Research Spotlight

Calkins, H., G. Hindricks, R. Cappato, Y. H. Kim, E. B. Saad, L. Aguinaga, J. G. Akar, V. Badhwar, J. Brugada, J. Camm, P. S. Chen, S. A. Chen, M. K. Chung, J. C. Nielsen, A. B. Curtis, D. Wyn Davies, J. D. Day, A. d’Avila, N. de Groot, L. Di Biase, M. Duytschaever, J. R. Edgerton, K. A. Ellenbogen, P. T. Ellinor, S. Ernst, G. Fenelon, E. P. Gerstenfeld, D. E. Haines, M. Haissaguerre, R. H. Helm, E. Hylek, W. M. Jackman, J. Jalife, J. M. Kalman, J. Kautzner, H. Kottkamp, K. H. Kuck, K. Kumagai, R. Lee, T. Lewalter, B. D. Lindsay, L. Macle, M. Mansour, F. E. Marchlinski, G. F. Michaud, H. Nakagawa, A. Natale, S. Nattel, K. Okumura, D. Packer, E. Pokushalov, M. R. Reynolds, P. Sanders, M. Scanavacca, R. Schilling, C. Tondo, H. M. Tsao, A. Verma, D. J. Wilber and T. Yamane (2017). “2017 hrs/ehra/ecas/aphrs/solaece expert consensus statement on catheter and surgical ablation of atrial fibrillation: Executive summary.” J Interv Card Electrophysiol: 2017 Sep [Epub ahead of print].

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During the past three decades, catheter and surgical ablation of atrial fibrillation (AF) have evolved from investigational procedures to their current role as effective treatment options for patients with AF. Surgical ablation of AF, using either standard, minimally invasive, or hybrid techniques, is available in most major hospitals throughout the world. Catheter ablation of AF is even more widely available, and is now the most commonly performed catheter ablation procedure.

Mueller-Kronast, N. H., O. O. Zaidat, M. T. Froehler, R. Jahan, M. A. Aziz-Sultan, R. P. Klucznik, J. L. Saver, F. R. Hellinger, Jr., D. R. Yavagal, T. L. Yao, D. S. Liebeskind, A. P. Jadhav, R. Gupta, A. E. Hassan, C. O. Martin, H. Bozorgchami, R. Kaushal, R. G. Nogueira, R. H. Gandhi, E. C. Peterson, S. R. Dashti, C. A. Given, 2nd, B. P. Mehta, V. Deshmukh, S. Starkman, I. Linfante, S. H. McPherson, P. Kvamme, T. J. Grobelny, M. S. Hussain, I. Thacker, N. Vora, P. R. Chen, S. J. Monteith, R. D. Ecker, C. M. Schirmer, E. Sauvageau, A. Abou-Chebl, C. P. Derdeyn, L. Maidan, A. Badruddin, A. H. Siddiqui, T. M. Dumont, A. Alhajeri, M. A. Taqi, K. Asi, J. Carpenter, A. Boulos, G. Jindal, A. S. Puri, R. Chitale, E. M. Deshaies, D. H. Robinson, D. F. Kallmes, B. W. Baxter, M. A. Jumaa, P. Sunenshine, A. Majjhoo, J. D. English, S. Suzuki, R. D. Fessler, J. E. Delgado Almandoz, J. C. Martin and D. C. Haussen (2017). “Systematic evaluation of patients treated with neurothrombectomy devices for acute ischemic stroke: Primary results of the stratis registry.” Stroke 48(10): 2760-2768.

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BACKGROUND AND PURPOSE: Mechanical thrombectomy with stent retrievers has become standard of care for treatment of acute ischemic stroke patients because of large vessel occlusion. The STRATIS registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) aimed to assess whether similar process timelines, technical, and functional outcomes could be achieved in a large real world cohort as in the randomized trials. METHODS: STRATIS was designed to prospectively enroll patients treated in the United States with a Solitaire Revascularization Device and Mindframe Capture Low Profile Revascularization Device within 8 hours from symptom onset. The STRATIS cohort was compared with the interventional cohort of a previously published SEER patient-level meta-analysis. RESULTS: A total of 984 patients treated at 55 sites were analyzed. The mean National Institutes of Health Stroke Scale score was 17.3. Intravenous tissue-type plasminogen activator was administered in 64.0%. The median time from onset to arrival in the enrolling hospital, door to puncture, and puncture to reperfusion were 138, 72, and 36 minutes, respectively. The Core lab-adjudicated modified Thrombolysis in Cerebral Infarction >/=2b was achieved in 87.9% of patients. At 90 days, 56.5% achieved a modified Rankin Scale score of 0 to 2, all-cause mortality was 14.4%, and 1.4% suffered a symptomatic intracranial hemorrhage. The median time from emergency medical services scene arrival to puncture was 152 minutes, and each hour delay in this interval was associated with a 5.5% absolute decline in the likelihood of achieving modified Rankin Scale score 0 to 2. CONCLUSIONS: This largest-to-date Solitaire registry documents that the results of the randomized trials can be reproduced in the community. The decrease of clinical benefit over time warrants optimization of the system of care.

Keller, D. S., J. Qiu and A. J. Senagore (2017). “Predicting opportunities to increase utilization of laparoscopy for rectal cancer.” Surg Endosc: 2017 Sep [Epub ahead of print].

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BACKGROUND: Despite proven safety and efficacy, rates of laparoscopy for rectal cancer in the US are low. With reports of inferiority with laparoscopy compared to open surgery, and movements to develop accredited centers, investigating utilization and predictors of laparoscopy are warranted. Our goal was to evaluate current utilization and identify factors impacting use of laparoscopic surgery for rectal cancer. METHODS: The Premier Hospital Database was reviewed for elective inpatient rectal cancer resections (1/1/2010-6/30/2015). Patients were identified by ICD-9-CM diagnosis codes, and then stratified into open or laparoscopic approaches by ICD-9-CM procedure codes or billing charge. Logistic multivariable regression identified variables predictive of laparoscopy. The Cochran-Armitage test assessed trend analysis. The main outcome measures were trends in utilization and factors independently associated with use of laparoscopy. RESULTS: 3336 patients were included-43.8% laparoscopic (n = 1464) and 56.2% open (n = 1872). Use of laparoscopy increased from 37.6 to 55.3% during the study period (p < 0.0001). General surgeons performed the majority of all resections, but colorectal surgeons were more likely to approach rectal cancer laparoscopically (41.31 vs. 36.65%, OR 1.082, 95% CI [0.92, 1.27], p < 0.3363). Higher volume surgeons were more likely to use laparoscopy than low-volume surgeons (OR 3.72, 95% CI [2.64, 5.25], p < 0.0001). Younger patients (OR 1.49, 95% CI [1.03, 2.17], p = 0.036) with minor (OR 2.13, 95% CI [1.45, 3.12], p < 0.0001) or moderate illness severity (OR 1.582, 95% CI [1.08, 2.31], p < 0.0174) were more likely to receive a laparoscopic resection. Teaching hospitals (OR 0.842, 95% CI [0.710, 0.997], p = 0.0463) and hospitals in the Midwest (OR 0.69, 95% CI [0.54, 0.89], p = 0.0044) were less likely to use laparoscopy. Insurance status and hospital size did not impact use. CONCLUSIONS: Laparoscopy for rectal cancer steadily increased over the years examined. Patient, provider, and regional variables exist, with hospital status, geographic location, and colorectal specialization impacting the likelihood. However, surgeon volume had the greatest influence. These results emphasize training and surgeon-specific outcomes to increase utilization and quality in appropriate cases.

Motzer, R. J., R. A. Figlin, J. F. Martini, S. Hariharan, N. Agarwal, C. X. Li, J. A. Williams and T. E. Hutson (2017). “Germline genetic biomarkers of sunitinib efficacy in advanced renal cell carcinoma: Results from the renal effect trial.” Clin Genitourin Cancer 15(5): 526-533.

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BACKGROUND: Sunitinib, the vascular endothelial growth factor pathway inhibitor, is an established standard-of-care for advanced renal cell carcinoma (RCC). This study aimed to assess correlations between candidate germline single nucleotide polymorphisms (SNPs) and sunitinib efficacy in patients from the RENAL EFFECT trial (NCT00267748), a randomized phase II study in patients with metastatic RCC comparing the 4-weeks-on/2-weeks-off schedule and a continuous daily dosing schedule. PATIENTS AND METHODS: Informed consent for pharmacogenetics research was obtained from 202 out of 289 treated patients in the trial. Associations between 9 SNP variants (CXCL8, LOXL2, CCDC26, SH3GL2, CLLU1, IL2RA, AURKB, and 2 SNPs on Chromosomes 7 and 12) and progression-free survival (PFS), objective response rate, and overall survival were assessed using Kaplan-Meier analysis, Cox proportional hazard model, and the Fisher exact test. RESULTS: CXCL8 rs1126647 A/A versus A/T (P = .004) or T/T (P < .0001) and SH3GL2 rs10963287 C/C versus C/T (P = .005) or T/T (P = .018) were associated with improved overall survival in all patients. CLLU1 rs525810 A/A genotype versus A/G (P = .014) or G/G (P = .048) was associated with improved PFS in the continuous daily dosing arm. IL2RA rs7893467 T/G versus T/T was associated with improved PFS (P = .034) in the 4-weeks-on/2-weeks-off arm and objective response rate (P = .034) in all patients. No significant associations between improved efficacy and genotype were found for other SNPs. CONCLUSION: Germline variants in CLLU1, IL2RA, CXCL8, and SH3GL2 warrant further retrospective study in independent cohorts of patients with metastatic RCC treated with vascular endothelial growth factor-class inhibitors, to test their biological significance and potential clinical fitness as biomarkers to guide treatment.

Podgaetz, E., G. S. Schwartz and D. P. Mason (2017). “Minimally invasive posterior basilar segmentectomy by a posterior approach: Should we start flipping?” J Thorac Cardiovasc Surg 154(4): 1440-1441.

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Multiple studies have demonstrated that sublobar resection is an acceptable treatment modality for small peripheral tumors without suggestive lymphadenopathy. 1 Although wedge resection can be achieved thoracoscopically for peripheral lesions, lesions located deep in the lung parenchyma often require a segmentectomy or lobectomy to be certain to fully encompass the tumor. Segmentectomies are far less common than lobectomy and are significantly more technically demanding, even when performed via thoracotomy.