Heather Wachtel

The rise in metastasectomy across cancer types over the past decade

Although studies of metastasectomy have been limited primarily to institutional experiences, reports of favorable long‐term outcomes have generated increasing interest. In the current study, the authors attempted to define the national practice patterns in metastasectomy for 4 common malignancies with varying responsiveness to systemic therapy.

Clark level risk stratifies patients with mitogenic thin melanomas for sentinel lymph node biopsy.

BackgroundThe role for sentinel lymph node biopsy (SLNB) in patients with thin melanoma (≤1xa0mm) remains controversial. We examined a large cohort of patients with thin melanoma to better define predictors of SLN positivity.MethodsFrom 1995 to 2011, 781 patients with thin primary melanoma and evaluable clinicopathologic data underwent SLNB at our institution. Predictors of SLN positivity were determined using univariate and multivariate regression analyses, and patients were risk-stratified using a classification and regression tree (CART) analysis.ResultsIn the study cohort (nxa0=xa0781), 29 patients (3.7xa0%) had nodal metastases. In the univariate analysis, mitotic rate [odds ratio (OR)xa0=xa08.11, pxa0=xa00.005], Clark level (OR 4.04, pxa0=xa00.003), and thickness (OR 3.33, pxa0=xa00.011) were significantly associated with SLN positivity. In the multivariate analysis, MR (OR 7.01) and level IV–V (OR 3.45) remained significant predictors of SLN positivity. CART analysis initially stratified lesions by mitotic rate; nonmitogenic lesions (nxa0=xa0273) had a 0.7xa0% SLN positivity rate versus 5.6xa0% in mitogenic lesions (nxa0=xa0425). Mitogenic lesions were further stratified by Clark level; patients with level II–III had a 2.9xa0% SLN positivity rate (nxa0=xa0205) versus 8.2xa0% with level IV–V (nxa0=xa0220). With median follow-up of 6.3xa0years, five SLN-negative patients developed nodal recurrence and four SLN-positive patients died of disease.ConclusionsSLN positivity is low in patients with thin melanoma (3.7xa0%) and exceedingly so in nonmitogenic lesions (0.7xa0%). Appreciable rates of SLN positivity can be identified in patients with mitogenic lesions, particularly with concurrent level IV–V regardless of thickness. These factors may guide appropriate selection of patients with thin melanoma for SLNB.

Parathyroidectomy in dialysis patients

BACKGROUNDnThe optimal surgical treatment for secondary hyperparathyroidism is not well defined. Subtotal parathyroidectomy and total parathyroidectomy (tPTX) with autotransplant are accepted options; treatment method is left to surgeon preference. We sought to describe different characteristics of patients with secondary hyperparathyroidism receiving surgical treatment and to compare outcomes between the two treatment strategies.nnnMETHODSnWe conducted a retrospective cohort study of patients aged >18xa0y and on dialysis who received a parathyroidectomy (Current Procedural Terminology codexa0=xa060500) using the American College of Surgeons National Surgical Quality Improvement Program Participant Use File (2008-2011). Procedures were classified as subtotal if no autotransplant was performed and total if autotransplant was performed. Descriptive statistics were performed. The primary outcome variable of interest was 30-day morbidity. Secondary outcome variables studied were operative time, postoperative length of stay (LOS), 30-day mortality, and 30-day readmission. Univariate analyses were performed.nnnRESULTSnA total of 898 patients studied; of which, 236 patients (26.4%) received a tPTX and 662 (73.7%) received a subtotal parathyroidectomy. The median age was 49xa0y (interquartile range [IQR]: 38, 59), and majority of patients were American Society of Anesthesiologists class III (629, 70%). Nearly half of the patients were black (447, 49.8%); blacks were more likely to receive a tPTX than whites (30.2% versus 19.9%, Pxa0=xa00.01). Median operative time (133xa0min, IQR: 92, 160 versus 120xa0min, IQR: 103, 181; Pxa0<xa00.01) and median LOS (4xa0d, IQR: 3, 7 versus 4xa0d, IQR: 2, 6; Pxa0<xa00.01) were longer after a tPTX. There was no difference in the 30-day morbidity, mortality, or readmission rates between the two treatments.nnnCONCLUSIONSnWe used a national multi-institutional data set to show that despite the high-risk patient cohort and difference in operative duration, there is no difference in the more general postoperative complication rates.

Surgery for metastatic neuroendocrine tumors with occult primaries.

INTRODUCTIONnNeuroendocrine tumors (NETs) frequently metastasize prior to diagnosis. Although metastases are often identifiable on conventional imaging studies, primary tumors, particularly those in the midgut, are frequently difficult to localize preoperatively.nnnMATERIALS AND METHODSnPatients with metastatic NETs with intact primaries were identified. Clinical and pathologic data were extracted from medical records. Primary tumors were classified as localized or occult based on preoperative imaging. The sensitivities and specificities of preoperative imaging modalities for identifying the primary tumors were calculated. Patient characteristics, tumor features, and survival in localized and occult cases were compared.nnnRESULTSnSixty-one patients with an intact primary tumor and metastatic disease were identified. In 28 of these patients (46%), the primary tumor could not be localized preoperatively. A median of three different preoperative imaging studies were utilized. Patients with occult primaries were more likely to have a delay (>6 mo) in surgical referral from time of onset of symptoms (57% versus 27%, P = 0.02). Among the 28 patients with occult primary tumors, 18 (64%) were found to have radiographic evidence of mesenteric lymphadenopathy corresponding, in all but one case, to a small bowel primary. In all but three patients (89%), the primary tumor could be identified intraoperatively.nnnCONCLUSIONnThe primary tumor can be identified intraoperatively in a majority of patients with metastatic NETs, irrespective of preoperative localization status. Referral for surgical management should not, therefore, be influenced by the inability to localize the primary tumor.

Surgical Palliation for Pancreatic Malignancy: Practice Patterns and Predictors of Morbidity and Mortality

IntroductionMost patients with pancreatic cancer present with, or develop, biliary or duodenal obstruction. We sought to characterize palliative surgery utilization in a contemporary cohort and identify patients at high risk of morbidity and mortality.MethodsThe ACS NSQIP database (2005–2011) was queried for patients with a pancreatic malignancy undergoing gastrojejunostomy, biliary bypass, or laparotomy without resection. Univariate analysis and multivariate logistic regression identified factors associated with increased risk of 30-day morbidity or mortality.ResultsOperations for the 1,126 patients undergoing palliative bypass were gastrojejunostomy alone (33xa0%), bile duct bypass alone (27xa0%), both (31xa0%), or cholecystojejunostomy (9xa0%). A major complication occurred in 20xa0% and mortality in 6.5xa0% at 30xa0days. Risk factors for morbidity and mortality were defined in multivariate models. The number of identified risk factors stratified morbidity from 14.8–50xa0% and mortality from 1.6–50xa0% (pu2009<u20090.0001 for each). Laparotomy alone (nu2009=u2009622) was associated with lower morbidity than bypass (12 vs. 20xa0%, pu2009<u20090.0001), but equivalent mortality (5 vs. 6.5xa0%, pu2009=u20090.21).ConclusionPalliative bypass for pancreatic cancer is associated with a high rate of morbidity and mortality. In select patients, this risk may be prohibitive. Patient selection reflecting predictors of morbidity and mortality may allow for improved outcomes.

Reoperative parathyroidectomy: who is at risk and what is the risk?

BACKGROUNDnPersistent and recurrent hyperparathyroidism necessitate reoperation, which is associated with increased procedure-specific complication rates. The effect of reoperative parathyroidectomy on more generalized outcomes is poorly understood. We sought to determine patient, provider, and perioperative characteristics associated with reoperation, as well as to determine the associated risks.nnnMETHODSnAll patients receiving a parathyroidectomy in the American College of Surgeons National Surgical Quality Improvement Program database (2008-2011) were identified. Patients receiving initial parathyroidectomy were compared with those receiving reoperative parathyroidectomy. Descriptive statistics and univariate analyses were performed. Multivariate logistic regression models were developed for significant outcome measures.nnnRESULTSnOf 9114 parathyroidectomies performed, 8738 (95.9%) were initial and 376 (4.1%) were reoperative. The annual rate of reoperation was 3.6%-4.8%. Patients undergoing reoperative parathyroidectomy were more likely to be obese (48.5 versus 40.0%, P = 0.009) and American Society of Anesthesiologist class 3 (40.7 versus 30.3%, P = 0.001) than patients undergoing initial parathyroidectomy. There was no difference in gender, age, or race. Reoperations had a longer median operative time (101 minimum, interquartile range [IQR] [74-146] versus 76 [55-105], P <0.001) and a longer postoperative length of stay (median days until discharge 1, IQR [1-1] versus 1, IQR [0-1], P <0.001). No difference was found in the rates of mortality and common postoperative morbidity as measured in NSQIP. Patients undergoing reoperation were more likely to be readmitted within 30 d (12.7 versus 2.6%, P <0.001). After adjusting for confounders, reoperation continued to be significantly associated with readmission (odds ratio 3.82, confidence interval: 1.63-8.97; P = 0.002).nnnCONCLUSIONSnObesity and an American Society of Anesthesiologist 3 classification are independently associated with reoperation. Readmission within 30 d is associated with reoperation and is a target for patient education and quality improvement after this procedure.

Racial Disparities in Initial Presentation of Benign Thyroid Disease for Resection

BackgroundRacial disparities exist in thyroidectomy outcomes. One contributing factor may be the disease state upon presentation to a surgeon. Minorities with thyroid cancer present at a later disease stage and with larger tumors. This relationship has not been examined for benign thyroid disease. We sought to examine the association between race, referral patterns, and disease severity for benign thyroid conditions.MethodsWe analyzed all patients receiving a thyroidectomy for benign disease in our institutional endocrine surgery registry. Patient demographics, disease history, disease severity, and postoperative outcomes were investigated. Univariate analysis compared black and white patients. Multivariable linear regression examined the relationship between race and time to surgical referral.ResultsOf the 1189 patients studied, the majority (86.0xa0%) were white. Black and white patients differed in median income and reason for referral. When compared with white patients, black patients more commonly presented with compressive symptoms (black: 45.0xa0% vs. white: 21.2xa0%, pxa0<xa0.01) and dysphagia (19.0xa0% vs. 10.1xa0%, pxa0<xa0.01), and after a longer disease duration [black: median 0xa0years (interquartile ratio, IQR, 0–5) vs. white: 0xa0years (IQR, 0–2)]. Blacks also had larger glands than white [median 71 grams (IQR, 33.5–155.3) vs. 24.3 grams (IQR, 15.0–50.2)]. With the exception of reintubation rate, there were no differences in postoperative outcomes.ConclusionsBlack patients with benign thyroid conditions have a longer time to surgical referral and present for surgical evaluation with more severe disease than white patients. Identification of these disparities is the first step in eliminating differences in patient care.