Society of Surgical Oncology, 2007

Just got back from a surprisingly cold meeting in one of my favorite towns, Washington, DC. While I was hoping to see a cherry blossom or two, it was obviously a few weeks too early, so I settled for the shelter of a dark conference hall.

A few highlights:

-SSO President, Raphael Pollock, announced an interest in opening SSO membership to all surgeons, rather than its primarily academic base of membership.
-Efforts have been initiated to make Surgical Oncology a board-certified specialty.

-Great talks overall on hepatobiliary surgery
-Eddie Abdalla (MD Anderson) gave a nice overview of portal vein embolization... Before this talk, I never really realized the rationale between PVE over hepatic artery embolization. From a physiological standpoint, PVE creates portal flow diversion that increases GI trophic factors that lead to hypertrophy of the contralateral liver lobe. Neat!
-Alan Koffron (Northwestern) had a cine-filled presentation on Laparoscopic Hepatic Resection. Here the technology seemed key, with use of a mix of the Laparoscopic Habib (RF bipolar; RITA Medical Systems), Saline-Enhanced Radiofrequency Ablation (SERF), and staplers.

-The Basic Science lecture by Leroy Hood was interesting, stressing the importance of viewing biology as an informational science - a product of digital and analog systems and signals (very engineering based concepts!)

-Among GI presentations, the peripheral opioid antagonist, methylnaltrexone, had been randomized in 65 patients with segmental colectomies receiving IV PCA narcotics. Methylnaltrexone led to significant improvements in 1st bowel movement (1 day) and discharge eligibility (1 day), but didn't effect time to PO tolerance, flatus, or actual discharge. The study seemed underpowered to detect differences in those factors.

-Amongst the Breast talks, extirpation of the primary in Stage IV breast cancer was revisited by a retrospective review of the SEER database by investigators at Wash U. Nearly half of the 9734 patients with Stage IV breast cancer had surgical excision of the breast tumor, with a survival advantage of about 35% after controlling for age, race, tumor size/grade, ER/PR status, and use of radiotherapy.

-Amongst the exhibitors, Incisive Surgical has developed a new skin stapler that creates an everted, interrupted subcuticular closure using absorbable polylactide-polyglicolide (INSORB). The device contains 20 absorbable staples and is packaged with disposable forceps. The closure can then be reinforced with adhesive strips.

-In conferences, my favorite talks are always the debates.
-The first was regarding excision alone versus excision+radiotherapy for DCIS, between Mel Silverstein and Terry Mamounas. I was surprised to learn that based on SEER data, a third of all DCIS in this country is being treated with excision alone. Mamounas discussed the differences in local recurrence seen in a few RCTs, including NSABP B-17, and the use of prospective rather than retrospective data. Silverstein focused on pathologic criteria (i.e. Van Nuys -margin, grade, necrosis) and age as important determinants of recurrence, and that margin status was not an issue of focus in the RCTs. He also stressed the fact that there is no survival benefit from radiation in DCIS, and that you would have to irradiate 250 people to save 1 life... a low absolute versus relative benefit. Plus there are issues with access, and later use of radiation in the same breast.
-The third debate was regarding local excision versus LAR/APR for Stage I cancer, between Julio Garcia-Aguilar and James Fleshman. Clearly the limitation of local excision is an inability to assess nodal status. Garcia-Aguilar focused on staging with EUS and MRI and proper preoperative selection, as well as avoiding the morbidities associated with abdominal approaches, including sexual and urinary function, as well as stoma formation. Fleshman saw as a limitation access to tumors (although this may be obviated with Transanal Endoscopic Microsurgery), as well as the high rates of local recurrence seen with local excision, especially for T2 tumors. I only wished they discussed more about the role of neoadjuvant therapies in their discussion.
-I think the consensus from the discussions of both DCIS and Stage 1 rectal cancer is that ideally with good preoperative selection criteria "doing less" may be appropriate in a subset of favorable patients (i.e. excision alone for DCIS with low VNPI score; local excision for small, low-grade uT1N0 rectal cancers without lymphovascular invasion), but the safer approach would continue to be "doing more" (excision + XRT; APR/LAR), primarily due to issues related to local recurrence. The problems are the decisions for favorable criteria depend on the quality of the pathologist, radiologist, and/or the EUS-operator and are probably highly variable between institutions.

But does one treatment fit all? It made me think about how new assays like Oncotype DX can help select for patients who can benefit from chemotherapy in addition to Tamoxifen with node-negative ER+ breast cancer. Rather than treating all patients aggressively with chemo, now only the subset of patients at high risk of recurrence need to be treated.

What if there were objective molecular marker(s) for severity of rectal cancer that could help select patients who might be amenable to local excision? What if there were biomarkers of invasion that could classify DCIS into low risk and high risk categories? DCIS is technically a pre-invasive stage of cancer, but what if we could know through a marker whether it confers risk of recurrence or harbors invasion without worrying about the ability of the human eye to detect it?

Late... SG