Search

Background: This study aims to compare the LACE + readmission index to a novel hepatopancreatobiliary readmission risk score (HRRS) in predicting post-operative hepatopancreatobiliary (HPB) cancer patient readmissions., Methods: A retrospective review of 104 postoperative HPB cancer patients from January 2017 to July of 2019 was performed. Univariable and multivariable analyses were utilized., Results: The LACE + index did not predict 30-day (OR 1.01, 95% CI, 0.97-1.05, p = 0.81, c-statistic = 0.52) or 90-day (OR 1.02, 95% CI, 0.98-1.05, p = 0.43) readmission. Patients readmitted within 30 days had significantly increased HRRS scores compared to those who were not (0 vs 34, p < 0.001). A single unit increase in HRRS corresponded to a 6.5% increased risk of readmission; (OR 1.065, 95% CI, 1.038-1.094, p < 0.0001). HRRS independently predicted 30-day (OR 1.07, 95% CI, 1.04-1.11, p < 0.0001) and 90-day postoperative readmission (OR 1.05, 95% CI 1.03-1.08, p < 0.0001)., Conclusions: HRRS better predicts postoperative readmissions for HPB surgical patients compared to LACE+. Accurate assessment of postoperative readmission must include readmission scores focused on clinically relevant perioperative parameters., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective, aggressive approach to treating intraperitoneal carcinomatosis. This study aimed to test the efficacy/safety of an enhanced recovery (ERAS) program after CRS-HIPEC surgery., Methods: Review of an IRB-approved prospectively maintained HIPEC database from 2003 to 2019. Adverse events and outcomes related to the primary operation were noted., Results: 125 HIPEC procedures performed met inclusion criteria, with 20 treated through ERAS. There was an improvement in LOS (ERAS: 9, 6.0-28.0; non-ERAS: 11.0, 6.0-45.1, P = 0.5), a significant reduction in opioid use during hospitalization (ERAS Total Morphine Equivalents 156 vs Non-ERAS of 856, p < 0.001), and a significant reduction in discharge opioid requirements (ERAS 55% of patients, non-ERAS 97%, p < 0.02)., Conclusion: ERAS for CRS-HIPEC is safe, while maintaining quality outcomes, and leads to significant reductions in hospital opioid use and discharge narcotic usage. Our experience supports the full implementation of an ERAS protocol for HIPEC., Competing Interests: Declaration of competing interest Bryce M Marshall, Prejesh Philips, Michael Egger, Kelly M McMasters, Charles Scoggins, and Robert C.G. Martin declare no conflicts of interest regarding the article “Enhanced Recovery After Surgery is Safe for Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy,” submitted to American Journal of Surgery on 3/25/2020., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The preoperative and intraoperative factors that could predict a higher risk of anastomotic/staple line leak for gastric cancer patients has not been accurately defined., Methods: Patients who underwent surgery with curative intent for gastric malignancies between 2002 and 2018 were evaluated from a single prospective database., Results: A total of 195 patients were evaluated with an overall complication rate of 40%. Anastomotic/staple line leak occurred in 13%, with 4% undergoing reoperation during the same hospitalization. Significant risk factors affecting postoperative complications (POC) were identified in the patients including number of comorbidities (≥2) (HR, 5.30; 95% CI, 1.1-15.3; P = 0.037) and operation type (Total vs Distal) (HR, 2.5; CI 1.08-8.5; p = 0.048). Subset analysis of gastric adenocarcinoma patients demonstrates a five-year overall survival (OS) for patients without perioperative complications was 68%, compared with 41% for patients with POCs (p 0.001)., Conclusions: In a large single-institutional study, POCs were associated with decreased survival in patients undergoing surgery for gastric adenocarcinoma. Optimizing these patients post-operatively with limited anastomotic stress and enteral feeding tube may allow for a less complicated course., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: In January 2014, Kentucky expanded Medicaid coverage in an effort to improve access to healthcare. This study evaluated the early impact of Medicaid expansion on diagnosis and treatment of benign gallbladder disease in Kentucky., Methods: Administrative claims data were queried for patients undergoing cholecystectomy for benign gallbladder disease between 2011 and 2015. Demographic, procedure, and outcome variables from 2011 to 2013 (PRE) and 2014-2015 (POST) were compared., Results: After Medicaid expansion, patients were more likely to have their operation performed as an outpatient (80.0% vs. 78.2%, p < 0.001). A significant trend was noted toward a shorter hospital stay (p < 0.001) among inpatients. For both inpatients and outpatients, a significant shift was noted toward increased hospital charges (p < 0.001)., Conclusions: The expansion of Kentucky Medicaid in 2014 has been associated with an increase in outpatient cholecystectomy, shorter hospital stays for inpatients, and increased hospital charges for both inpatients and outpatients. Increased charges for all procedures may represent a mechanism for hospitals to offset the cost of providing global care for more patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Current data suggests that decreasing VTE incidence may require focus on other factors. This study aimed to identify perioperative risk factors for VTE in patients undergoing surgery for gastrointestinal (GI) malignancy., Methods: Patients undergoing surgery for GI malignancy from 2013 to 2016 were grouped according to whether or not they developed a postoperative VTE, and groups were compared along demographic, perioperative, and outcome variables., Results: Patients who developed VTE were more likely to be older (67 ± 11 VTE vs. 61 ± 10 no VTE, p = 0.04), male (92% vs. 59%, p = 0.02), and have a history of atrial fibrillation (39% vs. 11%, p = 0.01). They also experienced higher intraoperative blood loss (328 ± 724 mL no VTE vs. 918 ± 1885 mL VTE, p = 0.01). On multivariable analysis, history of atrial fibrillation was independently associated with development of postoperative VTE (odds ratio = 3.83, 95% confidence interval = 1.13-13.05, p = 0.03)., Conclusion: A prior history of atrial fibrillation independently predicts increased risk of developing VTE after surgery for GI malignancy. Improving understanding of the underlying VTE pathophysiology in these patients can help guide effective prevention strategies., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: We have previously reported favorable response and survival rates using drug-eluting beads loaded with doxorubicin (DEBDOX) for unresectable hepatic metastases. This study investigates the quality of life (QoL) impact of DEBDOX for the treatment of unresectable hepatic metastases from melanoma., Methods: A multi-center, prospective, non-controlled clinical trial was reviewed. QoL was assessed at baseline and after each treatment, and doxorubicin-specific effects were assessed after each treatment., Results: Twenty patients received 61 DEBDOX treatments. After each treatment, at least 83% of patients reported "little" to "none" doxorubicin-related symptoms. For the 8 FACT-Hep subscales, QoL scores were unchanged through 3 treatments for 18 of 24 total time points by ANOVA, with a small-to-moderate ES change through the last treatment in 36 of 40 time points., Conclusions: Hepatic arterial therapy with DEBDOX is safe with minimal QOL changes in treating unresectable liver-dominant melanoma metastasis., Clinical Trial: NCT01010984., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The goal of this study was to compare the outcome after partial hepatectomy for hepatocellular carcinoma (HCC) in which a margin less than or equal to 5 mm or greater than 5 mm was achieved., Methods: A review of our 3300-patient prospective HPB database was performed from 12/2002 to 4/2015. Patients were stratified into two groups: resection margins ≤5 ("narrow") and >5 mm ("wide") as measured on final pathologic assessment., Results: One-hundred thirty patients were included in the analysis (margin ≤5 mm, n = 41 and margin >5 mm, n = 89). At the time of analysis 54 patients had developed 56 recurrences, 15 (37%) in the narrow margin group and 41 (46%) in the wide margin group, p = 0.45. The pattern of recurrence was similar in the two groups: intrahepatic 11 (79%) versus 30 (75%), p = 1, and extra-hepatic 6 (43%) versus 17 (43%), p = 1. Median disease-free survival was similar in both groups, 18.1 versus 19.5 months (p = 0.85)., Conclusions: A narrow resection margin (5 mm or less) does not detract from oncologic outcomes after partial hepatectomy for HCC. Tailoring resection margins may lead to greater preservation of hepatic parenchyma. Factors other than margin status represent the driving forces for local and systemic recurrence., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The benefit of adjuvant chemotherapy occurs with early initiation, but is commonly delayed due to postoperative complications. Minimally invasive surgery is proven to significantly reduce complications and hospital length of stay. This study compares open versus laparoscopic liver resection in patients requiring adjuvant chemotherapy., Methods: 120 consecutive patients with metastatic colorectal liver cancer who underwent liver resection between 2007 through 2012 were reviewed from an IRB prospective database., Results: 44 laparoscopic cases were compared to 76 open cases having equivalent resections. Laparoscopic liver resection patients had lower blood loss (276 ml) than patients with open resection (614 ml). Patients with laparoscopy had shorter length of hospital stay (5 days) than patients with open resection (9 days). Patients with laparoscopic resection had a shorter time of chemotherapy initiation postoperatively (24 days v 39 days). Overall complication rates were higher, but statistically insignificant in patients with open resection., Conclusions: Our data showed that the shorter LOS with laparoscopic major hepatectomies allows earlier initiation of chemotherapy compared to the open group, without jeopardizing surgical margins or extent of resection., Summary: Over the past decade multiple authors have established that, despite occasional longer operating times, laparoscopic liver surgery is associated with reduced blood loss, reduced postoperative morbidity and shorter hospital stay. The purpose of this analysis was to determine if the advantages of a minimally invasive approach correspond to shorter initiation of adjuvant chemotherapy versus an open approach., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Accessory spleens located within the pancreatic parenchyma (intrapancreatic accessory spleen, IPAS) pose a unique clinical challenge. In many cases, despite imaging and other diagnostic studies, malignancy cannot be excluded and patients are subjected to pancreatic resection. We review our experience with the presentation, diagnosis, and treatment of patients with IPAS to provide insight into improving pre-operative evaluation of these patients METHODS: A retrospective chart review identified seven patients who underwent surgical resection of an intrapancreatic spleen at University of Louisville Hospital between 2004 and 2015. Charts were analyzed for presenting symptoms, pre-operative imaging, operative therapy, and final pathologic evaluation. Patients were included in the study if they underwent pancreatic resection for a pancreatic mass and were diagnosed with an IPAS on final pathologic evaluation., Results: Patient age ranged from 38 to 72 with a median age of 62.5, including five males and two females. Lesions ranged from 1.4 to 7.4 cm in maximal diameter (mean 3.8 cm). All lesions were identified as round, hypervascular, well-circumscribed masses in the pancreatic tail. The most common pre-operative diagnosis was a non-functioning pancreatic neuroendocrine tumor (NF-PNET). The most common operative approach was laparoscopic distal pancreatectomy and splenectomy., Conclusion: IPAS are benign tumors commonly mistaken for pancreatic neoplasms such as NF-PNET. A combination of CT, MRI and nuclear medicine examinations can confirm the diagnosis of IPAS and prevent unnecessary surgical resection., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The multifactorial incidence of infectious complications carries considerable consequences for patients undergoing more extensive surgery with intent to cure metastatic colorectal cancer. Advances in ablation techniques have emerged as an efficacious method in regional control for liver metastasis from colorectal cancer; however, the degree of increased risk of infectious complications when ablation is performed in combination with colon resection has not been defined., Methods: An analysis of a single institution's prospective database from August 1998 to December 2012 was performed for patients undergoing colon resection. Patients were stratified into a colon resection combined with either microwave ablation (MWA) or radiofrequency ablation (RFA) compared to a colon resection only group. Variables included baseline clinicopathologic data, type of operation, complication grade, and infectious outcome. Fisher exact test, Student t test, and analysis of variance were used to detect significance levels of P values less than .05., Results: A total of 132 patients with colon cancer of various origins were identified. The group of colon resection combined with RFA and/or MWA was 53 patients (34 male:19 female) and was compared to a matched group of 79 patients (40 male:39 female) who underwent colon resection alone. Median age (58 vs 60 years; P = .209), complication rate (60.7% vs 62.5%; P = .722), infection rate (28.7% vs 35.4%; P = 1.0), mean blood loss (352.7 vs 468.4 mL; P = .452), mean blood transfused (1.36 vs .76 U; P = .247), and receipt of neoadjuvant chemotherapy (47.1% vs 51.85%; P = .724) were all similar between the ablation group and colon only group, respectively. Transfusion rate was higher in the ablation group (39.6% vs 18.9%; P = .016). Overall complication rate was 60.6%, with 32.6% infections. One mortality was observed in each group. High-grade (grade, III to V) complications (35.8% vs 18.9%; P = .0112) and liver-specific complications (n = 4; P = .024) were significantly increased in the combined ablation group., Conclusions: Combining MWA or RFA techniques with colon resection for liver metastasis appears to have similar infectious and overall complication rates when compared to performing an isolated resection of the primary colon cancer alone, although there may be a higher degree of complication seen in the more aggressive approach for curative intent in patients with colorectal liver metastasis., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to determine the impact of a restrictive blood transfusion protocol on the number of transfusions performed and the related effect on patient morbidity., Methods: A cohort study was performed using our prospective database with information from January 1, 2000, to June 1, 2013. The restrictive blood transfusion protocol was implemented in September 2011, so this date served as the separation point for the date of operation criteria., Results: For the study, 415 patients undergoing operation for an abdominal malignancy were reviewed. After the restrictive blood transfusion protocol, the percentage of patients who received blood dropped from 35.6% to 28.3%. The percentage of patients who experienced perioperative complication was significantly higher in transfused patients compared with those who did not receive blood (P = .0001). There was no statistical significance observed between the 5 groups for the length of stay at the hospital after their procedure., Conclusions: The restrictive blood transfusion protocol resulted in a reduction of the percentage of patients transfused, and there was no evidence to suggest that it negatively affected the outcomes of patients in this group., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Management of anemia in surgical oncology patients remains one of the key quality components in overall care and cost. Continued reports demonstrate the effects of hospital transfusion, which has been demonstrated to lead to a longer length of stay, more complications, and possibly worse overall oncologic outcomes. The hypothesis for this study was that a dedicated restrictive transfusion protocol in patients undergoing hepatectomy would lead to less overall blood transfusion with no increase in overall morbidity., Methods: A cohort study was performed using our prospective database from January 2000 to June 2013. September 2011 served as the separation point for the date of operation criteria because this marked the implementation of more restrictive blood transfusion guidelines., Results: A total of 186 patients undergoing liver resection were reviewed. The restrictive blood transfusion guidelines reduced the percentage of patients that received blood from 31.0% before January 9, 2011 to 23.3% after this date (P = .03). The liver procedure that was most consistently associated with higher levels of transfusion was a right lobectomy (16%). Prior surgery and endoscopic stent were the 2 preoperative interventions associated with receiving blood. Patients who received blood before and after the restrictive period had similar predictive factors: major hepatectomies, higher intraoperative blood loss, lower preoperative hemoglobin level, older age, prior systemic chemotherapy, and lower preoperative nutritional parameters (all P < .05). Patients who received blood did not have worse overall progression-free survival or overall survival., Conclusions: A restrictive blood transfusion protocol reduces the incidence of blood transfusions and the number of packed red blood cells transfused. Patients who require blood have similar preoperative and intraoperative factors that cannot be mitigated in oncology patients. Restrictive use of blood transfusions can reduce cost and does adversely affect patients undergoing liver resection., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Venous thromboembolism is a common cause of morbidity. Guidelines recommend perioperative thromboprophylaxis, but clinicians remain cautious of bleeding after major oncologic resections., Methods: Retrospective analysis of a single institution's prospective hepatopancreatobiliary database was performed for patients undergoing surgery between January 2010 and February 2013. A total of 223 patients received postoperative thromboprophylaxis and 93 patients were dosed with low-molecular-weight heparin (LMWH) preoperatively., Results: Two hundred twenty-three patients were analyzed; 50.6% underwent pancreatic and 49.3% underwent liver resection. There were no differences in previous venous thromboembolism (3.8% vs 3.3%; P = .56) or preoperative venous thromboembolism scores (5.74 vs 5.67; P = .82). Estimated blood loss (537 mL vs 592 mL; P = .54), transfusions (25.4% vs 30.4%; P = .25), and complications (52.3% vs 43.5%; P = .12) were equivalent. Incidence of thromboembolic events was lower (6.1% vs 1.1%; P = .05); however, bleeding requiring intervention was increased in the preoperative LMWH group (10.9% vs 3.1%; P = .026)., Conclusions: Caution must be exercised when using LMWH, as bleeding remains a concern for oncologic hepatopancreatobiliary surgery., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Gender is an established prognostic factor in cutaneous melanoma; women as a group have a better overall prognosis than men. However, the investigators hypothesized that melanoma in young women may have distinct clinicopathologic features and biologic behavior compared with melanoma in older women, possibly related to tanning bed use and excessive acute episodes of sun exposure., Methods: A retrospective analysis was performed of a large multicenter study that accrued patients between 1996 and 2003 and included patients aged 18 to 70 years with cutaneous melanoma ≥1 mm Breslow thickness and no evidence of regional or distant metastatic disease. All women with follow-up data were included. Univariate and multivariate analyses as well as Kaplan-Meier (KM) analysis were performed to test for differences in clinicopathologic variables, disease-free survival (DFS), and overall survival (OS) between female patients ≤40 and >40 years of age., Results: A total of 1,056 female patients were divided into 2 groups: those >40 years of age (n = 757 [71.7%]) and those ≤40 years of age (n = 299 [28.3%]). Overall, there were no differences in Breslow thickness, ulceration, or sentinel lymph node status between groups. Compared with older women, younger women were more likely to have truncal melanomas (39.5% vs 29.5%, P = .0017) and less likely to have regression of the primary tumor (6.4% vs 11.5%, P = .0208). The mean number of sentinel lymph nodes removed was 2.82 for younger women and 2.29 for older women (P < .0001). Multivariate analysis revealed that Breslow thickness, ulceration, and tumor-positive sentinel lymph node were associated with worse DFS in both the younger and older groups; truncal location was associated with worse DFS in the younger group only. The same factors were predictive of OS in both groups, except that ulceration was not significant in the younger patient group. In the younger patient group, the 5-year KM DFS rates were 78.1% for truncal melanomas and 92.5% for nontruncal melanoma locations (P = .0009); the corresponding 5-year KM OS rates were 76.6% and 93.9% (P = .0003). In the older patient group, the 5-year KM DFS rates were 84.1% for truncal and 82.8% for nontruncal melanomas (P = NS), and the corresponding 5-year KM OS rates were 81.6% and 87.5% (P = .0049)., Conclusions: Although women with cutaneous melanoma tend to have a better prognosis than men, women ≤40 years of age with primary melanoma of the trunk may represent a subgroup at higher risk for disease recurrence and metastasis., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Prognostic factors and risk factors for positive sentinel lymph node (SLN) biopsy results are important to identify in superficial spreading melanoma (SSM)., Methods: A single-center database and a prospective clinical trial database were reviewed for all patients with diagnoses of SSM. Logistic regression, Kaplan-Meier survival analysis, and univariate and multivariate Cox models were used., Results: A total of 1,643 patients with SSM were identified. Independent risk factors for positive SLN biopsy results were Breslow thickness (BT) ≥2.0 mm, age <60 years, and presence of ulceration. BT ≥2.0 mm, ulceration, lymphovascular invasion, and positive SLN and positive non-SLN biopsy results were independent risk factors for worse disease-free survival. Independent overall survival risk factors included BT ≥2.0 mm, age ≥60 years, ulceration, nonextremity tumor location, lymphovascular invasion, and positive SLN biopsy results., Conclusions: BT, ulceration, lymphovascular invasion, and SLN and non-SLN status are important risk factors for SSM., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Introduction: Neoadjuvant chemotherapy has been associated with an increased risk of surgery because of chemotherapy-associated steatohepatitis and sinusoidal obstruction. The aim of the current study was to assess for other predictors of steatohepatitis and sinusoidal obstruction and to determine the role of obesity as a risk factor in patients with colorectal liver metastasis (CLM)., Methods: An institutional review board-approved prospectively maintained database of 1,605 patients who underwent hepatic procedures for CLM from 2001 to 2009 was reviewed., Results: In a review of 208 resected patients, body mass index was the only predictor of liver injury according to multivariate analysis (P < .001, odds ratio = 3.88). Diabetes, neoadjuvant chemotherapy, sleep apnea, alcohol use, tobacco use, age, and sex were not significant predictors. Among preoperative chemotherapy patients, BMI was a predictor of chemotherapy liver injury according to multivariate analysis (P < .0001). The rate of obesity (BMI >30) was 36%, and among obese patients (BMI >30) the rate of steatosis or steatohepatitis was 39%., Conclusions: Obesity is the strongest predictor of steatosis and steatohepatitis in patients with CLM, and this risk is independent of the use of preoperative chemotherapy., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: This study was performed to identify clinicopathologic factors associated with survival in acral lentiginous melanoma., Methods: A post hoc analysis of a prospective clinical trial and local database was performed in all patients with acral lentiginous melanomas. Multivariate analyses of factors associated with a tumor-positive sentinel lymph node (SLN) biopsy, disease-free survival (DFS), overall survival (OS), and local and in-transit recurrence-free survival (LITRFS) were performed. Kaplan-Meier survival analyses were performed., Results: Eighty-five patients were identified. Age younger than 59 years and Breslow thickness (BT) of 2.0 mm or greater were independent risk factors for a positive SLN. SLN status was the only independent risk factor for DFS and LITRFS on multivariate analysis. A BT of 2.0 mm or greater was the only independent risk factor for OS. SLN status distinguished differences in DFS, OS, and LITRFS on Kaplan-Meier analysis., Conclusions: SLN status is the dominant factor for recurrence and survival in acral lentiginous melanoma. BT and ulceration are less important in this histologic subtype., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: In patients with cutaneous melanoma, mitotic rate (MR) historically has been reported as the number of mitoses per high-power field (hpf) or per 10 hpf. The most recent revision of the American Joint Committee on Cancer melanoma staging system now incorporates MR and specifies that MR should be reported as mitoses per mm(2), with a conversion factor of 1 mm(2) equaling 4 hpf. However, because many pathologists continue to report MR in hpf units, we sought to compare the 2 conventions for reporting MR; this is important now that MR is used for staging and prognostic information., Methods: A retrospective analysis was performed of a database that combined patients from a large multicenter study and our single-institution melanoma database. All patients with pathology reports that included MR were included. For patients with MR reported in hpf units, MR was converted to mitoses per 10 hpf. Statistical analysis was performed to test differences in Breslow thickness (BT), ulceration, sentinel lymph node (SLN) status, and overall survival (OS) (log-rank test) between the mitoses per mm(2) group versus the mitoses per 10-hpf group., Results: A total of 1,148 patients were identified; of these, 759 were reported as per mm(2) and 389 were reported in hpf units. When patients were subdivided into categories of MR of 0, 1, or more than 1, there was no statistically significant difference in mean or median BT, ulceration, or SLN positivity within categories between patients with MR per mm(2) versus patients with MR reported per 10 hpf. There was also no difference in OS between groups. Subdividing into smaller categories of MR of 0, 1, 2, 3, 4, 5, or more than 5 did not yield different results., Conclusions: Although the American Joint Committee on Cancer staging system reports a conversion factor for MR of 1 mm(2) equals 4 hpf, no clinically meaningful differences in predictors of prognosis (BT, ulceration, SLN positivity) or OS were seen between groups when a conversion factor of 1 mm(2) equaling 10 hpf was used. Therefore, for practical purposes, MR reported per 10 hpf approximates MR per mm(2)., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Breslow thickness, ulceration, and sentinel lymph node (SLN) status are well established as the most important prognostic factors for patients with cutaneous melanoma. Anatomic location of the primary tumor is generally considered to play a minor role in determining prognosis compared with these other factors. This analysis was performed to better define the influence of anatomic location of the primary melanoma on prognosis., Methods: In this post hoc analysis of a prospective randomized trial that included patients ages 18 to 70 years with melanomas 1 mm or greater in Breslow thickness, all patients underwent SLN biopsy and completion lymphadenectomy if tumor-positive SLN were found. Kaplan-Meier survival analysis and univariate and multivariate analyses were performed to evaluate factors predictive of disease-free survival (DFS), local and in-transit recurrence-free survival (LITRFS), and overall survival (OS)., Results: A total of 2,500 patients were included in this analysis with a median follow-up period of 68 months. Anatomic locations included head, neck, trunk, upper extremity, and lower extremity. Age, Breslow thickness, and percentage of patients with a positive SLN were significantly different by anatomic location on univariate analysis, as were positive SLN status, presence of regression, sex, and histologic subtype (P < .0001). On multivariate analysis, anatomic location was an independent predictor of SLN status (P < .0001), DFS (P = .045), LITRFS (P = .023), and OS (P < .0001). By Kaplan-Meier analysis, anatomic location was associated significantly with DFS, LITRFS, and OS., Conclusions: Anatomic location of the primary melanoma is an important independent predictor of SLN status and prognosis. Patients with primary melanomas of the head/neck and trunk have a worse prognosis than primary melanomas of other anatomic locations., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: The current American Joint Committee on Cancer AJCC staging system applies to all soft-tissue sarcomas and does not allow for consideration of many features unique to retroperitoneal sarcomas (RPSs). The aim of this study was to analyze factors predictive of recurrence and survival for patients with resected RPSs., Methods: This was a retrospective analysis of consecutive patients with primary RPS who underwent resection. A 3-tiered histological classification was examined: atypical lipomatous tumors (ALTs), non-ALT liposarcomas (LPSs), and other. Univariate and multivariate analyses were used to identify factors associated with differences in disease-free survival (DFS) and overall survival (OS) among groups., Results: Sixty RPS patients were analyzed: 16 patients (27%) had ALTs, 7 patients (12%) had LPSs, and 37 patients (62%) had other histologies. A comparison of the 3 groups showed a significant difference in OS among groups (P < .017). High-grade tumors favored shorter DFS (P = .06) but were not associated with decreased OS when compared with low-grade tumors (P = .86)., Conclusions: These findings support an alternative staging system for RPS, inclusive of histology, which may prove useful in operative planning and prognostication., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Patients with pancreatic cancer who present with biliary symptoms may undergo cholecystectomy and thus delay cancer diagnosis. We hypothesized that prior cholecystectomy leads to decreased overall survival in patients with pancreatic adenocarcinoma., Methods: Retrospective study of hepatobiliary database., Results: Three hundred sixty-five patients with a diagnosis of resectable periampullary pancreatic adenocarcinoma were identified. Eighty-seven patients underwent prior cholecystectomy. Median age (P = .48), body mass index (BMI) (P = .8), diabetes status (P = .06), American Society of Anesthesiologists (ASA) class (P = .22), stent placement (P = .13), operative time (P = .76), estimated blood loss (EBL) (P = .24), intraoperative transfusion (P = .91), portal vein resection (P = .25), LOS (P = .09) adjuvant therapy (P = .2), tumor size (P = .89), differentiation (P = .67), angiolymphatic invasion (P = .69), perineural invasion (P = 54), nodal metastasis (P = .43), complication rate (P = .75), and 30-day mortality (P = .58) were not statistically different between patients with previous cholecystectomy and those without. Median survival was 14 months for patients with a history of cholecystectomy and 16 months for those without (P = .25). Previous cholecystectomy was not a predictor of survival on Cox regression analysis., Conclusion: There was no difference in overall survival in patients with pancreatic cancer with prior cholecystectomy versus those without., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: The significance of mitotic rate (MR) in melanoma remains controversial., Methods: In this retrospective analysis of a prospective randomized trial that included patients with melanoma of 1.0 mm or greater, all patients underwent wide excision and sentinel node (sentinel lymph node [SLN]) biopsy. Univariate and multivariate analyses were performed to evaluate factors predictive of disease-free survival (DFS) and overall survival (OS)., Results: A total of 551 patients had MR reported. A cut-off point of 6 mitoses/mm(2) best discriminated DFS and OS: 455 patients (82.6%) had MR less than 6/mm(2). SLN were tumor-positive in 14.7% of low MR versus 31.3% of high MR patients (P = .0003). There were significant differences in DFS (P = .0014) and OS (P = .0002) between the 2 groups, however, MR failed to remain significant in the multivariate model., Conclusions: MR is weakly predictive of SLN status but it is not an independent predictor of survival for melanomas 1.0 mm or thicker., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: Men have a higher lifetime incidence of melanoma than women., Methods: Data from the 2005 Health Interview Survey were analyzed for sex differences in response to sun exposure and reported preventive measures among adults., Results: There were 31,428 people surveyed representing the US population. Although women were more likely to burn after 1 hour of sun (8.7% vs 5.4%), they also reported fewer sunburns than men (mean .7 vs .9). Women were also more likely stay in the shade (11.2% vs 6.2%) and always use sunscreen. However, women used a tanning bed more than men (2.1 vs .6 times per year) and were less likely to wear protective clothing when in the sun than men. After controlling preventive behaviors, men were 1.4 times more likely to have had a sunburn during the last 12 months., Conclusions: Although men more often wear protective clothing and are less likely to use a tanning bed, women are more likely to avoid sun exposure and use sunscreen. The higher incidence of melanoma in men may be explained, in part, by an increased incidence of preventive measures taken by women., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: Peritoneal carcinomatosis has a typical natural history of bowel obstruction and death. Significant evidence suggests that cytoreduction with heated intraperitoneal chemotherapy (HIPEC) improves long-term survival for these tumors., Methods: A retrospective case series of patients who underwent initial HIPEC treatment was performed at 2 moderate-volume centers. Clinicopathologic data were reviewed and univariate analyses performed to determine predictors of periprocedural complications., Results: Twenty-eight patients underwent HIPEC procedures. The most common pathologies were colonic adenocarcinoma and pseudomyxoma peritonei. The median preoperative peritoneal cancer index was 9.5. Thirteen patients had 34 complications, with no postoperative deaths. Pleural effusion and wound infection were the most common complications. Preoperative performance status and the extent of disease were predictive of complications., Conclusions: Cytoreduction and HIPEC can be done at moderate-volume centers with morbidity and mortality rates comparable with published results from large-volume centers. Preoperative performance status and the extent of disease predict postoperative complications.

Background: Little is known about the long-term prognosis of small bowel carcinoids because currently no staging system exists., Methods: A search of the Surveillance, Epidemiology and End Results (SEER) database identified 6,380 patients with small bowel carcinoid tumors from 1977 to 2004. Patients were analyzed according to various clinicopathologic factors and a tumor (T1, T2, T3), lymph node (N0, N1), and metastasis (M0, M1) staging system was created according to these parameters., Results: Among the 6,380 patients, 2,985 women and 3,395 men, with a median age of 66 years (range 14-98), the median tumor size was 1.9 cm (range .1-30 cm). Multivariate analysis demonstrated that age, size of the primary tumor, and depth of invasion were significant factors. Four stages were created according to statistically significant prognostic factors: 13% of patients were classified into stage I, 31% into stage II, 16% into stage III, and 40% into stage IV. Five-year survival rates were 96%, 87%, 74%, and 43% for stages I through IV, respectively., Conclusions: The newly developed TNM staging system accurately discriminates prognosis for small bowel carcinoid tumors.

Background: Proper resection in gastric cancer should include more than 15 lymph nodes for accurate staging. We sought to determine if adequate nodal dissection would result in more accurate N staging without an increase in mortality., Methods: Data from a prospectively maintained (January 1996 to August 2006) foregut malignancy database were reviewed, and trends in treatment from 3 time periods (1996-1998, 1999-2001, and 2002-2006) were compared., Results: Three hundred fifty-three patients treated had an average number of nodes examined of 13.1, with a significant increase in the number of nodes from years 1996 to 1998 (9.2), 1999 to 2001(10.2), and 2002 to 2005 (15.9) (P = .001). There was a significant decrease in 30-day (11.9% to 11.8% to 3.5%, P = .001) and 60-day mortality (15.2% to 18.6% to 10.6%, P = .001) during those same time periods., Conclusions: Through an increase in multidisciplinary collaboration, the surgical standards in gastric cancers has improved, with greater lymph node evaluation, greater lymph node staging accuracy, and decreased overall mortality.

Background: The use of radiation therapy (RT) after breast-conserving surgery (BCS) is inconsistent in patients treated with hormonal therapy (HT). We sought to identify factors influencing the decision to use RT in this setting., Methods: Patients in the North American Fareston vs. Tamoxifen Adjuvant (NAFTA) trial who had BCS were evaluated for factors influencing the use of RT using univariate and multivariate analyses., Results: Of the 1,811 patients enrolled in the NAFTA trial, 1,222 (67.4%) had BCS. Of these, 241 (19.7%) did not have RT. There were no significant differences in tumor grade, lymphovascular invasion, estrogen receptor status, or nodal status between those who received RT and those who did not. On univariate analyses, patients who did not receive RT were more likely to be older (median 72 versus 66 years, P < .001), have larger tumors (median 1.35 versus 1.10 cm, P = .009), and be progesterone negative (18.3% versus 13.1%, P = .048). Surgeons in the West were most likely to omit RT, whereas those in the Midwest were least likely to omit it (26.7% versus 7.2%, P < .001). Surgical oncologists were more likely to omit RT after BCS than general surgeons (21.8% versus 13.7%, P < .001). Academic affiliation (P < .001), number of breast procedures performed per year (P = .017), and the percentage of breast practice (P = .019) also correlated with whether or not RT was used. On multivariate analysis, patient age (P < .001), geographic region (P = .006), and surgeon specialty (P = .027) remained significant., Conclusion: Patient age, geographic region, and surgeon training influence the decision to use RT after BCS in patients receiving HT.

Background: The purpose of this study was to create a model that predicts which breast cancer patients will have sentinel lymph node (SLN)-only metastasis., Methods: SLN-positive breast cancer patients (N = 1,253) were analyzed. Multivariate analysis was performed to identify factors predicting SLN-only disease; a prediction rule was created., Results: Median tumor size was 2 cm. The median number of SLNs removed was 2; the median number of positive SLNs was 1. Multivariate analysis found tumor size, number of positive SLN, and proportion of SLN positive were significant predictors of SLN-only disease (P < .001). A prediction rule with 1 point being given for >1 positive SLN, 1 point for >50% of SLN positive, and up to 4 points for tumor size (T1a = 1, T1b or T1c = 2, T2 = 3, and T3 = 4) was established. Ninety-five percent of patients with 1 point had SLN-only disease (P < .0001)., Conclusion: An integer-based model may predict SLN-only disease and may be useful in determining whether completion axillary lymph node dissection is required.

Background: In the era of sentinel lymph node (SLN) biopsy, there has been concern that manipulation, injection, and massage of intact primary melanomas (after incisional or shave biopsy) could lead to an artifactual increased rate of SLN micrometastases or an actual increased risk of recurrence. The aim of this study was to evaluate the difference in the incidence of SLN metastasis, locoregional recurrence (LRR), disease-free survival (DFS), distant disease-free survival (DDFS), or overall survival (OS) for patients who undergo excisional versus incisional versus shave biopsy., Methods: Analysis of database from a multicenter prospective randomized study from centers across the United States and Canada. Eligible patients were 18 to 71 years old, with cutaneous melanoma > or = 1.0 mm Breslow thickness. All patients underwent SLN biopsy using blue dye and radioactive colloid injection. SLNd were evaluated by serial histological sections with S100 immunohistochemistry. Statistical analysis was performed using univariate and multivariate analyses with a significance level of P < .05; survival analysis was performed by the Kaplan-Meier method with the log-rank test., Results: A total of 2,164 patients were evaluated; 382 patients were excluded for lack of biopsy information. Positive SLNs were found in 220 of 1,130 (19.5%), 58 of 281 (20.6%), and 67 of 354 (18.9%) of patients with excisional, incisional, or shave biopsy, respectively (no significant difference). There were significant differences among the 3 biopsy types in ulceration (P = .018, chi2) and regression (P = .022, chi2); there were no differences in age, gender, Breslow thickness, Clark level, lymphovascular invasion, tumor location, or histologic subtype. Biopsy type did not significantly affect LRR, DFS, DDFS, or OS., Conclusions: The concern that incomplete excision of primary melanomas may result in an increased incidence of SLN micrometastases, artifactual or real, is unfounded. Similarly, there is no evidence that biopsy type adversely affects locoregional or distant recurrence. Although shave biopsy is generally discouraged because it may lead to inaccurate tumor thickness measurements, it does not appear to affect overall patient outcome.

Background: We sought to determine whether the results of sentinel lymph node (SLN) biopsy are related to practice and community factors., Methods: This prospective study included more than 300 surgeons from a variety of practice environments. Most surgeons had minimal experience with SLN biopsy prior to this study. Patients underwent attempted SLN biopsy, followed by completion axillary dissection. Univariate and multivariate analyses were performed to assess factors related to the SLN identification rate and the false negative rate., Results: A total of 4131 patients were enrolled. SLN identification rate was 93%; the false negative (FN) rate was 7.9%. The only factor that was significantly associated with improved SLN identification rate (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.12 to 2.36, P = .0126) and FN rate (OR 2.39, 95% CI 1.32 to 4.79, P = .0073) was surgeon experience (>20 SLN cases)., Conclusions: Surgeon experience is the major factor that contributes to improved SLN biopsy results. SLN biopsy can be performed equally well by community and academic surgeons.

Background: This study sought to determine whether the type of biopsy examination independently affects sentinel lymph node (SLN) status in breast cancer patients., Methods: A prospective multicenter study of patients who had SLN biopsy examination followed by axillary node dissection was analyzed to determine whether the type of biopsy examination influenced SLN status., Results: Of the 3853 patients studied, 32% had a positive SLN. Patients were diagnosed by fine-needle (N = 293), core-needle (N = 2154), excisional (N = 1386), or incisional (N = 20) biopsy procedures. The rates of SLN positivity for these groups were 45%, 32%, 29%, and 65%, respectively (P < .001). Other factors predictive of SLN status included: patient age (P < .001), tumor size (P < .001), tumor palpability (P < .001), number of SLN removed (P < .001), type of surgery (mastectomy vs. lumpectomy) (P < .001), histologic subtype (P = .048), and the use of immunohistochemistry (P < .001). All of these factors remained significant in the multivariate model except for histologic subtype and biopsy examination type., Conclusions: Biopsy examination type does not independently influence the risk for nodal metastasis.

Background: Sentinel lymph node (SLN) biopsy examination is an accepted method of staging breast cancer patients. SLN biopsy examination in patients with drainage to the internal mammary chain (IMC) nodes is controversial., Methods: A prospective study of SLN biopsy examination followed by axillary dissection was analyzed to determine how surgeons manage patients with IMC drainage and the rates of axillary SLN identification and positivity in these cases., Results: Lymphoscintigraphy was performed in 2196 (53.2%) of the 4131 patients in this study. IMC drainage was noted in 80 patients (3.6%). An axillary SLN was identified in 29 of the 40 patients with IMC drainage alone (72.5%). The rate of finding a positive axillary lymph node did not differ based on the lymphoscintigraphic pattern (P = .470)., Conclusions: Most surgeons do not perform IMC SLN biopsy procedures. Even when lymphoscintigraphy shows isolated drainage to IMC nodes, axillary SLNs usually are identified. Lymphoscintigraphy therefore has limited usefulness.