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ABSTRACT: IMPORTANCE Although prospective randomized data are available to guide the multidisciplinary management of soft tissue sarcoma (STS) of the extremities, controversy exists regarding adjuvant chemotherapy and radiation therapy. OBJECTIVE To determine if clinical specialty introduces bias in recommendations for multimodality treatment of STS. DESIGN Electronic survey. SETTING Database of active members of the American Society of Clinical Oncology, the Society of Surgical Oncology, and the Connective Tissue Oncology Society. PARTICIPANTS Members of specialty oncology societies with an active interest in STS. EXPOSURE Physician specialty. MAIN OUTCOMES AND MEASURES Survey responses regarding the multidisciplinary management of STS were scored on a 5-point Likert scale and analyzed using analysis of variance. RESULTS The questionnaire was completed by 320 of 490 potential respondents (65%), including medical (18%), radiation (8%), orthopedic (22%), and surgical oncologists (45%). Respondents concurred on the use of radiation therapy for margins positive for tumor, for high-grade tumors, for improvement in local control, for tumors larger than 10 cm, and for tumors in close proximity to a neurovascular bundle. Respondents diverged on the use of radiation therapy for tumors 5 to 10 cm in size, for low-grade tumors, for radiation-associated STS, and for survival benefit. Only radiation oncologists felt that radiation therapy was underutilized as a treatment modality (mean [SEM] Likert scale score, 2.44 [0.12]; P < .001). There was agreement on the use of chemotherapy for synovial sarcoma, for high-grade tumors, for tumors larger than 10 cm, for patients younger than 50 years of age, and for survival benefit. Medical oncologists were more likely to recommend chemotherapy for margins positive for tumor (mean [SEM] score, 3.12 [0.12]; P = .03) and for improvement in local control (mean [SEM] score, 2.91 [0.12] P = .08). Surgical oncologists placed the least emphasis on chemotherapy in the overall treatment plan (mean [SEM] score, 2.60 [0.07]; P = .001). CONCLUSIONS AND RELEVANCE Specialty bias exists in adjuvant treatment recommendations for STS. This highlights the importance of multidisciplinary STS tumor boards and interdisciplinary care to facilitate consensus decision making for individual patients.
JAMA surgery. 03/2013;
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ABSTRACT: BACKGROUND: Although controversial, surgical resection for metastatic carcinoid tumors (MCTs) can potentially prolong survival. METHODS: Patients with MCTs were identified from the Surveillance, Epidemiology and End Results database. Patients undergoing surgery were compared to unresected patients. RESULTS: Surgery was performed in 33% of patients. Predictors of surgery included age <50 years (odds ratio [OR], 2.4), low grade (OR, 3.1), and the appendix (OR, 36.2) or small intestine (OR, 27.2) as the primary site. Predictors of adverse survival included high grade (hazard ratio, 2.4) and no surgery (hazard ratio, 2.5) or surgery on only primary or distant disease (hazard ratio, 1.5) compared with surgery for both. Survival at 5 years was 5% with no surgery, 28% with surgery on either site, and 46% with surgery at both sites (P < .001). CONCLUSIONS: Surgery for MCTs is more common in younger patients, those with low-grade disease, and those with small bowel or appendiceal primary tumors. Although selection bias cannot be excluded, these data lend support to "debulking" for MCT.
American journal of surgery 02/2013; · 2.36 Impact Factor
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ABSTRACT: BACKGROUND: Lymph lymph node metastasis from melanoma ≤0.50 mm (ultrathin) is an infrequent event. However, because many newly diagnosed melanomas are ultrathin, a significant proportion of patients who present with lymph node disease have an ultrathin melanoma. The authors hypothesized that ultrathin melanomas that present with lymph node metastasis represent biologically aggressive lesions with a worse prognosis. METHODS: The Surveillance, Epidemiology, and End Results registry data were queried to identify patients with cutaneous melanoma who presented with lymph node metastasis diagnosed between 1998 and 2008. Hazard ratios (HRs) from Cox proportional hazards regression models were used to compare disease-specific survival (DSS) between various tumor depths. RESULTS: In total, 6134 patients with lymph node-positive melanoma were identified and stratified according to tumor depth, including 588 (10%) with a tumor depth ≤0.50 mm, 519 (8%) with a tumor depth from 0.51 to 1.00 mm, 1669 (27%) with a tumor depth from 1.01 to 2.00 mm, 1871 (31%) with a tumor depth from 2.01 to 4.00 mm, and 1487 (24%) with a tumor depth >4.00 mm; and the respective 5-year DSS rates were 63%, 76%, 75%, 60%, and 43%. Multivariable analysis confirmed a similar trend in HRs for DSS: The HR was 1.00 for a tumor depth ≤0.50 mm (reference category) and 0.64 (P < .001), 0.65 (P < .001), 0.95 (P = .57), and 1.42 (P < .001) for tumor depths of 0.51 to 1.00 mm, 1.01 to 2.00 mm, 2.01 to 4.00 mm, and >4.00 mm, respectively. This association of tumor depth with DSS persisted for N1 and N2 disease but not for N3 disease. CONCLUSIONS: Ultrathin melanoma (≤0.50 mm) was identified as a marker of poor prognosis in the setting of lymph node metastasis. These results may improve recommendations for adjuvant therapy, surveillance protocols, and risk stratification for clinical trials. Cancer 2013;. © 2013 American Cancer Society.
Cancer 02/2013; · 4.77 Impact Factor
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ABSTRACT: BACKGROUND:: A body of research has found that patients who travel a significant distance to obtain medical treatment experience better outcomes, a phenomenon termed "distance bias." This study uses risk-adjusted surgical outcomes data to analyze distance bias in a population of patients treated surgically at a tertiary care institution. METHODS:: We used risk-adjusted surgical outcomes data from the National Surgical Quality Improvement Project at the Mayo Clinic to calculate observed and expected risk of a severe complication. Operations were stratified into quintiles based on the distance traveled by the patient. RESULTS:: The average age of patients in our cohort was 56.7 years, and 59.2% were female; patients traveled an average of 226 miles for treatment. Patients living closest to the Mayo Clinic (quintile 1) had lower observed and expected risks of a severe complication relative to patients in quintiles 2-5. Patients from quintile 1 had outcomes which were better than predicted [observed:expected risk ratio of 0.82 (range, 0.63-0.99)]. Patients traveling intermediate distances (quintile 2) had outcomes which were worse than predicted [observed:expected risk ratio of 1.18 (range, 1.00-1.42)]. Operations performed on patients from greater distances (quintiles 3-5) had an observed risk of severe complications which was similar to expected. DISCUSSION:: The phenomenon of distance bias which has previously been documented in medical and oncologic treatment is not demonstrated in this study. An opposite phenomenon may be more pertinent, where patients who are treated locally are less likely to have a severe complication and have outcomes which are better than predicted.
Medical care 10/2012; · 3.24 Impact Factor
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ABSTRACT: Excisional biopsy is currently recommended for atypical ductal hyperplasia (ADH) diagnosed on core needle breast biopsy (CNB), due to risk of upstaging to invasive or in situ carcinoma (DCIS). The study goal was to identify patients who may potentially forego excisional biopsy if the risk of upstaging is low.
We conducted a retrospective review of patients diagnosed with ADH on CNB who underwent excisional biopsy at one institution (5/2000-5/2011). We evaluated the upstaging rate and clinicopathologic factors associated with increased upstaging risk.
A total of 114 cases of ADH were diagnosed on CNB. The median patient age was 64 years. On mammography, a mass/density/area of distortion was present in 23 % of cases; calcifications were present in 77 %. Most biopsies (79 %) were performed stereotactically. Twenty lesions (18 %) were upstaged to infiltrating carcinoma (5 %) or DCIS (13 %). Residual ADH was present in 43 biopsies (38 %). On univariate analysis, significant variables associated with upstaging included age >50 years, a mass lesion on mammography, and shorter length of biopsy core (p < 0.05). No patient ≤50 years of age was upstaged. Three patients who were not upstaged (3 %) developed ipsilateral disease (2 DCIS and 1 infiltrating ductal carcinoma) at a median time of 37 months.
The rate of upstaging when ADH is diagnosed on CNB at our institution is 18 %, and routine excisional biopsy is currently recommended for all patients. However, patients <50 years old with focal atypia only and no residual calcifications postbiopsy may represent a low-risk group who could potentially avoid excisional biopsy.
Annals of Surgical Oncology 08/2012; 19(10):3264-9. · 4.17 Impact Factor
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ABSTRACT: ObjectivesSurgical therapy for invasive breast cancer includes breast conservation therapy (BCT), unilateral mastectomy (UM), or bilateral
mastectomy, including contralateral prophylactic mastectomy (CPM) with or without reconstruction (±R). The goal of this study
was to determine factors associated with CPM.
MethodsA breast cancer database collected from 2000 through 2008 was retrospectively reviewed. Treatment groups analyzed included
BCT, UM±R, and CPM±R. Variables were compared using ANOVA F-tests and chi-square tests. Multivariate analysis was performed
using logistic regression.
ResultsA total of 1,391 patients underwent surgery for invasive breast cancer: 69% BCT, 21% UM, and 10% bilateral mastectomy. Of
those undergoing bilateral mastectomy, 30% had bilateral cancer and were excluded from analysis. The rate of CPM increased
significantly from 0 to 20% (p<0.001), whereas the rate of UM remained relatively stable. Factors associated with CPM included younger age, significant
family history, genetic testing, positive BRCA gene mutation, and preoperative magnetic resonance imaging (MRI). Tumor characteristics
associated with CPM included positive axillary lymph node metastases and triple-negative disease (ER-/PR-/HER2 normal). Breast
reconstruction was more common among women who underwent CPM (p<0.001). On multivariate regression comparing BCT with CPM, younger age, larger tumors, multifocal disease, and MRI significantly
predicted CPM. Comparing UM with CPM, only age and genetic testing significantly predicted CPM.
ConclusionsThe rate of bilateral mastectomy for unilateral breast cancer is increasing. This is particularly true for younger patients
with strong family history. The availability of breast reconstruction may play a role and the effects of stage and multifocal
disease needs further exploration.
Annals of Surgical Oncology 04/2012; 17:330-337. · 4.17 Impact Factor
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ABSTRACT: Surgery is the cornerstone of potentially curative therapy for upper gastrointestinal cancer. We analyzed the patterns of treatment regarding the use of surgery for early-stage upper gastrointestinal cancer in the United States.
The Surveillance, Epidemiology, and End Research database was used to identify patients with cancer of the esophagus, stomach, pancreas, liver, gallbladder, biliary tract, or duodenum (2004-2007). Only patients with potentially resectable stage I and II disease were selected. The primary outcome measure was the use of curative intent surgery. The secondary outcomes were the predictors of surgery.
We identified 29,249 patients with a median age of 69 years. Only 54% of the patients underwent cancer-directed surgical resection, ranging from 28% for liver cancer to 89% for gallbladder cancer. The remaining patients underwent either local excision (8%) or no surgery (38%). Among the no surgery group, most patients (79%) were documented as "not being recommended for resection." The independent variables on multivariate analysis predictive of a nonoperative approach included black race, age older than 75 years, tumor size greater than 5 cm, and high poverty level (P < 0.001). Patients who did not undergo surgery had worse median and overall survival at 3 years than patients undergoing surgery (11 months versus 36 months and 14% versus 43%, respectively; P < 0.001).
Almost one half of patients with early-stage upper gastrointestinal cancer did not receive potentially curative surgery, with an adverse effect on overall survival. A combination of demographic, tumor, and socioeconomic factors were predictive of a lack of surgical resection.
Journal of Surgical Research 03/2012; 177(1):55-62. · 2.25 Impact Factor
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ABSTRACT: Obesity has been linked to many adverse health consequences, including breast cancer; however, the impact on clinical presentation, tumor characteristics, and survival outcomes has yet to be clearly defined.
Retrospective review of a prospectively collected database of patients treated at a single institution for invasive breast cancer from 2000-2008 comparing two groups: nonobese (body mass index of <30) and obese (body mass index of ≥30) patients. Continuous variables, categorical variables, and survival data were analyzed.
Of 1352 total patients, 76% were classified as nonobese and 24% were obese. When comparing age, obese patients presented less frequently than nonobese patients <50 years old (10% vs. 90%), and when comparing patients >50 years old (18% vs. 82%, P = 0.0019). Obese patients were more likely to present with disease detected by imaging when compared to nonobese patients (67% vs. 56%, P = 0.0006). Obese patients had larger tumors (1.7 cm vs. 1.4 cm, P < 0.001) and higher rates of lymph node (LN) metastases (31% vs. 25%, P = 0.026). On multivariate analysis, obesity was associated with nonpalpable tumors, larger tumors, a higher incidence of LN metastasis, lower incidence of Her2 positivity, lower incidence of multifocality, and less likely to undergo reconstruction after mastectomy.
Obese patients clinically present at older ages with mammographically detected breast cancer at more advanced stages than nonobese patients. Strategies to encourage screening among the obese patient population are important.
Annals of Surgical Oncology 03/2012; 19(9):3012-8. · 4.17 Impact Factor
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ABSTRACT: The recently published 7th edition of the American Joint Committee on Cancer (AJCC) TNM staging criteria for gastric adenocarcinoma contains important revisions to T and N classifications, as well as overall stage grouping. Our goal was to validate the new staging system using a cancer registry.
Retrospective review of gastric cancer patients from Surveillance, Epidemiology, and End Results (SEER) registry data (2004-2007). Patients were staged according to both 6th and 7th edition criteria, and 3-year disease-specific survival was compared.
Thirteen thousand five hundred forty-seven patients with gastric adenocarcinoma were identified with complete staging information. When using 7th edition criteria, there was an increase in the number of patients classified as stage III (23% vs. 13%), and a decrease in patients classified as stage IV (47% vs. 53%). Statistically significant differences in 3-year disease-specific survival were observed for all T and N categories and re-staging the same population according to the 7th edition criteria improved survival discrimination. Multivariate analysis revealed statistically significant differences in survival and linear progression of hazard ratios for each stage grouping.
The 7th edition AJCC staging criteria for gastric adenocarcinoma demonstrate better survival discrimination and risk stratification than previous criteria.
Journal of Gastrointestinal Surgery 01/2012; 16(1):53-61; discussion 61. · 2.83 Impact Factor
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ABSTRACT: Breast cancer screening recommendations are in flux. We reviewed the methods of detecting newly diagnosed breast neoplasms at our institution.
A retrospective review of patients stratified by age was performed to compare mammography with self- (SBE) and clinical (CBE) breast examination methods of cancer detection from 2005 to 2009.
We identified 782 patients. Patients aged <50 years were more likely to present with palpable disease (P < 0.001). Overall, 75% of patients had a mammogram within 24 months. There was a higher incidence of Tis tumors and lower incidence of T1 tumors if patients had mammography performed within 12 months versus 13-24 months (P < 0.01); tumor size, hormonal status, and lymph node (LN) status were comparable between these two groups. Patients diagnosed by SBE/CBE who had mammography performed within 12 months versus 13-24 months did not differ statistically according to tumor characteristics. In the screened cohort (mammography within 24 months), the majority of patients (64%) were diagnosed by mammography. Cancers detected by SBE/CBE were larger tumors (2.4 vs. 1.3 cm), higher grade, more frequently ER- (29 vs. 16%), triple-negative (21 vs. 10%), and lymph node-positive (39 vs. 18%; all P ≤ 0.01). There were no statistically significant differences in tumor size, T stage, or hormonal status in patients who had analog versus digital mammography.
Whereas the majority of patients had image-detected breast cancer, a significant number of image-screened patients presented with palpable disease, which were more aggressive cancers. Until imaging techniques are refined, SBE and CBE remain important for breast cancer diagnosis.
Annals of Surgical Oncology 12/2011; 19(5):1484-90. · 4.17 Impact Factor
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ABSTRACT: Patients are often concerned about the participation of junior trainees in their operative treatment. Breast-conserving therapy (BCT) for nonpalpable breast lesions requires the use of localization devices and carries a significant risk for positive margins of excision. It was therefore hypothesized that the participation of junior residents in BCT operations for nonpalpable breast lesions could result in an increased rate of positive margins of excision.
Retrospective analysis of a prospective database of all patients with nonpalpable tumors who underwent BCT from August 1999 to August 2009 was performed. Patient and tumor characteristics and factors involved in resection were analyzed. A ≥2-mm margin of normal breast tissue beyond tumor was considered an adequate margin. Chi-square analysis and Student's t test were performed to determine relationships between independent variables and margin status.
Of 308 BCT procedures for nonpalpable tumors, 241 (78%) were performed by attending surgeons and junior residents (group 1) and 67 (22%) by attending surgeons without resident assistance (group 2). The operations for group 1 took significantly longer than the operations for group 2 (mean, 130 vs 116 min, P = .006). Intraoperative reexcision of margins was performed for 37% of group 1 patients and 31% of group 2 patients (P = .249), and reoperation for inadequate margins was performed in 11% of group 1 patients and 13% of group 2 patients (P = .361).
Junior resident participation in BCT procedures was not associated with higher rates of inadequate margins of excision. Patients can be reassured that junior resident involvement in their BCT operations is safe and effective.
American journal of surgery 12/2011; 202(6):654-7; discussion 657-8. · 2.36 Impact Factor
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Geneviève L Egnatios,
Amylou C Dueck,
James B Macdonald,
Susan D Laman,
Karen E Warschaw,
David J DiCaudo,
Shari A Nemeth,
Aleksandar Sekulic,
Richard J Gray, Nabil Wasif,
Barbara A Pockaj
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ABSTRACT: After skin biopsy of malignant melanoma, the findings in the subsequent wide local excision (WLE) sometimes result in upgrading of the T-category. Herein, we examine the influence of biopsy technique on residual disease in melanoma WLE specimens and on upstaging.
We performed a retrospective review of data from malignant melanoma patients who underwent sentinel lymph node biopsy between 1997 and 2010.
A total of 609 patients were biopsied by shave (51%), punch (19%), and excision (30%). Residual disease was seen in 240 patients (39%) at WLE, of whom 60% had undergone shave biopsy. Fifty-nine patients had a T-category upgrade after WLE (10% of all patients); 64% were sampled by shave. Seven percent of patients with a T-category upgrade had negative margins initially. Positive biopsy margin and greater thickness predicted T-category upgrade.
Partial biopsy for melanoma resulted in more residual disease at WLE and a higher rate of T-category upgrade. Moreover, the presence of negative margins at biopsy did not ensure lack of residual disease.
American journal of surgery 12/2011; 202(6):771-7; discussion 777-8. · 2.36 Impact Factor
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ABSTRACT: Although trends and variations in the use of breast conservation therapy (BCT) for ductal carcinoma have been studied, little is known about uncommon breast cancer histologies.
The Surveillance, Epidemiology and End Results (SEER) database was used to identify 338,682 patients with T1 or T2 (≤5 cm) ductal, lobular, tubular, mucinous, medullary, or papillary carcinoma of the breast from 1998 to 2008. Multivariate logistic regression analysis was used to identify predictors of BCT.
The majority of patients underwent BCT (60%). The rate of BCT remained relatively constant from 1998 to 2008 overall but varied from 50% for lobular to 79% for tubular. The highest rate of mastectomy was seen in lobular (49%). Nodal positivity following surgical staging was lowest for tubular (6%) and mucinous (8%). Adjuvant radiation was given to 72% overall and was lowest for papillary (58%). Predictors of BCT included tubular (OR 1.8, 95% CI 1.7-1.9) and medullary (OR 2.0, 95% CI 1.8-2.2) subtypes (vs. ductal).
Patients with uncommon breast cancer histologies show wide variation in the application of BCT depending on the primary tumor. This suggests that an individualized approach in the use of BCT depending on histology should be used.
Journal of Surgical Oncology 11/2011; 105(6):586-90. · 2.10 Impact Factor
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ABSTRACT: Radioactive seed localization (RSL) is an alternative to wire localization for nonpalpable breast lesions, with reported lower rates of positive surgical margins.
A retrospective review of all consecutive RSL procedures performed at a single institution from 01/2003 through 10/2010 was conducted.
One thousand RSL breast procedures were performed in 978 patients. Indications for RSL included invasive carcinoma (52%), in situ carcinoma (22%), atypical hyperplasia (11%), and suspicious percutaneous biopsy findings (15%). A total of 1,148 seeds were deployed using image guidance, with 76% placed ≥1 day before surgery. Most procedures (86%) utilized one seed. A negative margin was achieved at the first operation in 97% of patients with invasive carcinoma and 97% of patients with ductal carcinoma in situ (DCIS). An additional 9% of patients with invasive carcinoma and 19% of patients with DCIS had close (≤2 mm) margins, and underwent re-excision. Sentinel lymph node biopsy was successfully performed in 99.8% of cases. Adverse events included 3 seeds (0.3%) not deployed correctly on first attempt and 30 seeds (2.6%) displaced from the breast specimen during excision of the targeted lesion. All seeds were successfully retrieved, with no radiation safety concerns. Local recurrence rates were 0.9% for invasive breast cancer and 3% for DCIS after mean follow-up of 33 months. There was no evidence of a learning curve.
RSL is a safe, effective procedure that is easy to learn, with a low incidence of positive/close margins. RSL should be considered as the method of choice for localization of nonpalpable breast lesions.
Annals of Surgical Oncology 10/2011; 18(11):3096-101. · 4.17 Impact Factor
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ABSTRACT: Proper patient selection is important for nipple-sparing mastectomy, and we aimed to identify preoperative factors predictive of pathologic nipple-areola complex (NAC) involvement to assist with surgical planning.
We retrospectively reviewed a prospectively collected database of patients who underwent mastectomy for DCIS or invasive breast cancer at a single institution. Cases with NAC involvement, NAC(+), were compared with those without NAC involvement, NAC(-). Multivariate logistic regression analysis was performed to determine preoperative factors independently predictive of NAC involvement.
A total of 238 standard, 107 skin-sparing, and 47 nipple-sparing mastectomies were performed, and the NAC was pathologically involved in 16% (N = 62). Clinical NAC involvement, as determined by patient symptoms or physical exam, was present in 61% of NAC(+) but only 14% of NAC(-) cases (P < .0001) and carried a 92% negative predictive value (NPV). Preoperative imaging involved the NAC in 38% of NAC(+) but only 4% of NAC(-) cases (P < .0001) and carried an 89% NPV. NAC(+) tumors were larger, with mean size 3.3 cm versus 2.5 cm for NAC(-) tumors (P = .024). The mean tumor-to-nipple distance was 2.0 cm for NAC(+) versus 4.7 cm for NAC(-) tumors (P < .0001). On multivariate analysis, independent predictors of NAC involvement were the presence of clinical NAC involvement (odds ratio [OR] 5.11, 95% confidence interval [95% CI] 2.53-10.35) and imaging involvement of the NAC (OR 5.82, 95% CI 2.43-13.94).
Clinical and imaging abnormalities at the NAC are the only independent preoperative predictors of NAC pathology, and the absence of these factors conveys a low probability of NAC involvement.
Annals of Surgical Oncology 08/2011; 18(11):3123-8. · 4.17 Impact Factor
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ABSTRACT: Malignant peripheral nerve sheath tumors (MPNST) are a rare form of soft tissue sarcoma with few studies reporting on patient outcomes and prognostic variables.
A retrospective review of 175 patients diagnosed with MPNST from 1985 to 2010 was performed. Patient, tumor, and treatment characteristics were evaluated to identify prognostic variables.
The median age of our study population was 44 years, and 51% were female. Median tumor size was 6 cm, and 61% of patients had high-grade tumors. Tumors were most commonly located on the extremities (45%), then trunk (34%) and head/neck (19%). The majority of patients underwent surgical resection (95%) and adjuvant treatment with chemotherapy (6%), radiation (42%) or both (22%). Margin status was R0 in 69%, R1 in 2%, R2 in 9%, and unknown in 20%. The local recurrence rate was 22%, and 5- and 10-year disease-specific survival (DSS) were 60% and 45%, respectively. On univariate analysis, no predictors for local recurrence were identified. Tumor size ≥ 5 cm, high tumor grade, tumor location, presence of neurofibromatosis type 1, local recurrence, and adjuvant chemotherapy were all associated with DSS. On multivariate analysis, size ≥ 5 cm [hazard ratio (HR)= 6.1, 95% confidence interval (CI) 1.5-25.0], local recurrence (HR = 4.4, 95% CI 1.7-11.4), high tumor grade (HR = 3.8, 95% CI 1.1-13.2), and truncal location (HR = 3.7, 95% CI 1.1-12.7) were poor prognostic indicators for DSS.
High tumor grade and tumor size ≥ 5 cm predict adverse DSS for MPNST. In the context of a multidisciplinary treatment regimen, local recurrence and survival outcomes at 5 and 10 years were better than previously reported for MPNST.
Annals of Surgical Oncology 08/2011; 19(3):878-85. · 4.17 Impact Factor
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ABSTRACT: Although multimodal management of extremity soft tissue sarcoma (STS) is the standard of care, considerable variation exists in the sequencing of radiotherapy (RT) or chemotherapy (CT). Our goal was to identify factors responsible for this variation.
Members of specialty societies with an interest in STS were emailed a questionnaire about multimodal treatment of STS. Survey responses were scored on a 5-point Likert scale (1 = always preoperative and 5 = always postoperative) and analyzed by specialty, years in practice, and percentage of practice consisting of STS.
The questionnaire was completed by 320 (65%) of 490 physicians, including medical oncologists (18%), radiation oncologists (8%), orthopedic oncologists (22%), surgical oncologists (45%), and others (7%). Respondents were evenly split on the use of neoadjuvant RT (mean 3.03 ± 0.06) and showed a slight preference for neoadjuvant CT (2.89 ± 0.06). Radiation oncologists (2.52 ± 0.18), physicians with a >75% STS practice (2.58 ± 0.17), and those in practice <5 years (2.79 ± 0.12) preferred neoadjuvant RT. Neoadjuvant CT was preferred by orthopedic oncologists (2.62 ± 0.12) and physicians with >75% STS practice (2.51 ± 0.16). Factors influencing the choice for neoadjuvant RT were well-defined treatment volume, increased acute morbidity, and decreased late morbidity, while for CT, they were in-situ disease monitoring and early treatment of micrometastases.
Treatment sequencing in STS is influenced by specialty and clinical experience, with no clear consensus. These patterns may reflect the recent trend toward regionalization of STS care.
Annals of Surgical Oncology 07/2011; 19(2):504-10. · 4.17 Impact Factor
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ABSTRACT: The relative contributions of patient and tumor factors versus radiologic localization technique to the rates of inadequate margins of excision in breast-conserving therapy have not been defined.
Patients undergoing breast-conserving therapy were studied. Margins less than 2 mm from tumor were considered inadequate.
Of 539 patients, 31% were guided by palpation and 69% were guided by preoperative radiologic localization. The palpation-guidance patients had larger tumors (P < .0001) and more nodal metastases (P = .0005). The rates of inadequate margins were 10% for palpation-guided patients and 11% for radiologic-localization patients (P = .53). The 3-year rates of local recurrence were .7% for palpation-guided patients and 1.8% for radiologic-guided patients (P = .5).
Patient, tumor, and intraoperative pathologic factors, not just localization device shortcomings, produce inadequate margins of excision in breast-conserving therapy. A reasonable expected rate of inadequate margins owing to patient and tumor factors is 10%. Quality improvement for margin management must focus on intraoperative assessment of margins, especially for patients with identified risk factors, in addition to improving localization technique.
American journal of surgery 05/2011; 202(3):281-5. · 2.36 Impact Factor
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ABSTRACT: Patients with Stage IV melanoma have limited therapeutic options with few long-term survivors. Our goal was to study the impact of metastasectomy on survival in these patients.
Patients with Stage IV melanoma were identified from the Surveillance, Epidemiology, and End Results (SEER) database (1988-2006). Those who had metastasectomy performed were compared with patients that did not.
The median age of the study population (n = 4,229) was 63 years and median survival was 7 months. Patients who underwent metastasectomy (33.6%) had an improved median and 5-year overall survival as compared to patients who did not; 12 months versus 5 months and 16% versus 7% (P < 0.001). In patients with M1a disease (n = 1,994), this improvement of survival following metastasectomy was enhanced; median survival of 14 months versus 6 months and 5-year overall survival of 20% versus 9% (P < 0.001). Younger age and diagnosis from 2001 to 2006 were predictors of metastasectomy. Metastasectomy was an independent and significant predictor of survival for the entire cohort (HR 0.59, 95% CI 0.55-0.63).
Metastasectomy in patients with Stage IV melanoma may improve long-term survival. The true therapeutic benefit, if any, of metastatectomy needs to be determined by a randomized trial.
Journal of Surgical Oncology 03/2011; 104(2):111-5. · 2.10 Impact Factor
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ABSTRACT: BACKGROUND:Colonoscopic screening has increased detection of malignant colonic polyps (MPs). The goal of this study was to analyze trends and patterns in the surgical treatment of MPs and to assess outcomes as measured by lymph node retrieval and patient survival.METHODS:The Surveillance, Epidemiology, and End Results (SEER) registry was queried to identify 19,743 patients with MPs from 1988 to 2003.RESULTS:The majority of MPs were present in the sigmoid and descending colon (54%), and 38% were tubular, 40% were tubulovillous, and 22% were villous. During the study period, the incidence of MPs increased from 29% to 42% and surgical resection (SR) was increasingly used for treatment, from 54% to 70%. Predictors of SR were aged <70 years (odds ratio [OR], 1.3; 95% confidence interval [95% CI], 1.2-1.4), high-grade tumors (OR, 1.5; 95% CI, 1.2-1.9), diagnosis in 1999 through 2003 (OR, 1.7; 95% CI, 1.5-1.9), villous subtype (OR, 2.3; 95% CI, 2.0-2.6), and right colon location (OR, 8.1; 95% CI, 7.0-9.4). In patients undergoing SR, the mean and median number of lymph nodes was only 4 and 1, respectively. A significant percentage of patients (49%) had no lymph nodes retrieved and a worse overall survival at 5 years compared with patients who had at least 1 lymph node examined (64% vs 74%; P <.001).CONCLUSIONS:MPs appear to be increasing in incidence, and there is a trend toward increased use of SR for treatment. However, patients undergoing SR for MPs undergo suboptimal assessment of lymph nodes, with a detrimental impact on survival. Adequate lymphadenectomy and lymph node evaluation are crucial to improve outcomes in patients with these potentially curable lesions. Cancer 2011. © 2010 American Cancer Society.
Cancer 02/2011; 117(5):931 - 937. · 4.77 Impact Factor
