Kathryn E. Engelhardt

Wrong-Site Surgery

Case Summary A postmenopausal woman with abnormal breast imaging had 2 palpable masses within her right breast, 1 of which had ductal carcinoma in situ (DCIS) on biopsy. The other mass appeared benign on further imaging and did not require treatment. Partial mastectomy for the DCIS was performed. No intraoperative imaging was used because the mass was palpable and the examination note documented which of the 2 masses contained DCIS. The excised breast mass was labeled “right breast mass, 9:00 position” and sent to the pathology department and the patient was discharged home from the recovery area. The final pathology report noted “benign breast tissue, no evidence of biopsy site changes or biopsy clip.”

Treatment trends in early-stage lung cancer in the United States, 2004 to 2013: A time-trend analysis of the National Cancer Data Base

Objective The study objective was to evaluate trends in the use of surgical therapy for patients with early‐stage (IA‐IIA) non–small cell lung cancer when stereotactic ablative radiotherapy was introduced in the United States. Methods Patients with clinical stage IA to IIA non–small cell lung cancer diagnosed from January 1, 2004, to December 31, 2013, were identified in the National Cancer Data Base. The Cochran–Armitage trend test was used to evaluate the change in the proportion of patients undergoing surgery over time. Logistic regression was used to identify the factors associated with receipt of surgery compared with radiation. Results Of 200,404 eligible patients from 1235 hospitals, 79.8% (n = 159,943) underwent surgery. For all stages combined, the rate of surgery decreased from 83.9% in 2004 to 75.1% in 2013 (P < .0001), with the largest decrease seen in patients with stage IIA: stage IA 86.5% to 77.1% (P < .0001); stage IB 79.6% to 71.5% (P < .0001); and stage IIA 94.7% to 70.3% (P < .001). Patients were more likely to undergo surgery if they were younger and white, had higher income, or had private or Medicare insurance. Conclusions From 2004 to 2013, there was an overall decrease in the use of surgical therapy for lung cancer in early‐stage disease. Because resection remains the standard of care for most patients with early‐stage disease, these data suggest a potentially significant quality gap in the treatment of patients with non–small cell lung cancer.

Treatment Approaches and Outcomes for Primary Mediastinal Sarcoma: Analysis of 976 Patients

BACKGROUNDnPrimary mediastinal sarcomas are rare and deadly. Our objective was to describe the clinicopathological features, treatment strategies, and overall survival outcomes for a contemporary cohort of patients diagnosed with primary mediastinal sarcoma in the United States.nnnMETHODSnWe queried the National Cancer Database for cases of mediastinal sarcoma diagnosed from 2004 to 2012. Five-year overall survival (OS) was examined using the Kaplan-Meier method. Differences in OS were assessed using log-rank analysis and Cox proportional hazards regression.nnnRESULTSnThe mean age of diagnosis was 53 years (range, 0 to 90) with a male predominance (59.2%). The most common histological subtype was hemangiosarcoma (27.1%). Fewer than half of patients underwent surgery (48.9%), and 19.7% of patients had no treatment. For all patients, OS was 14.8%. The best unadjusted OS was seen in patients treated with surgery and radiation (40.1%); untreated patients had the worst unadjusted OS (4.2%). Of those who underwent surgery (nxa0= 477, 48.9%), OS was significantly better for those who achieved an R0 resection (30.1% versus 18.9%; pxa0= 0.002). In multivariable analysis, surgery combined with radiation therapy was again associated with the best survival (HR, 0.24; 95% CI, 0.16 to 0.36). Other factors associated with improved OS included younger age, fewer comorbidities, and leiomyosarcoma histology. Worse OS was associated with poorly differentiated or undifferentiated grade, metastases, treatment in the New England region, and having Medicaid or no insurance. Sex and tumor size had no effect on OS.nnnCONCLUSIONSnThe 5-year OS for primary mediastinal sarcoma is poor. Surgical resection can be successful and should be considered whenever possible.

Comparing apples to oranges: Short-term mortality after surgery versus stereotactic body radiotherapy for early-stage non-small cell lung cancer

Lung cancer is the leading cause of cancer-related death in the United States (US) with 224,390 new cases and 158,080 deaths estimated in 2016 (1). For patients with early stage (stage IA–IIA) non-small cell lung cancer (NSCLC), surgical resection provides the best chance for cure (2). In the past decade, stereotactic body radiotherapy (SBRT) has emerged as an alternate to surgical therapy for high medical risk patients with localized disease. Multiple analyses, including meta-analyses and Markov decision models, have suggested oncologic outcomes comparable to resection in medically inoperable patient populations with regard to locoregional control, disease-free survival, and overall survival (3-9). However, the data regarding short-term outcomes, including morbidity and mortality due to treatment, is limited.

Evaluation of Reasons Why Surgical Residents Exceeded 2011 Duty Hour Requirements When Offered Flexibility: A FIRST Trial Analysis.

bechallenging.Withoutgovernment-subsidizedhealthcare,families and patients can spend considerable portions of income on NCD management.6 In our population, only half of the patients with diabetes were receiving therapy before admission. DownstreamconsequencesofNCDs, includingamputation,furtherimpair a family’s or individual’s ability to cover cost of medical care as income from potentially employable individuals is lost.6 Addressing the rapid increase of NCDs in SSA is critical now and represents an opportunity for collaboration among surgeons, physicians,andpublichealthprofessionals.Studylimitationsinclude the retrospective design and incomplete capture of all amputations performed.

The effect of smoking on 30-day outcomes in elective hernia repair

BACKGROUNDnAdverse postoperative outcomes related to smoking are well established, yet current smokers continue to be offered elective surgery in the US. It is unknown whether patients undergoing low-risk, elective procedures, who actively smoke experience increased risk of complications. We sought to determine the increased burden of complications following elective hernia repair procedures in patients identified as current smokers.nnnMETHODSnWe identified patients undergoing elective incisional, inguinal, umbilical, or ventral hernia repair from 2011 to 2014 using the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database. Multivariable logistic regression analysis was used to examine the association between current smoking and 30-day postoperative outcomes, adjusting for demographics and comorbidities.nnnRESULTSnOf 220,629 patients who underwent elective hernia repair, 40,446 (18.3%) self-identified as current smokers within the past 12 months. Current smokers experienced an increased likelihood (Odds Ratio [95% Confidence interval]) of reoperation (OR 1.23 [95% CI 1.11-1.36]), readmission (OR 1.24 [95% CI 1.16-1.32]), and death (OR 1.53 [95% CI 1.06-2.22]). Furthermore, smokers experienced an increased risk of postoperative pulmonary, infectious, and wound complications, but there was no increased risk of requiring transfusion or of postoperative cardiac or thromboembolic events.nnnCONCLUSIONSnCurrent smokers were more likely to experience serious postoperative complications within 30 days. Given the volume of elective hernia surgery performed in the US, encouraging smoking cessation prior to offering elective repair could reduce postoperative complications, reoperation, readmission, and mortality.

Under-treatment of small cell lung cancer: the case for surgical resection

Limited stage (LS) small cell lung cancer (SCLC) has traditionally been treated with chemoradiation but the potential role of surgical treatment in early stage disease remains a topic of debate.

Editorial: Should We Abandon TNM Staging in Favor of Gene Profiles in Node-Positive Melanoma?

Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern Institute for Comparative Effectiveness Research (NICER) in Oncology, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL