LRCR) and a group that underwent colon/rectal resection synchronous with or before liver resection (CRLR). Overall survival (OR) was evaluated using Cox proportional hazard models, whereas logistic regression was used for binary outcomes. RESULTS:Among 10,959 patients, 1178 underwent LRCR and 9781 underwent CRLR. Utilization of LRCR increased from 5.37% in 2010 to 15.43% in 2020. Predictors of LRCR utilization included rectal primary sites (OR, 5.88; 95% confidence interval [CI], 4.55-7.60) and academic treatment facilities (OR, 2.74; 95% CI, 1.25-6.00). Predictors of lower LRCR included lymphovascular invasion (OR, 0.69; 95% CI, 0.54-0.87) and moderate (OR, 0.61; 95% CI, 0.39-0.95) to poorly differentiated (OR, 0.47; 95% CI, 0.27-0.81) pathology. Patients undergoing the LRCR approach were associated with better overall survival than those undergoing CRLR (hazard ratio, 0.87; 95% CI, 0.77-0.99). The 90-day mortality (1.11% vs 4.47%; p < 0.01) and 30-day readmissions (3.69% vs 5.81%; p<0.01) after primary tumor resection were lower in the LRCR group. CONCLUSION:The LRCR approach has been increasingly used over time. Compared with CRLR, the LRCR approach was associated with better overall survival, lower postoperative mortality and fewer readmissions after colon/rectal resection.

PURPOSE:Diffusion of Innovation (DOI) model, used in finance to evaluate technology adoption, was applied to medicine using robotic surgery adoption as a case study. METHODS:National Cancer Database (2010-2021), facility level compound annual growth rate (CAGR) in colorectal surgical volume was calculated. Facilities were grouped by year of robotic adoption into DOI categories. Multivariable linear regression estimated associations between CAGR, DOI groups, initial surgical volume and robotic utilization. RESULTS:There were 714,742 patients. DOI groups demonstrated a bell-shaped association with CAGR (Innovators β = 1.88; Early Majority β = 3.98; Late Majority: 2.57; Laggards: 2.07; all p < 0.01). Patients travelled further to Innovator/Early Adopters (β = 7.42 miles) and Early Majority hospitals (β: 8.25 miles, both p < 0.01). CONCLUSION:DOI served as a useful model to evaluate the impact of technology adoption at various points of dissemination, demonstrating largest surgical volume growth in institutions who adopt the technology after a period of initial dissemination.

BACKGROUND:The role of adjuvant immunotherapy (IO) in the treatment of Merkel cell carcinoma (MCC) is currently being explored in clinical trials. Here we aim to evaluate the real-world impact of adjuvant IO on survival in patients with MCC. METHODS:A retrospective analysis of the National Cancer Database was performed to identify patients with stage I-III MCC. Our main predictor of interest was IO in an adjuvant setting, stratified by receipt of radiotherapy (RT). A multivariable Cox proportional hazards regression model with inverse probability treatment weighting was used to estimate overall survival. RESULTS:A total of 353 patients received adjuvant IO, while 5,340 underwent surgery without adjuvant therapy. Among patients who received adjuvant IO, 10.2% had stage I disease, 7.1% stage II, and 82.7% stage III. Overall, adjuvant IO was not associated with a difference in survival (hazard ratio [HR], 1.04; 95% CI, 0.86-1.26). Stratified analyses by stage demonstrated similar findings (stage I: HR, 1.4; 95% CI, 0.79-2.50; stage II: HR, 1.45; 95% CI, 0.67-3.13; stage III: HR, 0.98; 95% CI, 0.79-1.20). However, when an interaction term with RT was introduced with adjuvant IO, both treatments were associated with improved survival compared with surgery alone (HR, 0.53; 95% CI, 0.28-0.99), whereas adjuvant IO without RT was not associated with a significant survival difference (HR, 1.14; 95% CI, 0.83-1.60). CONCLUSIONS:The association between adjuvant IO on survival may be modified by RT, which should be considered when interpreting current adjuvant IO trials in MCC.

BACKGROUND AND OBJECTIVES:Parotidectomy is the most common salivary gland surgery, but there remains a paucity of literature regarding its outcomes in the hands of surgical oncologists. METHODS:A retrospective review was conducted of all patients (n = 74) who underwent parotidectomy by surgical oncologists at a single institution over 10 years (2015-2025). Demographics, perioperative characteristics, and complications were compared. Associations between clinical factors and complications were evaluated by multivariate logistic regression. RESULTS:Most patients were White (85.1%) and male (51.4%) with a mean age of 59.9 years. The most common comorbidities were hypertension (48.6%), current smoking (40.5%), and anxiety (17.6%). Temporary facial nerve paresis occurred in 40.3% of patients by postoperative day one, with no cases of permanent facial nerve paresis. Frey's syndrome occurred in 9.0% and First Bite Syndrome (FBS) in 10.4% of tumor cases; a higher proportion of malignant cases experienced these complications in comparison to benign indications. Positive lymph node status was associated with FBS (p = 0.015), potentially reflecting more extensive surgical dissection. No significant risk factors were identified for other complications. CONCLUSIONS:This study suggests that surgical oncologists with appropriate training can perform parotidectomies with complication rates within published ranges. Larger multicenter studies are needed to validate these findings and examine associations between clinical factors and rare complications, further establishing the role of surgical oncologists in parotidectomy.

INTRODUCTION:Microsatellite instability-high/deficient mismatch repair (MSI-H/dMMR) colon cancers are associated with reduced lymph node (LN) metastasis and improved outcomes in early-stage disease; however, whether these associations vary by patient age remains unclear. MATERIALS AND METHODS:Using the National Cancer Database (2018-2021), we identified 116,623 patients with stage I-III colon adenocarcinoma undergoing upfront surgery and stratified them by age (<65 vs. ≥65 years) and MSI status (MSI-H/dMMR vs. microsatellite stable). Multivariable linear regression assessed LN positivity and lymph node ratio, and Cox proportional hazards models evaluated overall survival, including an interaction term between age and MSI status. RESULTS:MSI-H tumors were more common in older patients (24.9% vs. 13.6%). MSI-H status was independently associated with 0.53 fewer positive lymph nodes (95% CI -0.73 to -0.34), and older age was associated with 0.37 fewer positive lymph nodes (95% CI -0.47 to -0.28). A significant interaction between age and MSI status demonstrated attenuation of the MSI-associated nodal protection in older adults. In node-negative disease, MSI-H was associated with improved overall survival in younger but not older patients, whereas in stage III disease MSI-H was associated with worse survival in older patients. The age-MSI interaction remained significant in adjusted survival models. DISCUSSION:These findings suggest that the prognostic and biologic implications of MSI-H in stage I-III colon cancer are meaningfully modified by age and should be interpreted within an age-specific context.

BACKGROUND AND OBJECTIVE:Endoscopic resection (ER) is increasingly used for early-stage duodenal adenocarcinoma (DA). This study aimed to identify factors guiding ER selection for clinical T1/T2N0 DA. METHODS:A retrospective National Cancer Database analysis (2010-2021) included patients with clinical T1/T2N0M0 DA with available pathological staging among those who underwent surgical resection. Outcomes were overall survival and lymph node upstaging (LNU). Survival was evaluated using Cox proportional hazard models, and predictors of LNU were assessed using logistic regression. RESULTS:Among 527 patients, 68 underwent ER and 459 underwent a major resection. Overall survival did not differ between the two groups (HR: 0.96, 95% CI: 0.65-1.40). Among major resections, nodal upstaging occurred in about 40% of patients and was associated with worse survival (T1 HR: 1.72, 95% CI: 1.18-2.50) and (T2 HR: 2.06, 95% CI: 1.28-3.33). Poor differentiation (OR: 2.83, 95% CI: 1.08-7.45), lymphovascular invasion (OR 7.19, 95% CI: 4.48-11.53), and age (≥ 80 compared to < 65-OR: 0.40, 95% CI: 0.20-0.82) were significant predictors of LNU. CONCLUSION:Nearly 40% of clinically node-negative T1/T2 DA patients who underwent a major resection had LNU, which was associated with worse overall survival. Pathologic features should guide ER selection.

BACKGROUND:Robot-assisted pancreaticoduodenectomy (PD) has emerged as a surgical technique for an operation known for high postoperative morbidities. However, its impact on intraoperative and oncologic endpoints, and postoperative outcomes across higher body mass index (BMI) groups is not well established. METHODS:We conducted a retrospective analysis of 116 patients undergoing robot-assisted PD between 2018 and 2023, categorized by BMI into underweight/normal, overweight, and obese groups. Intraoperative (operative time, estimated blood loss), oncologic (lymph node yield, positive nodes), and postoperative (length of stay, composite adverse events) outcomes were compared using multivariate regression analysis. RESULTS:Among 116 patients undergoing robot-assisted PD, 31.9% were underweight/normal, 45.7% overweight, and 22.1% were obese. Operative time (obese: 321.88 ± 77.87 min; overweight: 311.45 ± 71.21 min; normal: 304.16 ± 67.80 min; p = 0.63) and estimated blood loss (obese: 94.81 ± 81.57 mL; overweight: 115.00 ± 161.53 mL; normal: 104.3 ± 101.1 mL; p = 0.80) were similar across BMI groups. Lymph node yield did not significantly differ (obese: 24.81 ± 9.07; overweight: 21.83 ± 5.90; normal: 20.97 ± 5.06; p = 0.06). However, obese patients experienced a significantly higher rate of composite adverse events (CAE) (42.31%) than overweight (13.21%) and normal BMI groups (18.92%; p = 0.01). In the multivariable analysis, obesity was associated with increased odds of CAE (OR 3.50, 95% CI: 1.01-2.16). However, operative time, blood loss, lymph node yields, and length of stay did not have significant association with BMI. CONCLUSION:Higher BMI was not associated with worse intraoperative and oncologic surgical quality with robot-assisted PD. However, obese patients were more likely to experience postoperative complications after robot-assisted PDs.

AIMS:Patients with stage II melanoma have multiple adjuvant therapy options in national guidelines. We evaluated management strategies to better define treatment in this heterogeneous population. METHODS:Using the National Cancer Database (2010-2021), we identified patients with pathological stage IIA-IIC cutaneous melanoma who underwent surgical resection. Adjuvant treatment categories included no additional therapy (i.e. surgery only), immunotherapy, radiation, and immunotherapy plus radiation. Multivariable Cox proportional models evaluated overall survival by T-stage groups: T2b/T3a, T3b/T4a, and T4b and margin status (negative vs. positive). RESULTS:54,848 patients were identified (T2b/T3a n = 26,916; T3b/T4a n = 18,547; T4b n = 9,385). With negative margins, adjuvant therapy did not improve survival in T2b/T3a patients. Adjuvant immunotherapy in the negative margin cohort improved survival in T3b/T4a (HR 0.52, 95% CI: 0.44-0.62) and T4b (HR 0.54, 95% CI: 0.47-0.62) melanoma. Among patients with positive margins, no benefit was observed with adjuvant therapy of any modality among all T-stage group cohorts. CONCLUSION:The impact of adjuvant treatment on overall survival in stage II melanoma depended on T-stage and margin status. Patients with low-risk disease had no survival benefit, while those with high-risk melanoma, T3b/T4a and T4b, benefited from adjuvant immunotherapy after R0 resection.

The modern era of hepatic resection began with the first published report on "formal" right hemi-hepatectomy by Jean Louis Lortat-Jacob in France in 1952.1 Advanced imaging has enabled improved patient selection for potentially curative resection.2 Dramatic clinical and technical innovations over the last several decades have resulted in >50% five-year survival for patients undergoing resection; however, only about 25% patients with colorectal hepatic metastases (CRHM) will be candidates for operation.3 Given this modest rate of resectability, most patients will require a combination of systemic and local non-surgical therapies  In this patient population, besides systemic chemotherapy, treatment modalities collectively termed "regional hepatic therapies (RHT)" may be employed. RHT include trans-arterial chemotherapy, hepatic artery infusion (HAI) pumps, trans-arterial radio-embolization (TARE) with Yttrium-90 (Y-90) and thermal tumor ablation using radiofrequency ablation (RFA) or microwave ablation (MWA). 4   In this review, we introduce RHT and discuss their utility in the modern day.

Minimally invasive (MIS) liver surgery has grown tremendously in the past two decades and today represents a major weapon in the fight against primary and metastatic neoplasms of the liver. This review catered towards the modern evolution of MIS hepatectomy techniques in addition to the role of robotic surgery in this field. The article also addresses the utility of advanced intra-operative techniques in hepatic parenchymal transection ranging from the Glissonian pedicle approach to the use of indocyanine green (ICG) guided near-infrared fluorescence in non-anatomic resections. In addition, we briefly discuss ablation techniques utilized for liver cancer, including microwave ablation and the novel histotripsy ablation.

BACKGROUND: Patients older than 65 years have unique needs and treatment outcomes goals. The objective of this study was to evaluate the impact of Geriatric Surgery Verification (GSV) initiative in oncology patients >= 65 years undergoing major abdominal surgeries. STUDY DESIGN: We implemented the American College of Surgeons' GSV program protocols for patients 65 and older starting in 2022. A retrospective review was conducted of patients undergoing major abdominal oncologic surgeries from January 2021 through December 2022 to create pre-GSV and post-GSV initiative cohorts. Main outcomes variables were postoperative institutionalization and change in the patient's primary residence disposition (measured as primary residence score, PRS, as a proxy for loss of independence). RESULTS: 57 patients in the control group and 43 patients in the intervention group met inclusion criteria. The average age was 76.5 and 75 years, respectively. Patients were well matched for clinical and sociodemographic characteristics. The intervention group had a shorter mean length of stay (LOS) 4.4 +/- 2.5 days vs 6.5 +/- 3.6 days in control group (p<.01) and were less likely to be newly discharged to an institution (7.3% vs 24.1%, p=0.03). The GSV initiative was associated with 72% lower odds of increased PRS (i.e. care needs) at time of discharge (OR 0.28, 95% CI 0.1 - 0.81). CONCLUSION: The GSV initiative intervention in geriatric oncology patients undergoing major abdominal surgeries was associated with reducing postoperative institutionalization and change in primary residence disposition. Further studies to explore different mechanisms within GSV that lead to improved outcomes in geriatric oncologic population will be informative.

BACKGROUND:Endoscopic resection is increasingly favored as a first-line curative treatment over surgery for early gastric cancer with minimal risk of lymph node metastasis. Our objective is to identify factors that may guide the treatment decision between endoscopic resection and gastrectomy in early gastric cancer. METHODS:A retrospective analysis of the National Cancer Database from 2010 to 2021 for patients with cT1aN0M0 gastric adenocarcinoma was performed comparing endoscopic resection versus gastrectomy. Our main outcomes of interest were overall survival and lymph node upstaging. Multivariate logistic regression and Cox proportional hazards models were used. RESULTS:A total of 2,177 patients were identified; 1,007 (46.3%) had endoscopic resection and 1,170 (53.7%) had gastrectomy. On average, endoscopic resection patients were more likely to be male (72.6% vs 61.1%, P < .01), older (69.7 ± 10.9 vs 65.4 ± 13.1 years, P < .01), and non-Hispanic White (80.3% vs 67%, P < .01). Compared with gastrectomy, tumors undergoing endoscopic resection were smaller, lower grade, more often in the cardia, and had lower rates of lymphovascular invasion and signet morphology. Endoscopic resection resulted in higher margin positivity (15.3% vs 4.6%, P < .01), but both approaches had similar survival (log-rank P = .24). There was a pathologic lymph node upstaging rate of 15.6% in gastrectomy. Factors predicting lymph node upstaging included larger tumor size (odds ratio: 1.01, 95% confidence interval: 1.01-1.02), poor differentiation (odds ratio: 2.65, 95% confidence interval: 1.15-6.09), lymphovascular invasion (odds ratio: 13.15, 95% confidence interval: 7.86-22.01), and positive margins (odds ratio: 5.85, 95% confidence interval: 2.30-14.87). Although signet morphology did not predict lymph node upstaging, it predicted having those aforementioned high-risk features for lymph node upstaging (odds ratio: 12.02, 95% confidence interval: 4.60-31.39). CONCLUSION:In the real-world analysis of early gastric cancer treatment, endoscopic resection alone achieved similar survival to gastrectomy for cT1aN0M0 early gastric cancer. Despite these early gastric cancer staged as cN0, approximately 15% of gastrectomy patients had lymph node upstaging. We found tumor size, grade, margin positivity, and particularly lymphovascular invasion to be important clinical predictors of pathologic lymph node upstaging that should be considered in early gastric cancer treatment decision-making.

IntroductionSignificant gains in advanced melanoma have been made through immunotherapy trials. Factors influencing equitable access and survival impact of these novel therapies are not well-defined.MethodRetrospective analysis using National Cancer Database of patients with advanced stage III and IV melanoma from 2004 to 2021. Multivariable logistic regression was used to study the use of immunotherapy and Cox proportional hazard regression to evaluate overall survival (OS).Results47,427 patients with increasing utilization of immunotherapy from 13.78% in 2004 to 65.88% by 2021. Inequitable adoption were impacted by age, sex, socioeconomic status/affordability, insurance types and residential educational/income level. Receiving immunotherapy was associated with a 44% improvement in OS (HR 0.56, 95% CI 0.54-0.57) and receiving a clinical trial-based therapy was associated with a 37% improvement (HR 0.63, 95% CI 0.53-0.75). Among patients who received immunotherapy or clinical trial-base therapy, there was 40% worse survival in non-Hispanic Black patients (HR 1.40, 95% CI 1.16-1.69) compared to non-Hispanic Whites.ConclusionThere are disparities in utilization of immunotherapy that is influenced by socioeconomic status. Race and ethnicity had a significant influence in differential impact on survival outcomes of immunotherapies highlighting the importance of increasing underrepresented population participation in trials that lead to novel therapies.

BACKGROUND:We sought to determine the significance of age and frailty in predicting peri-operative outcomes of robotic pancreaticoduodenectomy (RPD). METHODS:Data from our institution's prospectively collected robotic pancreaticoduodenectomy database was analyzed for the years 2018-2023. The 5-factor modified frailty index (mFI-5) was used as a concise stratification tool for frailty. Predictive models for composite adverse event (CAE) variable were created using adjusted logistic regressions. RESULTS:116 patients underwent RPD. Mean age of this cohort was 70.65 years (±11.44). The mean operative time was 311.47 min (±71.35) and the estimated blood loss was 107.07 mL (±128.49). The most common postoperative complications included in the CAE were pancreatic leak (n = 10, 8.62 %), delayed gastric emptying (n = 10, 8.62 %), bleeding (n = 5, 4.31 %), and atrial fibrillation (n = 2, 1.72 %). The 90-day mortality was 1.72 %. There was a gradual increase in the odds ratio of CAE with increasing mFI-5 score: OR 1.52 (95 % CI 0.25-9.20) for mFI-5 score of 1 and OR 31.92 (95 % CI 1.79-570.09) for mFI-5 score of 4 compared to score of 0. DISCUSSION:Preoperative mFI-5 score may serve as a risk stratification tool for RPDs.