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Journal of the American College of Surgeons 2019 Jul
Authors:
Kantor O, Pesce C, Kopkash K, Barrera E, Winchester DJ, Kuchta K, Yao K
Abstract
In 2014, the Society of Surgical Oncology and American Society for Radiation Oncology guidelines defined negative margin for stage I and II breast cancer as "no tumor on ink." We hypothesized that repeat operation rates have decreased since the guideline introduction and would be associated with changes in overall surgical trends.
The National Cancer Database was used to identify women who underwent initial breast-conserving surgery (BCS) for stage I and II breast cancer from 2004 to 2015.
Of 521,578 patients that underwent initial BCS, 82.7% had BCS alone and 17.3% had repeat operation: 67% with BCS followed by another BCS, 24% with BCS followed by unilateral mastectomy, and 9% with BCS followed by bilateral mastectomy (BM). The repeat operation rate decreased from 16.2% in 2004 to 14.0% in 2015 (p < 0.01). Breast-conserving surgery with repeat BCS decreased from 12.8% to 9.7%, and BCS followed by BM increased from 0.7% in 2004 to 1.9% 2013, then decreased to 1.4% in 2015. Trends for all surgical patients regardless of initial procedure showed a BCS rate of 64.0% in 2013 that increased to 67.6% in 2015. The BM rate increased from 4.6% in 2004 to 13.6% in 2013, then decreased to 12.8% in 2015 (p < 0.05). Adjusted multivariable regression found independent predictors of repeat operation to be diagnosis before 2014 (odds ratio [OR] 1.25), age younger than 50 years (OR 1.70), Her2neu receptor-positive tumors (OR 1.61), and lobular histology (OR 1.61).
Repeat operation rates are decreasing after 2014, which is also associated with a rise in BCS and decrease in BM rates. Dissemination of margin guidelines for early-stage breast cancer might be impacting overall surgical trends.
PMID:
30902638
[PubMed - as supplied by publisher]
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Authors:
Yan H, Hunter E, Akoulitchev A, Park P, Winchester DJ, Moo-Young TA, Prinz RA
Abstract
Fine needle aspiration has been the traditional method for diagnosing thyroid cancer. Epigenetic chromatin conformation changes offer an alternative method of diagnosing cancer. The purpose of this study is to evaluate an EpiSwitch assay of epigenetic markers that can be used to diagnose thyroid cancer in blood samples.
From 2014 to 2016, adult patients with thyroid nodules having thyroidectomy were recruited and grouped based on benign, malignant, and atypia of undetermined significance or follicular lesions of undetermined significance fine needle aspiration cytology. Blood samples were collected before surgery. Final pathologic diagnosis was made from the thyroid specimens. Patients' blood samples were analyzed using the EpiSwitch assay, (Oxford Biodynamics, Oxford, UK), and the results were compared with surgical pathology to determine assay performance.
In total, 58 patients were recruited: 20 benign, 20 malignant, and 18 atypia or follicular lesions of undetermined significance. An analysis of the malignant and benign fine needle aspiration groups found 6 epigenetic markers for thyroid. A total of 28 (48%) patients had thyroid cancer. The assay was able to correctly identify 25 of the 28 malignant nodules, showing sensitivity of 89.3% and specificity of 66.7%. The positive predictive value for the assay was 71.4%, whereas the negative predictive value was 87.0%.
An epigenetic assay of peripheral blood shows high sensitivity in detecting thyroid cancer and provides an additional method for its diagnosis.
PMID:
30377001
[PubMed - as supplied by publisher]
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American journal of surgery 2019 Mar
Authors:
Yan H, Calcatera N, Moo-Young TA, Prinz RA, Winchester DJ
Abstract
Primary hyperparathyroidism (HPT) is an undertreated disease. This study's purpose is to determine if the calcium levels correlate with prevalence of symptoms and surgical treatment in patients with primary HPT.
Patients treated in 2006-2015 with serum calcium≥10.0 mg/dL and PTH>65 pg/mL were identified and stratified based on calcium level: 10.0-10.3 (normocalcemia), 10.4-11.2 (moderate), and ≥11.3 (severe) mg/dL. Clinical variables and rates of surgery were compared between the three groups.
A total of 2266 patients were identified: 303 with normocalcemia, 1513 with moderate hypercalcemia, and 450 with severe hypercalcemia. All three groups had similar rates of nephrolithiasis (p = 0.10), osteoporosis (p = 0.82), and reduced GFR (p = 0.06). Most patients (85%) had at least one surgical indication, but only 29% underwent parathyroidectomy. Higher calcium levels were correlated with higher surgical rates: 12% for Ca 10.0-10.3, 27% for Ca 10.4-11.2, and 46% for Ca≥11.3 (p < 0.01).
Prevalence of symptoms does not correlate with calcium levels. Patients with normocalcemia and moderate hypercalcemia were equally likely to have a surgical indication, but normocalcemic patients are less likely to receive surgery.
PMID:
30262120
[PubMed - as supplied by publisher]
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The breast journal 2018 11
Authors:
Yan H
Abstract
Well-differentiated thyroid cancer (WDTC) is unique in that patient age is part of staging. Several studies have shown a need to increase the age threshold in staging for WDTC, but the separate impact of age on prognosis for papillary and follicular carcinomas has not been examined. We hypothesize that age impacts survival differently for papillary and follicular carcinomas.
Patients with invasive papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC) between 2004 and 2013 were identified in the National Cancer Database, and were stratified by histologic type. Overall survival (OS) was analyzed using multivariable Cox regression, and the Youden index was used to find the optimal age threshold for both histologies.
A total of 204,139 patients with WDTC were identified. Ninety-two percent had PTC, while 7.7% had FTC. The average age was 48.4 years and OS was 96.3%, with a median follow-up of 52.7 months. When analyzing age in 5-year increments, 10-year mortality increased incrementally by 30-50% per age group for PTC, from age < 35 to ≥ 70 years, without an obvious inflection point. However, FTC patients experienced a more than threefold increase in 10-year mortality from age 40-44 years (2.5%) to age 45-49 years (7.9%). The same pattern was found on multivariable Cox regression. The Youden index found the optimal age thresholds were 58.5 years for PTC and 46.2 years for FTC.
OS for PTC decreases incrementally with age, but OS for FTC decreases significantly in patients aged 45 years and older. A higher age threshold may inappropriately downstage some high-risk follicular cancer patients.
PMID:
30051547
[PubMed - as supplied by publisher]
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Annals of surgical oncology 2018 Aug
Authors:
Gaines S, Suss N, Barrera E, Pesce C, Kuchta K, Winchester DJ, Yao K
Abstract
We examined axillary surgery in mastectomy patients with tumor-positive nodes and how the type of axillary surgery impacted use of postmastectomy chest wall radiation therapy (PMRT).
Using the National Cancer Data Base, we selected patients with AJCC cT1/T2c N0 breast cancer with one to three tumor-positive lymph nodes treated between 2013 and 2014. Type of axillary surgery was analyzed using the FORDS scope of regional lymph node surgery variable. Multivariable logistic regression modeling was used to identify independent predictors associated with SNB alone and the use of PMRT.
Of 8089 patients, 2482 (30.7%) underwent SNB alone, 1339 (16.6%) underwent axillary dissection (ALND) alone, and 4268 (52.7%) underwent SNB followed by ALND. Fifty-seven percent of patients with micrometastases underwent SNB alone compared with 22.6% of patients with macrometastases. Independent predictors of SNB alone for patients with micrometastases were African American race, number of nodes positive, and PMRT. For patients with macrometastases, age, facility type and location, and PMRT were independent predictors for SNB alone. Of 2449 patients who underwent SNB alone, 1538 (62.8%) had no PMRT, 261 (10.7%) had PMRT alone, and 650 (26.5%) had PMRT with regional nodal irradiation. Patients undergoing SNB alone were 1.70 times [96% confidence interval (CI) 1.45-2.00] more likely to undergo PMRT than upfront ALND and 1.51 times (96% CI 1.34-1.71) more likely than SNB followed by ALND.
Surgeons are omitting completion ALND in a third of early-stage, node-positive mastectomy patients. SNB alone patients are more likely to undergo PMRT than patients undergoing ALND.
PMID:
29626303
[PubMed - as supplied by publisher]
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Authors:
Rajjoub SR, Yan H, Calcatera NA, Kuchta K, Wang CE, Lutfi W, Moo-Young TA, Winchester DJ, Prinz RA
Abstract
Histologic subtypes of papillary thyroid cancer affect prognosis. The objective of this study was to examine whether survival is affected by extent of surgery for conventional versus follicular-variant papillary thyroid cancer when stratified by tumor size.
Using the National Cancer Data Base, we evaluated 33,816 adults undergoing surgery for papillary thyroid cancer from 2004 to 2008 for 1.0-3.9 cm tumors and clinically negative lymph nodes. Conventional and follicular-variant papillary thyroid cancers were divided into separate groups. Cox regression models stratified by tumor size were used to determine if extent of surgery affected overall survival.
A total of 30,981 patients had total thyroidectomy and 2,835 had thyroid lobectomy; 22,899 patients had conventional papillary thyroid cancer and 10,918 had follicular-variant papillary thyroid cancer. On unadjusted KM analysis, total thyroidectomy was associated with improved survival for conventional (P = 0.02) but not for follicular-variant papillary thyroid cancer patients (P = 0.42). For conventional papillary thyroid cancer, adjusted analysis showed total thyroidectomy was associated with improved survival for 2.0-3.9 cm tumors (P = 0.03) but not for 1.0-1.9 cm tumors (P = 0.16). For follicular-variant, lobectomy and total thyroidectomy had equivalent survival for 1.0-1.9 cm (P = 0.45) and 2.0-3.9 cm (P = 0.88) tumors.
Tumor size, histologic subtype, and surgical therapy are important factors in papillary thyroid cancer survival. Total thyroidectomy was associated with improved survival in patients with 2.0-3.9 cm conventional papillary thyroid cancer, and should be considered for 2.0-3.9 cm papillary thyroid cancers when preoperative molecular analysis is not used to distinguish conventional from follicular-variant.
PMID:
29426618
[PubMed - as supplied by publisher]
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Authors:
Suss NR, Talamonti MS, Bryan DS, Wang CH, Kuchta KM, Stocker SJ, Bentrem DJ, Roggin KK, Winchester DJ, Marsh R, Prinz RA, Murad FM, Baker MS
Abstract
The benefit of adding external beam radiation to adjuvant chemotherapy in patients that have undergone a margin positive resection for early stage, pancreatic ductal adenocarcinoma has not been determined definitively.
The National Cancer Data Base was queried to evaluate the utility of adjuvant radiation in patients with pathologic stage I-II pancreatic ductal adenocarcinoma who underwent upfront pancreatoduodenectomy with a positive margin (margin positive resection) between 2004 and 2013.
In the study, 1,392 patients met inclusion criteria, of whom 263 (18.9%) were lymph node-negative (pathologic stages IA, IB, IIA) and 1,129 (81.1%) were node-positive (pathologic stage IIB); 938 (67.4%) patients received adjuvant radiation and chemotherapy, while 454 (32.6%) received adjuvant chemotherapy alone. Cox modeling stratified by nodal status demonstrated the benefit of radiation to be statistically significant only in node positive patients (hazard ratio 0.81, 95% confidence interval, 0.71-0.93). Node-positive patients receiving adjuvant radiation and chemotherapy had an adjusted median survival of 17.5 months vs 15.2 months for those receiving adjuvant chemotherapy alone (P=.003). In patients who had negative nodes, there was no difference in overall survival with radiation (22.5 vs 23.6 months, P=.511).
Addition of radiation to adjuvant chemotherapy after a margin positive resection confers a survival benefit albeit limited (about 2 months) in patients with node-positive pancreatic head cancer. (Surgery 2017;160:XXX-XXX.).
PMID:
29336810
[PubMed - as supplied by publisher]
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HPB : the official journal of the International Hepato Pancreato Biliary Association 2018 02
Authors:
Kantor O, Talamonti MS, Wang CH, Roggin KK, Bentrem DJ, Winchester DJ, Prinz RA, Baker MS
Abstract
Few studies have examined the relation between extent of vascular resection and morbidity following pancreaticoduodenectomy (PD) with vein resection (PDVR).
Patients undergoing PD for malignancy were identified using the American College of Surgeons National Surgical Quality Improvement Project from 2006 to 2013. Current procedural terminology codes were used to characterize PDVR.
9235 patients underwent PD, 977 (10.6%) had PDVR - 640 with direct and 224 with graft repair. PDVR had longer operative times (456 ± 136 vs 374 ± 128 min, p < 0.05) and higher intraoperative transfusions (1.8 ± 3.4 vs 4.3 ± 4.9 units, p < 0.05) than PD alone. On adjusted multivariable regression, PDVR with either direct or graft repairs was associated with higher rates of overall morbidity (OR [odds ratio] 1.50 for direct, 1.74 for graft, p < 0.05), bleeding (OR 2.18 for direct, 3.26 for graft, p < 0.05), and DVT (OR 2.12 for direct, 2.62 for graft, p < 0.05) compared to PD alone. Graft repair was further associated with increased risk of reoperation (OR 1.59), septic shock (OR 2.77) and 30-day mortality (OR 2.72), all p < 0.05.
The risk of significant morbidity and mortality for PDVR is associated with the extent of vascular resection, with graft repairs having increased morbidity and mortality rates.
PMID:
29191690
[PubMed - as supplied by publisher]
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Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists 2018 Jan
Authors:
Calcatera NA, Lutfi W, Suman P, Suss NR, Wang CH, Prinz RA, Winchester DJ, Moo-Young TA
Abstract
Clinical stage (cStage) in thyroid cancer determines extent of surgical therapy and completeness of resection. Pathologic stage (pStage) is an important determinant of outcome. The rate of discordance between clinical and pathologic stage in thyroid cancer is unknown.
The National Cancer Data Base was queried to identify 27,473 patients ≥45 years old with cStage I through IV differentiated thyroid cancer undergoing surgery from 2008-2012.
There were 16,286 (59.3%) cStage I patients; 4,825 (17.6%) cStage II; 4,329 (15.8%) cStage III; and 2,013 (7.3%) cStage IV patients. The upstage rate was 15.1%, and the downstage rate was 4.6%. For cStage II, there was a 25.5% upstage rate. The change in cStage was a result of inaccurate T-category in 40.8%, N-category in 36.3%, and both in 22.9%. On multivariate analysis, the patients more likely to be upstaged had papillary histology, tumors 2.1 to 4 cm, total thyroidectomy, nodal surgery, positive margins, or multifocal disease. Upstaged patients received radioiodine more frequently (75.3% vs. 48.1%; P<.001).
Approximately 20% of cStage is discordant to pStage. Certain populations are at risk for inaccurate staging, including cT2 and cN0 patients. Upstaged patients are more likely to receive radioactive iodine therapy.
CI = confidence interval; cStage = clinical stage; DTC = differentiated thyroid cancer; NCDB = National Cancer Data Base; OR = odds ratio; pStage = pathologic stage; RAI = radioactive iodine.
PMID:
29144811
[PubMed - as supplied by publisher]