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Original article

Obesity surgery and malignancy: our experience after 1500 casesDaniel J. Gagné, M.D.*, Pavlos K. Papasavas, M.D., Majed Maalouf, M.D.,

Jorge E. Urbandt, M.D., Philip F. Caushaj, M.D.Department of Surgery, Western Pennsylvania Hospital, Temple University Medical School Clinical Campus, Pittsburgh, Pennsylvania

Received May 16, 2008; accepted July 26, 2008

bstract Background: Obesity is a risk factor for cancer and is associated with increased mortality from anumber of malignancies. We describe our experience with bariatric surgery patients with a historyof malignancy and review the safety and outcomes of bariatric surgery in patients with a history ofcancer.Methods: We performed a retrospective review of prospectively collected data from all patientsdiagnosed with a malignancy before, during, or after bariatric surgery. Data on weight loss,co-morbidities, and recurrence were collected.Results: From July 1999 to February 2008, 1566 patients underwent bariatric surgery. Of these1566 patients, 36 (2.3%) had a history of malignancy before they underwent bariatric evaluation andsurgery, 4 (0.26%) were diagnosed with a malignancy during their preoperative evaluation, 2 ofwhom subsequently underwent bariatric surgery, and 2 had intraoperative findings suspicious formalignancy; bariatric surgery was completed in both cases. The evaluation revealed renal cellcarcinoma and low-grade lymphoma, respectively. No procedures were aborted because of asuspicion of malignancy. Postoperatively, 16 patients (0.9%) were diagnosed with cancer, 3 ofwhom had a history of malignancy: 1 with metastatic renal cell, 1 with recurrent melanoma, and 1,who had had prostate cancer, with bladder cancer.Conclusion: A history of malignancy does not appear to be a contraindication for bariatricsurgery as long as the life expectancy is reasonable. Screening for bariatric surgery might revealthe malignancy. Bariatric surgery does not seem to have a negative effect on the treatment ofmalignancies that are discovered in the postoperative period. (Surg Obes Relat Dis 2009;5:160 –164.) © 2009 American Society for Metabolic and Bariatric Surgery. All rights reserved.

eywords: Morbid obesity; Obesity; Bariatric surgery; Gastric bypass; Cancer; Malignancy; Renal cell cancer; Pancreatic

Surgery for Obesity and Related Diseases 5 (2009) 160–164

cancer; Breast cancer; Lymphoma; Cervical cancer

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Multiple epidemiologic population-based studies havedentified obesity as a risk factor for developing cancer,ncluding endometrial, renal, gallbladder, breast, colon,ancreatic, and esophageal cancer [1–5]. Obesity also in-reases the death rates from cancer at any site comparedith the rates for nonobese patients [6]. It has been also

uggested that maintaining a low body mass index (BMI)ight lower the risk of developing cancer. It has been

stimated that �90,000 deaths annually from cancer might

*Reprint requests: Daniel J. Gagné, M.D., Bariatric Surgery, Westenn Hospital, 4800 Friendship Avenue, 4600 N, Pittsburgh, PA 15224.

mE-mail: dgagne@wpahs.org

550-7289/09/$ – see front matter © 2009 American Society for Metabolic and Boi:10.1016/j.soard.2008.07.013

e avoided if everyone in the adult population could main-ain a BMI of �25 kg/m2 throughout life [6]. Becauseariatric surgery is becoming one of the most commonlyerformed types of surgeries in the United States, it isxpected that a larger number of patients with a history ofalignancy will seek bariatric surgery.We report our experience with patients diagnosed with

alignancy before, during, and after bariatric surgery.

ethods

This study was a retrospective review of a prospectively

aintained database and office charts of 1566 patients who

ariatric Surgery. All rights reserved.

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161D. J. Gagné et al. / Surgery for Obesity and Related Diseases 5 (2009) 160–164

ere evaluated for, and underwent, bariatric surgery fromuly 1999 to February 2008. The institutional review boardf our hospital approved this study. The patient inclusionriteria were a diagnosis of malignancy before seeking bari-tric surgery; a diagnosis with malignancy during the eval-ation for bariatric surgery; a diagnosis of malignancy dur-ng bariatric surgery; and a new diagnosis of malignancyuring the bariatric follow-up period.

We routinely advise patients to follow the recommendedcreening guidelines for colorectal, breast, and gynecologicancer [7].

The patients who had a history of malignancy at theirnitial evaluation and subsequently never pursued bariatricurgery were not included. The patient demographics, ma-ignancies, treatments, and follow-up data were collected.

Descriptive statistics were performed for the demo-raphic data and intervals. For the continuous variables, theescriptive statistics included the number of observations,ean, standard deviation, median, and range (minimum andaximum). For the categorical variables, the descriptive

tatistics included the frequency and percentage.

esults

From July 1999 to February 2008, 1566 patients under-ent bariatric surgery. Of these 1566 patients, 55 (3.5%)et the study inclusion criteria.

iagnosis of malignancy before seeking bariatric surgery

Of the 1566 patients, 36 (2.3%) had a known history ofalignancy before undergoing bariatric surgery (Table 1).he mean patient age at bariatric surgery was 51 years

range 33–71). Of the 36 patients, 27 were women and 9ere men. The mean body BMI was 48 kg/m2 (range5–63). The median interval between the diagnosis of thealignancy and bariatric surgery was 6.5 years (range 1.5–

7). The bariatric procedures included laparoscopic Roux-n-Y gastric bypass (RYGB) in 31, laparoscopic revision of

able 1atients with cancer before bariatric surgery

Malignancy n (%)

Breast 7 (19)Cervical 5 (14)Melanoma 4 (11)Lymphoma 4 (11)Renal 3 (8)Prostate 2 (6)Colon/rectal 2 (6)Leukemia 2 (6)Uterine 2 (6)Testicular 2 (6)Bladder 1 (3)Thyroid 1 (3)

hSmall cell lung 1 (3)

ertical banded gastroplasty to RYGB in 2, laparoscopicdjustable gastric banding in 1, laparoscopic (converted topen) revision of gastric bypass in 1, and laparoscopiceversal of gastric bypass to normal anatomy in 1.

At a median follow-up of 22 months (range 3–59.3), 1atient had developed a new secondary malignancy (bladderancer) and died of metastatic disease (see below). Oneatient with history of renal call carcinoma (Stage 1) devel-ped isolated metastatic disease to the pancreas 4 years afteradical nephrectomy and 13 months after laparoscopicYGB (see below). One patient with history of melanomaeveloped 2 new melanoma lesions 15 years after her orig-nal diagnosis and 3.5 years after gastric bypass (see below).

iagnosis of malignancy during bariatricurgery evaluation

During the preoperative bariatric surgery evaluation, 4atients (0.26%) were diagnosed with a malignancy (Table). Of these 4 patients, 2 were diagnosed with rectal cancer.either had undergone screening colonoscopy before theirariatric visit. One patient developed hematochezia and had

rectal mass on examination that was confirmed byolonoscopy; he subsequently died of complications relatedo colorectal surgery. The second patient had a rectal massn screening colonoscopy, underwent preoperative chemo-herapy, radiotherapy, and low anterior resection. She sub-equently underwent placement of a laparoscopic adjustableastric band. One woman was diagnosed with breast cancern her yearly mammogram, underwent treatment, and sub-equently underwent laparoscopic RYGB. The fourth pa-ient was found to have an incidental right renal mass onreoperative right upper quadrant ultrasonography. Thisas diagnosed as renal cell carcinoma. The patient under-ent resection but was lost to follow-up.

iagnosis of malignancy intraoperatively

Two patients (0.13%) had intraoperative findings suspi-ious for malignancy (Table 3). Bariatric surgery was com-leted in both cases. No procedures were aborted because ofsuspicion of malignancy in the entire cohort of patients.ne patient with a BMI of 64 kg/m2 (198 kg) was found to

able 2atients diagnosed with cancer during screening for bariatric surgery

alignancy Age (y)/sex

BMI(kg/m2)

Procedure Outcome

ectal 67/M 46 Resection Diedectal 59/F 39 CHT/RT/LAR LAGBreast 56/F 38 Resection/RT/CHT LRYGBenal 57/F 38 Resection Unknown

BMI � body mass index; M � male; F � female; CHT � chemotherapy;T � radiotherapy; LAR � low anterior resection; LAGB � laparoscopicdjustable gastric banding; LRYGB � laparoscopic Roux-en-Y gastric bypass.

ave left retroperitoneal mass at surgery after creating the

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162 D. J. Gagné et al. / Surgery for Obesity and Related Diseases 5 (2009) 160–164

astric pouch and elevating the transverse mesocolon. Be-ause of the patient’s size and limits of the computed to-ography scanner, the laparoscopic RYGB procedure was

ompleted to allow the patient to lose enough weight fordditional evaluation. At the 6-week follow-up visit, theatient had lost 23.7 kg, and was able to undergo computedomography, which confirmed left renal cell carcinoma. Henderwent left radical nephrectomy and was alive and dis-ase free at 50 months of follow-up.

The other malignancy discovered during bariatric sur-ery was mesenteric panniculitis that was later confirmed toe low-grade lymphoma (mesenteric panniculitis type) onmaging studies and biopsy. This was also discovered afterreating the gastric pouch and elevating the transverse me-ocolon. This patient was under observation without anyype of chemotherapy at 22 months of follow-up.

iagnosis of malignancy after bariatric surgery

Postoperatively, 16 patients (0.9%) were diagnosed withmalignancy, 3 of whom had previous history of malig-

ancy: 1 with metastatic renal cell, 1 with recurrent mela-oma, and 1, who had had prostate cancer, with bladder

able 3atients diagnosed with cancer intraoperatively

alignancy Age (y)/sex

BMI(kg/m2)

Procedure Outcome

enal 44/M 64 LRYGB;nephrectomy

Alive, 50-mofollow-up

ymphoma 31/M 41 LRYGB Alive, 22-mofollow-up

Abbreviations as in Table 2.

able 4atients who developed cancer after bariatric surgery

ge* (y)/sex Procedure Cancer

7/F LRYGB Colon9/F LRYGB Lymphoma4/F LRYGB Pancreas1/F LRYGB Renal7/M LRYGB Duodenal GIST6/F LRYGB AML1/M† LRYGB Bladder3/M LVBG-RY Glioblastoma6/F LRYGB Pancreas4/F LRYGB Breast6/F LRYGB Glioblastoma5/F LRYGB Uterine3/F LVBG-RY Breast7/M LRYGB Rectal5/F† LRYGB Melanoma5/F† LRYGB Renal metastases

S-C � bariatric surgery to cancer diagnosis; GIST � gastrointestinal stroo Roux-en-Y gastric bypass; AML � acute myelogenous leukemia.

* Age at cancer diagnosis.

† Patient with history of preoperative malignancy.

ancer (Table 4). These 3 patients had undergone the rec-mmended screening to detect recurrence of their malig-ancy before undergoing bariatric surgery.

Of the 16 patients, 12 were women and 4 were men.heir mean age at the cancer diagnosis was 53 years (range1–71). The mean interval between bariatric surgery and theiagnosis of cancer was 26.5 months (range 4–72). At aedian follow-up of 12.5 months (range 1–48), 12 patients

75%) were alive, 2 with known controlled metastatic dis-ase, 1 with duodenal gastrointestinal (GI) stromal tumorith liver metastases and 1 with renal cell carcinoma withetastatic disease limited to the pancreas.One woman was found to have a mass on her yearly

creening mammogram, underwent excision and radiother-py, and was disease free at 7 months of follow-up. Anotheroman, who had a negative mammogram 2 years prior to

urgery, presented with a malignant breast mass. She un-erwent neoadjuvant chemotherapy and breast conservationurgery and was disease free at 4 years of follow-up.

The patient with the duodenal GI stromal tumor wasiagnosed using laparoscopic transgastric endoscopy per-ormed for chronic anemia 11 months after RYGB. One ofhe patients with pancreatic cancer underwent pancreati-oduodenectomy but died of metastatic disease 13 monthsfter the diagnosis. The other patient with pancreatic cancerresented with metastatic disease and was undergoing pal-iative chemotherapy and radiotherapy at last follow-up.

iscussion

Obesity is a risk factor for cancer [1–6]. In a prospectivemerican cohort study, patients with a BMI �35 kg/m2

S–C interval (mo) Follow-up (mo) Death

20 11 Yes36 19 No60 13 Yes25 12 No11 28 No36 14 No

6 11 Yes4 2 No

30 5 No15 7 No72 4 Yes12 1 No11 48 No29 25 No41 12 No13 22 No

or; LVBG-RY � laparoscopic conversion of vertical banded gastroplasty

mal tum

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163D. J. Gagné et al. / Surgery for Obesity and Related Diseases 5 (2009) 160–164

ere found to have increased death rates from cancer at anyite compared with nonobese patients [6]. These resultsere most considerable in the population with a BMI �40g/m2. In that population, a death rate 52% greater than thator the nonobese patients was reported for men and 62% foromen. For the population �50 years old, obesity is esti-ated to contribute to about 14% and 20% of all deaths

rom cancer in men and women, respectively [6].Weight loss surgery is associated with reduction of can-

er death risk. In an observational 2-cohort study, Christout al. [8] reported a relative death risk reduction of .24 in theariatric surgery patient cohort compared with controls.dams et al. [9] conducted a retrospective cohort study with

ontrols obtained from driver license records that wereatched to patients who had undergone RYGB. In the

ohort of patients who had undergone RYGB, deaths fromll causes were reduced by 40% and cancer-related deathsy 60%.

Patients with a history of malignancy who seek bariatricurgery should undergo the appropriate screening to rule outecurrence. We routinely obtain previous medical recordsnd operative and pathology reports pertaining to cancerreatment. Although no clear guidelines have been devel-ped on the timing of bariatric surgery after cancer treat-ent, issues such as the type and stage of malignancy, the

isk of recurrence, and life expectancy should be consid-red. Close communication between the bariatric surgeonnd oncologist/primary care provider is needed to betterssess whether these patients are appropriate candidates forariatric surgery. On the basis of our results, it does notppear that bariatric surgery has a negative effect on pa-ients with a history of malignancy. One could argue thateight loss might reduce the risk of subsequent cancer

reatment as the patient’s co-morbidities improve. In pa-ients with a history of RYGB requiring chemotherapy,ccessing the gastric remnant might be a useful tool forutritional support.

We routinely request that all patients evaluated foreight loss surgery undergo the appropriate cancer screen-

ng evaluations, as recommended by the American Cancerociety [7].

During this process, we have identified patients withectal cancer and 1 patient with breast cancer. In the Unitedtates, routine esophagogastroduodenoscopy (EGD) is notsed as a screening test. Several bariatric surgeons havedvocated the routine use of EGD before weight loss sur-ery. In 1 study, abnormal findings that could change orostpone surgery were found in 61.5% of patients undergo-ng preoperative routine EGD [10]. This is still a contro-ersial issue. We perform EGD selectively in patients withlong history of gastroesophageal reflux disease.Intraoperative issues during bariatric surgery in patients

ith a history of malignancy can include altered GI tractnatomy and adhesions. In our group of patients, 3 patients

ad previously undergone radiotherapy for their malignancy s

cervical cancer in 2 and lymphoma in 1). The patient withymphoma had also undergone open splenectomy as a partf his treatment, resulting in dense upper abdominal adhe-ions. One patient with a history of cervical cancer andadiotherapy had undergone an attempted laparoscopicYGB elsewhere, with conversion to an open procedureecause of the extensive adhesions. She underwent laparo-copic conversion to normal anatomy for persistent nauseand pain. One patient who had undergone open gastricypass and cervical radiotherapy underwent laparoscopiconversion to open approach for Roux limb lengtheningwing to extensive small bowel adhesions from the radio-herapy.

Two patients had intraoperative findings suspicious foralignancy: a left retroperitoneal mass and mesenteric pan-

iculitis. The postoperative workup revealed renal cell car-inoma in 1 and low-grade lymphoma in 1. Obesity haseen shown to be a risk factor for renal cancer and has beeneported to occur after RYGB [11]. Bariatric surgery did notave a negative effect on these 2 patients’ disease or sub-equent treatment.

Bariatric surgery does not seem to have a negative effectn the treatment of malignancies that are discovered in theostoperative period. In our series, 2 patients developedancreatic cancer after weight loss surgery. Obesity is a riskactor for pancreatic cancer in both men and women12,13]. Despite the altered GI tract anatomy, 1 patientnderwent a successful Whipple procedure [14].

Laparoscopic-assisted transgastric endoscopy is a valu-ble tool to evaluate the excluded GI tract for benign andalignant diseases after RYGB [15]. In our series, 1 patientith chronic anemia and heme-positive stool underwent

aparoscopic-assisted transgastric endoscopy 11 months af-er RYGB. A GI stromal tumor of the duodenum wasiscovered. Five cases of adenocarcinoma of the gastricemnant have been reported, 3–22 years after bariatric sur-ery [16–21]. No clear evidence has been reported that theltered upper GI anatomy after RYGB contributes to aelayed diagnosis of upper GI malignancies.

This study had several limitations. We included a heter-geneous group of patients with a variety of malignancieshat were discovered at different periods in relation to theeight loss operation. Information on the number of pa-

ients who underwent preoperative screening for colorectal,reast, and gynecologic cancer was not captured. Also, theatient follow-up was relatively short.

onclusion

The results of our study have shown that a history ofalignancy does not seem to be a contraindication for

ariatric surgery as long as the life expectancy is reasonablend the appropriate follow-up evaluations have taken place.outine cancer screening of patients undergoing bariatric

urgery may reveal malignancies. Bariatric surgery does not

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eem to have a negative effect on the treatment of malig-ancies that are discovered in the postoperative period.

isclosures

The authors claim no commercial associations that mighte a conflict of interest in relation to this article.

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