Annals of Surgical Oncology

This study was designed to develop a more robust predictive model, beyond T-stage alone, for incidental gallbladder cancer (IGBC) for discovering locoregional residual (LRD) and distant disease (DD) at reoperation, and estimating overall survival (OS). T-stage alone is currently used to guide treatment for incidental gallbladder cancer. Residual disease at re-resection is the most important factor in predicting outcomes. All patients with IGBC who underwent reoperation at 10 institutions from 2000 to 2015 were included. Routine pathology data from initial cholecystectomy was utilized to create the gallbladder cancer predictive risk score (GBRS). Of 449 patients with gallbladder cancer, 262 (58 %) were incidentally discovered and underwent reoperation. Advanced T-stage, grade, and presence of lymphovascular (LVI) and perineural (PNI) invasion were all associated with increased rates of DD and LRD and decreased OS. Each pathologic characteristic was assigned a value (T1a: 0, T1b: 1, T2: 2, T3/4: 3; well-diff: 1, mod-diff: 2, poor-diff: 3; LVI-neg: 1, LVI-pos: 2; PNI-neg: 1, PNI-pos: 2), which added to a total GBRS score from 3 to 10. The scores were separated into three risk-groups (low: 3–4, intermediate: 5–7, high: 8–10). Each progressive GBRS group was associated with an increased incidence LRD and DD at the time of re-resection and reduced OS. By accounting for subtle pathologic variations within each T-stage, this novel predictive risk-score better stratifies patients with incidentally discovered gallbladder cancer. Compared with T-stage alone, it more accurately identifies patients at risk for locoregional-residual and distant disease and predicts long-term survival as it redistributes T1b, T2, and T3 disease across separate risk-groups based on additional biologic features. This score may help to optimize treatment strategy for patients with incidentally discovered gallbladder cancer.

The choice of a local control (LC) modality for Ewing sarcoma (EWS) of the femur is controversial. This study aimed to determine the effect of LC modality on tumor LC and patient outcomes. The study reviewed the treatment and outcomes for 115 patients who had EWS of the femur treated with similar chemotherapy in three cooperative group trials. Patient outcomes were analyzed according to the LC modality using the log-rank test and the cumulative incidence of local or distant failure using competing risks regression. The median age of the patients was 13 years. The most common tumor location was the proximal femur followed by the mid femur. For 55 patients with available data, the tumor was larger than 8 cm in 29 patients and 8 cm or smaller in 26 patients. For 84 patients (73 %), surgery only was performed, whereas 17 patients (15 %) had surgery plus radiation, and 14 patients (12 %) had radiation only. The 5-year event-free survival (EFS) rate was 65 % (95 % confidence interval [CI], 55–73 %), and the 5-year overall survival (OS) rate was 70 % (95 % CI, 61–78 %). Patient outcomes did not differ significantly according to tumor location within the femur (proximal, mid or distal) or tumor size (<8 vs ≥8 cm). The findings showed no statistically significant differences in EFS, OS, cumulative incidence of local failure, or cumulative incidence of distant failure according to LC modality (surgery, surgery plus radiation, or radiation). The LC modality did not significantly affect disease outcome for EWS of the femur. Further study of treatment complications and functional outcome may help to define the optimal LC modality.

Oncoplastic surgical techniques offer an option of breast conserving surgery for larger tumors with the use of glandular reshaping to prevent postoperative deformity. A technique for the excision of lower inner quadrant tumors via a V incision is described, the lower-inner quadrant-V (LIQ-V) mammoplasty, and the results of a pilot study are reported. Retrospective collection of pre- and postoperative data was collected from patients undergoing a LIQ-V mammoplasty for a LIQ tumor. Twenty-two patients were operated on between 2004 and 2011 at a mean age of 58 years. The mean follow-up was 55 months. The mean resection weight was 101 g for tumors ranging in size from 4 to 31 mm. The margins were clear in 95 % of cases. There was one case of local recurrence and metastatic disease. The cosmetic outcome was judged as excellent in 68 % of cases, and no patient required further ipsilateral or contralateral symmetrizing surgery. The deformity often associated with tumors of the LIQ is adequately addressed by this new technique. It has a complication rate comparable to other mammoplasty series and a high rate of clear resection margins. Many oncoplastic surgery techniques are based on inverted T mammoplasty, but these are not suited for all tumor locations. The LIQ-V mammoplasty is an adaptation of the standard techniques that best suit the LIQ. It is oncologically safe and provides disease-free margins, and although the resection volumes are large, the cosmetic outcome is not compromised.

Most patients with melanoma have a thin (≤1.00 mm) lesion. There is uncertainty as to which patients with thin melanoma should undergo sentinel lymph node (SN) biopsy. We sought to quantify the proportion of SN metastases in patients with thin melanoma and to determine the pooled effect of high-risk features of the primary lesion on SN positivity. Published literature between 1980 and 2015 was searched and critically appraised. Primary outcome was the proportion of SN metastases in patients with thin cutaneous melanoma. Secondary outcomes included the effect of high-risk pathological features of the primary lesion on the proportion of SN metastases. Summary measures were estimated by Mantel–Haenszel method using random effects meta-analyses. Sixty studies (10,928 patients) met the criteria for inclusion. Pooled SN positivity was 4.5 % [95 % confidence interval (CI) 3.8–5.2 %]. Predictors of a positive SN were: thickness ≥0.75 mm [adjusted odds ratio (AOR) 1.90 (95 % CI 1.08–3.34); with a likelihood of SN metastases of 8.8 % (95 % CI 6.4–11.2 %)]; Clark level IV/V [AOR 2.24 (95 % CI 1.23–4.08); with a likelihood of 7.3 % (95 % CI 6.2–8.4 %)]; ≥1 mitoses/mm2 [AOR 6.64 (95 % CI 2.77–15.88); pooled likelihood 8.8 % (95 % CI 6.2–11.4 %)]; and the presence of microsatellites [unadjusted OR 6.94 (95 % CI 2.13–22.60); likelihood 26.6 % (95 % CI 4.3–48.9 %)]. The pooled proportion of SN metastases in thin melanoma is 4.5 %. Thickness ≥0.75 mm, Clark level IV/V, mitoses, and microsatellites significantly increased the odds of SN positivity and should prompt strong consideration of SN biopsy.

Lymphatic mapping and sentinel lymph node dissection (LM/SLND) for surgical staging of cutaneous primary melanoma is currently being evaluated, but the role of these techniques in recurrent (secondary) melanoma is largely unexplored. Our experience with 12 patients indicates the potential usefulness of LM/SLND in the management of locally recurrent melanoma at subcutaneous sites. We have even used mapping to localize the sentinel node draining a subcutaneous local recurrence after previous LM/SLND for primary melanoma. The application of LM/SLND may therefore be extended beyond primary melanoma management as we understand more about the technical issues and appropriate selection of patients.

This multicenter analysis evaluated patient outcome and clinical pathologic features of thymic epithelial tumors after complete surgical resection and adjuvant treatment. Histologic classification and clinical staging were performed according to WHO classification and Masaoka staging system, respectively. We analyzed 62 patients, 20 (32 %) of whom had myasthenia at diagnosis. Clinical and pathologic staging was as follows: 31 (50 %) and 30 (48 %) patients had stage I disease, 19 (30 %) and 22 (35 %) stage II, 5 (8 %) and 3 (6 %) stage III, 2 (4 %) and 2 (3 %) stage IVa, and 5 (8 %) and 5 (8 %) stage IVb, respectively. Histologic examination revealed 11 (19%) type A tumors, 19 (30%) type AB tumors, 7 (12 %) type B1 tumors, 11 (17 %) type B2 tumors, 11 (17 %) type B3 tumors, and 3 (5 %) type C tumors. Adjuvant therapies comprised chemotherapy in 3 (5 %) patients and radiotherapy in 16 (26 %) patients. Median follow-up was 71 months (range 1–145). DFS and OS at 48, 60, and 72 months were 89 and 89 %, 86 and 97 %, and 95% and 92%, respectively. Myasthenia at the onset of disease (P = 0.18 for DFS; P = 0.97) and tumor size >5 cm (P = 0.94 for DFS; P = 0.56) were not prognostic factors. TETs are rare and indolent tumors. Complete surgical resection followed by adjuvant therapies, such as chemotherapy and/or radiotherapy, in patients at risk of recurrence show very good DFS and OS results, even in cases with radically resected pleural-pulmonary metastases.

Gastric cancer continues to be a major global health problem. In the American College of Surgeons Patient Care study on gastric cancer, 5-year disease-specific survival was 26%, with an overall survival of 14%. Improvements in survival will require both earlier diagnosis and new therapeutic strategies. The ability of surgical oncologists to understand the natural history of the disease, accurately define its extent, and provide the most effective treatment places them in a key position to see that improvements in outcome are brought about expeditiously.