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Background In the era of coronavirus disease 2019 (COVID-19), many Complex General Surgical Oncology (CGSO) fellowship programs implemented virtual interviews (VI) during the 2020 interview season. At our institution, we had the unique opportunity to conduct an in-person interview (IPI) prior to the pandemic-related travel restrictions, and a VI after the restrictions were in place. Objective The goal of this study was to understand how the VI model compares with the traditional IPI approach. Methods Online surveys were distributed to both groups, collecting feedback on their interview experience. Responses were evaluated using a two-sample t test assuming equal variances. Results Twenty-three of 26 (88%) applicants completed the survey. Most applicants reported that the interview gave them a satisfactory understanding of the CGSO fellowship (100% IPI, 92% VI) and the majority in both groups felt that the interview experience allowed them to accurately represent themselves (92% and 82%, respectively). All participants in the IPI group felt they were able to get an adequate understanding of the culture of the program, while only 64% in the VI group agreed with that statement (p = 0.02). IPI applicants were more likely to agree that the interview experience was sufficient to allow them to make a ranking decision (92% vs. 54%; p = 0.04). Conclusions While the VI modality offers several advantages over the IPI, it still falls short in conveying some of the more subjective aspects of the programs, including program culture. Strategies to provide applicants with better insight into these areas during the VI will be important moving forward.

Amputation for localized extremity sarcoma (ES), once the primary therapy, is now rarely performed. We reviewed our experience to determine why patients with sarcoma still undergo immediate or delayed amputation, identify differences based on amputation timing, and evaluate outcomes. Records of patients with primary, nonmetastatic ES who underwent amputation at our institution from 2001 to 2011 were reviewed. Univariate analysis was performed, and survival outcomes were calculated. We categorized 54 patients into three cohorts: primary amputation (A1, n = 18, 33%), secondary amputation after prior limb-sparing surgery (A2, n = 22, 41%), and hand and foot sarcomas (HF, n = 14, 26%). Median age at amputation was 54 years (range 18–88 years). Common indications for amputation (> 40%) were loss of function, bone involvement, multiple compartment involvement, and large tumor size (A1); proximal location, joint involvement, neurovascular compromise, multiple compartment involvement, multifocal or fungating tumor, loss of function, and large tumor size (A2); and joint involvement and prior unplanned surgery (HF). There was no difference in disease-specific survival (DSS) (p = 0.19) or metastasis-free survival (MFS) (p = 0.31) between early (A1) and delayed (A2) amputation. Compared with cohorts A1/A2, HF patients had longer overall survival (OS) (p = 0.04). Indications for amputation for extremity sarcoma vary between those who undergo primary amputation, delayed amputation, and amputation for hand or foot sarcoma. Amputations chosen judiciously are associated with excellent disease control and survival. For patients who ultimately need amputation, timing (early vs. delayed) does not affect survival.

Radiation delivered as brachytherapy (BRT) via catheters placed during extremity soft tissue sarcoma (STS) resection results in acceptable local control rates; however, there are limitations in deep cavities. (125)I seeds embedded in mesh provide a flexible BRT platform that may be contoured to irregular deep cavities surfaces, but the risks and benefits are unknown.Patients with thoracic, abdominal, pelvic, retroperitoneal, and deep truncal STS undergoing resection and implantation of permanent (125)I mesh BRT at our institution were reviewed. Local recurrence rates within the tumor bed covered by mesh (in field) and postoperative complications were analyzed.Between 2000 and 2010, a total of 46 patients were treated for primary (n = 8, 17 %) or recurrent (n = 38, 83 %) deep cavity STS (median follow-up 34.8 months); 74 % received external-beam radiotherapy for this or a prior presentation. In-field recurrences were observed in 9 patients (19.5 %). Crude cumulative incidences of in-field, regional, and distant recurrences at 5 years were 26.3, 54.2, and 54.1 %, respectively. 5-year overall survival rate was 47.2 %; median survival was 44.0 months. Twenty-two patients (48 %) experienced complications, half of whom (24 %) developed grade III/IV complications requiring percutaneous intervention (n = 6) or reoperation (n = 5) at a median of 35.5 days. There were no postoperative deaths.To our knowledge, this is the first study to report safety and efficacy for permanent (125)I mesh BRT implantation after resection of deep cavity STS. Local in-field recurrence rates were relatively low in this high-risk population. However, 24 % developed complications requiring intervention. (125)I mesh BRT appears effective, but it should be used with caution.

Nipple-sparing mastectomies (NSM) have gained acceptance in the field of breast oncology. Ischemic complications involving the nipple-areolar complex (NAC) occur in 3-37 % of cases. Skin perfusion can be monitored intraoperatively using indocyanine green (IC-GREEN™, ICG) and a specialized infrared camera-computer system (SPY Elite™). The blood flow pattern to the breast skin and the NAC were evaluated and a classification scheme was developed.Preincision baseline and postmastectomy skin perfusion studies were performed intraoperatively using 3 mL of ICG. The pattern of arterial blood inflow was classified according to whether perfusion appeared to originate predominantly from the underlying breast tissue (V1), the surrounding skin (V2), or a combination of V1 and V2 (V3). Ischemia, resection, or delayed complications of NAC were recorded.Thirty-nine breasts were interrogated. Seven (18 %) demonstrated a V1 pattern, 18 (46 %) a V2 pattern, and 14 (36 %) a V3 pattern. Seven (18 %) NACs were removed; six intraoperatively and the seventh in a delayed fashion. Notably, five of the seven resected NACs had a V1 pattern. Overall, 71 % of all V1 cases demonstrated profound ischemic changes by intraoperative clinical judgment and SPY imaging. The rates of resection of the NAC differed significantly between perfusion patterns (Fisher's exact test, p = 0.0003).Three perfusion patterns for the NAC are defined. The V1 pattern had the highest rate of NAC ischemia in NSM. Imaging NAC and skin perfusion during NSMs is a useful adjunctive tool with potential to direct placement of mastectomy incisions and minimize ischemic complications.

The objective of this study was to determine the incidence and cause of disease-specific death in patients with mucoepidermoid carcinoma (MEC) affecting the major salivary glands. A total of 94 patients with MEC treated at Memorial Sloan-Kettering Cancer Center between 1985 and 2009 were identified from a preexisting database of 451 patients with major salivary gland cancer. Patient, tumor, and treatment characteristics were recorded from a retrospective analysis of patient charts. There were 49 males (52 %), and the median age was 57 years (range, 9–89 years). Of the 94 patients, 49 % had low, 22 % had intermediate, and 28 % had high-grade carcinoma. Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were calculated using the Kaplan–Meier method. Cause of death was determined by chart review. Predictors of DSS were identified by univariate analysis. With a median follow-up of 59 months (range, 1–257), the 5-year OS, DSS, and RFS for all patients were 76 %, 83 %, and 79 %, respectively. DSS was significantly poorer for high-grade MEC compared with low/intermediate-grade MEC (5-year DSS 37 % vs 100 %, P

Locoregional recurrence (LRR) rates following preoperative radiation therapy (RT) and radical resection for retroperitoneal sarcoma (RPS) are high. Targeted radiation dose escalation has been proposed as a means to decrease LRR, but is applicable only if LRRs are confined to within the RT field. We analyzed predictors for LRR and examined LRR locations to determine the potential benefit of dose escalation.For 33 patients treated with preoperative RT and radical resection, we determined high-risk tumor volumes appropriate for boost and identified the number of recurrences within this volume. Clinical and pathologic variables predictive of overall survival (OS), freedom from progression (FFP), LRR, and distant recurrence (DR) were evaluated.Median follow-up was 32.9 months. At 1 and 3 years, OS was 87 and 64 %, FFP rates were 71 and 45 %, cumulative incidences of LRR were 19 and 37 %, and of DR were 13 and 21 %. On multivariate analysis, multifocal disease was a significant predictor of increased incidence of LRR. At first relapse, 6 patients had isolated LR, 2 isolated RR, 6 isolated DR, 1 synchronous LR and RR, and 1 synchronous LR, RR, and DR. Ultimately, 4 patients (25 % of those who recurred) had isolated in-field recurrences within the hypothetical high-risk dose-painting boost volumes and that thus might have been prevented with dose-escalation.Following preoperative RT and resection, LRR rates are high and associated with multifocal disease. Preoperative dose escalation to high-risk tumor volumes may perhaps benefit only a limited subset of patients, and therefore strategies are needed to select appropriate patients for consideration of this approach.

Preoperative and postoperative RT for the treatment of high-grade soft-tissue sarcoma result in similar local control and overall survival rates, but morbidities differ. Postoperative RT is associated with a higher rate of long-term fibrosis, edema, and joint stiffness. Preoperative RT is associated with higher rates of wound complications. It is important to identify predictors for major wound complications (MWC) and to develop strategies to minimize this outcome. We reviewed our experience to determine predictors for MWC following preoperative radiotherapy (RT) and surgery for soft-tissue sarcoma.Between January 2006 and May 2011, 103 patients with soft-tissue sarcoma of the extremities and trunk were treated with preoperative RT followed by surgery. MWCs were defined as those requiring operative or prolonged nonoperative management. Fisher's exact test was used to compare rates. Logistic regression was used for multivariable analysis of factors potentially associated with MWCs.Median tumor size was 8.4 cm (range 2-25). All patients had wide or radical resections. Wound closures were primary in 70 %, a vascularized flap in 27 %, and split-thickness skin graft (STSG) in 3 %. There were 36 MWCs (35 %). Significant predictors for MWCs on univariate analysis included diabetes, tumors10 cm, tumors3 mm from skin surface, and vascularized flap/STSG closure. The same four variables were significant predictors on multivariable analysis.MWCs following preoperative RT and surgery were common. Tumor proximity to skin surface3 mm is a previously unreported independent predictor, and further strategies to minimize wound complications are needed.

Metastases to the thyroid gland are uncommon, with rates reported between 0.02% and 1.4% of surgically resected thyroid specimens. Our goal was to present our experience with surgical management of metastases to the thyroid gland.Twenty-one patients with metastatic disease to the thyroid were identified from a database of 1,992 patients with thyroid cancer who had surgery during 1986-2005. Patient, tumor, treatment, and outcome details were recorded by analysis of charts. The median age at time of surgery was 68 (range, 39-83) years; 12 were men and 9 were women.All patients were managed by surgery, including lobectomy in ten patients, total thyroidectomy in six, completion thyroidectomy in two, and subtotal thyroidectomy in one. In two patients, the thyroid lesion was found to be unresectable at the time of surgery. Histopathology revealed renal cell carcinoma in ten, malignant melanoma in three, gastrointestinal adenocarcinoma in three, breast cancer in one, sarcoma in one, and adenocarcinoma from an unknown primary site in three patients. Seventeen patients have died. The cause of death in all 17 was widespread metastatic disease from their respective primary tumors. The median survival from surgery to death or last follow-up was 26.5 (range, 2-114) months.In patients with metastases to the thyroid gland, local control of metastatic disease in the central compartment of the neck can be successfully achieved with minimal morbidity with surgical resection in selected patients.

Background The American Thyroid Association guidelines do not mention isthmusectomy as an appropriate procedure for thyroid cancer. Despite this, a small number of patients present with lesions isolated to the thyroid isthmus, which can be excised without exploring the trachyesophageal grooves or total thyroidectomy. This study was designed to analyze outcomes in patients treated with isthmusectomy for small well-differentiated thyroid cancer (WDTC) at our institution. Methods Nineteen patients with WDTC managed by isthmusectomy were identified from a database of 1,810 patients (1%) with WDTC managed by surgery in Memorial Sloan Kettering Cancer Center from 1986-2005. Demographic, surgical, pathological, and outcomes data were analyzed. Results Six patients were men and 13 were women. The median age was 46 (range, 28-83) years. All patients had a solitary nodule confined to the thyroid isthmus. The median size of lesion was 1 (range, 0.4-3) cm. Eighteen patients had a pathologically T1 lesion (pT1), and one patient had a pT2 lesion. Two patients had papillary carcinoma detected in perithyroid lymph nodes (pN1a). There were no complications of recurrent laryngeal nerve palsy or hypocalcaemia. With a median follow-up of 124 (range, 53-276) months, the 10-year disease-specific survival was 100% and 100% local and regional 10-year recurrence-free survival. Conclusions Our results suggest that isthmusectomy alone may be sufficient treatment for selected patients with small WDTC limited to the isthmus. This procedure has the benefit of avoiding dissection of the recurrent laryngeal nerve and parathyroid glands, thus limiting postoperative complications.

In patients with metastatic gastrointestinal stromal tumor (GIST) on first-line imatinib (IM) undergoing cytoreductive surgery, response to IM at time of surgery correlates with completeness of resection and progression-free and overall survival (PFS, OS). Impact of surgery in IM-resistant patients on second-line sunitinib (SU) is unknown.Patients on SU undergoing surgery for metastatic GIST at our institution were reviewed. Response to SU at time of surgery was categorized as responsive disease (RD), limited progression (LP) or generalized progression (GP).Fifty patients underwent surgery after a median 6.7 months of SU. Forty patients (80%) had prior surgery at initial presentation of GIST; 16 (32%) underwent prior surgery on IM. At time of surgery on SU, 10 patients (20%) had RD, 22 (44%) had LP, and 18 (36%) had GP. Resections were macroscopically complete in 25 patients (50%); completeness of resection did not correlate with response to SU. Complication rate was 54%; reoperations were required in 16%. Median PFS after surgery and start of SU was 5.8 and 15.6 months, respectively (median follow-up 15.2 months). Corresponding median OS was 16.4 and 26.0 months, respectively. Differences in PFS and OS based on response to SU were not significant. Younger age was prognostic of survival.Surgery is feasible in patients with metastatic GIST on SU, but incomplete resections are frequent and complication rates are high. Relevance of survival rates is difficult to assess given the selection bias. Benefits of surgery should be weighed against symptoms and alternative treatments.

Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is exceedingly rare. The role of adjuvant therapy remains undefined. This study evaluated outcomes after aggressive management. Records on 20 patients undergoing surgery for IVC LMS between January 1990 and April 2006 were retrieved. Histology was confirmed upon re-review. Most patients received perioperative chemotherapy (CT), radiation therapy (RT), or both (CRT). Disease-free and overall survival (DFS, OS) rates were calculated using the Kaplan-Meier method. Twenty patients (60% women, median age 57 years) with primary IVC LMS were treated with curative intent. Median follow-up was 41 months. All patients underwent resection of the primary tumor; one was found to have unresectable liver metastases. The IVC was managed with ligation (3), primary repair (12), or prosthetic graft (5). Additional organs were resected in 14 (70%) patients. Chemotherapy and/or RT were administered to 9 (45%) patients preoperatively (CT 2, RT 6, CRT 1) and 8 (40%) postoperatively (CT 4, RT 1, CRT 3). Median DFS was 21 months. Of 13 (68%) patients who developed recurrence, 4 underwent surgery, and 11 received CT. Median OS for 19 patients who underwent complete resection was 71 months. Tumor size was associated with disease recurrence (P = .004). No variables were prognostic for OS. Patients with IVC LMS treated with curative intent develop early recurrent disease. Nevertheless, long-term OS can be achieved even in the setting of metastatic disease. The independent impact of perioperative CT, RT, or CRT treatments cannot be adequately determined.

The prognosis for gastric cancer is better for Asian than for Caucasian patients. The primary driver of this difference is unknown. This study determined whether the survival advantage of Asian ethnicity continued to hold after control was used for other well-known prognostic factors. In this study, 12,773 patients who underwent gastrectomy for treatment of adenocarcinoma of the stomach were identified from the Surveillance, Epidemiology, and End Results cancer registry. Patients with cardia tumor were excluded from the study. The independent prognostic effect of ethnicity was evaluated by adjusting for other known factors. The Asian patients tended to have a diagnosis at an earlier age (66.8 vs. 68.5 years), more lymph nodes examined (16 vs. 13), and more positive lymph nodes (5.1 vs. 4.8). Survival was better for the Asian patients than for the Caucasian patients, with a 12 % 5-year survival difference. Among the patients with IB, IIA, and IIB disease, the Asian patients had 37, 72, and 13 months longer median survival time than the corresponding Caucasian patients. The multivariate Cox model showed persistence of this result after adjustment for imbalances of age, gender, tumor grade, and number of examined and positive lymph nodes. The largest risk reduction was observed for the stage IA patients (31 %) and the smallest for the stage IIIC patients (9 %). After excluding proximal gastric cancers, controlling for the imbalance of known prognostic factors, and decreasing in the influence of D2 lymphadenectomy, stage migration, and chemo/radiation therapy by including only patients treated in the United States, this study found that the survival advantage of Asian ethnicity continued to be present.

We evaluated the necessity of a tumor bed boost after whole-breast radiotherapy for early-stage breast cancer after breast-conserving surgery and negative re-excision. Of patients treated at the Virginia Commonwealth and Tufts Universities with breast-conservation therapy for early-stage breast cancer between 1983 and 1999, 205 required re-excision of the tumor cavity to obtain clear margins and were found to be without residual disease. Adjuvant conventionally fractionated whole-breast radiotherapy was given to a total dose of 50 Gy in 25 fractions. The tumor bed boost was omitted. The median follow-up was 98 months (range, 6–229 months). The tumor histological diagnosis was primarily infiltrating ductal carcinoma (183 cases; 89%). Nodal involvement was documented in 49 cases (24%). There were four documented recurrences at the tumor bed site. Five in-breast recurrences were documented to be in a location removed from the tumor bed. The overall Kaplan-Meier 15-year in-breast control rate was 92.4%, and the freedom from true recurrence rate was 97.6%. The findings support the concept that postlumpectomy radiotherapy can be tailored according to the degree of surgical resection. There is an easily identifiable subgroup of patients who can avoid a tumor bed boost, thus resulting in a reduced treatment time and improved cosmesis, while maintaining local control rates that approach 100%. The data suggest that in patients who undergo a negative re-excision, treatment with whole-breast radiotherapy to 50 Gy is a sufficient dose to maximally reduce the risk of local recurrence.

Colorectal cancer (CRC) claims 57,000 lives yearly in the United States.1 Although a modest decrease of 1.8% in the incidence rate for this disease occurred from 1985 to 1995, incidence rates since then have stabilized. Currently, CRC is the third leading cause of cancer death in both men and women. These statistics persist despite the understanding that the identification and removal of precursor adenomas during screening colonoscopy can prevent CRC. In the landmark National Polyp Study, reported in 1993,2 patients having colonoscopic screening with polypectomy at intervals of 1 and 3 years after baseline adenoma removal achieved a reduction in CRC incidence of approximately 76% to 90%, compared with three reference populations that did not receive polypectomies. Numerous subsequent studies have validated this observation. A particularly dramatic example of effective cancer prevention by close surveillance is provided by Jarvinen et al.3 These researchers studied asymptomatic members of families with hereditary nonpolyposis colorectal cancer to determine the effect of CRC screening over a 10-year surveillance period. One group of 133 subjects received screening at 3-year intervals, and a second group of 118 subjects was followed without screening. CRC occurred in 4.5% of the screened population versus 15% of the control group, providing a cancer incidence reduction of 62% that likely occurred because of polypectomy. Equally important, tumor stage at cancer diagnosis was much earlier in the screened population, and no deaths caused by CRC occurred in the screened group, versus five deaths in the control group. Although these data make it clear that CRC screening can dramatically decrease CRC incidence, the significant drawbacks of high cost and lack of patient acceptance mean that only 10% to 20% of the target population receives CRC screening. It is clear that, although we must continue to improve access to and utilization of CRC screening, we must also search for less costly and better accepted methods of cancer prevention. In addition to adenoma removal, a wealth of data from human epidemiology suggests that dietary or pharmacologic substances can reduce adenoma formation and, in doing so, prevent CRC.4 Because of the strength of the adenoma-carcinoma link in human observational studies and in polypectomy trials, the reduction of adenoma incidence is used as a surrogate endpoint for CRC in chemoprevention studies. The report in this issue by Chu et al.5 addresses the incidence of synchronous and metachronous adenoma formation in patients with recently diagnosed CRC. In this study, synchronous disease was defined as adenomas discovered at a baseline colonoscopy that took place within 1.5 years after the resection of an early stage CRC. Recurrent adenomas were those occurring at any time following the baseline colonoscopy. These investigators found that 60% of patients had synchronous adenomas, a figure consistent with other studies.6,7 The 3-year cumulative adenoma recurrence in this cohort was 35%. This figure is similar to that found in the placebo arm of an aspirin chemoprevention study reported earlier this year by Sandler et al.8 These patients also had a history of CRC; however, the time from initial cancer diagnosis to baseline colonoscopy was highly variable. Some patients entered the study immediately following cancer diagnosis, and others 5 or more years following successful treatment. Despite these differences in eligibility, the adenoma recurrence rates in the Sandler et al.8 study are comparable. By Kaplan-Meier estimation, the proportion of patients diagnosed with adenomas by 3 years after clearing colonoscopy was approximately 32%.8 Any cancer prevention treatment, even one as seemingly innocuous as calcium supplementation, comes with Received August 14, 2003; accepted August 22, 2003. From Brigham & Women’s Hospital, Boston, Massachusetts. Address correspondence to: Monica M. Bertagnolli, MD, Brigham & Women’s Hospital, 75 Francis St., Boston, MA 02115; Fax: 617-5826177; E-mail: mbertagnolli@partners.org.