Sameer A. Patel

Time to Surgery and Breast Cancer Survival in the United States.

IMPORTANCE Time to surgery (TTS) is of concern to patients and clinicians, but controversy surrounds its effect on breast cancer survival. There remains little national data evaluating the association. OBJECTIVE To investigate the relationship between the time from diagnosis to breast cancer surgery and survival, using separate analyses of 2 of the largest cancer databases in the United States. DESIGN, SETTING, AND PARTICIPANTS Two independent population-based studies were conducted of prospectively collected national data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database and the National Cancer Database (NCDB). The SEER-Medicare cohort included Medicare patients older than 65 years, and the NCDB cohort included patients cared for at Commission on Cancer-accredited facilities throughout the United States. Each analysis assessed overall survival as a function of time between diagnosis and surgery by evaluating 5 intervals (≤30, 31-60, 61-90, 91-120, and 121-180 days) and disease-specific survival at 60-day intervals. All patients were diagnosed with noninflammatory, nonmetastatic, invasive breast cancer and underwent surgery as initial treatment. MAIN OUTCOMES AND MEASURES Overall and disease-specific survival as a function of time between diagnosis and surgery, after adjusting for patient, demographic, and tumor-related factors. RESULTS The SEER-Medicare cohort had 94 544 patients 66 years or older diagnosed between 1992 and 2009. With each interval of delay increase, overall survival was lower overall (hazard ratio [HR], 1.09; 95% CI, 1.06-1.13; P < .001), and in patients with stage I (HR, 1.13; 95% CI, 1.08-1.18; P < .001) and stage II disease (HR 1.06; 95% CI, 1.01-1.11; P = .01). Breast cancer-specific mortality increased with each 60-day interval (subdistribution hazard ratio [sHR], 1.26; 95% CI, 1.02-1.54; P = .03). The NCDB study evaluated 115 790 patients 18 years or older diagnosed between 2003 and 2005. The overall mortality HR was 1.10 (95% CI, 1.07-1.13; P < .001) for each increasing interval, significant in stages I (HR, 1.16; 95% CI, 1.12-1.21; P < .001) and II (HR, 1.09; 95% CI, 1.05-1.13; P < .001) only, after adjusting for demographic, tumor, and treatment factors. CONCLUSIONS AND RELEVANCE Greater TTS is associated with lower overall and disease-specific survival, and a shortened delay is associated with benefits comparable to some standard therapies. Although time is required for preoperative evaluation and consideration of options such as reconstruction, efforts to reduce TTS should be pursued when possible to enhance survival.

Preoperative Delays in the US Medicare Population With Breast Cancer

PURPOSE Although no specific delay threshold after diagnosis of breast cancer has been demonstrated to affect outcome, delays can cause anxiety, and surgical waiting time has been suggested as a quality measure. This study was performed to determine the interval from presentation to surgery in Medicare patients with nonmetastatic invasive breast cancer who did not receive neoadjuvant chemotherapy and factors associated with a longer time to surgery. METHODS Medicare claims linked to Surveillance, Epidemiology, and End Results data were reviewed for factors associated with delay between the first physician claim for a breast problem and first therapeutic surgery. RESULTS Between 1992 and 2005, 72,586 Medicare patients with breast cancer had a median interval (delay) between first physician visit and surgery of 29 days, increasing from 21 days in 1992 to 32 days in 2005. Women (29 days v 24 days for men; P < .001), younger patients (29 days; P < .001), blacks and Hispanics (each 37 days; P < .001), patients in the northeast (33 days; P < .001), and patients in large metropolitan areas (32 days; P < .001) had longer delays. Patients having breast conservation and mastectomies had adjusted median delays of 28 and 30 days, respectively, with simultaneous reconstruction adding 12 days. Preoperative components, including imaging modalities, biopsy type, and clinician visits, were also each associated with a specific additional delay. CONCLUSION Waiting times for breast cancer surgery have increased in Medicare patients, and measurable delays are associated with demographics and preoperative evaluation components. If such increases continue, periodic assessment may be required to rule out detrimental effects on outcomes.

Improved operative efficiency of free fibula flap mandible reconstruction with patient-specific, computer-guided preoperative planning

Free fibula osteocutaneous flaps are the primary option for reconstruction after segmental mandibulectomies. This study evaluates the impact of CT‐guided preoperative planning on operative outcomes after free fibula mandible reconstruction.

A theoretical model describing arterial flow in the DIEP flap related to number and size of perforator vessels

BACKGROUND The deep inferior epigastric perforator flap is rapidly becoming a more widely employed method of autologous breast reconstruction. The technical considerations involved in the execution of the flap are many and include the selection of perforators to be incorporated in the flap. We attempt to give a mathematical explanation, based on the physics of flow through vessels and the properties of circuits with multiple resistances in parallel, for the clinical observations which have been arrived at through clinical experience. METHODS We compare the system of perforators to a circuit with multiple resistances in parallel. Each of these resistances represents a perforator vessel. In the event that there is only one perforator vessel, this simplifies to a single resistance in series with the capillary bed perfusing the flap. RESULTS The flow through the flap is optimized by incorporation of the largest diameter perforator. Inclusion of other smaller perforators in addition to the largest diameter perforator will reduce the overall resistance, but this reduction in resistance is dependent on the diameter of the additional perforator and may not be worth the additional trauma of dissection and increased operative time. Incorporating several smaller perforators at the expense of excluding the largest diameter perforator appears to increase the overall resistance, unless the smaller perforators are only slightly smaller. CONCLUSIONS We conclude that the best perfused flap involves use of the largest diameter vessel, that although adding additional perforators will decrease the resistance and increase flow, the magnitude of the benefit depends largely on the calibre of the additional perforator, and that this benefit needs to be weighed against the downside of increased muscle and facial trauma.

Surgery in the Multimodality Treatment of Sinonasal Malignancies

M alignancies of the paranasal sinuses represent a rare and biologically heterogeneous group of cancers. Understanding of tumor biology continues to evolve and will likely facilitate the development of improved treatment strategies. For example, some sinonasal tumors may benefit from treatment through primarily nonsurgical approaches, whereas others are best addressed through resection. The results of clinical trials in head and neck cancer may not be generalizable to this heterogeneous group of lesions, which is defined anatomically rather than through histogenesis. Increasingly sophisticated pathologic assessments and the elucidation of molecular markers, such as the human papilloma virus (HPV), in sinonasal cancers have the potential to transform the clinical management of these malignant neoplasms. Published reports often suggest that treatment approaches that include surgery result in better local control and survival. However, many studies are marked by selection bias. The availability of effective reconstruction makes increasingly complex procedures possible, with improved functional outcomes. With advances in surgery and radiation, the multimodal treatment of paranasal sinus cancers is becoming safer. The use of chemotherapy remains a subject of active investigation.

Reliability of venous couplers for microanastomosis of the venae comitantes in free radial forearm flaps for head and neck reconstruction.

The radial forearm free flap has gained popularity in head and neck reconstruction after oncologic resection because of its versatility. This popularity has only intensified with the advances in technique and instrumentation. Although debated in the past, the success of using the deep venae comitantes system for flap drainage is well documented. Although the use of couplers in a variety of flap anastomoses has been described in the literature, to our knowledge this is the first series presented on the use of couplers in small, deep system venae comitantes. We retrospectively examined our experience in 61 patients who underwent radial forearm free flaps for head and neck reconstruction. Of the 61 patients, 22 anastomoses were hand sewn, and 39 anastomoses were performed using venous couplers. No flap losses occurred in the group in whom venous couplers were used. In addition, no intraoperative thromboses, arterial or venous, were noted with coupler use. Our series demonstrates that the venous coupler is a safe and effective alternative to the hand-sewn anastomosis of the radial forearm free flap venous comitantes in head and neck reconstruction.

Principles and practice of reconstructive surgery for head and neck cancer.

Reconstruction after surgical treatment of head and neck cancers can be challenging. Goals for reconstruction include restoration of appearance as well as function when appropriate. Commonly encountered sites requiring reconstruction include the soft tissues of the face (including the critical areas of the eyes, ears, nose, and lips), scalp, tongue and oral cavity, maxilla, mandible, and pharynx. Advanced reconstructive techniques using microsurgery may be preferable to simpler techniques to obtain optimal outcomes. In this article, techniques for reconstruction in these areas as well as anticipated outcomes are discussed.

Improvement of the radial forearm flap donor defect by prelamination with human acellular dermal matrix.

The radial forearm free flap is the standard flap used for functional reconstruction of partial glossectomy defects.1–3 Disadvantages of the radial forearm free flap are primarily related to the forearm donor site, which usually requires skin grafting for closure. Complications include skin graft loss, tendon exposure, significant unsightly scaring, and poor texture.4,5 We introduce a new two-stage technique using human acellular dermal matrix (AlloDerm; LifeCell Corp., Branchburg, N.J.) that permits primary closure of the radial forearm free flap donor site at the time of flap elevation.

Asymptomatic Deep Peroneal Vein Thrombosis During Free Fibula Flap Harvest: A Review of the Literature, Strategies for Preoperative Assessment, and an Algorithm for Reconstruction.

AbstractThe free fibula flap is the preferred reconstructive method for oncologic defects of the mandible. Arterial inflow of the extremity is routinely evaluated with several modalities; however, venous screening is rarely performed. Patients with cancer are at elevated risk of occult deep venous thrombosis (DVT). An asymptomatic thrombus encountered during free fibula reconstruction is a serious concern. Although such cases have been reported, we suspect the incidence of DVT during fibula free flap harvest is underappreciated. This monograph uses a case example to review risk factors for occult DVT, present a strategy for preoperative assessment, and provide a reconstructive algorithm to for mandibular reconstruction in such instances.

Reduced-port approach to laparoscopic flap harvest (RALFH): An anterior sheath sparing rectus abdominis flap

Since first described in 1977, the rectus abdominis muscle flap has been a mainstay in the armamentarium of reconstructive surgeons. However, the traditional open technique is associated with significant donor site morbidity, including an unaesthetic incision and an increased incidence of abdominal wall hernias. While laparoscopic assisted tissue harvest has been described, there is a paucity of literature examining the laparoscopic approach to harvesting rectus abdominis muscle flaps without open dissection to access the vascular pedicle. In 2000, Greensmith et al. reported a totally laparoscopic rectus abdominis muscle flap harvest for free tissue transfer requiring five port incisions. Here we report our novel approach in two cases of totally laparoscopic pedicled rectus abdominis muscle flap harvest for reinforcement of the perineum using only two port sites in the reduced port technique.