Annals of Surgical Oncology

Sentinel lymph node biopsy (SLNB) has recently been used to detect occult lymph node metastases. The aim of this study was to assess the feasibility and clinical efficacy of SLNB in the treatment of clinically node-negative papillary thyroid carcinoma. A total of 114 consecutive patients with clinically node-negative papillary thyroid carcinoma were enrolled and underwent SLNB. After injection of 1% methylene blue around the tumors, blue-stained sentinel lymph nodes (SLN) were collected from the central compartments. All the patients underwent total thyroidectomy with bilateral central compartment neck dissection after SLNB. SLN were identified in 84 (73.7%) of the 114 patients. Of these 84 patients, 24 (28.6%) had metastases in the SLN. Among the 60 patients who had no metastases in their SLN in frozen biopsy samples, seven had metastatic foci in their SLN in the permanent biopsy samples and six had metastases in their non-SLN samples. Central compartment lymph node metastases were detected in 11 of the 30 patients in whom SLN were not identified. Thus, the sensitivity, specificity, and positive and negative predictive values of SLNB were 64.9, 100, 100, and 78.3%, respectively. The false-positive and false-negative rates were 0 and 35.1%, respectively. The detection of SLN led to no major complications. SLNB using methylene blue in papillary thyroid carcinoma is a safe and technically feasible procedure. However, it is of limited use in the management of clinically node-negative papillary thyroid carcinoma because of low sensitivity and a high false-negative rate.

Disparities in colon cancer care and outcomes by race/ethnicity, socioeconomic status (SES), and insurance are well recognized; however, the extent to which inequalities are driven by patient factors versus variation in hospital performance remains unclear. We sought to compare disparities in care delivery and outcomes at low- and high-performing hospitals. We identified patients with stage I–III colon adenocarcinoma from the 2012–2017 National Cancer Database. Adequate lymphadenectomy and timely adjuvant chemotherapy administration defined hospital performance. Multilevel regression models evaluated disparities by race/ethnicity, SES, and insurance at the lowest- and highest-performance quartile hospitals. Of 92,573 patients from 704 hospitals, 45,982 (49.7%) were treated at 404 low-performing hospitals and 46,591 (50.3%) were treated at 300 high-performing hospitals. Low-performing hospitals treated more non-Hispanic (NH) Black, Hispanic, low SES, and Medicaid patients (all p < 0.01). Among low-performing hospitals, patients with low versus high SES (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.82–0.92), and Medicare (OR 0.90, 95% CI 0.85–0.96) and Medicaid (OR 0.88, 95% CI 0.80–0.96) versus private insurance, had decreased odds of receiving high-quality care. At high-performing hospitals, NH Black versus NH White patients (OR 0.83, 95% CI 0.72–0.95) had decreased odds of receiving high-quality care. Low SES, Medicare, Medicaid, and uninsured patients had worse overall survival at low- and high-performing hospitals (all p < 0.01). Disparities in receipt of high-quality colon cancer care occurred by SES and insurance at low-performing hospitals, and by race at high-performing hospitals. However, survival disparities by SES and insurance exist irrespective of hospital performance. Future steps include improving low-performing hospitals and identifying mechanisms affecting survival disparities.

The functional consequences of resecting the femoral nerve in conjunction with soft tissue sarcoma management are not well described. In comparison, sciatic nerve involvement by sarcoma was once considered an indication for amputation, but sciatic resection is now commonly performed as part of a limb-salvage approach. We compared functional outcomes following resection of either the femoral or sciatic nerve in patients with soft tissue sarcoma. We also compared both groups with patients with large thigh sarcomas without nerve involvement. The prospectively collected database from a tertiary referral center for sarcomas was retrospectively reviewed to identify all patients with resection of the femoral nerve performed during wide excision of a soft tissue sarcoma. Patient demographics, treatment, complications, and functional outcomes in the form of the Musculoskeletal Tumor Society (MSTS) 1987 score, MSTS 1993 score, and Toronto Extremity Salvage Score (TESS) were collected. Control groups of sarcoma patients with sciatic nerve resection in the thigh as well as similarly sized tumors in the quadriceps requiring no nerve resections were also analyzed. Ten patients with femoral nerve resections were identified, all women, aged 47–78 years, with large soft tissue sarcomas of varied subtypes. All patients received adjuvant radiotherapy, most preoperatively. Six patients developed fractures during long-term follow-up, four in nonirradiated portions of the skeleton but directly from falls related to absent active knee extensors, and two at least partially attributable to sequelae of radiation. MSTS 1987 hip scores demonstrated one excellent, four good, and five fair results. MSTS 1993 hip scores averaged 71.4 ± 17.2% and TESS averaged 61.7 ± 21.8. There were no significant differences between the functional scores for patients with femoral or sciatic nerve resections (P = 1.0). Femoral nerve resection appears more morbid than anticipated. The falls to which patients were prone, even years after surgery, subject them to ongoing long-term risks for fractures and other injuries. These nerve-specific functional implications should be considered when counseling patients in preparation for possible resection of the femoral nerve when it is directly involved by a soft tissue sarcoma.

Hepatocellular carcinoma (HCC) primarily affects patients with a cirrhotic liver. Reports on the characteristics of patients with HCC in noncirrhotic liver, as well as predictors of recurrence and survival, are scarce. Between 1992 and 2011, 334 patients treated for HCC in noncirrhotic liver were identified from three major hepatobiliary centers. Clinicopathological characteristics were analyzed and independent predictors of recurrence and overall survival were identified using Cox proportional hazards models. Median patient age was 58 years and 77 % were male. Most patients had a solitary (81 %) and poorly or undifferentiated tumor (56 %); median size was 6.5 cm. The majority of patients (96 %) underwent liver resection (microscopically negative margins in 94 %), whereas a few had transarterial chemoembolization or transplantation (4 %). Median recurrence-free survival (RFS) was 2.5 years, and 1- and 5-year RFS was 71.1, and 35 %, respectively. Elevated alkaline phosphatase levels [hazards ratio (HR) = 1.82], poor tumor differentiation (HR = 1.4), macrovascular invasion (HR = 2.18), and the presence of satellite lesions (HR = 1.9), or intrahepatic metastases (HR = 2.59) were independently associated with shorter RFS; in contrast, an intact tumor capsule independently prolonged RFS (HR = 0.46). Median overall survival was 5.9 years, and 1- and 5-year overall survival was 86.9, and 54.5 %, respectively. Tumor size ≥5 cm (HR = 2.27), macrovascular (HR = 2.72) or adjacent organ invasion (HR = 3.34), and satellite lesions (HR = 2.18) were independently associated with shorter overall survival, whereas an intact tumor capsule showed a protective effect (HR = 0.51). Following resection of HCC in the setting of no cirrhosis, more than one-half of patients were alive after 5 years. However, even among patients with no cirrhosis, recurrence was common. Factors associated with RFS and overall survival included tumor characteristics, such as tumor capsule, satellite lesions, and vascular invasion.

The volume-outcome hypothesis suggests that if increased provider procedure volume is associated with improved patient outcomes, then greater regionalization to high-volume providers should improve region-level outcomes. Quality improvement interventions for pancreas cancer surgery implemented in year 1999 in Ontario, Canada were designed to regionalize surgery to high-volume hospitals and decrease operative mortality. Similar interventions were not used in Quebec, Canada. We assessed the volume-outcome hypothesis and the impact of the Ontario quality improvement interventions. Administrative databases helped identify pancreatic resections from years 1994 to 2004 and relevant patient and hospital characteristics. Hospitals were high-volume if they provided ≥10 procedures in a given calendar year. Outcomes were regionalization of surgery to high-volume providers and rates of operative mortality. From 1994 to 2004 the percentage of cases in high-volume hospitals increased from 33 to 71% in Ontario and from 36 to 76% in Quebec. Annual rates of operative mortality dropped in Ontario (10.4–2.2% or less) and changed little in Quebec (7.2–9.8%). Changes in measures over time in both provinces were similar before and after year 1999. Regionalization was associated with improved operative mortality in Ontario but not in Quebec, undermining the volume-outcome hypothesis. The Ontario quality improvement interventions likely were of little influence since patterns in regionalization and operative mortality were similar before and after year 1999.