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IN THE NEWS
GENERAL SURGERY NEWS / JANUARY 2022
Top Surgery Papers Reviewed at Regional Society Meeting Topics Include Surgical Oncology, Trauma and Colorectal Cancer By MONICA J. SMITH
ATLANTA—Presenters at the Southeastern Surgical Surgical Congress’s Top Papers session are asked to perform form no small feat: Identify the past year’s most outtstanding papers in their disciplines and describe them in 10 minutes or less. What they found for 2020-2021 clarified treatments for some of the deadliest cancers, challenged long-held standard practices, and presented a new way to stay on the cutting edge of research.
Surgical Oncology Breast Cancer Sherry Wren, MD, a surgeon who specializes in gastrointestinal operations, not breast cancer, selected a paper that confirmed the superiority of lumpectomy with radiation over mastectomy for most patients. “This paper really capped off the debate that’s been going on for 20-plus years,” said Dr. Wren, a professor of general surgery at Stanford University School of Medicine, in California. The study, which included 48,986 patients over a sixyear follow-up, confirmed the superiority of breast conservation surgery with radiation over mastectomy with both an overall and a breast cancer–specific relative survival gain of 56% to 70% in node-negative patients. This association remained true in women with low-burden node–positive, but not high-burden node-positive, disease (JAMA Surg 2021;156[7]:628-637). “Because there was no inferior survival from breastconserving surgery and radiation, this shows that there’s no reason to advocate for mastectomy unless a patient has some other significant risk factor, like a strong family history or gene mutations. This also adds doubt to the routine practice of offering mastectomy,” Dr. Wren said. Pancreatic Cancer Researchers at Mayo Clinic aimed to clarify the optimal timing for total neoadjuvant therapy (TNT) and chemoradiation in patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma by identifying factors associated with morbidity, death and survival in these patients (Ann Surg 2021;273[2]:341-349). “TNT has been most talked about in rectal cancer, and now is expanding to pancreatic tumors with no consensus on the protocol to use,” Dr. Wren said. The final analysis included 231 borderline resectable patients (using Alliance criteria); 85% were treated with folfirinox, 34% got gemcitabine/nab-paclitaxel (GA) and 19% switched regimens. The median number of cycles was six, with 37% having eight or more. Ultimately, the investigators found three factors associated with longer survival: extended chemotherapy (at least six cycles), optimal post-chemotherapy CA19-9 response and a strong pathologic response. “Overall, the radiolographic downstaging rate was 28%, and there was no association with any chemotherapy regimen,” Dr. Wren said. “When you look at survivorships, the three-year recurrence-free survival was 62%, which is really respectable for pancreatic ductal adenocarcinoma, again showing how neoadjuvant has really changed our field.”
Surgical Oncology Resources for Surgical Trainees Lastly, Dr. Wren shared resources she has found particularly helpful for surgical trainees: NCCN.org, “which will walk you through how to work up, stage, treat and surveil almost every cancer,” and the Toronto Video Video Atlas of Surgery, “a free resource that help helps you plan and learn through videob based modules the operative approach to many procedures.” Also, a novel approach to look up any research currently being conducted that may have an impact on pancreatic cancer outcomes: the living Evidence Map of Pancreatic Surge gery (www.evidencemap.surgery). “T “This is something you can download as an app (EVIglance) and it’s an unbelievable resource— it’s really a way of democratizing all of the data going on out there and putting it on your phone,” Dr. Wren said. The researchers intend to expand into other disease states. For now, Evidence Map covers only pancreatic cancer.
Trauma Hard Signs of Extremity Vascular Injury Trauma surgeons have long relied on hard signs (absent distal pulse, distal ischemia, active hemorrhage and others) to decide whether to operate on extremity vascular trauma, said S. Rob Todd, MD, in introducing the research titled “Hard signs gone soft: a critical evaluation of presenting signs of extremity vascular injury” (J Trauma Acute Care Surg 2020;90[1]:1-10). “The study objective was to determine if the hard signs we currently use in deciding the need for surgery are still appropriate today,” said Dr. Todd, the chief of acute care surgery at Grady Memorial Hospital, in Atlanta. Analyzing data from 1,910 patients in the American Association from the Surgery of Trauma registry identified as having vascular injury, they found patients without hard signs were more likely to be diagnosed by computed tomography angiography (CTA), whereas those with hard signs were more likely to be diagnosed via operative exploration. There was no difference between the CTA and exploration groups in terms of amputation, reintervention, hospital length of stay or mortality. “In conclusion, the authors state that the hard signs of vascular injury have significant limitations, and that hemorrhagic and ischemic signs provide far greater clinical utility,” Dr. Todd said. Traumatic Intracranial Hemorrhage Dr. Todd’s second top paper, an investigation of platelet transfusions in patients with traumatic intracranial hemorrhage, also challenged a long-held practice backed by little data (J Trauma Acute Care Surg 2020;88[6]:847-854). “The researchers asked three questions: In patients with traumatic intracranial hemorrhage on pre-hospital antiplatelet therapy, did platelet transfusion improve mortality, reduce the progression of hemorrhage or reduce the need for neurosurgical intervention?” They found no decrease in all-cause mortality in patients who received platelet transfusion. In fact, there was an increased odds ratio for death, 1.29. There was also no difference in hemorrhage progression or decrease in neurosurgical intervention when patients received platelet transfusion.
“The authors did provide the caveat that a small subset of the population might benefit from platelet transfusion; however, the data were insufficient to ascertain that,” Dr. Todd said.
Colorectal Cancer Total Neoadjuvant Therapy and Rectal Cancer Paul Rider, MD, the chief of the Division of Colorectal Surgery at the University of South Alabama, in Mobile, chose only one trial to discuss, but it is an important one: the RAPIDO trial (Rectal cancer And Perioperative Induction therapy followed by Dedicated Operation), which investigated TNT in patients with rectal cancer (Lancet Oncol 2021;22[1]:29-42). “In my practice, I’ve had to delay surgery because of the risks of doing major operational interventions during the COVID-19 pandemic. This paper helped me make better decisions and have a stronger platform to stand on in regards to taking care of patients with rectal cancer,” Dr. Rider said. The trial included patients with newly diagnosed, high-risk adenocarcinoma of the rectum, cancers classified as cT4a/b—a particularly challenging population. “Vascular invasion, nodal positivity, involved mesorectal fascia, enlarged lateral lymph node—patients had to have at least one of those, and there were a few that had two, less that had three or four,” Dr. Rider said. The 462 patients in the experimental arm received short-course radiotherapy (five fractions ✕ 5 Gy, 25 Gy), followed by chemotherapy in six or nine cycles depending on the agent, and then surgery two to four weeks after completion. The 455 patients in the control arm received standard of care.
‘In my practice, I’ve had to delay surgery because of the risks of doing major operational interventions during the COVID-19 pandemic. This paper helped me make better decisions and have a stronger platform to stand on in regards to taking care of patients with rectal cancer.’ —Paul Rider, MD In the experimental arm, 128 patients (23.7%) achieved the primary end point of disease-related treatment failure at three years, compared with 30.4% in the control arm. “That doesn’t sound like much. But in essence you’re getting around 6% or 7% in a population that does poorly one-third of the time. So, it’s a pretty good finding,” Dr. Rider said. Many of the secondary end points did not reach statistical difference, but the difference in pathologic complete response, which was 14% in the control arm and 28% in the experimental arm, was highly significant (P=0.0001). Dr. Rider acknowledged a major criticism of the paper, which is that the investigators changed their primary end point, which was originally disease-free survival. “But they realized that in a neoadjuvant study, some people are never disease-free. So they changed it to disease-related treatment failure, and I think that’s OK when you consider the value of the study and that ■ they recognize they made an error,” he said.
