Journal of Surgical Oncology最新文献

Background/objectives: Intraoperative peripheral margin sampling in soft tissue sarcoma (STS) is a routine practice among musculoskeletal oncologists. Practice patterns are variable, and evidence to support it is lacking. Rates of peripheral margin sampling at our institution were analyzed in addition to its clinical utility and cost-effectiveness.

Methods: Peripheral margin sampling patterns at a tertiary sarcoma center were retrospectively evaluated. Concordance between peripheral margins and final pathology was assessed using McNemar's test and κ Coefficient. Clinical outcomes were compared, and a cost-utility analysis was performed.

Results: A total of 179 patients were included. 66% had peripheral margins sampled of which 23% had frozen margins analyzed. Ten patients had positive margins (5.5% of all patients; 8.4% in those with margins sampled) and R1 margins on the final tumor specimen were identified in 15 patients (8.4%). There were no R2 resections. Three patients underwent repeat surgical resection (20%). Three patients with R1 resections had negative peripheral margins sampled, suggesting falsely reassuring peripheral margins. Peripheral margin sampling averaged $5000/patient.

Conclusions: Routine peripheral margin sampling in STS resection is of questionable utility with added cost. Prospective studies are warranted to determine the optimal approach to surgical margin assessment.

Background and objectives: Routine intraoperative peripheral margin sampling is often employed by musculoskeletal surgical oncologists. Several recommendations exist regarding this practice pattern. It is unknown what the practice patterns of Musculoskeletal Tumor Society (MSTS) members are. Evidence-based data to support or refute this practice is currently lacking. We developed an anonymous survey with two primary objectives. To determine the practice patterns of active MSTS members with respect to intraoperative peripheral margin sampling and to elucidate the most common rationale for routine sampling.

Methods: An anonymous survey was distributed through the MSTS to 320 active members. Results were collected with a branching logic fashion via Microsoft Forms®.

Results: Surveys were sent to 320 MSTS members in 2021. A total of 108 responses were collected. A total of 55 (51%) respondents noted that they routinely send intraoperative peripheral margins. Primary reasons for margin assessment included concerns about adequacy of margins. Members who routinely send frozen margins sent on average 4-6 specimens.

Conclusions: There is significant variability in this practice amongst MSTS members. Given there is no evidence to support or refute this practice, Further investigation is required to determine the clinical utility of routine intraoperative peripheral margin sampling.

Introduction: Pancreatic adenocarcinoma (PDAC) is a challenging disease, with outcomes influenced by several factors including socioeconomic status. The area deprivation index (ADI) has been used to understand how neighborhood disadvantages affect healthcare outcomes. Prior research has indicated that a higher ADI, reflective of a greater neighborhood disadvantage, is associated with an increased risk of major complications and unplanned readmission following PDAC resection. This study aimed to extend this investigation to the Northwell Health System in New York and explore the association between neighborhood ADI and surgical outcomes in patients with PDAC.

Methods: A retrospective analysis of the Northwell Health multicenter pancreatic cancer database from 2014 to 2023 included patients who underwent PDAC resection. The ADI scores were divided into low (1-3), moderate (4-6), and high (7-10), as previously described. Multinomial regression models and Kaplan-Meier log-rank tests were used to compare differences in surgical outcomes between the patients in each ADI group.

Results: Out of 314 PDAC patients who underwent resection and had available ADI data, 116 (36.9%) were in the low, 163 (51.9%) in the moderate, and 35 (11.2%) in the high ADI category. The median ADI score was 4 (IQR: 3-5). Adjusted multinomial regression analysis revealed the following disparities: compared to the low ADI group, patients in the moderate ADI group demonstrated a significantly higher risk of diabetes (RR: 1.76, 95% CI 1.06-2.90, p = 0.028); high ADI was associated with a poorer response to neoadjuvant therapy (RR 3.13, 95% CI 1.11-8.82, p = 0.031), higher incidence of microscopic positive margins (RR 1.87, 95% CI 1.11-5.17, p = 0.028), increased severe complications (Clavien-Dindo class III-IV) (RR 1.36, 95% CI 1.04-1.80, p = 0.027), and a higher failure-to-rescue (FTR) rate (RR 1.44, 95% CI 1.12-1.85, p = 0.048). Although readmission and mortality rates at 30 and 90 days did not show significant differences (p > 0.05), the Kaplan-Meier log-rank test indicated a marked disparity in survival probabilities among ADI ranks (p = 0.0025).

Conclusion: This study underscores a pronounced survival disparity across ADI categories among PDAC patients, suggesting an association between socioeconomic status and postoperative survival. Consideration of patient ADI may guide tailored healthcare strategies, such as the distribution of navigation and resources, to bridge the gap in survival outcomes and ensure equitable care for all socioeconomic strata.

Management of peritoneal surface malignancies is currently entrusted to a multimodality approach. Computed tomography (CT) scan remains the first imaging method despite the limitations in identifying small implants in critical regions. Magnetic resonance imaging is usually recommended for its performance in small implants, mesentery, and small bowel assessment. Positron emission tomography/CT plays an important role only in pseudomyxoma peritonei. Thus, becoming aware of the imaging strengths and drawbacks and having a multimodality imaging approach might be the best option for the patients.

Background: Chondrosarcoma accounts for 20% of all bony sarcomas and may present with extraosseous extension (EOE). The presence of an extraosseous component, along with positive surgical margins, has been separately associated with increased risk of local recurrence and decreased survival. This study compared the outcomes between patients with EOE, EOE and positive margins, and a control chondrosarcoma cohort with neither feature.

Methods: This was a retrospective review of 91 patients over a consecutive 13-year period. Data including treatment details and outcomes were included. Thirty-two patients had EOE of their chondrosarcoma, 7 patients had positive margins and EOE, and 52 chondrosarcoma patients had neither characteristic. Tumor characteristics, patient demographics, and overall survival, recurrence rates, and metastatic rates were compared among the three groups.

Results: Patients with positive surgical margins and EOE were noted to have significantly higher resection grade, dedifferentiation on presentation, and use of adjuvant chemotherapy compared to control. Patients with EOE alone were noted to have significantly higher grade and use of adjuvant chemotherapy compared to control. Patients with positive surgical margins and EOE additionally had significantly higher rates of mortality, recurrence, and metastasis on survival analysis compared to control. However, patients with EOE alone did not have significantly different survival rates compared to control.

Conclusion: This study is one of the first to analyze the survival impact of EOE with positive surgical margins in chondrosarcoma. The significance found in mortality, recurrence, and metastatic rates in this unique subgroup may warrant further longitudinal observation and dictate future treatment options.

Intramedullary nailing (IMN) is a common option for managing impending or pathologic fractures of the humerus secondary to metastatic disease. We sought to assess the (1) early complications, (2) failure rates and mechanisms, and (3) functional outcomes. A systematic review using the PubMed, Embase, and Cochrane databases was performed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The study was registered on PROSERO (CRD42023406905). The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used for quality assessment. Studies describing postoperative outcomes of patients with impending or pathologic fractures of the humerus treated with IMN were included. Implant failure was classified into mechanical and nonmechanical causes. Functional outcomes were assessed via the Musculoskeletal Tumor Society (MSTS) score. Overall, 41 studies comprising 1431 patients were included. Early complications occurred in 5.5% of patients, with 2.8% of patients having systemic complications. The overall implant failure rate was 4.9%, and the mean MSTS score at the last follow-up was 79.9%. IMN was associated with good postoperative functional outcomes and low implant failure rates. Systemic complications were the most common type of early complication, and tumor progression was the main cause of implant failure. LEVEL OF EVIDENCE: III.

Introduction: Recent advancements in glioma treatment are largely driven by the identification of genetic alterations, which enhance diagnostic precision and prognostic assessments, and unveil potential therapeutic targets. TERT promoter mutations, in particular, are associated with a poorer prognosis and aggressive clinical behavior.

Methodology: This study explores the genetic interplay between TERT and other genes (ntrk, pdl1, alk, idh, p53, egfr, her2) in brain tumors through an integrative literature review. This method synthesizes evidence from selected articles spanning 2014 to 2023.

Results: The review identified 65 articles based on defined inclusion criteria, out of which 14 were analyzed in depth. Findings reveal that TERT, TP53, and IDH1 are the most frequently mutated genes in gliomas. The prognosis of glioma patients can be refined through the combined analysis of IDH and TERT mutations. Additionally, PD-L1 expression levels are associated with prognosis and may influence treatment responses, particularly, in immunotherapy.

Discussion: The study underscores the importance of molecular diagnostics, such as Next-Generation Sequencing (NGS), in detecting key genetic mutations. These advancements have paved the way for new therapeutic strategies and better patient outcomes. The findings highlight the crucial role of genetic markers in glioma treatment and prognosis, advocating for continued research to enhance clinical applications and patient care.

Conclusion: The use of NGS is indispensable in identifying biomarkers associated with mutations in the TERT gene.

Background and objectives: Indication for sentinel lymph node (SLN) biopsy in ductal carcinoma in situ (DCIS) patients with high-upstaging risk remains inconsistent. Our previous systematic review and meta-analysis had reported five variables that were significantly higher in the upstaging group. We developed the "high-risk upstaging model" and investigated its predictivity and accuracy.

Methods: The study included patients initially diagnosed with DCIS in a medical center between 2011 and 2020. Patients' clinicopathological data were obtained through web-based surgical medical record database. Two prediction models were built, in which patients who met at least one (Model A) or two (Model B) of the predictors would be predicted to upstage in the final pathology. We compared the accuracy of our models with National Comprehensive Cancer Network (NCCN) guideline and original data.

Results: The analyses included 249 patients, of which 67 DCIS patients upstaged in final pathology. The excess treatment in Model A (70%) was lower than the original data (80.2%). The incomplete treatment in Model A (3%) was lower than the NCCN guideline model (38.8%) and the original data (7.5%). Both Model A and Model B yielded a higher receiver operating characteristic (AUC) curve compared with original data.

Conclusions: Our Model A derived from the systematic review of the real-world data reduced the incomplete treatment rate of SLNB. Our Model B also showed the highest predictive value. With the two models, we provided a clearer indication for surgeons to perform SLNB in DCIS patients and demonstrated proof of concept, allowing ready input of patient data.