Hospital lymph node examination rates and survival after resection for colon cancer

CONTEXT

Several studies suggest improved survival among patients in whom a higher number of nodes are examined after colectomy for colon cancer. The National Quality Forum and other organizations recently endorsed a 12-node minimum as a measure of hospital quality.

OBJECTIVE

To assess whether hospitals that examine more lymph nodes after resection for colon cancer have superior late survival rates.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort study, using the national Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database (1995-2005), of US patients undergoing colectomy for nonmetastatic colon cancer (n = 30 625). Hospitals were ranked according to the proportion of their patients in whom 12 or more lymph nodes were examined and then were sorted into 4 evenly sized groups. Late survival rates were assessed for each hospital group, adjusting for potentially confounding patient and clinician characteristics.

MAIN OUTCOME MEASURES

Hospitals' lymph node examination rates in association with cancer staging, use of adjuvant chemotherapy (indicated for patients with node-positive disease), and 5-year survival rate.

RESULTS

Hospitals with the highest proportions of patients with examination of 12 or more lymph nodes tended to treat lower-risk patients and had substantially higher procedure volumes. After adjusting for these and other factors, there remained no statistically significant relationship between hospital lymph node examination rates and survival after surgery (adjusted hazard ratio, highest vs lowest hospital quartile, 0.95; 95% confidence interval, 0.88-1.03). Although the 4 hospital groups varied widely in the number of lymph nodes examined, they were equally likely to find node-positive tumors and had very similar overall unadjusted rates of adjuvant chemotherapy (26% vs 25%, highest vs lowest hospital quartile).

CONCLUSIONS

The number of lymph nodes hospitals examine following colectomy for colon cancer is not associated with staging, use of adjuvant chemotherapy, or patient survival. Efforts by payers and professional organizations to increase node examination rates may have limited value as a public health intervention.

Patterns of Surgical Treatment for Women Diagnosed with Early Breast Cancer in Queensland

BACKGROUND

Australian women with early breast cancer should be given the choice between breast-conserving surgery (BCS) or mastectomy. This is the first Australian study to report on patterns of surgical care specifically for early breast cancer at a population level.

METHODS

Two population-based routine data collections were linked to obtain surgical treatment information for breast cancer cases diagnosed in 2004 in Queensland, from which we identified 1274 cases of early female breast cancer. Logistic regression was used to assess the likelihood of female breast cancer patients having mastectomy, BCS, and axillary node dissection, after adjusting for patient and hospital demographics, tumor size, and comorbidities.

RESULTS

Three-quarters (77%) of women had BCS, 29% had a mastectomy, and 86% had dissection of the axillary lymph nodes. The likelihood of women having mastectomy was higher among women living in rural areas, those treated in public hospitals, and women who had comorbidities of anemia or heart failure. In contrast, BCS was more likely for women treated in private hospitals or hospitals with high surgical caseload. Heart failure decreased the likelihood of BCS. Having an axillary node dissection was more likely among younger women and those treated in high caseload hospitals.

CONCLUSION

The observed differentials in surgical treatment for early breast cancer patients suggest that access issues may have contributed to the decision-making process. Understanding the reasons why women with early breast cancer choose a certain treatment strategy should be a focus of future research.

Local recurrence after mastectomy in patients with T3pN0 breast carcinoma treated without postoperative radiation therapy

OBJECTIVE

The need for comprehensive adjuvant radiotherapy in patients with T3pN0 breast cancer is controversial. This retrospective analysis was performed to assess the frequency of local and distant recurrence in patients treated with mastectomy without postoperative radiation.

MATERIALS AND METHODS

A single institution database of 2362 patients with breast carcinoma treated from 1974 to 1994 yielded 101 patients who had T3pN0 disease and did not receive chest wall or nodal irradiation. The median follow-up time was 93 months (range, 10-256 months). Sites of first failure were categorized as isolated chest wall (CWF), regional lymph nodes (RNF, which in this case were considered to be either axillary or supraclavicular), or distant sites (DF). CWF and/or RNF were considered local recurrences. Patients with simultaneous CWF and DF or RNF and DF were scored as DF. A comparison was made to 286 T2pN0 patients, also treated between 1974 and 1994.

RESULTS

Twenty-two T3N0 patients developed recurrent disease. Site of first recurrence was isolated local recurrence in 11 patients and distant in 11 patients. Four patients had simultaneous local and distant recurrences. Site of isolated local recurrence was CWF in 5 patients and RNF in 6 patients. Median tumor size was 6 cm (range, 5-10.5 cm). There was no difference in local recurrence for tumor sizes < or =7 cm versus >7 cm (P = 0.07). The crude recurrence rate for T3pN0 patients treated by mastectomy was similar to T2pN0 patients treated in similar fashion (P = 0.3).

CONCLUSION

The risk of isolated local recurrence in patients with T3pN0 breast cancer and negative margins is moderately low and similar to T2pN0 patients. These results suggest that routine use of postoperative chest wall and nodal irradiation in all T3pN0 patients may not be required.

Lymphadénectomie lombo-aortique cœlioscopique par voie extrapéritonéale gauche: morbidité et apprentissage de la technique

OBJECTIVE

Description of the morbidity and the learning curve of the left extraperitoneal laparoscopic paraaortic lymphadenectomy in patients with gynecologic cancers.

PATIENTS AND METHODS

Retrospective study of patients treated with the left extraperitoneal laparoscopic paraaortic lymphadenectomy between August 1999 and January 2005. Duration of surgery, per and post-operative complications, duration of the hospital stay, number of retrieved nodes, and pathologic results were studied. A comparative analysis of the results was performed between trained and training surgeons.

RESULTS

Eighty-one patients were planned for the left extraperitoneal laparoscopic paraaortic lymphadenectomy. The major indication (90% of cases) was advanced cervical carcinomas (stage IB2 and more). The median number of retrieved nodes was 14, with a mean operative time of 109 minutes. The median hospital stay was 3 days. Two major complications related to the surgical technique were observed: a laceration of the inferior vena cava and an acute abdominal syndrome. Seven lymphocysts (8.6%) were observed (with associated symptoms in 2 cases). Trained surgeons to the technique displayed higher success rate of this surgical technique and higher number of retrieved lymph nodes.

DISCUSSION AND CONCLUSIONS

The left extraperitoneal laparoscopic paraaortic lymphadenectomy allows the accurate staging and management of patients with gynecologic cancers and mainly women affected by advanced cervical carcinoma. The surgical technique is safe and reproducible when performed by trained surgeons.

Changes in survival during the past two decades for breast cancer at the Kyoto University Hospital

AIMS

To report the changes in survival over 20 years of 775 breast cancer women operated between 1982 and 2003 at the Kyoto University Hospital in Japan, reflecting changes in clinical practice over that period.

RESULTS

Survival curves have significantly improved between the periods 1982-1989 and 1990-2003. The 5- and 10-year survival rates between these periods were 80.3% and 85.1%, and 67.5% and 75.0%, respectively. Moreover, there was a difference in overall survival curves of patients of stages II and III, of 35-54 ages, or of positive estrogen receptor (ER) status between these periods.

CONCLUSION

The present study presented the recent advance of the survival rates might be due to the rational development of breast cancer treatment, and suggested the possibility that the patients of stages II and III, of 35-54 ages, or of positive ER status were received benefits by these treatments.

Clinicopathological evaluation of radical retropubic prostatectomy-positive outcome even at institutes with relatively limited experience

A total of 161 patients underwent radical retropubic prostatectomy at our 11 institutions in the three-year period from January 2001 to December 2003. The numbers per institution ranged from 1-36, with 5 institutions conducting 20 or more (131 cases), and 6 performing less than 15 (30 cases). Here we examined the differences in operation parameters and patient outcome between these two groups. Time for surgery, associated loss of blood, lymphadenectomy, preservation of neurovascular bundles, time for removal of indwelling catheters, post-operation complications, and subsequent urinary incontinence, were assessed. There were no differences between the two groups of hospitals, except with regard to surgery time and incontinence, where the period to 'pad-free' was an average of more than 40 days longer in institutions undertaking only a small number of operations. From our experience with radical retropubic prostatectomy, series of hospitals, there is no reduction in safety with such intervention performed by institutions undertaking only a small number of operations.

[Early postoperative complications of radical cystectomy and urinary diversion in elderly patients]

Clinical and operative features and early postoperative complications were reviewed in 26 patients 75 years old and older who were treated with radical cystectomy including pelvic lymphadenectomy and urinary diversion in our hospital from 1994 to 2005. These findings were compared with those in 170 patients younger than 75 years old who received the same surgery and in 26 patients 75 years old and older who were not surgically treated. Early postoperative complications were found in 9 elderly patients (34%), but there were no deaths in the preoperative and early postoperative periods. There was no significant difference in the rate of early postoperative complications between patients 75 years old and older and those younger than 75. Preoperative performance status (PS) and the American Society of Anesthesiologists Score (ASA score) were significantly better in elderly patients with the surgery than those without surgery. Therefore, evaluation with PS and the ASA score may allow urologists to appropriately select elderly candidates for radical cystectomy and urinary diversion. Chronological age alone is not a determinant for indicating the surgery.

Surgical staging, treatment, and follow-up of borderline tumors in different hospital categories: a prospective nationwide survey in Finland

BACKGROUND

Surgical treatment and staging of ovarian borderline tumors have been reported to be often suboptimal and differ considerably. We evaluated the extent of surgical treatment of these tumors in different hospital categories.

MATERIAL AND METHODS

A prospective survey performed in 1999 included 65 patients operated on for borderline ovarian tumors and covered 78% of such patients reported to the Finnish Cancer Registry. Detailed information of demographic data and surgical treatment was reported by the responsible physicians using a special questionnaire after confirmation of histopathology.

RESULTS

Fifty-eight patients (89%) had stage I tumor, only two patients (3%) had stage II disease and five patients (8%) had stage III disease with peritoneal implants. The majority of the patients underwent bilateral salpingo-oophorectomy (66%) and hysterectomy (58%). Unilateral salpingo-oophorectomy was performed for 21 (32%) and omentectomy for 22 (34%) patients. Ten out of the 16 women under 40 years of age had fertility-sparing surgery. Peritoneal biopsies were taken in 16 (25%) women and lymphadenectomy was performed for 9 (14%) patients with clinical suspicion of invasive ovarian carcinoma. Frozen section was taken in half of the patients and the histology remained the same in 72% of the final pathology reports. No clear differences of the extent of surgical treatment were detected between different hospital categories. Overall cumulative 5-year relative survival rate was 96%.

CONCLUSIONS

Bilateral salpingo-oophorectomy and hysterectomy was performed for the majority of patients with borderline ovarian tumor. More attention should be paid to adequate staging of borderline tumors in all hospital categories.

Surgical outcomes for colon and rectal cancer over a decade: results from a consecutive monocentric experience in 902 unselected patients

Background

This study evaluates the surgical morbidity and long-term outcome of colorectal cancer surgery in an unselected group of patients treated over the period 1994–2003.

Methods

A consecutive series of 902 primary colorectal cancer patients (489 M, 413 F; mean age: 63 years ± 11 years, range: 24–88 years) was evaluated and prospectively followed in a university hospital (mean follow-up 36 ± 24 months; range: 3–108 months). Perioperative mortality, morbidity, overall survival, curative resection rates, recurrence rates were analysed.

Results

Of the total, 476 colorectal cancers were localized to the colon (CC, 53%), 406 to the rectum (RC, 45%), 12 (1%) were multicentric, and 8 were identified as part of HNPCC (1%). Combining all tumours, there were 186 cancers (20.6%) defined as UICC stage I, 235 (26.1%) stage II, 270 (29.9%) stage III and 187 (20.6%) stage IV cases. Twenty-four (2.7%) cases were of undetermined stage. Postoperative complications occurred in 38% of the total group (37.8% of CC cases, 37.2% of the RC group, 66.7% of the synchronous cancer patients and 50% of those with HNPCC, p = 0.19) Mortality rate was 0.8%, (1.3% for colon cancer, 0% for rectal cancer; p = 0.023). Multivisceral resection was performed in 14.3% of cases. Disease-free survival in cases resected for cure was 73% at 5-years and 72% at 8 years. The 5- and 8-year overall survival rates were 71% and 61% respectively (total cases). At 5-year analysis, overall survival rates are 97% for stage I disease, 87% for stage II, 73% for stage III and 22% for stage IV respectively (p < 0.0001). The 5-year overall survival rates showed a marked difference in R0, R1+R2 and non resected patients (82%, 35% and 0% respectively, p < 0.0001). On multivariate analysis, resection for cure and stage at presentation but not tumour site (colon vs. rectum) were independent variables for overall survival (p < 0.0001).

Conclusion

A prospective, uniform follow-up policy used in a single institution over the last decade provides evidence of quality assurance in colorectal cancer surgery with high rates of resection for cure where only stage at presentation functions as an independent variable for cancer-related outcome.

Secular Trends in the Use, Quality, and Outcomes of Gastrectomy for Noncardia Gastric Cancer in the United States

BACKGROUND

The overall survival with non-cardia gastric adenocarcinoma in the United States has remained poor and relatively unchanged over the past 2 decades. This brings into question the utilization and quality of gastrectomy and lymphadenectomy. We examined the trends, extent, and determinants of surgical treatment and the influence of gastrectomy and adequacy of lymphadenectomy (defined as collection of 15 or more lymph nodes) on non-cardia gastric cancer survival.

METHODS

Data from Surveillance, Epidemiology, and End Results (SEER) registries was used to identify patients with non-cardia adenocarcinoma diagnosed during 1983-2002. Logistic regression was used to examine determinants of gastric resection and adequacy of lymphadenectomy. Cox proportional hazard (PH) models were used to examine determinants of mortality risk for patients treated surgically. All models examined year of diagnosis, age, race, gender, geographic region, and cancer spread.

RESULTS

There were 16,846 patients with non-cardia gastric cancer of whom 10,534 (62.5%) underwent gastric resection. Approximately 77.9% with localized disease underwent resection. Resection for non-cardia gastric cancer declined 6% for all stages and 20% for local stages between 1983 and 2002. In multivariable models, gastrectomies were less likely to be performed between 1998-2002 (-37% compared to 1983-1987), for localized disease (-78% compared to regional disease), for patients older than 70 (-39% compared to patients younger than 40), and for patients from New Mexico (-45% compared to highest in Hawaii). Wide racial variability was also found (lowest for Whites [-54%] compared to Asians). Adequate LN sampling (15 or more LN) was recorded in only 25% overall and 20% of localized disease. Improvement in LN collection since 1997 has been modest, with only a 7% relative increase. The mortality risk of surgically treated non-cardia cancer patients has been unchanged for 15 years. Adequate lymphadenectomy was associated with a 19% decreased mortality risk in this group. Gender and racial differences in mortality risk were present (up to 13% higher in men compared to women and 22% higher in Whites compared Asians).

CONCLUSION

Gastrectomy for non-cardia gastric adenocarcinoma is underutilized, especially for localized disease. In the majority of operations for non-cardia gastric cancer, LN collection is inadequate. Racial and geographic variations with gastric resection and LN sampling are as significant as patient age and stage of the cancer. Disparities based on race and geographic region, as well as surgeon and facility factors need to be investigated and addressed to bring forth improvements in outcomes for non-cardia adenocarcinoma.

Detection Rate and Operating Time Required for γ Probe-Guided Sentinel Lymph Node Resection after Injection of Technetium-99m Nanocolloid into the Prostate with and without Preoperative Imaging

OBJECTIVE

To investigate the usefulness of presurgical image fusion of three-dimensional single photon emission computed tomography (SPECT) with computed tomography/magnetic resonance imaging (CT/MRI) for detecting primary prostatic lymphatic landing sites (sentinel lymph nodes [SLNs]) using an intraoperative gamma probe in patients undergoing radical prostatectomy for organ-confined prostate cancer after intraprostatic (99m)Tc-nanocolloid injection.

METHODS

In 15 patients the surgeon was unaware of the preoperative SPECT/CT/MRI fusion imaging results. In 21 patients the surgeon was supported by the preoperative SPECT/CT/MRI images. Selective SLN resection was followed by an extended backup pelvic lymph node dissection (PLND) and radical prostatectomy.

RESULTS

In the group of 15 patients (gamma probe-guided SLN search only) presurgical SPECT/CT/MRI identified 137 SLNs (median of 10/patient; range: 2-19) and a total of 135 SLNs (median of 8/patient; range: 2-20) were detected intraoperatively (detection rate 98.5%). In the group of 21 patients with the surgeon knowing the preoperative SPECT/CT/MRI findings, 189 (median of 9/patient; range: 3-20) of the 190 imaged SLNs (median of 8/patient, range: 2-19) were found intraoperatively (detection rate 99.5%). Median operating time for sentinel lymphadenectomy using gamma probe only was 100 min (range: 40-130) versus 70 min (range: 20-140) for the SPECT/CT/MRI-supported resection (p=0.025). A median of 9 SLNs per patient (range: 2-19) was confirmed histologically.

CONCLUSIONS

Preoperative SPECT/CT/MRI is highly reliable to detect nonmetastatic sentinel nodes of the prostate. The operating time for SPECT/CT/MRI-supported SLN resection is significantly reduced compared to SLN resection guided by gamma probe alone. Both procedures take significantly longer than routine extended PLND.

The prognostic value of N-ratio in patients with gastric cancer: validation in a large, multicenter series

AIMS

The proportion between metastatic and examined lymph nodes (N-ratio) has been proposed as an independent prognostic factor in patients with gastric cancer. In the present work we validated the reliability of N-ratio in a large, multicenter series.

PATIENTS AND METHODS

We retrospectively reviewed the data of 1853 patients who underwent radical resection for gastric carcinoma. Survival of patients with >15 (Group-1, n=1421) and those with < or =15 (Group-2, n=432) lymph nodes examined was separately analyzed in order to evaluate the influence of lymph node dissection on disease staging. N-ratio categories (N-ratio 0, 0%; N-ratio 1, 1-9%; N-ratio 2, 10-25%; N-ratio 3, >25%) were determined by the best cut-off approach.

RESULTS

At multivariate analysis, N-ratio (but not TNM N-category) was retained as an independent prognostic factor both in Group-1 and Group-2 (HR for N-ratio 1, N-ratio 2 and N-ratio 3=1.67, 2.96 and 6.59, and 1.56, 2.68 and 4.28, respectively). After a median follow-up of 45.5 months, the 5-year overall survival rates of TNM N0, N1 and N2 patients were significantly different in Group-1 vs Group-2. This was not the case when adopting the N-ratio classification, suggesting that a low number of excised lymph nodes can lead to patients being understaged using the N-category, but not N-ratio. Moreover, N-ratio identified subsets of patients with significantly different survival rates within TNM N1 and N2 categories in both groups.

CONCLUSIONS

N-ratio is a simple and reproducible prognostic tool that can stratify patients with gastric cancer, including those cases with limited lymph node dissection. These data support the rationale to propose the implementation of N-ratio into the current TNM staging system.

A declining rate of completion axillary dissection in sentinel lymph node-positive breast cancer patients is associated with the use of a multivariate nomogram

OBJECTIVE

To compare sentinel lymph node (SLN)-positive breast cancer patients who had completion axillary dissection (ALND) with those who did not, with particular attention to clinicopathologic features, nomogram scores, rates of axillary local recurrence (LR), and changes in treatment pattern over time.

BACKGROUND

While conventional treatment of SLN-positive patients is to perform ALND, there may be a low-risk subgroup of SLN-positive patients in whom ALND is not required. A multivariate nomogram that predicts the likelihood of residual axillary disease may assist in identifying this group.

METHODS

Among 1960 consecutive SLN-positive patients (1997-2004), 1673 (85%) had ALND ("SLN+/ALND") and 287 (15%) did not ("SLN+/no ALND"). We compare in detail the clinicopathologic features, nomogram scores, and rates of axillary LR between groups.

RESULTS

Compared with the SLN+/ALND group, patients with SLN+/no ALND were older, had more favorable tumors, were more likely to have breast conservation, had a lower median predicted risk of residual axillary node metastases (9% vs. 37%, P < 0.001), and had a marginally higher rate of axillary LR (2% vs. 0.4%, P = 0.004) at 23 to 30 months' follow-up; half of all axillary LR in SLN+/no ALND patients were coincident with other local or distant sites. For patients in whom intraoperative frozen section was either negative or not done, the rate of completion ALND declined from 79% in 1997 to 62% in 2003 to 2004 but varied widely by surgeon, ranging from 37% to 100%. For 10 of 10 evaluable surgeons, the median nomogram scores in the SLN+/no ALND group were <or=10.5.

CONCLUSIONS

SLN+/no ALND breast cancer patients, a selected group with relatively favorable disease characteristics, had a 9% predicted likelihood of residual axillary disease by nomogram but an observed axillary LR of 2%. A gradual and significant decline over time in the rate of completion ALND is associated with, but not entirely explained by, the institution of a predictive nomogram. It is reasonable to omit ALND for a low-risk subset of SLN-positive patients.

Factors Determining Adequacy of Axillary Node Dissection in Breast Cancer Patients

With increased focus on quality assurance, a complete axillary lymph node dissection (ALND) has been defined as the removal of 10 or more lymph nodes (LN). The objective of this study was to determine which patient, physician, and geographic factors predict the adequacy of ALND in breast cancer patients. The University of Louisville Breast Cancer Sentinel Lymph Node Study is a multicenter, prospective study of 4,131 patients, all of whom had a sentinel node biopsy and completion ALND. Univariate and multivariate analyses were performed to determine which factors were independently associated with the removal of 10 or more LN. Of the 4,131 patients in this study, the median number of LN removed was 11 (range; 3-45). Ten or more LN were removed in 3,213 (77.8%) patients. The median patient age in this study was 60 (range; 27-100), with a median tumor size of 1.5 cm (range; 0.1-11.0 cm). On univariate analysis, patient age, tumor size, and palpability were correlated with adequacy of ALND. Academic affiliation and percentage of breast practice were significant physician factors predictive of adequacy of ALND. Both geographic region and community size were significantly correlated with adequacy of ALND. On multivariate analysis, patient age (p = 0.024), surgeon academic affiliation (p < 0.001), percentage breast practice (p < 0.001), and community size (p = 0.003) were significant determinants of adequacy of ALND. Younger patients were more likely to have an adequate ALND. Surgeons in academic practice had a higher rate of adequate ALND, as did those practicing in larger communities. Surgeons with a more breast experience had a lower rate of adequate ALND. Patient age, surgeon academic affiliation, and breast experience, as well as community size are all significant factors predictive of adequacy of ALND.

Breast cancer in the elderly: histological, hormonal and surgical characteristics

The characteristics, menstrual risk factors and surgical therapy of 187 consecutive patients more than 70 years of age (mean: 75.9) were investigated and compared with those of 609 patients less than 70 years of age (mean: 53.9). There was no difference in stage, size, state of axillary nodes, grade, histological types, Ki-67, vascular invasion, estrogen receptor rate, and HER-2/neu (+) rate. Positive progesterone receptor rate was higher in older patients (54.7% vs. 63.1%). Tumors were larger (p=0.01) and their stage higher (p=0.014) in patients more than 80 years of age. All menstrual risk factors were similar in the two groups. Positive familial history was more frequent in patients <60 years. Significantly more young patients used hormone replacement therapy (HRT) (21.8 vs. 8.6%). Older patients underwent less breast-conserving surgery (36.1 vs. 55.1%), and less axillary lymph node dissection (ALND) (69.7 vs. 84.9%). We conclude that breast cancer characteristics and menstrual risk factors are similar in the two age groups.

Factors influencing the volume-outcome relationship in gastrectomies: a population-based study

BACKGROUND

A relationship between hospital procedural volume and patient outcomes has been observed in gastrectomies for primary gastric cancer, but modifiable factors influencing this relationship are not well elaborated.

METHODS

We performed a population-based study of 1864 patients undergoing gastrectomy for primary gastric cancers at 214 hospitals. Hospitals were stratified as high-, intermediate-, or low-volume centers. Multivariate models were constructed to evaluate the effect of institutional procedural volume and other hospital- and patient-specific factors on the risk of in-hospital mortality, adverse events, and failure to rescue, defined as mortality after an adverse event.

RESULTS

High-volume centers attained an in-hospital mortality rate of 1.0% and failure-to-rescue rate of .7%, both less than one-fifth of that seen at intermediate- and low-volume centers, although adverse event rates were similar across the three volume tiers. In multivariate modeling, treatment at a high-volume hospital decreased the odds of mortality (odds ratio [OR], .22; 95% confidence interval [95% CI], .05-.89), whereas treatment at an institution with a high ratio of licensed vocational nurses per bed increased the odds of mortality (OR, 1.96; 95% CI, 1.04-3.75). Being treated at a hospital with a greater than median number of critical care beds decreased odds of mortality (OR, .46; 95% CI, .25-.81) and failure to rescue (OR, .53; 95% CI, .29-.97).

CONCLUSIONS

Undergoing gastrectomy at a high-volume center is associated with lower in-hospital mortality. However, improving the rates of mortality after adverse events and reevaluating nurse staffing ratios may provide avenues by which lower-volume centers can improve mortality rates.

An observational longitudinal study to evaluate miction, defecation, and sexual function after radical hysterectomy with pelvic lymphadenectomy for early-stage cervical cancer

The objective of this study was to evaluate the problems with miction, defecation, and sexuality after a radical hysterectomy with or without adjuvant radiotherapy for the treatment of cervical cancer stage I-IIA. This study included an observational longitudinal study of self-reported bladder, defecation, and sexual problems with a baseline score. Ninety-four women were included in the study. An age-matched control group consisted of 224 women. The patients showed significantly more negative effects on sexual function compared with both the controls and their situation before the treatment throughout 24 months of follow-up. The problems included less lubrication, a narrow and short vagina, senseless areas around the labia, dyspareunia, and sexual dissatisfaction. Up to 12 months after the treatment, the patients complained significantly more of little or no urge to urinate and diarrhea as compared with the controls. Adjuvant radiotherapy did not increase the risk of bladder dysfunction, colorectal motility disorders, and sexual functions. We conclude that a radical hysterectomy for the treatment of early-stage cervical carcinoma is associated with adverse effects mainly on sexual functioning.

Clinical outcomes of uterine sarcomas: results from 14 years worth of experience in the Kinki district in Japan (1990-2003)

To review clinical outcomes and therapeutic varieties, we were invited to submit data from the patients who were treated for uterine sarcomas in Japan from 1990 to 2003. Uterine sarcomas were defined as leiomyosarcoma (LMS), endometrial stromal sarcoma (ESS), and carcinosarcoma (CS). Of a total of 97 patients, 36 (37.1%) were diagnosed with LMS of the uterine corpus, 15 (15.5%) with ESS, 46 (47.4%) with CS. Median age at diagnosis was 59 (21-85) years. Clinical stages based on FIGO were 41 (42.3%) with stage I disease, 6 (6.2%) with staged II, 34 (35.1%) with stage III, and 16 (16.5%) with stage IV. The median follow-up period for all patients was 13 (1-108) months and median disease-free period was 9 (0-96) months. The 1-year survival rate and disease-free survival (DFS) rate were calculated in patients with all sarcomas (overall survival [OAS], 61.3%; DFS, 46.6%). Statistical analysis showed that younger age (less than 50 years), early stage (stages I and II), and surgical procedure (extended hysterectomy [EH] and radical hysterectomy [RH]) were associated with significantly better OAS. Histologic types did not affect the survival period. In conclusion, aggressive surgery including EH or RH at the time of initial operation offers the possibility of prolonged survival.

Gender differences in non-small cell lung cancer: a population-based study

BACKGROUND

A retrospective study including all patients with non-small cell lung cancer carcinoma in a population-based registry was performed to characterize gender differences in lung cancer and to analyze the factors influencing prognosis in women.

METHODS

We retrieved through the Tuscan Cancer Registry (RTT) archive 2,523 lung tumor cases diagnosed during the period 1996-1998 in the provinces of Florence and Prato, central Italy. We compared the prognosis within 464 non-small lung cancer women and 1,798 men in a population-based case series. The influence of the following variables on postoperative survival were analyzed: age, cell type, pathologic T and N status, site of tumor and type of surgical resection.

RESULTS

The age at diagnosis was similar in women and in men. Women were significantly more likely to have adenocarcinoma but less likely to have squamous cell carcinoma compared with men. Fewer pneumonectomies were performed in women than in men. Nevertheless, prognosis was similar in both sexes and type of surgical resection was significant prognostic factor.

CONCLUSIONS

Lung cancer was more frequent in men than in women, but overall survival is similar. Differences in lung cancer histology and rate of pneumonectomies were found between men and women.

Surgeon characteristics and variations in treatment for early-stage breast cancer

HYPOTHESIS

Adherence to National Institutes of Health consensus statement recommendations for early-stage breast cancer will vary by surgeon characteristics.

DESIGN

Secondary data analysis using the Surveillance, Epidemiology, and End Results national tumor registry linked with Medicare claims data. Logistic regression was used to analyze data on a cohort of 1045 surgeons who operated on 9449 Medicare patients with early-stage breast cancer.

MAIN OUTCOME MEASURE

Care adherent to the 1990 National Institutes of Health consensus statement recommendations.

RESULTS

Surgeon age and specialty were not associated with adherent care overall, nor among breast-conserving surgery or mastectomy subgroups. Patients of higher-volume surgeons were significantly more likely to undergo adherent care overall because of greater use of lymph node dissection among women who received either breast-conserving surgery or mastectomy. Patients of female surgeons and surgeons with a medical school affiliation were less likely to undergo adherent care overall, which was related to greater use of breast-conserving surgery and lesser use of lymph node dissection among patients who underwent breast-conserving surgery.

CONCLUSIONS

Several surgeon characteristics are significantly associated with variations in breast cancer treatment received. These results warrant further investigation into the association between these surgeon characteristics and cancer care outcomes.

Predictive factors associated with prolonged chest drain production after esophagectomy

After esophagectomy, pleural drainage is performed to ensure complete drainage of the pleural cavities. The aim of this study was to detect predisposing factors for prolonged drainage. Patients who underwent transhiatal or extended transthoracic esophagectomy for adenocarcinoma of the distal esophagus or gastroesophageal junction were included. Patients who underwent esophagectomy produced a median total drainage volume of 2477 mL (range 30-14,908). Seventy-five patients needed chest drainage = 7 days (short drainage) while 57 patients needed chest drainage > 7 days (prolonged drainage). Factors associated with prolonged drainage were a transthoracic approach (P < 0.001), a higher volume of blood loss (P = 0.027), a higher number of resected lymphnodes (P = 0.046) and a radical dissection (P = 0.033). Prolonged pleural drainage is associated with a transthoracic approach and is seen more often in patients after a microscopically radical dissection. Prolonged drainage is a sign of adequate dissection on the site of the primary tumor, probably due to the more extensive trauma to the lymphatic vessels in the mediastinum.