Christopher A. Staley

Adenocarcinoma ex-goblet cell carcinoid (appendiceal-type crypt cell adenocarcinoma) is a morphologically distinct entity with highly aggressive behavior and frequent association with peritoneal/intra-abdominal dissemination: an analysis of 77 cases

High-grade versions of appendiceal goblet cell carcinoids (‘adenocarcinoma ex-goblet cell carcinoids’) are poorly characterized. We herein document 77 examples. Tumors occurred predominantly in females (74%), mean age 55 years (29–84), most with disseminated abdominal (77% peritoneal, 58% gynecologic tract involvement) and stage IV (65%) disease. Many presented to gynecologic oncologists, and nine had a working diagnosis of ovarian carcinoma. Metastases to liver (n=3) and lung (n=1) were uncommon and none arose in adenomatous lesions. Tumors had various histologic patterns, in variable combinations, most of which were fairly specific, making them recognizable as appendiceal in origin, even at metastatic sites: I: Ordinary goblet cell carcinoid/crypt pattern (rounded, non-luminal acini with well-oriented goblet cells), in variable amounts in all cases. II: Poorly cohesive goblet cell pattern (diffusely infiltrative cords/single files of signet ring-like/goblet cells). III: Poorly cohesive non-mucinous cell (diffuse-infiltrative growth of non-mucinous cells). IV: Microglandular (rosette-like glandular) pattern without goblet cells. V: Mixed ‘other’ carcinoma foci (including ordinary intestinal/mucinous). VI: goblet cell carcinoid pattern with high-grade morphology (marked nuclear atypia). VII: Solid sheet-like pattern punctuated by goblet cells/microglandular units. Ordinary nested/trabecular (‘carcinoid pattern’) was very uncommon. In total, 33(52%) died of disease, with median overall survival 38 months and 5-year survival 32%. On multivariate analysis perineural invasion and younger age (<55) were independently associated with worse outcome while lymph-vascular invasion, stage, and nodal status trended toward, but failed to reach, statistical significance. Worse behavior in younger patients combined with female predilection and ovarian-affinity raise the possibility of hormone-assisted tumor progression. In conclusion, ‘adenocarcinoma ex-goblet cell carcinoid’ is an appendix-specific, high-grade malignant neoplasm with distinctive morphology that is recognizable at metastatic sites and recapitulates crypt cells (appendiceal crypt cell adenocarcinoma). Unlike intestinal-type adenocarcinoma, it occurs predominantly in women, is disguised as gynecologic malignancy, and spreads along peritoneal surfaces with only rare hematogenous metastasis. It appears to be significantly more aggressive than appendiceal mucinous neoplasms.

Association Between Hospital Finances, Payer Mix, and Complications After Hyperthermic Intraperitoneal Chemotherapy: Deficiencies in the Current Healthcare Reimbursement System and Future Implications

BackgroundDespite increasing implementation of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), there are little data on its financial implications. We analyzed hospital cost and reimbursement data within the context of insurance provider type and postoperative complications.MethodsClinicopathologic variables, hospital costs, and reimbursement for all patients undergoing CRS/HIPEC at a single institution from 2009 to 2013 were analyzed.ResultsA total of 64 patients underwent CRS/HIPEC. Median PCI score was 19, and average operative time was 550xa0min. Tumor histology included appendiceal (nxa0=xa040; 62xa0%), colorectal (nxa0=xa016; 25xa0%), goblet cell (nxa0=xa05; 8xa0%), and mesothelioma (nxa0=xa03; 5xa0%). Median length-of-stay was 13xa0days. Complications occurred in 42 patients (66xa0%), including 13 (20xa0%) with major (Clavien grade III–IV) complications. Payer mix included 42 private insurance and 22 Medicare/Medicaid. Financial data was available for 56 patients: average total hospital cost was

The 5-Item Modified Frailty Index Is Predictive of 30-Day Postoperative Complications in Patients Undergoing Kyphoplasty Vertebral Augmentation

49,248 and reimbursement was

Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Surgical Management of Distal Radius Fractures

63,771, for a hospital profit of

Frailty predicts mortality and complications in chronologically young patients with traumatic orthopaedic injuries

14,523/patient. Despite similar costs between Medicare/Medicaid and private-insurance patients, Medicare/Medicaid reimbursed much less (

The Effect of Season and Weather on Orthopaedic Trauma: Consult Volume Is Significantly Correlated with Daily Weather

30,713 vs

Outpatient and Inpatient Single-Level Cervical Total Disc Replacement: A Comparison of 30-day Outcomes

80,747; pxa0<xa00.001), resulting in a net loss of

Motorcycles and Helmets: A National Review and the Dangers Associated with Repealing Universal Helmet Laws

17,342 per patient. For private-insured patients, major complications were associated with increased cost and increased reimbursement, resulting in a net profit of

Overlapping Surgery: Prevalence, Practice, and an Outline for Change

36,285, compared with a net loss of

Redefining the Ki-67 index stratification for low-grade pancreatic neuroendocrine tumors: improving its prognostic value for recurrence of disease

54,274 in Medicare/Medicaid patients.ConclusionsCRS/HIPEC is profitable in privately insured patients, even for those with major complications, but loses money in patients with Medicare/Medicaid. Under a future bundled-reimbursement system, complications will be negatively associated with profit. With these impending changes, hospitals must place emphasis on value, recalculate the reimbursement necessary for financial viability, and focus on decreasing costs and minimizing complications.