Faculty Bibliography

Background: Beyond the most common adenocarcinoma type, several gallbladder cancer (GBC) histologies have been described as being associated with more favorable (papillary) or less favorable outcome (adenosquamous, mucinous, signet ring). We sought to examine the added value of histologic type and grade on the existing AJCC staging system for resected GBC. Methods: Patients who underwent resection of GBC from 1988-2013 were identified using the Surveillance Epidemiology End Results (SEER) registry. A prognostic score was created by assigning points for T stage, N stage, grade and histology based on the regression coefficient in multivariate analysis. The score was externally validated using the US Extrahepatic Biliary Malignancy Consortium (USEBMC) database (2000- 2015) and compared with the AJCC staging system. Results: Of 7,915 patients identified in SEER, 83% had adenocarcinoma, 7% papillary, 4% adenosquamous, 4% mucinous, and 2% signet ring. In the USEBMC database, the frequencies of the respective histologies were 86, 9, 2, 1 and 2%. Median survival per histologic type, for SEER and USEBMC respectively, were 45 and 110 mos for papillary, 16 and 24 mos for adenocarcinoma, 14 and 12mos for mucinous, 8 and 4mos for adenosquamous, and 9 and 15mos for signet ring (P between histologies < 0.001 for both cohorts). On multivariate analysis, T stage, N stage, grade and histology were independent predictors of survival. The developed prognostic score, based on points for each of these 4 variables, showed excellent discriminatory ability both in the SEER and USEBMC cohorts. The AUC for the prognostic score was significantly improved compared with the AJCC system (0.69 vs. 0.64, both P < 0.001 using SEER, and 0.76 vs. 0.66, both P < 0.001 using USEBMC). Conclusions: The incorporation of histology and grade into the TNM system allows for a simple and accurate tool to determine prognosis following resection of GBC. (Table Presented)

Purpose: Obesity is an established risk factor for many types of cancer. While obesity has been linked to worse long-term outcomes among patients with breast and colorectal cancer, the relationship of body mass index (BMI) and adrenocortical carcinoma (ACC) remains ill-defined. Since ACC can express adipokine and estrogen receptors, the impact of BMI on outcomes in this patient population is important. We sought to define the association of BMI on ACC clinical and biologic factors, as well as long-term survival. Methods: Data was obtained on 187 patients who underwent surgery for ACC at 13 institutions for whom BMI data were available. Patients were stratified according to the WHO classification of BMI: BMI<25, 25-29.9, 30-34.9, 35-39.9 and >=40. Demographics, tumor biology, management strategies and clinical outcomes were assessed relative to BMI category. Categorical data were analyzed by Fisher's exact test, while continuous variables were analyzed by ANOVA model; disease-free and overall survival were analyzed by Kaplan-Meier survival curves. Results: Mean BMI was 29.5, with a range of 19 to 69. Patient age was comparable among all BMI groups (p=0.9917). Patient sex (p=0.0079) and race (p=0.0373) varied by BMI category. Mean tumor size was 12.1 cm and mean tumor weight was 875 grams, which was similar in all BMI groups. AJCC stage (Stage I: n=12; Stage II: n=62; Stage III: n=47; and Stage IV: n=48) and ENSAT stage (Stage I: n=12; Stage II: n=62; Stage III: n=72; and Stage IV: n=23) did not vary by BMI. BMI tended to be associated with mean mitotic rate (BMI<25: 12.4; 25-29.9: 14.2; 30-34.9: 21.0; 35-39.9: 33.8 and >=40: 8.7; p=0.0773) and percent lymphatic invasion (BMI<25: 37%; 25-29.9: 68%; 30-34.9: 60%; 35-39.9: 67% and>=40: 44%; p=0.0818). In addition, R0 resection rate differed by BMI group (BMI<25: 68%; 25-29.9: 76%; 30-34.9: 50%; 35-39.9: 27% and >=40: 71%; p=0.0029). BMI was not associated with disease-free interval or overall survival. Conclusion: Increased BMI was associated with ACC tumor characteristics but did not affect disease-free or overall survival in our cohort. Further studies are needed to evaluate whether the endocrine effect of lipocytes influences ACC pathology

Background: Incidence and prevalence of idiopathic pulmonary fibrosis (IPF) from electronic databases without case confirmation may be inaccurate. Objectives: Assess the positive predictive value (PPV) of claims-based algorithms to identify IPF and estimate its incidence and prevalence in the US. Methods: We developed two algorithms to identify IPF cases 50 years of age or older in the HealthCore Integrated Research DatabaseSM from 2006 to 2012. One algorithm was developed to be sensitive and the other specific. Medical records were reviewed to determine the PPV of each algorithm and measure the corrected incidence and period prevalence of IPF as identified by the sensitive algorithm. Results: We identified 4,598 patients using the sensitive algorithm and 2,052 (44.6%) patients using the specific algorithm. After medical record review, the PPV of the sensitive and specific algorithms were 40.0% (95% CI 26.4-54.8) and 56.1% (95% CI 43.3-68.3). PPV was higher in patients over the age of 65 years. The incidence and prevalence of IPF identified by the sensitive algorithm and confirmed by chart review were 12.7 per 100,000 person-years and 50.1 per 100,000 persons respectively. Incidence and prevalence of IPF Conclusions: The low PPV of the sensitive algorithm confirmed that non-validated case-finding approaches overestimate the incidence and prevalence of IPF. A revised specific algorithm with improved PPV is needed. (Table Presented)

AIM: To evaluate the locoregional control and treatment toxicity of patients with pleomorphic adenoma after resection with close or positive margins followed by postoperative radiation therapy (PORT). PATIENTS AND METHODS: Between 2002 and 2011, twenty-one patients underwent PORT at the Mount Sinai Beth Israel Medical Center for pleomorphic adenoma of the parotid with close or positive margins. Four out of the 21 patients (19%) had recurrent lesions. The median dose was 57.6 Gy (range 55.8-69.96) delivered at 1.8-2.12 Gy/fraction. Treatment and follow-up data were retrospectively analyzed for locoregional control as well as acute- and late-treatment toxicities. Actuarial survival analysis was also performed. RESULTS: Twelve women and 9 men with a median age of 46 (26-65) at PORT were included in this study. Eighty-one percent of the cohort had positive resection margins while 19% had close margins. At a median follow-up of 92 months, 19/21 patients (90%) had locoregional control. Two patients who failed had primary lesions which recurred locally, and initially had positive margins. The two recurrences occurred at 8 months and 12 months. Acute Radiation Therapy Oncology Group (RTOG) grade 1 and 2 toxicities were experienced by 11 (52%) and 4 (19%) patients, respectively, while 2 (10%) experienced late RTOG grade 1 toxicities. No patients experienced any grade 2-4 late toxicities. Actuarial survival was 100%. CONCLUSION: PORT for patients with pleomorphic adenoma of the parotid gland after resection with close or positive margins results in excellent locoregional control and low treatment-related morbidity.

Concomitant chemoradiotherapy provides organ preservation for those patients with head and neck cancer. We report the results of a prospective study that examined functional outcomes and quality of life (QOL) after chemoradiotherapy over the first 6 months post-treatment (tx). Twenty-nine patients with head and neck cancer were treated with chemoradiotherapy. All were seen baseline and 3 and 6 months post-tx. Assessments included the performance status scale (PSS), Karnofsky performance status scale, tongue strength, jaw opening, and saliva weight. QOL was patient-rated using the eating assessment tool (EAT-10), MD Anderson dysphagia inventory, speech handicap index (SHI), and the EORTC H&N35 scale. Repeated-measures ANOVAs were used, with significance at p < 0.05. PSS scores were significantly different across time points. Tongue strength, jaw range of motion (ROM), and saliva weight were significantly lower at 3 and 6 months than at baseline. QOL was significantly worse after tx, although it improved by 6 months as rated with the EAT-10 and the SHI scores were significantly worse at 3 and 6 months. EORTC domains of swallowing, senses, speech, dry mouth, and sticky saliva were significantly worse at 3 and 6 months. Concomitant chemoradiotherapy for treatment of head and neck tumors can result in impaired performance outcomes and QOL over the first 6 months post-tx. However, performance status, tongue strength, jaw ROM, and eating QOL were only mildly impaired by 6 months post-tx. Saliva production and speech QOL remained significantly impaired at 6 months post-treatment. Current studies are examining outcomes at 12 and 24 months post-treatment to better predict outcomes over time in this population.