Surgical Oncology

CORONADO, CALIF.– Today’s clinicians are ordering more postdiagnosis imaging tests in patients with thyroid cancer than they did in the early 1990s, results from the largest study of its kind showed.

“There is very little data on surveillance imaging for cancers in general, and especially for thyroid cancer,” lead author Dr. Jaime L. Wiebel said in an interview in advance of at the annual meeting of the American Thyroid Association, where the work was presented. “This study revealed that, over time, there has been an increase in all postdiagnosis imaging studies: ultrasound, I-131 [radioactive iodine] scans, and PET scans.”

Dr. Wiebel of the University of Michigan’s metabolism, endocrinology, and diabetes clinic, Ann Arbor, and her associates used records from the linked database to identify patients diagnosed with localized, regional, or distant well-differentiated thyroid cancer between 1991 and 2009. Next, they reviewed medical claims and determined the use of thyroid ultrasound, I-131 scan, or PET scan within 3 years post diagnosis. The researchers used linear regression analysis to evaluate imaging trends during the study period and multivariate logistic regression to estimate the likelihood of imaging use based on patient characteristics.

In all, 23,669 patients with well-differentiated thyroid cancer were included in the analysis. Most (79%) were younger than age 75 years, and 70% were female. Dr. Wiebel and her associates observed an increased use of both thyroid ultrasound and I-131 among patients with localized disease (P < .001 and P = .003, respectively). Use of the two modalities also increased among patients with regional disease (both P < .001) as well as among patients with distant disease (P = .001 and P = .015).

After controlling for patient characteristics, the researchers found that patients diagnosed during 2001-2009 were 2.15 times more likely to undergo a thyroid ultrasound, compared with those diagnosed during 1991-2000. In addition, PET scan use during 2005-2009, compared with 1996-2004, increased 32.4-fold among those with localized disease, 13.1-fold among those with regional disease, and 33.4-fold among those with distant disease (all significant at P < .001). Patients diagnosed with thyroid cancer after the year 2000 were more likely to have smaller, localized cancer.

“A few of our findings were unexpected,” Dr. Wiebel said. “We had anticipated that since more low-risk thyroid cancer is being diagnosed in the United States, that postdiagnosis surveillance imaging would decrease over time. We found the exact opposite. Despite the rise in low-risk thyroid cancer, there has been an increase in postdiagnosis imaging in the United States. Especially surprising was the very large increase in PET scan use.”

She acknowledged certain limitations of the analysis, including lack of data regarding indications for the imaging studies, “including iodine avidity of the tumor, disease recurrence, or patient preferences,” and the fact that most of the patients were over age 65 years. “However, we suspect that imaging practices in younger patients are similar,” she said.

Dr. Wiebel reported having no financial disclosures.

[email protected]

On Twitter @dougbrunk

CORONADO, CALIF.– Today’s clinicians are ordering more postdiagnosis imaging tests in patients with thyroid cancer than they did in the early 1990s, results from the largest study of its kind showed.

“There is very little data on surveillance imaging for cancers in general, and especially for thyroid cancer,” lead author Dr. Jaime L. Wiebel said in an interview in advance of at the annual meeting of the American Thyroid Association, where the work was presented. “This study revealed that, over time, there has been an increase in all postdiagnosis imaging studies: ultrasound, I-131 [radioactive iodine] scans, and PET scans.”

Dr. Wiebel of the University of Michigan’s metabolism, endocrinology, and diabetes clinic, Ann Arbor, and her associates used records from the linked database to identify patients diagnosed with localized, regional, or distant well-differentiated thyroid cancer between 1991 and 2009. Next, they reviewed medical claims and determined the use of thyroid ultrasound, I-131 scan, or PET scan within 3 years post diagnosis. The researchers used linear regression analysis to evaluate imaging trends during the study period and multivariate logistic regression to estimate the likelihood of imaging use based on patient characteristics.

In all, 23,669 patients with well-differentiated thyroid cancer were included in the analysis. Most (79%) were younger than age 75 years, and 70% were female. Dr. Wiebel and her associates observed an increased use of both thyroid ultrasound and I-131 among patients with localized disease (P < .001 and P = .003, respectively). Use of the two modalities also increased among patients with regional disease (both P < .001) as well as among patients with distant disease (P = .001 and P = .015).

After controlling for patient characteristics, the researchers found that patients diagnosed during 2001-2009 were 2.15 times more likely to undergo a thyroid ultrasound, compared with those diagnosed during 1991-2000. In addition, PET scan use during 2005-2009, compared with 1996-2004, increased 32.4-fold among those with localized disease, 13.1-fold among those with regional disease, and 33.4-fold among those with distant disease (all significant at P < .001). Patients diagnosed with thyroid cancer after the year 2000 were more likely to have smaller, localized cancer.

“A few of our findings were unexpected,” Dr. Wiebel said. “We had anticipated that since more low-risk thyroid cancer is being diagnosed in the United States, that postdiagnosis surveillance imaging would decrease over time. We found the exact opposite. Despite the rise in low-risk thyroid cancer, there has been an increase in postdiagnosis imaging in the United States. Especially surprising was the very large increase in PET scan use.”

She acknowledged certain limitations of the analysis, including lack of data regarding indications for the imaging studies, “including iodine avidity of the tumor, disease recurrence, or patient preferences,” and the fact that most of the patients were over age 65 years. “However, we suspect that imaging practices in younger patients are similar,” she said.

Dr. Wiebel reported having no financial disclosures.

[email protected]

On Twitter @dougbrunk

CORONADO, CALIF.– Today’s clinicians are ordering more postdiagnosis imaging tests in patients with thyroid cancer than they did in the early 1990s, results from the largest study of its kind showed.

“There is very little data on surveillance imaging for cancers in general, and especially for thyroid cancer,” lead author Dr. Jaime L. Wiebel said in an interview in advance of at the annual meeting of the American Thyroid Association, where the work was presented. “This study revealed that, over time, there has been an increase in all postdiagnosis imaging studies: ultrasound, I-131 [radioactive iodine] scans, and PET scans.”

Dr. Wiebel of the University of Michigan’s metabolism, endocrinology, and diabetes clinic, Ann Arbor, and her associates used records from the linked database to identify patients diagnosed with localized, regional, or distant well-differentiated thyroid cancer between 1991 and 2009. Next, they reviewed medical claims and determined the use of thyroid ultrasound, I-131 scan, or PET scan within 3 years post diagnosis. The researchers used linear regression analysis to evaluate imaging trends during the study period and multivariate logistic regression to estimate the likelihood of imaging use based on patient characteristics.

In all, 23,669 patients with well-differentiated thyroid cancer were included in the analysis. Most (79%) were younger than age 75 years, and 70% were female. Dr. Wiebel and her associates observed an increased use of both thyroid ultrasound and I-131 among patients with localized disease (P < .001 and P = .003, respectively). Use of the two modalities also increased among patients with regional disease (both P < .001) as well as among patients with distant disease (P = .001 and P = .015).

After controlling for patient characteristics, the researchers found that patients diagnosed during 2001-2009 were 2.15 times more likely to undergo a thyroid ultrasound, compared with those diagnosed during 1991-2000. In addition, PET scan use during 2005-2009, compared with 1996-2004, increased 32.4-fold among those with localized disease, 13.1-fold among those with regional disease, and 33.4-fold among those with distant disease (all significant at P < .001). Patients diagnosed with thyroid cancer after the year 2000 were more likely to have smaller, localized cancer.

“A few of our findings were unexpected,” Dr. Wiebel said. “We had anticipated that since more low-risk thyroid cancer is being diagnosed in the United States, that postdiagnosis surveillance imaging would decrease over time. We found the exact opposite. Despite the rise in low-risk thyroid cancer, there has been an increase in postdiagnosis imaging in the United States. Especially surprising was the very large increase in PET scan use.”

She acknowledged certain limitations of the analysis, including lack of data regarding indications for the imaging studies, “including iodine avidity of the tumor, disease recurrence, or patient preferences,” and the fact that most of the patients were over age 65 years. “However, we suspect that imaging practices in younger patients are similar,” she said.

Dr. Wiebel reported having no financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – Gynecologists, general surgeons, and primary care physicians now share an unprecedented opportunity to put a major dent in the incidence of ovarian cancer, according to Dr. Farr R. Nezhat.

Mounting evidence suggests that identification and complete surgical removal of endometriosis reduce the risk of several histologic types of ovarian cancer. So when a woman visits her primary care physician for pelvic pain or vaginal bleeding that might be due to endometrial pathology, or a general surgeon finds asymptomatic endometriosis during pelvic surgery, these encounters provide an opportunity for preventive intervention, explained Dr. Nezhat, professor of ob.gyn. and director of minimally invasive surgery and gynecologic robotics at Mount Sinai Medical Center, New York.

The latest thinking about the pathophysiology of ovarian cancer, he noted, is that there are two different types of the malignancy. One type, which likely arises from endometriosis as the precursor lesion, is characterized by low-grade serous, clear cell, and endometrioid carcinomas, which tend to present at an earlier stage and are more indolent. They are associated with mutations in the PTEN, BCL2, and ARID1A genes.

A pooled analysis of 13 ovarian cancer case-control studies conducted by investigators in the Ovarian Cancer Association Consortium made the point that women with endometriosis are at increased risk of specific subtypes of the malignancy. The analysis, which included 7,911 women with invasive ovarian cancer, 1,907 others with borderline ovarian cancer, and more than 13,000 controls, concluded that women with a self-reported history of endometriosis had a 3.05-fold increased risk of clear cell invasive ovarian cancer, compared with controls, a 2.04-fold increased risk of endometrioid ovarian cancer, and a 2.11-fold greater likelihood of low-grade serous ovarian cancer.

In contrast, no association was apparent between endometriosis and the risk of high-grade serous or mucinous invasive ovarian cancer or borderline tumors. Thus, the pathogenesis of low- and high-grade serous ovarian cancers may differ (Lancet Oncol. 2012;13:385-94).

Dr. Nezhat cited as another influential study a Swedish national registry case-control study involving all Swedes with a first-time hospital discharge diagnosis of endometriosis during 1969-2007. The cases in this study were all 220 Swedish women diagnosed with epithelial ovarian cancer at least 1 year after their endometriosis was diagnosed. Each was matched with two controls with no ovarian cancer diagnosis before the date of the case’s cancer diagnosis.

This was the first published study to demonstrate that treatment of endometriosis has a salutary impact on subsequent risk of ovarian cancer. Complete surgical removal of all visible endometriotic tissue was associated with a 63% reduction in the risk of ovarian cancer in a univariate analysis and a 70% relative risk reduction in a multivariate analysis. One-sided oophorectomy involving the endometriosis-involved ovary was similarly associated with a 58% risk reduction for ovarian cancer in a univariate analysis and an 81% reduction in risk in a multivariate analysis (Acta Obstet. Gynecol. Scand. 2013:92:546-54).

An earlier study in which Dr. Nezhat was senior author highlighted that different histologic types of early-stage ovarian carcinoma feature distinctive patterns of clinical symptoms. The study included 76 consecutive patients with FIGO stage I ovarian carcinoma, of which 54 – that is, more than two-thirds – were nonserous, which is a much higher proportion than is seen in women diagnosed with stage III and IV disease.

Most patients with serous papillary carcinoma in this series presented with an asymptomatic pelvic mass. In contrast, most of those with endometrioid or clear cell carcinoma presented with pelvic pain or abnormal vaginal bleeding with or without a pelvic mass (Fertil. Steril. 2007;88:906-10).

Endometrioisis is a pervasive condition. Dr. Nezhat said the endometriosis patients he considers to be at possible increased risk for ovarian cancer include those with longstanding endometriosis, a history of infertility, endometriosis diagnosed at an early age, as well as those with ovarian endometriomas. Eventually it will be possible to pin down more precisely the ovarian cancer risk of an individual with endometriosis through screening for genetic mutations, but the evidence base isn’t yet sufficient to introduce this into everyday practice, he said.

One audience member said it’s her practice and that of many of her gynecologic colleagues that when they incidentally find a patient has asymptomatic endometriosis, for example, during surgery for ectopic pregnancy, they will often leave it in place, even if it is quite severe. Is it time to rethink that practice and instead remove all visible endometriosis, even if the patient is asymptomatic? she asked.

“The short answer is, Yes,” Dr. Nezhat replied. “The most important thing is that when you do surgery, remove it all or else do biopsies to make sure you’re not leaving early ovarian cancer behind. Draining endometriomas is not adequate.”

He reported having no relevant financial conflicts.

[email protected]

LAS VEGAS – Gynecologists, general surgeons, and primary care physicians now share an unprecedented opportunity to put a major dent in the incidence of ovarian cancer, according to Dr. Farr R. Nezhat.

Mounting evidence suggests that identification and complete surgical removal of endometriosis reduce the risk of several histologic types of ovarian cancer. So when a woman visits her primary care physician for pelvic pain or vaginal bleeding that might be due to endometrial pathology, or a general surgeon finds asymptomatic endometriosis during pelvic surgery, these encounters provide an opportunity for preventive intervention, explained Dr. Nezhat, professor of ob.gyn. and director of minimally invasive surgery and gynecologic robotics at Mount Sinai Medical Center, New York.

The latest thinking about the pathophysiology of ovarian cancer, he noted, is that there are two different types of the malignancy. One type, which likely arises from endometriosis as the precursor lesion, is characterized by low-grade serous, clear cell, and endometrioid carcinomas, which tend to present at an earlier stage and are more indolent. They are associated with mutations in the PTEN, BCL2, and ARID1A genes.

A pooled analysis of 13 ovarian cancer case-control studies conducted by investigators in the Ovarian Cancer Association Consortium made the point that women with endometriosis are at increased risk of specific subtypes of the malignancy. The analysis, which included 7,911 women with invasive ovarian cancer, 1,907 others with borderline ovarian cancer, and more than 13,000 controls, concluded that women with a self-reported history of endometriosis had a 3.05-fold increased risk of clear cell invasive ovarian cancer, compared with controls, a 2.04-fold increased risk of endometrioid ovarian cancer, and a 2.11-fold greater likelihood of low-grade serous ovarian cancer.

In contrast, no association was apparent between endometriosis and the risk of high-grade serous or mucinous invasive ovarian cancer or borderline tumors. Thus, the pathogenesis of low- and high-grade serous ovarian cancers may differ (Lancet Oncol. 2012;13:385-94).

Dr. Nezhat cited as another influential study a Swedish national registry case-control study involving all Swedes with a first-time hospital discharge diagnosis of endometriosis during 1969-2007. The cases in this study were all 220 Swedish women diagnosed with epithelial ovarian cancer at least 1 year after their endometriosis was diagnosed. Each was matched with two controls with no ovarian cancer diagnosis before the date of the case’s cancer diagnosis.

This was the first published study to demonstrate that treatment of endometriosis has a salutary impact on subsequent risk of ovarian cancer. Complete surgical removal of all visible endometriotic tissue was associated with a 63% reduction in the risk of ovarian cancer in a univariate analysis and a 70% relative risk reduction in a multivariate analysis. One-sided oophorectomy involving the endometriosis-involved ovary was similarly associated with a 58% risk reduction for ovarian cancer in a univariate analysis and an 81% reduction in risk in a multivariate analysis (Acta Obstet. Gynecol. Scand. 2013:92:546-54).

An earlier study in which Dr. Nezhat was senior author highlighted that different histologic types of early-stage ovarian carcinoma feature distinctive patterns of clinical symptoms. The study included 76 consecutive patients with FIGO stage I ovarian carcinoma, of which 54 – that is, more than two-thirds – were nonserous, which is a much higher proportion than is seen in women diagnosed with stage III and IV disease.

Most patients with serous papillary carcinoma in this series presented with an asymptomatic pelvic mass. In contrast, most of those with endometrioid or clear cell carcinoma presented with pelvic pain or abnormal vaginal bleeding with or without a pelvic mass (Fertil. Steril. 2007;88:906-10).

Endometrioisis is a pervasive condition. Dr. Nezhat said the endometriosis patients he considers to be at possible increased risk for ovarian cancer include those with longstanding endometriosis, a history of infertility, endometriosis diagnosed at an early age, as well as those with ovarian endometriomas. Eventually it will be possible to pin down more precisely the ovarian cancer risk of an individual with endometriosis through screening for genetic mutations, but the evidence base isn’t yet sufficient to introduce this into everyday practice, he said.

One audience member said it’s her practice and that of many of her gynecologic colleagues that when they incidentally find a patient has asymptomatic endometriosis, for example, during surgery for ectopic pregnancy, they will often leave it in place, even if it is quite severe. Is it time to rethink that practice and instead remove all visible endometriosis, even if the patient is asymptomatic? she asked.

“The short answer is, Yes,” Dr. Nezhat replied. “The most important thing is that when you do surgery, remove it all or else do biopsies to make sure you’re not leaving early ovarian cancer behind. Draining endometriomas is not adequate.”

He reported having no relevant financial conflicts.

[email protected]

LAS VEGAS – Gynecologists, general surgeons, and primary care physicians now share an unprecedented opportunity to put a major dent in the incidence of ovarian cancer, according to Dr. Farr R. Nezhat.

Mounting evidence suggests that identification and complete surgical removal of endometriosis reduce the risk of several histologic types of ovarian cancer. So when a woman visits her primary care physician for pelvic pain or vaginal bleeding that might be due to endometrial pathology, or a general surgeon finds asymptomatic endometriosis during pelvic surgery, these encounters provide an opportunity for preventive intervention, explained Dr. Nezhat, professor of ob.gyn. and director of minimally invasive surgery and gynecologic robotics at Mount Sinai Medical Center, New York.

The latest thinking about the pathophysiology of ovarian cancer, he noted, is that there are two different types of the malignancy. One type, which likely arises from endometriosis as the precursor lesion, is characterized by low-grade serous, clear cell, and endometrioid carcinomas, which tend to present at an earlier stage and are more indolent. They are associated with mutations in the PTEN, BCL2, and ARID1A genes.

A pooled analysis of 13 ovarian cancer case-control studies conducted by investigators in the Ovarian Cancer Association Consortium made the point that women with endometriosis are at increased risk of specific subtypes of the malignancy. The analysis, which included 7,911 women with invasive ovarian cancer, 1,907 others with borderline ovarian cancer, and more than 13,000 controls, concluded that women with a self-reported history of endometriosis had a 3.05-fold increased risk of clear cell invasive ovarian cancer, compared with controls, a 2.04-fold increased risk of endometrioid ovarian cancer, and a 2.11-fold greater likelihood of low-grade serous ovarian cancer.

In contrast, no association was apparent between endometriosis and the risk of high-grade serous or mucinous invasive ovarian cancer or borderline tumors. Thus, the pathogenesis of low- and high-grade serous ovarian cancers may differ (Lancet Oncol. 2012;13:385-94).

Dr. Nezhat cited as another influential study a Swedish national registry case-control study involving all Swedes with a first-time hospital discharge diagnosis of endometriosis during 1969-2007. The cases in this study were all 220 Swedish women diagnosed with epithelial ovarian cancer at least 1 year after their endometriosis was diagnosed. Each was matched with two controls with no ovarian cancer diagnosis before the date of the case’s cancer diagnosis.

This was the first published study to demonstrate that treatment of endometriosis has a salutary impact on subsequent risk of ovarian cancer. Complete surgical removal of all visible endometriotic tissue was associated with a 63% reduction in the risk of ovarian cancer in a univariate analysis and a 70% relative risk reduction in a multivariate analysis. One-sided oophorectomy involving the endometriosis-involved ovary was similarly associated with a 58% risk reduction for ovarian cancer in a univariate analysis and an 81% reduction in risk in a multivariate analysis (Acta Obstet. Gynecol. Scand. 2013:92:546-54).

An earlier study in which Dr. Nezhat was senior author highlighted that different histologic types of early-stage ovarian carcinoma feature distinctive patterns of clinical symptoms. The study included 76 consecutive patients with FIGO stage I ovarian carcinoma, of which 54 – that is, more than two-thirds – were nonserous, which is a much higher proportion than is seen in women diagnosed with stage III and IV disease.

Most patients with serous papillary carcinoma in this series presented with an asymptomatic pelvic mass. In contrast, most of those with endometrioid or clear cell carcinoma presented with pelvic pain or abnormal vaginal bleeding with or without a pelvic mass (Fertil. Steril. 2007;88:906-10).

Endometrioisis is a pervasive condition. Dr. Nezhat said the endometriosis patients he considers to be at possible increased risk for ovarian cancer include those with longstanding endometriosis, a history of infertility, endometriosis diagnosed at an early age, as well as those with ovarian endometriomas. Eventually it will be possible to pin down more precisely the ovarian cancer risk of an individual with endometriosis through screening for genetic mutations, but the evidence base isn’t yet sufficient to introduce this into everyday practice, he said.

One audience member said it’s her practice and that of many of her gynecologic colleagues that when they incidentally find a patient has asymptomatic endometriosis, for example, during surgery for ectopic pregnancy, they will often leave it in place, even if it is quite severe. Is it time to rethink that practice and instead remove all visible endometriosis, even if the patient is asymptomatic? she asked.

“The short answer is, Yes,” Dr. Nezhat replied. “The most important thing is that when you do surgery, remove it all or else do biopsies to make sure you’re not leaving early ovarian cancer behind. Draining endometriomas is not adequate.”

He reported having no relevant financial conflicts.

[email protected]

Patients with liver cancer and cirrhosis who underwent laparoscopic hepatic resection had fewer complications, shorter hospital stays, no port site recurrences, and no significant difference in survival, compared with patients who had open resections, according to a single-center, 10-year study published online in the Journal of the American College of Surgeons.

The study is the first to report long-term favorable results of laparoscopic hepatic resection for liver cancer in patients with cirrhosis, said Dr. Yo-ichi Yamashita and associates at Kyushu University, Fukuoka, Japan. Based on the data, laparoscopic instead of open resection should be considered for patients with cirrhosis whose hepatocellular carcinomas fall within the Milan criteria, the investigators said (J. Am. Coll. Surg. 2014 Sept. 9 [doi: 10.1016/j.jamcollsurg.2014.09.003]).

©avatavat/thinkstockphotos.com

The retrospective study included 162 patients with cirrhosis and hepatocellular carcinoma within the Milan criteria. In all, 99 patients had open hepatic resections, while 63 underwent laparoscopic resections, the investigators said. Only 10% of laparoscopy patients had complications of grade 2 or higher, compared with 26% of open surgery cases (P = .0459), they reported. And while 7% of the open surgery patients developed ascites after surgery, none of the laparoscopy patients did (P = .0077), possibly because they experienced less tissue damage and because the deliberate induction of carbon dioxide pneumoperitoneum during laparoscopy can reduce local inflammatory responses, the researchers said. Laparoscopy patients also averaged 6 fewer days in the hospital after their procedures, Dr. Yamashita and associates reported (median length of stay, 10 vs. 16 days; P = .0008).

The laparoscopy group had no port site recurrences or peritoneal seeding of hepatocellular carcinoma, the investigators noted. Rates of disease-free and overall survival were similar between the two groups (P = .5196 and P = .6791, respectively), they added. Five-year and 10-year overall survival rates were 78% and 69% for laparoscopy patients, and were 77% and 57% for open resection patients, they said.

The authors disclosed no funding sources and reported having no conflicts of interest.

Patients with liver cancer and cirrhosis who underwent laparoscopic hepatic resection had fewer complications, shorter hospital stays, no port site recurrences, and no significant difference in survival, compared with patients who had open resections, according to a single-center, 10-year study published online in the Journal of the American College of Surgeons.

The study is the first to report long-term favorable results of laparoscopic hepatic resection for liver cancer in patients with cirrhosis, said Dr. Yo-ichi Yamashita and associates at Kyushu University, Fukuoka, Japan. Based on the data, laparoscopic instead of open resection should be considered for patients with cirrhosis whose hepatocellular carcinomas fall within the Milan criteria, the investigators said (J. Am. Coll. Surg. 2014 Sept. 9 [doi: 10.1016/j.jamcollsurg.2014.09.003]).

©avatavat/thinkstockphotos.com

The retrospective study included 162 patients with cirrhosis and hepatocellular carcinoma within the Milan criteria. In all, 99 patients had open hepatic resections, while 63 underwent laparoscopic resections, the investigators said. Only 10% of laparoscopy patients had complications of grade 2 or higher, compared with 26% of open surgery cases (P = .0459), they reported. And while 7% of the open surgery patients developed ascites after surgery, none of the laparoscopy patients did (P = .0077), possibly because they experienced less tissue damage and because the deliberate induction of carbon dioxide pneumoperitoneum during laparoscopy can reduce local inflammatory responses, the researchers said. Laparoscopy patients also averaged 6 fewer days in the hospital after their procedures, Dr. Yamashita and associates reported (median length of stay, 10 vs. 16 days; P = .0008).

The laparoscopy group had no port site recurrences or peritoneal seeding of hepatocellular carcinoma, the investigators noted. Rates of disease-free and overall survival were similar between the two groups (P = .5196 and P = .6791, respectively), they added. Five-year and 10-year overall survival rates were 78% and 69% for laparoscopy patients, and were 77% and 57% for open resection patients, they said.

The authors disclosed no funding sources and reported having no conflicts of interest.

Patients with liver cancer and cirrhosis who underwent laparoscopic hepatic resection had fewer complications, shorter hospital stays, no port site recurrences, and no significant difference in survival, compared with patients who had open resections, according to a single-center, 10-year study published online in the Journal of the American College of Surgeons.

The study is the first to report long-term favorable results of laparoscopic hepatic resection for liver cancer in patients with cirrhosis, said Dr. Yo-ichi Yamashita and associates at Kyushu University, Fukuoka, Japan. Based on the data, laparoscopic instead of open resection should be considered for patients with cirrhosis whose hepatocellular carcinomas fall within the Milan criteria, the investigators said (J. Am. Coll. Surg. 2014 Sept. 9 [doi: 10.1016/j.jamcollsurg.2014.09.003]).

©avatavat/thinkstockphotos.com

The retrospective study included 162 patients with cirrhosis and hepatocellular carcinoma within the Milan criteria. In all, 99 patients had open hepatic resections, while 63 underwent laparoscopic resections, the investigators said. Only 10% of laparoscopy patients had complications of grade 2 or higher, compared with 26% of open surgery cases (P = .0459), they reported. And while 7% of the open surgery patients developed ascites after surgery, none of the laparoscopy patients did (P = .0077), possibly because they experienced less tissue damage and because the deliberate induction of carbon dioxide pneumoperitoneum during laparoscopy can reduce local inflammatory responses, the researchers said. Laparoscopy patients also averaged 6 fewer days in the hospital after their procedures, Dr. Yamashita and associates reported (median length of stay, 10 vs. 16 days; P = .0008).

The laparoscopy group had no port site recurrences or peritoneal seeding of hepatocellular carcinoma, the investigators noted. Rates of disease-free and overall survival were similar between the two groups (P = .5196 and P = .6791, respectively), they added. Five-year and 10-year overall survival rates were 78% and 69% for laparoscopy patients, and were 77% and 57% for open resection patients, they said.

The authors disclosed no funding sources and reported having no conflicts of interest.

SAN FRANCISCO – Directing radiation therapy to lymph nodes in the breast or chest wall as part of treatment for early node-negative breast cancer does not increase lymphedema risk, according to a secondary analysis of the National Surgical Adjuvant Breast and Bowel Project’s B-32 trial.

“There was no evidence to suggest a detrimental impact of nonregional nodal breast or chest wall radiation on the risk of lymphedema beyond surgery,” lead author Dr. Susan A. McCloskey of the University of California, Los Angeles, said at the annual scientific meeting of the American Society for Radiation Oncology.

The results also showed that subjectively perceived lymphedema was less common than objectively measured lymphedema, and the two were poorly correlated. “Additional analyses of our objective data are currently in progress to evaluate quantification methods that may better correlate with the subjective assessment,” she said.

In the trial, women with clinically node-negative breast cancer were randomized to sentinel node resection followed by routine axillary lymph node dissection (ALND) – the standard when the trial began – or to sentinel node resection followed by ALND only if that node was positive.

Previously reported results showed that the two strategies yielded statistically equivalent overall survival, disease-free survival, and regional control (Lancet Oncol. 2010;11:927-933) and that ALND increased the risk of lymphedema (J. Surg. Oncol. 2010;102:111-8).

“In large part, on the basis of these findings, sentinel node resection alone became [the] standard of care for women presenting with clinically negative axillary nodes,” Dr. McCloskey noted.

The new analysis compared lymphedema outcomes according to receipt of radiation among the 3,894 women with pathologically negative sentinel nodes. Most underwent breast-conserving surgery, and 83% received radiation therapy as part of their treatment, nearly always breast or chest wall–only radiation (that is, nonregional nodal radiation).

The women were evaluated for the presence of lymphedema every 6 months. Subjective lymphedema, assessed with a questionnaire, was defined as a report that swelling was somewhat, quite, or very bothersome. Objective lymphedema, assessed with a water displacement test, was defined as a relative difference in volumes between arms exceeding 10%.

During 36 months of follow-up, there was no significant difference at any time point between women who did and did not receive radiation in the adjusted rate of lymphedema, whether it was assessed subjectively or objectively, reported Dr. McCloskey. The findings were the same when women were stratified by the extent of nodal surgery.

The rate of subjective lymphedema was consistently lower than the rate of objective lymphedema, both among women who had only sentinel node resection (averaging roughly 2.5% vs. 7.5%) and among women who had sentinel node resection followed by ALND (averaging roughly 10% vs. 15%). Overall, there was poor agreement between objectively and subjectively measured lymphedema, with kappa values ranging from just 0.02 to 0.21, where 1.0 would represent perfect agreement.

“Some considerations that we view as hypothesis generating at this point are that a relative arm volume difference of less than 10% is bothersome to some women, and conversely, a relative arm volume difference of greater than 10% is not bothersome to all women. So there may be issues of body habitus or handedness that may affect these metrics,” Dr. McCloskey commented. “Also, I think the jury is still out on exactly what the best metric is to measure lymphedema, both in terms of water displacement and the relative arm volume difference equation.”

In a related press briefing, she said that the findings could affect treatment decisions, given that some women with early breast cancer opt for mastectomy in part because of fears about radiation therapy.

“Where I practice, we run a multidisciplinary breast clinic where all women who are newly diagnosed come to see a team of physicians at the time of their diagnosis. I find that one of the most feared topics for discussion is radiation, and many women will talk about a litany of potential side effects that they are fearful of. And as many of you know, there have been dramatic increases in rates of mastectomy in the United States,” she said. “So it’s an opportunity, I think, to reassure women who are particularly fearful of lymphedema that yes, there is still a risk from the surgery and the type of surgery that’s done, but it doesn’t appear that choice of breast conservation and having routine breast radiation is going to impact that risk beyond the surgery. So I think it can affect what women choose.”

The findings are good news when it comes to quality of life after breast cancer treatment, agreed Dr. Tracy Balboni, a radiation oncologist at the Dana-Farber Cancer Institute in Boston and moderator of the press briefing. The evidence suggesting that conventional radiation therapy doesn’t add to the risk of lymphedema for patients “help[s] us feel assured that we’re not going to be reducing the quality of life of our cancer patients through the addition of conventional radiation therapy to the whole breast,” she said.

Dr. McCloskey disclosed no relevant conflicts of interest.

SAN FRANCISCO – Directing radiation therapy to lymph nodes in the breast or chest wall as part of treatment for early node-negative breast cancer does not increase lymphedema risk, according to a secondary analysis of the National Surgical Adjuvant Breast and Bowel Project’s B-32 trial.

“There was no evidence to suggest a detrimental impact of nonregional nodal breast or chest wall radiation on the risk of lymphedema beyond surgery,” lead author Dr. Susan A. McCloskey of the University of California, Los Angeles, said at the annual scientific meeting of the American Society for Radiation Oncology.

The results also showed that subjectively perceived lymphedema was less common than objectively measured lymphedema, and the two were poorly correlated. “Additional analyses of our objective data are currently in progress to evaluate quantification methods that may better correlate with the subjective assessment,” she said.

In the trial, women with clinically node-negative breast cancer were randomized to sentinel node resection followed by routine axillary lymph node dissection (ALND) – the standard when the trial began – or to sentinel node resection followed by ALND only if that node was positive.

Previously reported results showed that the two strategies yielded statistically equivalent overall survival, disease-free survival, and regional control (Lancet Oncol. 2010;11:927-933) and that ALND increased the risk of lymphedema (J. Surg. Oncol. 2010;102:111-8).

“In large part, on the basis of these findings, sentinel node resection alone became [the] standard of care for women presenting with clinically negative axillary nodes,” Dr. McCloskey noted.

The new analysis compared lymphedema outcomes according to receipt of radiation among the 3,894 women with pathologically negative sentinel nodes. Most underwent breast-conserving surgery, and 83% received radiation therapy as part of their treatment, nearly always breast or chest wall–only radiation (that is, nonregional nodal radiation).

The women were evaluated for the presence of lymphedema every 6 months. Subjective lymphedema, assessed with a questionnaire, was defined as a report that swelling was somewhat, quite, or very bothersome. Objective lymphedema, assessed with a water displacement test, was defined as a relative difference in volumes between arms exceeding 10%.

During 36 months of follow-up, there was no significant difference at any time point between women who did and did not receive radiation in the adjusted rate of lymphedema, whether it was assessed subjectively or objectively, reported Dr. McCloskey. The findings were the same when women were stratified by the extent of nodal surgery.

The rate of subjective lymphedema was consistently lower than the rate of objective lymphedema, both among women who had only sentinel node resection (averaging roughly 2.5% vs. 7.5%) and among women who had sentinel node resection followed by ALND (averaging roughly 10% vs. 15%). Overall, there was poor agreement between objectively and subjectively measured lymphedema, with kappa values ranging from just 0.02 to 0.21, where 1.0 would represent perfect agreement.

“Some considerations that we view as hypothesis generating at this point are that a relative arm volume difference of less than 10% is bothersome to some women, and conversely, a relative arm volume difference of greater than 10% is not bothersome to all women. So there may be issues of body habitus or handedness that may affect these metrics,” Dr. McCloskey commented. “Also, I think the jury is still out on exactly what the best metric is to measure lymphedema, both in terms of water displacement and the relative arm volume difference equation.”

In a related press briefing, she said that the findings could affect treatment decisions, given that some women with early breast cancer opt for mastectomy in part because of fears about radiation therapy.

“Where I practice, we run a multidisciplinary breast clinic where all women who are newly diagnosed come to see a team of physicians at the time of their diagnosis. I find that one of the most feared topics for discussion is radiation, and many women will talk about a litany of potential side effects that they are fearful of. And as many of you know, there have been dramatic increases in rates of mastectomy in the United States,” she said. “So it’s an opportunity, I think, to reassure women who are particularly fearful of lymphedema that yes, there is still a risk from the surgery and the type of surgery that’s done, but it doesn’t appear that choice of breast conservation and having routine breast radiation is going to impact that risk beyond the surgery. So I think it can affect what women choose.”

The findings are good news when it comes to quality of life after breast cancer treatment, agreed Dr. Tracy Balboni, a radiation oncologist at the Dana-Farber Cancer Institute in Boston and moderator of the press briefing. The evidence suggesting that conventional radiation therapy doesn’t add to the risk of lymphedema for patients “help[s] us feel assured that we’re not going to be reducing the quality of life of our cancer patients through the addition of conventional radiation therapy to the whole breast,” she said.

Dr. McCloskey disclosed no relevant conflicts of interest.

SAN FRANCISCO – Directing radiation therapy to lymph nodes in the breast or chest wall as part of treatment for early node-negative breast cancer does not increase lymphedema risk, according to a secondary analysis of the National Surgical Adjuvant Breast and Bowel Project’s B-32 trial.

“There was no evidence to suggest a detrimental impact of nonregional nodal breast or chest wall radiation on the risk of lymphedema beyond surgery,” lead author Dr. Susan A. McCloskey of the University of California, Los Angeles, said at the annual scientific meeting of the American Society for Radiation Oncology.

The results also showed that subjectively perceived lymphedema was less common than objectively measured lymphedema, and the two were poorly correlated. “Additional analyses of our objective data are currently in progress to evaluate quantification methods that may better correlate with the subjective assessment,” she said.

In the trial, women with clinically node-negative breast cancer were randomized to sentinel node resection followed by routine axillary lymph node dissection (ALND) – the standard when the trial began – or to sentinel node resection followed by ALND only if that node was positive.

Previously reported results showed that the two strategies yielded statistically equivalent overall survival, disease-free survival, and regional control (Lancet Oncol. 2010;11:927-933) and that ALND increased the risk of lymphedema (J. Surg. Oncol. 2010;102:111-8).

“In large part, on the basis of these findings, sentinel node resection alone became [the] standard of care for women presenting with clinically negative axillary nodes,” Dr. McCloskey noted.

The new analysis compared lymphedema outcomes according to receipt of radiation among the 3,894 women with pathologically negative sentinel nodes. Most underwent breast-conserving surgery, and 83% received radiation therapy as part of their treatment, nearly always breast or chest wall–only radiation (that is, nonregional nodal radiation).

The women were evaluated for the presence of lymphedema every 6 months. Subjective lymphedema, assessed with a questionnaire, was defined as a report that swelling was somewhat, quite, or very bothersome. Objective lymphedema, assessed with a water displacement test, was defined as a relative difference in volumes between arms exceeding 10%.

During 36 months of follow-up, there was no significant difference at any time point between women who did and did not receive radiation in the adjusted rate of lymphedema, whether it was assessed subjectively or objectively, reported Dr. McCloskey. The findings were the same when women were stratified by the extent of nodal surgery.

The rate of subjective lymphedema was consistently lower than the rate of objective lymphedema, both among women who had only sentinel node resection (averaging roughly 2.5% vs. 7.5%) and among women who had sentinel node resection followed by ALND (averaging roughly 10% vs. 15%). Overall, there was poor agreement between objectively and subjectively measured lymphedema, with kappa values ranging from just 0.02 to 0.21, where 1.0 would represent perfect agreement.

“Some considerations that we view as hypothesis generating at this point are that a relative arm volume difference of less than 10% is bothersome to some women, and conversely, a relative arm volume difference of greater than 10% is not bothersome to all women. So there may be issues of body habitus or handedness that may affect these metrics,” Dr. McCloskey commented. “Also, I think the jury is still out on exactly what the best metric is to measure lymphedema, both in terms of water displacement and the relative arm volume difference equation.”

In a related press briefing, she said that the findings could affect treatment decisions, given that some women with early breast cancer opt for mastectomy in part because of fears about radiation therapy.

“Where I practice, we run a multidisciplinary breast clinic where all women who are newly diagnosed come to see a team of physicians at the time of their diagnosis. I find that one of the most feared topics for discussion is radiation, and many women will talk about a litany of potential side effects that they are fearful of. And as many of you know, there have been dramatic increases in rates of mastectomy in the United States,” she said. “So it’s an opportunity, I think, to reassure women who are particularly fearful of lymphedema that yes, there is still a risk from the surgery and the type of surgery that’s done, but it doesn’t appear that choice of breast conservation and having routine breast radiation is going to impact that risk beyond the surgery. So I think it can affect what women choose.”

The findings are good news when it comes to quality of life after breast cancer treatment, agreed Dr. Tracy Balboni, a radiation oncologist at the Dana-Farber Cancer Institute in Boston and moderator of the press briefing. The evidence suggesting that conventional radiation therapy doesn’t add to the risk of lymphedema for patients “help[s] us feel assured that we’re not going to be reducing the quality of life of our cancer patients through the addition of conventional radiation therapy to the whole breast,” she said.

Dr. McCloskey disclosed no relevant conflicts of interest.

SAN FRANCISCO – Only a fraction of patients with breast cancer who are eligible for neoadjuvant therapy are getting it, partly because of confusion around the significance of achieving a pathologic complete response, Dr. William M. Sikov said in an interview at a breast cancer symposium sponsored by the American Society of Clinical Oncology.

Dr. Sikov of Brown University, Providence, R.I., explained why it’s been difficult for researchers to show improved outcomes even after a pathologic complete response (pCR) is obtained, but argued that waiting for long-term outcomes data for neoadjuvant therapy could be a disservice to some patients with breast cancer.

Breast cancer surgeons at his own institution have become converts in favor of neoadjuvant therapy, and Dr. Sikov explained why in this video report.

He reported having no relevant financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Only a fraction of patients with breast cancer who are eligible for neoadjuvant therapy are getting it, partly because of confusion around the significance of achieving a pathologic complete response, Dr. William M. Sikov said in an interview at a breast cancer symposium sponsored by the American Society of Clinical Oncology.

Dr. Sikov of Brown University, Providence, R.I., explained why it’s been difficult for researchers to show improved outcomes even after a pathologic complete response (pCR) is obtained, but argued that waiting for long-term outcomes data for neoadjuvant therapy could be a disservice to some patients with breast cancer.

Breast cancer surgeons at his own institution have become converts in favor of neoadjuvant therapy, and Dr. Sikov explained why in this video report.

He reported having no relevant financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Only a fraction of patients with breast cancer who are eligible for neoadjuvant therapy are getting it, partly because of confusion around the significance of achieving a pathologic complete response, Dr. William M. Sikov said in an interview at a breast cancer symposium sponsored by the American Society of Clinical Oncology.

Dr. Sikov of Brown University, Providence, R.I., explained why it’s been difficult for researchers to show improved outcomes even after a pathologic complete response (pCR) is obtained, but argued that waiting for long-term outcomes data for neoadjuvant therapy could be a disservice to some patients with breast cancer.

Breast cancer surgeons at his own institution have become converts in favor of neoadjuvant therapy, and Dr. Sikov explained why in this video report.

He reported having no relevant financial disclosures.

[email protected]

On Twitter @sherryboschert

Patients who underwent laparoscopic total mesorectal excision with coloanal anastomosis for rectal cancer had similar rates of mortality and morbidity, regardless of whether the extraction was performed transanally or transabdominally, a long-term single-center study showed.

“There are few data of full laparoscopic coloanal anastomosis for rectal cancer, including small series and short follow-up,” authors led by Dr. Quentin Denost of the department of surgery at Saint-André Hospital, Bordeau, France, wrote. “Moreover, the risk of anastomotic or perineal recurrence induced by transanal extraction of the rectal specimen is not known.” In addition, they continued, functional outcomes of laparoscopic coloanal anastomosis “have never been reported, and therefore the potential risk of anal incontinence related to transanal specimen extraction has never been discussed.”

In an effort to investigate the long-term outcome of laparoscopic coloanal anastomosis for rectal cancer, the researchers evaluated records of 220 patients who underwent laparoscopic total mesorectal excision and coloanal anastomosis for rectal cancer at Saint-André Hospital between 2000 and 2010 (Ann. Surg. 2014 Sept. 1 [doi:10.1097/SLA.0000000000000855]). Study endpoints of interest were circumferential margin, mesorectal grade, local recurrence, survival, and functional outcome obtained by a questionnaire sent to patients free of disease with at least 1 year of follow-up after stoma closure.

More than half of the patients (63%) were male, their median age was 64, and their median body mass index was 25 kg/m2. The tumors were a median of 4 cm from the anal verge and 1 cm from the anal ring, and 82% of the patients had stage T3 or T4 disease.

The authors reported that the overall mortality and surgical morbidity rates were 0.5% and 17%, respectively, the rate of positive circumferential resection margin was 9%, and the median anal continence score was 6 (range, 0-20). After a median follow-up of 51 months, the local recurrence rate was 4%, while at 5 years, the overall survival and disease-free survival rates were 83% and 70%, respectively.

When the authors evaluated results by extraction site, no significant differences were observed between the transanal extraction and transabdomonal extraction groups in the rate of overall mortality (0.8% vs. 0%, respectively; P = 1.000), overall morbidity (34% vs. 43%), positive circumferential margin (7% vs. 11%; P = .324), mesorectal grade, local recurrence (4% vs. 5%; P = .98), and disease-free survival (72% vs. 68%; P = .63). The median continence score was 6 in both groups (P = .92).

The findings demonstrated that pelvic control and survival “were not compromised by the association between mini invasive surgery and ultralow sphincter preservation,” the authors concluded. “Moreover, we demonstrated the safety and efficacy of transanal extraction of the rectal specimen with similar oncologic and functional outcome than the conventional abdominal extraction. Because of the wound advantages of transanal extraction, in terms of abdominal wall preservation, transanal extraction can be recommended in laparoscopic surgical management of low rectal cancer.”

They acknowledged certain limitations of the study, including the fact that BMI was slightly lower in the transanal group, compared with the transabdomonal group (24.3 vs. 25.8 kg/m2, respectively; P = .01). This suggests “that some obese patients probably received transabdominal instead of transanal extraction,” Dr. Denost and associates wrote. “Therefore, as we recommend preventing excessive stretching of the anal sphincter during rectal extraction, we also recommend to be cautious when performing transanal extraction in obese patients with wide mesorectal specimen, especially to avoid mesorectal injury and tumor spillage.”

The authors reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

Patients who underwent laparoscopic total mesorectal excision with coloanal anastomosis for rectal cancer had similar rates of mortality and morbidity, regardless of whether the extraction was performed transanally or transabdominally, a long-term single-center study showed.

“There are few data of full laparoscopic coloanal anastomosis for rectal cancer, including small series and short follow-up,” authors led by Dr. Quentin Denost of the department of surgery at Saint-André Hospital, Bordeau, France, wrote. “Moreover, the risk of anastomotic or perineal recurrence induced by transanal extraction of the rectal specimen is not known.” In addition, they continued, functional outcomes of laparoscopic coloanal anastomosis “have never been reported, and therefore the potential risk of anal incontinence related to transanal specimen extraction has never been discussed.”

In an effort to investigate the long-term outcome of laparoscopic coloanal anastomosis for rectal cancer, the researchers evaluated records of 220 patients who underwent laparoscopic total mesorectal excision and coloanal anastomosis for rectal cancer at Saint-André Hospital between 2000 and 2010 (Ann. Surg. 2014 Sept. 1 [doi:10.1097/SLA.0000000000000855]). Study endpoints of interest were circumferential margin, mesorectal grade, local recurrence, survival, and functional outcome obtained by a questionnaire sent to patients free of disease with at least 1 year of follow-up after stoma closure.

More than half of the patients (63%) were male, their median age was 64, and their median body mass index was 25 kg/m2. The tumors were a median of 4 cm from the anal verge and 1 cm from the anal ring, and 82% of the patients had stage T3 or T4 disease.

The authors reported that the overall mortality and surgical morbidity rates were 0.5% and 17%, respectively, the rate of positive circumferential resection margin was 9%, and the median anal continence score was 6 (range, 0-20). After a median follow-up of 51 months, the local recurrence rate was 4%, while at 5 years, the overall survival and disease-free survival rates were 83% and 70%, respectively.

When the authors evaluated results by extraction site, no significant differences were observed between the transanal extraction and transabdomonal extraction groups in the rate of overall mortality (0.8% vs. 0%, respectively; P = 1.000), overall morbidity (34% vs. 43%), positive circumferential margin (7% vs. 11%; P = .324), mesorectal grade, local recurrence (4% vs. 5%; P = .98), and disease-free survival (72% vs. 68%; P = .63). The median continence score was 6 in both groups (P = .92).

The findings demonstrated that pelvic control and survival “were not compromised by the association between mini invasive surgery and ultralow sphincter preservation,” the authors concluded. “Moreover, we demonstrated the safety and efficacy of transanal extraction of the rectal specimen with similar oncologic and functional outcome than the conventional abdominal extraction. Because of the wound advantages of transanal extraction, in terms of abdominal wall preservation, transanal extraction can be recommended in laparoscopic surgical management of low rectal cancer.”

They acknowledged certain limitations of the study, including the fact that BMI was slightly lower in the transanal group, compared with the transabdomonal group (24.3 vs. 25.8 kg/m2, respectively; P = .01). This suggests “that some obese patients probably received transabdominal instead of transanal extraction,” Dr. Denost and associates wrote. “Therefore, as we recommend preventing excessive stretching of the anal sphincter during rectal extraction, we also recommend to be cautious when performing transanal extraction in obese patients with wide mesorectal specimen, especially to avoid mesorectal injury and tumor spillage.”

The authors reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

Patients who underwent laparoscopic total mesorectal excision with coloanal anastomosis for rectal cancer had similar rates of mortality and morbidity, regardless of whether the extraction was performed transanally or transabdominally, a long-term single-center study showed.

“There are few data of full laparoscopic coloanal anastomosis for rectal cancer, including small series and short follow-up,” authors led by Dr. Quentin Denost of the department of surgery at Saint-André Hospital, Bordeau, France, wrote. “Moreover, the risk of anastomotic or perineal recurrence induced by transanal extraction of the rectal specimen is not known.” In addition, they continued, functional outcomes of laparoscopic coloanal anastomosis “have never been reported, and therefore the potential risk of anal incontinence related to transanal specimen extraction has never been discussed.”

In an effort to investigate the long-term outcome of laparoscopic coloanal anastomosis for rectal cancer, the researchers evaluated records of 220 patients who underwent laparoscopic total mesorectal excision and coloanal anastomosis for rectal cancer at Saint-André Hospital between 2000 and 2010 (Ann. Surg. 2014 Sept. 1 [doi:10.1097/SLA.0000000000000855]). Study endpoints of interest were circumferential margin, mesorectal grade, local recurrence, survival, and functional outcome obtained by a questionnaire sent to patients free of disease with at least 1 year of follow-up after stoma closure.

More than half of the patients (63%) were male, their median age was 64, and their median body mass index was 25 kg/m2. The tumors were a median of 4 cm from the anal verge and 1 cm from the anal ring, and 82% of the patients had stage T3 or T4 disease.

The authors reported that the overall mortality and surgical morbidity rates were 0.5% and 17%, respectively, the rate of positive circumferential resection margin was 9%, and the median anal continence score was 6 (range, 0-20). After a median follow-up of 51 months, the local recurrence rate was 4%, while at 5 years, the overall survival and disease-free survival rates were 83% and 70%, respectively.

When the authors evaluated results by extraction site, no significant differences were observed between the transanal extraction and transabdomonal extraction groups in the rate of overall mortality (0.8% vs. 0%, respectively; P = 1.000), overall morbidity (34% vs. 43%), positive circumferential margin (7% vs. 11%; P = .324), mesorectal grade, local recurrence (4% vs. 5%; P = .98), and disease-free survival (72% vs. 68%; P = .63). The median continence score was 6 in both groups (P = .92).

The findings demonstrated that pelvic control and survival “were not compromised by the association between mini invasive surgery and ultralow sphincter preservation,” the authors concluded. “Moreover, we demonstrated the safety and efficacy of transanal extraction of the rectal specimen with similar oncologic and functional outcome than the conventional abdominal extraction. Because of the wound advantages of transanal extraction, in terms of abdominal wall preservation, transanal extraction can be recommended in laparoscopic surgical management of low rectal cancer.”

They acknowledged certain limitations of the study, including the fact that BMI was slightly lower in the transanal group, compared with the transabdomonal group (24.3 vs. 25.8 kg/m2, respectively; P = .01). This suggests “that some obese patients probably received transabdominal instead of transanal extraction,” Dr. Denost and associates wrote. “Therefore, as we recommend preventing excessive stretching of the anal sphincter during rectal extraction, we also recommend to be cautious when performing transanal extraction in obese patients with wide mesorectal specimen, especially to avoid mesorectal injury and tumor spillage.”

The authors reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

SAN FRANCISCO – Women undergoing mastectomy and breast reconstruction for the treatment of breast cancer are more likely to develop perioperative complications if they opt for prophylactic mastectomy of the other breast at the same time, a study of 18,229 cases found.

Compared with women who had a unilateral mastectomy and reconstruction, the 36% of patients who chose bilateral mastectomy and reconstruction were 55% more likely to lose a breast implant (if implants were used for reconstruction), twice as likely to need a transfusion regardless of whether the reconstruction used implants or autologous material, and twice as likely to remain hospitalized for at least 2 days regardless of reconstruction method, Dr. Amanda K. Silva and her associates reported in a poster presentation at a breast cancer symposium sponsored by the American Society of Clinical Oncology.

The reconstruction used implants in 89% of women undergoing bilateral mastectomy and 79% of those getting unilateral mastectomy, Dr. Silva and her colleagues reported.

The overall rate of complications was low, however, averaging 5%, said Dr. Silva, a surgeon at the University of Chicago, and her associates.

In this video interview, Dr. Silva discusses factors that physicians and patients should consider when choosing unilateral or bilateral mastectomy and reconstruction.

Previous studies have compared the risks of unilateral versus bilateral mastectomy without reconstruction, she said, and this study provides some of the first data of risks from either type of mastectomy with reconstruction.

Dr. Silva reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Women undergoing mastectomy and breast reconstruction for the treatment of breast cancer are more likely to develop perioperative complications if they opt for prophylactic mastectomy of the other breast at the same time, a study of 18,229 cases found.

Compared with women who had a unilateral mastectomy and reconstruction, the 36% of patients who chose bilateral mastectomy and reconstruction were 55% more likely to lose a breast implant (if implants were used for reconstruction), twice as likely to need a transfusion regardless of whether the reconstruction used implants or autologous material, and twice as likely to remain hospitalized for at least 2 days regardless of reconstruction method, Dr. Amanda K. Silva and her associates reported in a poster presentation at a breast cancer symposium sponsored by the American Society of Clinical Oncology.

The reconstruction used implants in 89% of women undergoing bilateral mastectomy and 79% of those getting unilateral mastectomy, Dr. Silva and her colleagues reported.

The overall rate of complications was low, however, averaging 5%, said Dr. Silva, a surgeon at the University of Chicago, and her associates.

In this video interview, Dr. Silva discusses factors that physicians and patients should consider when choosing unilateral or bilateral mastectomy and reconstruction.

Previous studies have compared the risks of unilateral versus bilateral mastectomy without reconstruction, she said, and this study provides some of the first data of risks from either type of mastectomy with reconstruction.

Dr. Silva reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Women undergoing mastectomy and breast reconstruction for the treatment of breast cancer are more likely to develop perioperative complications if they opt for prophylactic mastectomy of the other breast at the same time, a study of 18,229 cases found.

Compared with women who had a unilateral mastectomy and reconstruction, the 36% of patients who chose bilateral mastectomy and reconstruction were 55% more likely to lose a breast implant (if implants were used for reconstruction), twice as likely to need a transfusion regardless of whether the reconstruction used implants or autologous material, and twice as likely to remain hospitalized for at least 2 days regardless of reconstruction method, Dr. Amanda K. Silva and her associates reported in a poster presentation at a breast cancer symposium sponsored by the American Society of Clinical Oncology.

The reconstruction used implants in 89% of women undergoing bilateral mastectomy and 79% of those getting unilateral mastectomy, Dr. Silva and her colleagues reported.

The overall rate of complications was low, however, averaging 5%, said Dr. Silva, a surgeon at the University of Chicago, and her associates.

In this video interview, Dr. Silva discusses factors that physicians and patients should consider when choosing unilateral or bilateral mastectomy and reconstruction.

Previous studies have compared the risks of unilateral versus bilateral mastectomy without reconstruction, she said, and this study provides some of the first data of risks from either type of mastectomy with reconstruction.

Dr. Silva reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

Open breast biopsy accounted for 34% of breast biopsies in 25,965 U.S. inpatients between 2008 and 2010, a retrospective study found.

The finding suggests that minimally invasive breast biopsy techniques are underutilized, with a national rate that’s far off the widely acknowledge goal of having at least 90% of biopsies for suspicious breast lesions be minimally invasive, Dr. Linda Adepoju reported.

Most breast biopsies are performed in outpatient settings. Although the study analyzed a national data sample for hospitalized patients, the rate of open breast biopsy is consistent with previous studies of outpatient databases for individual institutions or states that have reported rates of open breast biopsy from 24% to 36%, noted Dr. Adepoju of the University of Toledo (Ohio).

She and her associates analyzed data from 46 states in the Healthcare Cost and Utilization Project National Inpatient Sample for 2008-2010, excluding 222 cases in which an open breast biopsy and minimally invasive breast biopsy were performed during the same hospital stay.

Open breast biopsy rates were significantly higher in women aged 49 years or younger (47%), compared with older women (29%), and in Asian women (40%) or Hispanic women (41%), compared with white women (34%) or black women (31%). Open breast biopsy also was significantly more likely in women who had private insurance than in women covered by Medicaid or Medicare – 41% vs. 31% (Am. J. Surg. 2014;208:382-90).

The type and location of hospital also was associated with open biopsy rates, with higher rates in small, private, rural, and/or nonteaching hospitals.

"Interventions targeting small, rural, and nonteaching hospitals could significantly decrease hospital costs and improve the overall quality of breast care," Dr. Adepoju and her associates commented, but "we must be sensitive" to the needs and limitations of various health care delivery settings, they added.

"A critical access hospital in rural Ohio may not be able to afford a mammographer and stereotactic equipment" for minimally invasive breast biopsy. Previous data "are clear that patients preferably seek their care in and near their community. Given workforce shortages and the current economic climate, this may mean accepting higher open breast biopsy rates in rural America," the investigators concluded.

Patients who had open breast biopsies in the current study were more likely to need more than one biopsy for diagnosis (1.2%), compared with women who had minimally invasive breast biopsies (0.5%). Hematoma drainage was needed in 1.4% of patients after open breast biopsy and 0.6% after minimally invasive biopsy. Open breast biopsy also was more expensive, based on analysis of data from the University of Toledo, averaging $1,700 in Medicare reimbursement, compared with $300-$1,100 for minimally invasive breast biopsy, depending on the specific procedure, Dr. Adepoju reported.

Previous data have shown that minimally invasive breast biopsies are less expensive, less scarring, require less recovery time, cause fewer complications, reduce the time between diagnosis and definitive treatment, produce fewer positive margins, and facilitate preoperative multidisciplinary treatment planning, compared with open breast biopsies.

The report from the third international consensus conference on image-detected breast cancer in 2009 called minimally invasive breast biopsy a best practice that should be the gold standard for initial diagnosis and proposed a goal of limiting open breast biopsy to 5%-10% of cases (J. Am. Coll. Surg. 2009;209:504-20).

Dr. Adepoju reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

Open breast biopsy accounted for 34% of breast biopsies in 25,965 U.S. inpatients between 2008 and 2010, a retrospective study found.

The finding suggests that minimally invasive breast biopsy techniques are underutilized, with a national rate that’s far off the widely acknowledge goal of having at least 90% of biopsies for suspicious breast lesions be minimally invasive, Dr. Linda Adepoju reported.

Most breast biopsies are performed in outpatient settings. Although the study analyzed a national data sample for hospitalized patients, the rate of open breast biopsy is consistent with previous studies of outpatient databases for individual institutions or states that have reported rates of open breast biopsy from 24% to 36%, noted Dr. Adepoju of the University of Toledo (Ohio).

She and her associates analyzed data from 46 states in the Healthcare Cost and Utilization Project National Inpatient Sample for 2008-2010, excluding 222 cases in which an open breast biopsy and minimally invasive breast biopsy were performed during the same hospital stay.

Open breast biopsy rates were significantly higher in women aged 49 years or younger (47%), compared with older women (29%), and in Asian women (40%) or Hispanic women (41%), compared with white women (34%) or black women (31%). Open breast biopsy also was significantly more likely in women who had private insurance than in women covered by Medicaid or Medicare – 41% vs. 31% (Am. J. Surg. 2014;208:382-90).

The type and location of hospital also was associated with open biopsy rates, with higher rates in small, private, rural, and/or nonteaching hospitals.

"Interventions targeting small, rural, and nonteaching hospitals could significantly decrease hospital costs and improve the overall quality of breast care," Dr. Adepoju and her associates commented, but "we must be sensitive" to the needs and limitations of various health care delivery settings, they added.

"A critical access hospital in rural Ohio may not be able to afford a mammographer and stereotactic equipment" for minimally invasive breast biopsy. Previous data "are clear that patients preferably seek their care in and near their community. Given workforce shortages and the current economic climate, this may mean accepting higher open breast biopsy rates in rural America," the investigators concluded.

Patients who had open breast biopsies in the current study were more likely to need more than one biopsy for diagnosis (1.2%), compared with women who had minimally invasive breast biopsies (0.5%). Hematoma drainage was needed in 1.4% of patients after open breast biopsy and 0.6% after minimally invasive biopsy. Open breast biopsy also was more expensive, based on analysis of data from the University of Toledo, averaging $1,700 in Medicare reimbursement, compared with $300-$1,100 for minimally invasive breast biopsy, depending on the specific procedure, Dr. Adepoju reported.

Previous data have shown that minimally invasive breast biopsies are less expensive, less scarring, require less recovery time, cause fewer complications, reduce the time between diagnosis and definitive treatment, produce fewer positive margins, and facilitate preoperative multidisciplinary treatment planning, compared with open breast biopsies.

The report from the third international consensus conference on image-detected breast cancer in 2009 called minimally invasive breast biopsy a best practice that should be the gold standard for initial diagnosis and proposed a goal of limiting open breast biopsy to 5%-10% of cases (J. Am. Coll. Surg. 2009;209:504-20).

Dr. Adepoju reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

Open breast biopsy accounted for 34% of breast biopsies in 25,965 U.S. inpatients between 2008 and 2010, a retrospective study found.

The finding suggests that minimally invasive breast biopsy techniques are underutilized, with a national rate that’s far off the widely acknowledge goal of having at least 90% of biopsies for suspicious breast lesions be minimally invasive, Dr. Linda Adepoju reported.

Most breast biopsies are performed in outpatient settings. Although the study analyzed a national data sample for hospitalized patients, the rate of open breast biopsy is consistent with previous studies of outpatient databases for individual institutions or states that have reported rates of open breast biopsy from 24% to 36%, noted Dr. Adepoju of the University of Toledo (Ohio).

She and her associates analyzed data from 46 states in the Healthcare Cost and Utilization Project National Inpatient Sample for 2008-2010, excluding 222 cases in which an open breast biopsy and minimally invasive breast biopsy were performed during the same hospital stay.

Open breast biopsy rates were significantly higher in women aged 49 years or younger (47%), compared with older women (29%), and in Asian women (40%) or Hispanic women (41%), compared with white women (34%) or black women (31%). Open breast biopsy also was significantly more likely in women who had private insurance than in women covered by Medicaid or Medicare – 41% vs. 31% (Am. J. Surg. 2014;208:382-90).

The type and location of hospital also was associated with open biopsy rates, with higher rates in small, private, rural, and/or nonteaching hospitals.

"Interventions targeting small, rural, and nonteaching hospitals could significantly decrease hospital costs and improve the overall quality of breast care," Dr. Adepoju and her associates commented, but "we must be sensitive" to the needs and limitations of various health care delivery settings, they added.

"A critical access hospital in rural Ohio may not be able to afford a mammographer and stereotactic equipment" for minimally invasive breast biopsy. Previous data "are clear that patients preferably seek their care in and near their community. Given workforce shortages and the current economic climate, this may mean accepting higher open breast biopsy rates in rural America," the investigators concluded.

Patients who had open breast biopsies in the current study were more likely to need more than one biopsy for diagnosis (1.2%), compared with women who had minimally invasive breast biopsies (0.5%). Hematoma drainage was needed in 1.4% of patients after open breast biopsy and 0.6% after minimally invasive biopsy. Open breast biopsy also was more expensive, based on analysis of data from the University of Toledo, averaging $1,700 in Medicare reimbursement, compared with $300-$1,100 for minimally invasive breast biopsy, depending on the specific procedure, Dr. Adepoju reported.

Previous data have shown that minimally invasive breast biopsies are less expensive, less scarring, require less recovery time, cause fewer complications, reduce the time between diagnosis and definitive treatment, produce fewer positive margins, and facilitate preoperative multidisciplinary treatment planning, compared with open breast biopsies.

The report from the third international consensus conference on image-detected breast cancer in 2009 called minimally invasive breast biopsy a best practice that should be the gold standard for initial diagnosis and proposed a goal of limiting open breast biopsy to 5%-10% of cases (J. Am. Coll. Surg. 2009;209:504-20).

Dr. Adepoju reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

BOSTON – Central lymph node dissection may not be necessary in patients with small parathyroid carcinomas, results of a data review suggest.

Among 405 U.S. patients treated in the last two decades for parathyroid carcinomas, disease-specific mortality and degree of local tumor invasion did not differ depending on nodal involvement, reported Dr. Kun-Tai Hsu, an associate research specialist in the surgery department at the University of Wisconsin, Madison.

Patients with tumors greater than 3 cm in diameter and distal metastasis had worse disease-specific mortality, and larger tumors were significantly more likely to be associated with positive lymph nodes, Dr. Hsu reported at the annual meeting of the American Association of Endocrine Surgeons.

The findings raise the question of whether central lymph node dissection is necessary for all patients with parathyroid carcinomas, but "our conclusions may not translate directly into definitive recommendations," said Dr. Hsu, who advised further study of whether patients with tumors larger than 3 cm may benefit from lymph node dissection.

Parathyroid carcinomas are rare cancers, accounting for 0.005% of all malignancies and less than 1% of primary hyperparathyroidism. The current standard of therapy is en bloc removal of the parathyroid tumor and ipsilateral lobectomy, isthmusectomy, and central lymph node dissection.

Over at least 5 years of follow-up, neither tumor size nor lymph node status was significantly predictive of outcomes in an earlier retrospective study of 286 patients treated in the 1980s and 1990s.

In addition, a 2006 study using data from the Surveillance, Epidemiology and End Results (SEER) database showed a significant increase in the incidence of this malignancy from 1988 through 2003. The authors identified younger age, female sex, more recent diagnosis, and absence of distant metastases as favorable prognostic factors (Cancer 2007;109:1736-41).

What the previous studies could not answer, however, was whether lymph node metastases were associated with worse disease-specific mortality and whether central lymph node dissection might improve survival in patients with parathyroid carcinomas, Dr. Hsu noted.

He and his colleagues queried SEER for disease-specific survival outcomes and lymph-node status of all patients treated in the United States for parathyroid carcinomas from 1988 through 2010.

They identified 212 female and 193 male patients. Among all patients, 112 (27.7%) had tumors 3 cm or greater, and 12 (3%) had positive lymph nodes. Median follow-up was 68 months.

In a multivariate analysis of disease-specific mortality predictors adjusted for sex and age only, tumors 3 cm or greater and the presence of metastasis were predictive of worse survival, with respective hazard ratios of 5.35 (P = .01) and 45.1 (P less than .01).

Similarly, an analysis adjusted for sex, age, and year of diagnosis showed that tumor size but not age or sex significantly predicted lymph node metastasis (HR, 19.48; P = .02)

A comparison of outcomes between patients with and without lymph node examinations found no differences in disease-specific mortality by sex, age, year of diagnosis, tumor size, local invasion, or metastasis. Significant predictors of disease-specific mortality in this analysis included surgery type (parathyroidectomy, en bloc excision, or debulking), the use of radiation, and white race.

Dr. Hsu noted that the study was limited by its retrospective design, lack of information on other significant clinical variables, lack of detailed follow-up data, and the possibility of misclassification or miscoding of cases.

He acknowledged that uncertainty about the diagnosis is a drawback to SEER-based studies, but that given the rarity of the disease, SEER data are the most reliable source of information.

The study was supported by the Wisconsin Surgical Outcomes Research Program. Dr. Hsu reported having no relevant disclosures. Study coauthor Dr. Rebecca Sippel is a member of this publication’s editorial advisory board.

BOSTON – Central lymph node dissection may not be necessary in patients with small parathyroid carcinomas, results of a data review suggest.

Among 405 U.S. patients treated in the last two decades for parathyroid carcinomas, disease-specific mortality and degree of local tumor invasion did not differ depending on nodal involvement, reported Dr. Kun-Tai Hsu, an associate research specialist in the surgery department at the University of Wisconsin, Madison.

Patients with tumors greater than 3 cm in diameter and distal metastasis had worse disease-specific mortality, and larger tumors were significantly more likely to be associated with positive lymph nodes, Dr. Hsu reported at the annual meeting of the American Association of Endocrine Surgeons.

The findings raise the question of whether central lymph node dissection is necessary for all patients with parathyroid carcinomas, but "our conclusions may not translate directly into definitive recommendations," said Dr. Hsu, who advised further study of whether patients with tumors larger than 3 cm may benefit from lymph node dissection.

Parathyroid carcinomas are rare cancers, accounting for 0.005% of all malignancies and less than 1% of primary hyperparathyroidism. The current standard of therapy is en bloc removal of the parathyroid tumor and ipsilateral lobectomy, isthmusectomy, and central lymph node dissection.

Over at least 5 years of follow-up, neither tumor size nor lymph node status was significantly predictive of outcomes in an earlier retrospective study of 286 patients treated in the 1980s and 1990s.

In addition, a 2006 study using data from the Surveillance, Epidemiology and End Results (SEER) database showed a significant increase in the incidence of this malignancy from 1988 through 2003. The authors identified younger age, female sex, more recent diagnosis, and absence of distant metastases as favorable prognostic factors (Cancer 2007;109:1736-41).

What the previous studies could not answer, however, was whether lymph node metastases were associated with worse disease-specific mortality and whether central lymph node dissection might improve survival in patients with parathyroid carcinomas, Dr. Hsu noted.

He and his colleagues queried SEER for disease-specific survival outcomes and lymph-node status of all patients treated in the United States for parathyroid carcinomas from 1988 through 2010.

They identified 212 female and 193 male patients. Among all patients, 112 (27.7%) had tumors 3 cm or greater, and 12 (3%) had positive lymph nodes. Median follow-up was 68 months.

In a multivariate analysis of disease-specific mortality predictors adjusted for sex and age only, tumors 3 cm or greater and the presence of metastasis were predictive of worse survival, with respective hazard ratios of 5.35 (P = .01) and 45.1 (P less than .01).

Similarly, an analysis adjusted for sex, age, and year of diagnosis showed that tumor size but not age or sex significantly predicted lymph node metastasis (HR, 19.48; P = .02)

A comparison of outcomes between patients with and without lymph node examinations found no differences in disease-specific mortality by sex, age, year of diagnosis, tumor size, local invasion, or metastasis. Significant predictors of disease-specific mortality in this analysis included surgery type (parathyroidectomy, en bloc excision, or debulking), the use of radiation, and white race.

Dr. Hsu noted that the study was limited by its retrospective design, lack of information on other significant clinical variables, lack of detailed follow-up data, and the possibility of misclassification or miscoding of cases.

He acknowledged that uncertainty about the diagnosis is a drawback to SEER-based studies, but that given the rarity of the disease, SEER data are the most reliable source of information.

The study was supported by the Wisconsin Surgical Outcomes Research Program. Dr. Hsu reported having no relevant disclosures. Study coauthor Dr. Rebecca Sippel is a member of this publication’s editorial advisory board.

BOSTON – Central lymph node dissection may not be necessary in patients with small parathyroid carcinomas, results of a data review suggest.

Among 405 U.S. patients treated in the last two decades for parathyroid carcinomas, disease-specific mortality and degree of local tumor invasion did not differ depending on nodal involvement, reported Dr. Kun-Tai Hsu, an associate research specialist in the surgery department at the University of Wisconsin, Madison.

Patients with tumors greater than 3 cm in diameter and distal metastasis had worse disease-specific mortality, and larger tumors were significantly more likely to be associated with positive lymph nodes, Dr. Hsu reported at the annual meeting of the American Association of Endocrine Surgeons.

The findings raise the question of whether central lymph node dissection is necessary for all patients with parathyroid carcinomas, but "our conclusions may not translate directly into definitive recommendations," said Dr. Hsu, who advised further study of whether patients with tumors larger than 3 cm may benefit from lymph node dissection.

Parathyroid carcinomas are rare cancers, accounting for 0.005% of all malignancies and less than 1% of primary hyperparathyroidism. The current standard of therapy is en bloc removal of the parathyroid tumor and ipsilateral lobectomy, isthmusectomy, and central lymph node dissection.

Over at least 5 years of follow-up, neither tumor size nor lymph node status was significantly predictive of outcomes in an earlier retrospective study of 286 patients treated in the 1980s and 1990s.

In addition, a 2006 study using data from the Surveillance, Epidemiology and End Results (SEER) database showed a significant increase in the incidence of this malignancy from 1988 through 2003. The authors identified younger age, female sex, more recent diagnosis, and absence of distant metastases as favorable prognostic factors (Cancer 2007;109:1736-41).

What the previous studies could not answer, however, was whether lymph node metastases were associated with worse disease-specific mortality and whether central lymph node dissection might improve survival in patients with parathyroid carcinomas, Dr. Hsu noted.

He and his colleagues queried SEER for disease-specific survival outcomes and lymph-node status of all patients treated in the United States for parathyroid carcinomas from 1988 through 2010.

They identified 212 female and 193 male patients. Among all patients, 112 (27.7%) had tumors 3 cm or greater, and 12 (3%) had positive lymph nodes. Median follow-up was 68 months.

In a multivariate analysis of disease-specific mortality predictors adjusted for sex and age only, tumors 3 cm or greater and the presence of metastasis were predictive of worse survival, with respective hazard ratios of 5.35 (P = .01) and 45.1 (P less than .01).

Similarly, an analysis adjusted for sex, age, and year of diagnosis showed that tumor size but not age or sex significantly predicted lymph node metastasis (HR, 19.48; P = .02)

A comparison of outcomes between patients with and without lymph node examinations found no differences in disease-specific mortality by sex, age, year of diagnosis, tumor size, local invasion, or metastasis. Significant predictors of disease-specific mortality in this analysis included surgery type (parathyroidectomy, en bloc excision, or debulking), the use of radiation, and white race.

Dr. Hsu noted that the study was limited by its retrospective design, lack of information on other significant clinical variables, lack of detailed follow-up data, and the possibility of misclassification or miscoding of cases.

He acknowledged that uncertainty about the diagnosis is a drawback to SEER-based studies, but that given the rarity of the disease, SEER data are the most reliable source of information.

The study was supported by the Wisconsin Surgical Outcomes Research Program. Dr. Hsu reported having no relevant disclosures. Study coauthor Dr. Rebecca Sippel is a member of this publication’s editorial advisory board.