Annals of Surgical Oncology (Ann Surg Oncol)

Publications in this journal

• Article: Multivisceral Resection in Colorectal Cancer: A Systematic Review.

  H M Mohan, M D Evans, J O Larkin, J Beynon, D C Winter
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  ABSTRACT: BACKGROUND: The objective of this study was to critically evaluate current literature on outcomes following multivisceral resection (MVR) in colorectal cancer (CRC). Adequate surgical resection with clear margins is imperative in achieving long-term survival in colorectal cancer. Where there is adherence to or invasion of adjacent organs, (MVR) may be needed to achieve complete disease clearance. METHODS: A systematic review of MVR in CRC was performed. Pubmed/Medline and Cochrane databases were searched for English language articles from 1995 to 2012 using a predefined strategy. Retrieved abstracts were independently screened for relevance and data extracted from selected studies by 2 researchers. Results are reported as weighted means. RESULTS: Included were 22 studies comprising 1575 patients (87.0 % primary colorectal cancer; 13.0 % recurrent, 63.8 % rectal; 36.2 % colon). The most common organs resected were the bladder and reproductive organs. The perioperative mortality was 4.2 % with morbidity of 41.5 % (95 % CI, 40.8-42.2 %). The overall 5-year survival rate was 50.3 % (95 % CI, 49.9-50.8 %). Surgery for recurrence was associated with worse outcomes than primary tumors with 5-year survival 19.5 % (95 % CI, 17.8-21.1 %) for recurrent rectal cancer and primary rectal tumors 5-year overall survival 52.8 % (95 % CI, 52.0-53.8 %). R0 resection was the strongest factor associated with long-term survival. CONCLUSIONS: Multivisceral resection provides the best possibility of long-term survival in locally advanced primary colorectal cancer in which a clear margin has been achieved.
  Annals of Surgical Oncology 05/2013;
• Article: Erratum to: Analysis of Prognostic Factors in Extraosseous Ewing Sarcoma Family of Tumors: Review of St. Jude Children's Research Hospital Experience.

  W Shannon Orr, Jason W Denbo, Catherine A Billups, Jianrong Wu, Fariba Navid, Bhaskar N Rao, Andrew M Davidoff, Matthew J Krasin
  Annals of Surgical Oncology 05/2013;
• Article: Diagnostic Ureteroscopy Independently Correlates with Intravesical Recurrence after Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma.

  Hao Lun Luo, Chih Hsiung Kang, Yen Ta Chen, Yao Chi Chuang, Wei Ching Lee, Yuan Tso Cheng, Po Hui Chiang
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  ABSTRACT: BACKGROUND: Little is known about the effects of diagnostic ureteroscopy on intravesical recurrence after nephroureterectomy. METHODS: This study was designed to determine the effect of diagnostic ureteroscopy on intravesical recurrence after nephroureterectomy. From 2004 to 2010, 446 patients underwent nephroureterectomy for upper urinary tract cancer at our tertiary medical center. We included 115 patients who underwent preoperative diagnostic ureteroscopy and 281 patients who did not. This study analyzed the impact of the reported risk factors and diagnostic ureteroscopy for intravesical recurrence after nephroureterectomy by multivariate Cox regression model. RESULTS: The rates of metastasis and cancer-specific mortality did not differ significantly between the two groups. Diagnostic ureteroscopy was associated with a higher incidence of intravesical recurrence in patients with (p = 0.02) and without (p = 0.016) a previous history of bladder cancer. Ureter tumor biopsy (p = 0.272) and ureter involvement (p = 0.743) were not associated with the rate of intravesical recurrence in this study. Multivariate Cox regression analysis showed that only bladder cancer history (p < 0.001), multifocal tumor (p = 0.05), and diagnostic ureteroscopy (p = 0.05) were independently associated with intravesical recurrence. CONCLUSIONS: Diagnostic ureteroscopy for upper urinary tract cancer was not associated with metastasis and cancer-specific mortality. However, ureteroscopy was associated with an increased incidence of intravesical tumor recurrence. Methods of prevention should be considered to decrease intravesical recurrence and avoid repeated surgical interventions or the development of advanced bladder disease in patients at risk.
  Annals of Surgical Oncology 05/2013;
• Article: Are Breast Cancer Subtypes Prognostic for Nodal Involvement and Associated with Clinicopathologic Features at Presentation in Early-Stage Breast Cancer?

  Tiffanie Jones, Hanmanth Neboori, H Wu, Qifeng Yang, Bruce G Haffty, Susan Evans, Susan Higgins, Meena S Moran
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  ABSTRACT: BACKGROUND: Breast cancer subtypes (BCS) determined from immunohistochemical staining have been correlated with molecular subtypes and associated with prognosis and outcomes, but there are limited data correlating these BCS and axillary node involvement. This study was conducted to assess whether BCS predicted for nodal metastasis or was associated with other clinicopathologic features at presentation. METHODS: Patients with stage I/II disease who underwent breast-conserving surgery and axillary surgical assessment with available tissue blocks underwent a institutional pathological review and construction of a tissue microarray. The slides were stained for estrogen receptor, progesterone receptor, and HER-2/neu (HER-2) for classification into BCS. Nodal involvement and other clinicopathologic features were analyzed to assess associations between BCS and patient and tumor characteristics. Outcomes were calculated a function of BCS. RESULTS: The study cohort consisted of 453 patients (luminal A 48.6 %, luminal B 16.1 %, HER-2 11.0 %, triple negative 24.2 %), of which 22 % (n = 113) were node positive. There were no significant associations with BCS and pN stage, node positivity, or absolute number of nodes involved (p > 0.05 for all). However, there were significant associations with subtype and age at presentation (p < 0.001), method of detection (p = 0.049), tumor histology (p < 0.001), race (p = 0.041), and tumor size (pT stage, p < 0.001) by univariate and multivariate analysis. As expected, 10-year outcomes differed by BCS, with triple negative and HER-2 subtypes having the worse overall (p = 0.03), disease-free (p = 0.03), and distant metastasis-free survival (p < 0.01). CONCLUSIONS: There is a significant association between BCS and age, T stage, histology, method of detection, and race, but no associations to predict nodal involvement. If additionally validated, these findings suggest that BCS may not be a useful prognostic variable for influencing regional management considerations.
  Annals of Surgical Oncology 05/2013;
• Article: Meta-Analysis to Determine if Surgical Resection of the Primary Tumour in the Setting of Stage IV Breast Cancer Impacts on Survival.

  Elly Harris, Mitchel Barry, Malcolm R Kell
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  ABSTRACT: INTRODUCTION: The role of primary tumor excision in patients with stage IV breast cancer is unclear. Therefore, a meta-analysis of relevant studies was performed to determine whether surgical excision of the primary tumor enhances oncological outcome in the setting of stage IV breast cancer. METHODS: A comprehensive search for relevant published trials that evaluated outcomes following excision of the primary tumor in stage IV breast cancer was performed using MEDLINE and available data were cross-referenced. Data were extracted following review of appropriate studies by authors. The primary outcome was overall survival following surgical removal of the primary tumor. RESULTS: Data from ten studies included 28,693 patients with stage IV disease of whom 52.8 % underwent excision of the primary carcinoma. Surgical excision of the primary tumor in the setting of stage IV breast cancer was associated with a superior survival at 3 years (40 % (surgery) versus 22 % (no surgery) (odds ratio 2.32, 95 % confidence interval 2.08-2.6, p < 0.01). Subgroup analyses for selection of patients for surgery or not, favored smaller primary tumors, less competing medical comorbidities and lower metastatic burden (p < 0.01). There was no statistical difference between the two groups regarding location of metastatic disease, grade of tumor, or receptor status. CONCLUSIONS: Patients with stage IV disease undergoing surgical excision of the primary tumor achieve a superior survival rate then their nonsurgical counterparts. In the absence of robust evidence, this meta-analysis provides evidence base for primary resection in the setting of stage IV breast cancer for appropriately selected patients.
  Annals of Surgical Oncology 05/2013;
• Article: Surgery for the Intact Primary and Stage IV Breast Cancer…Lacking "Robust Evidence"

  Seema A Khan
  Annals of Surgical Oncology 05/2013;
• Article: Gd-EOB-DTPA-Enhanced MRI is Better than MDCT in Decision Making of Curative Treatment for Hepatocellular Carcinoma.

  Sun Hong Yoo, Jong Young Choi, Jeong Won Jang, Si Hyun Bae, Seung Kew Yoon, Dong Goo Kim, Young Kyoung Yoo, Sung Eun Rha, Young Joon Lee, Eun Sun Jung
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  ABSTRACT: BACKGROUND: We assessed the change in the therapeutic decision among curative treatments after adding Gd-EOB-DTPA-enhanced MRI to triple-phase MDCT for patients with early-stage HCC. METHODS: This study retrospectively investigated two groups: 33 pathologically confirmed HCC patients after liver transplantation in group 1; 34 HCC patients without pathology in group 2. In group 1, we simulated the therapeutic decision-making process by pretransplant MDCT and Gd-EOB-DTPA-enhanced MRI. In group 2, including the 34 early-stage HCC patients consecutively enrolled, we investigated the change of therapeutic decision after adding Gd-EOB-DTPA-enhanced MRI to MDCT. RESULTS: In the simulation from group 1, after adding Gd-EOB-DTPA-enhanced MRI, 33.3 % (11/33 patients) of treatment decisions were changed from the decision based on MDCT alone. Among 22 patients considered eligible for resection and 33 patients for radiofrequency ablation, the therapeutic decision was changed for 10 patients in the surgical group and 4 patients for the RFA group (45.5 and 12.1 %). In group 2, the rate of change in the therapeutic decision after adding Gd-EOB-DTPA-enhanced MRI to MDCT was 41.2 % (14/34 patients). In group 1 with explants pathology, the median diameter of HCCs not detected by MDCT but detected by Gd-EOB-DTPA-enhanced MRI was 1.15 cm (0.3-3.0 cm). The median diameter of HCCs seen only in the explanted liver was 1.0 cm (0.3-1.7 cm), and 60.7 % of them were well-differentiated HCCs. CONCLUSIONS: This study suggests that performing Gd-EOB-DTPA-enhanced MRI before deciding on curative treatment for early-stage HCC may improve the accuracy of treatment decision for early-stage HCC.
  Annals of Surgical Oncology 05/2013;
• Article: Is Head and Neck Melanoma Different from Trunk and Extremity Melanomas with Respect to Sentinel Lymph Node Status and Clinical Outcome?

  Niloofar Fadaki, Rui Li, Brian Parrett, Grant Sanders, Suresh Thummala, Lea Martineau, Servando Cardona-Huerta, Suzette Miranda, Shih-Tsung Cheng, James R Miller, Mark Singer, James E Cleaver, Mohammed Kashani-Sabet, Stanley P L Leong
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  ABSTRACT: BACKGROUND: Previous studies showed conflicting and inconsistent results regarding the effect of anatomic location of the melanoma on sentinel lymph node (SLN) positivity and/or survival. This study was conducted to evaluate and compare the effect of the anatomic locations of primary melanoma on long-term clinical outcomes. METHODS: All consecutive cutaneous melanoma patients (n = 2,079) who underwent selective SLN dissection (SLND) from 1993 to 2009 in a single academic tertiary-care medical center were included. SLN positive rate, disease-free survival (DFS), and overall survival (OS) were determined. Kaplan-Meier survival, univariate, and multivariate analyses were performed to determine predictive factors for SLN status, DFS, and OS. RESULTS: Head and neck melanoma (HNM) had the lowest SLN-positive rate at 10.8 % (16.8 % for extremity and 19.3 % for trunk; P = 0.002) but had the worst 5-year DFS (P < 0.0001) and 5-year OS (P < 0.0001) compared with other sites. Tumor thickness (P < 0.001), ulceration (P < 0.001), HNM location (P = 0.001), mitotic rate (P < 0.001), and decreasing age (P < 0.001) were independent predictive factors for SLN-positivity. HNM with T3 or T4 thickness had significantly lower SLN positive rate compared with other locations (P ≤ 0.05). Also, on multivariate analysis, HNM location versus other anatomic sites was independently predictive of decreased DFS and OS (P < 0.001). By Kaplan-Meier analysis, HNM was associated significantly with the worst DFS and OS. CONCLUSIONS: Primary melanoma anatomic location is an independent predictor of SLN status and survival. Although HNM has a decreased SLN-positivity rate, it shows a significantly increased risk of recurrence and death as compared with other sites.
  Annals of Surgical Oncology 05/2013;
• Article: REG1A Expression Status Suggests Chemosensitivity Among Advanced Thoracic Esophageal Squamous Cell Carcinoma Patients Treated with Esophagectomy Followed by Adjuvant Chemotherapy.

  Yusuke Sato, Satoru Motoyama, Hiroshi Nanjo, Satoru Ito, Kei Yoshino, Tomohiko Sasaki, Kuniaki Kuribayashi, Yushi Nagaki, Kazuhiro Imai, Hajime Saito, Yoshihiro Minamiya, Jun-Ichi Ogawa
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  ABSTRACT: BACKGROUND: Regenerating gene 1A (REG1A) plays an important role in tissue regeneration and in cell proliferation in the mucous membrane of the gastrointestinal tract. We previously reported that the positive expression status of REG1A was predictive of chemoradiosensitivity in patients treated with preoperative chemoradiotherapy before esophagectomy or with definitive chemoradiotherapy. To further confirm the utility of REG1A as a chemosensitivity marker, we carried out an additional retrospective clinical study aimed at determining whether REG1A is a reliable chemosensitivity marker in patients treated with esophagectomy followed by adjuvant chemotherapy. METHOD: A total of 177 patients with T2-4 thoracic esophageal squamous cell carcinoma received curative surgery without preoperative treatment at Akita University Hospital between 2001 and 2011. A tissue microarray was constructed, and REG1A expression status was analyzed immunohistochemically. We then statistically analyzed the relationships between REG1A expression status and 5-year overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS). RESULTS: In the adjuvant group (n = 105), REG1A-positive patients showed significantly better prognoses than REG1A-negative patients. (5-year OS, p = .0022; DSS, p = .0004; and DFS, p = .0040). However, there were no significant differences between REG1A-positive and REG1A-negative patients in the surgery group (n = 72). Univariate and multivariate analyses showed REG1A expression status to be a significant prognostic factor affecting 5-year DSS, comparable to lymph node metastatic status. CONCLUSION: The present study suggests REG1A expression status has the potential to be a highly reliable and clinically useful chemosensitivity marker in patients treated with advanced thoracic esophageal squamous cell carcinoma. REG1A expression status will provide a good indication of treatment strategy and enable more individualized treatment for patients.
  Annals of Surgical Oncology 05/2013;
• Article: Embedded Cervical Esophagogastrostomy: A Simple and Convenient Method Using a Circular Stapler After Esophagectomy for Esophageal Carcinomas.

  Sen Wu, Mingyao Chen, Li Wei, Zhong Chen
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  ABSTRACT: BACKGROUND: Cervical esophagogastrostomy is currently the most common method for esophageal reconstruction after esophagectomy. The advantages and disadvantages of hand-sewn, linear-stapled, or circular-stapled anastomoses have been subject to debate in recent years. We explored a new method of end-to-side anastomosis using a circular stapler that embeds the anastomosis and the remaining esophageal tissue into the gastric cavity to reduce the occurrence of anastomotic leakage and to prevent gastroesophageal reflux. METHODS: In 127 patients with esophageal carcinomas, end-to-side anastomoses with esophageal embedding were performed by connecting the anvil and body of the circular stapler inside the stomach before firing and embedding the anastomosis and remaining esophagus into the stomach after esophagectomy. Retrospective investigations on postoperative complications such as leakage, stricture, and gastroesophageal reflux were conducted. RESULTS: A total of 123 patients (96.9 %) had successful surgery, and 4 patients (3.3 %) developed anastomotic leakage, with the total morbidity of 20 of 123 (16.3 %) and in-hospital mortality of 1 of 123 (0.8 %). The incidence of stricture (<1 cm) affected 14 of 123 patients (11.4 %). Eight patients underwent dilatation treatment as a result of severe dysphagia (6.5 %). Half of the patients [62 of 123 (50.4 %)] experienced postoperative heartburn, 11 of 123 patients (8.9 %) experienced acid regurgitation, and 16 of 123 patients (13.0 %) experienced nocturnal cough. CONCLUSIONS: Embedded cervical esophagogastrostomy with circular stapler is a simple and convenient method, with low incidence of anastomotic leakage and a good antireflux effect.
  Annals of Surgical Oncology 05/2013;
• Article: Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Patients with Cytologically Proven Node-positive Breast Cancer at Diagnosis.

  Seho Park, Ji Min Park, Jung Hoon Cho, Hyung Seok Park, Seung Il Kim, Byeong-Woo Park
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  ABSTRACT: BACKGROUND: The performance of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NCT) was investigated in patients with locally advanced breast cancer (LABC). METHODS: After NCT of 178 patients with cytology-proven axillary/supraclavicular nodes metastasis at the time of diagnosis, SLNB using radioisotope was performed including completion node dissection between 2008 and 2011. The detection rate, sensitivity, false negative rate (FNR), negative predictive value (NPV) and accuracy of SLNB were analyzed. RESULTS: SLNB was successfully performed in 169 (94.9 %) patients. Tumor nonresponse and extensive residual nodal disease were found to be significantly associated with detection failure of sentinel nodes. Sensitivity, FNR, NPV, and accuracy of SLNB were 78.0, 22.0, 75.8, and 87.0 %, respectively, and a greater number of retrieved SLNs increased all four of these performance measures. Conversion to node-negative disease was achieved in 69 (40.8 %) patients: 24 % of patients with the luminal A subtype, 51.6 % of patients with the luminal B, 51.7 % of patients with the HER2-enriched, and 58.5 % of patients with the triple-negative breast cancer (TNBC) subtype. Luminal B, HER2-enriched, and TNBC subtypes showed comparable responses to NCT; however, the TNBC subtype had a significantly better FNR and accuracy. CONCLUSIONS: SLNB was found to be technically feasible, but its routine use was not recommended for LABCs after NCT. However, acceptable performance was noted for locally advanced TNBCs, and thus SLNB might be safely considered in these selected patients.
  Annals of Surgical Oncology 05/2013;
• Article: Fluctuating Mastectomy Rates Across Time and Geography.

  Carlos A Garcia-Etienne, Mariano Tomatis, Joerg Heil, Mahmoud Danaei, Christoph J Rageth, Lorenza Marotti, Marco Rosselli Del Turco, Antonio Ponti
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  ABSTRACT: In 2009, 2 single-institution studies from the United States reported increasing mastectomy rates during the last decade. We have recently reported unilateral mastectomy trends from a European database and demonstrated a significant trend of decreasing mastectomy rates from 38.1 % in 2005 to 13.1 % in 2010. A recent study from the SEER registry in the United States confirmed a previously reported decrease in mastectomy rates from 40.1 % in year 2000 to 35.6 % in 2005, but showed a statistically significant increase in mastectomy rates up to 38.4 % in 2008. This report provides evidence that mastectomy trends may be in opposite directions in different geographical areas. The sharpest increase in mastectomy rates across all ages in the recent SEER study occurs right after year 2005, which interestingly corresponds with the time of publication of the meta-analysis by the EBCTCG that highlighted the importance of local control in breast cancer. The coincident timing raises the question of whether this evidence may have indirectly triggered an increase in mastectomy rates in the United States that would partially explain the observed trend, and more importantly, of whether an increase would be justified on this basis. Multiple factors influence the proportion between mastectomy and breast conservation, so it may be unreasonable to think of an optimal cutoff. There is not necessarily a right or wrong direction for mastectomy trends, but aiming to determine explanations for these differences may help provide a clearer insight of the decision-making process involved in the surgical management of breast cancer.
  Annals of Surgical Oncology 05/2013;
• Article: Financial Comparison of Laparoscopic Versus Open Hepatic Resection Using Deviation-Based Cost Modeling.

  Robert M Cannon, Charles R Scoggins, Glenda G Callender, Amy Quillo, Kelly M McMasters, Robert C G Martin
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  ABSTRACT: BACKGROUND: There is a growing body of evidence suggesting the equivalence and in some cases superiority of laparoscopic liver resection versus open resection. Fewer data exist regarding the financial impact of laparoscopic liver resection. METHODS: Retrospective review of 98 consecutive patients at a single institution from 2007 through 2011 undergoing first time hepatic resection was performed. Laparoscopic and open cases were compared primarily on OR and hospital charges. Deviation-based cost modeling and weighted average mean cost for the two procedures were used to determine both financial and clinical efficacy on the basis of differences in length of stay, complications, and charges. RESULTS: There were 57 laparoscopic and 41 open cases included in the study. Right hepatectomy was the most common procedure performed in both the laparoscopic (n = 23, 40.4 %) and open (n = 22, 53.7 %) groups. Patients in the laparoscopic group were significantly more likely to have an "on course" postoperative hospitalization (73.7 vs. 26.8 %; p < 0.001), which translated into a WAMC of $58,401 for the laparoscopic cases and $69,728 for the open cases. In the subset of patients undergoing right hepatectomy, patients in the laparoscopic group remained more likely to have an on course hospitalization (61.2 vs. 31.8 %; p = 0.025). WAMC for the laparoscopic right hepatectomy group, however, was higher than the open group ($69,544 vs. $68,266). CONCLUSIONS: The cost-effectiveness of laparoscopic hepatectomy appears to vary with the complexity of the procedure. Overall, laparoscopy offers a cost advantage; however, with more complex procedures such as right hepatectomy, higher up-front operating room charges offset the financial benefits of less complicated hospitalization.
  Annals of Surgical Oncology 05/2013;
• Article: Should an Involved but Functioning Recurrent Laryngeal Nerve be Shaved or Resected in a Locally Advanced Papillary Thyroid Carcinoma?

  Brian Hung-Hin Lang, Chung-Yau Lo, Kai Pun Wong, Koon Yat Wan
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  ABSTRACT: BACKGROUND: The issue of whether an involved but functioning recurrent laryngeal nerve (RLN) should be shaved or resected in locally advanced papillary thyroid carcinoma (PTC) remains controversial. Our study aimed to compare the early and late outcomes between those who underwent shaving and those who underwent resection and also to identify independent prognostic factors in this subset of patients. METHODS: Of the 77 patients with 1 RLN involved by PTC, 39 (50.6 %) underwent RLN preservation (group I) while 38 (49.4 %) underwent RLN resection (group II). Early and late vocal cord function (as assessed by flexible laryngoscopy) and disease status were compared between the 2 groups. A multivariate Cox proportional hazards model was carried out to identify independent factors. RESULTS: Baseline characteristics were comparable between the 2 groups. Although temporary vocal cord palsy rate was similar between the 2 groups (p = 0.532), 5 patients in group II (13.2 %) suffered temporary bilateral vocal cord palsies with 1 requiring a tracheostomy lasting for 1 month. After a median follow-up of 113.8 months, 1 patient from each group developed new onset vocal cord palsy. Presence of distant metastases (hazard ratio [HR] = 5.892, 95 % CI = 1.971-17.604, p = 0.001) and incomplete surgical resection in non-RLN concomitant sites (HR = 2.491, 95 % CI = 1.181-5.476, p = 0.024) were the 2 independent predictors for a poor cancer-specific survival. CONCLUSIONS: Our data suggested that shaving could preserve the normal functionality in most of the involved RLNs (>90 %) in the short to medium term. In the presence of distant metastases or incomplete resection in other non-RLN concomitant sites, the argument for shaving over resection appears even stronger.
  Annals of Surgical Oncology 05/2013;
• Article: The Financial Burden of Reexcising Incompletely Excised Soft Tissue Sarcomas: A Cost Analysis.

  Vignesh K Alamanda, Gadini O Delisca, Shannon L Mathis, Kristin R Archer, Jesse M Ehrenfeld, Mark W Miller, Kelly C Homlar, Jennifer L Halpern, Herbert S Schwartz, Ginger E Holt
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  ABSTRACT: BACKGROUND: Although survival outcomes have been evaluated between those undergoing a planned primary excision and those undergoing a reexcision following an unplanned resection, the financial implications associated with a reexcision have yet to be elucidated. METHODS: A query for financial data (professional, technical, indirect charges) for soft tissue sarcoma excisions from 2005 to 2008 was performed. A total of 304 patients (200 primary excisions and 104 reexcisions) were identified. Wilcoxon rank sum tests and χ (2) or Fisher's exact tests were used to compare differences in demographics and tumor characteristics. Multivariable linear regression analyses were performed with bootstrapping techniques. RESULTS: The average professional charge for a primary excision was $9,694 and $12,896 for a reexcision (p < .001). After adjusting for tumor size, American Society of Anesthesiologists status, grade, and site, patients undergoing reexcision saw an increase of $3,699 in professional charges more than those with a primary excision (p < .001). Although every 1-cm increase in size of the tumor results in an increase of $148 for a primary excision (p = .006), size was not an independent factor in affecting reexcision charges. The grade of the tumor was positively associated with professional charges of both groups such that higher-grade tumors resulted in higher charges compared to lower-grade tumors (p < .05). CONCLUSIONS: Reexcision of an incompletely excised sarcoma results in significantly higher professional charges when compared to a single, planned complete excision. Additionally, when the cost of the primary unplanned surgery is considered, the financial burden nearly doubles.
  Annals of Surgical Oncology 04/2013;
• Article: Lymph Node Harvest in Esophageal Cancer After Neoadjuvant Chemoradiotherapy.

  Ravi Shridhar, Sarah E Hoffe, Khaldoun Almhanna, Jill M Weber, Michael D Chuong, Richard C Karl, Kenneth Meredith
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  ABSTRACT: BACKGROUND: This study was designed to determine the effects of lymph node (LN) harvest on survival in esophageal cancer after neoadjuvant chemoradiation (nCRT). METHODS: An analysis of surgically resected esophageal cancer patients after nCRT was performed to determine an association between the number of LNs resected and survival. Overall survival (OS) and disease-free survival (DFS) curves were calculated according to the Kaplan-Meier method and log-rank analysis. Multivariate analysis (MVA) was performed by the Cox proportional hazard model. RESULTS: We identified 358 patients with a mean follow-up of 27.3 months. The number of LN removed was not impacted by the type of surgical procedure. The number of LNs removed (<10 vs. ≥10, <12 vs. ≥12, and <15 vs. ≥15) did not impact OS or DFS. We found a significant difference in OS and DFS by pathologic response. The median and 5-year OS for patients with complete, partial, and no response was 65.6 months and 52.7 %, 29.7 months and 30.4 %, and 17.7 months and 25.4 % (p = 0.0002). However, the number of LN harvested did not impact OS and DFS when patients were stratified by pathologic response. MVA also revealed that the number of lymph nodes removed was not prognostic for OS or DFS. Higher age, higher stage, and less than a complete response were associated with a decreased OS. Higher stage and less than a complete response were prognostic for worse DFS. CONCLUSIONS: The number of LNs harvested during esophagectomy does not impact survival after nCRT. Stage and pathologic response continue to be the strongest prognostic factors for survival in esophageal cancer after nCRT.
  Annals of Surgical Oncology 04/2013;
• Article: Staging Stage IV Colorectal Cancer.

  Michael D'Angelica
  Annals of Surgical Oncology 04/2013;
• Article: Does Hürthle Cell Carcinoma of the Thyroid Have a Poorer Prognosis than Ordinary Follicular Thyroid Carcinoma?

  Kiminori Sugino, Kaori Kameyama, Koichi Ito, Mitsuji Nagahama, Wataru Kitagawa, Hiroshi Shibuya, Keiko Ohkuwa, Takashi Uruno, Junko Akaishi, Akifumi Suzuki, Chie Masaki, Kunihiko Ito
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  ABSTRACT: BACKGROUND: Hürthle cell carcinoma (HCC) is a rare form of thyroid carcinoma and is considered an oxyphilic variant of follicular thyroid carcinoma. However, little is known about its biological characteristics or clinical behavior. We conducted a retrospective study to determine whether the prognosis of HCC differs from that of ordinary follicular thyroid carcinoma (OFC). METHODS: The subjects were the 558 patients with follicular thyroid carcinoma who underwent initial surgery at our institution between 1989 and 2010 and consisted of 73 patients with HCC and 485 patients with OFC. There were 410 females and 148 males, and their median age was 51 years. A univariate analysis was conducted in relation to cumulative cause-specific survival (CSS) according to the Kaplan-Meier method for the following variables: age at the time of initial surgery, gender, tumor size, invasiveness, distant metastasis at presentation, and histological type (HCC vs OFC). Differences between groups were analyzed for significance by the log-rank test. Multivariate analysis was performed by using the Cox proportional hazard model. RESULTS: A total of 4 patients (5.5 %) in the HCC group had distant metastasis compared with 106 patients (21.9 %) in the OFC group. Significant factors in relation to CSS in the univariate analyses were age, tumor size, and invasiveness, but there were no significant differences between the HCC group and the OFC group. Multivariate analysis showed that age, tumor size, and distant metastasis at presentation were significant factors. CONCLUSIONS: HCC does not have a poorer prognosis than OFC.
  Annals of Surgical Oncology 04/2013;
• Article: Does Postoperative Complication Have a Negative Impact on Long-Term Outcomes Following Hepatic Resection for Colorectal Liver Metastasis?: A Meta-Analysis.

  Akihisa Matsuda, Satoshi Matsumoto, Tomoko Seya, Takeshi Matsutani, Taro Kishi, Kimiyoshi Yokoi, Ping Wang, Eiji Uchida
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  ABSTRACT: BACKGROUND: The negative impact of postoperative complications (POCs) on long-term outcomes is well documented for several cancer surgeries, but conclusive evidence has yet to be provided on the influence of POCs on long-term oncological outcomes after hepatic resection for colorectal liver metastasis (CRLM). METHODS: Studies published through February 2012 evaluating the oncological impact of POCs after hepatectomy for CRLM were identified by an electronic literature search. Finally, 4 studies were identified and included in the meta-analysis. The main outcome measures were 5-year disease-free survival (DFS) and overall survival (OS). A meta-analysis was performed using the DerSimonian-Laird random-effects models to compute odds ratio (OR) along with 95 % confidence intervals (95 % CI). RESULTS: The outcomes of 2,280 patients were studied. Meta-analysis of 5-year DFS data extracted from three studies demonstrated a significant reduction in 5-year DFS after POCs, with an OR of 1.98 (95 % CI = 1.33-2.96; P = .0008). Meta-analysis of 5-year OS data extracted from four studies demonstrated a significant reduction in 5-year OS after POCs, with an OR of 1.68 (95 % CI = 1.25-2.27; P = .0006). No differences between study heterogeneity were observed in either the DFS or the OS analyses. CONCLUSIONS: This study provides persuasive evidence that POCs following hepatic resection for CRLM have significant adverse oncological outcomes. These findings emphasize the need for meticulous surgical technique and careful perioperative management to minimize POCs.
  Annals of Surgical Oncology 04/2013;
• Article: Preoperative Plasma Hyperfibrinogenemia is Predictive of Poor Prognosis in Patients with Nonmetastatic Colon Cancer.

  Hae-Jung Son, Ji Won Park, Hee Jin Chang, Dae Yong Kim, Byung Chang Kim, Sun Young Kim, Sung Chan Park, Hyo Seong Choi, Jae Hwan Oh
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  ABSTRACT: BACKGROUND: The outcomes of colorectal cancer are determined by host factors, including systemic inflammation. The purpose of this study was to evaluate the prognostic significance of fibrinogen and inflammation-based scores, as markers of the inflammatory response, in colon cancer. METHODS: We retrospectively reviewed the medical records of patients with nonmetastatic colon cancer who underwent curative resection between January 2005 and December 2007. Fibrinogen, albumin, C-reactive protein, neutrophil, lymphocyte, and platelet counts were measured at the time of diagnosis. Correlations between preoperative plasma fibrinogen levels and clinicopathologic characteristics were analyzed. Univariate and multivariate survival analyses were performed to identify factors associated with disease-free and overall survival. RESULTS: A total of 624 patients who underwent curative resection for colon cancer were eligible for this study. Mean preoperative plasma fibrinogen levels were 325.24 ± 88.19 mg/dl. Higher preoperative plasma fibrinogen levels were associated with sex (male), old age, poorly/mucinous differentiated tumor, advanced tumor stage, elevated carcinoembryonic antigen (CEA) levels, higher modified Glasgow Prognostic Score, and higher neutrophil:lymphocyte and platelet:lymphocyte ratios. In multivariate analysis, elevated plasma fibrinogen level [disease-free survival: hazard ratio (HR) 1.999, 95 % confidence interval (95 % CI) 1.081-3.695, P = .027; overall survival: HR 3.138, 95 % CI 1.077-9.139, P = .036], advanced tumor stage, and higher CEA levels were independently associated with worse disease-free survival and overall survival. None of the inflammation-based scores were significantly associated with survival. CONCLUSIONS: Fibrinogen as one of inflammatory markers may be considered a possible prognostic marker in colon cancer.
  Annals of Surgical Oncology 04/2013;