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Inferior Vena Cava Leiomyosarcoma: Is Reconstruction Necessary after Resection?
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ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
patients in the latter half of the experience being significantly older (61 þ/-13 years old at the time perfusion) versus the first half of the experience (54 þ/- 16 years old) (p ¼ 0.03). Only 6% of patients were 40 years old or less in the second half versus 27% during the first fifteen years (p ¼ 0.01). The number of upper vs. lower extremity perfusions performed was not significant when comparing the two time periods. As expected, patient length of stay was increased in the earlier years (8.3 þ/- 2.9 days) compared to the later time-period (5.6 þ/2.2 days) with p ¼ 0.04, however younger patients (60 years). Days in the intensive care unit were the same in both groups (1.4 þ/- 0.9 days for first half versus 1.5 þ/- 1.1 days for second half) (p ¼ NS). Several different chemotherapeutic agents were used in the perfusate during the course of this experience. In the early time period, cisplatin was used for 83% of patients versus only 3% in the later time period (p < 0.01). In the later experience, melphalan became the drug of choice and was used in 95% of cases versus only 15% of cases before 1995. There was no observed difference in length of hospital stay based on the chemotherapy agent utilized. Time of perfusion shifted from 60 min. pump times to 90 min. in the later years. In terms of the effect of the type of chemotherapeutic agent used or the time of perfusion on disease progression, there was no significant difference observed in either group with regard to the number of patients who subsequently required adjuvant systemic chemotherapy for relapse following HILP. Conclusions: From this thirty year experience with hyperthermic isolated limb perfusion for extremity melanoma, of the variables analyzed and compared between the earlier and later time frames of treatment, the later years (1995-2009) demonstrated a significant decrease in length of hospital stay especially in younger patients as well as a shift in treatment toward an older patient population. These changes reflect trends seen with many other lengthy major surgical procedures including cardiac bypass and whipple procedures. While this data provides some insight as to how maturation of the technique has expanded patient selection, there is still a critical need for further innovations in this treatment modality as a majority of patients still fail to durably respond to this therapy regardless of the type of chemotherapeutic utilized or the length of perfusion time tested over the years.
29.5. Inferior Vena Cava Leiomyosarcoma: Is Reconstruction Necessary after Resection? R. Daylami, V. P. Khatri, P. D. Schneider, C. Troppmann, A. Amiri; University of California Davis, Sacramento, CA Background: Leiomyosarcomas of the inferior vena cava represent a rare form of soft tissue sarcomas. Management strategies necessarily vary due to limited experience. Questions regarding necessity of multimodality therapy and IVC reconstruction remain. Study Design: Six patients were referred to our institution over a period of six years for leiomyosarcomas of the inferior vena cava. Demographic data, imaging results, pathology reports, preoperative radiation regimen and postoperative outcomes were reviewed. Outcomes were compared to that of other published institutional experiences. Results: After preoperative external beam radiation (45005000 cGy) all patients underwent en-bloc resection of the primary malignancy. Four patients (66%) had an R0 resection. All tumors were high grade. No reconstruction of the inferior vena cava was undertaken. One patient (17%) developed pulmonary metastasis postoperatively and was successfully treated with chemotherapy and metastectomy. Three patients (50%) developed acute renal failure, but all recovered full function. Two patients (34%) developed Chylous leak. Although three patients developed lower extremity edema this was well tolerated and did not lead to any long term sequelae. Conclusion: Leiomyosarcomas of the inferior vena cava is a treatable malignancy. Preoperative external beam radiation facilitates marginal resection, though our study is too small to demonstrate a survival benefit. Reconstruction of the inferior vena cava is not necessary for resection of tumors below the level of the hepatic veins.
Lower extremity edema following ligation of the inferior vena cava is well tolerated. Acute renal failure may be a common, albeit transient, early postoperative complication. Extensive periaortic dissection may be associated with Chylous leak which can be managed with internal or external drainage. 29.6. Race/Ethnicity Has No Impact on Outcome for Patients with Triple-Receptor Negative Breast Cancer. A. Henderson, G. Burton, C. Parker, F. Ampil, B. D. Li, Q. D. Chu; Louisiana State University Health Sciences Center, Shreveport, LA Introduction: African-American women with breast cancer have a worse outcome when compared to Caucasian women. Triple-receptor negative breast cancer (TNBC) is biologically aggressive and is associated with a worse prognosis. Since TNBC is more prevalent among African-American women, it has been postulated that this contributes to worse outcomes in African-American women. To understand the impact of race/ethnicity on outcome for TNBC, socioeconomic status (SES) needs to be controlled. We examined the impact of race/ethnicity on a cohort of patients of low SES who have TNBC. Methods: A prospective database created in 1998 collected data on 786 patients with Stage 0-III breast. Of these, 202 patients had TNBC (26%). Primary endpoints were cancer recurrence and death. ZIP code-based income tract and financial data from our computer services were used to assess SES. Data were analyzed using Kaplan-Meier survival analysis, log-rank tests, Cox Proportional hazard regression, chi square test, and t-tests. A p-value 0.05 was considered statistically significant. Results: Of the 468 African-Americans (60%) in the database, 138 had TNBC; 64 of 318 Caucasians had TNBC. Mean age at diagnosis was 49 years. Eighty-eight percent of patients had an annual income of $20,000, and 79% were either free care or Medicaid. The 5-yr overall survival was 72% for African-American women versus 75% for Caucasian women (p ¼ 0.93). On multivariate analysis, race/ethnicity had an impact on disease-
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
patients in the latter half of the experience being significantly older (61 þ/-13 years old at the time perfusion) versus the first half of the experience (54 þ/- 16 years old) (p ¼ 0.03). Only 6% of patients were 40 years old or less in the second half versus 27% during the first fifteen years (p ¼ 0.01). The number of upper vs. lower extremity perfusions performed was not significant when comparing the two time periods. As expected, patient length of stay was increased in the earlier years (8.3 þ/- 2.9 days) compared to the later time-period (5.6 þ/2.2 days) with p ¼ 0.04, however younger patients (60 years). Days in the intensive care unit were the same in both groups (1.4 þ/- 0.9 days for first half versus 1.5 þ/- 1.1 days for second half) (p ¼ NS). Several different chemotherapeutic agents were used in the perfusate during the course of this experience. In the early time period, cisplatin was used for 83% of patients versus only 3% in the later time period (p < 0.01). In the later experience, melphalan became the drug of choice and was used in 95% of cases versus only 15% of cases before 1995. There was no observed difference in length of hospital stay based on the chemotherapy agent utilized. Time of perfusion shifted from 60 min. pump times to 90 min. in the later years. In terms of the effect of the type of chemotherapeutic agent used or the time of perfusion on disease progression, there was no significant difference observed in either group with regard to the number of patients who subsequently required adjuvant systemic chemotherapy for relapse following HILP. Conclusions: From this thirty year experience with hyperthermic isolated limb perfusion for extremity melanoma, of the variables analyzed and compared between the earlier and later time frames of treatment, the later years (1995-2009) demonstrated a significant decrease in length of hospital stay especially in younger patients as well as a shift in treatment toward an older patient population. These changes reflect trends seen with many other lengthy major surgical procedures including cardiac bypass and whipple procedures. While this data provides some insight as to how maturation of the technique has expanded patient selection, there is still a critical need for further innovations in this treatment modality as a majority of patients still fail to durably respond to this therapy regardless of the type of chemotherapeutic utilized or the length of perfusion time tested over the years.
29.5. Inferior Vena Cava Leiomyosarcoma: Is Reconstruction Necessary after Resection? R. Daylami, V. P. Khatri, P. D. Schneider, C. Troppmann, A. Amiri; University of California Davis, Sacramento, CA Background: Leiomyosarcomas of the inferior vena cava represent a rare form of soft tissue sarcomas. Management strategies necessarily vary due to limited experience. Questions regarding necessity of multimodality therapy and IVC reconstruction remain. Study Design: Six patients were referred to our institution over a period of six years for leiomyosarcomas of the inferior vena cava. Demographic data, imaging results, pathology reports, preoperative radiation regimen and postoperative outcomes were reviewed. Outcomes were compared to that of other published institutional experiences. Results: After preoperative external beam radiation (45005000 cGy) all patients underwent en-bloc resection of the primary malignancy. Four patients (66%) had an R0 resection. All tumors were high grade. No reconstruction of the inferior vena cava was undertaken. One patient (17%) developed pulmonary metastasis postoperatively and was successfully treated with chemotherapy and metastectomy. Three patients (50%) developed acute renal failure, but all recovered full function. Two patients (34%) developed Chylous leak. Although three patients developed lower extremity edema this was well tolerated and did not lead to any long term sequelae. Conclusion: Leiomyosarcomas of the inferior vena cava is a treatable malignancy. Preoperative external beam radiation facilitates marginal resection, though our study is too small to demonstrate a survival benefit. Reconstruction of the inferior vena cava is not necessary for resection of tumors below the level of the hepatic veins.
Lower extremity edema following ligation of the inferior vena cava is well tolerated. Acute renal failure may be a common, albeit transient, early postoperative complication. Extensive periaortic dissection may be associated with Chylous leak which can be managed with internal or external drainage. 29.6. Race/Ethnicity Has No Impact on Outcome for Patients with Triple-Receptor Negative Breast Cancer. A. Henderson, G. Burton, C. Parker, F. Ampil, B. D. Li, Q. D. Chu; Louisiana State University Health Sciences Center, Shreveport, LA Introduction: African-American women with breast cancer have a worse outcome when compared to Caucasian women. Triple-receptor negative breast cancer (TNBC) is biologically aggressive and is associated with a worse prognosis. Since TNBC is more prevalent among African-American women, it has been postulated that this contributes to worse outcomes in African-American women. To understand the impact of race/ethnicity on outcome for TNBC, socioeconomic status (SES) needs to be controlled. We examined the impact of race/ethnicity on a cohort of patients of low SES who have TNBC. Methods: A prospective database created in 1998 collected data on 786 patients with Stage 0-III breast. Of these, 202 patients had TNBC (26%). Primary endpoints were cancer recurrence and death. ZIP code-based income tract and financial data from our computer services were used to assess SES. Data were analyzed using Kaplan-Meier survival analysis, log-rank tests, Cox Proportional hazard regression, chi square test, and t-tests. A p-value 0.05 was considered statistically significant. Results: Of the 468 African-Americans (60%) in the database, 138 had TNBC; 64 of 318 Caucasians had TNBC. Mean age at diagnosis was 49 years. Eighty-eight percent of patients had an annual income of $20,000, and 79% were either free care or Medicaid. The 5-yr overall survival was 72% for African-American women versus 75% for Caucasian women (p ¼ 0.93). On multivariate analysis, race/ethnicity had an impact on disease-