- Email: [email protected]
Prenatal Solid Tumor Volume Index: Novel Prenatal Predictor of Adverse Outcome in Sacrococcygeal Teratoma
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
225
substantial under-reporting of adverse outcomes. In this regard, the utility of NIS or NSQIP for identifying areas of improvement and ranking of quality may be limited.
22.6. Prenatal Solid Tumor Volume Index: Novel Prenatal Predictor of Adverse Outcome in Sacrococcygeal Teratoma. A. Coleman, B. Kline-Fath, S. Keswani, F. Lim; Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio Introduction: Sacrococcygeal teratoma (SCT) is the most common neonatal tumor. Fetuses with large tumors may develop hydrops from high cardiac output state (HCOS) and progress rapidly to fetal demise (IUFD). Although careful monitoring and prenatal intervention have improved mortality, there are still few criteria to predict outcome and risk of HCOS and hydrops development. We postulate that the prenatal solid tumor volume index (STVI), defined as the ratio of solid tumor volume to the estimated fetal weight (EFW), has greater impact than the total tumor volume in the development of HCOS/hydrops and death. Methods: A retrospective chart review of all SCT patients (n¼38) between 2005 and 2012 was conducted. Terminated pregnancies (n¼3), multiple tumors in a single fetus (n¼1), and patients with inadequate prenatal or follow up data (n¼3) were excluded. Volume and percent of solid tumor volume were calculated by magnetic resonance imaging for each patient (n¼31). We then normalized these values to head circumference (HC) or EFW and compared them on basis of outcome. Outcomes measured were HCOS, hydrops, and survival. We defined HCOS as a combined ventricular output of > two standard deviations above the mean (normal range¼4256100 ml/min/kg) and abnormal doppler or echocardiographic changes or onset of mirror syndrome in the mother. Data was analyzed using T-test, Fisher’s exact test, and receiver operating characteristics (ROC). Results: All deaths (n¼7) had either HCOS or hydrops. In terms of survival and development of HCOS, all variables were significant (table). ROC analysis revealed total volume/EFW >0.1475 to have an 87.5% sensitivity and 80% specificity and STVI (solid volume/EFW) >0.024 to have a 100% sensitivity and 73.33% specificity in regard to HCOS. At a STVI >0.024, the patient was 84 times more likely to develop HCOS (p <0.0001) with a positive predictive value (PPV) of 80% and a negative predictive value (NPV) of 100%. At a total volume/EFW >0.1475, the patient was 28 times more likely to develop HCOS (p¼0.0002) with a PPV of 82.35% and a NPV of 85.71%. Conclusions: While total tumor volume aids in stratifying patients into high risk categories, the solid tumor volume seems to be more predictive of outcomes. STVI (solid volume/EFW) is a better predictor of adverse outcome than total tumor volume. This data will allow us to identify patients that are high risk and guide appropriate therapy.
22.7. Does Bigger Mean Better? An Outcome Comparison of Tertiary Medical Centers and Community Hospitals Following Colorectal Cancer Surgery in an Equal Access System. M. D. DeBarros,1 M. W. Causey,1 Q. Hatch,1 D. Stoddard,1 E. B. Fitzpatrick,1 E. K. Johnson,1 J. Maykel,2 S. R. Steele1; 1Madigan Army Medical Center, Tacoma, WA; 2 University of Massachusetts Medical School, Worcester, MA Introduction: Previous reports have suggested a difference in outcomes following surgery for colorectal cancer (CRC) based on specialist and volume-related metrics. We sought to determine if this held true in an equal access system by comparing community and tertiary medical centers. Methods: We queried the Department of Defense Automated Central Tumor registry (ACTUR) to identify CRC patients undergoing surgical treatment between January 1993 and December 2004 with follow-up through December 2009. Patients were stratified by care at a tertiary (MEDCEN) versus community (MEDDAC) medical center. Diseasefree and overall survival outcomes were calculated including Cox multivariate analysis of survival accounting for patient demographics, nodal harvest, and AJCC stage. Results: 6,438 patients met inclusion criteria (mean age 62 years; 39% female; 74% white; 7.6% active duty; rectal cancer 22%; median follow-up 4.9 years). Overall, 3,347 operations were performed at MEDCENs (11 centers; 52%) and 3,091 operations were performed at MEDDACs (11 centers; 48%). For the entire cohort, 27% were Stage 1, 27% Stage 2, 30% Stage 3, and 16% Stage 4. Mean number
TABLE FROM ABSTRACT 22.6
Survivor (mean6SEM) Death (mean6SEM) p value NCO (mean6SEM) HCOS (mean6SEM) p value Total Volume (cm3) Total Volume/HC (cm3/cm) Total Volume/EFW (cm3/g) Solid Tumor Volume (cm3) Solid Tumor Volume HC (cm3/cm) Solid Tumor Volume EFW (STVI) (cm3/g)
173.3 6 57.49 4.948 6 1.167 0.165 6 0.038 76.69 6 28.57 2.140 6 0.573 0.072 6 0.021
455.3 6 114.8 22.63 6 4.695 0.745 6 0.095 337.4 6 71.55 16.91 6 2.863 0.571 6 0.605
HCOS ¼ High Cardiac Output State; NCO ¼ Normal Cardiac Output. *p-value<0.05.
0.0293* <0.0001* <0.0001* 0.0004* <0.0001* <0.0001*
108.6 6 44.94 4.404 6 1.625 0.104 6 0.026 30.91 6 19.04 1.198 6 0.650 0.022 6 0.008
357.3 6 89.11 14.33 6 3.289 0.476 6 0.086 233.7 6 51.62 10.47 6 2.284 0.337 6 0.064
0.021* 0.0119* 0.0004* 0.0012* 0.0006* <0.0001*
225
substantial under-reporting of adverse outcomes. In this regard, the utility of NIS or NSQIP for identifying areas of improvement and ranking of quality may be limited.
22.6. Prenatal Solid Tumor Volume Index: Novel Prenatal Predictor of Adverse Outcome in Sacrococcygeal Teratoma. A. Coleman, B. Kline-Fath, S. Keswani, F. Lim; Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio Introduction: Sacrococcygeal teratoma (SCT) is the most common neonatal tumor. Fetuses with large tumors may develop hydrops from high cardiac output state (HCOS) and progress rapidly to fetal demise (IUFD). Although careful monitoring and prenatal intervention have improved mortality, there are still few criteria to predict outcome and risk of HCOS and hydrops development. We postulate that the prenatal solid tumor volume index (STVI), defined as the ratio of solid tumor volume to the estimated fetal weight (EFW), has greater impact than the total tumor volume in the development of HCOS/hydrops and death. Methods: A retrospective chart review of all SCT patients (n¼38) between 2005 and 2012 was conducted. Terminated pregnancies (n¼3), multiple tumors in a single fetus (n¼1), and patients with inadequate prenatal or follow up data (n¼3) were excluded. Volume and percent of solid tumor volume were calculated by magnetic resonance imaging for each patient (n¼31). We then normalized these values to head circumference (HC) or EFW and compared them on basis of outcome. Outcomes measured were HCOS, hydrops, and survival. We defined HCOS as a combined ventricular output of > two standard deviations above the mean (normal range¼4256100 ml/min/kg) and abnormal doppler or echocardiographic changes or onset of mirror syndrome in the mother. Data was analyzed using T-test, Fisher’s exact test, and receiver operating characteristics (ROC). Results: All deaths (n¼7) had either HCOS or hydrops. In terms of survival and development of HCOS, all variables were significant (table). ROC analysis revealed total volume/EFW >0.1475 to have an 87.5% sensitivity and 80% specificity and STVI (solid volume/EFW) >0.024 to have a 100% sensitivity and 73.33% specificity in regard to HCOS. At a STVI >0.024, the patient was 84 times more likely to develop HCOS (p <0.0001) with a positive predictive value (PPV) of 80% and a negative predictive value (NPV) of 100%. At a total volume/EFW >0.1475, the patient was 28 times more likely to develop HCOS (p¼0.0002) with a PPV of 82.35% and a NPV of 85.71%. Conclusions: While total tumor volume aids in stratifying patients into high risk categories, the solid tumor volume seems to be more predictive of outcomes. STVI (solid volume/EFW) is a better predictor of adverse outcome than total tumor volume. This data will allow us to identify patients that are high risk and guide appropriate therapy.
22.7. Does Bigger Mean Better? An Outcome Comparison of Tertiary Medical Centers and Community Hospitals Following Colorectal Cancer Surgery in an Equal Access System. M. D. DeBarros,1 M. W. Causey,1 Q. Hatch,1 D. Stoddard,1 E. B. Fitzpatrick,1 E. K. Johnson,1 J. Maykel,2 S. R. Steele1; 1Madigan Army Medical Center, Tacoma, WA; 2 University of Massachusetts Medical School, Worcester, MA Introduction: Previous reports have suggested a difference in outcomes following surgery for colorectal cancer (CRC) based on specialist and volume-related metrics. We sought to determine if this held true in an equal access system by comparing community and tertiary medical centers. Methods: We queried the Department of Defense Automated Central Tumor registry (ACTUR) to identify CRC patients undergoing surgical treatment between January 1993 and December 2004 with follow-up through December 2009. Patients were stratified by care at a tertiary (MEDCEN) versus community (MEDDAC) medical center. Diseasefree and overall survival outcomes were calculated including Cox multivariate analysis of survival accounting for patient demographics, nodal harvest, and AJCC stage. Results: 6,438 patients met inclusion criteria (mean age 62 years; 39% female; 74% white; 7.6% active duty; rectal cancer 22%; median follow-up 4.9 years). Overall, 3,347 operations were performed at MEDCENs (11 centers; 52%) and 3,091 operations were performed at MEDDACs (11 centers; 48%). For the entire cohort, 27% were Stage 1, 27% Stage 2, 30% Stage 3, and 16% Stage 4. Mean number
TABLE FROM ABSTRACT 22.6
Survivor (mean6SEM) Death (mean6SEM) p value NCO (mean6SEM) HCOS (mean6SEM) p value Total Volume (cm3) Total Volume/HC (cm3/cm) Total Volume/EFW (cm3/g) Solid Tumor Volume (cm3) Solid Tumor Volume HC (cm3/cm) Solid Tumor Volume EFW (STVI) (cm3/g)
173.3 6 57.49 4.948 6 1.167 0.165 6 0.038 76.69 6 28.57 2.140 6 0.573 0.072 6 0.021
455.3 6 114.8 22.63 6 4.695 0.745 6 0.095 337.4 6 71.55 16.91 6 2.863 0.571 6 0.605
HCOS ¼ High Cardiac Output State; NCO ¼ Normal Cardiac Output. *p-value<0.05.
0.0293* <0.0001* <0.0001* 0.0004* <0.0001* <0.0001*
108.6 6 44.94 4.404 6 1.625 0.104 6 0.026 30.91 6 19.04 1.198 6 0.650 0.022 6 0.008
357.3 6 89.11 14.33 6 3.289 0.476 6 0.086 233.7 6 51.62 10.47 6 2.284 0.337 6 0.064
0.021* 0.0119* 0.0004* 0.0012* 0.0006* <0.0001*