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Background: There is a scarcity of data exploring the benefits of adjuvant or neoadjuvant chemotherapy in the treatment of breast cancer in older women. We aimed to explore the effect of adding chemotherapy to local therapy on overall survival in older women with triple-negative breast cancer., Methods: For this propensity-matched analysis, we used data from the National Cancer Database, a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. We included data from women aged 70 years or older with surgically treated, American Joint Committee on Cancer (AJCC) Stage I-III invasive triple-negative breast cancer diagnosed from 2004 to 2014. Patients with T1aN0M0 disease and those with incomplete data on oestrogen receptor status, progesterone receptor status, or HER2 status were excluded. To reduce bias, patients were subdivided into three groups: those who were recommended chemotherapy but did not receive it; those who received chemotherapy; and those for whom chemotherapy was not recommended and not given. The primary outcome was overall survival. Multivariate Cox regression analysis and propensity score matching were done to minimise bias., Findings: Between Jan 1, 2004, and Dec, 31, 2014, 16 062 women with triple-negative breast cancer in the database met the inclusion criteria for this analysis. Median follow-up was 38·3 months (IQR 20·7-46·1, range 0-138·0; 95% CI 37·8-38·7). Collectively, the 5-year overall survival estimate of the 16 062 patients in the study cohort was 62·3% (95% CI 59·7-64·4). 5-year estimated overall survival was 68·5% (95% CI 66·4-70·6) for patients receiving chemotherapy, 61·1% (59·0-63·2) for patients recommended but not given chemotherapy, and 53·7% (51·8-55·8) for patients not recommended chemotherapy and not given chemotherapy (pooled log rank p<0·0001). Multivariate Cox regression analysis of a propensity score-matched sample comparing those who received chemotherapy with those who were recommended but not given chemotherapy (n=1884 matched pairs) identified improved overall survival with chemotherapy (hazard ratio [HR] 0·69 [95% CI 0·60-0·80]; p<0·0001). After stratifying the propensity score matching sample, this benefit persisted for node-negative women (HR 0·80 [95% CI 0·66-0·97]; p=0·007), node-positive women (0·76 [0·64-0·91]; p=0·006), and those with a comorbidity score greater than 0 (HR 0·74 [95% CI 0·59-0·94]; p=0·013)., Interpretation: These data support consideration of chemotherapy in the treatment of women aged 70 years or older with triple-negative breast cancer., Funding: None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Triple-negative breast cancer (TNBC) is an aggressive form of breast cancer associated with poor survival, in which adjuvant systemic treatments are limited to chemotherapy. Due to competing mortality risks and comorbidities, older patients with TNBC are often undertreated with adjuvant chemotherapy, and clinical trials on this problem are scarce, despite a growing patient population. This study aimed to assess outcomes for patients aged 70 years and older with TNBC with or without chemotherapy in a national population-based registry, to provide information that can assist in treatment decisions for these patients., Methods: In this population-based registry study, data on all patients aged 70 years and older diagnosed with primary early TNBC (larger than 5 mm in diameter and without distant metastasis) and surgically treated between Jan 1, 2009, and Dec 31, 2016, were retrieved from the Swedish National Breast Cancer Register, the Swedish Patient Register, and the Swedish Cause of Death Register. Patients with incomplete data (on oestrogen receptor, progesterone receptor, or human epidermal growth factor receptor 2 status, surgical procedure in the breast, or information about chemotherapy) were excluded. A propensity score-matched (PSM) model was used to examine the outcomes of adjuvant chemotherapy on 5-year breast cancer-specific survival (BCSS) and 5-year overall survival (OS), adjusted for age, tumour size, tumour grade, nodal status, and comorbidities., Findings: Of 1130 women eligible for analysis, 368 (32·6%) received adjuvant chemotherapy, 45 (4·0%) received neoadjuvant treatment, and 717 (63·5%) did not receive chemotherapy. 5-year BCSS was significantly improved in patients who received adjuvant chemotherapy (85% [95% CI 81-89]) compared with patients who did not receive chemotherapy (68% [64-72]; p<0·0001). A similar benefit was observed in 5-year OS (79% [95% CI 75-84] vs 49% [45-53]; p<0·0001). In our PSM analysis, 5-year BCSS in patients treated with adjuvant chemotherapy was 83% (95% CI 78-89), versus 73% (67-80; p=0·014) in patients not treated with chemotherapy. 5-year OS in patients treated with adjuvant chemotherapy was 75% (95% CI 69-82), versus 63% (57-71; p=0·029) in patients who did not receive chemotherapy., Interpretation: In this PSM registry analysis of surgically treated female patients aged 70 years and older with TNBC without distant metastasis, we identified a significant benefit both in 5-year BCSS and 5-year OS with adjuvant chemotherapy versus no chemotherapy, which persisted when adjusting for age and comorbidities. These results underline the importance of considering adjuvant chemotherapy in older patients., Funding: Knut and Alice Wallenberg Foundation, Assar Gabrielsson Foundation., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Importance: Combined-modality therapy with chemotherapy and radiation therapy plays a crucial role in the upfront treatment of patients with limited-stage small cell lung cancer (SCLC), but there may be barriers to utilization in the United States., Objective: To estimate utilization rates and factors associated with chemotherapy and radiation therapy delivery for limited-stage SCLC using the National Cancer Database., Design, Setting, and Participants: Analysis of initial management of all limited-stage SCLC cases from 2004 through 2013 in the National Cancer Database., Main Outcomes and Measures: Utilization rates of chemotherapy and radiation therapy at time of initial treatment. Multivariable analysis identified independent clinical and socioeconomic factors associated with utilization and overall survival., Results: A total of 70 247 cases met inclusion criteria (55.3% female; median age, 68 y [range, 19-90 y]). Initial treatment was 55.5% chemotherapy and radiation therapy, 20.5% chemotherapy alone, 3.5% radiation therapy alone, and 20.0% neither (0.5% not reported). Median survival was 18.2 (95% CI, 17.9-18.4), 10.5 (95% CI, 10.3-10.7), 8.3 (95% CI, 7.7-8.8), and 3.7 (95% CI, 3.5-3.8) months, respectively. Being uninsured was associated with a lower likelihood of both chemotherapy (odds ratio [OR], 0.65; 95% CI, 0.56-0.75; P < .001) and radiation therapy (OR, 0.75; 95% CI, 0.67-0.85; P < .001) administration on multivariable analysis. Medicare/Medicaid insurance had no impact on chemotherapy use, whereas Medicaid (OR, 0.79; 95% CI, 0.72-0.87; P < .001) and Medicare (OR, 0.86; 95% CI, 0.82-0.91; P < .001) were independently associated with a lower likelihood of radiation therapy delivery. Lack of health insurance (HR, 1.19; 95% CI, 1.13-1.26; P < .001), Medicaid (HR, 1.27; 95% CI, 1.21-1.32; P < .001), and Medicare (HR, 1.12; 95% CI, 1.09-1.15; P < .001) coverage were independently associated with shorter survival on adjusted analysis, while chemotherapy (HR, 0.55; 95% CI, 0.54-0.57; P < .001) and radiation therapy (HR, 0.62; 95% CI, 0.60-0.63; P < .001) were associated with a survival benefit., Conclusions and Relevance: Substantial proportions of patients documented in a major US cancer registry did not receive radiation therapy or chemotherapy as part of initial treatment for limited-stage SCLC, which, in turn, was associated with poor survival. Lack of radiation therapy delivery was uniquely associated with government insurance coverage, suggesting a need for targeted access improvement in this population. Additional work will be necessary to conclusively define exact population patterns, specific treatment deficiencies, and causative factors leading to heterogeneous care delivery.

To better define the value of antimicrobial prophylaxis (AMP) and antiseptic skin preparation (ASP) in thyroid and parathyroid surgery, we examined the rate of surgical site infections (SSIs) with and without AMP. Retrospective analysis was performed using the National Surgical Quality Improvement Program database at a single institution. Patients undergoing thyroid or parathyroid surgery with data entered into the National Surgical Quality Improvement Program database at our institution between November 2007 and June 2015 were studied, including patient demographics, wound classification, other risk factors for SSI, and wound outcome. Charts were retrospectively reviewed for AMP, ASP, and use of drains. Of the 534 patients who underwent thyroid (n = 358) or parathyroid (n = 176) surgery, 58 (10.9%) were diabetic, 54 (10.1%) used tobacco, and 14 (2.6%) were on steroids. Most wounds were classified as "clean" (99.6%). Betadine was used for ASP in 96 per cent. AMP was given to 141 patients (26%) using cefazolin, vancomycin, or clindamycin. The remaining 393 patients (74%) received no AMP. Zero infections occurred in the group who did not receive AMP. One (0.7%) superficial, nonpurulent SSI occurred in the group that received AMP which was not statistically significantly different (P = 0.319). The rates of SSI after thyroid and parathyroid surgery are extremely low, around two per 1000 cases, and do not decrease with AMP. Therefore, AMP is not necessary in thyroid and parathyroid surgery and should be avoided to reduce costs, adverse reactions, and antibiotic resistance.

Background: The outcomes of patients with unresected anaplastic thyroid carcinoma (ATC) from the National Cancer Data Base (NCDB) were assessed, and potential correlations were explored between radiation therapy (RT) dose and overall survival (OS)., Methods: The study cohort was comprised of patients who underwent either no surgery or grossly incomplete resection. Correlates of OS were explored using univariate analysis and multivariable analysis (MVA)., Results: In total, 1288 patients were analyzed. The mean patient age was 70.2 years, 59.7% of patients were women, and 47.6% received neck RT. The median OS was 2.27 months, and 11% of patients remained alive at 1 year. A positive RT dose-survival correlation was observed for the entire study cohort, for those who received systemic therapy, and for those with stage IVA/IVB and IVC disease. On MVA, older age (hazard ratio [HR], 1.317; 95% confidence interval [CI], 1.137-1.526), ≥ 1 comorbidity (HR, 1.587; 95% CI, 1.379-1.827), distant metastasis (HR, 1.385; 95% CI, 1.216-1.578), receipt of systemic therapy (HR, 0.637; 95% CI, 0.547-0.742), and receipt of RT compared with no RT (<45 grays [Gy]:HR, 0.843; 95% CI, 0.718-0.988; 45-59.9 Gy: HR, 0.596; 95% CI, 0.479-0.743; 60-75 Gy: HR, 0.419; 95% CI, 0.339-0.517) correlated with OS. The RT dose-survival correlation for patients who received higher (60-75 Gy) versus lower (45-59.9 Gy) therapeutic doses was confirmed by propensity-score matching., Conclusions: Survival was poor in this cohort of patients with unresected ATC, and more effective therapies are needed. However, the association of RT dose with OS highlights the importance of identifying patients with unresected ATC who may still yet benefit from multimodal locoregional treatment that incorporates higher dose RT. Cancer 2017;123:1653-1661. © 2017 American Cancer Society., (© 2016 American Cancer Society.)

Background: Medullary breast cancer (MBC) is a rare tumor associated with a better prognosis compared with other breast cancers. The role of adjuvant chemotherapy has not been extensively studied., Methods: Female patients with invasive MBC reported to the National Cancer Data Base from 2004 to 2012 were analyzed. Overall survival (OS) and treatment were studied using the Kaplan-Meier method and the Cox proportional hazard model. Patients who had node-negative (N0), non-metastatic (M0) tumors 10 to 50 mm in size (T1cN0M0 and T2N0M0) treated with and without chemotherapy were analyzed using propensity score matching., Results: Of 3739 patients with MBC, 2642 (71%) had T1b-T2N0M0 disease treated with and without chemotherapy. Multivariable analysis showed that for all MBC patients, the significant predictors of OS were age older than 65 years, one or more comorbidities, tumor larger than 2 cm, positive nodes, distant metastasis, and treatment with chemotherapy or radiation therapy. Patients with T1cN0M0 and T2N0M0 had improved OS if they received chemotherapy (p < 0.0005). Patients with T1bN0M0 who received chemotherapy did not show better OS than those who did not. Patients with T1c-T2N0M0 were then matched by propensity score based on age, presence of comorbidities, tumor size, and treatment methods used. After matching, the group receiving chemotherapy showed an improved OS (hazard ratio [HR], 0.40; 95% confidence interval [CI], 0.26-0.62; p < 0.0005) compared to the group that did not receive chemotherapy., Conclusions: For patients with T1c-T2N0M0 MBC, chemotherapy significantly improves OS.

Background: The benefit of thoracic lymphadenectomy in the treatment of resectable non-small cell lung cancer (NSCLC) continues to be debated. We hypothesized that the number of lymph nodes (LNs) removed for patients with pathologic node-negative NSCLC would correlate with survival., Methods: The National Cancer Data Base (NCDB) was queried for resected, node-negative, NSCLC patients treated between 2004 and 2014. Patients were grouped according to the number of LNs removed (1-4, 5-8, 9-12, 13-16, and ≥17). Patients with <10 LNs removed were also compared with those with ≥10 LNs removed. A Cox regression analysis was performed and hazard ratios (HRs) calculated, with 95 % confidence intervals (CIs)., Results: Of 1,089,880 patients with NSCLC reported to the NCDB during the study period, 98,970 (9.0 %) underwent resection without evidence of pathologic nodal involvement. Lobectomy was performed in 83.9 %, sublobar resection was performed in 12.7 % and pneumonectomy was performed in 2.8 % of patients. The number of LNs removed correlated with increasing tumor size and extent of resection. On multivariate analysis, increasing age, male sex, white ethnicity, high tumor grade, larger tumor size, pneumonectomy, and positive surgical margins were all negatively correlated with overall survival. The number of LNs removed and lobectomy/bi-lobectomy correlated with improved survival. The removal of <10 LNs was associated with a 12 % increased risk of death (HR: 1.12, 95 % CI 1.09-1.14; p < 0.001)., Conclusion: Survival of early-stage NSCLC patients is associated with the number of LNs removed. The surgical management of early-stage NSCLC should include thoracic lymphadenectomy of at least 10 nodes.

Backgrounds and Objectives: Medullary breast carcinoma (MBC) is a subtype with a more favorable prognosis. Tumors with some, but not all, characteristics of MBC are classified as atypical medullary carcinoma of the breast (AMCB)., Methods: Patients with invasive MBC and AMCB reported to the National Cancer Data Base (NCDB) from 2004 to 2013 were compared for tumor characteristics and overall survival, using infiltrating ductal carcinoma (IDC) as a reference., Results: Patients with MBC (n = 3,688), AMCB (n = 288), and IDC (n = 918,870) met inclusion criteria. Comparing MBC with AMCB, the mean age at diagnosis (52.9 vs. 53.9 years), mean tumor size (2.4 vs. 2.5 cm), lymph node positivity (22.8% vs. 22.4%), estrogen receptor (ER) positivity (22% vs. 25%), progesterone receptor (PR) positivity (14% vs. 15%), HER2 positivity (11% vs. 14%), rate of breast conserving surgery (67% vs. 68%), use of chemotherapy (76% vs. 75%), and use of hormonal therapy (19% vs. 18%), respectively, were not clinically or statistically different. Five-year (92% vs. 89%) and 10-year survival rates (85% vs. 87%) were not significantly different (P = 0.46)., Conclusions: There does not appear to be any reason to differentiate between AMCB and MBC given the similarities in presentation, treatment and prognosis. J. Surg. Oncol. 2016;114:533-536. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Background: Malignant melanoma (MM) arising in a giant pigmented nevus (GPN) is a rare disease in adults with no large series published to our knowledge., Objective: We sought to describe the characteristics, treatment, and survival of MM in GPN for adults., Methods: Adults with invasive MM in GPN (n = 976) reported to the National Cancer Data Base from 1998 to 2012 were evaluated for patient and tumor characteristics, treatment, and survival. For comparison, data from adults with invasive superficial spreading melanoma (SSM) (n = 111,870) and nodular melanoma (n = 35,962) were used., Results: Compared with patients with SSM, patients with MM in GPN had a thicker Breslow depth, more positive lymph nodes, and distant metastasis more frequently. Multivariate analysis identified age older than 65 years, Breslow thickness greater than 2 mm, presence of ulceration, presence of distant metastasis, and positive margins as independent predictors of survival in patients with MM in GPN. At all stages, having MM in GPN has similar overall survival compared with SSM., Limitations: The study is retrospective and registry-based., Conclusions: Invasive MM in GPN occurs in adults, with overall survival similar to SSM. Clinicians should be aware of the continued risk of MM in adults with GPN with low threshold for biopsy., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Invasive secretory breast carcinoma (SBC) is a rare subtype of breast malignancy., Methods: Cases of SBC and infiltrating ductal carcinoma (IDC) from the National Cancer Database (1998-2011) were queried., Results: Patients with SBC (n = 246) and IDC were identified (n = 1,564,068). The group with SBC was younger (age 56.4 ± 16.0 vs. 60.4 ± 13.9 years, P < 0.001), had similar tumor size (19.9 ± 17.8 vs. 21.6 ± 25.5 mm, P = 0.297), more frequently African-Americans (24.1 vs. 14.8 vs. 13.7; P = 0.004), more well-differentiated (32 vs. 18%, P < 0.001) and less likely to be hormone receptor positive (ER: 64 vs. 76%, P = 0.001; PR: 43 vs. 65%, P < 0.001). No differences were found for incidence of node-positivity (32 vs. 34%, P = 0.520) and stage IV presentation (2.4 vs. 3.6%, P = 0.372). Breast conserving surgery (60 vs. 58%, P = 0.405) and hormonal therapy (67 vs. 71%, P = 0.489) rates were similar. Systemic chemotherapy was used less often for SBC (38 vs. 45%, P = 0.035). The overall survival of all patients with SBC was better than all patients with IDC (median not reached vs. 14.8 years, P = 0.025)., Conclusion: SBC is an uncommon tumor that is often well-differentiated and seen in younger women. Contrary to prior reports, they are frequently hormone receptor-positive. Compared to IDC, overall survival is improved. J. Surg. Oncol. 2016;113:721-725. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Background: Insular thyroid carcinoma (ITC) is a rare but aggressive thyroid malignancy., Methods: Patients with ITC (n = 508) reported to the National Cancer Data Base from 1998 to 2012 were evaluated for patient, tumor, and treatment characteristics and outcomes., Results: Compared to papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC), patients with ITC cancer were older, more often were men, had larger tumors, were more likely to present with distant metastasis, were less likely to have an R0 resection, more likely to receive external beam radiation and chemotherapy, and had significantly worse survival. Multivariate Cox regression identified age >65 years (hazard ratio [HR] = 1.53), presence of at least 1 comorbidity (HR = 1.80), positive lymph nodes (HR = 1.67), the presence of metastasis (HR = 2.73), positive margins (HR = 2.48), and radioactive iodine therapy (HR = 0.63) as significant and independent predictors of survival in ITC., Conclusion: Treatment recommendations should incorporate the use of radioactive iodine after complete surgical resection and clearance of involved nodal basins. © 2016 Wiley Periodicals, Inc. Head Neck 38: 906-912, 2016., (© 2016 Wiley Periodicals, Inc.)

Objectives: Our objectives were to (1) compare 30- and 90-day mortality rates after esophagectomy, (2) compare drivers of 30- and 90-day mortality, and (3) examine whether 90-day mortality affects hospital rankings., Background: Operative mortality has traditionally been assessed at 30 days. Ninety-day mortality has been suggested as a more appropriate indicator of quality, particularly after complex cancer surgery., Methods: Esophagectomies for nonmetastatic esophageal cancer patients diagnosed between 2007 and 2011 were identified in the National Cancer Data Base. Mortality rates were examined by patient demographics, tumor characteristics, and hospital procedural volume. Risk-adjusted hierarchical logistic regression models examined hospital performance for mortality., Results: A total of 15,796 esophagectomy patients at 977 hospitals were available for analysis. Ninety-day overall mortality was more than double the 30-day mortality (8.9% vs 4.2%; P < 0.0001). In multivariate analysis, while both 30- and 90-day mortality were associated with patient factors such as age, comorbidity, and hospital volume, only 90-day mortality was influenced by tumor- and management-related variables such as stage, tumor location, and receipt of neoadjuvant therapy. Hospital performance was examined as top 10%, middle 10% to 90%, and lowest 10% as ranked using risk-adjusted odds of mortality. There was moderate correlation between ranking based on 30- and 90-day mortality [weighted κ = 0.45 (95% confidence interval, 0.39-0.52)]. Compared with 30-day mortality rankings, nearly 20% of hospitals changed their ranking category when 90-day mortality rankings were used., Conclusions: Examination of 90-day mortality after esophagectomy reflects cancer patient management decisions and may provide actionable targets for quality improvement.

Variations in the course of the recurrent laryngeal nerve (RLN) can occur, including the development of a nonrecurrent inferior laryngeal nerve (NRILN). Rarely, both a right RLN and a right NRILN have been reported in the same patient, merging before they enter the larynx. A case is presented, including images, and the literature concerning this rare anatomical finding is reviewed, including studies suggesting alternative explanations for these cases. Fourteen previously reported cases of coexisting RLN and NRILN were identified, all involving the right side. Some cases were associated with an anomalous origin of the right subclavian artery and some were not. The alternative explanations that a communicating branch of the sympathetic nerve, which joins the RLN, is mistaken for an NRILN or that a collateral branch from an NRILN is mistaken for an RLN in these cases are also considered. Surgeons must be aware of these unusual variations to minimize nerve injury during neck surgery.

Background: Operative mortality traditionally has been defined as the rate within 30 days or during the initial hospitalization, and studies that established the volume-outcome relationship for pancreatectomy used similar definitions., Methods: Pancreatectomies reported to the National Cancer Data Base (NCDB) during 2007-2010 were examined for 30- and 90-day mortality. Unadjusted mortality rates were compared by type of resection, stage, comorbidities, and average annual hospital volume. Hierarchical logistic regression models generated risk-adjusted odds ratios for 30- and 90-day mortality., Results: After 21,482 pancreatectomies, the unadjusted 30-day mortality rate was 3.7 % (95 % confidence interval [CI] 3.4-3.9 %), which doubled at 90 days to 7.4 % (95 % CI 7.0-7.8). The unadjusted and risk-adjusted mortality rates were higher at 30 days with increasing age, increasing stage, male gender, lower income, low hospital volume, resections other than distal pancreatectomy, Medicare or Medicaid insurance coverage, residence in a Southern census division, history of prior cancer, and multiple comorbidities. The lowest-volume hospitals (<5 per year) performed 19 % of the pancreatectomies, with a risk-adjusted odds ratios for mortality that were 4.2 times higher (95 % CI 3.1-5.8) at 30 days and remained 1.9 times higher (95 % CI 1.5-2.3) at 30-90 days compared with hospitals that had high volumes (≥40 per year)., Conclusion: Mortality rates within 90 days after pancreatic resection are double those at 30 days. The volume-outcome relationship persists in the NCDB. Reporting mortality rates 90 days after pancreatectomy is important. Hospitals should be aware of their annual volume and mortality rates 30 and 90 days after pancreatectomy and should benchmark the use of high-volume hospitals.

Objective: To evaluate 30-day and 90-day mortality after major pulmonary resection for lung cancer including the relationship to hospital volume., Methods: Major lung resections from 2007 to 2011 were identified in the National Cancer Data Base. Mortality was compared according to annual volume and demographic and clinical covariates using univariate and multivariable analyses, and included information on comorbidity. Statistical significance (P<.05) and 95% confidence intervals were assessed., Results: There were 124,418 major pulmonary resections identified in 1233 facilities. The 30-day mortality rate was 2.8%. The 90-day mortality rate was 5.4%. Hospital volume was significantly associated with 30-day mortality, with a mortality rate of 3.7% for volumes less than 10, and 1.7% for volumes of 90 or more. Other variables significantly associated with 30-day mortality include older age, male sex, higher stage, pneumonectomy, a previous primary cancer, and multiple comorbidities. Similar results were found for 90-day mortality rates. In the multivariate analysis, hospital volume remained significant with adjusted odds ratios of 2.1 (95% confidence interval [CI], 1.7-2.6) for 30-day mortality and 1.3 (95% CI, 1.1-1.6) for conditional 90-day mortality for the hospitals with the lowest volume (<10) compared with those with the highest volume (>90). Hospitals with a volume less than 30 had an adjusted odds ratio for 30-day mortality of 1.3 (95% CI, 1.2-1.5) compared with those with a volume greater than 30., Conclusions: Mortality at 30 and 90 days and hospital volume should be monitored by institutions performing major pulmonary resection and benchmarked against hospitals performing at least 30 resections per year., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine whether faculty could successfully evaluate residents using a competency-based modified Milestones global evaluation tool., Design: A program's leadership team modified a draft Surgery Milestones Working Group summative global assessment instrument into a modified Milestones tool (MMT) for local use during faculty meetings devoted to semiannual resident review. Residents were scored on 15 items spanning all competencies using an 8-point graphic response scale; unstructured comments also were solicited. Arithmetic means were computed at the resident and postgraduate year cohort levels for items and competency item sets. Score ranges (highest minus lowest score) were calculated; variability was termed "low" (range <2.0 points), "moderate" (range = 2.0), or "high" (range >2.0). A subset of "low" was designated "small" (1.0-1.9). Trends were sought among item, competency, and total Milestones scores. MMT correlations with examination scores and multisource (360°) assessments were explored. The success of implementing MMT was judged using published criteria for educational assessment methods., Setting: Fully accredited, independently sponsored residency., Participants: Program leaders and 22 faculty members (71% voluntary, mean 12y of experience)., Results: Twenty-six residents were assessed, yielding 7 to 13 evaluations for MMT per categorical resident and 3 to 6 per preliminary trainee. Scores spanned the entire response scale. All MMT evaluations included narrative comments. Individual resident score variability was low (96% within competencies and 92% across competencies). Subset analysis showed that small variations were common (35% within competencies and 54% across competencies). Postgraduate year cohort variability was higher (61% moderate or high within competencies and 50% across competencies). Cohort scores at the item, competency, and total score levels exhibited rising trajectories, suggesting MMT construct validity. MMT scores did not demonstrate concurrent validity, correlating poorly with other metrics. The MMT met multiple criteria for good assessment., Conclusions: A modified Milestones global evaluation tool can be successfully adopted for semiannual assessments of resident performance by volunteer faculty members., (© 2013 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Adenoid cystic carcinoma (ACC) is a rare subtype of breast malignancy., Methods: Patients with ACC and infiltrating ductal carcinoma (IDC) reported to the National Cancer Data Base from 1998 to 2008 were reviewed for patient age, ethnicity, tumor size, nodal status, American Joint Committee on Cancer TNM Stage, tumor grade, initial treatment, hormone receptor status (for patients from 2004 to 2008), and survival (for patients from 1998 to 2003)., Results: A total of 933 patients with ACC and 729,938 with IDC were identified. No differences were found for incidence by race/ethnicity (p = 0.97). The group with ACC was older (median 60 vs. 58 years), had larger tumors (median 18 vs. 16 mm), had more grade 1 tumors (46 vs. 18 %), was less likely to undergo axillary lymph node evaluation (75.9 vs. 96.3 %), had fewer node-positive patients (5.1 vs. 35.5 %), had fewer estrogen receptor-positive tumors (15.4 vs. 75.6 %), had fewer progesterone receptor-positive tumors (13.3 vs. 65.2 %), and underwent breast-conserving surgery more often (69.8 vs. 59.8 %). Chemotherapy was provided less often for ACC (11.3 vs. 46.4 %), as was hormone therapy (9.1 vs. 42.3 %). All of these differences were statistically significant (p < 0.0001). With a median follow-up of 65.7 months (ACC) and 64.9 months (IDC), 5-year overall survival (OS) was 88 % for ACC vs. 84 % for IDC (p = 0.02). Grade 1 OS (ACC, 91 % vs. IDC, 92 %; p = 0.50) and stage I OS (ACC, 90 % vs. IDC, 91 %; p = 0.93) were equal., Conclusions: Compared with IDC, ACC has different characteristics (lower grade, hormone receptor negative, node negative), is treated differently (less axillary surgery, fewer mastectomies, less chemotherapy, less hormone therapy), and has an improved prognosis, with 88 % 5-year survival.

Purpose: To examine gender-specific differences in breast cancer utilizing the National Cancer Data Base (NCDB)., Methods: Breast cancer patients entered in the NCDB from 1998 through 2007 were compared by gender for demographics, tumor characteristics, treatment, and outcomes., Results: A total of 13,457 men were compared to 1,439,866 women. Men were older, more often African American, less often Hispanic, had larger tumors, less often had low-grade disease, less often had stage 0 or I disease, and were more likely to have metastases to lymph nodes and/or distantly. Cancers in men were less likely lobular and more likely estrogen receptor and/or progesterone receptor positive. Men were more likely to have total mastectomy and less likely to receive radiotherapy. There was no difference in chemotherapy and little difference in hormone therapy rates. Differences in overall survival (OS) were highly significant (p < 0.0001): 83 % 5-year OS for women with breast cancer (median survival 129 months) versus 74 % for men (median survival 101 months). Women had better 5-year OS (p < 0.0001) for stage 0 (94 vs. 90 %), stage I (90 vs. 87 %), and stage II (82 vs. 74 %) breast cancer. There were no differences in 5-year OS for stage III (56.9 vs. 56.5 %, p = 0.99) or stage IV (19 vs. 16 %, p = 0.20) disease., Conclusions: At first glance, this large study demonstrated numerous gender-specific differences. However, after accounting for differences in presentation, absence of data on disease-specific survival, and inherent deficiencies in reporting cancer registry data, breast cancer in men and women appears more alike than different.

Background: This study assesses the outcomes of nondesignated preliminary (NDP) residents in general surgery (GS) at an independent, nonuniversity training program., Methods: Records of all NDP residents from 1984-1985 through 2008-2009 were reviewed, and residents' careers were followed. Designated preliminary and categorical residents were excluded., Results: Sixty-two residents completed the NDP year. Three of these residents also completed a second postgraduate NDP year. A total of 60 NDPs (97%) continued in accredited postgraduate programs. Forty-eight graduates (77%) pursued surgery-associated careers: 26 (42%) in GS and 22 (35%) in other surgery-related specialties. Eleven of the 26 NDPs who entered GS (42%) became categorical residents in our program. All NDP GS graduates are board certified, board eligible, or are residents in training., Conclusions: After a preliminary year in GS, NDPs continued in postgraduate medical education followed by board certification, usually in GS or surgery-related specialties. NDPs often obtain categorical positions in the parent GS program., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: To assess applicant preferences in general surgery program selection, we surveyed current and former residents of our non-university general surgery residency program over the last 20 years, with particular emphasis on male and female selection preferences., Methods: Surveys were distributed to current and former categorical residents. Respondents were asked to rate 25 residency criteria using a Likert scale. Responses by males and females were compared using the Mann-Whitney U-test. Results are reported as mean scores, with p-values indicating statistical significance of trends toward higher scores., Results: Of 50 former (76% male, 24% female) and 18 current residents (56% male, 44% female), 56 responded (38 male, 18 female), for an overall response rate of 82%. For both male and female respondents, the top 4 selection criteria by mean average score were identical: variety and number of cases, friendly training environment, camaraderie among residents, and quality of relationships with attendings. Selection criteria that received significantly higher scores among women were camaraderie among residents, the number of female residents, and the number of female attendings (p < 0.05). For men, a suburban location, compensation and benefits, and the reputation of the program director received significantly higher scores (p < 0.05). Gender-related selection preference was most marked for the number of female residents (mean, 2.4 for women vs 1.3 for men) and the number of female attendings (mean, 2.3 for women vs 1.4 for men). These 2 criteria, however, were ranked 20th and 21st (of the 25), respectively, by the female respondents., Conclusions: The most important selection criteria, regardless of gender, relate to operative experience, training environment, and quality relationships. Gender-based preferences seem to play only a minor role in general surgery program selection.

A previously unreported late complication of a transanastomotic stent across a pancreaticotojejunostomy is described. The stent migrated distally into the jejunal lumen, through the biliary anastomis into the bile duct and proximally into the liver where it served as a nidus for infection with abscess formation. A percutaneous transhepatic interventional radiologic approach both drained the abscess and pushed the stent out of the liver and biliary tree and into the bowel, with complete recovery. The decision by the surgeon to use a stent in these patients is discussed, and the complications associated with stenting a pancreaticojejunostomy are reviewed.

Background: Metaplastic breast cancer (MBC) is characterized by various combinations of adenocarcinoma, mesenchymal, and other epithelial components. It was officially recognized as a distinct pathologic diagnosis in 2000. With few published reports, we hypothesized that MBC may have markedly different characteristics at presentation than typical infiltrating ductal carcinoma (IDC) and may be managed differently., Methods: Data from patients with MBC and IDC reported to the National Cancer Database from January 2001 through December 2003 were reviewed for year of diagnosis, patient age, race/ethnicity, tumor size, nodal status, American Joint Committee on Cancer (AJCC) stage, tumor grade, hormone receptor status, and initial treatment, and were analyzed statistically by the Pearson chi(2) test., Results: A total of 892 patients with MBC and 255,164 patients with IDC were identified. The group with MBC was older (mean age, 61.1 vs. 59.7 years; P = .001), had a significantly increased proportion of African American (14.1%, 126 of 892, vs. 10.2%, 25,900 of 255,164; odds ratio [OR], 1.455, P = .001) and Hispanic patients (5.5%, 49 of 892 vs. 3.9%, 9,947 of 255,164; OR, 1.817, P = .001), had fewer T1 tumors (29.5% vs. 65.2%), more N0 tumors (78.1% vs. 65.7%, OR, .5, P = .001), more poorly or undifferentiated tumors (67.8% vs. 38.8%), and fewer estrogen receptor-positive tumors (11.3% vs. 74.1%, OR, 22.4, P = .001) than the IDC group. Patients with MBC were treated with breast-conserving surgery less frequently than patients with IDC (38.5% vs. 55.8%, OR, 2.0, P = .001) because of the larger tumor size. Chemotherapy was used more often for patients with MBC (53.4% vs. 42.1%, OR, 1.6, P = .001) because of more advanced AJCC stage., Conclusions: MBC is a rare tumor with different characteristics than IDC: it presents with larger tumor size, less nodal involvement, higher tumor grade, and hormone receptor negativity. Patients with MBC are treated more aggressively than IDC (more often with mastectomy and chemotherapy) because of a higher stage at presentation, but are being treated by the same principles as IDC. Follow-up will determine the long-term results of the current treatment.

Background: This article attempts to assess the effect of the duty-hour limitations implemented in 2003 on voluntary withdrawal of general surgery residents., Study Design: A questionnaire asked the program directors how many categorical general surgery residents left voluntarily in 2003 to 2004, their training levels, why they left, and where they went. Results were compared with an identical study of 2000 to 2001 and analyzed statistically using chi-square analysis., Results: A total of 215 programs (85%) responded, compared with 206 programs (81%) in the previous study. One hundred two programs (48%) reported voluntary attrition of 148 residents, compared with 110 programs (53%) and 167 residents previously. An average of 1.5 residents per program left in programs that reported attrition and 0.7 residents per program in all responders, compared with 1.5 and 0.8 residents in the previous study. In both studies, most programs with attrition lost one (66% [2000 to 2001] and 65% [2003 to 2004]) or two residents (21% [2000 to 2001] and 27% [2003 to 2004]). Most attrition occurred at PGY1 (47%) and PGY2 (28%) levels; a total of 75% of all attrition occurred at these levels, compared with a total of 76% in the previous study. One hundred eleven residents (75%) entered other medical specialties, and 23 (16%) transferred to other general surgery programs, compared with 105 residents (63%) and 40 residents (24%) in the previous study. In both studies, personal issues and work hours/lifestyle were cited as the most common reasons for leaving. In each study, the net loss to general surgery (the number of residents who left voluntarily divided by the total resident population at risk) was 3% for that academic year. Analysis showed no statistically significant difference., Conclusions: Rates and patterns of attrition seem to have been unaffected by Accreditation Council for Graduate Medical Education work-hours limitations.

Operative time in thyroid surgery can be safely reduced through use of a new bipolar electrosealing device (LigaSure). We evaluated consecutive patients undergoing thyroid surgery from January 2003 through January 2005 (n=155). During the first half of the study, hemostasis was obtained using silk ties (conventional group, n=70). During the second half of the study period, hemostasis was obtained with a bipolar electrosealing device (LigaSure group, n=85). The mean operative time was 130 +/- 37 minutes in the conventional group and 110 +/- 33 minutes (P < 0.001) in the LigaSure group. EBL in the LigaSure group was statistically significantly less (43 +/- 53 vs 33 +/- 33 mL; P < 0.05). Postoperative calcium level was statistically significantly higher in the LigaSure group (8.2 +/- 0.5 vs 8.4 +/- 0.6 mg/dL, P < 0.05). Hospital length of stay (LOS) did not differ significantly. One patient in each group developed neck hematoma requiring reoperation. One permanent recurrent nerve injury occurred in the conventional group and one transient bilateral recurrent nerve injury occurred in the LigaSure group. The occurrence of symptomatic hypocalcemia was similar between the two groups. The training level of the surgical resident had no significant impact on the operative time, estimated blood loss (EBL), LOS, or complication rate. LigaSure bipolar electrosealer as the primary means of hemostasis during thyroidectomy significantly reduces mean operative times. Rates of operative complications were unchanged. LigaSure use in thyroid surgery can safely increase efficiency.

Bronchopulmonary sequestration is an uncommon developmental abnormality that frequently presents as an incidental mass. Differential diagnosis includes malignancy. Reports of extralobar abdominal pulmonary sequestration in adults are sparse. Only 2.5% of all pulmonary sequestrations are detected below the diaphragm. The authors present a case of a 45-year-old woman and a literature review. Computed tomography, magnetic resonance imaging, and operative and pathologic findings are provided. A review of diagnosis and therapy is presented.

Objective: To present a series of cases of parathyroid incidentalomas and review the related medical literature., Methods: The medical records of all patients of one surgeon who underwent unplanned removal of enlarged parathyroid glands found either during a surgical procedure performed for indications other than hyperparathyroidism or by ultrasonography of the thyroid gland between September 1989 and December 2003 were reviewed retrospectively. Clinical and laboratory data-- especially serum calcium and parathyroid hormone (PTH) levels--as well as information on postoperative parathyroid function are reported., Results: Among 421 patients (355 who underwent thyroidectomy and 66 who underwent transhiatal esophagectomy), 5 cases of parathyroid incidentalomas (1.2%) were identified. These incidental parathyroid adenomas were found during thyroidectomy for thyroid cancer in two patients, during esophagectomy for esophageal cancer in one patient (the first such reported case), and during ultrasonography of the neck for evaluation of thyroid nodules in two patients. Of the five patients, three had a normal and one had a slightly increased serum calcium concentration preoperatively; the serum calcium level was not determined preoperatively in the other patient. In one patient in whom intraoperative PTH level was determined both before and after resection of a large parathyroid adenoma, the initially high PTH value (180 pg/mL) declined to the normal range (48.2 pg/mL). In another patient, bone densitometry 9 months postoperatively showed an 8% increase in T-score for the lumbar spine and a 3.9% increase in T-score at the femoral neck, in comparison with bone density tests done 3 months preoperatively. No patient had persistent or recurrent hyperparathyroidism or hypoparathyroidism postoperatively or during subsequent follow-up., Conclusion: Incidental identification of enlarged parathyroid glands during a neck surgical procedure is not common but does occur. Intraoperative and postoperative measurements of serum calcium and PTH along with postoperative bone density testing can help determine whether such parathyroid incidentalomas are functional. These enlarged parathyroid glands should be removed.

Hypothesis: Resection of the nipple-areolar complex (NAC) for central breast cancers that involve the nipple or areola, with postoperative radiation therapy, adheres to the oncologic principles established for breast conservation surgery of other breast cancers. Good or excellent cosmetic results can be achieved. The rate of ipsilateral breast recurrence will be similar to that seen with peripheral breast cancers. The indications for breast conservation surgery can be safely extended to include patients with breast cancers that involve the NAC., Design: Retrospective medical record review; follow-up patient questionnaire., Setting: Community teaching hospital., Patients: Fifteen patients, aged 46 to 88 years, whose central breast cancers involved the NAC precluding preservation of the NAC., Interventions: Nipple-areolar complex resection, postoperative radiation therapy., Main Outcome Measures: Ipsilateral breast recurrence, survival, cosmesis., Results: Ten patients had subareolar cancers that directly involved the nipple or areola; 5 patients had Paget disease of the nipple. Average tumor size was 1.6 cm (range, 0.2-3.5 cm). With a mean follow-up of 32 months (range, 4-109 months), there has been only 1 recurrence (7%), which was treated successfully by modified radical mastectomy. All 15 patients are alive and free of disease. Cosmetic results are satisfactory to excellent, as judged by both the patients and the surgeons., Conclusions: Nipple-areolar complex resection for central subareolar cancers that directly involve the NAC, as well as for Paget disease of the nipple, extends the indications for breast conservation in other areas of the breast, and with acceptable cosmesis.

We describe a case of primary intramural, extraluminal leiomyosarcoma of the common iliac artery. The patient presented with pelvic and leg pain and pheochromocytoma-like symptoms. The diagnosis was made intraoperatively, the tumor was resected, vascular reconstruction was performed, and postoperative radiation therapy was administered. Primary leiomyosarcoma of a major peripheral artery is extremely rare, and this report examines the clinical presentation, treatment, and prognosis of these patients.

We report a rare case of adenocarcinoid tumor of the ampulla of Vater. The tumor contained an intermixture of adenocarcinoma and carcinoid tumor and was removed successfully by pancreaticoduodenectomy. The characteristics of these rare tumors are reviewed.

Background: The use of screening mammography in women aged 40 to 50 years is controversial because of a relative lack of data demonstrating survival benefit for this segment of the population., Patients and Methods: The charts of 809 consecutive women who underwent needle localized breast biopsy over a 6 1/2-year period were reviewed to determine the effect of age on the biopsy results. Patient ages ranged from 27 to 91 years (mean 56)., Results: Two hundred nineteen (27%) of the 809 needle localized breast biopsies were malignant, with a mean tumor diameter of 1.46 cm. This procedure identified malignancy in 3 (5%) of 60 patients age 40, and in 32 (15%) of 207 patients aged 40 to 49 years. Malignancy was significantly more likely in patients 50 years of age or older and was found in 184 (34%) of the 542 (P<0.001). Overall, 33% of all patients undergoing the procedure were under age 50., Conclusions: Without screening mammography, the diagnosis of breast cancer would have been delayed in 32 women aged 40 to 50, 15% of the total diagnosed with nonpalpable breast cancer in this study. We recommend the use of screening mammography in this age group.

Hyperparathyroid crisis is a rare, life-threatening condition that requires prompt removal of the involved parathyroid gland(s). This report describes a patient with hyperparathyroid crisis caused by a mediastinal parathyroid adenoma, which was localized before operation and removed at the initial operation, without neck exploration. Surgical approaches to hyperparathyroid crisis and the importance of preoperative localization studies are discussed.

Malignant fibrous histiocytoma, the major subset of soft tissue sarcomas, was examined for prognostic factors that could influence clinical management and research. Two hundred twenty-seven patients with localized disease, having surgery as the principal modality, were reviewed retrospectively to identify clinical outcomes. The mean age of the patients was 54 years. Extremities were the primary tumor site in 157 patients (62.2%). Overall survival rate was 50%, including 38 patients who died of other causes. Distant metastases were most common to the lung (90%). Local recurrence alone occurred in 37 patients (16%), distant metastases alone in 52 (23%), and distant metastases with local recurrence in 25 (11%). The primary tumor size indicated the 5-year survival rate: tumors smaller than 5 cm had a survival rate of 82%; 5 to 10 cm, 68%; and larger than 10 cm, 51%. Intermediate-grade tumors yielded a 5-year survival rate of 80%, and the 5-year survival rate for high-grade tumors was 60%. Survival rates for both grades were affected by size: tumors of high grade and smaller than 5 cm in diameter had a survival rate of 79%; 5 to 10 cm, 63%; and more than 10 cm, 41%. Grade and size emerge as significant prognostic indicators. These variables will prove helpful in treatment decisions and design of clinical studies.

Forty-six patients with extremity soft-tissue sarcomas were treated with a mean of 4.4 cycles of preoperative adriamycin-based combination chemotherapy, followed by definitive local surgery and radiotherapy. All tumors were larger than 5 cm and of histologic type having significant risk of metastasis. Eighteen patients (40%) had an objective clinical response to the chemotherapy, while 27 patients (60%) did not respond. Patients with tumors responsive to chemotherapy had significantly improved overall survival (median 60 + months versus 32.7 months; p = 0.02), continuous disease-free survival (median 60 + months versus 15.1 months; p = 0.04), and distant metastasis-free survival (median 60+ months versus 28.5 months; p = 0.006) compared to the nonresponding patients. Tumor response to preoperative chemotherapy provides strong prognostic information and identifies a subgroup of patients most likely to benefit from chemotherapy.

Papillary-cystic neoplasm of the pancreas is a rare tumor which has recently been described as a distinct, clinicopathological entity. Forty-four previously described cases from the literature and an additional 52 cases referred to in a brief abstract are reviewed. An additional case occurring in a 25-year-old woman is reported. This tumor occurs primarily in young women (mean age 23.3 years) and presents as a large abdominal mass (mean size 10.3 cm) in 63% of patients. Treatment is surgical resection of the involved portions of the pancreas and results of treatment are excellent following this form of therapy alone. The tumor appears to represent a low-grade malignancy, possibly of ductal cell origin. Only two patients with recurrences and two patients with metastatic disease have been reported. Surgeons should be aware of this curable pancreatic malignancy as they are most often responsible for the evaluation and treatment of the patient presenting with a large abdominal mass.