Christopher M. Pezzi

Ninety-day mortality after resection for lung cancer is nearly double 30-day mortality.

OBJECTIVE To evaluate 30-day and 90-day mortality after major pulmonary resection for lung cancer including the relationship to hospital volume. METHODS Major lung resections from 2007 to 2011 were identified in the National Cancer Data Base. Mortality was compared according to annual volume and demographic and clinical covariates using univariate and multivariable analyses, and included information on comorbidity. Statistical significance (P<.05) and 95% confidence intervals were assessed. RESULTS There were 124,418 major pulmonary resections identified in 1233 facilities. The 30-day mortality rate was 2.8%. The 90-day mortality rate was 5.4%. Hospital volume was significantly associated with 30-day mortality, with a mortality rate of 3.7% for volumes less than 10, and 1.7% for volumes of 90 or more. Other variables significantly associated with 30-day mortality include older age, male sex, higher stage, pneumonectomy, a previous primary cancer, and multiple comorbidities. Similar results were found for 90-day mortality rates. In the multivariate analysis, hospital volume remained significant with adjusted odds ratios of 2.1 (95% confidence interval [CI], 1.7-2.6) for 30-day mortality and 1.3 (95% CI, 1.1-1.6) for conditional 90-day mortality for the hospitals with the lowest volume (<10) compared with those with the highest volume (>90). Hospitals with a volume less than 30 had an adjusted odds ratio for 30-day mortality of 1.3 (95% CI, 1.2-1.5) compared with those with a volume greater than 30. CONCLUSIONS Mortality at 30 and 90 days and hospital volume should be monitored by institutions performing major pulmonary resection and benchmarked against hospitals performing at least 30 resections per year.

The present and future use of physician extenders in general surgery training programs: one response to the 80-hour work week.

BACKGROUND The aim of this study was to assess the use of physician extenders (PEs) in general surgery residency programs. STUDY DESIGN We surveyed the program directors in surgery for the number of chief residents, PEs on general surgery services, PE duties, whether PEs were hired in response to Accreditation Council for Graduate Medical Education work-hour restrictions, plans to hire additional PEs, and program type. Data were analyzed using the Students t-test; p values are two-tailed and considered significant if <0.05. RESULTS There were 163 programs (65%) that responded, (87 university, 70 nonuniversity, and 6 military programs), with a total of 689 graduating chief residents per year. One hundred sixty programs use 840 PEs (median, 3.5 PEs per program; mean, 5.3 PEs per program, 2 PEs per chief resident). One hundred twenty-seven programs (79%) use at least 1 PE (range 1 to 50 PEs); 93 programs (57%) hired 513 (61%) PEs in response to work-hour restrictions. Before 2003, the mean number of PEs per program was 2.0; after 2003, there were 5.3 per program (p=0.0001). Most common uses of PEs included taking histories and physicals (84%), seeing consults (58%), first-assisting (52%), and seeing patients in the emergency department (47%). Forty-seven of 162 (29%) programs plan to hire more PEs in the next 3 years, 76 programs (47%) would like to, but are unsure of funding; 23 programs (14%) are not planning to increase the total, and 16 programs (10%) are unsure. With available funding, 431 additional PEs may be hired in the next 3 years, for a total of 1,271 PEs in 163 programs, or an average of 7.8 PEs per program and 1.8 PEs per chief resident. CONCLUSIONS PEs have been hired in large numbers to assist on general surgery teaching services, with most hired in response to Accreditation Council for Graduate Medical Education work-hour restrictions, and most of their duties are intended to aid resident education. Almost 80% of programs currently use PEs; 76% would like to hire more. Currently 1.2 PEs are used per graduating chief resident; this could increase to 1.8 PEs per chief resident in the next 3 years.

Serous cystadenocarcinoma of the pancreas with metachronous hepatic metastasis.

A 68-year-old woman presented with a 2-week history of flank pain. Medical history included sarcoidosis, hypertension, diabetes mellitus, and renal cell carcinoma treated 28 years earlier by radical nephrectomy and irradiation. Physical examination and laboratory studies were normal. Computed tomography (CT) scan demonstrated a 4 5 cm multicystic mass in the head of the pancreas, obstructing the pancreatic duct and compressing the splenoportal venous confluence (Fig. 1). CT-guided biopsy demonstrated sclerotic fibroconnective tissue containing numerous variably sized glands lined by bland cuboidal epithelium with clear cytoplasm containing glycogen on periodic acid-Schiff stain and histologically typical of serous cystic neoplasm (SCN) of the pancreas. Surgery for this histologic benign lesion was not recommended, because of the splenoportal venous involvement. Three years later, CT scan showed minimal enlargement with 3 new small masses in the right hepatic lobe (Fig. 2). CT-guided biopsy and repeat biopsy identified the hepatic and pancreatic lesions as SCN (Fig. 3). Periodic acid-Schiff staining confirmed the diagnosis of metastatic serous cystadenocarcinoma of the pancreas to the liver. Six months later, the patient developed anemia as a result of bleeding from tumor erosion through the duodenum, 20-pound weight loss, weakness, and abdominal pain. She was not a candidate for radiation therapy because of prior irradiation for her renal cancer, declined palliative chemotherapy, and was treated by palliative care. The pancreatic tumor enlarged slowly, and liver metastases developed for a total of 7. She expired from local tumor progression and the metastatic disease, 45 months after initial presentation. Serous cystadenocarcinoma of the pancreas was first reported in 1989. Nineteen cases of documented or sus-

Results of needle localized breast biopsy in women under age 50

BACKGROUND The use of screening mammography in women aged 40 to 50 years is controversial because of a relative lack of data demonstrating survival benefit for this segment of the population. PATIENTS AND METHODS The charts of 809 consecutive women who underwent needle localized breast biopsy over a 6 1/2-year period were reviewed to determine the effect of age on the biopsy results. Patient ages ranged from 27 to 91 years (mean 56). RESULTS Two hundred nineteen (27%) of the 809 needle localized breast biopsies were malignant, with a mean tumor diameter of 1.46 cm. This procedure identified malignancy in 3 (5%) of 60 patients age 40, and in 32 (15%) of 207 patients aged 40 to 49 years. Malignancy was significantly more likely in patients 50 years of age or older and was found in 184 (34%) of the 542 (P<0.001). Overall, 33% of all patients undergoing the procedure were under age 50. CONCLUSIONS Without screening mammography, the diagnosis of breast cancer would have been delayed in 32 women aged 40 to 50, 15% of the total diagnosed with nonpalpable breast cancer in this study. We recommend the use of screening mammography in this age group.

Rare breast cancer: 246 invasive secretory carcinomas from the National Cancer Data Base.

Invasive secretory breast carcinoma (SBC) is a rare subtype of breast malignancy.

Radiation therapy dose is associated with improved survival for unresected anaplastic thyroid carcinoma: Outcomes from the National Cancer Data Base

The outcomes of patients with unresected anaplastic thyroid carcinoma (ATC) from the National Cancer Data Base (NCDB) were assessed, and potential correlations were explored between radiation therapy (RT) dose and overall survival (OS).

Atypical medullary carcinoma of the breast has similar prognostic factors and survival to typical medullary breast carcinoma: 3,976 cases from the National Cancer Data Base.

Medullary breast carcinoma (MBC) is a subtype with a more favorable prognosis. Tumors with some, but not all, characteristics of MBC are classified as atypical medullary carcinoma of the breast (AMCB).

Treatment and survival of patients with insular thyroid carcinoma: 508 cases from the National Cancer Data Base

Insular thyroid carcinoma (ITC) is a rare but aggressive thyroid malignancy.

Coexisting right nonrecurrent and right recurrent inferior laryngeal nerves: a rare and controversial entity

Variations in the course of the recurrent laryngeal nerve (RLN) can occur, including the development of a nonrecurrent inferior laryngeal nerve (NRILN). Rarely, both a right RLN and a right NRILN have been reported in the same patient, merging before they enter the larynx. A case is presented, including images, and the literature concerning this rare anatomical finding is reviewed, including studies suggesting alternative explanations for these cases. Fourteen previously reported cases of coexisting RLN and NRILN were identified, all involving the right side. Some cases were associated with an anomalous origin of the right subclavian artery and some were not. The alternative explanations that a communicating branch of the sympathetic nerve, which joins the RLN, is mistaken for an NRILN or that a collateral branch from an NRILN is mistaken for an RLN in these cases are also considered. Surgeons must be aware of these unusual variations to minimize nerve injury during neck surgery.

Big Data and Clinical Research in Oncology: The Good, the Bad, the Challenges, and the Opportunities

National cancer registries provide an ever-growing volume of data and increasing access to that data for the purpose of clinical research in oncology. In the United States, three national cancer-specific registries have been developed to collect data on cancer patients, their cancers, how they are treated, and their outcomes. Beginning with the passage of the National Cancer Act of 1971 and funded since 1973, the National Cancer Institute (NCI)’s Surveillance Epidemiology and End Results (SEER) program is a population-based registry from 20 U.S. geographic areas, covering *28 % of the U.S. population. In 1989, the American College of Surgeons (ACoS) Commission on Cancer (CoC) started a joint program with the American Cancer Society: the National Cancer Data Base (NCDB). Approximately 70 % of all new cancer cases diagnosed in the United States each year are currently captured by the NCDB, which contains the records of *29 million patients from *1,500 institutions (making the NCDB a hospitalbased, not population-based, registry). Finally, the National Program of Cancer Registries (NPCR) was established in 1992 and is administered by the U.S. Centers for Disease Control and Prevention (CDC). NPCR supports cancer registries in 45 states, representing 96 % of the U.S. population. The data entered into each of these three national cancer registries are not collected completely independently of the others. The processes, system, and rules that govern the data collection for all three registries significantly overlap, as do the professionals (cancer registrars/CTRs) who actually collect and enter the data. The North American Association of Central Cancer Registries Inc. (NAACR), established in 1987, is a collaborative umbrella organization that develops and promotes uniform data standards for the cancer registries. All central cancer registries in the United States (and Canada) are members of NAACR, although each registry may require a different subset of data elements to be reported. In this issue of Annals of Surgical Oncology, In et al. from the ACoS CoC and nearby Chicago hospitals, bring to light one of several important weaknesses of the data currently collected and reported in these national cancer registries: accurate information on local, regional, and distant recurrence rates and the timing of those recurrences after a first course of treatment is completed. The authors point out that the data reported by each of these registries have traditionally concentrated on the initial presentation and first course of treatment, with little follow-up information reliably collected, except death. The NCDB does attempt to collect data on the time of first recurrence as well as the type of recurrence (local, regional, distant), and the authors examined the completeness of these data points in the NCDB for more than 700,000 patients with five common tumor types diagnosed between 2002 and 2005. Disappointingly, they report that complete information to allow an accurate determination if and when a recurrence had occurred after completion of the first course of treatment, and the type of recurrence, was lacking at a majority of the more than 1,400 hospitals for more than half of their patients. On average, hospitals had incomplete recurrence information on 56.7–66.7 % of patients studied. Only 9.0 % of hospitals collected recurrence information well on all five of the cancer sites examined. The absence of reliable information on recurrence after treatment of primary cancer makes the determination of This is an editorial to the article available at doi:10.1245/s10434-0143516-x.