Laurence E. McCahill

Variability in Reexcision Following Breast Conservation Surgery

CONTEXT Health care reform calls for increasing physician accountability and transparency of outcomes. Partial mastectomy is the most commonly performed procedure for invasive breast cancer and often requires reexcision. Variability in reexcision might be reflective of the quality of care. OBJECTIVE To assess hospital and surgeon-specific variation in reexcision rates following partial mastectomy. DESIGN, SETTING, AND PATIENTS An observational study of breast surgery performed between 2003 and 2008 intended to evaluate variability in breast cancer surgical care outcomes and evaluate potential quality measures of breast cancer surgery. Women with invasive breast cancer undergoing partial mastectomy from 4 institutions were studied (1 university hospital [University of Vermont] and 3 large health plans [Kaiser Permanente Colorado, Group Health, and Marshfield Clinic]). Data were obtained from electronic medical records and chart abstraction of surgical, pathology, radiology, and outpatient records, including detailed surgical margin status. Logistic regression including surgeon-level random effects was used to identify predictors of reexcision. MAIN OUTCOME MEASURE Incidence of reexcision. RESULTS A total of 2206 women with 2220 invasive breast cancers underwent partial mastectomy and 509 patients (22.9%; 95% CI, 21.2%-24.7%) underwent reexcision (454 patients [89.2%; 95% CI, 86.5%-91.9%] had 1 reexcision, 48 [9.4%; 95% CI, 6.9%-12.0%] had 2 reexcisions, and 7 [1.4%; 95% CI, 0.4%-2.4%] had 3 reexcisions). Among all patients undergoing initial partial mastectomy, total mastectomy was performed in 190 patients (8.5%; 95% CI, 7.2%-9.5%). Reexcision rates for margin status following initial surgery were 85.9% (95% CI, 82.0%-89.8%) for initial positive margins, 47.9% (95% CI, 42.0%-53.9%) for less than 1.0 mm margins, 20.2% (95% CI, 15.3%-25.0%) for 1.0 to 1.9 mm margins, and 6.3% (95% CI, 3.2%-9.3%) for 2.0 to 2.9 mm margins. For patients with negative margins, reexcision rates varied widely among surgeons (range, 0%-70%; P = .003) and institutions (range, 1.7%-20.9%; P < .001). Reexcision rates were not associated with surgeon procedure volume after adjusting for case mix (P = .92). CONCLUSION Substantial surgeon and institutional variation were observed in reexcision following partial mastectomy in women with invasive breast cancer.

Surgical Resection of Primary Tumors in Patients Who Present With Stage IV Colorectal Cancer: An Analysis of Surveillance, Epidemiology, and End Results Data, 1988 to 2000

BackgroundSurgical resection of the primary tumor for patients who present with incurable stage IV colorectal cancer is controversial. National practice patterns have not been described. We evaluated the use of primary tumor resection in patients presenting with stage IV colorectal cancer.MethodsPatients with stage IV colorectal cancer diagnosed between 1988 and 2000 were selected from the Surveillance, Epidemiology, and End Results database. Patients undergoing primary tumor resection were analyzed on the basis of sex, race, year of diagnosis, and the anatomical site of the primary tumor. We compared the survival of resected and nonresected patients.ResultsA total of 17,658 (66%) of the 26,754 patients presenting with stage IV colorectal cancer underwent primary tumor resection. Patients with resected disease were more likely to be young (mean age of 67.1 vs. 70.3 years) and to have right-sided tumors (75.3%, 73.0%, and 45.6%, respectively, for right, left, and rectal; P < .001). In all age groups, patients undergoing resection had higher median and 1-year survival rates (colon: 11 vs. 2 months, 45% vs. 12%, P < .001; rectum: 16 vs. 6 months, 59% vs. 25%, P < .001) when compared with patients who did not undergo resection.ConclusionsMost patients who present with stage IV colorectal cancer undergo resection of the primary tumor. The proportion of patients undergoing resection depends on patient age and race and the anatomical location of the primary tumor. The degree to which case selection explains the treatment and survival differences observed is not known. Further investigation of the role of surgery in the management of incurable stage IV colorectal cancer is warranted.

Primary mFOLFOX6 Plus Bevacizumab Without Resection of the Primary Tumor for Patients Presenting With Surgically Unresectable Metastatic Colon Cancer and an Intact Asymptomatic Colon Cancer: Definitive Analysis of NSABP Trial C-10

PURPOSE Major concerns surround combining chemotherapy with bevacizumab in patients with colon cancer presenting with an asymptomatic intact primary tumor (IPT) and synchronous yet unresectable metastatic disease. Surgical resection of asymptomatic IPT is controversial. PATIENTS AND METHODS Eligibility for this prospective, multicenter phase II trial included Eastern Cooperative Oncology Group (ECOG) performance status 0 to 1, asymptomatic IPT, and unresectable metastases. All received infusional fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6) combined with bevacizumab. The primary end point was major morbidity events, defined as surgical resection because of symptoms at or death related to the IPT. A 25% major morbidity rate was considered acceptable. Secondary end points included overall survival (OS) and minor morbidity related to IPT requiring hospitalization, transfusion, or nonsurgical intervention. RESULTS Ninety patients registered between March 2006 and June 2009: 86 were eligible with follow-up, median age was 58 years, and 52% were female. Median follow-up was 20.7 months. There were 12 patients (14%) with major morbidity related to IPT: 10 required surgery (eight, obstruction; one, perforation; and one, abdominal pain), and two patients died. The 24-month cumulative incidence of major morbidity was 16.3% (95% CI, 7.6% to 25.1%). Eleven IPTs were resected without a morbidity event: eight for attempted cure and three for other reasons. Two patients had minor morbidity events only: one hospitalization and one nonsurgical intervention. Median OS was 19.9 months (95% CI, 15.0 to 27.2 months). CONCLUSION This trial met its primary end point. Combining mFOLFOX6 with bevacizumab did not result in an unacceptable rate of obstruction, perforation, bleeding, or death related to IPT. Survival was not compromised. These patients can be spared initial noncurative resection of their asymptomatic IPT.

Laparoscopic approaches to resection of suspected gastric gastrointestinal stromal tumors based on tumor location

BackgroundSurgical resection of gastric gastrointestinal stromal tumor (GIST) should be optimized to achieve a negative pathologic surgical margin while limiting the extent of stomach volume loss. Careful identification of exact gastric tumor location using preoperative computed tomography (CT) scans and gastroscopy should allow for selection of a specific operative approach.MethodsThis retrospective case series involved 12 patients (7 men and 5 women; mean age, 60.5 years) with suspected gastric GIST undergoing tumor resection at Fletcher Allen Health Care, a university medical center, from January 2005 to August 2006. The main outcome measures were pathologic resection margins, operative time, estimated blood loss (EBL), morbidity, and duration of hospital stay.ResultsThe 12 patients were separated into three groups on the basis of tumor location as follows: type 1 (fundus/greater curvature, n = 5), type 2 (prepyloric/antrum, n = 3), and type 3 (lesser curvature/perigastroesophageal junction, n = 4). Preoperative imaging (CT scan and/or endoscopy) used to identify tumor location accurately predicted the operative approach before surgery for 11 of the12 patients. The surgical approach was selected solely by tumor location as follows: type 1 (laparoscopic partial gastrectomy [LPG]), type 2 (laparoscopic distal gastrectomy [LDG]), and type 3 (laparoscopic transgastric resection [LTG]). Nine patients had a final pathologic diagnosis of GIST. The average tumor size was 4.6 cm, but this did not influence procedure selection. Histologic margins were microscopically negative in all patients. The LPG and LTG approaches had similar outcomes in terms of estimated blood loss (EBL; 80 vs 100 ml) and hospital stay (3.4 vs 3.3 days; p = 0.0198), but LTG had longer operative times (236 vs 180 min). The LDG procedure had longer operative times, greater EBL, and a longer hospital stay. The operative morbidity was 17%, and there was no operative mortality.ConclusionThe selection of an operative technique for resection of gastric submucosal tumors can be based on preoperative identification of tumor location, for better definition of both the extent of gastric resection and the technical complexity of the laparoscopic procedure.

Indications and use of palliative surgery-results of society of surgical oncology survey

Background: Despite increasing attention to end-of-life care in oncology, palliative surgery (PS) remains poorly defined. A survey to test the definition, assess the extent of use, and evaluate attitudes and goals of surgeons regarding PS was devised.Methods: A survey of Society of Surgical Oncology (SSO) members.Results: 419 SSO members completed a 110-item survey. Surgeons estimated 21% of their cancer surgeries as palliative in nature. Forty-three percent of respondents felt PS was best defined based on pre-operative intent, 27% based on post-operative factors, and 30% on patient prognosis. Only 43% considered estimated patient survival time an important factor in defining PS, and 22% considered 5-year survival rate important. The vast majority (95%) considered tumor still evident following surgery in a patient with poor prognosis constituted PS. Most surgeons felt PS could be procedures due to generalized illness related to cancer (80%) or related to cancer treatment complications (76%). Patient symptom relief and pain relief were identified as the two most important goals in PS, with increased survival the least important.Conclusion: PS is a major portion of surgical oncology practice. Quality-of-life parameters, not patient survival, were identified as the most important goals of PS.

Arterioportal fistulas : Introduction of a novel classification with therapeutic implications

Arterioportal fistulas (APFs) are arteriovenous communications between the splanchnic arteries and the portal vein that represent an infrequent cause of presinusoidal portal hypertension. They can be acquired or congenital. Penetrating hepatic trauma, including liver biopsies, represent the most common etiology. They can be asymptomatic or manifest with portal hypertension. An abdominal bruit is a valuable physical finding. Persistence of an APF can cause hepatoportal sclerosis and possibly portal fibrosis. A detailed radiologic evaluation is mandatory. One must differentiate between small peripheral intrahepatic APFs (type 1) and large central APFs (type 2). The former usually resolve spontaneously, whereas the latter can cause portal hypertension and hepatic parenchymal changes. Type 1 APFs caused by needle injury can be followed by Doppler ultrasound. All other fistulas need treatment. Arterioportal fistulas are first treated by transcatheter embolization. Surgical approaches are reserved for complex cases. Congenital APFs (type 3) are diffuse and intrahepatic and can be difficult to manage. Overall, the prognosis is good. Herein, we propose a novel classification for arterioportal fistulas with therapeutic implications.

A prospective evaluation of palliative outcomes for surgery of advanced malignancies.

Background: We prospectively evaluated the effectiveness of major surgery in treating symptoms of advanced malignancies.Methods: Fifty-nine patients were evaluated for major symptoms of intent to treat and were followed up until death or last clinical evaluation. Surgeons identified planned operations before surgery as either curative or palliative and estimated patient survival time. An independent observer assessed symptom relief. A palliative surgery outcome score was determined for each symptomatic patient.Results: Surgeons identified 22 operations (37%) as palliative intent and 37 (63%) as curative intent. The median overall survival time was 14.9 months and did not differ between curative and palliative operations. Surgical morbidity was high but did not differ between palliative (41%) and curative (44%) operations. Thirty-three patients (56%) were symptomatic before surgery, and major symptom resolution was achieved after surgery in 26 (79%) of 33. Good to excellent palliation, defined as a palliative surgery outcome score >70, was achieved in 64% of symptomatic patients.Conclusions: Most symptomatic patients with advanced malignancies undergoing major operations attained good to excellent symptom relief. Outcome measurements other than survival are feasible and can better define the role of surgery in multimodality palliative care. A new outcome measure to evaluate major palliative operations is proposed.

Quality Measures for Breast Cancer Surgery: Initial Validation of Feasibility and Assessment of Variation Among Surgeons

OBJECTIVES To identify and quantify surgical outcomes as possible quality measures of initial breast cancer surgery and to assess variation among surgeons. DESIGN Descriptive analysis of concurrently collected outcome measures. SETTING University hospital with a designated breast cancer center. PATIENTS Patients with a preoperative diagnosis of invasive breast cancer or ductal carcinoma in situ undergoing their initial cancer surgery from April 1, 2003, to March 30, 2008. MAIN OUTCOME MEASURES Eight measures were identified: (1) total mastectomy rate; (2) close (<1 mm) and positive margin rate following initial partial mastectomy; (3) number of operations required in breast conservation; (4) number of nodes obtained from sentinel lymph node biopsy; (5) number of nodes from axillary dissection; (6) proportion of patients with positive sentinel lymph node biopsy undergoing axillary dissection; (7) use of intraoperative lymph node assessment; and (8) time from diagnosis to surgery. RESULTS Nine hundred ten operations (218 for ductal carcinoma in situ, 692 for invasive breast cancer) were performed by 6 surgeons. Variation existed among surgeons in the combined close and positive margin rate, number of nodes obtained from sentinel lymph node biopsy, and use of intraoperative lymph node assessment. No significant variation was seen for the overall mastectomy rate, mean number of operations, positive margin rate alone, and number of lymph nodes from axillary dissection. CONCLUSIONS Quality indicators for breast cancer surgery can be identified and readily monitored. Outcome variation exists at a high-volume breast center. Further study into the causes and effects of this variation on short- and long-term patient outcomes as well as health care costs is needed.

When the Sun Can Set on an Unoperated Bowel Obstruction: Management of Malignant Bowel Obstruction

Mr XY is a 75-year-old man with known recurrent rectosigmoid adenocarcinoma in the pelvis. He had an emergency Hartmann’s procedure 2 years earlier for a bowel perforation caused by tumor. The patient had been offered a surgical intervention 3 months earlier for the recurrent pelvic mass visualized on CT, but he declined any additional surgical intervention. No metastatic disease was noted at that time. He had no symptoms of bowel obstruction at the time, although there were signs of minimal proximal bowel dilatation. He presented to the Emergency Department on three separate occasions in a 3-week period with nausea, vomiting, abdominal cramping, and no colostomy output. A partial small bowel obstruction was confirmed on plain film x-rays. Clinically, the patient was in good condition and had no physical inhibitions. He was treated with nasogastric decompression on each occasion and the symptoms quickly resolved and bowel function resumed. On the first two occasions, he was able to eat a regular diet and return home within 3 to 5 days of being admitted to the hospital. He had a small bowel follow-through after the second obstruction episode, which was nondiagnostic. After the third episode, a lengthy conversation was undertaken with the patient about his goals and concerns related to an operation. This revealed fears of the pain related to surgery. After discussion about the likelihood of continued episodes of bowel obstruction and the assurance that diligent perioperative pain management would be practiced, including the possible use of an epidural catheter, he agreed to have an operation. The goals of restoring his capacity to eat, and the hope of allowing him to remain home without multiple readmissions to the hospital, were clearly delineated. We believed that the obstruction was most likely from a single site at his pelvic recurrence, and we were likely to achieve these goals. It was made clear to the patient that he could have more disease or adhesions than expected, making a definitive surgical approach difficult or impossible, and necessitating alternative therapies. He was told that even with surgery, bowel obstruction and wound complications could occur in the future. At operation, there were extremely dense adhesions throughout his entire peritoneal cavity, especially in the pelvis. He did not have peritoneal carcinomatosis, although he did have tumor nodules throughout his liver. The source of the bowel obstruction was difficult to locate because no area of decompressed bowel was found, and extensive adhesiolysis was required. The colostomy site was closely inspected to ensure that it was not the site of obstruction. Ultimately, a loop of very distal small bowel was adherent to a pelvic tumor mass overlaying the iliac vessels and ureter. The small bowel was folded on itself, creating a small blind loop. The decision was made to do a small resection instead of a bypass.This was accomplished with a primary anastamosis without complication. Postoperatively, the patient’s bowel function was slow to resume. Otherwise, he recovered uneventfully and went home 8 days after the operation. One month after operation he remains at home without symptoms or signs of recurrent bowel obstruction.

Patient and surgeon decision making regarding surgery for advanced cancer

PURPOSE/OBJECTIVES To describe a program of research related to outcomes of palliative surgery and focus on one phase of this research involving decision making by patients and surgeons considering surgery for advanced disease. DESIGN Descriptive. SAMPLE 10 patients undergoing surgery and 3 oncology surgeons. METHODS Qualitative interviews were conducted with patients and their surgeons pre- and postoperatively. Transcripts were content analyzed to identify major themes in patient and surgeon interviews based on study questions. MAIN RESEARCH VARIABLES Decision making, palliative surgery, quality of life. FINDINGS The study findings highlight the issues of greatest concern to patients and surgeons considering palliative surgery. This phase was an important component of the overall program of palliative surgery research. CONCLUSIONS Comprehensive care for patients with advanced cancer seeks to achieve a balance of providing aggressive care, ensuring optimum symptom management, and maintaining a focus on comfort. Further study of palliative surgery as an aspect of interdisciplinary care is warranted. IMPLICATIONS FOR NURSING Patients undergoing surgery for advanced disease require expert nursing care to address quality-of-life concerns. Further research is needed in this area.