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ABSTRACT: The goal of this study was to characterize the association of age with postoperative mortality and need for transitional care following hepatectomy for liver metastases.
A retrospective cohort study using the Nationwide Inpatient Sample (2005-2008) was performed. Patients undergoing hepatectomy for liver metastases were categorized by age as: Young (aged <65 years); Old (aged 65-74 years), and Oldest (aged ≥75 years). Multivariate logistic regression analyses were performed to identify predictors of in-hospital mortality and need for transitional care (non-home discharge).
A total of 4026 patients were identified; 36.6% (n = 1475) were elderly (aged ≥65 years). Rates of in-hospital mortality and non-home discharge increased with advancing age group [1.3% vs. 2.2% vs. 3.3% (P = 0.005) and 2.1% vs. 6.1% vs. 18.3% (P < 0.001), respectively]. Independent predictors of in-hospital mortality were age within the Oldest category [odds ratio (OR) 2.21, 95% confidence interval (CI) 1.19-4.12] and a Deyo Comorbidity Index score of ≥3 (OR 6.95, 95% CI 3.55-13.60). Independent predictors for need for transitional care were age within the Old group (OR 2.44, 95% CI 1.66-3.58), age within the Oldest group (OR 8.48, 95% CI 5.87-12.24), a Deyo score of 1 (OR 2.00, 95% CI 1.40-2.85), a Deyo score of 2 (OR 4.70, 95% CI 2.93-7.56), a Deyo score of ≥3 (OR 6.41, 95% CI 3.67-11.20), and female gender (OR 1.56, 95% CI 1.15-2.11).
Although increasing age was associated with higher risk for in-hospital mortality, the absolute risk was low and within accepted ranges, and comorbidity was the primary driver of mortality. Conversely, need for transitional care was significantly more common in elderly patients. Therefore, liver resection for metastases is safe in well-selected elderly patients, although consideration should be made for potential transitional care needs.
HPB 12/2012; 14(12):863-70. · 1.60 Impact Factor
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ABSTRACT: Radical rectal resection with total mesorectal excision is the current standard of care for the operative treatment of rectal cancer. Local excision is an acceptable alternative in selected patients with early disease (T(is)0-T(1)) and low-risk features, in whom radical resection may be associated with unacceptably high morbidity. With recent data demonstrating favorable results in well-selected patients, the role of local excision for rectal cancer is expanding.1 (,) 2 Transanal endoscopic microsurgery (TEM), which requires the use of an operating anoscope, has been used for the local excision of mid-upper rectal tumors. We describe an alternative approach to TEM for rectal cancer.
We present a stepwise technique for TEM using a single-incision laparoscopic (SILS) port. The patient is a 64 year-old male with a right anterolateral rectal polyp 7 cm from the anal verge, which on snare polypectomy demonstrated in-situ carcinoma with positive margins. Endoscopic ultrasound demonstrated uT(1) disease with no lymphadenopathy. He opted for local excision and underwent TEM. Our stepwise approach includes: (1) delineation of excision margins, (2) full thickness incision of the rectal wall, (3) circumferential dissection, and full thickness excision, and (4) suture repair.
The procedure was performed without intraoperative or postoperative complications. Final pathology revealed in-situ carcinoma with widely negative margins. At 1- and 3-week follow-up visits, the patient was pain free with normal bowel activity and no rectal bleeding or genitourinary dysfunction.
TEM using a SILS port is an effective technique for the local excision of mid-upper rectal cancer in well-selected patients.
Annals of Surgical Oncology 04/2012; 19(9):2859. · 4.17 Impact Factor
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ABSTRACT: Laparoscopic-assisted (LA) colorectal resections have improved short-term outcomes compared with open resections. Lack of tactile feedback, though, has led to lengthy operations and high conversion rates with attendant adverse effects on patients. Hand-assisted laparoscopy (HAL), in contrast, provides tactile feedback while still being minimally invasive. We hypothesize that HAL compared with LA for colorectal cancer resections will be associated with lower conversion rates and decreased operative times, without compromising the advantages of laparoscopy.
We performed a retrospective case-matched study of patients undergoing LA or HAL colorectal cancer resections from 2002 to 2010, using a prospectively maintained colorectal cancer database at a Veterans Affairs Medical Center. Short-term outcomes analyzed (using the Wilcoxon signed rank and McNemar's tests) included operative and perioperative variables and surrogate markers of adequacy of oncologic care.
Forty-seven LA patients were matched 1:1 by age and resection with 47 HAL patients. Patients in the HAL group had significantly lower blood loss (100 versus 150 cc, P = 0.04), operative times (206 versus 252 min, P = 0.002), and conversion rates (6% versus 38%, P < 0.0005). They also spent fewer days in the intensive care unit (0 versus 1, P = 0.004) and had quicker return of flatus (3 versus 4 d, P = 0.03). HAL resulted in more lymph nodes resected (21 versus 15, P = 0.03) and a more adequate lymph node harvest (98% versus 77%, P = 0.01).
HAL is associated with improved operative efficiency, conversion rates, and lymphadenectomy as compared with LA colorectal cancer resections. HAL should be considered in the management of colorectal cancer patients.
Journal of Surgical Research 03/2012; 177(2):e53-8. · 2.25 Impact Factor
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ABSTRACT: Cirrhosis is a risk factor for postoperative morbidity and mortality after general surgical procedures. However, the impact of cirrhosis on outcomes of surgical resection for gastrointestinal (GI) malignancies has not been described. The authors' objective was to characterize early postoperative and transitional outcomes in cirrhotic patients undergoing GI cancer surgery.
Query of the National Inpatient Sample Database (2005-2008) identified 106,729 patients who underwent resection for GI malignancy; 1479 (1.4%) had cirrhosis. The association of cirrhosis with postoperative outcomes was examined. The primary outcome measure was in-hospital mortality. Secondary outcomes included length-of-stay (LOS) and discharge to long-term care facility (LTCF).
Cirrhotic patients had higher risk of in-hospital mortality (8.9% vs 2.8%, P < .001), longer LOS (11.5 ± 0.26 vs 10.0 ± 0.03 days, P < .001), and higher rate of discharge to LTCF (19.0% vs 15.7%, P < .001). Mortality was highest in patients with moderate to severe liver dysfunction (21.5% vs 6.5%, P < .001). On multivariate analysis, cirrhosis was an independent predictor of in-hospital mortality (odds ratio [OR], 3.0; 95% confidence interval [CI] 2.5-3.7) and nonhome discharge (OR, 1.7; 95% CI, 1.4-2.0). In cirrhotic patients, moderate to severe liver dysfunction was the only independent predictor of in-hospital mortality (OR, 4.03; 95% CI, 2.7-5.9), but did not predict discharge disposition.
Resection of GI malignancy in cirrhotics is associated with poor early postoperative and transitional outcomes, with severity of liver disease being the primary determinant of postoperative mortality. These data suggest that GI cancer operations can be performed safely in well-selected cirrhotic patients with mild liver dysfunction.
Cancer 12/2011; 118(14):3494-500. · 4.77 Impact Factor
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ABSTRACT: To identify cancer-specific predictors of postoperative surgical site infection (SSI), and to develop a risk-stratification prognostic tool and compare its performance with traditional measures.
The incidence and risk factors for SSI in cancer patients are unknown; current risk-stratification tools are not cancer-specific.
A prospective cohort study of patients undergoing elective operations (n = 503) at a tertiary cancer center was conducted. SSI was assessed using postdischarge active surveillance. Multivariate logistic regression analyses were performed to identify predictors of SSI, and β-coefficients were used to create a scoring system. The sum of these was used to create a Risk of Surgical Site Infection in Cancer (RSSIC) score. The RSSIC was validated using bootstrapping techniques, and its discrimination was compared with the National Nosocomial Infection Surveillance (NNIS) risk index.
The 30-day SSI incidence was 24%. Significant predictors of SSI included preoperative chemotherapy (OR = 1.94 [95% CI, 1.16-3.25]), clean-contaminated wounds (OR = 2.1 [95% CI, 1.24-3.55]), operative time ≥2 hours (OR = 1.75 [95% CI, 1.01-3.04]) and ≥4 hours (OR = 2.24 [95% CI, 1.22-4.1]), and surgical site: groin (OR = 4.65 [95% CI, 1.69-12.83]), and head/neck (OR = 0.12 [95% CI, 0.02-0.89]). The RSSIC score stratified patients into 4 risk strata for SSI. The performance of this score exceeded that of the NNIS score (AUC = 0.70 vs. 0.63, respectively; P = 0.01).
SSIs are common following cancer surgery. Preoperative chemotherapy, in addition to other common risk factors, was identified as a significant predictor for SSI in cancer patients. The RSSIC improves risk-stratification of cancer patients and identifies those that may benefit from more aggressive or novel preventive strategies.
Annals of surgery 12/2011; 255(1):134-9. · 7.90 Impact Factor
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ABSTRACT: Minimally invasive surgery (MIS) techniques are beneficial compared with open techniques. There is a paucity of data of the potential advantages of MIS in colon cancer surgery for veterans. Therefore, we hypothesize that use of MIS in colon cancer resections in a Veterans Affairs Medical Center will lead to improved short-term outcomes without compromising oncologic outcomes.
A retrospective analysis of a prospectively maintained database was performed. We compared surgical, short-term, and oncologic outcomes in MIS versus open surgery.
MIS patients had significantly less blood loss, surgical time, days to return of bowel function, and hospital and intensive care unit stays. Also, they had a greater and more adequate lymphadenectomy, and were less likely to experience a postoperative complication. Survival analyses showed no difference in overall and disease-free survival.
The use of MIS in colon cancer leads to improved short-term outcomes and similar oncologic outcomes when compared with open surgery.
American journal of surgery 09/2011; 202(5):528-31. · 2.36 Impact Factor
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ABSTRACT: The ability to identify patients with colorectal cancer (CRC) liver metastasis (LM) using administrative data is unknown. The goals of this study were to evaluate whether administrative data can accurately identify patients with CRCLM and to develop a diagnostic algorithm capable of identifying such patients.
A retrospective cohort study was conducted to validate the diagnostic and procedural codes found in administrative databases of the Veterans Administration (VA) system. CRC patients evaluated at a major VA center were identified (1997-2008, n = 1671) and classified as having liver-specific ICD-9 and/or CPT codes. The presence of CRCLM was verified by primary chart abstraction in the study sample. Contingency tables were created and the positive predictive value (PPV) for CRCLM was calculated for each candidate administrative code. A multivariate logistic-regression model was used to identify independent predictors (codes) of CRCLM, which were used to develop a diagnostic algorithm. Validity of the algorithm was determined by discrimination (c-statistic) of the model and PPV of the algorithm.
Multivariate logistic regression identified ICD-9 diagnosis codes 155.2 (OR 9.7 [95% CI 2.5-38.4]) and 197.7 (84.6 [52.9-135.3]), and procedure code 50.22 (5.9 [1.3-25.5]) as independent predictors of CRCLM diagnosis. The model's discrimination was 0.89. The diagnostic algorithm, defined as the presence of any of these codes, had a PPV of 87%.
VA administrative databases reliably identify patients with CRCLM. This diagnostic algorithm is highly predictive of CRCLM diagnosis and can be used for research studies evaluating population-level features of this disease within the VA system.
Journal of Surgical Research 08/2011; 176(1):141-6. · 2.25 Impact Factor
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ABSTRACT: We sought to evaluate population-based temporal trends in perioperative management, as well as short- and long-term outcomes associated with the operative management of colorectal liver metastasis (CRLM).
Using Surveillance, Epidemiology and End Results-Medicare linked data, we identified 2,121 patients with operatively managed CRLM between 1991 and 2006. Clinicopathologic data, trends in operative management, and survival were examined.
Preoperative evaluation included computed tomography (CT; 66%), magnetic resonance imaging (MRI; 5%), and positron emission tomography (PET; 2%) with a temporal increase in the use of all 3 modalities over time (all P < .05). Patients undergoing hepatectomy only (n = 1,267; 60%) decreased over time, whereas the use of ablation alone (n = 668; 32%) and combined resection plus ablation (n = 186; 9%) increased (all P < .05). The use of both preoperative (10% to 16%) and adjuvant chemotherapy (35% to 47%) increased over time (P < .05). There was a marked temporal increase in patient comorbidities (>3 comorbidities: 1991-1995, 3%; 2003-2006, 12%; P < .001); however, perioperative complications (63%) and 30-day mortality (3%) did not change over time (both P > .05); 90-day mortality decreased from 9% to 7% over the study period (P = .007). Overall the 1-, 3-, and 5-year survivals were 74%, 42%, and 28% with no improvement over time (P = .19). On multivariate analysis, synchronous disease (hazard ratio [HR], 1.7) and use of ablation alone (HR, 1.2) were associated independently with a worse survival (both P < .05).
Most patients were evaluated with CT; PET was employed rarely. Although there was a temporal increase in chemotherapy utilization, only one half of patients received perioperative chemotherapy. Mortality associated with hepatic operations was low, but morbidity remained high with no temporal change despite an increased number of patient medical comorbidities.
Surgery 08/2011; 150(2):204-16. · 3.10 Impact Factor
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ABSTRACT: Neoadjuvant therapy has been used to improve survival in operable pancreatic cancer. The authors' objective was to compare long-term outcomes in patients receiving neoadjuvant versus adjuvant therapy for resectable pancreatic adenocarcinoma.
The California Cancer Surveillance Program for Los Angeles County retrospectively identified 458 patients with nonmetastatic pancreatic adenocarcinoma who underwent definitive pancreatic resection and received systemic chemotherapy between 1987 and 2006. The cohort was grouped by timing of systemic therapy-neoadjuvant or adjuvant. Clinicopathologic characteristics and overall survival were compared. Multivariate Cox regression analysis was used to determine the benefit of neoadjuvant therapy, independent of other significant factors.
Of the 458 patients, 39 (8.5%) received neoadjuvant therapy, and 419 (91.5%) received adjuvant therapy. There was a significantly lower rate of lymph node positivity in the neoadjuvant group (45% vs 65%; P = .011) despite a higher rate of extrapancreatic tumor extension. On Kaplan-Meier analysis, the neoadjuvant group had significantly better overall survival compared with the adjuvant group (median survival, 34 vs 19 months; P = .003). Overall survival was also improved in the neoadjuvant therapy patients with extrapancreatic disease (median survival, 31 vs 19 months; P = .018). On multivariate Cox regression analysis, neoadjuvant therapy was an independent predictor of improved survival (hazard ratio, 0.57; 95% confidence interval, 0.37-0.89; P = .013).
This is the first population-based study to compare neoadjuvant versus adjuvant treatment strategies in resectable pancreatic cancer. Neoadjuvant therapy is associated with a lower rate of lymph node positivity and improved overall survival and should be considered an acceptable alternative to the surgery-first paradigm in operable pancreatic cancer.
Cancer 05/2011; 117(10):2044-9. · 4.77 Impact Factor
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ABSTRACT: The Clinical Outcomes of Surgical Therapy Group (COST) trial published in 2004 demonstrated that minimally invasive surgery (MIS) for colorectal cancer provided equivalent oncologic results and better short-term outcomes when compared to open surgery. Before this, MIS comprised approximately 3% of colorectal cancer cases. We hypothesized that there would be a dramatic increase in the use of MIS for colon cancer after this publication.
The National Inpatient Sample database was used to retrospectively review MIS and open colon resections from 2005 through 2007. ICD-9-specific procedure codes were used to identify open and MIS colon cancer resections. Statistical analyses performed included Pearson χ(2) tests and dependent t tests, and Cramer's V was used to measure the strength of association.
A total of 240,446 colon resections were performed between 2005 and 2007. The percentage of resections performed laparoscopically increased from 4.7% in 2005 to 6.7% in 2007 for colon cancer and remained relatively unchanged for benign disease (25.2% in 2005 vs. 27.4% in 2007, P < 0.007). Patients undergoing laparoscopic colectomy were younger, had lower comorbidity scores, had lower rates of complications (20.1 vs. 25.1%, P < 0.001), had shorter lengths of stay (7.2 vs. 9.6 days, P < 0.001), and had lower mortality (1.5 vs. 3.0%, P < 0.001). Furthermore, when evaluating adoption trends, urban teaching hospitals adopted laparoscopy more rapidly than rural nonteaching centers.
Adoption of MIS for the treatment of colorectal cancer has been slow. Additional studies to evaluate barriers in the adoption of MIS for colon cancer resection are warranted.
Annals of Surgical Oncology 01/2011; 18(5):1412-8. · 4.17 Impact Factor
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ABSTRACT: The objective of this study was to evaluate the establishment of a minimally invasive surgery program on the cost of care at the investigators' institution. It was hypothesized that a minimally invasive surgery program would decrease overall inpatient treatment costs for veterans with colon cancer.
All patients who were admitted for colon cancer surgery in fiscal year 2009 were included in this study. The main outcome measures were inpatient treatment cost and length of stay.
The median inpatient cost incurred in the laparoscopic colectomy group was 33% ($6,000, P < .01) less than the in open colectomy group. The median length of hospital stay and operative time were also shorter by 31% (3.5 days, P < .05) and 37% (108 minutes, P < .01), respectively, in the laparoscopic colectomy group.
In this study, colon cancer patients who underwent minimally invasive surgery for colon cancer experienced shorter hospital stay and operative times, which resulted in lower overall inpatient treatment cost.
American journal of surgery 11/2010; 200(5):632-5. · 2.36 Impact Factor
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ABSTRACT: Inequalities in access to care have been hypothesized to be the cause of ethnic disparities in colon cancer. The aim of this study was to determine if ethnic disparities in the outcomes of colon cancer patients exist in a system with equal access.
A review of 214 consecutive patients who underwent elective colon resection for adenocarcinoma at 1 institution was conducted. Statistical analysis was performed using independent t tests and χ² tests. The Kaplan-Meier method was used for survival estimates.
Of the 214 patients who underwent colon cancer resection, 38% (n = 82) were African American, while 62% (n = 132) were Caucasian. There was no significant difference in the stage of disease at presentation and between the mean times from diagnosis to surgical resection for African American and Caucasian patients. Also, there were no differences in survival.
There does not appear to be a disparity in outcomes for colon cancer patients where equal access to medical care exists. This is based on findings of equal stages at presentation, time to referral, and survival among groups.
American journal of surgery 11/2010; 200(5):636-9. · 2.36 Impact Factor
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ABSTRACT: Aging of the population - global graying - is occurring rapidly, with significant effects on epidemiology, treatment and outcomes for cancer patients. In colorectal cancer, outcomes for the elderly are worse than those for younger patients, partially driven by treatment disparities between the two groups. Nonetheless, standard-of-care treatment for the elderly results in equivalent long-term outcomes to those observed in the younger population; and available data support the use of aggressive surgery and adjuvant therapies in well-selected patients. Data evaluating epidemiology, treatment patterns and outcomes in elderly patients with colorectal cancer liver metastasis are lacking. Liver resection offers the only curative approach, but it is rarely offered to older adults. Current data support the use of hepatectomy for well-selected elderly colorectal cancer patients with liver metastasis; however, this and other evolving therapies need to be assessed in the elderly to better define their role, indications, safety and outcomes.
Critical reviews in oncology/hematology 03/2010; 77(2):100-8. · 5.27 Impact Factor
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ABSTRACT: Necrotizing soft tissue infections (NSTIs) are associated with a high mortality rate; however, there is no uniform way to categorize the severity of this disease early in its course. The goal of this study was to develop a clinical score based on data available at the time of initial assessment to aid in stratifying patients according to their risk of death.
A cohort of all 350 patients admitted with NSTI to two institutions over a nine-year period was examined retrospectively. Using random split sampling, two datasets were created: Prediction (PD) and validation (VD). Multivariable stepwise regression analysis of the PD identified independent predictors of death using data available at the time of admission. Model performance was evaluated for accuracy, discrimination, and calibration. A clinical score to predict death was created, and using the Trauma and Injury Severity Score (TRISS) methodology, the score was validated on the VD (z-statistic).
Six admission parameters independently predicted death: Age > 50 years, heart rate > 110 beats/min, temperature <36 degrees C, white blood cell count > 40,000/mcL, serum creatinine concentration > 1.5 mg/dL, and hematocrit > 50%. The accuracy of this model was 86.8%; the area under the receiver-operating characteristic curve was 0.81, and the Hosmer-Lemeshow statistic was 11.8. Additionally, the score had excellent performance in evaluation on the VD (z-score/statistic 0.23 to - 0.83).
A clinical score that categorizes patients with NSTI according to the risk of death was created. It uses simple variables, all available at the time of first assessment. It stratifies patients according to disease severity and can guide the use of aggressive or novel therapeutic strategies and selection of patients for clinical trials.
Surgical Infections 12/2009; 10(6):517-22. · 1.80 Impact Factor
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Guy Lahat MD,
John E. Madewell MD,
Daniel A. Anaya MD,
Wei Qiao MS,
Daniel Tuvin MD,
Robert S. Benjamin MD,
Dina C. Lev MD,
PhD Ralphael E. Pollock MD,
Guy Lahat,
John E. Madewell, Daniel A. Anaya,
Wei Qiao,
Daniel Tuvin,
Robert S. Benjamin,
Dina C. Lev,
Ralphael E. Pollock
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ABSTRACT: BACKGROUND:Well differentiated (WD) and dedifferentiated (DD) retroperitoneal liposarcoma (RPLS) have distinct biologic behaviors. Consequently, the therapeutic approaches for these tumors differ and mandate an accurate preoperative diagnosis. The authors of this report evaluated whether computed tomography (CT) can be used to differentiate between WD and DD RPLS.METHODS:Imaging studies (CT, magnetic resonance imaging, and positron emission tomography-CT) from 78 patients with RPLS who underwent surgery at the University of Texas M. D. Anderson Cancer Center (UTMDACC) between 2001 and 2007 were reviewed by a senior bone and soft tissue sarcoma radiologist who was blinded to the final histopathologic diagnosis. A focal nodular/water density area within an RPLS was interpreted as a marker suggestive of DD. Correlations between imaging diagnosis, histology, and clinical outcome were analyzed.RESULTS:The study radiologist identified 60 RPLS as DD and 17 RPLS as WD. A radiologic diagnosis of a WD was correlated with preoperative biopsy and postoperative histology in all patients (100%). Focal nodular/water density was a very sensitive marker of DD (97.8%); however, it had relatively low specificity (51.5%). Sixteen WD RPLS (48.5%) contained focal nodular/water density areas, leading to their misdiagnosis as DD; half of those tumors had hypercellular WD. Of 78 preoperative biopsies, 22 (28.2%) were performed at UTMDACC under CT guidance. Preoperative histologic diagnoses obtained from 12 biopsies derived from focal nodular/water density areas were confirmed as unchanged on final pathology; whereas, in 50% of biopsies that were not taken from a suspicious area, DD histology was misdiagnosed as WD.CONCLUSIONS:When CT features are suggestive of WD, no further diagnostic tests are needed for tumor characterization. Moreover, CT can accurately identify most DD, thereby rendering their under-treatment unlikely; however, a CT-guided biopsy is needed to differentiate between DD and WD RPLS that contain focal nodular/water density areas, thereby avoiding their over treatment. Cancer 2009. © 2009 American Cancer Society.
Cancer 02/2009; 115(5):1081 - 1090. · 4.77 Impact Factor
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02/2009: pages 39-49;
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ABSTRACT: Well differentiated (WD) and dedifferentiated (DD) retroperitoneal liposarcoma (RPLS) have distinct biologic behaviors. Consequently, the therapeutic approaches for these tumors differ and mandate an accurate preoperative diagnosis. The authors of this report evaluated whether computed tomography (CT) can be used to differentiate between WD and DD RPLS.
Imaging studies (CT, magnetic resonance imaging, and positron emission tomography-CT) from 78 patients with RPLS who underwent surgery at the University of Texas M. D. Anderson Cancer Center (UTMDACC) between 2001 and 2007 were reviewed by a senior bone and soft tissue sarcoma radiologist who was blinded to the final histopathologic diagnosis. A focal nodular/water density area within an RPLS was interpreted as a marker suggestive of DD. Correlations between imaging diagnosis, histology, and clinical outcome were analyzed.
The study radiologist identified 60 RPLS as DD and 17 RPLS as WD. A radiologic diagnosis of a WD was correlated with preoperative biopsy and postoperative histology in all patients (100%). Focal nodular/water density was a very sensitive marker of DD (97.8%); however, it had relatively low specificity (51.5%). Sixteen WD RPLS (48.5%) contained focal nodular/water density areas, leading to their misdiagnosis as DD; half of those tumors had hypercellular WD. Of 78 preoperative biopsies, 22 (28.2%) were performed at UTMDACC under CT guidance. Preoperative histologic diagnoses obtained from 12 biopsies derived from focal nodular/water density areas were confirmed as unchanged on final pathology; whereas, in 50% of biopsies that were not taken from a suspicious area, DD histology was misdiagnosed as WD.
When CT features are suggestive of WD, no further diagnostic tests are needed for tumor characterization. Moreover, CT can accurately identify most DD, thereby rendering their under-treatment unlikely; however, a CT-guided biopsy is needed to differentiate between DD and WD RPLS that contain focal nodular/water density areas, thereby avoiding their over treatment.
Cancer 02/2009; 115(5):1081-90. · 4.77 Impact Factor
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ABSTRACT: Head and neck melanoma often approaches critical structures. Therefore, excision is often limited, leading to positive margins, and increased local recurrence. Immediate reconstruction carries concern for rearrangement or concealment of cancerous tissues. Therefore, reconstruction is often delayed until confirming negative margins on permanent pathology. Our purpose is to identify variables associated with a positive margin and establish criteria for reconstruction timing. We reviewed 117 consecutive patients who underwent wide local excision of head and neck melanoma. Reconstruction was immediate for 107 and delayed for 10. Six percent of patients had a positive margin after wide local excision with no difference in incidence between immediate and delayed reconstruction (P = 0.11). Tumor characteristics associated with a positive margin were locally recurrent, ulcerated, and T4 tumors (P < 0.05); and delayed reconstruction should be considered in these circumstances. Immediate reconstruction is safe for the majority of head and neck melanoma and should be based on knowledge of tumor characteristics.
Annals of plastic surgery 02/2009; 62(2):144-8. · 1.29 Impact Factor
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ABSTRACT: To evaluate the significance of multifocality on overall survival (OS) in patients with retroperitoneal sarcoma (RPS) and establish a data-derived, prognostically and therapeutically useful definition of sarcomatosis.
The incidence, clinical features, and prognostic significance of multifocality in RPS is unknown. No current standardized definition for sarcomatosis is available.
We conducted a retrospective analysis of 393 patients with primary or recurrent nonmetastatic RPS treated at a comprehensive cancer center between 1996 and 2006. Baseline and treatment variables were compared in patients with unifocal and multifocal disease. A multivariate model was used to evaluate the association of multifocality and OS and identify additional prognostic factors in patients with multifocal disease.
The median follow-up time for all patients was 69 months; 79 patients (20%) presented with multifocal disease. The 5-year OS rate was less in the multifocal group compared with the unifocal group (31% vs. 60%, respectively; P < 0.0001). After multivariate analysis, multifocality remained an independent predictor of worse OS {hazard ratio (HR) 1.7 (95% confidence interval (CI), 1.2-2.5); P = 0.004}. Additionally, patients with more tumors had significantly worse prognosis (>7 tumors, HR 2.1 (95% CI, 1.1-3.9); P = 0.03), with a 5-year OS rate of 7%.
Multifocal RPS is associated with worse OS in patients with either primary or recurrent RPS; Patients with >7 tumors had the worst prognosis. This criterion can be used to define sarcomatosis, thereby identifying patients whose survival will ultimately depend on effective systemic therapy.
Annals of surgery 01/2009; 249(1):137-42. · 7.90 Impact Factor
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ABSTRACT: Retroperitoneal sarcomas (RPS) represent approximately 15% of all soft tissue sarcomas (STS). Clinical and prognostic features as well as oncologic outcomes are well known in this group of patients. Post-operative margin status specifically, is a major predictor of local and distant recurrence and survival. The purpose of this review is to define complete resection as it applies to RPS and evaluate its effect on future outcomes in these patients.
Journal of Surgical Oncology 01/2009; 98(8):607-10. · 2.10 Impact Factor
