Surgical Oncology Insight最新文献

Background

Surgeon-performed intraoperative ultrasound-guided wire localization (IOL) offers an improved patient experience and decreased cost compared to preoperative localization by radiology, yet literature on this technique is sparse. Here we evaluate the safety and margin positivity rate after surgeon-performed IOL for breast cancer.

Methods

Patients with biopsy-proven breast malignancy and planned breast conservation who underwent IOL by a single breast surgeon between 2017–2023 and had follow-up at our institution were retrospectively identified. Patient and tumor characteristics, method of diagnosis, imaging findings, use of oncoplastic surgery, and follow-up data were analyzed.

Results

A total of 137 IOLs were performed for biopsy-proven ductal carcinoma in situ (DCIS) or invasive cancer. The median patient age was 69 years. Most patients had a non-palpable tumor (n = 104, 76.5%). 84.6% of patients underwent pre-operative biopsy by ultrasound guidance, 12.5% by stereotactic guidance, and 2.9% by MRI. In total, 7.3% of patients (n = 10) had positive margins, including 2 with invasive disease at the margin and 8 with DCIS at the margin. Nine patients underwent re-excision for positive or close margins, of which 8 had successful margin-negative breast conservation and 1 patient underwent mastectomy. Thirty-day postoperative complications occurred in 21 patients (15.3%). Of these, most (n = 19, 90.4%) had minor complications including seroma (n = 14), cellulitis (n = 3), and skin allergy (n = 2). At median follow-up of 20.4 months, no patients experienced recurrence.

Conclusions

In our single-surgeon series, IOL is a safe technique for localization of invasive carcinoma and DCIS with margin positivity, re-excision, and postoperative complication rates within previously published ranges.

Synopsis

This study evaluates the safety of and re-excision rates after intraoperative surgeon-performed ultrasound-guided wire localization (IOL) for breast cancer. Results demonstrate margin positivity and re-excision rates equivalent to or lower than rates reported in literature utilizing preoperative localization techniques.

Background

Despite an identified need for palliative surgery to have a clear definition and well-defined therapeutic goals, comprehensive assessment of utilization of the term palliative has not been performed in the surgical literature. The objective of this scoping review is to characterize use of the word palliative in reference to surgery performed for adult general surgery patients.

Methods

Four electronic databases were searched for peer-reviewed articles published from January 2000 to April 2023. Two independent reviewers extracted data and conducted a qualitative thematic synthesis of included studies. Representative analytic themes were generated and agreed upon by all authors.

Results

6906 studies were identified and 222 met inclusion criteria. 96.4% of studies were performed in oncology patient populations. Thematic synthesis revealed two domains: the language of palliative surgery and the evaluation of palliative surgery, each with associated themes. There was wide variability in the use and meaning of the term palliative. Many researchers reported survival as the sole outcome measure and very few studies utilized a validated instrument to quantify post-operative outcomes related to palliation. There was often a misalignment between the patient population, study objectives, study design, and conclusions drawn.

Conclusions

Disparate definitions of palliative surgery and poor study design compromise the validity of studies investigating palliative-intent surgery. Patient-reported and patient-centered outcomes are not routinely measured and lead to unwarranted conclusions. Consistent and accurate use of medical terminology, in addition to proper study design, is required to inform surgeons who counsel patients and families regarding the potential benefits of palliative-intent surgical interventions.

Introduction

The feasibility of the outpatient mastectomy in a rural setting is poorly characterized. The aim of this study is to analyze the efficacy and safety of an outpatient mastectomy program in our tertiary care facility treating rural Appalachian patients.

Methods

We performed a single-institution, retrospective review of all women with breast cancer older than 18 years of age treated with mastectomy with or without immediate alloplastic breast reconstruction at JW Ruby Memorial Hospital from 2019 to 2022. Our primary objective was to determine the 30, 60, and 90-day readmission rates and complications. Our secondary objective analyzed perioperative pain control variables that contribute to appropriate discharge.

Results

We identified thirty-two women between 2019–2022 who underwent same-day mastectomy at JW Ruby Memorial Hospital in Morgantown, West Virginia. Overall readmission rates at 30- 60- and 90-days were 3.1% (n = 1), 9.4% (n = 3) and 9.4% (n = 3), respectively. Two patients were admitted for reasons unrelated to surgery. The patient in the 30-day readmission group required washout for hematoma due to perioperative apixaban making the overall surgical readmission rate 3.1% (n = 1). Preoperatively, 90.6% (n = 29) of women received a local anesthetic block by the anesthesia provider. The mean milligram morphine equivalents received for the duration of the hospital encounter was 15.9 (STD = 10.1).

Conclusion

Outpatient mastectomy is a safe and effective option for eligible patients in rural settings. Careful patient selection and a multidisciplinary team should assess the individual circumstances to determine if outpatient mastectomy is appropriate.

Introduction

Assessment of preoperative function is important for determining fitness for surgery, preoperative optimisation and predicting postoperative morbidity in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). This study explored correlations between preoperative cardiopulmonary exercise testing (CPET) variables, and six-minute walk test (6MWT), five-times sit to stand test (5STS) and Short Form-36 (SF-36) physical component score in patients scheduled for elective CRS-HIPEC.

Methods

This study included patients who underwent preoperative CPET, 6MWT, 5STS and responded to the SF-36 survey prior to elective CRS-HIPEC at Royal Prince Alfred Hospital in Sydney. CPET was performed using a cycle ergometer and measured peak oxygen uptake (VO2 peak) and anaerobic threshold (AT). The associations between preoperative CPET variables and preoperative 6MWT, 5STS and SF-36 were assessed using correlation test.

Results

A total of 133 patients scheduled for elective CRS-HIPEC were included in this study. The median VO₂, AT and VE/VCO₂ were 20.3 [6.5] ml/kg/min, 13.1 [4.9] ml/kg/min and 29 [4.5], respectively. The median 6MWT, 5STS and SF-36 physical component score were 525 m, 9.2 s and 50.2, respectively. CPET variables were significantly correlated with 6MWT (VO₂ r = 0.51; AT r = 0.35; VE/VCO₂ r = −0.25; p < 0.01), 5STS (VO₂ r = −0.32; AT r = −0.27; VE/VCO₂ r = 0.24; p < 0.01) and SF-36 (VO₂ r = 0.42; AT r = 0.38; VE/VCO₂ r = −0.23; p < 0.01).

Conclusions

6MWT, 5STS and SF-36 are at best moderately correlated with CPET variables, which suggests that these tests may serve as adjuncts rather than a replacement to CPET in the clinical setting.

Background

Pancreatic cancer is one of the leading causes of death in Canada and is projected to be the second leading cause of cancer death by 2030. This study sought to evaluate education and income inequalities in pancreatic cancer mortality in Canada between 1990 and 2019.

Methods

Using a unique census division level dataset (n = 280) constructed from the Canadian Vital Statistics Death Database, Canadian Census of Population (1991, 1996, 2001, 2006, 2016), and National Household Survey (2011) we assess socioeconomic inequalities in pancreatic cancer in Canada. Age-standardized Concentration index was used to quantify income and education inequalities in pancreatic cancer mortality. Trends analyses were conducted to assess changes in income and education inequalities in pancreatic cancer mortality over time.

Results

Our results show that crude pancreatic cancer mortality in Canada increased significantly from 10.23 for males and 9.65 for females in 1990, to 15.99 for males and 14.28 for females in 2019, per 100,000 people. The statistically significant negative values of age-standardized Concentration indices suggest persistent income and education inequalities in pancreatic cancer mortality in Canada. Trend analyses indicates reductions in income and education inequalities in pancreatic cancer mortality over time, particularly among females.

Conclusions

Significant income and education inequalities in pancreatic cancer mortality in Canada warrant public policy concern and action. Further research is required to understand whether differential access to treatment across socioeconomic groups played a role in the observed socioeconomic inequalities.

Transhiatal esophagectomy (THE) involves a partially blunt dissection in the posterior mediastinum with incomplete visualization. The technical feasibility and safety of THE following thoracic surgery is unclear. We retrospectively identified cases of patients(5) who underwent transhiatal esophagectomy following major thoracic procedures. All patients had successful Transhiatal resections of esophageal cancer with minimal intraoperative complications (Table 1). THE is a feasible and safe approach, in experienced hands, for patients with previous thoracic surgeries especially in patients who are not candidates for single lung ventilation.

Background

Metastatic sarcoma is an aggressive disease with few effective treatment options. Standard of care for limited pulmonary metastasis is surgical resection, however micrometastasis are often present and go undetected. Here, we determine the maximal tolerated dose and safety of doxorubicin delivered via In Vivo Lung Perfusion (IVLP) for patients with resectable sarcoma pulmonary metastases.

Methods

This is a phase I dose escalation study using doxorubicin during IVLP in sarcoma patients with surgically resectable bilateral pulmonary metastases from 2017 to 2022. While the bilateral disease was surgically resected, only a single side underwent IVLP with doxorubicin at different dose levels (DL 1–3). Intraoperative serum, perfusate and lung tissue were collected and evaluated for doxorubicin levels. Patients were closely monitored intra- and post-operatively for adverse events.

Results

8 patients consented and six patients met the inclusion criteria, while 2 patients had progressive disease before surgery and were excluded. Initial dose of 5ucg/ml perfusate of doxorubicin (DL1) was used in 1 patient, 3 patients had a dose escalation to 7ucg/ml (DL2), 2 patients with the final dose escalation of doxorubicin to 9ucg/ml (DL3). With DL3, lung infiltrates were observed, therefore it was declared as the maximal administered dose and DL2 was deemed to be the recommended phase 2 dose (RP2D). There were no safety concerns during the IVLP procedure and no deaths within the first 90 days.

Conclusions

Here, we demonstrate the safety and feasibility of doxorubicin as a treatment during IVLP for resectable limited pulmonary metastases for sarcomas.

Introduction

Breast cancer among patients under 50 years old accounts for 18% of new cases. Few studies have reported current trends in clinical-pathologic features and treatment patterns for young patients. We evaluated these trends in a modern cohort of breast cancer patients under 50.

Methods

We identified women with breast cancer from the National Cancer Database from 2004–2017. Patients were grouped into 18–29, 30–39, 40–49, and ≥ 50-year cohorts. Proportions and temporal comparisons between demographic, clinicopathologic features, and treatment types were evaluated. Temporal trends across sequential periods were performed.

Results

Of the 2387,902 patients selected, 554,941 (23.3%) were younger than 50. During 2004–2017, the proportions remained stable in the 18–29 (0.5–0.6%) and 30–39 (4.5–5%) age groups, while decreasing in the 40–49 group (absolute difference: −4.8%, p < 0.001). Overall, in those younger than 50, early-stage breast cancer (clinical stage 0-II) increased by 3.9%, while stages III and IV decreased by 2.7% and 1.3% (p < 0.001), respectively. Mastectomy rates and neoadjuvant systemic therapy use increased by 10.4% and 9.8%, respectively (p < 0.001) in all groups under 50.

Conclusions

Despite stable proportions in the youngest age groups (18–29 and 30–39), a noteworthy decrease in the 40–49 age group was observed, suggesting potential shifts in disease detection. The rise in early-stage disease and neoadjuvant systemic therapies should theoretically translate into an increase in the number of breast-conserving candidates. However, the increase in mastectomies highlights the need to better understand the factors influencing treatment decisions in this population.

Background

With the release of the 2015 management guidelines, the American Thyroid Association narrowed the indications for postoperative radioactive iodine (RAI) in well-differentiated thyroid cancer. However, the adoption of new guidelines varies between healthcare entities. The goal of this study was to characterize the appropriateness of RAI use within our health system, before and after the 2015 guideline changes.

Methods

In this retrospective cohort study, we identified patients who were treated for well-differentiated thyroid cancer between 2011–2020. Patients were characterized as “undertreated,” “appropriately treated,” or “overtreated” with RAI. Variation in RAI use was assessed using interrupted time series and multivariable logistic regression analyses.

Results

Among 6310 patients, the mean age was 50 ± 15 years, and 74% were female. There was an immediate drop in the likelihood of receiving RAI after the release of the 2015 guidelines (p = 0.016), and the likelihood of receiving RAI therapy continued to significantly decline over time (OR 0.83, p < 0.001). Despite this trend in the absolute rate of RAI use, there was a significant increase in overtreatment with RAI after the release of the 2015 guidelines (p < 0.001), indicating imperfect uptake of the new criteria. Two hospitals within the health system were identified as disproportionate contributors to overtreatment (Hospital 4: OR 6.50, p < 0.001; Hospital 6: OR 8.63, p < 0.001).

Conclusions

While the use of postoperative RAI was largely appropriate across our health system, rates of guideline adherence differed between hospitals. Efforts to standardize treatment protocols systemwide may enable more rapid and consistent uptake of new management guidelines.