Surgical Oncology

CHICAGO – The extent of lymph node involvement provides independent prognostic information in patients with early-stage T1 or T2 small intestinal neuroendocrine tumors, according to a study involving nearly 3,000 lymph node–positive individuals.

This metric, best expressed as the lymph node ratio, or the number of positive nodes divided by the total number of lymph nodes examined, is not included in current European and American Joint Committee on Cancer staging classification guidelines. But it should be, Dr. Michelle K. Kim said at the annual Digestive Disease Week.

"The lymph node ratio is a readily available marker of disease progression. It’s available as part of usual clinical care; it’s not something extra you have to ask for. It may help identify patients who may require more-aggressive therapy," according to Dr. Kim of Mount Sinai School of Medicine, New York.

Current staging guidelines merely make a binary distinction: lymph node–positive or –negative. But previous studies in colon, gastric, and pancreatic cancers indicate the lymph node ratio (LNR) further differentiates outcomes in node-positive patients. The same now appears to be true for small intestinal neuroendocrine tumors (SI-NETs), which are the most common of the gastroenteropancreatic neuroendocrine tumors. Indeed, the incidence of SI-NETs has tripled during the last 3 decades, she noted.

Dr. Kim presented an analysis of the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database, which included 2,984 patients with surgically resected lymph node–positive, metastasis-negative SI-NETs diagnosed in 1988-2010. Dr. Kim and coinvestigators classified patients into three LNR groups: 531 were LNR 1, defined as an LNR ratio of 0.2 or less; 1,525 patients were LNR 2, with a ratio of 0.21-0.5; and 928 were LNR 3, with a ratio greater than 0.5. Patients with T1 and T2 disease were overrepresented in the LNR 1 group.

The primary outcome in the study was disease-specific survival. The more-extensive the lymph node involvement in patients with T1 or T2 disease, the poorer their disease-specific survival. For example, LNR 1 patients with T1 or T2 SI-NETs were 1.6-fold more likely to experience disease-specific mortality during 10 years of follow-up than did a reference control group of node-negative T1/T2 patients, an elevation in risk that did not achieve statistical significance. However, the risk of disease-specific mortality was increased 2.29-fold in LNR 2 patients with T1/T2 disease and 4.52-fold in LNR 3 patients with T1/T2 SI-NETs, compared with node-negative controls, and those differences were significant.

In contrast, there was no difference in disease-specific survival according to LNR status in patients with more-advanced T3 or T4 disease.

This study was funded by Mount Sinai School of Medicine and the National Center for Advancing Translational Sciences. Dr. Kim reported having no financial conflicts.

[email protected]

CHICAGO – The extent of lymph node involvement provides independent prognostic information in patients with early-stage T1 or T2 small intestinal neuroendocrine tumors, according to a study involving nearly 3,000 lymph node–positive individuals.

This metric, best expressed as the lymph node ratio, or the number of positive nodes divided by the total number of lymph nodes examined, is not included in current European and American Joint Committee on Cancer staging classification guidelines. But it should be, Dr. Michelle K. Kim said at the annual Digestive Disease Week.

"The lymph node ratio is a readily available marker of disease progression. It’s available as part of usual clinical care; it’s not something extra you have to ask for. It may help identify patients who may require more-aggressive therapy," according to Dr. Kim of Mount Sinai School of Medicine, New York.

Current staging guidelines merely make a binary distinction: lymph node–positive or –negative. But previous studies in colon, gastric, and pancreatic cancers indicate the lymph node ratio (LNR) further differentiates outcomes in node-positive patients. The same now appears to be true for small intestinal neuroendocrine tumors (SI-NETs), which are the most common of the gastroenteropancreatic neuroendocrine tumors. Indeed, the incidence of SI-NETs has tripled during the last 3 decades, she noted.

Dr. Kim presented an analysis of the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database, which included 2,984 patients with surgically resected lymph node–positive, metastasis-negative SI-NETs diagnosed in 1988-2010. Dr. Kim and coinvestigators classified patients into three LNR groups: 531 were LNR 1, defined as an LNR ratio of 0.2 or less; 1,525 patients were LNR 2, with a ratio of 0.21-0.5; and 928 were LNR 3, with a ratio greater than 0.5. Patients with T1 and T2 disease were overrepresented in the LNR 1 group.

The primary outcome in the study was disease-specific survival. The more-extensive the lymph node involvement in patients with T1 or T2 disease, the poorer their disease-specific survival. For example, LNR 1 patients with T1 or T2 SI-NETs were 1.6-fold more likely to experience disease-specific mortality during 10 years of follow-up than did a reference control group of node-negative T1/T2 patients, an elevation in risk that did not achieve statistical significance. However, the risk of disease-specific mortality was increased 2.29-fold in LNR 2 patients with T1/T2 disease and 4.52-fold in LNR 3 patients with T1/T2 SI-NETs, compared with node-negative controls, and those differences were significant.

In contrast, there was no difference in disease-specific survival according to LNR status in patients with more-advanced T3 or T4 disease.

This study was funded by Mount Sinai School of Medicine and the National Center for Advancing Translational Sciences. Dr. Kim reported having no financial conflicts.

[email protected]

CHICAGO – The extent of lymph node involvement provides independent prognostic information in patients with early-stage T1 or T2 small intestinal neuroendocrine tumors, according to a study involving nearly 3,000 lymph node–positive individuals.

This metric, best expressed as the lymph node ratio, or the number of positive nodes divided by the total number of lymph nodes examined, is not included in current European and American Joint Committee on Cancer staging classification guidelines. But it should be, Dr. Michelle K. Kim said at the annual Digestive Disease Week.

"The lymph node ratio is a readily available marker of disease progression. It’s available as part of usual clinical care; it’s not something extra you have to ask for. It may help identify patients who may require more-aggressive therapy," according to Dr. Kim of Mount Sinai School of Medicine, New York.

Current staging guidelines merely make a binary distinction: lymph node–positive or –negative. But previous studies in colon, gastric, and pancreatic cancers indicate the lymph node ratio (LNR) further differentiates outcomes in node-positive patients. The same now appears to be true for small intestinal neuroendocrine tumors (SI-NETs), which are the most common of the gastroenteropancreatic neuroendocrine tumors. Indeed, the incidence of SI-NETs has tripled during the last 3 decades, she noted.

Dr. Kim presented an analysis of the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database, which included 2,984 patients with surgically resected lymph node–positive, metastasis-negative SI-NETs diagnosed in 1988-2010. Dr. Kim and coinvestigators classified patients into three LNR groups: 531 were LNR 1, defined as an LNR ratio of 0.2 or less; 1,525 patients were LNR 2, with a ratio of 0.21-0.5; and 928 were LNR 3, with a ratio greater than 0.5. Patients with T1 and T2 disease were overrepresented in the LNR 1 group.

The primary outcome in the study was disease-specific survival. The more-extensive the lymph node involvement in patients with T1 or T2 disease, the poorer their disease-specific survival. For example, LNR 1 patients with T1 or T2 SI-NETs were 1.6-fold more likely to experience disease-specific mortality during 10 years of follow-up than did a reference control group of node-negative T1/T2 patients, an elevation in risk that did not achieve statistical significance. However, the risk of disease-specific mortality was increased 2.29-fold in LNR 2 patients with T1/T2 disease and 4.52-fold in LNR 3 patients with T1/T2 SI-NETs, compared with node-negative controls, and those differences were significant.

In contrast, there was no difference in disease-specific survival according to LNR status in patients with more-advanced T3 or T4 disease.

This study was funded by Mount Sinai School of Medicine and the National Center for Advancing Translational Sciences. Dr. Kim reported having no financial conflicts.

[email protected]

An expert review panel from the American Society for Clinical Oncology largely endorsed new guidelines for "no ink on tumor" margins in early breast conservation surgery, while emphasizing the role of post-lumpectomy imaging in patients with microcalcifications and adding several other "minor qualifications."

Published earlier this year, the guidelines from the Society of Surgical Oncology (SSO) and the American Society of Radiation Oncology (ASTRO) focus on stage I and II breast cancer patients who are undergoing lumpectomy with whole-breast radiation. In these patients, a "no ink on tumor" margin "is associated with low rates of [ipsilateral breast tumor recurrence] and has the potential to decrease re-excision rates, improve cosmetic outcomes, and decrease health care costs," the guideline’s authors wrote (Ann. Surg. Oncol. 2014;21:704-16). The guidelines mark a step toward consensus on a historically controversial topic. "Widespread adoption of this guideline, which defines a margin as being adequate as long as there is no cancer at the inked lumpectomy surface by microscopic pathology evaluation, will result in fewer re-excision lumpectomies and enhanced cosmesis with breast conserving surgery," said Dr. Lisa Newman.

The recommended margin reflects the current era of treatment, in which better systemic therapies and earlier diagnosis of breast cancer mean that patients may no longer derive extra benefit from thicker or "widely negative" lumpectomy margins, Dr. Newman added in an interview.

Two staff members at ASCO reviewed the guidelines for developmental rigor. The guidelines "scored high (77%) in terms of methodologic quality, with only minor deviations from the ideal," members of the separate ad hoc panel of ASCO experts wrote (J. Clin. Onc. 2014 [doi:10.1200/JCO.2014.55.1572]). But panel members also called for flexibility in applying the guideline, citing the "inherent weaknesses" and "selection bias" of the retrospective, observational studies on which the recommendations were based.

The guidelines provide a framework, but clinical judgment remains important in managing breast-conserving surgery patients, emphasized Dr. Newman, who served as cochair on the ASCO panel that reviewed the guideline and who is a surgical oncologist, professor of surgery, and director of the Breast Care Center for the University of Michigan, Ann Arbor. She said clinicians should carefully evaluate lumpectomy margins, which "can provide important clues regarding the burden of disease in the breast, and the likelihood of successful treatment with lumpectomy and breast radiation."

ASCO panel members also stressed the importance of postsurgical imaging in cases involving microcalcifications. Imaging is important to minimize the risk of leaving pockets of disease in the breast despite achieving microscopically negative margins, Dr. Newman said. Surgeons can work with their colleagues in breast imaging to review microcalcifications and correlate them with pathology findings, she added.

In particular, a lumpectomy specimen that has several close margins and evidence of diffuse disease "may well represent a different category of risk regarding local recurrence, compared to a well defined, unifocal cancer that has a single microscopic focus of cancer abutting one margin," Dr. Newman added. Ideally, surgeons and radiation oncologists should discuss these aspects of cases, and should consider them when counseling patients about outcomes from lumpectomy surgery, she said.

Both ASCO and SSO/ASTRO recommended monitoring outcomes as institutions implement the new margin guidelines. Authors of the ASCO opinion reported having no conflicts of interest.

An expert review panel from the American Society for Clinical Oncology largely endorsed new guidelines for "no ink on tumor" margins in early breast conservation surgery, while emphasizing the role of post-lumpectomy imaging in patients with microcalcifications and adding several other "minor qualifications."

Published earlier this year, the guidelines from the Society of Surgical Oncology (SSO) and the American Society of Radiation Oncology (ASTRO) focus on stage I and II breast cancer patients who are undergoing lumpectomy with whole-breast radiation. In these patients, a "no ink on tumor" margin "is associated with low rates of [ipsilateral breast tumor recurrence] and has the potential to decrease re-excision rates, improve cosmetic outcomes, and decrease health care costs," the guideline’s authors wrote (Ann. Surg. Oncol. 2014;21:704-16). The guidelines mark a step toward consensus on a historically controversial topic. "Widespread adoption of this guideline, which defines a margin as being adequate as long as there is no cancer at the inked lumpectomy surface by microscopic pathology evaluation, will result in fewer re-excision lumpectomies and enhanced cosmesis with breast conserving surgery," said Dr. Lisa Newman.

The recommended margin reflects the current era of treatment, in which better systemic therapies and earlier diagnosis of breast cancer mean that patients may no longer derive extra benefit from thicker or "widely negative" lumpectomy margins, Dr. Newman added in an interview.

Two staff members at ASCO reviewed the guidelines for developmental rigor. The guidelines "scored high (77%) in terms of methodologic quality, with only minor deviations from the ideal," members of the separate ad hoc panel of ASCO experts wrote (J. Clin. Onc. 2014 [doi:10.1200/JCO.2014.55.1572]). But panel members also called for flexibility in applying the guideline, citing the "inherent weaknesses" and "selection bias" of the retrospective, observational studies on which the recommendations were based.

The guidelines provide a framework, but clinical judgment remains important in managing breast-conserving surgery patients, emphasized Dr. Newman, who served as cochair on the ASCO panel that reviewed the guideline and who is a surgical oncologist, professor of surgery, and director of the Breast Care Center for the University of Michigan, Ann Arbor. She said clinicians should carefully evaluate lumpectomy margins, which "can provide important clues regarding the burden of disease in the breast, and the likelihood of successful treatment with lumpectomy and breast radiation."

ASCO panel members also stressed the importance of postsurgical imaging in cases involving microcalcifications. Imaging is important to minimize the risk of leaving pockets of disease in the breast despite achieving microscopically negative margins, Dr. Newman said. Surgeons can work with their colleagues in breast imaging to review microcalcifications and correlate them with pathology findings, she added.

In particular, a lumpectomy specimen that has several close margins and evidence of diffuse disease "may well represent a different category of risk regarding local recurrence, compared to a well defined, unifocal cancer that has a single microscopic focus of cancer abutting one margin," Dr. Newman added. Ideally, surgeons and radiation oncologists should discuss these aspects of cases, and should consider them when counseling patients about outcomes from lumpectomy surgery, she said.

Both ASCO and SSO/ASTRO recommended monitoring outcomes as institutions implement the new margin guidelines. Authors of the ASCO opinion reported having no conflicts of interest.

An expert review panel from the American Society for Clinical Oncology largely endorsed new guidelines for "no ink on tumor" margins in early breast conservation surgery, while emphasizing the role of post-lumpectomy imaging in patients with microcalcifications and adding several other "minor qualifications."

Published earlier this year, the guidelines from the Society of Surgical Oncology (SSO) and the American Society of Radiation Oncology (ASTRO) focus on stage I and II breast cancer patients who are undergoing lumpectomy with whole-breast radiation. In these patients, a "no ink on tumor" margin "is associated with low rates of [ipsilateral breast tumor recurrence] and has the potential to decrease re-excision rates, improve cosmetic outcomes, and decrease health care costs," the guideline’s authors wrote (Ann. Surg. Oncol. 2014;21:704-16). The guidelines mark a step toward consensus on a historically controversial topic. "Widespread adoption of this guideline, which defines a margin as being adequate as long as there is no cancer at the inked lumpectomy surface by microscopic pathology evaluation, will result in fewer re-excision lumpectomies and enhanced cosmesis with breast conserving surgery," said Dr. Lisa Newman.

The recommended margin reflects the current era of treatment, in which better systemic therapies and earlier diagnosis of breast cancer mean that patients may no longer derive extra benefit from thicker or "widely negative" lumpectomy margins, Dr. Newman added in an interview.

Two staff members at ASCO reviewed the guidelines for developmental rigor. The guidelines "scored high (77%) in terms of methodologic quality, with only minor deviations from the ideal," members of the separate ad hoc panel of ASCO experts wrote (J. Clin. Onc. 2014 [doi:10.1200/JCO.2014.55.1572]). But panel members also called for flexibility in applying the guideline, citing the "inherent weaknesses" and "selection bias" of the retrospective, observational studies on which the recommendations were based.

The guidelines provide a framework, but clinical judgment remains important in managing breast-conserving surgery patients, emphasized Dr. Newman, who served as cochair on the ASCO panel that reviewed the guideline and who is a surgical oncologist, professor of surgery, and director of the Breast Care Center for the University of Michigan, Ann Arbor. She said clinicians should carefully evaluate lumpectomy margins, which "can provide important clues regarding the burden of disease in the breast, and the likelihood of successful treatment with lumpectomy and breast radiation."

ASCO panel members also stressed the importance of postsurgical imaging in cases involving microcalcifications. Imaging is important to minimize the risk of leaving pockets of disease in the breast despite achieving microscopically negative margins, Dr. Newman said. Surgeons can work with their colleagues in breast imaging to review microcalcifications and correlate them with pathology findings, she added.

In particular, a lumpectomy specimen that has several close margins and evidence of diffuse disease "may well represent a different category of risk regarding local recurrence, compared to a well defined, unifocal cancer that has a single microscopic focus of cancer abutting one margin," Dr. Newman added. Ideally, surgeons and radiation oncologists should discuss these aspects of cases, and should consider them when counseling patients about outcomes from lumpectomy surgery, she said.

Both ASCO and SSO/ASTRO recommended monitoring outcomes as institutions implement the new margin guidelines. Authors of the ASCO opinion reported having no conflicts of interest.

Fear seems to be a major driver of contralateral prophylactic mastectomy after initial breast cancer surgery.

Almost two-thirds of those who had the procedure had no clinical indication for it, Sarah T. Hawley, Ph.D., and her colleagues wrote in the May 21 online issue of JAMA Surgery (doi:10.1001/jamasurg.2013.5689). The women choosing contralateral prophylactic mastectomy (CPM) for which there was no clinical indication were more highly educated than were those who didn’t elect the surgery, more likely to be white, and two to four times more likely to be worried about a recurrence.

Fear of recurrence was a "powerful nonclinical factor" in the analysis, wrote Dr. Hawley of the University of Michigan, Ann Arbor – and education may be the best way to overcome it.

"A patient’s decision to undergo contralateral prophylactic mastectomy based on a strong fear of recurrence in the absence of clinical indications presents an important clinical challenge for surgeons," she and her colleagues wrote. "Growing literature supports the notion that patients have a difficult time assessing and interpreting their own risk and that fear and anxiety related to disease recurrence often supersede accurate risk perceptions to drive health decisions."

Dr. Hawley and her coinvestigators extracted their data from the Surveillance, Epidemiology, and End Results (SEER) registries for Los Angeles and Detroit. They included records from 1,447 women aged 20-79 years who had been diagnosed with a first incident primary ductal carcinoma in situ or invasive breast cancer of stages I-IIIa.

About half of the sample was white; 21% was black, and 30% Hispanic. Other groups made up the balance. More than half (59%) had achieved some college-level education.

About half the respondents (57%) underwent breast-conserving surgery (BCS). Other surgical treatments included unilateral mastectomy (UM; 34%), and contralateral prophylactic mastectomy (8%).

CPM was pondered more frequently than it was an executed, the investigators said, with 19% of the entire sample considering it "strongly or very strongly."

Most of the women who had CPM said that they did it to prevent recurrence, with 78% citing that worry as a very important driver of their decision. However, the authors said, of the 106 women who underwent CPM, only 31% had clinical indications, while the majority (67%) did not.

A multivariate analysis determined the relationships between patient characteristics and breast surgery,

Those with some college-level education were five times more likely to have CPM than UM, and four times more likely to have that than BCS. Those with high worry were almost three times more likely to have CPM than UM, and four times more likely to have CPM than BCS.

Women who had positive genetic testing were 10 times more likely to have contralateral prophylactic mastectomy than unilateral mastectomy, and 19 times more likely to have CPM than BCS. But those with negative results were still twice as likely to have the CPM as either of the other surgeries.

Having at least two close relatives with breast or ovarian cancer also significantly increased the likelihood of a CMP vs. UM (relative risk = 5) or BCS (RR = 4). Having had a diagnostic MRI doubled the chance of having CPM, compared with the other surgeries.

"Our results provide evidence that decisions about CPM represent a clear case in which better strategies to increase patient knowledge about their own risk of developing contralateral cancer as well as the net benefit of treatment are needed and should be made only after patients are accurately informed about these issues," Dr. Hawley and her coauthors said, adding that such patients need to clearly understand the consequences of CMP, "including lengthy recovery time and increased risk for serious operative complications."

The National Institutes of Health and the University of Michigan supported the study. Neither Dr. Hawley nor her coauthors had any financial disclosures.

[email protected]

On Twitter @alz_gal

Fear seems to be a major driver of contralateral prophylactic mastectomy after initial breast cancer surgery.

Almost two-thirds of those who had the procedure had no clinical indication for it, Sarah T. Hawley, Ph.D., and her colleagues wrote in the May 21 online issue of JAMA Surgery (doi:10.1001/jamasurg.2013.5689). The women choosing contralateral prophylactic mastectomy (CPM) for which there was no clinical indication were more highly educated than were those who didn’t elect the surgery, more likely to be white, and two to four times more likely to be worried about a recurrence.

Fear of recurrence was a "powerful nonclinical factor" in the analysis, wrote Dr. Hawley of the University of Michigan, Ann Arbor – and education may be the best way to overcome it.

"A patient’s decision to undergo contralateral prophylactic mastectomy based on a strong fear of recurrence in the absence of clinical indications presents an important clinical challenge for surgeons," she and her colleagues wrote. "Growing literature supports the notion that patients have a difficult time assessing and interpreting their own risk and that fear and anxiety related to disease recurrence often supersede accurate risk perceptions to drive health decisions."

Dr. Hawley and her coinvestigators extracted their data from the Surveillance, Epidemiology, and End Results (SEER) registries for Los Angeles and Detroit. They included records from 1,447 women aged 20-79 years who had been diagnosed with a first incident primary ductal carcinoma in situ or invasive breast cancer of stages I-IIIa.

About half of the sample was white; 21% was black, and 30% Hispanic. Other groups made up the balance. More than half (59%) had achieved some college-level education.

About half the respondents (57%) underwent breast-conserving surgery (BCS). Other surgical treatments included unilateral mastectomy (UM; 34%), and contralateral prophylactic mastectomy (8%).

CPM was pondered more frequently than it was an executed, the investigators said, with 19% of the entire sample considering it "strongly or very strongly."

Most of the women who had CPM said that they did it to prevent recurrence, with 78% citing that worry as a very important driver of their decision. However, the authors said, of the 106 women who underwent CPM, only 31% had clinical indications, while the majority (67%) did not.

A multivariate analysis determined the relationships between patient characteristics and breast surgery,

Those with some college-level education were five times more likely to have CPM than UM, and four times more likely to have that than BCS. Those with high worry were almost three times more likely to have CPM than UM, and four times more likely to have CPM than BCS.

Women who had positive genetic testing were 10 times more likely to have contralateral prophylactic mastectomy than unilateral mastectomy, and 19 times more likely to have CPM than BCS. But those with negative results were still twice as likely to have the CPM as either of the other surgeries.

Having at least two close relatives with breast or ovarian cancer also significantly increased the likelihood of a CMP vs. UM (relative risk = 5) or BCS (RR = 4). Having had a diagnostic MRI doubled the chance of having CPM, compared with the other surgeries.

"Our results provide evidence that decisions about CPM represent a clear case in which better strategies to increase patient knowledge about their own risk of developing contralateral cancer as well as the net benefit of treatment are needed and should be made only after patients are accurately informed about these issues," Dr. Hawley and her coauthors said, adding that such patients need to clearly understand the consequences of CMP, "including lengthy recovery time and increased risk for serious operative complications."

The National Institutes of Health and the University of Michigan supported the study. Neither Dr. Hawley nor her coauthors had any financial disclosures.

[email protected]

On Twitter @alz_gal

Fear seems to be a major driver of contralateral prophylactic mastectomy after initial breast cancer surgery.

Almost two-thirds of those who had the procedure had no clinical indication for it, Sarah T. Hawley, Ph.D., and her colleagues wrote in the May 21 online issue of JAMA Surgery (doi:10.1001/jamasurg.2013.5689). The women choosing contralateral prophylactic mastectomy (CPM) for which there was no clinical indication were more highly educated than were those who didn’t elect the surgery, more likely to be white, and two to four times more likely to be worried about a recurrence.

Fear of recurrence was a "powerful nonclinical factor" in the analysis, wrote Dr. Hawley of the University of Michigan, Ann Arbor – and education may be the best way to overcome it.

"A patient’s decision to undergo contralateral prophylactic mastectomy based on a strong fear of recurrence in the absence of clinical indications presents an important clinical challenge for surgeons," she and her colleagues wrote. "Growing literature supports the notion that patients have a difficult time assessing and interpreting their own risk and that fear and anxiety related to disease recurrence often supersede accurate risk perceptions to drive health decisions."

Dr. Hawley and her coinvestigators extracted their data from the Surveillance, Epidemiology, and End Results (SEER) registries for Los Angeles and Detroit. They included records from 1,447 women aged 20-79 years who had been diagnosed with a first incident primary ductal carcinoma in situ or invasive breast cancer of stages I-IIIa.

About half of the sample was white; 21% was black, and 30% Hispanic. Other groups made up the balance. More than half (59%) had achieved some college-level education.

About half the respondents (57%) underwent breast-conserving surgery (BCS). Other surgical treatments included unilateral mastectomy (UM; 34%), and contralateral prophylactic mastectomy (8%).

CPM was pondered more frequently than it was an executed, the investigators said, with 19% of the entire sample considering it "strongly or very strongly."

Most of the women who had CPM said that they did it to prevent recurrence, with 78% citing that worry as a very important driver of their decision. However, the authors said, of the 106 women who underwent CPM, only 31% had clinical indications, while the majority (67%) did not.

A multivariate analysis determined the relationships between patient characteristics and breast surgery,

Those with some college-level education were five times more likely to have CPM than UM, and four times more likely to have that than BCS. Those with high worry were almost three times more likely to have CPM than UM, and four times more likely to have CPM than BCS.

Women who had positive genetic testing were 10 times more likely to have contralateral prophylactic mastectomy than unilateral mastectomy, and 19 times more likely to have CPM than BCS. But those with negative results were still twice as likely to have the CPM as either of the other surgeries.

Having at least two close relatives with breast or ovarian cancer also significantly increased the likelihood of a CMP vs. UM (relative risk = 5) or BCS (RR = 4). Having had a diagnostic MRI doubled the chance of having CPM, compared with the other surgeries.

"Our results provide evidence that decisions about CPM represent a clear case in which better strategies to increase patient knowledge about their own risk of developing contralateral cancer as well as the net benefit of treatment are needed and should be made only after patients are accurately informed about these issues," Dr. Hawley and her coauthors said, adding that such patients need to clearly understand the consequences of CMP, "including lengthy recovery time and increased risk for serious operative complications."

The National Institutes of Health and the University of Michigan supported the study. Neither Dr. Hawley nor her coauthors had any financial disclosures.

[email protected]

On Twitter @alz_gal

In patients with colorectal cancer, laparoscopic resection reduced total hospital stay by a median of 2 days, compared with open surgery, researchers reported online May 5 in the Journal of Clinical Oncology.

However, laparoscopy did not significantly improve physical fatigue at 1 month, compared with open surgery, and it did not affect other secondary clinical outcomes, said Prof. Robin Kennedy of St. Mark’s Hospital, Harrow, England, and his associates.

The researchers conducted a multicenter, randomized trial of 204 patients with colorectal cancer, of whom 103 underwent laparoscopic resection and 101 had open surgery within a standardized enhanced recovery program (J. Clin. Oncol. 2014 May 5 [doi: 10.1200/JCO.2013.54.3694]).

Median total hospital stay was significantly shorter in the laparoscopy group (5 days; interquartile range, 4-9 days) vs. the open surgery group (7 days; IQR, 5-11 days; P = .033), the investigators reported. However, 1-month physical fatigue scores on the Multidimensional Fatigue Inventory 20 were similar between the two groups (mean for laparoscopy patients, 12.28; 95% confidence interval, 11.37-13.19; mean for open surgery patients, 12.05; 95% CI, 11.14-12.96; adjusted mean difference, –0.23; 95% CI, –1.52-1.07), the researchers reported. Other outcomes also were similar, including quality of the specimens based on central pathologic review, the researchers said.

The findings contradicted those of prior studies in which shorter duration of hospital stay correlated with less "pain, ileus, and other complications, leading to earlier mobilization, feeding, and recovery," the researchers noted. They recommended more studies to determine whether the similarities between other outcomes were due to a lack of power or truly indicated comparable short-term recoveries.

The research was funded by Cancer Research UK, the National Institute for Health Research, Ethicon Endo-Surgery Europe, the Medical Research Council ConDuCT Hub, and Yorkshire Cancer Research. The authors reported that they had no relevant conflicts of interest.

In patients with colorectal cancer, laparoscopic resection reduced total hospital stay by a median of 2 days, compared with open surgery, researchers reported online May 5 in the Journal of Clinical Oncology.

However, laparoscopy did not significantly improve physical fatigue at 1 month, compared with open surgery, and it did not affect other secondary clinical outcomes, said Prof. Robin Kennedy of St. Mark’s Hospital, Harrow, England, and his associates.

The researchers conducted a multicenter, randomized trial of 204 patients with colorectal cancer, of whom 103 underwent laparoscopic resection and 101 had open surgery within a standardized enhanced recovery program (J. Clin. Oncol. 2014 May 5 [doi: 10.1200/JCO.2013.54.3694]).

Median total hospital stay was significantly shorter in the laparoscopy group (5 days; interquartile range, 4-9 days) vs. the open surgery group (7 days; IQR, 5-11 days; P = .033), the investigators reported. However, 1-month physical fatigue scores on the Multidimensional Fatigue Inventory 20 were similar between the two groups (mean for laparoscopy patients, 12.28; 95% confidence interval, 11.37-13.19; mean for open surgery patients, 12.05; 95% CI, 11.14-12.96; adjusted mean difference, –0.23; 95% CI, –1.52-1.07), the researchers reported. Other outcomes also were similar, including quality of the specimens based on central pathologic review, the researchers said.

The findings contradicted those of prior studies in which shorter duration of hospital stay correlated with less "pain, ileus, and other complications, leading to earlier mobilization, feeding, and recovery," the researchers noted. They recommended more studies to determine whether the similarities between other outcomes were due to a lack of power or truly indicated comparable short-term recoveries.

The research was funded by Cancer Research UK, the National Institute for Health Research, Ethicon Endo-Surgery Europe, the Medical Research Council ConDuCT Hub, and Yorkshire Cancer Research. The authors reported that they had no relevant conflicts of interest.

In patients with colorectal cancer, laparoscopic resection reduced total hospital stay by a median of 2 days, compared with open surgery, researchers reported online May 5 in the Journal of Clinical Oncology.

However, laparoscopy did not significantly improve physical fatigue at 1 month, compared with open surgery, and it did not affect other secondary clinical outcomes, said Prof. Robin Kennedy of St. Mark’s Hospital, Harrow, England, and his associates.

The researchers conducted a multicenter, randomized trial of 204 patients with colorectal cancer, of whom 103 underwent laparoscopic resection and 101 had open surgery within a standardized enhanced recovery program (J. Clin. Oncol. 2014 May 5 [doi: 10.1200/JCO.2013.54.3694]).

Median total hospital stay was significantly shorter in the laparoscopy group (5 days; interquartile range, 4-9 days) vs. the open surgery group (7 days; IQR, 5-11 days; P = .033), the investigators reported. However, 1-month physical fatigue scores on the Multidimensional Fatigue Inventory 20 were similar between the two groups (mean for laparoscopy patients, 12.28; 95% confidence interval, 11.37-13.19; mean for open surgery patients, 12.05; 95% CI, 11.14-12.96; adjusted mean difference, –0.23; 95% CI, –1.52-1.07), the researchers reported. Other outcomes also were similar, including quality of the specimens based on central pathologic review, the researchers said.

The findings contradicted those of prior studies in which shorter duration of hospital stay correlated with less "pain, ileus, and other complications, leading to earlier mobilization, feeding, and recovery," the researchers noted. They recommended more studies to determine whether the similarities between other outcomes were due to a lack of power or truly indicated comparable short-term recoveries.

The research was funded by Cancer Research UK, the National Institute for Health Research, Ethicon Endo-Surgery Europe, the Medical Research Council ConDuCT Hub, and Yorkshire Cancer Research. The authors reported that they had no relevant conflicts of interest.

BOSTON – Relaxing eligibility criteria for cytoreductive surgery may improve overall survival among patients with carcinoid metastases to the liver, investigators report.

Lowering the debulking threshold from 90% to 70% and including patients with intermediate-grade disease and/or extrahepatic disease resulted in 5-year overall survival rates of 90%, compared with 61%-74% rates reported by other treatment centers, said Dr. Amanda N. Graff-Baker, a surgical oncology resident at the Oregon Health and Science University (OHSU), Portland.

Neil Osterweil/Frontline Medical News

"The use of expanded criteria would substantially increase the number of patients eligible for debulking without compromising survival," she reported at the annual meeting of the American Association of Endocrine Surgeons.

Carcinoid tumors, a subset of neuroendocrine tumors, originate in the enterochromaffin cells of the aerodigestive tract. Approximately 60% of these tumors occur in the gastrointestinal tract, most commonly in the small intestine.

Approximately 60%-80% of patients with small bowel carcinoid tumors will have metastases to the liver, with liver failure from hepatic replacement by tumor being the most common cause of death, she explained.

Although there are no standardized patient selection criteria for liver debulking surgery in these patients, many U.S. centers follow NANETS (North American Neuroendocrine Tumor Society) treatment guidelines, which recommend surgical excision of at least 90% of all visible tumor. In addition, many centers choose not to offer cytoreductive surgery to patients with extrahepatic disease, Dr. Graff-Baker said.

Using these criteria, centers have reported 5-year survival rates ranging from 61% to 74%, but only about 20% of patients with carcinoid metastases to the liver are eligible for resection.

The investigators hypothesized that expanded eligibility criteria used at OHSU for several years could improve both liver progression-free and disease-specific survival rates. The criteria include a lower liver debulking threshold (70% or greater) and allow inclusion of patients with extrahepatic disease and/or intermediate-grade tumors.

They tested this idea by reviewing records of patients with metastatic carcinoid tumors who underwent liver debulking procedures at their center from 2007 to 2011. A single pathologist rated the grade of primary and metastatic tumors, and investigators correlated clinical factors with outcomes.

They identified a total of 52 patients, ranging in age from 29 to 77 years. Of this group, 32 (62%) had carcinoid syndrome, and 34 (65%) had extrahepatic disease.

The patients underwent a total of 51 wedge resections and 16 anatomic resections.

The mean number of metastases resected was 22 (range, 1-131). The mean size of metastases was 3 cm (range, 0.3-16 cm).

On pathologic review, all primary tumors were found to be low grade, but one-third of patients had one or more intermediate-grade metastases, suggesting a significant degree of tumor heterogeneity, Dr. Graff-Baker said.

The median liver progression-free survival was 72 months. A comparison between patients with liver progression and those with stable liver disease showed that there were no significant differences between the groups in either the percentage of tumor resected, number of resections, tumor size, presence of one or more intermediate-grade metastases, or extrahepatic disease. The only factor associated with a significant difference between groups was age. The mean age of patients with stable disease was 60.1 years, compared with 52 years for patients with liver progression (P = .016).

A separate analysis by age confirmed the last finding, with patients 50 years and older having significantly better liver progression-free survival than patients under age 50 (P = .001).

The 5-year disease-specific survival rate among all patients was 90%. All deaths were due to liver failure caused by tumor progression.

An analysis of factors predicting disease-specific survival showed once again that older patients for a change fared better than their more youthful counterparts (P = .03).

"The number, size, grade, extent of resection, and presence of extrahepatic disease did not have an adverse impact on outcomes," Dr. Graff-Baker said.

The study was internally funded. Dr. Graff-Baker reported having no financial disclosures.

BOSTON – Relaxing eligibility criteria for cytoreductive surgery may improve overall survival among patients with carcinoid metastases to the liver, investigators report.

Lowering the debulking threshold from 90% to 70% and including patients with intermediate-grade disease and/or extrahepatic disease resulted in 5-year overall survival rates of 90%, compared with 61%-74% rates reported by other treatment centers, said Dr. Amanda N. Graff-Baker, a surgical oncology resident at the Oregon Health and Science University (OHSU), Portland.

Neil Osterweil/Frontline Medical News

"The use of expanded criteria would substantially increase the number of patients eligible for debulking without compromising survival," she reported at the annual meeting of the American Association of Endocrine Surgeons.

Carcinoid tumors, a subset of neuroendocrine tumors, originate in the enterochromaffin cells of the aerodigestive tract. Approximately 60% of these tumors occur in the gastrointestinal tract, most commonly in the small intestine.

Approximately 60%-80% of patients with small bowel carcinoid tumors will have metastases to the liver, with liver failure from hepatic replacement by tumor being the most common cause of death, she explained.

Although there are no standardized patient selection criteria for liver debulking surgery in these patients, many U.S. centers follow NANETS (North American Neuroendocrine Tumor Society) treatment guidelines, which recommend surgical excision of at least 90% of all visible tumor. In addition, many centers choose not to offer cytoreductive surgery to patients with extrahepatic disease, Dr. Graff-Baker said.

Using these criteria, centers have reported 5-year survival rates ranging from 61% to 74%, but only about 20% of patients with carcinoid metastases to the liver are eligible for resection.

The investigators hypothesized that expanded eligibility criteria used at OHSU for several years could improve both liver progression-free and disease-specific survival rates. The criteria include a lower liver debulking threshold (70% or greater) and allow inclusion of patients with extrahepatic disease and/or intermediate-grade tumors.

They tested this idea by reviewing records of patients with metastatic carcinoid tumors who underwent liver debulking procedures at their center from 2007 to 2011. A single pathologist rated the grade of primary and metastatic tumors, and investigators correlated clinical factors with outcomes.

They identified a total of 52 patients, ranging in age from 29 to 77 years. Of this group, 32 (62%) had carcinoid syndrome, and 34 (65%) had extrahepatic disease.

The patients underwent a total of 51 wedge resections and 16 anatomic resections.

The mean number of metastases resected was 22 (range, 1-131). The mean size of metastases was 3 cm (range, 0.3-16 cm).

On pathologic review, all primary tumors were found to be low grade, but one-third of patients had one or more intermediate-grade metastases, suggesting a significant degree of tumor heterogeneity, Dr. Graff-Baker said.

The median liver progression-free survival was 72 months. A comparison between patients with liver progression and those with stable liver disease showed that there were no significant differences between the groups in either the percentage of tumor resected, number of resections, tumor size, presence of one or more intermediate-grade metastases, or extrahepatic disease. The only factor associated with a significant difference between groups was age. The mean age of patients with stable disease was 60.1 years, compared with 52 years for patients with liver progression (P = .016).

A separate analysis by age confirmed the last finding, with patients 50 years and older having significantly better liver progression-free survival than patients under age 50 (P = .001).

The 5-year disease-specific survival rate among all patients was 90%. All deaths were due to liver failure caused by tumor progression.

An analysis of factors predicting disease-specific survival showed once again that older patients for a change fared better than their more youthful counterparts (P = .03).

"The number, size, grade, extent of resection, and presence of extrahepatic disease did not have an adverse impact on outcomes," Dr. Graff-Baker said.

The study was internally funded. Dr. Graff-Baker reported having no financial disclosures.

BOSTON – Relaxing eligibility criteria for cytoreductive surgery may improve overall survival among patients with carcinoid metastases to the liver, investigators report.

Lowering the debulking threshold from 90% to 70% and including patients with intermediate-grade disease and/or extrahepatic disease resulted in 5-year overall survival rates of 90%, compared with 61%-74% rates reported by other treatment centers, said Dr. Amanda N. Graff-Baker, a surgical oncology resident at the Oregon Health and Science University (OHSU), Portland.

Neil Osterweil/Frontline Medical News

"The use of expanded criteria would substantially increase the number of patients eligible for debulking without compromising survival," she reported at the annual meeting of the American Association of Endocrine Surgeons.

Carcinoid tumors, a subset of neuroendocrine tumors, originate in the enterochromaffin cells of the aerodigestive tract. Approximately 60% of these tumors occur in the gastrointestinal tract, most commonly in the small intestine.

Approximately 60%-80% of patients with small bowel carcinoid tumors will have metastases to the liver, with liver failure from hepatic replacement by tumor being the most common cause of death, she explained.

Although there are no standardized patient selection criteria for liver debulking surgery in these patients, many U.S. centers follow NANETS (North American Neuroendocrine Tumor Society) treatment guidelines, which recommend surgical excision of at least 90% of all visible tumor. In addition, many centers choose not to offer cytoreductive surgery to patients with extrahepatic disease, Dr. Graff-Baker said.

Using these criteria, centers have reported 5-year survival rates ranging from 61% to 74%, but only about 20% of patients with carcinoid metastases to the liver are eligible for resection.

The investigators hypothesized that expanded eligibility criteria used at OHSU for several years could improve both liver progression-free and disease-specific survival rates. The criteria include a lower liver debulking threshold (70% or greater) and allow inclusion of patients with extrahepatic disease and/or intermediate-grade tumors.

They tested this idea by reviewing records of patients with metastatic carcinoid tumors who underwent liver debulking procedures at their center from 2007 to 2011. A single pathologist rated the grade of primary and metastatic tumors, and investigators correlated clinical factors with outcomes.

They identified a total of 52 patients, ranging in age from 29 to 77 years. Of this group, 32 (62%) had carcinoid syndrome, and 34 (65%) had extrahepatic disease.

The patients underwent a total of 51 wedge resections and 16 anatomic resections.

The mean number of metastases resected was 22 (range, 1-131). The mean size of metastases was 3 cm (range, 0.3-16 cm).

On pathologic review, all primary tumors were found to be low grade, but one-third of patients had one or more intermediate-grade metastases, suggesting a significant degree of tumor heterogeneity, Dr. Graff-Baker said.

The median liver progression-free survival was 72 months. A comparison between patients with liver progression and those with stable liver disease showed that there were no significant differences between the groups in either the percentage of tumor resected, number of resections, tumor size, presence of one or more intermediate-grade metastases, or extrahepatic disease. The only factor associated with a significant difference between groups was age. The mean age of patients with stable disease was 60.1 years, compared with 52 years for patients with liver progression (P = .016).

A separate analysis by age confirmed the last finding, with patients 50 years and older having significantly better liver progression-free survival than patients under age 50 (P = .001).

The 5-year disease-specific survival rate among all patients was 90%. All deaths were due to liver failure caused by tumor progression.

An analysis of factors predicting disease-specific survival showed once again that older patients for a change fared better than their more youthful counterparts (P = .03).

"The number, size, grade, extent of resection, and presence of extrahepatic disease did not have an adverse impact on outcomes," Dr. Graff-Baker said.

The study was internally funded. Dr. Graff-Baker reported having no financial disclosures.

PHOENIX – In patients with recurrent papillary thyroid cancer, fine-needle aspiration cytology and thyroglobulin washout was a highly sensitive and specific means of detecting metastatic disease, according to a retrospective analysis.

Surgeon-performed FNA-Tg washout appears to increase the diagnostic accuracy in detecting metastatic disease in this patient population. Routine performance of the combined modalities should be considered in patients with suspicious metastatic lymphadenopathies, said Dr. Hossam Mohamed of the division of endocrine and oncological surgery in the department of surgery at Tulane University, New Orleans.

In a retrospective study of 117 patients with recurrent papillary thyroid cancer, the combination of surgeon-performed fine-needle aspiration cytology (FNAC) with fine-needle aspiration thyroglobulin washout (FNA-Tg) had a 100% specificity, 94.9% sensitivity, and negative predictive value of 93.75%, with a diagnostic accuracy of 97.1%, he said.

"Cervical lymph node involvement has been reported to be up to 46% at initial diagnosis, hence ultrasonography and fine-needle aspiration have been standard diagnostic modalities used to detect and evaluate cervical lymph nodes in patients with thyroid malignancies," he said at the annual Society of Surgical Oncology Cancer Symposium.

His team hypothesized that by adding surgeon-performed ultrasonography with Tg washout to FNAC for the management of patients with suspicious lymphadenopathies, they might be able to increase the accuracy of the combined tests for detecting metastatic disease in patients with recurrent papillary thyroid cancers.

In a retrospective study, they looked at results for patients who underwent preoperative FNAC and FNA-Tg washout followed by selective neck dissection. All dissections were performed by senior author Dr. Emad Kandil, chief of the endocrine surgery section at Tulane University.

They correlated the test results with the final pathology results of the dissected lymph nodes, and compared the sensitivity and specificity of the combined modalities to those of standard FNAC alone.

Of the 117 patients, 76% were female, and mean age was 52 years. Nearly half of the patients (47.6%) had cervical lymph node dissections, 39.7% had modified radical lymph node dissections, 6.35% had combined modified-radical, and 12.7% had combined modified-radical and cervical resections. Half of the group required second resections.

When the researchers compared the individual modalities to the final pathology results, they found that the respective sensitivity of FNAC, FNA-Tg, and the two combined were 84.6%, 89.4%, and 94.9%. They found the respective specificities to be 100%, 96.8%, and 100%.

The negative predictive value of FNAC was 87.1%. and of FNA-Tg was 85.7%. When the two diagnostic methods were used together, they ruled out metastases with 93.75% accuracy.

"Only one patient had a negative lymph node pathology with a positive FNA-Tg washout, which we couldn’t find an explanation for," Dr. Mohamed said.

Two patients who had negative FNA-Tg washout levels had evidence of atypical cells on FNAC and elevated serum Tg levels. These patients were therefore taken to surgery, and were found to have metastatic disease on final pathology, he said.

The study was internally funded. Dr. Mohamed reported having no financial disclosures.

PHOENIX – In patients with recurrent papillary thyroid cancer, fine-needle aspiration cytology and thyroglobulin washout was a highly sensitive and specific means of detecting metastatic disease, according to a retrospective analysis.

Surgeon-performed FNA-Tg washout appears to increase the diagnostic accuracy in detecting metastatic disease in this patient population. Routine performance of the combined modalities should be considered in patients with suspicious metastatic lymphadenopathies, said Dr. Hossam Mohamed of the division of endocrine and oncological surgery in the department of surgery at Tulane University, New Orleans.

In a retrospective study of 117 patients with recurrent papillary thyroid cancer, the combination of surgeon-performed fine-needle aspiration cytology (FNAC) with fine-needle aspiration thyroglobulin washout (FNA-Tg) had a 100% specificity, 94.9% sensitivity, and negative predictive value of 93.75%, with a diagnostic accuracy of 97.1%, he said.

"Cervical lymph node involvement has been reported to be up to 46% at initial diagnosis, hence ultrasonography and fine-needle aspiration have been standard diagnostic modalities used to detect and evaluate cervical lymph nodes in patients with thyroid malignancies," he said at the annual Society of Surgical Oncology Cancer Symposium.

His team hypothesized that by adding surgeon-performed ultrasonography with Tg washout to FNAC for the management of patients with suspicious lymphadenopathies, they might be able to increase the accuracy of the combined tests for detecting metastatic disease in patients with recurrent papillary thyroid cancers.

In a retrospective study, they looked at results for patients who underwent preoperative FNAC and FNA-Tg washout followed by selective neck dissection. All dissections were performed by senior author Dr. Emad Kandil, chief of the endocrine surgery section at Tulane University.

They correlated the test results with the final pathology results of the dissected lymph nodes, and compared the sensitivity and specificity of the combined modalities to those of standard FNAC alone.

Of the 117 patients, 76% were female, and mean age was 52 years. Nearly half of the patients (47.6%) had cervical lymph node dissections, 39.7% had modified radical lymph node dissections, 6.35% had combined modified-radical, and 12.7% had combined modified-radical and cervical resections. Half of the group required second resections.

When the researchers compared the individual modalities to the final pathology results, they found that the respective sensitivity of FNAC, FNA-Tg, and the two combined were 84.6%, 89.4%, and 94.9%. They found the respective specificities to be 100%, 96.8%, and 100%.

The negative predictive value of FNAC was 87.1%. and of FNA-Tg was 85.7%. When the two diagnostic methods were used together, they ruled out metastases with 93.75% accuracy.

"Only one patient had a negative lymph node pathology with a positive FNA-Tg washout, which we couldn’t find an explanation for," Dr. Mohamed said.

Two patients who had negative FNA-Tg washout levels had evidence of atypical cells on FNAC and elevated serum Tg levels. These patients were therefore taken to surgery, and were found to have metastatic disease on final pathology, he said.

The study was internally funded. Dr. Mohamed reported having no financial disclosures.

PHOENIX – In patients with recurrent papillary thyroid cancer, fine-needle aspiration cytology and thyroglobulin washout was a highly sensitive and specific means of detecting metastatic disease, according to a retrospective analysis.

Surgeon-performed FNA-Tg washout appears to increase the diagnostic accuracy in detecting metastatic disease in this patient population. Routine performance of the combined modalities should be considered in patients with suspicious metastatic lymphadenopathies, said Dr. Hossam Mohamed of the division of endocrine and oncological surgery in the department of surgery at Tulane University, New Orleans.

In a retrospective study of 117 patients with recurrent papillary thyroid cancer, the combination of surgeon-performed fine-needle aspiration cytology (FNAC) with fine-needle aspiration thyroglobulin washout (FNA-Tg) had a 100% specificity, 94.9% sensitivity, and negative predictive value of 93.75%, with a diagnostic accuracy of 97.1%, he said.

"Cervical lymph node involvement has been reported to be up to 46% at initial diagnosis, hence ultrasonography and fine-needle aspiration have been standard diagnostic modalities used to detect and evaluate cervical lymph nodes in patients with thyroid malignancies," he said at the annual Society of Surgical Oncology Cancer Symposium.

His team hypothesized that by adding surgeon-performed ultrasonography with Tg washout to FNAC for the management of patients with suspicious lymphadenopathies, they might be able to increase the accuracy of the combined tests for detecting metastatic disease in patients with recurrent papillary thyroid cancers.

In a retrospective study, they looked at results for patients who underwent preoperative FNAC and FNA-Tg washout followed by selective neck dissection. All dissections were performed by senior author Dr. Emad Kandil, chief of the endocrine surgery section at Tulane University.

They correlated the test results with the final pathology results of the dissected lymph nodes, and compared the sensitivity and specificity of the combined modalities to those of standard FNAC alone.

Of the 117 patients, 76% were female, and mean age was 52 years. Nearly half of the patients (47.6%) had cervical lymph node dissections, 39.7% had modified radical lymph node dissections, 6.35% had combined modified-radical, and 12.7% had combined modified-radical and cervical resections. Half of the group required second resections.

When the researchers compared the individual modalities to the final pathology results, they found that the respective sensitivity of FNAC, FNA-Tg, and the two combined were 84.6%, 89.4%, and 94.9%. They found the respective specificities to be 100%, 96.8%, and 100%.

The negative predictive value of FNAC was 87.1%. and of FNA-Tg was 85.7%. When the two diagnostic methods were used together, they ruled out metastases with 93.75% accuracy.

"Only one patient had a negative lymph node pathology with a positive FNA-Tg washout, which we couldn’t find an explanation for," Dr. Mohamed said.

Two patients who had negative FNA-Tg washout levels had evidence of atypical cells on FNAC and elevated serum Tg levels. These patients were therefore taken to surgery, and were found to have metastatic disease on final pathology, he said.

The study was internally funded. Dr. Mohamed reported having no financial disclosures.

PHOENIX – More than one-fourth of men under age 50 undergoing surgery for benign goiter were found to have thyroid cancers, based on a chart review performed at the University of Pennsylvania.

The overall incidence of thyroid cancers in the patient series was 12%. Among men under age 45, the rate was "surprisingly" 28%, said Douglas R. Farquhar, a medical student at the University of Pennsylvania School of Medicine in Philadelphia.

Neil Osterweil/Frontline Medical News

Although thyroid goiters have traditionally been thought to be associated with a low risk for malignancy, recent studies have suggested otherwise. "In the literature we have seen published rates of up to 35%, which is much higher than we all had anticipated," Mr. Farquhar said at the annual Society of Surgical Oncology Cancer Symposium.

To get a better handle on the preoperative and patient characteristics associated with incident thyroid cancer and characterize the types of thyroid cancer discovered incidentally, Mr. Farquhar and his colleagues reviewed charts on all patients who underwent either total thyroidectomy or thyroid lobectomy for goiter at the center from 2004 through 2012.

Many cases of goiter can be medically managed, but surgery may be indicated in cases of pressure symptoms, cosmesis, or suspicion of malignancy, the investigators noted.

They excluded from their study patients with preoperative fine-needle aspiration pathology findings of Bethesda level III-VI (follicular lesion of undetermined significance, follicular neoplasm, suspicious or positive for malignancy).

Among 418 patients undergoing goiter surgery, 367 had goiter only, and 51 (12%) had an incident thyroid cancer. In all, 38 (75%) had papillary carcinomas, 10 (20%) had follicular carcinomas, 3 (6%) had Hürthle cell carcinomas, and 2 (4%) had thyroid lymphomas (two patients had multiple thyroid cancers, explaining the percentage greater than 100). An additional 67 patients (16%) were found to have micropapillary lesions.

Looking at the population as a whole, the investigators found that patients with thyroid cancer tended to be younger, with a mean age of 49.5 vs. 54.6 years (P = .012). There was a trend toward more cancers among men than women, but it was not significant.

There were no significant differences in any preoperative factors between patients with cancers and those with goiter only, including number of nodules, site of dominant nodule (right, left, or isthmus), thyroid function, thyroid weight, or fine-needle aspiration results (percentage deemed benign or nondiagnostic).

In a multivariate analysis, male sex was associated with a more than twofold risk for thyroid cancer (odds ratio, 2.39; 95% confidence interval, 1.152-4.978). There were also trends toward a lower risk of cancer with each additional decade of life, and a higher risk among patients who had undergone thyroid lobectomy, but these were nonsignificant associations.

"Knowledge of these associations may prove to be useful for both patient counseling and surgical decision making," Mr. Farquhar said.

The study was internally funded. The senior author was Dr. Douglas L. Fraker, chief of the division of endocrine and oncologic surgery at the University of Pennsylvania.

Mr. Farquhar and his coauthors reported having no relevant financial disclosures.

PHOENIX – More than one-fourth of men under age 50 undergoing surgery for benign goiter were found to have thyroid cancers, based on a chart review performed at the University of Pennsylvania.

The overall incidence of thyroid cancers in the patient series was 12%. Among men under age 45, the rate was "surprisingly" 28%, said Douglas R. Farquhar, a medical student at the University of Pennsylvania School of Medicine in Philadelphia.

Neil Osterweil/Frontline Medical News

Although thyroid goiters have traditionally been thought to be associated with a low risk for malignancy, recent studies have suggested otherwise. "In the literature we have seen published rates of up to 35%, which is much higher than we all had anticipated," Mr. Farquhar said at the annual Society of Surgical Oncology Cancer Symposium.

To get a better handle on the preoperative and patient characteristics associated with incident thyroid cancer and characterize the types of thyroid cancer discovered incidentally, Mr. Farquhar and his colleagues reviewed charts on all patients who underwent either total thyroidectomy or thyroid lobectomy for goiter at the center from 2004 through 2012.

Many cases of goiter can be medically managed, but surgery may be indicated in cases of pressure symptoms, cosmesis, or suspicion of malignancy, the investigators noted.

They excluded from their study patients with preoperative fine-needle aspiration pathology findings of Bethesda level III-VI (follicular lesion of undetermined significance, follicular neoplasm, suspicious or positive for malignancy).

Among 418 patients undergoing goiter surgery, 367 had goiter only, and 51 (12%) had an incident thyroid cancer. In all, 38 (75%) had papillary carcinomas, 10 (20%) had follicular carcinomas, 3 (6%) had Hürthle cell carcinomas, and 2 (4%) had thyroid lymphomas (two patients had multiple thyroid cancers, explaining the percentage greater than 100). An additional 67 patients (16%) were found to have micropapillary lesions.

Looking at the population as a whole, the investigators found that patients with thyroid cancer tended to be younger, with a mean age of 49.5 vs. 54.6 years (P = .012). There was a trend toward more cancers among men than women, but it was not significant.

There were no significant differences in any preoperative factors between patients with cancers and those with goiter only, including number of nodules, site of dominant nodule (right, left, or isthmus), thyroid function, thyroid weight, or fine-needle aspiration results (percentage deemed benign or nondiagnostic).

In a multivariate analysis, male sex was associated with a more than twofold risk for thyroid cancer (odds ratio, 2.39; 95% confidence interval, 1.152-4.978). There were also trends toward a lower risk of cancer with each additional decade of life, and a higher risk among patients who had undergone thyroid lobectomy, but these were nonsignificant associations.

"Knowledge of these associations may prove to be useful for both patient counseling and surgical decision making," Mr. Farquhar said.

The study was internally funded. The senior author was Dr. Douglas L. Fraker, chief of the division of endocrine and oncologic surgery at the University of Pennsylvania.

Mr. Farquhar and his coauthors reported having no relevant financial disclosures.

PHOENIX – More than one-fourth of men under age 50 undergoing surgery for benign goiter were found to have thyroid cancers, based on a chart review performed at the University of Pennsylvania.

The overall incidence of thyroid cancers in the patient series was 12%. Among men under age 45, the rate was "surprisingly" 28%, said Douglas R. Farquhar, a medical student at the University of Pennsylvania School of Medicine in Philadelphia.

Neil Osterweil/Frontline Medical News

Although thyroid goiters have traditionally been thought to be associated with a low risk for malignancy, recent studies have suggested otherwise. "In the literature we have seen published rates of up to 35%, which is much higher than we all had anticipated," Mr. Farquhar said at the annual Society of Surgical Oncology Cancer Symposium.

To get a better handle on the preoperative and patient characteristics associated with incident thyroid cancer and characterize the types of thyroid cancer discovered incidentally, Mr. Farquhar and his colleagues reviewed charts on all patients who underwent either total thyroidectomy or thyroid lobectomy for goiter at the center from 2004 through 2012.

Many cases of goiter can be medically managed, but surgery may be indicated in cases of pressure symptoms, cosmesis, or suspicion of malignancy, the investigators noted.

They excluded from their study patients with preoperative fine-needle aspiration pathology findings of Bethesda level III-VI (follicular lesion of undetermined significance, follicular neoplasm, suspicious or positive for malignancy).

Among 418 patients undergoing goiter surgery, 367 had goiter only, and 51 (12%) had an incident thyroid cancer. In all, 38 (75%) had papillary carcinomas, 10 (20%) had follicular carcinomas, 3 (6%) had Hürthle cell carcinomas, and 2 (4%) had thyroid lymphomas (two patients had multiple thyroid cancers, explaining the percentage greater than 100). An additional 67 patients (16%) were found to have micropapillary lesions.

Looking at the population as a whole, the investigators found that patients with thyroid cancer tended to be younger, with a mean age of 49.5 vs. 54.6 years (P = .012). There was a trend toward more cancers among men than women, but it was not significant.

There were no significant differences in any preoperative factors between patients with cancers and those with goiter only, including number of nodules, site of dominant nodule (right, left, or isthmus), thyroid function, thyroid weight, or fine-needle aspiration results (percentage deemed benign or nondiagnostic).

In a multivariate analysis, male sex was associated with a more than twofold risk for thyroid cancer (odds ratio, 2.39; 95% confidence interval, 1.152-4.978). There were also trends toward a lower risk of cancer with each additional decade of life, and a higher risk among patients who had undergone thyroid lobectomy, but these were nonsignificant associations.

"Knowledge of these associations may prove to be useful for both patient counseling and surgical decision making," Mr. Farquhar said.

The study was internally funded. The senior author was Dr. Douglas L. Fraker, chief of the division of endocrine and oncologic surgery at the University of Pennsylvania.

Mr. Farquhar and his coauthors reported having no relevant financial disclosures.

MADRID – Blacks may need additional guidance from clinicians to use radiotherapy for potentially curable lung cancer, a retrospective population-based study suggests.

Among 6,628 patients diagnosed with early-stage nonsquamous non–small cell lung cancer (NSCLC), primary radiation therapy doubled median survival from 11 months to 22.6 months for cases not receiving surgery (Log rank P value less than .0001).

Despite the survival advantage, blacks were significantly more likely than whites were to skip radiotherapy for stage IA NSCLC (46% vs. 37.5%; P = .02), Dr. Eric Flenaugh, chief of pulmonary and critical care medicine and vice chair of the department of medicine at Morehouse School of Medicine, Atlanta, reported at the world congress of the American College of Chest Physicians.

A subgroup analysis of nonsurgical stage IA cases in which surgery was not recommended or was contraindicated showed that 61% of whites went on to radiotherapy, compared with 47% of blacks (P = .007). When surgical resection was recommended but not performed, radiotherapy use was similar between races.

"What this basically says is that if they [blacks] chose not to have surgery, then they weren’t going to have anything," Dr. Flenaugh said in an interview. "We have to look at our approach to discussing with African Americans who have curable-stage cancer, particularly the IAs, that if you’re not a surgical candidate or choose not to have surgery, there are other options like radiotherapy that can improve your survival."

The data did not allow the investigators to determine patients’ chemotherapy status or which factors drove the lower uptake of radiotherapy, but prior research has shown that blacks undergo surgery for lung cancer less often than whites, even after access to care has been demonstrated (J. Clin. Oncol. 2006;24:413-8).

The current analysis, led by internal medicine resident Srinadh Annangi, MBBS, used data from the National Cancer Institute’s SEER (Surveillance, Epidemiology, and End Results) database for 6,628 patients diagnosed with NSCLC between 2004 and 2010, of which 4,210 did not receive surgery. NSCLC was staged as IA, IB, IIA, and IIB according to AJCC (American Joint Committee on Cancer) 6th edition classifications.

A little more than half of the 5,915 whites and 713 African-Americans were male, with a median age of 78 years and 67.5 years, respectively.

The proportion of tumors less than 2 cm in size for stages IA and IIA and less than 5 cm for stages IB and IIB was not significantly different between races, according to the poster presentation.

No significant racial disparities were seen for nonsurgical stage IB, IIA, and IIB cancers.

Among operable NSCLC cases, whites were significantly more likely to have surgery than were blacks (37% vs. 32%; P = .0004), whereas blacks were significantly more likely to have surgery recommended but refused or not performed (9% vs. 6%; P = .012).

Importantly, the proportion of blacks undergoing their recommended surgery was lower for both stage IA (78.3% vs. 86%; P less than .05) and IB cancers (74.6% vs. 81.3%; P less than .05).

The authors note that surgical resection remains the preferred treatment approach for operable stage I and II NSCLC, but conclude that eliminating the racial disparities in radiotherapy for early-stage NSCLC deemed inoperable or where surgery is refused can improve survival in the African American population.

Dr. Flenaugh and his coauthors reported no financial disclosures.

[email protected]

MADRID – Blacks may need additional guidance from clinicians to use radiotherapy for potentially curable lung cancer, a retrospective population-based study suggests.

Among 6,628 patients diagnosed with early-stage nonsquamous non–small cell lung cancer (NSCLC), primary radiation therapy doubled median survival from 11 months to 22.6 months for cases not receiving surgery (Log rank P value less than .0001).

Despite the survival advantage, blacks were significantly more likely than whites were to skip radiotherapy for stage IA NSCLC (46% vs. 37.5%; P = .02), Dr. Eric Flenaugh, chief of pulmonary and critical care medicine and vice chair of the department of medicine at Morehouse School of Medicine, Atlanta, reported at the world congress of the American College of Chest Physicians.

A subgroup analysis of nonsurgical stage IA cases in which surgery was not recommended or was contraindicated showed that 61% of whites went on to radiotherapy, compared with 47% of blacks (P = .007). When surgical resection was recommended but not performed, radiotherapy use was similar between races.

"What this basically says is that if they [blacks] chose not to have surgery, then they weren’t going to have anything," Dr. Flenaugh said in an interview. "We have to look at our approach to discussing with African Americans who have curable-stage cancer, particularly the IAs, that if you’re not a surgical candidate or choose not to have surgery, there are other options like radiotherapy that can improve your survival."

The data did not allow the investigators to determine patients’ chemotherapy status or which factors drove the lower uptake of radiotherapy, but prior research has shown that blacks undergo surgery for lung cancer less often than whites, even after access to care has been demonstrated (J. Clin. Oncol. 2006;24:413-8).

The current analysis, led by internal medicine resident Srinadh Annangi, MBBS, used data from the National Cancer Institute’s SEER (Surveillance, Epidemiology, and End Results) database for 6,628 patients diagnosed with NSCLC between 2004 and 2010, of which 4,210 did not receive surgery. NSCLC was staged as IA, IB, IIA, and IIB according to AJCC (American Joint Committee on Cancer) 6th edition classifications.

A little more than half of the 5,915 whites and 713 African-Americans were male, with a median age of 78 years and 67.5 years, respectively.

The proportion of tumors less than 2 cm in size for stages IA and IIA and less than 5 cm for stages IB and IIB was not significantly different between races, according to the poster presentation.

No significant racial disparities were seen for nonsurgical stage IB, IIA, and IIB cancers.

Among operable NSCLC cases, whites were significantly more likely to have surgery than were blacks (37% vs. 32%; P = .0004), whereas blacks were significantly more likely to have surgery recommended but refused or not performed (9% vs. 6%; P = .012).

Importantly, the proportion of blacks undergoing their recommended surgery was lower for both stage IA (78.3% vs. 86%; P less than .05) and IB cancers (74.6% vs. 81.3%; P less than .05).

The authors note that surgical resection remains the preferred treatment approach for operable stage I and II NSCLC, but conclude that eliminating the racial disparities in radiotherapy for early-stage NSCLC deemed inoperable or where surgery is refused can improve survival in the African American population.

Dr. Flenaugh and his coauthors reported no financial disclosures.

[email protected]

MADRID – Blacks may need additional guidance from clinicians to use radiotherapy for potentially curable lung cancer, a retrospective population-based study suggests.

Among 6,628 patients diagnosed with early-stage nonsquamous non–small cell lung cancer (NSCLC), primary radiation therapy doubled median survival from 11 months to 22.6 months for cases not receiving surgery (Log rank P value less than .0001).

Despite the survival advantage, blacks were significantly more likely than whites were to skip radiotherapy for stage IA NSCLC (46% vs. 37.5%; P = .02), Dr. Eric Flenaugh, chief of pulmonary and critical care medicine and vice chair of the department of medicine at Morehouse School of Medicine, Atlanta, reported at the world congress of the American College of Chest Physicians.

A subgroup analysis of nonsurgical stage IA cases in which surgery was not recommended or was contraindicated showed that 61% of whites went on to radiotherapy, compared with 47% of blacks (P = .007). When surgical resection was recommended but not performed, radiotherapy use was similar between races.

"What this basically says is that if they [blacks] chose not to have surgery, then they weren’t going to have anything," Dr. Flenaugh said in an interview. "We have to look at our approach to discussing with African Americans who have curable-stage cancer, particularly the IAs, that if you’re not a surgical candidate or choose not to have surgery, there are other options like radiotherapy that can improve your survival."

The data did not allow the investigators to determine patients’ chemotherapy status or which factors drove the lower uptake of radiotherapy, but prior research has shown that blacks undergo surgery for lung cancer less often than whites, even after access to care has been demonstrated (J. Clin. Oncol. 2006;24:413-8).

The current analysis, led by internal medicine resident Srinadh Annangi, MBBS, used data from the National Cancer Institute’s SEER (Surveillance, Epidemiology, and End Results) database for 6,628 patients diagnosed with NSCLC between 2004 and 2010, of which 4,210 did not receive surgery. NSCLC was staged as IA, IB, IIA, and IIB according to AJCC (American Joint Committee on Cancer) 6th edition classifications.

A little more than half of the 5,915 whites and 713 African-Americans were male, with a median age of 78 years and 67.5 years, respectively.

The proportion of tumors less than 2 cm in size for stages IA and IIA and less than 5 cm for stages IB and IIB was not significantly different between races, according to the poster presentation.

No significant racial disparities were seen for nonsurgical stage IB, IIA, and IIB cancers.

Among operable NSCLC cases, whites were significantly more likely to have surgery than were blacks (37% vs. 32%; P = .0004), whereas blacks were significantly more likely to have surgery recommended but refused or not performed (9% vs. 6%; P = .012).

Importantly, the proportion of blacks undergoing their recommended surgery was lower for both stage IA (78.3% vs. 86%; P less than .05) and IB cancers (74.6% vs. 81.3%; P less than .05).

The authors note that surgical resection remains the preferred treatment approach for operable stage I and II NSCLC, but conclude that eliminating the racial disparities in radiotherapy for early-stage NSCLC deemed inoperable or where surgery is refused can improve survival in the African American population.

Dr. Flenaugh and his coauthors reported no financial disclosures.

[email protected]