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The prevalence of Hospital Acquired Complications (HACs) within major hospitals and intensive care units (ICUs) is often used as an indication of care quality. We performed a retrospective cohort study of acute care separations from four adult public hospitals in the state of South Australia, Australia. Data were derived from the Integrated South Australian Activity Collection (ISAAC) database, subdivided into those admitted to ICU or non-ICU (Ward) in tertiary referral or (other major) metropolitan hospitals. During the five-year study period (1 July 2013 to 30 June 2018), there were 471,934 adult separations with 65,133 HAC events reported in 43,987 (9.32%) at a mean rate of 13.8 (95% confidence interval (CI) 13.7 to 13.9) HAC events per 100 separations and 18.5 (95% CI 18.4 to 18.7) per 1000 bed days. The Ward cohort accounted for the majority (430,583 (91.2%)) of separations, in-hospital deaths (6928 (66.4%)) and HAC events (29,826 (67.8%)). The smaller ICU cohort (41,351 (8.76%)) had a higher mortality rate (8.46% versus 1.61%; P< 0.001), longer length of stay (median 10.0 (interquartile range (IQR) 6.0–18.0) days versus 4.0 (IQR 3.0–8.0) days P< 0.001), and higher HAC prevalence (62.1 (95% CI 61.3 to 62.9) versus 9.16 (95% CI 9.07 to 9.25) per 100 separations P< 0.001). Both ICU and Ward HAC prevalence rates were higher in tertiary referral than major metropolitan hospitals (P< 0.001). In conclusion, higher HAC prevalence rates in the ICU and tertiary referral cohorts may be due to high-risk patient cohorts, variable provision of care, or both, and warrants urgent clinical investigation and further research.

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Supplemental Digital Content is available in the text.

Adequate pre-hospital trauma triage is crucial to enable optimal care in inclusive trauma systems. Transport of children in need of specialised trauma care to lower-level trauma centres is associated with adverse patient outcomes. We aimed to evaluate the diagnostic accuracy of paediatric field triage based on patient destination and triage tools.

The Department of Surgery at the University of Cincinnati developed the Surgeons, Scholars, and Leaders Symposium to address the underappreciated aspects of surgical education that are critical in the development of the academic surgeon. Surgical education has undergone many gaps since the beginning of a traditional surgical residency, first pioneered by Dr. Halsted in 1904; still, many gaps in surgical education remain. Topics such as research, financial planning, leadership, career development, and many others are not adequately addressed in formalized training. The Surgeons, Scholars, and Leaders Symposium was first held in January 2015 in Jackson Hole, WY, and has subsequently become an annual event. Recurrent themes addressed at the Symposium include global health, resident autonomy, research program development, leadership, mentorship, career development, and managing transitions. The annual Surgeons, Scholars, and Leaders Symposium has been instrumental in addressing these underappreciated aspects of surgeon development and will continue to be an important venue for the next generation of surgical leaders.

Restoration of SPH levels through direct SPH administration, or conversion of increased ceramide to SPH by NC, reduces mortality and mitigates pulmonary infection after burn injury. Burn patients with concomitant pulmonary Pseudomonas aeruginosa (PA) infection have mortality rates as high as 50%, despite antibiotic therapy. Sphingosine is generated from ceramide via ceramidase and has been reported to have antimicrobial properties. We observed a reduction in sphingosine and a concurrent increase in ceramide in bronchial epithelial cells after burn injury. After PA inoculation, these mice had a significant decrease in survival compared to noninjured mice. However, when injured mice were pretreated with sphingosine or neutral ceramidase and subsequently infected, mortality and bacterial levels were robustly reduced. We further observed that sphingosine directly kills PA. Together, these results demonstrate that reduction in sphingosine is associated with an increased susceptibility to pulmonary infection after burn injury. Restoration of sphingosine levels through direct sphingosine administration or conversion of the increased ceramide to sphingosine by neutral ceramidase reduces mortality and mitigates pulmonary infection after burn injury.

Published work suggests a survival benefit for patients with trauma who undergo total-body CT scanning during the initial trauma assessment; however, level 1 evidence is absent. We aimed to assess the effect of total-body CT scanning compared with the standard work-up on in-hospital mortality in patients with trauma.

Interest in global health has been increasing for years among American residents and medical students. Many residency programs have developed global health tracks or electives in response to this need.

Predictors of success in surgical residency have been poorly understood. Previous studies have related prior performance to future success without consideration of personal attributes that help an individual succeed. Surgical educators should consider how residents learn to gain insight into early identification of residents at risk of failing to complete their surgical training.

Long-term evaluation protocolled treatment of pronation external rotation (PER) type III–IV (OTA type C) ankle fractures.

To evaluate long-term results after protocoled treatment of supination–external rotation (SER) Type II–IV ankle injuries.

Currently, total body computed tomography (TBCT) is rapidly implemented in the evaluation of trauma patients. With this review, we aim to evaluate the clinical implications—mortality, change in treatment, and time management—of the routine use of TBCT in adult blunt high-energy trauma patients compared with a conservative approach with the use of conventional radiography, ultrasound, and selective computed tomography.

Thoracoabdominal MultiDetector-row Computed Tomography (MDCT) is frequently used as a diagnostic tool in trauma patients. One potential side-effect of performing MDCT is the detection of incidental findings and their subsequent consequences on medical treatment. The objective was to evaluate frequency and effects of incidental findings in trauma patients.

HYPOTHESIS Sentinel lymph node (SLN) biopsy provides valuable prognostic information for patients with thick (T4) melanoma. DESIGN Post hoc analysis of data from a prospective, randomized trial. SETTING Academic and private hospitals. PATIENTS Data of 240 patients with melanoma thicker than 4 mm were analyzed. Patients with tumor-positive SLNs underwent completion lymphadenectomy. Disease-free and overall survival were evaluated by Kaplan-Meier analysis. Univariate and multivariate analyses were performed to evaluate factors predictive of tumor-positive SLNs and disease-free and overall survival. RESULTS Median thickness of melanoma was 5.6 mm, and patients were followed up for a median of 50 months. The SLNs were tumor positive in 100 patients (41.7%); 18% of these had additional positive nodes on completion lymphadenectomy. Extremity tumor location (risk ratio, 1.66; 95% confidence interval, 1.24-2.24; P = .001), Clark level (1.95; 1.33-2.87; P = .02), and lymphovascular invasion (1.57; 1.13-2.17; P = .01) were associated with a greater risk of tumor-positive SLNs. The patients with tumor-negative SLNs had significantly better median disease-free survival (46.5 vs 31.0 months; P = .04) and overall survival (55.5 vs 43.0 months; P = .004) compared with patients with tumor-positive SLNs. On multivariate analysis, male sex (risk ratio, 1.59; 95% confidence interval, 1.05-2.50; P = .02), increasing Breslow thickness (1.58; 1.10- 2.30; P = .03), ulceration (1.73; 1.18-2.59; P = .02), and tumor-positive SLNs (1.68; 1.17-2.43; P = .009) were associated with worse overall survival. CONCLUSION The SLN biopsy provides useful prognostic information for patients with T4 melanoma.Arch Surg. 2010;145(7):622-627--

The objective of this study was to determine the incidence of multiple primary melanomas (MPM) and other cancers types among patients with melanoma. Factors associated with development of MPM were assessed in a post hoc analysis of the database from a multi-institutional prospective randomized trial of patients with melanoma aged 18 to 70 years with Breslow thickness 1 mm or greater. Disease-free survival (DFS) and overall survival (OS) were evaluated by Kaplan-Meier analysis. Forty-eight (1.9%) of 2506 patients with melanoma developed additional primary melanomas. Median follow-up was 66 months. Except in one patient, the subsequent melanomas were thinner (median, 0.32 mm vs1.50 mm; P <0.0001). Compared with patients without MPM, patients with MPM were more likely to be older (median age, 54.5 vs51.0 years; P= 0.048), to have superficially spreading melanomas (SSM) (P= 0.025), to have negative sentinel lymph nodes (P= 0.021), or to lack lymphovascular invasion (LVI) (P= 0.008) with the initial tumor. On multivariate analysis, age (P= 0.028), LVI (P= 0.010), and SSM subtype of the original melanoma (P= 0.024) were associated with MPM. Patients with MPM and patients with single primary melanoma had similar DFS (5-year DFS 88.7 vs81.3%, P = 0.380), but patients with MPM had better OS (5-year OS 95.3 vs80.0%, P = 0.005). Nonmelanoma malignancies occurred in 152 patients (6.1%). Ongoing surveillance of patients with melanoma is important given that a significant number will develop additional melanoma and nonmelanoma tumors. With close follow-up, second primary melanomas are usually detected at an early stage.

This study was performed to determine the agreement between and within surgeons concerning the influence on treatment plan of routine versus selective multidetector-row computed tomography (MDCT) findings in blunt trauma patients.

Discussion still remains which polytraumatized patients require radiologic thoracolumbar spine (TL spine) screening. The purpose of this study is to determine whether pelvic fractures are associated with TL spine fractures after a blunt trauma. Additionally, the sensitivity of conventional TL spine radiographs and pelvic radiographs (PXRs) is evaluated.

Sun exposure is known to cause melanoma; what is not known is whether patients from the Southern United States have a different profile of clinicopathologic factors and outcomes than those from the Northern United States. Data from a prospective, randomized trial on surgery for cutaneous melanoma were analyzed. All patients underwent wide excision and sentinel lymph node biopsy. Patients were categorized into two groups: Northern or Southern according to their state of residence. Clinicopathologic factors and outcomes were compared between groups. A total of 2025 patients were included in the analysis; 1214 (60%) were from Southern states. The median follow-up was 52 months. Despite significant differences in clinicopathologic features between groups on both univariate and multivariate analysis, two important factors, namely primary tumor thickness and ulceration were not different, nor was the rate of lymph node metastasis. Additionally, there were no differences in disease-free survival or overall survival between the two groups. Significant differences exist between primary melanomas based on geographic regions; however there are no differences in survival. Cumulative versusepisodic sun exposure may play some role in these differences.

Discussion still remains whether computed tomography (CT) of the abdomen, pelvis, and lumbar spine should be performed routinely after blunt trauma with high energy impact or only in restricted situations. The purpose of this study was to evaluate the additional value of a routine CT algorithm as compared with a more restricted, selective CT algorithm.

Multidetector computed tomography (CT) is more sensitive and specific in detecting traumatic injuries than conventional radiology is. However, still little is known about the diagnostic value and the therapeutic impact of indicated thoraco-abdominal CT scan when it is performed in addition to the complete conventional radiologic work-up for blunt trauma patients.

Body mass index (BMI) is associated with breast cancer risk, but its relationship with stage at diagnosis is unclear. BMI was calculated for patients in the North American Fareston and Tamoxifen Adjuvant trial, and was correlated with clinicopathologic factors, including stage at diagnosis. One thousand eight hundred fourteen patients were enrolled in the North American Fareston and Tamoxifen Adjuvant study; height and weight were recorded in 1451 (80%) of them. The median BMI was 27.1 kg/m2(range, 14.7–60.7). The median patient age was 68 years (range, 42–100); median tumor size was 1.3 cm (range, 0.1–14 cm). One thousand seven hundred ninety-three (99.0%) patients were estrogen receptor positive, and 1519 (84.7%) were progesterone receptor positive. There was no significant relationship between BMI (as a continuous variable) and nodal status (P= 0.469), tumor size (P= 0.497), American Joint Committee on Cancer stage (P= 0.167), grade (P= 0.675), histologic subtype (P= 0.179), or estrogen receptor status (P= 0.962). Patients with palpable tumors, however, had a lower BMI than those with nonpalpable tumors (median 26.4 kg/m2vs27.5 kg/m2, P< 0.001). Similar results were found when BMI was classified as a categorical variable (<25 vs25–29.9 vs=30). Increased BMI does not lead to a worse stage at presentation. Obese patients, however, tend to have nonpalpable tumors. Mammography in this population is especially important.

Traditional nonparametric statistical methods do not provide a quantitative measure of the lifetime benefit from adjuvant therapy. This deficiency makes it difficult to determine the long-term difference in impact between the two treatment arms of a clinical trial. To assess the impact of breast carcinoma recurrence, parametric survival models were derived from two randomized, controlled clinical trials of adjuvant therapy for Stage II breast carcinoma. To assess time to death from causes other than breast carcinoma, actuarial models derived from 1980 Census data were used. These two models were then combined to estimate the mean time to event (MTE) as a function of patient age, with the event being either recurrence or death from other causes. The MTE was then used to measure the differential benefit between two arms of a clinical trial. In the first trial, differences in MTE between treatment groups varied from 2.7 years for 35-year-old patients to 1.4 years for 75-year-old patients. For this trial, the mechanism of survival benefit was an increase in time to recurrence. In the second trial, differences in MTE varied from 7.6 to 1.6 years over the same age ranges. For this trial, the mechanism of survival benefit was an increase in the likelihood of cure, i.e., an increase in the asymptote of the curve that represents proportion of patients without relapse. When applied to data from controlled clinical trials, MTE offers a quantitative measure of long-term outcome from adjuvant therapy. The greatest benefit is achieved when therapy that increases the likelihood of cure is provided to young patients. Cancer 2003;97:1139–46. © 2003 American Cancer Society. DOI 10.1002/cncr.11171

The clinical course of cutaneous melanoma is associated with pathologic and clinical factors, such as thickness, ulceration, and location of tumor and gender of the patient. The authors used a parametric survival model that incorporated a cured fraction of patients to translate these factors into specific estimates of long-term outcome. A cohort study was conducted of 5837 patients who were treated for localized cutaneous melanoma between 1978 and 1990 at the Duke Comprehensive Cancer Center. Of these, 495 patients were excluded because the survival status or one or more of the prognostic factors was unknown. Maximum follow-up was 22 years. The primary outcome measures examined were cured fraction (probability of cure), median tumor specific survival (i.e., median time to death from tumor), and the probability of tumor-related survival at fixed intervals after treatment. For an example of a class of patients with a relatively good prognosis, consider women with nonulcerated lesions measuring 0.5 mm thick on an extremity. The probability of cure (± standard error) for these patients was estimated at 80.8% ± 2.0%, and the median tumor specific survival was 10.0 years ± 0.8 years. This suggests that, in these patients, half of the deaths from melanoma will occur more than 10 years after treatment, barring death from other causes. Conversely, men with ulcerated lesions measuring 8.00 mm thick on the trunk have a relatively poor prognosis. The probability of cure for these patients was 16.8% ± 2.4%, and the median tumor specific survival was 2.7 years ± 0.2 years. Despite this poor initial prognosis, the conditional probability of cure increased to 90%; after 15 years of recurrence free survival. Parametric statistical analysis provides quantitative measures of long-term survival. These measures show that late recurrence—longer than a decade after treatment—is to be expected in a significant portion of patients, although the probability of cure increases with progressively longer recurrence free survival. Cancer 2002;95:1286–93. © 2002 American Cancer Society. DOI 10.1002/cncr.10813

There are no data available from randomized controlled trials that compare the efficacy of sentinel lymph node (SLN) biopsy with Level I/II axillary lymph node dissection (ALND) in patients with breast carcinoma. We performed a formal decision analysis to determine whether SLN biopsy is appropriate, compared with ALND, for patients with T1, T2, and T3 tumors and to quantify the relative value of these two procedures in the management of patients with breast carcinoma. All clinically relevant outcomes were modeled for both SLN biopsy and ALND. The probabilities of complications and outcomes were derived using data from the University of Louisville Breast Cancer Sentinel Lymph Node Study and from extensive review of previous studies. Utilities were assigned by the authors, incorporating values from the literature whenever possible. The expected utility of SLN biopsy was higher than the expected utility for ALND for T1 and T2 tumors that were 4.0 cm or smaller. There was no clear preference for either procedure with tumors that were larger than 4.0 cm. The T1 and T2 results were robust to sensitivity analysis. The results of this decision analysis suggest that SLN biopsy is preferred over ALND for patients with breast tumors that are 4.0 cm or smaller. Patients should be aware of the potential for false-negative results in SLN biopsy, but this risk is outweighed by the decreased morbidity associated with the procedure itself. Cancer 2002;95:478–87. © 2002 American Cancer Society. DOI 10.1002/cncr.10696

No abstract.

Abstract: Background: Evaluating the performance of a trauma system may be attempted by comparing outcome in different trauma populations. Controlling for injury severity is a necessity for such evaluations. We compare two current models for doing so: the “Trauma and Injury Severity Score” (TRISS) and “A Severity Characterization Of Trauma” (ASCOT). Material and Methods: This study of high-energy trauma victims took place in Leiden, the Netherlands, between 1993 and 1998. Using the Hosmer-Lemeshow (HL) test and receiver operator characteristic (ROC) analysis, the TRISS and ASCOT models were compared for calibration and discrimination. Results: 1,024 patients, with an average Injury Severity Score (ISS) of 13.5, were eligible for inclusion. Blunt trauma was the predominant cause of injuries. Both models gave accurate, though pessimistic, results in predicting the actual number of fatalities (n = 71). The HL test indicated a sufficient fit for the ASCOT model (p = 0.28) and an insufficient fit (p = 0.02) for TRISS. The ROC curves were nearly identical (0.97). Including age as a linear variable, instead of using the current age groups, resulted in an improved discriminative power of the models. Conclusions: The ASCOT model proved superior over TRISS in its accuracy to estimate of survival chances. This difference was most evident for victims with an estimated survival chance of 60–90%. Future national trauma researchers should therefore collect ASCOT data. Improved ASCOT models could be developed, with age as a linear variable.

Abstract: Background: The objective of this study was to identify the variables needed for an alternative method by which the quality of care for trauma patients can be quantified. Patients and Methods: A prospective analysis of the clinical parameters and interventions was performed for the extramural as well as the intramural scene. Based on the information available after completion of the primary survey, the interventions needed were identified by a multidisciplinary forum made up of internal and external observers. These interventions were compared with the treatment, which was actuallc performed. We evaluated the reproducibility of the decisions made by the forum by means of a variability analysis. Results: During the review period, 275 patients were evaluated. An Injury Severity Score (ISS) ≥ 18 was recorded in 41 cases. 69 ABC stabilizing interventions were identified by the forum of the injury scene, 32 of which were not performed by the personnel of the emergency medical service (EMS). 91 in-hospital ABC stabilizing interventions were indicated, 22 of which were not performed by the emergency room (ER) personnel. Twelve patients succumbed within the 1st month. Conclusions: The pilot study confirms the feasibility of using a forum to identify the interventions prescribed by protocol for each individual patient. Forum-based case-to-case evaluation will be used as a surveillance tool to evaluate the adequacy of interventions and to quantify the quality of trauma care.

We have recently demonstrated a role for interleukin-12 (IL-12) in the induction and development of hepatic ischemia/reperfusion injury. IL-12 mediates its effects through the transcription factor, signal transducer and activator of transcription-4 (STAT4). Therefore, we investigated the response to hepatic ischemia/reperfusion in STAT4-deficient mice.

Although numerous studies have demonstrated that sentinel lymph node (SLN) biopsy can accurately determine the axillary nodal status for early breast cancer some studies have suggested that SLN biopsy may be less reliable for tumors >2 cm in size. This analysis was performed to determine whether tumor size affects the accuracy of SLN biopsy. The University of Louisville Breast Cancer Sentinel Lymph Node Study is a prospective multi-institutional study involving 226 surgeons. The study was approved by the Institutional Review Board of each institution, and informed consent was obtained from all patients. Patients with clinical stage T1–2N0breast cancer were eligible for the study. Some patients with T3tumors were included because they were clinically staged as T2but on final pathology were found to have tumors >5 cm. This analysis includes 2148 patients who were enrolled from August 1997 through October 2000. All patients underwent SLN biopsy using a combination of radioactive colloid and blue dye injection followed by completion Level I/II axillary dissection. Statistical comparison was performed by chi-square analysis. The SLN identification rate, false negative rate, and overall accuracy of SLN biopsy were not significantly different among tumor stages T1, T2, and T3. We conclude that SLN biopsy is no less accurate for T2–3breast cancers compared with T1tumors.

Introduction:Most melanoma patients with sentinel lymph nodes (SLN) that are histologically positive for metastasis have no additional positive lymph nodes found upon completion lymph node dissection (CLND). Therefore, it has been suggested that CLND may not be required for all patients with positive SLN. This study was undertaken to determine the frequency with which nonsentinel nodes contain melanoma cells detected by RT-PCR.

Hemorrhage and liver failure are the two greatest concerns for patients undergoing major liver resection. Inflow occlusion (Pringle maneuver) is often used to minimize blood loss, but hepatic ischemia results in an increased risk of postoperative hepatic dysfunction. We report our experience with the Harmonic Scalpel ultrasonically activated shears (UAS; Ethicon Endo-Surgery, Cincinnati, OH) and a vascular stapler for hepatic resection as technological advances that aid in minimizing blood loss and thereby reduce the need for inflow occlusion. We retrospectively reviewed liver resections performed from September 1997 through July 1998, in which the UAS and articulating vascular endoscopic linear cutting stapler were used. The vascular stapler was used to divide the appropriate portal vein branch and hepatic vein(s) before parenchymal transection. Parenchymal dissection was performed with UAS to a depth of approximately 2 to 3 cm, and the remainder of the liver parenchyma was divided by a clamp crush and clip and suture ligate technique. Patients underwent segmental resection (n = 12), lobectomy (n = 13), or extended lobectomy (n = 11). Resection was performed for metastatic disease, primary liver tumors, or benign disease in 21, 8, and 7 patients, respectively. A Pringle maneuver was performed in 7 of 36 patients (mean clamp time, 8 minutes). The median required intraoperative blood transfusion was 0 units of packed red blood cells. Major and minor complications occurred in 12 and 3 patients, respectively. Two deaths were related to pneumonia and abdominal infection. The vascular stapler safely and securely divides portal vein branches and hepatic veins. The UAS initiates parenchymal transection with minimal blood loss. These two technologies facilitate the surgeon's aim of liver resection without blood transfusion or Pringle maneuver.

Abstract:The development of an oratorical literary genre is connected with the work of Antiphon, the first in the canon of ten Attic orators. This paper argues against the modern view that the beginnings of literary oratory date to the 420s B.C. when Antiphon began publishing his speeches. It argues that this view depends on a mistaken conception of literacy in the ancient world and that Antiphon's speech-writing activities began much earlier. The argument is based on references to Antiphon in contemporary and later sources, the dating of his speeches, the authenticity and dating of the Tetralogies, and Antiphon's reputation in antiquity as the first logographer.

Liver injury induced by hepatic ischemia/reperfusion is characterized by activation of the transcription factor NF-κB, increased production of tumor necrosis factor-α (TNFα), liver neutrophil accumulation, and hepatocellular damage. Exogenous administration of interleukin-4 (IL-4) or IL-13 was recently shown to regulate this inflammatory injury in association with activation of signal transducer and activator of transcription-6 (STAT6). The objective of the present study was to determine whether STAT6 was required for the regulation of liver inflammation by IL-4 and IL-13. Wild-type and STAT6 knockout mice underwent 90 minutes of hepatic ischemia followed by 8 hours of reperfusion. Hepatic ischemia/reperfusion in wild-type and STAT6 knockout mice significantly increased (P< 0.05) NF-κB activation, serum levels of TNFα, liver accumulation of neutrophils [measured by myeloperoxidase (MPO) content], and hepatocellular damage [measured by serum alanine aminotransferase (ALT)] compared to sham controls. In wild-type mice, activation of STAT6 was not observed after ischemia/reperfusion. Administration of 1 μg of IL-4 or IL-13 at reperfusion reduced serum TNFα, liver neutrophil accumulation, and hepatocellular injury in wild-type mice. Treatment with IL-4 or IL-13 had no effect on liver NF-κB activation but significantly increased activation of STAT6. In STAT6 knockout mice, neither IL-4 nor IL-13 had any effect on TNFα, MPO, or ALT values, the regulatory effects of these cytokines being completely abolished. The data suggest that activation of STAT6 may regulate liver inflammatory injury.

Basosquamous carcinoma is a rare malignancy, with features of both basal cell carcinoma and squamous cell carcinoma. Some authors believe that basosquamous carcinoma merely is a variant of basal cell carcinoma, whereas others have suggested that basosquamous carcinoma may behave more aggressively. To the authors' knowledge the largest published series to date, comprised of 35 cases, was reported > 20 years ago. The authors reviewed their recent experience with basosquamous carcinoma to identify prognostic factors influencing recurrence. The medical records of all patients with the diagnosis of basosquamous carcinoma treated at the University of Louisville-affiliated hospitals between 1985–1988 were reviewed by a senior pathologist. Prognostic factors were analyzed using Cox regression analysis and the log rank test. Thirty-one cases of basosquamous carcinoma were identified in 28 patients. The median age at diagnosis was 68 years (range, 10–94 years). The median follow-up was 60 months (range, 12–312 months). Seventy-five percent of cases were located on the face, neck, and scalp. One patient had regional lymph node metastasis synchronous with the primary tumor. Patterns of recurrence were: local recurrence only (five patients), local recurrence plus regional lymph nodes (three patients), and pulmonary plus regional lymph nodes (one patient). One patient died of pulmonary metastasis. Significant factors predictive of recurrence (P &lt; 0.01) were male gender, positive surgical resection margin, lymphatic invasion, and perineural invasion. Although tumor size was not a statistically significant factor overall (P = 0.076), the 3 patients with lymph node metastases had large tumors (measuring 2 cm, 5 cm, and 5 cm, respectively). Basosquamous carcinoma is an aggressive epithelial neoplasm with a propensity for local recurrence and potential for distant metastatic spread. This behavior differs substantially from basal cell carcinoma. Complete resection with negative surgical margins is essential. Long term follow-up for the detection of local recurrence and distant metastatic spread is recommended. Cancer 2000;88:1365–9. © 2000 American Cancer Society.