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Background Patients can experience recurrence following curative-intent resection of non-functional pancreatic neuroendocrine tumors (NF-pNETs). We sought to develop a nomogram to risk stratify patients relative to recurrence following resection of NF-pNETs. Methods Patients who underwent curative-intent resection for NF-pNETs between 1997 and 2016 were identified from a multi-institutional database. The impact of clinicopathologic factors, including tumor burden score (TBS) (TBS 2  = (maximum tumor diameter) 2  + (number of tumors) 2 ), was assessed relative to recurrence-free survival (RFS), and a nomogram was developed and internally validated. Results With a median follow-up of 31.0 months (IQR 11.3–56.6 months), 66 (15.8%) out of 416 patients in the cohort experienced tumor recurrence. Overall, 3-, 5-, and 10-year RFS following curative-intent resection was 83.2%, 74.0%, and 44.7%, respectively. Several factors were associated with risk of recurrence including tumor grade (referent G1: G2, HR 4.07, 95% CI 2.29–7.26, p  < 0.001; G3, HR 10.83, 95% CI 3.72–31.53, p  < 0.001), lymph node metastasis (LNM) (HR 4.71, 95% CI 2.69–8.26, p  < 0.001), as well as TBS (referent low: medium, HR 4.36, 95% CI 2.06–9.24, p  < 0.001; high, HR 6.04, 95% CI 2.96–12.31, p  < 0.001). A weighted nomogram including tumor grade (G1 0, G2 54.19, G3 100), LNM (N0 0, N1 42.06), and TBS (low 0, medium 44.07, high 56.48) was developed. The discriminatory power of the nomogram was very good with a C-index of 0.75 (95% CI, 0.66–0.79) in the training cohort and 0.71 (95% CI, 0.65–0.75) in the validation cohort. In addition, the nomogram performed better than the current 8th edition of AJCC TNM staging system, which had a C-index of 0.67 (95% CI, 0.60–0.73). Conclusions A nomogram that incorporated tumor grade, LNM, and TBS was established that had good discrimination and calibration. The nomogram may be an effective tool to stratify patients relative to recurrence risk following resection of NF-pNETs.

Most gallbladder cancers (GBCs) are discovered incidentally after routine cholecystectomy. The influence of timing of diagnosis on disease stage, treatment, and prognosis is not known. Patients with GBC who underwent resection at 10 institutions from 2000 to 2015 were included. Patients diagnosed incidentally (IGBC) and nonincidentally (non-IGBC) were compared. Primary outcome was overall survival (OS). Of 445 patients with GBC, 266 (60%) were IGBC and 179 (40%) were non-IGBC. Compared with IGBC, non-IGBC patients were more likely to have R2 resections (43% vs 19%; P < 0.001), advanced T-stage (T3/T4: 70% vs 40%; P < 0.001), high-grade tumors (50% vs 31%; P < 0.001), lymphovascular invasion (64% vs 45%; P = 0.01), and positive lymph nodes (60% vs 43%; P = 0.009). Receipt of adjuvant chemotherapy was similar between groups (49% vs 49%). Non-IGBC was associated with worse median OS compared with IGBC (17 vs 32 months; P < 0.001), which persisted among stage III patients (12 vs 29 months; P < 0.001), but not stages I, II, or IV. Despite accounting for other adverse pathologic factors (grade, T-stage, lymphovascular invasion, margin, lymph node), adjuvant chemotherapy was associated with improved OS only in stage III IGBC, but not in non-IGBC. Compared with incidental discovery, non-IGBC is associated with reduced OS, which is most evident in stage III disease. Despite being well matched for other adverse pathologic factors, adjuvant chemotherapy was associated with improved survival only in stage III patients with incidentally discovered cancer. This underscores the importance of timing of diagnosis in GBC and suggests that these two groups may represent a distinct biology of disease, and the same treatment paradigm may not be appropriate.

Background Radiographic calcifications and cystic morphology are associated with higher and lower tumor grade, respectively, in pancreatic neuroendocrine tumors (PNETs). Whether calcifications and/or cystic morphology could be used preoperatively to predict post-resection survival in patients with PNETs remains elusive. Methods Patients undergoing curative-intent resection of well-differentiated PNETs from 2000 to 2017 at eight academic institutions participating in the US Neuroendocrine Tumor Study Group were identified. Preoperative cross-sectional imaging reports were reviewed to identify the presence of calcifications and of a cystic component occupying >50% of the total tumor area. Clinicopathologic characteristics and recurrence-free survival (RFS) were compared. Results Of 981 patients studied, 18% had calcifications and 17% had cystic tumors. Tumors with calcifications were more commonly associated with Ki-67 ≥3% (47% vs. 33%; p  = 0.029), lymph node metastasis (36% vs. 24%; p  = 0.011), and distant metastasis (13% vs. 4%; p  < 0.001). In contrast, cystic tumors were less commonly associated with lymph node metastasis (12% vs. 30%; p  < 0.001). Five-year RFS after resection was most favorable for cystic tumors without calcifications (91%), intermediate for solid tumors without calcifications (77%), and least favorable for any calcified PNET (solid 69%, cystic 67%; p  = 0.043). Calcifications remained an independent predictor of RFS on multivariable analysis ( p  = 0.043) controlling for nodal ( p  < 0.001) and distant metastasis ( p  = 0.001). Conclusions Easily detectable radiographic features, such as calcifications and cystic morphology, can be used preoperatively to stratify prognosis in patients with PNETs and possibly inform the decision to operate or not, as well as guide the extent of resection and potential use of neoadjuvant therapy.

Introduction Postoperative complications (POCs) negatively impact oncologic outcomes in some malignancies; however, little is known regarding their effect in soft tissue sarcoma (STS). The aim of this study was to determine the impact of POCs on survival after resection of truncal and extremity STS. Methods All patients who underwent resection for a primary truncal or extremity STS at a single academic institution from 2000 to 2015 were included and analyzed. Primary outcome was disease-specific survival (DSS). Results Among 546 STS patients, POCs occurred in 159 (29%) patients; 57% were major and 55% were surgical site infections. Patients with POCs were older (61 vs. 53 years), had more comorbidities (50 vs. 38%), longer operative time (127 vs. 93 min), higher-grade tumors (93 vs. 86%), and were more likely to receive preoperative radiation (42 vs. 33%; all p  < 0.05). There was no difference in receipt of postoperative therapy between the POCs and no POCs groups (19 vs. 18%, p  = 0.74). Median follow-up for survivors was 37 months, and the 5-year DSS for the entire cohort was 78%. Compared with patients without POCs, patients with POCs had a worse DSS (68% vs. 81%, p  = 0.001). Predictors for decreased DSS on univariate analysis included POCs (hazard ratio [HR] 2.12, 95% confidence interval [CI] 1.37–3.28, p  = 0.001), advanced age, neurovascular/bone resection, positive margin, high grade, and preoperative and postoperative therapy (all p  < 0.05). POCs (HR 1.76, 95% CI 1.08–2.87, p  = 0.02) remained an independent predictor for reduced DSS on multivariate analysis, along with age (HR 1.02, p  = 0.046) and tumor grade (HR 7.62, p  = 0.046). Conclusions POCs following resection of truncal and extremity STS are associated with decreased DSS. Efforts to optimize modifiable risk factors and decrease the rate of POCs warrant further investigation.

Background Surgical resection is a necessary component of curative-intent treatment for most solid-organ cancers but is occasionally aborted, most often due to occult metastatic disease or unanticipated unresectability. Despite its frequency, little research has been performed on the experiences, care needs, and treatment preferences of patients who experience an aborted cancer surgery. Methods Semistructured interviews of patients who had previously experienced an aborted cancer surgery were conducted, focusing on their recalled experiences and stated preferences. All interviews were audio recorded, transcribed, and coded by two independent researchers by using NVivo 12. An integrative approach to qualitative analysis was used—both inductive and deductive methods—and iteratively identifying themes until saturation was reached. Results Fifteen patients with an aborted cancer surgery participated in the interviews. Cancer types included pancreatic ( n = 9), cholangiocarcinoma ( n = 3), hepatocellular carcinoma ( n = 1), gallbladder ( n = 1), and neuroendocrine ( n = 1). The most common reasons for aborting surgery included local tumor unresectability ( n = 8) and occult metastatic disease ( n = 7). Five subthemes that characterized the patient experience following an aborted cancer surgery emerged, including physical symptoms, emotional responses, impact on social and life factors, coping mechanisms, and support received. Conclusions This qualitative study characterizes the impact of aborted cancer surgery on multiple domains of quality of life: physical, emotional, social, and existential. These results highlight the importance of developing patient-centered interventions that focus on enhancing quality of life after aborted cancer surgery.

Background While surgery is generally necessary for most solid-organ cancers, curative-intent resection is occasionally aborted due to unanticipated unresectability or occult metastases. Following aborted cancer surgery (ACS), patients have unique and complex care needs and yet little is known about the optimal approach to their management. Objective The aim of this study was to define the practice patterns and perspectives of an international cohort of cancer surgeons on the management of ACS. Methods A validated survey assessing surgeon perspectives on patient care needs and management following ACS was developed. The survey was distributed electronically to members of the Society of Surgical Oncology (SSO). Results Among 190 participating surgeons, mean age was 49 ± 11 years, 69% were male, 61% worked at an academic institution, and most had a clinical practice focused on liver/pancreas (30%), breast (23%), or melanoma/sarcoma cancers (20%). Participants estimated that ACS occurred in 7 ± 6% of their cancer operations, most often due to occult metastases (67%) or local unresectability (30%). Most surgeons felt (very) comfortable addressing their patients’ surgical needs (92%) and cancer treatment-related questions (90%), but fewer expressed comfort addressing psychosocial needs (83%) or symptom-control needs (69%). While they perceived discussing next available therapies as the patients’ most important priority after ACS, surgeons reported avoiding postoperative complications as their most important priority ( p  < 0.001). While 61% and 27% reported utilizing palliative care and psychosocial oncology, respectively, in these situations, 46% noted care coordination as a barrier to addressing patient care needs. Conclusions Results from this SSO member survey suggest that ACS is relatively common and associated with unique patient care needs. Surgeons may feel less comfortable assessing psychosocial and symptom-control needs, highlighting the need for novel patient-centered approaches.