Kristine Kuchta

Patient satisfaction with nipple-sparing mastectomy: A prospective study of patient reported outcomes using the BREAST-Q

The authors sought to study patient‐reported outcomes following nipple‐sparing mastectomy (NSM).

Thyroid lobectomy is not sufficient for T2 papillary thyroid cancers

Background: 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. Methods: 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. Results: 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. Conclusion: 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.

Ideal Characteristics of a Laser-Protected Endotracheal Tube: ABEA and AHNS Member Survey and Biomechanical Testing

Objectives: To determine the characteristics of laser-protected endotracheal tubes (LPETs) valued by otolaryngologists performing transoral laser surgery in the head and neck and to measure LPET stiffness. Methods: An online questionnaire was completed by American Broncho-Esophagological Association (ABEA) and American Head and Neck Society (AHNS) members. LPET distal end compliance was measured in a biomechanics laboratory. Results: A total of 228 out of 2109 combined ABEA and AHNS members completed the survey. The following LPET characteristics, which were properties of the Medtronic Laser-Shield II tube (MLST), were highly valued: softness and flexibility, surface smoothness, and a tight-to-shaft balloon (all P < .01). Prior to industry-driven discontinuation of the MLST, 52% of surgeons (78% of fellowship-trained laryngologists [FTLs]) reported using it; afterward, 58% reported using the stainless steel, Mallinckrodt Laser-Flex tube (MLFT). Forty-six percent of all respondents (69% of FTLs) did not consider cost being a factor in LPET choice. Biomechanical testing revealed the distal end of the MLST to be 3.45 times more compliant than the MLFT (P < .01). Conclusion: Members of the ABEA and AHNS, particularly FTLs, highly value distinguishing properties of the now discontinued MLST. Manufacturers should consider this in the design of new LPETs.

Neoadjuvant and adjuvant chemotherapy use in upper tract urothelial carcinoma

OBJECTIVE To determine trends in neoadjuvant and adjuvant chemotherapy use for upper tract urothelial cancer and assess its effects on survival. MATERIALS AND METHODS We identified all patients diagnosed with upper tract urothelial cancer who underwent surgical treatment in the SEER-Medicare database from 2002 to 2011. We collected and analyzed patient demographic, clinical, and pathologic characteristics. We strictly defined neoadjuvant and adjuvant chemotherapy and studied patients who met such criteria. Multivariable Cox proportional hazards models identified were used to identify independent predictors of overall and cancer-specific survival. RESULTS A total of 3,432 patients met inclusion criteria, and their median age was 77 years. Overall, 86.4% of patients underwent surgery alone, 1.8% received neoadjuvant chemotherapy plus surgery, and 11.8% underwent surgery and adjuvant chemotherapy. Neoadjuvant chemotherapy use increased during the study period. Gemcitabine, carboplatin, cisplatin, and paclitaxel were the most commonly used agents. Cancer-specific survival at 5 years was 65.0% (95% CI: 63.2%-66.8%). Cox proportional hazards modeling controlling for sex, race, year of diagnosis, location, and pathologic stage revealed that higher pathologic nodal stage, tumor size>3cm, increased age, and carcinoma in situ predicted for worse survival. CONCLUSION Age, nodal stage, and tumor size>3cm predict for worse cancer-specific survival. Neoajduvant chemotherapy is underused.

Characterization of common bile duct injury after laparoscopic cholecystectomy in a high-volume hospital system

BackgroundDespite the popularity of laparoscopic cholecystectomy, rates of common bile duct injury remain higher than previously observed in open cholecystectomy. This retrospective chart review sought to determine the prevalence of, and risk factors for, biliary injury during laparoscopic cholecystectomy within a high-volume healthcare system.Methods800 of approximately 3000 cases between 2009 and 2015 were randomly selected and retrospectively reviewed. A single reviewer examined all operative notes, thereby including all cases of BDI regardless of ICD code or need for a second procedure. Biliary injuries were classified per Strasberg et al. (J Am Coll Surg 180:101–125, 1995). Logistic regression models were utilized to identify univariable and multivariable predictors of biliary injuries.Results31.0% of charts stated that the Critical View of Safety was obtained, and 12.4% of charts correctly described the critical view in detail. Three patients (0.4%) had a cystic duct leak, and 4 (0.5%) had a common bile duct injury. Of the four CBDI, three patients had a partial transection of the CBD and one had a partial stricture. Patients who suffered BDI were more likely to have had lower hemoglobin, urgent surgery, choledocholithiasis, or acutely inflamed gallbladder. Multivariable analysis of BDI risk factors showed higher preoperative hemoglobin to be independently protective against CBDI. Acutely inflamed gallbladder and choledocholithiasis were independently predictive of CBDI.ConclusionsThe rate of CBDI in this study was 0.5%. Acutely inflamed conditions were risk factors for biliary injury. Multivariable analysis suggests a protective effect of higher preoperative hemoglobin. There was no correlation of CVS with prevention of biliary injury, although only 12.4% of charts could be verified as following the technique correctly. Better implementation of CVS, and increased caution in patients with perioperative inflammatory signs, may be important for preventing bile duct injury. Additionally, counseling patients with acute inflammation on increased risk is important.

Axillary Surgery for Early-Stage, Node-Positive Mastectomy Patients and the Use of Postmastectomy Chest Wall Radiation Therapy

BackgroundWe 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).MethodsUsing 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.ResultsOf 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.ConclusionsSurgeons 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.

PD39-04 COMBINED PLACEMENT OF ARTIFICIAL URINARY SPHINCTER AND INFLATABLE PENILE PROSTHESIS DOES NOT INCREASE RISK OF PERIOPERATIVE COMPLICATIONS OR IMPACT LONG-TERM DEVICE SURVIVAL

OBJECTIVE To determine the impact of concurrent inflatable penile prosthesis (IPP) and artificial urinary sphincter (AUS) implantation on perioperative complications and long-term device survival, among men with postprostatectomy erectile dysfunction and urinary incontinence. METHODS We identified men older than 65 treated with radical prostatectomy in the Surveillance, Epidemiology, and End Results Medicare database between 2002 and 2016. IPP or AUS placement was determined by current procedural terminology (CPT) code, with dual implantation (DI) defined as IPP and AUS placement on the same date. Device survival was assessed using CPT codes for device removal, replacement, and/or repair. Complications were assessed within 90 days using ICD-9 codes. Statistical analysis was performed using SAS v9.3 (Cary, NC). RESULTS A total of 37,599 men underwent radical prostatectomy, with AUS placed in 793 (2.1%), IPP placed in 644 (1.7%), and DI in 62 (0.2%). Relative to AUS placement alone, men undergoing DI were younger (68.8 vs 70.2 years, P = 0.03), but had equivalent Charlson comorbidity index, tumor grades, and rates of prior radiotherapy. Relative to IPP placement alone, men were more likely to undergo DI if treated with adjuvant or salvage radiotherapy. The incidence of complications within 30 and 90 days of prosthetic implantation did not differ between groups. Long-term device survival on Kaplan-Meier analysis was not impacted by DI relative to single device implantation with median follow-up of 61 months. CONCLUSION Combined AUS and IPP placement does not adversely affect perioperative complications or device survival relative to placement of either device alone.

Neoadjuvant Chemoradiation Shows No Survival Advantage to Chemotherapy Alone in Stage IIIA Patients

BACKGROUND For operable patients with clinical stage IIIA non-small cell lung cancer, the optimum neoadjuvant treatment strategy remains unclear. Our aim was to compare perioperative and long-term outcomes for patients receiving neoadjuvant chemoradiotherapy (NCRT) versus neoadjuvant chemotherapy (NCT) alone. METHODS We queried the National Cancer Database to identify all patients with N2 and either T1-T2 non-small cell lung cancer who received either NCRT or NCT followed by lobectomy between 2006 and 2012. Patients with T3 tumors were excluded. A propensity match analysis was performed incorporating preoperative variables, and the incidence of postoperative complications, pathologic downstaging, and long-term survival were compared. RESULTS In all, 1,936 patients met criteria, 745 NCT and 1,191 NCRT. The NCRT patients were younger, less likely to be treated at an academic medical center, and more likely to have adenocarcinoma. After propensity matching, patients in the NCT group showed lower 30-day mortality (1.3% versus 2.9%) and 90-day mortality (2.9% versus 6.0%), and were more likely to undergo a minimally invasive resection (25.7% versus 14.1%). The NCRT patients were more likely to have a pathologic complete response (14.2% versus 4.0%) and to be N0 at the time of resection (45.2% versus 38.7%). In the multivariable analysis, NCRT patients were at a greater risk of mortality than NCT patients (hazard ratio 1.18, 95% confidence interval: 1.03 to 1.36). CONCLUSIONS In our cohort, combined neoadjuvant chemotherapy and radiation therapy was associated with improved pathologic downstaging but showed increased perioperative mortality with no improvement in long-term overall survival. For stage IIIA patients with smaller tumors without local invasion, chemotherapy alone may be the preferred neoadjuvant treatment.

Does adjuvant radiation provide any survival benefit after an R1 resections for pancreatic cancer

Background: 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. Methods: 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. Results: 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). Conclusion: 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.)

Abstract 97: Unilateral versus Bilateral Mastectomy and Reconstruction

Sarday, M ay 9, 2018 METHODS: In this prospective study we sampled previously implanted samples of ADM. These ADMs were implanted during the first stage of tissue expander based immediate breast reconstruction, and a 1cm squared sample was excised during the stage II expander-implant exchange procedure. Samples were incubated and cultured for 48 hours in tryptic soy broth. Those samples which showed growth were further cultured on tryptic soy broth and blood agar plates. Patient records were also analyzed, to determine if ADM sterilization and microbial growth were correlated with infectious complications following the stage I and stage II operations.