RESUMEN
BACKGROUND: Although breast cancer (BC) is uncommon in women age ≤ 35 years, women in this age group may have more aggressive cancer subtypes and high-risk pathogenic variants (HRPVs). Higher recurrence and mortality rates in young patients may be related to differences in tumor biology, pathologic mutation status, or treatment. The purpose of this study was to evaluate germline mutation status and other factors that affect recurrence-free survival (RFS) and overall survival (OS) in young women with BC. MATERIALS AND METHODS: This was a retrospective study of women diagnosed with BC at age ≤ 35 years at Allina Health System from 2000 through 2017 (n = 306). Information was collected on germline mutation status, tumor characteristics (grade, hormone receptor, and human epidermal growth factor receptor 2), molecular subtype, pregnancy-associated cancers, and treatment. Survival analyses using Kaplan-Meier curves were conducted for RFS and OS. RESULTS: With mean follow-up of 6.5 years, OS was 87.0% for invasive cancers, RFS was 84.7%; 69% obtained genetic testing, and 26.9% had HRPVs. There were no differences in RFS or OS between patients with HRPV versus unknown/low/moderate risk variants. Recurrence analysis showed increased recurrence rates in luminal B-like cancers followed by triple negative and human epidermal growth factor receptor 2-positive cancers (P = .041). Pregnancy-associated BC diagnoses, angiolymphatic invasion, and tumor stage were associated with reduced OS. In spite of young age at diagnosis, nearly one-third of patients did not receive germline genetic testing. CONCLUSIONS: Similar survival patterns were found between women with HRPV versus no known mutations. Luminal B-like subtype, pregnancy-associated BC, angiolymphatic invasion, and cancer stage were associated with reduced OS.
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Neoplasias de la Mama/mortalidad , Neoplasias de la Mama/terapia , Supervivencia sin Enfermedad , Mutación de Línea Germinal , Adulto , Neoplasias de la Mama/genética , Femenino , Humanos , Recurrencia Local de Neoplasia , Estadificación de Neoplasias , Pronóstico , Estudios RetrospectivosRESUMEN
BACKGROUND AND OBJECTIVES: Preoperative breast magnetic resonance imaging (B-MRI) staging in newly diagnosed breast cancer increases detection of synchronous contralateral findings, but may result in false-positive outcomes. This study objective was to identify women more likely of having mammographically occult, MRI detected contralateral breast cancer (CBC). METHODS: We performed a retrospective review of patients who had preoperative B-MRI prior to surgery from 2010 to 2015 and collected patient imaging and clinicopathologic data. Multivariate logistic regression was used to identify predictors of CBC. RESULTS: MRI resulted in contralateral findings in 201 of 1894 patients (10.6%). Overall 3.2% (60 of 1894) had synchronous CBC detected on B-MRI. The majority of CBCs (n = 60) were stage 0 or IA (85.0%), hormone receptor positive (94.9%), human epidermal growth factor receptor 2 (HER2/neu) negative (89.7%), and low/intermediate pathological grade (87.2%). Women more likely to have CBC were older (P < .001), had lobular index cancer (P = .03), and estrogen receptor (ER)+ (P = .027) or progesterone receptor (PR)+ (P = .002) tumors. On multivariate analysis (receiver operating characteristic curve area = 0.75), PR + status (P = .022), and older age (P = .004) were predictive of CBC. CONCLUSIONS: Preoperative MRI is most effective in detecting early stage, hormone receptor-positive CBC in older women.
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Neoplasias de la Mama/diagnóstico por imagen , Neoplasias Primarias Múltiples/diagnóstico por imagen , Adulto , Anciano , Neoplasias de la Mama/patología , Neoplasias de la Mama/cirugía , Femenino , Humanos , Modelos Logísticos , Imagen por Resonancia Magnética/métodos , Mastectomía/métodos , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias Primarias Múltiples/patología , Neoplasias Primarias Múltiples/cirugía , Valor Predictivo de las Pruebas , Cuidados Preoperatorios/métodos , Estudios RetrospectivosRESUMEN
Clinical management of microinvasive breast cancer (Tmic) remains controversial. Although metastases are infrequent in Tmic carcinoma patients, surgical treatment typically includes lymph node sampling. The objective of this study was to determine the rate and predictors of lymph node metastases, recurrence, and survival in a large series of Tmic breast carcinomas. Consecutive cases of Tmic were identified within our health care system from 2001 to 2015. We reviewed results of lymph node sampling and other pathologic factors including hormone receptor/HER2 status, associated in situ tumor size/grade, margin status, number of invasive foci, surgical/adjuvant therapies, and recurrence/survival outcomes. In this cohort, 294 Tmic cases were identified with mean follow-up of 4.6 years. Of 260 patients who underwent axillary staging, lymph node metastases were identified in 1.5% (all of which were ductal type). All Tmic cases with positive lymph node metastases had associated DCIS with size > 5 cm (5.3-8.5 cm) compared to a median DCIS tumor size of 2.5 cm (0.2-19.0 cm) for the entire cohort. No lymph node metastases were seen with microinvasive lobular carcinoma. During the follow-up period, there were no regional/distant recurrences or breast cancer-associated deaths in a mean follow-up period of 4.6 years. Two patients developed subsequent ipsilateral breast cancer (DCIS) in a different quadrant than the original Tmic. Clinical behavior of microinvasive breast cancer in this series is similar to DCIS. Lymph node metastases are uncommon and were only seen with ductal type microinvasive carcinoma. Our data suggest limited benefit for routine node sampling and support management of Tmic similar to DCIS, particularly for patients with DCIS < 5 cm in size.
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Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/patología , Carcinoma Intraductal no Infiltrante/patología , Carcinoma Lobular/patología , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/terapia , Carcinoma Ductal de Mama/terapia , Carcinoma Intraductal no Infiltrante/terapia , Carcinoma Lobular/terapia , Terapia Combinada , Femenino , Humanos , Metástasis Linfática , Persona de Mediana Edad , Invasividad Neoplásica , Estudios Retrospectivos , Biopsia del Ganglio Linfático CentinelaRESUMEN
BACKGROUND: Invasive ductal carcinoma (IDC) and invasive lobular carcinoma (ILC) have distinct clinical, pathologic, and genomic characteristics. The objective of the current study was to compare the relative impact of adjuvant chemotherapy on the survival of patients with ILC versus those with IDC. METHODS: Women with estrogen receptor (ER)-positive, human epidermal growth factor receptor 1 (HER2) -negative, stage I/II IDC and ILC who received endocrine therapy were identified from the 2000 to 2014 California Cancer Registry. Patient, tumor, and treatment characteristics were collected. Ten-year overall survival (OS) was estimated using the Kaplan-Meier method and Cox proportional-hazards modeling. RESULTS: In total, 32,997 women with IDC and 4638 with ILC were identified. The receipt of chemotherapy significantly decreased during the study for both subtypes. For patients with IDC, the 10-year OS rate was 95% among those who received endocrine therapy alone versus 93% (P < .01) among those who received endocrine therapy plus chemotherapy. For patients with ILC, the 10-year OS rate was 94% among those who received endocrine therapy alone versus 92% (P < .01) among those who received endocrine therapy plus chemotherapy. After adjusting for patient and treatment factors, adjuvant chemotherapy was significantly associated with a decreased 10-year hazard of death for patients with IDC (hazard ratio, 0.83; 95% confidence interval, 0.74-0.92). In contrast, adjuvant chemotherapy was not independently associated with the adjusted 10-year hazard of death for patients with ILC (hazard ratio, 1.14; 95% confidence interval, 0.90-1.46). CONCLUSIONS: Adjuvant chemotherapy was not associated with improved OS for patients with ER-positive, HER2-negative, stage I/II ILC. Avoidance of ineffective chemotherapy will markedly reduce the adverse effects and economic burden of breast cancer treatment for a large proportion of patients with breast cancer. Cancer 2017;123:3015-21. © 2017 American Cancer Society.
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Antineoplásicos/uso terapéutico , Neoplasias de la Mama/tratamiento farmacológico , Carcinoma Ductal de Mama/tratamiento farmacológico , Carcinoma Lobular/tratamiento farmacológico , Sistema de Registros , Adolescente , Adulto , Factores de Edad , Anciano , Neoplasias de la Mama/metabolismo , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/metabolismo , Carcinoma Ductal de Mama/patología , Carcinoma Lobular/metabolismo , Carcinoma Lobular/patología , Quimioterapia Adyuvante , Femenino , Humanos , Estimación de Kaplan-Meier , Mastectomía , Mastectomía Segmentaria , Persona de Mediana Edad , Clasificación del Tumor , Estadificación de Neoplasias , Modelos de Riesgos Proporcionales , Radioterapia Adyuvante , Receptor ErbB-2/metabolismo , Receptores de Estrógenos/metabolismo , Receptores de Progesterona/metabolismo , Estudios Retrospectivos , Clase Social , Tasa de Supervivencia , Resultado del Tratamiento , Adulto JovenRESUMEN
As the incidence of melanoma and the number of melanoma survivors continues to rise, optimal surveillance strategies are needed that balance the risks and benefits of screening in the context of contemporary resource use. Detection of recurrences has important implications for clinical management. Most current surveillance recommendations for melanoma survivors are based on low-level evidence with wide variations in practice patterns and an unknown clinical impact for the melanoma survivor.
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Melanoma/diagnóstico , Recurrencia Local de Neoplasia/diagnóstico , Neoplasias Cutáneas/diagnóstico , Detección Precoz del Cáncer , Humanos , SobrevivientesRESUMEN
PURPOSE: To evaluate recurrence and survival for patients with occult (T0N+) breast cancer who underwent contemporary treatment, assessing outcomes for breast conservation and mastectomy. METHODS: We performed a single-institution review of women with occult breast cancer presenting with axillary metastasis without identifiable breast tumor or distant metastasis. We excluded patients with tumors in the axillary tail or mastectomy specimen, patients with additional nonbreast cancer diagnoses, and patients with a history of breast cancer. Breast conservation was defined as axillary node dissection with radiation therapy, without breast surgery. We evaluated patient, tumor, treatment, and outcome variables. Patients were assessed for local, regional, and distant recurrences. Overall survival was calculated using the Kaplan-Meier method. RESULTS: Thirty-six patients met criteria for occult breast cancer. Most of these patients (77.8 %) had N1 disease. Fifty percent of cancers (n = 18) were estrogen receptor-positive; 12 (33.3 %) were triple-negative. All patients were evaluated with mammography. Thirty-five patients had breast ultrasound (97.2 %) and 33 (91.7 %) had an MRI. Thirty-four patients (94.4 %) were treated with chemotherapy and 33 (91.7 %) with radiotherapy. Twenty-seven patients (75.0 %) were treated with breast conservation. The median follow-up was 64 months. There were no local or regional failures. One distant recurrence occurred >5 years after diagnosis, resulting in a 5-years overall survival rate of 100 %. There were no significant survival differences between patients receiving breast conservation versus mastectomy (p = 0.7). CONCLUSIONS: Breast conservation-performed with contemporary imaging and multimodality treatment-provides excellent local control and survival for women with T0N+ breast cancer and can be safely offered instead of mastectomy.
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Neoplasias de la Mama/terapia , Carcinoma Ductal de Mama/terapia , Carcinoma Lobular/terapia , Mastectomía Segmentaria , Recurrencia Local de Neoplasia/terapia , Adulto , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias de la Mama/mortalidad , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/mortalidad , Carcinoma Ductal de Mama/patología , Carcinoma Lobular/mortalidad , Carcinoma Lobular/patología , Terapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Escisión del Ganglio Linfático , Mamografía , Persona de Mediana Edad , Recurrencia Local de Neoplasia/mortalidad , Recurrencia Local de Neoplasia/patología , Estadificación de Neoplasias , Pronóstico , Tasa de Supervivencia , Ultrasonografía MamariaRESUMEN
BACKGROUND: Mediastinoscopy (MED) and endobronchial ultrasonography with transbronchial needle aspiration (EBUS-TBNA) have similar accuracy for mediastinal lymph node sampling (MLNS). The threatened financial and environmental sustainability of our health care system mandate that surgeons consider cost and environmental impact in clinical decision making of similarly effective procedures. We performed a cost and waste comparison of MED versus EBUS-TBNA for MLNS to raise awareness of the financial and environmental implications of our practices. METHODS: We conducted a retrospective review of outpatients who underwent MLNS under general anesthesia in the OR with MED or EBUS-TBNA (September 2007 to December 2009). We analyzed direct costs based on hospital charges, calculated expected payment using a decision support model, and profit margins (modeled expected payment-direct costs). Our waste comparison was measured in kilograms of solid waste per case. RESULTS: We performed MLNS in 148 patients (89 EBUS-TBNA, 39 MED, 20 EBUS + MED). Direct costs were lower for MED ($2,356) compared with EBUS-TBNA ($2,503), whereas expected payment was greater (MED, $3,449; EBUS-TBNA, $3,249), resulting in a profit margin that was $347 greater for MED. The amount of solid waste for each MED was 1.8 kg versus 0.5 kg for EBUS-TBNA. CONCLUSIONS: MED costs less than EBUS-TBNA in the OR setting but generates 3.6 times the amount of EBUS-TBNA waste. The cost of EBUS-TBNA may improve by performance in the endoscopy suite, and surgical pack revision could reduce the amount of MED solid waste. This comparison sets the stage for sophistication of our clinical decision making, taking into consideration the major threats to our health care system.
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Broncoscopía/economía , Biopsia por Aspiración con Aguja Fina Guiada por Ultrasonido Endoscópico/economía , Ganglios Linfáticos/diagnóstico por imagen , Ganglios Linfáticos/patología , Mediastinoscopía/economía , Residuos Sanitarios/economía , Costos y Análisis de Costo , Humanos , Estudios RetrospectivosRESUMEN
PURPOSE: To analyze factors that predict the use of trimodality treatment (chemotherapy, surgery, and radiation therapy [RT]) and evaluate the impact that trimodality treatment use has on survival for patients with inflammatory breast cancer (IBC). METHODS: Using the National Cancer Data Base, patients who underwent surgical treatment of nonmetastatic IBC from 1998 to 2010 were identified. We collected demographic, tumor, and treatment data and analyzed treatment and survival trends over time. Logistic regression and Cox proportional hazard models were used to examine factors predicting treatment and survival. RESULTS: We identified 10,197 patients who fulfilled study criteria. The use of trimodality therapy fluctuated annually (58.4% to 73.4%). Patients who were older, diagnosed earlier in the study period, lived in regions of the country outside of the Midwest, had lower incomes or public insurance, and had a higher comorbid score were significantly less likely to receive trimodality therapy (all P < .05). Five- and 10-year survival rates were highest among patients receiving trimodality treatment (55.4% and 37.3%, respectively) compared with patients who received the combination of surgery plus chemotherapy, surgery plus RT, or surgery alone. After adjusting for potential confounding variables, use of trimodality therapy remained a significant independent predictor of survival. CONCLUSION: Underutilization of trimodality therapy negatively impacted survival for patients with IBC. The use of trimodality therapy increased marginally with time, but there remain significant factors associated with differences in use of trimodality treatment. We have identified specific barriers to care that may be targeted to improve treatment delivery and potentially improve patient outcomes.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Quimioterapia Adyuvante/estadística & datos numéricos , Neoplasias Inflamatorias de la Mama/mortalidad , Neoplasias Inflamatorias de la Mama/terapia , Mastectomía , Radioterapia Adyuvante/estadística & datos numéricos , Adulto , Anciano , Humanos , Estimación de Kaplan-Meier , Mastectomía/métodos , Persona de Mediana Edad , Mortalidad/tendencias , Modelos de Riesgos Proporcionales , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: To guide resource utilization, we aimed to determine the impact of routine surveillance imaging for the detection of melanoma recurrences amenable to surgical resection with curative intent. BACKGROUND: The National Comprehensive Cancer Network guidelines for melanoma surveillance are largely consensus based. METHODS: Using single-institution, patient-level data (n = 1600), transition probabilities were calculated for a Markov model simulating the natural history of patients with stage I-III melanoma. As a base estimate, imaging was assumed to detect regional and distant recurrences of which 80% and 20% could be surgically treated with curative intent, respectively. Sensitivity analyses were conducted for all point estimates. For each disease stage, we calculated the number of surgically treatable regional or distant recurrence detected during 5 years per 10,000 patients undergoing computed tomography (CT) or positron emission tomography (PET)/CT scans at 6- or 12-month intervals. The associated positive and negative predictive values and life expectancy were also calculated and compared with clinical examination alone. RESULTS: At 5-year follow-up, CT or PET/CT at 6-month intervals detected surgically treatable regional or distant recurrence in 6.4% of patients with stage I, 18.5% of stage II, and 33.1% of stage III disease; 12-month intervals decreased the rates to 3.0%, 7.9%, and 13.0%, respectively. The high false-positive rates of CT (20%) and PET/CT (9%) resulted in overall low positive predictive values. However, both CT and PET/CT effectively predicted absence of disease. Life-expectancy gains were minimal (≤ 2 months) for all groups. CONCLUSIONS: The effectiveness of routine surveillance imaging for detecting treatable melanoma recurrences is limited. Even in patients with stage III disease, only minimal gains in life expectancy were achieved.
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Procedimientos Quirúrgicos Dermatologicos/métodos , Melanoma/cirugía , Estadificación de Neoplasias/métodos , Tomografía de Emisión de Positrones/métodos , Guías de Práctica Clínica como Asunto , Programa de VERF/normas , Tomografía Computarizada por Rayos X/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Femenino , Estudios de Seguimiento , Humanos , Masculino , Melanoma/diagnóstico , Persona de Mediana Edad , Recurrencia Local de Neoplasia/diagnóstico , Recurrencia Local de Neoplasia/cirugía , Curva ROC , Reproducibilidad de los Resultados , Estudios Retrospectivos , Neoplasias Cutáneas , Factores de Tiempo , Adulto Joven , Melanoma Cutáneo MalignoRESUMEN
BACKGROUND AND AIM: Regional lymph nodes are the most frequent site of spread of metastatic melanoma. Operative intervention remains the only potential for cure, but the reported morbidity rate associated with inguinal lymphadenectomy is approximately 50%. Minimally invasive lymph node dissection (MILND) is an alternative approach to traditional, open inguinal lymph node dissection (OILND). The aim of this study is to evaluate our early experience with MILND and compare this with our OILND experience. METHODS: We conducted a prospective study of 13 MILND cases performed for melanoma from 2010 to 2012 at two tertiary academic centers. We compared our outcomes with retrospective data collected on 28 OILND cases performed at the same institutions, by the same surgeons, between 2002 and 2011. Patient characteristics, operative outcomes, and 30-day morbidity were evaluated. RESULTS: Patient characteristics were similar in the two cohorts with no statistically significant differences in patient age, gender, body mass index, or smoking status. MILND required longer operative time (245 vs 138 min, p=0.0003). The wound dehiscence rate (0 vs 14%, p=0.07), hospital readmission rate (7 vs 21%, p=0.25), and hospital length of stay (1 vs 2 days, p=0.01) were all lower in the MILND group. The lymph node count was significantly higher (11 vs 8, p=0.03) for MILND compared with OILND. CONCLUSIONS: MILND for melanoma is a novel alternative to OILND, and our preliminary data suggest that MILND provides an equivalent lymphadenectomy while minimizing the severity of postoperative complications. Further research will need to be conducted to determine if the oncologic outcomes are similar.
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Neoplasias del Ano/patología , Escisión del Ganglio Linfático/métodos , Melanoma/secundario , Neoplasias Cutáneas/patología , Infección de la Herida Quirúrgica/etiología , Adulto , Anciano , Distribución de Chi-Cuadrado , Femenino , Humanos , Conducto Inguinal , Tiempo de Internación , Escisión del Ganglio Linfático/efectos adversos , Masculino , Melanoma/cirugía , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos , Tempo Operativo , Readmisión del Paciente , Estadísticas no Paramétricas , Dehiscencia de la Herida Operatoria/etiología , Infección de la Herida Quirúrgica/tratamiento farmacológicoRESUMEN
BACKGROUND: Esophageal stents provide immediate palliation of malignant dysphagia; however, radiotherapy (RT) is a superior long-term option. We review the outcomes of combined esophageal stenting and RT for patients with malignant dysphagia. METHODS: We retrospectively reviewed patients with esophageal stents placed for palliation of malignant dysphagia from esophageal stricture, esophageal extrinsic compression, or malignant tracheoesophageal fistula (TEF). We excluded patients with radiation-induced TEF in the absence of tumor. We analyzed and compared outcomes between patients with no RT, RT before stent placement, and RT after stent placement. RESULTS: We placed stents in 45 patients for esophageal stricture from esophageal cancer (n = 30; 66.7 %), malignant TEF (n = 8; 17.7 %), and esophageal compression from airway, mediastinal, or metastatic malignancies (n = 7; 15.6 %). Twenty patients (44.4 %) had no RT; 25 patients had RT before stent placement (n = 16; 35.6 %), RT after stent placement (n = 8; 17.8 %), or both (n = 1; 2.2 %). Median follow-up was 30 days. Complications requiring stent revision were similar with or without RT. Subjective symptom relief was achieved in 68.9 % of all patients, with no differences noted between groups (p = 0.99). The 30-day mortality was 15.6 %. Patients with RT after stent placement had a longer median survival compared to those without RT (98 vs. 38 days). CONCLUSIONS: Esophageal stent placement with RT is a safe approach for malignant dysphagia.
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Carcinoma de Células Escamosas/terapia , Trastornos de Deglución/terapia , Neoplasias Esofágicas/terapia , Cuidados Paliativos , Radioterapia , Stents , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/complicaciones , Terapia Combinada , Trastornos de Deglución/diagnóstico , Trastornos de Deglución/etiología , Neoplasias Esofágicas/complicaciones , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , PronósticoAsunto(s)
Neoplasias de la Mama/cirugía , Mastectomía Segmentaria/estadística & datos numéricos , Mastectomía/estadística & datos numéricos , Neoplasias de la Mama/radioterapia , Femenino , Humanos , Recurrencia Local de Neoplasia/prevención & control , Radioterapia Adyuvante , Factores de Riesgo , Estados UnidosRESUMEN
OBJECTIVES: Surgical resection is standard treatment for early-stage non-small cell lung cancer; however, perception of postoperative risk may influence the decision to proceed for elderly patients. With population data, we analyzed postoperative complications and morbidity predictors for older patients undergoing lobectomy for stage I non-small cell lung cancer. METHODS: The Surveillance Epidemiology and End-Results-Medicare linked database (2000-2005) identified patients (ages 66-80 years) undergoing lobectomy for stage I non-small cell lung cancer. We comprehensively evaluated in-hospital postoperative complications (pulmonary, cardiac, infectious, noncardiopulmonary) with International Classification of Diseases, Ninth Revision, diagnosis codes. Logistic regression models were constructed to identify patient, tumor, and treatment characteristics associated with complications. RESULTS: In all, 4171 patients were included, 2329 of whom had 4097 in-hospital postoperative complications (55.8%). Pulmonary complications were most common (n = 1598; 38.3%) followed by cardiac (n = 1020; 24.5%). Complications were significantly associated with age at least 75 years, male sex, higher comorbidity index, larger tumors, and treatment at nonteaching hospitals (P < .05). Patients with complications had a longer median stay (8 days) than patients without (6 days; P < .001). The 30-day mortality was 4.2%. CONCLUSIONS: Population-based analysis demonstrated that perioperative complications after lobectomy for stage I non-small cell lung cancer in older patients exceeded 50% and were associated with specific patient, tumor, and treatment characteristics. Better understanding of the impact of these risk factors may facilitate surgical decision making and encourage implementation of more effective perioperative care guidelines for older surgical patients.
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Carcinoma de Pulmón de Células no Pequeñas/cirugía , Neoplasias Pulmonares/cirugía , Neumonectomía/efectos adversos , Complicaciones Posoperatorias/etiología , Factores de Edad , Anciano , Anciano de 80 o más Años , Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Carcinoma de Pulmón de Células no Pequeñas/patología , Comorbilidad , Femenino , Mortalidad Hospitalaria , Humanos , Modelos Logísticos , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/patología , Masculino , Análisis Multivariante , Estadificación de Neoplasias , Oportunidad Relativa , Selección de Paciente , Neumonectomía/mortalidad , Complicaciones Posoperatorias/mortalidad , Medición de Riesgo , Factores de Riesgo , Programa de VERF , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
INTRODUCTION: The rate of contralateral prophylactic mastectomy (CPM) has recently increased. The aim of this study is to assess perceptions of contralateral breast cancer (CBC) risk among breast cancer patients and to evaluate tumor and patient factors associated with risk perception. METHODS: We conducted a prospective survey study to evaluate perceptions of CBC risk in women newly diagnosed with ductal carcinoma in situ (DCIS) or stage I/II invasive breast cancer. Surveys were distributed in clinic prior to surgical consultation. Exclusion criteria included history of breast cancer, bilateral breast cancer, neoadjuvant chemotherapy or radiation for the current breast cancer, or BRCA mutation. Survey questions used open-ended responses or five-point Likert scale scoring (5 = very likely, 1 = not at all likely). RESULTS: Seventy-four women (mean age 54.5 years) completed the survey. Diagnoses included invasive ductal cancer (66.2%), invasive lobular cancer (9.5%), and DCIS (20.3%). Most women (54.1%) underwent breast-conserving surgery; the remaining had bilateral mastectomy including CPM (17.6%) or unilateral mastectomy (10.8%). Overall, women substantially overestimated their risk of developing CBC. The mean estimated 10-year risk of CBC was 31.4% [95% confidence interval (CI) 24.7-37.9%] and 2.6 ± 0.15 on the rank scale. The perceived risk of CBC was not significantly associated with cancer stage, family history, age, or CPM. CONCLUSIONS: At time of surgical evaluation, women with unilateral breast cancer substantially overestimated their risk of CBC; however, this elevated risk perception was not associated with choosing CPM. Early physician counseling is needed to provide women with accurate information regarding their true CBC risk.
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Neoplasias de la Mama/psicología , Carcinoma Ductal de Mama/psicología , Carcinoma Intraductal no Infiltrante/psicología , Carcinoma Lobular/psicología , Mastectomía/psicología , Mastectomía/tendencias , Adulto , Anciano , Neoplasias de la Mama/prevención & control , Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama/prevención & control , Carcinoma Ductal de Mama/cirugía , Carcinoma Intraductal no Infiltrante/prevención & control , Carcinoma Intraductal no Infiltrante/cirugía , Carcinoma Lobular/prevención & control , Carcinoma Lobular/cirugía , Estudios de Cohortes , Femenino , Humanos , Persona de Mediana Edad , Percepción , Pronóstico , Estudios Prospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: Intrathoracic esophageal anastomotic leaks and perforations are very morbid and challenging problems. Esophageal stents are increasingly playing an integral role in the management of these patients. Our objective was to report our experience with esophageal stent placement for anastomotic leaks and perforations and to provide a treatment algorithm. METHODS: We performed a review of patients with stent placement for esophagogastric anastomotic leaks or esophageal perforation from March 2005 to August 2009. A prospective database was used to collect data. Success was defined as endoscopic defect closure, negative esophagram, and resumption of oral intake. Failure was defined as no change in leak size or clinical signs of ongoing infection. We collected and analyzed patient demographics, diagnosis, clinical history, and poststent outcomes using descriptive statistics. RESULTS: Thirty-seven patients underwent esophageal stent placement for anastomotic leaks (n = 22) and perforations (n = 15). The median time from original procedure to diagnosis of leak or perforation was 6 days (0-420 days). Nineteen patients (51%) had 21 associated procedures for source control. We placed 94 stents (mean = 2.7 stents/patient); 16 patients (43%) required more than 1 stenting procedure (mean = 1.8 procedures/patient). The median time to restoration of esophageal integrity was 33 days (7-120 days). There were 22 successes (59%); 2 failures were secondary to undrained abscess. Only 2 failures occurred in the last 15 patients (88% success). Strictures did not develop in any patients. Serious complications occurred in 3 patients (stent erosion, leak enlargement, fatal gastroaortic fistula). CONCLUSIONS: Esophageal stents can potentially play an integral role in the management of anastomotic leaks and perforations. Success depends on appropriate procedures for source control and surgeon experience.
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Fuga Anastomótica/terapia , Perforación del Esófago/terapia , Esofagectomía/efectos adversos , Esofagoscopía/instrumentación , Stents , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Fuga Anastomótica/diagnóstico , Fuga Anastomótica/etiología , Antiinfecciosos/uso terapéutico , Drenaje , Perforación del Esófago/diagnóstico , Perforación del Esófago/etiología , Esofagoscopía/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Minnesota , Selección de Paciente , Estudios Retrospectivos , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Cicatrización de Heridas , Adulto JovenRESUMEN
OBJECTIVE: Surgical morbidity may influence long-term cancer survival. Because resection of early stage nonsmall cell lung cancer (NSCLC) is primary therapy, we sought to determine the survival impact of surgical complications for elderly patients undergoing resection of stage I NSCLC. METHODS: Using the linked Surveillance Epidemiology and End Results-Medicare database (2000-2005), we identified elderly patients who underwent lobectomy for stage I NSCLC. We then assessed the unadjusted association between in-hospital, postoperative complications, and long-term survival for patients who survived more than 30 days after resection using the Kaplan-Meier method. Finally, we used Cox proportional hazards regression to evaluate the relationship between postoperative complications and 5-year cancer-specific (CSS) and overall survival (OS) after adjusting for patient, tumor, and treatment characteristics. RESULTS: We identified 3996 eligible patients. The overall in-hospital, postoperative complication rate was 54.2%. Pulmonary complications were the most common (n = 1464) followed by cardiac (n = 916). Unadjusted 5-year CSS was significantly worse for those who had an in-hospital, postoperative complication (70.9%) compared to those who did not (78.9%, P < 0.001). OS was also significantly worse (P < 0.001) for patients who developed a complication. Complications continued to predict worse 5-year CSS and OS after adjusting for patient, tumor, and treatment characteristics (HR: 1.38, 95% CI, 1.17-1.64). CONCLUSIONS: The occurrence of in-hospital postoperative complications was an independent predictor of worse 5-year CSS after resection of stage I NSCLC. Importantly, the impact of surgical complications extends well after the initial perioperative period. These findings may help identify important targets for best practice guidelines and quality-of-care measures.
Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Mortalidad Hospitalaria , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/cirugía , Neumonectomía , Complicaciones Posoperatorias/mortalidad , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Adenocarcinoma Bronquioloalveolar/mortalidad , Adenocarcinoma Bronquioloalveolar/patología , Adenocarcinoma Bronquioloalveolar/cirugía , Anciano , Anciano de 80 o más Años , Carcinoma de Pulmón de Células no Pequeñas/patología , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Causas de Muerte , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Neoplasias Pulmonares/patología , Masculino , Estadificación de Neoplasias , Modelos de Riesgos Proporcionales , Programa de VERF , Estados UnidosRESUMEN
BACKGROUND: Cancer risk assessment is an important decision-making tool for women considering irreversible risk-reducing surgery. Our objective was to determine the prevalence of BRCA testing among women undergoing bilateral prophylactic mastectomy (BPM) and to review the characteristics of women who choose BPM within a metropolitan setting. METHODS: We retrospectively reviewed records of women who underwent BPM in the absence of cancer within 2 health care systems that included 5 metropolitan hospitals. Women with invasive carcinoma or ductal carcinoma in situ (DCIS) were excluded; neither lobular carcinoma in situ (LCIS) nor atypical hyperplasia (AH) were exclusion criteria. We collected demographic information and preoperative screening and risk assessment, BRCA testing, reconstruction, and associated cancer risk-reducing surgery data. We compared women who underwent BRCA testing to those not tested. RESULTS: From January 2002 to July 2009, a total of 71 BPMs were performed. Only 25 women (35.2%) had preoperative BRCA testing; 88% had a BRCA mutation. Compared with tested women, BRCA nontested women were significantly older (39.1 vs. 49.2 years, P < 0.001), had significantly more preoperative biopsies and mammograms and had fewer previous or simultaneous cancer risk-reducing surgery (oophorectomy). Among BRCA nontested women, common indications for BPM were family history of breast cancer (n = 21, 45.6%) or LCIS or AH (n = 16, 34.8%); 9 nontested women (19.6%) chose BPM based on exclusively on cancer-risk anxiety or personal preference. CONCLUSION: Most women who underwent BPM did not receive preoperative genetic testing. Further studies are needed to corroborate our findings in other geographic regions and practice settings.
Asunto(s)
Neoplasias de la Mama/cirugía , Carcinoma in Situ/cirugía , Carcinoma Lobular/cirugía , Mastectomía , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/genética , Neoplasias de la Mama/patología , Carcinoma in Situ/genética , Carcinoma in Situ/patología , Carcinoma Lobular/genética , Carcinoma Lobular/patología , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Genes BRCA1 , Genes BRCA2 , Pruebas Genéticas , Humanos , Persona de Mediana Edad , Mutación/genética , Cuidados Preoperatorios , Pronóstico , Estudios Retrospectivos , Medición de Riesgo , Conducta de Reducción del RiesgoRESUMEN
The overall rates of BCS have remained stable or slightly increased over the past decade in the United States. The CPM rates have markedly increased while unilateral mastectomy rates have decreased. Increasingly, more women are not receiving RT after BCS, particularly high-risk women. These trends have important potential untoward consequences. Strategies are being developed to ensure adequate local therapy for breast cancer patients.
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Neoplasias de la Mama/cirugía , Mastectomía/estadística & datos numéricos , Neoplasias de la Mama/patología , Femenino , HumanosRESUMEN
BACKGROUND: Oxaliplatin (OX) is increasingly used for hyperthermic intraperitoneal chemotherapy (HIPC) for patients with peritoneal metastases. Our aim was to review electrolyte disturbances and complications after HIPC with oxaliplatin (OX) versus mitomycin C (MMC). MATERIALS AND METHODS: We included patients enrolled in single-institution prospective clinical trials who underwent cytoreductive surgery and HIPC with MMC or OX. We reviewed patient demographics, pathology, perioperative course, HIPC administration, and postoperative electrolyte disturbances. Measured postoperative sodium values were corrected for systemic hyperglycemia using the formula: (measured Na(+)) × [(glucose - 100/100) × 1.6]. RESULTS: From January 2002 to April 2009 we performed 80 HIPC procedures. A total of 60 patients (75%) received MMC (dose range 12.5-50 mg/m(2)) carried in lactated ringers solution. There were 20 patients (25%) who received OX (dose range 300 × 400 mg/m(2)) carried in 5% dextrose solution. For patients receiving HIPC with OX, electrolyte disturbances were the most common complication. Compared with MMC, patients receiving OX had significant 24-h postoperative uncorrected hyponatremia (P < 0.001), corrected hyponatremia (P < 0.001), hyperglycemia (P < 0.001), and metabolic acidosis (P < 0.001). In the OX group, corrected (mean 130.5) and uncorrected (mean 127.4) sodium levels were significantly lower than preoperatively (mean 139.9, P < 0.001). The overall nonelectrolyte complication rate was 56.2%. (MMC n = 33, 55.0%; OX n = 12, 60%); the 30-day mortality rate was 0% in both groups. CONCLUSIONS: Compared with MMC, HIPC with OX was associated with significant but predictable electrolyte disturbances; however, these electrolyte disturbances were not associated with higher overall complication rates. Close monitoring with early correction is imperative to maximize perioperative care. Further studies are needed to provide mechanistic insight.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias Gastrointestinales/complicaciones , Hipertermia Inducida , Mesotelioma/complicaciones , Neoplasias Peritoneales/complicaciones , Desequilibrio Hidroelectrolítico/etiología , Adulto , Anciano , Ensayos Clínicos Fase I como Asunto , Ensayos Clínicos Fase II como Asunto , Estudios de Cohortes , Terapia Combinada , Femenino , Neoplasias Gastrointestinales/terapia , Humanos , Masculino , Mesotelioma/terapia , Persona de Mediana Edad , Mitomicina/administración & dosificación , Compuestos Organoplatinos/administración & dosificación , Oxaliplatino , Neoplasias Peritoneales/terapia , Complicaciones Posoperatorias , Pronóstico , Estudios Prospectivos , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
BACKGROUND: Esophageal injury is a rare but catastrophic complication of anterior cervical spine surgery. Cases of esophageal perforation may be discovered intraoperatively, or as late as 10 years after surgery. In the current study we aim to review the principles of care and provide an algorithm that can be employed for successful management of this complex problem. METHODS: We performed a retrospective, Institutional Review Board-approved review of esophageal injuries resulting from anterior cervical spine surgery that were managed at our institution between January 1, 2007 and July 31, 2009. We collected demographic information, perioperative data, and final outcomes. Data were analyzed using descriptive statistics. RESULTS: We identified 6 patients who met our criteria. All patients presented with esophageal leaks, neck abscesses, and osteomyelitis. Similarly, all had been treated prior to transfer, without resolution of their leak. After debridement, removal of hardware, long-term antibiotic therapy, maximization of nutrition, and supportive care, 80% of patients resumed oral intake (median time 66.5 days). Mortality was 16.7%. CONCLUSIONS: Neck exploration with removal of hardware, debridement, and open neck wound management are the basic principles of care. Management is often prolonged and requires multiple procedures; however, with persistence, closure is possible in the majority of patients. Our report serves as a guide for the treatment of this devastating problem.