36.08 One-Year Postoperative Resource Utilization in Sarcopenic Patients

Posted on December 22, 2014

P. S. Kirk1, J. F. Friedman1, D. C. Cron1, M. N. Terjimanian1, L. D. Canvasser1, A. M. Hammoud1, J. Claflin1, M. B. Alameddine1, E. D. Davis1, N. Werner1, S. C. Wang1, D. A. Campbell1, M. J. Englesbe1  1University Of Michigan Health System,Department Of Surgery,Ann Arbor, MI, USA

Introduction:  It is well established that sarcopenic patients are at higher risk of postoperative complications and short-term healthcare utilization. Less well understood is how these patients fare over the long term after surviving the immediate postoperative period. We explored costs over the postoperative year among sarcopenic patients.

Methods:  We identified 1,298 patients in the Michigan Surgical Quality Collaborative (MSQC) database who underwent inpatient elective surgery at the University of Michigan Health System from 2006 to 2011. Sarcopenia, defined by gender-stratified tertile of lean psoas area (LPA), was determined from preoperative CT scans using validated analytic morphomics. Data were analyzed to assess sarcopenia’s relationship to costs, readmissions, discharge location, surgical intensive care unit (SICU) admissions, hospital length of stay (LOS), and mortality. Multivariate models adjusted for patient demographics and surgical risk factors.

Results: Sarcopenia was independently associated with increased adjusted costs at 30, 90, 180, and 365 days (p=0.001, p<0.001, p=0.091, and p=0.021, respectively) (Fig. 1). The difference in adjusted postsurgical costs between sarcopenic and non-sarcopenic patients increased from $5,541 at 30 days to $9,938 at one year. Sarcopenic patients were more likely to be discharged somewhere other than home (OR=4.44, CI=2.30-8.59, p<0.001) and more likely to die in the postoperative year (OR=3.24, CI=1.72-6.11, p<0.001). Sarcopenia was not an independent predictor of increased readmission rates in the postsurgical year (p=0.69).

Conclusion: Sarcopenia is a robust predictor of healthcare utilization in the first year after surgery. These patients accumulate costs at a faster rate than their non-sarcopenic counterparts. It may be appropriate to allocate additional resources to sarcopenic patients in the perioperative setting to reduce the incidence of negative postoperative outcomes.

 

33.10 Risk Stratification of Sentinel Lymph Node Positivity in Intermediate Thickness Melanoma

Posted on December 22, 2014

M. G. Peters1, E. K. Bartlett1, R. E. Roses1, B. J. Czerniecki1, D. L. Fraker1, R. R. Kelz1, G. C. Karakousis1  1Hospital Of The University Of Pennsylvania,General Surgery,Philadelphia, PA, USA

Introduction:  Patients with intermediate thickness cutaneous melanoma are routinely recommended for sentinel lymph node biopsy (SLNB) as standard of practice.  Conversely, those with thin melanoma are selectively offered the procedure given the low risk of SLN positivity in this group overall.  We sought to identify a low-risk subset of patients with intermediate thickness melanoma who, like many patients with thin melanoma, may be spared the additional LN procedure.

Methods: Demographics and histo-pathological characteristics of the primary tumor were reviewed for 952 patients undergoing SLNB for primary intermediate thickness cutaneous melanoma (1.01-4.00mm) treated at our institution from 1995-2011. Univariate analysis using chi-square and Wilcoxon rank-sum as appropriate was used to determine associations with SLN positivity. Factors approaching statistical significance (p<0.20) were included in a forward step-wise multivariate logistic regression.  All significant factors (p<0.05) were then included in a risk scoring system. 

Results:  The rate of positive SLNB in the study cohort was 16.5% (n=157).   In univariate analyses, significant factors associated with SLN positivity were increasing thickness (p<.001), absence of tumor infiltrating lymphocytes (p=.043), ulceration (p=.014), lymphovascular invasion (p<.001), and the presence of microsatellites (p<.001).   With regards to age <60 (p=.18) and presence of mitoses (p=.071), there was a trend toward significant association with SLN positivity.  When all of these factors were included in a multivariate model, five factors were identified as significantly associated with SLN positivity; younger age (<60 years, OR=1.52, p=.032), absence of tumor infiltrating lymphocytes (OR=1.64, p=.02), thicker primary tumors (OR=2.6 for 1.51-2, OR=3.5 for 2.01-4, p<.001), the presence of satellites (OR=2.2, p=.015), and lymphovascular invasion (OR=2.1, p=.014).  These factors were used to develop a risk stratification scoring system (see Table).  The rate of positive SLN ranged from 4.6% (when no factors were present, score=0) to 44.0% (when all factors were present, score= 5). 

Conclusion:Patients with intermediate thickness melanoma can be risk stratified for SLN positivity using clinical and pathologic factors. While SLNB appears justified for the majority of patients with intermediate thickness melanomas, for appreciable minority (nearly 10%) the risk of LN positivity is more similar to that of low risk T1 (<1.0mm) melanomas.  For this subgroup of patients, SLNB can be offered selectively.

34.01 Urinary Tract Infection After Surgery for Colorectal Malignancy: Risk Factors and Complications

Posted on December 22, 2014

A. C. Sheka1, S. Tevis1, G. Kennedy1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: Over 4% of patients undergoing colorectal surgery develop post-operative UTI, twice the rate of patients undergoing other gastrointestinal surgery and over three times greater than for those undergoing non-gastrointestinal surgery. Surgical patients who suffer post-operative UTI have increased mortality rates, lengths of stay, and costs of care. The aim of this study was to analyze the risk factors and post-operative complications associated with urinary tract infection (UTI) after surgery for colorectal malignancy.

 

Methods: The ACS-NSQIP database was queried for patients who underwent surgery for colorectal malignancy from 2005-2012. From these records, patients were identified and included in the study using International Classification of Diseases (ICD-9) and current procedural terminology (CPT) codes. Chi square analysis and Mann Whitney U test were used to identify pre-operative and intra-operative risk factors for post-operative UTI. Pre-operative and intra-operative variables found to have a p<0.1 in univariate analysis were included in a logistic regression model that was used to identify independent predictors of post-operative UTI. Chi square and Mann Whitney tests were also used to evaluate the association between UTI and post-operative outcomes.

 

Results: A total of 47,781 patients were included in this study. The overall rate of post-operative UTI was 3.7%. Independent predictors of UTI included female sex (OR 1.66, 95% CI 1.47-1.88), open procedure (OR 1.46, 95% CI 1.28-1.67), older age (p<0.001), non-independent functional status (OR 1.51, 95% CI 1.22-1.88), steroid use for a chronic condition (OR 1.54, CI 1.13-2.10), neoadjuvant radiotherapy (OR 1.31, 95% CI 1.09-1.59), higher anesthesia class (p<0.001), and longer total operation time (p<0.001). Patients who suffered post-operative UTI had an average hospital stay five days longer than those who did not contract a UTI (7 vs. 12 days, p<0.001). They also had significantly higher reoperation rates (11.9% vs 5.1%, p<0.001). Of patients with post-operative UTI, 3.3% had death with 30 days of surgery, compared to 1.7% of those without UTI after surgery (p<0.001). Post-operative UTI also correlated with other complications, including sepsis, surgical site infections, and pulmonary embolism (p<0.001 for all).

 

Conclusions: Post-operative UTI in patients undergoing surgery for colorectal malignancy correlates with longer hospital stay, higher reoperation rate, and increased 30-day mortality compared to patients without UTI. It also appears that patients who contract post-operative UTI may be at increased risk of developing multiple complications. This analysis demonstrates significant benefit to laparoscopic surgery for colorectal malignancy when controlling for other factors. In addition, it identifies several risk factors that may be targeted in prospective interventions aiming to reduce complications, specifically post-operative UTI, in this population. 

34.02 Indication and Risk for Pancreaticoduodenectomy in Patients Over 80: An ACS NSQIP Study

Posted on December 22, 2014

J. R. Bergquist1,2, C. R. Shubert1,2, D. S. Ubl2, C. A. Thiels1,2, M. L. Kendrick1, M. J. Truty1, E. B. Habermann2  1Mayo Clinic,General Surgery,Rochester, MN, USA 2Mayo Clinic,Center For The Science Of Health Care Delivery,Rochester, MN, USA

Introduction: Expected mortality after elective pancreaticoduodenectomy (PD) in contemporary series is less than 5% even in older patients (>80). The perioperative risk in these older patients has not been reported with consideration of the specific indication for PD. We hypothesized that 30-day mortality, major morbidity, and prolonged length of stay (PLOS) following PD varies by diagnosis risk group in patients over 80, and that those elderly patients with high risk diagnoses may have higher than expected peri-operative risk.

Methods: ACS-NSQIP was reviewed for all PDs from 2005-2012. ICD-9 diagnoses (indication for PD) were categorized into high and low diagnosis risk groups based on incidence of 30-day major morbidity. Univariate and multivariate analyses compared PD outcomes (1) by diagnosis risk among patients over 80 and (2) by age group (80+ vs 18-79 and vs 70-79) among patients in the same diagnosis risk group.

Results: Of 7192 total patients, pancreas cancer (N=4200) and chronic pancreatitis (N=608) experienced similar major morbidity (p=0.64) and were grouped as “low risk”. Bile duct and ampullary neoplasm (N=1503), duodenal neoplasm (N=686), and neuroendocrine tumor (N=195) experienced similar major morbidity (p=0.69) and were grouped as “high risk”. The 30 day mortality risk for patients aged 80+ (N=749) undergoing PD with high risk diagnosis was found to be 7.0% vs 4.1% for those with low risk diagnosis (p<0.001). Of patients with high-risk diagnoses, patients 80+ had greater mortality risk (7.0%) than those 70-79 (3.9%, p=0.037) or all patients aged 18-79 (2.9%, p<0.001). Risk of major morbidity and prolonged length of stay was also increased in patients 80 and older (see table). On multivariate analysis, controlling for diagnosis risk, patients over 80 had greater odds of 30 day mortality (OR 2.155, 95% CI 1.242-3.741, p=0.0063), any major complication (OR 1.658, 95% CI 1.312-2.095, p<0.001), and PLOS (OR 1.448, 95% CI 1.140-1.838, p=0.0024), and when compared with patients 18-79.

Conclusion: In patients over 80 undergoing PD, high-risk diagnoses are independently associated with increased 30-day mortality compared to those with low-risk diagnoses and younger age groups. Risk of 30-day mortality following PD in patients 80+ with high risk diagnoses exceeds the expected threshold of 5%; those with low risk diagnoses however do not. For 80+ patients with duodenal, neuroendocrine, or bile duct and ampullary neoplasm, pre-operative counseling and shared decision making should reflect the increased 30-day mortality risk for pancreaticoduodenectomy.

34.03 Observation of Minimally Invasive Surgery for Gastric Submucosal Tumor

Posted on December 22, 2014

Y. Shoji1, H. Takeuchi1, H. Kawakubo1, O. Goto2, R. Nakamura2, T. Takahashi2, N. Wada1, Y. Saikawa1, T. Omori1, N. Yahagi2, Y. Kitagawa1  1Keio University School Of Medicine,Department Of Surgery,Tokyo, TOKYO, Japan 2Keio University School Of Medicine,Tumor Center,Tokyo, TOKYO, Japan

Introduction:

Because gastric submucosal tumors including gastrointestinal stromal tumor  can be treated with local resection without lymph-node dissection, laparoscopic local resection (LAP) is widely used to manage relatively small tumors less than 5cm in diameter. To make the operation less invasive, new surgical strategies such as single incision laparoscopic surgery (SILS), laparoscopy endoscopy cooperative surgery (LECS) and non-exposed endoscopic wall-inversion surgery (NEWS) were developed.

Methods:

In this study, we made a comparative review of the patient’s characteristics, surgical outcome, postoperative courses of each procedure.

Results:

From January 2004 to June 2014, 130 patients with gastric submucosal tumor underwent surgical treatment in Department of Surgery, Keio University School of Medicine. Eighty-two patients received minimally invasive surgery mentioned above. Detail of the patients were LAP 53, SILS 11, LECS 11, NEWS 7 (other surgical procedure were as follows; open surgery 17, hand assisted laparoscopic surgery 6, laparoscopy assisted proximal gastrectomy 6, laparoscopy assisted distal gastrectomy 3, laparoscopy assisted pylorus preserving gastrectomy 2, endoscopic submucosal dissection 3, other laparoscopic surgery 7. 4 patients in LAP group were excluded because of combined resection of other organs).

There were no significant differences in patient characteristics such as age, sex, body mass index and the size nor the growth pattern of the tumor. LAP and SILS were not indicated to tumors of the esophagogastric junction (p<0.001).Mean operative duration of the LAP and SILS group was significantly shorter than the LECS and NEWS group (p<0.05). There were no differences in intraoperative blood loss among the groups.The mean value of C-reactive protein of the 1st postoperative day was significantly higher in the LECS group in comparison to other groups (p<0.05). There was no significant difference in postoperative hospitalization between the groups. There were totally 4 cases with postoperative complications (acute appendicitis, splenic vein thrombosis, stenosis, toxicodermatitis). Every patient recovered with conservative measures without sequelae. Other patients discharged with an uneventful recovery.

Conclusion:

LAP and SILS were not selected to treat the tumor of the esophagogastric junction in order to prevent the postoperative stricture of the cardia by its relatively wide extent of resection(p<0.001). On the 1st postoperative day, the value of CRP, as an indicator of inflammatory reaction was significantly higher in the LECS group (p<0.05). The reason is expected that LECS is the only surgical form in which the digestive fluid expose to the body cavity.

Operative procedure for gastric submucosal tumor must be chosen studiously by the patient’s characteristics and the tumor property. However, NEWS is suggested to be a widely applied, less invasive technique, which should be introduced positively.

34.04 Long-term Health-Related Quality of Life After Cancer Surgery: A Prospective Study

Posted on December 22, 2014

M. C. Mason1,2, G. M. Barden1,2, N. Massarweh1,2,3, S. Sansgiry1, A. Walder1, D. L. White1, D. L. Castillo1, A. Naik1, D. H. Berger1,2,3, D. A. Anaya1,2,3  1Michael E. DeBakey Veterans Affairs Medical Center,Houston VA Center For Innovations In Quality, Effectiveness, And Safety (IQUEST),Houston, TX, USA 2Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA 3Michael E. DeBakey Veterans Affairs Medical Center,Operative Care Line,Houston, TX, USA

Introduction: The Institute of Medicine recently emphasized the importance of patient-reported outcomes following cancer care, and their relevance for the growing geriatric population. There are limited data on the impact of cancer surgery on health-related quality of life (HRQoL) in elderly patients. The goal of our study was to examine trends over time and changes in HRQoL measures following cancer surgery, and to evaluate the effect of age and receipt of adjuvant therapy on these outcomes.

Methods:  A prospective cohort study of patients undergoing elective cancer surgery at a tertiary referral center was performed (2012-2014). Demographic, clinical, cancer, and treatment variables were recorded. Cancer-specific HRQoL was prospectively measured using the EORTC C-30 questionnaire (6 domains) at the preoperative visit and at 1-month and 6-months postoperatively. The primary outcome of interest was a clinically significant drop in HRQoL, defined using the validated cutoff of a ≥10 point drop in Global Health Score (GHS) preoperatively to 6-month postoperatively. Patients were categorized based on their age into Young (<65y) and Elderly (≥65y), and trends over time as well as changes in GHS scores were compared between both groups. Univariate and multivariate logistic regression analyses were used to examine the association between age ≥ 65 and the primary outcome (Model 1) adjusting for receipt of adjuvant therapy (Model 2) and other important cofounders (Model 3).

Results: A total of 236 patients were included; 177 (75%) had major surgery, 105 (44.5%) were elderly, and 73 (31%) received adjuvant therapy. Baseline mean GHS score (67.2 [± 24.6]) dropped at 1-month (61.0 [± 25.0]) and increased close to baseline at 6-months (64.2 [± 23.4]) for the whole cohort, with no differences in trends over time between age groups. In all, 74 patients (31.4%) experienced a clinically significant drop in GHS score. Age ≥65 years was not associated with a clinically significant drop in HRQoL after univariate (Model 1: OR 1.62 [95% CI 0.93-2.82], P=0.09), and multivariate analyses (Model 2: OR 1.62 [0.93-2.83], P=0.09; and Model 3: OR 1.67 [0.93-2.99]; P=0.08).

Conclusions: Cancer patients overall experience a drop in HRQoL shortly after surgery (1-month), with a return close to baseline by 6 months. However, a high proportion of patients do not regain their baseline HRQoL, with almost one-third having a clinically significant drop that persists at 6 months postoperatively. Clinically significant drops in HRQoL were not associated with age ≥65 years, even among patients who received adjuvant therapy. Surgical and multimodality treatment should not be withheld from elderly patients based on concerns regarding long-term HRQoL.

34.05 Efficacy of Post-Mastectomy Radiation Therapy in the Setting of T3 Node-Negative Breast Cancer

Posted on December 22, 2014

L. Elmore1, A. D. Deshpande1, J. A. Margenthaler1  1Washington University,Surgery,St. Louis, MO, USA

Introduction: In the absence of lymph node involvement, tumor size is arguably the most important prognostic factor for women with breast cancer.  Development of an optimal adjuvant treatment regimen for women with locally-advanced node-negative breast cancer is critical due to the risk of locoregional failure.  Radiation therapy has been shown to improve locoregional control in selected populations of women with breast cancer but its efficacy in T3 node-negative breast cancer is controversial.  We investigated patterns of post-mastectomy radiation therapy (PMRT) use and the survival impact of this treatment modality in women with T3 node-negative breast cancer.

Methods: A retrospective cohort study was conducted by identifying women with T3 node-negative breast cancer from the 1988-2009 Surveillance, Epidemiology and End Results (SEER) database.  Our primary outcome variable was breast cancer-specific mortality.  Several sociodemographic variables and tumor characteristics were obtained to evaluate patterns of use of adjuvant therapy.  Survival curves were generated using the Kaplan-Meier method.  Hazard ratios were computed using Cox proportional hazard analysis.  Propensity score analysis was used to evaluate the effect of radiation on overall and breast cancer-specific mortality.

Results:We identified 2874 patients with T3 node-negative breast cancer.  Within this cohort of women, 961 (33%) received PMRT and 1913 (67%) did not.  Statistically significant differences were seen in adjuvant radiation therapy use based upon patient age, marital status, tumor grade, tumor size and receptor status (p<0.05 for all).  Younger age at diagnosis, marriage, and grade 3 tumor pathology were associated with adjuvant therapy use. Tumor size >9cm was associated with decreased use of adjuvant radiation therapy.  Analysis of overall mortality demonstrated lower mortality in the PMRT group in unadjusted analysis (cHR 0.718; 95% CI 0.614,0.840); however, adjusted hazard ratios demonstrated no difference in overall mortality (aHR 0.898; 95% CI 0.765, 1.054).  Unadjusted analysis of breast-cancer specific mortality demonstrated no difference in those who received PMRT and those who did not (cHR 0.834; 95% CI 0.682,1.021).  After adjusting for potential confounders using a propensity score analysis, again no significant difference in breast-cancer specific mortality was observed based on PMRT use (aHR 0.939; 95% CI 0.762, 1.157).

Conclusion:Analysis of the SEER database demonstrated that several patient and tumor characteristics are associated with use of adjuvant radiation therapy.  Results of the current study indicate that receipt of PMRT does not affect breast-cancer specific or overall survival in women with T3 node-negative breast cancer.

 

34.06 The Effect of Surgical Approach on Oncologic Outcomes in Rectal Cancer Surgery

Posted on December 22, 2014

E. F. Midura2, D. J. Hanseman2, R. S. Hoehn2, B. R. Davis2, D. E. Abbott2, S. A. Shah2, I. M. Paquette2  2University Of Cincinnati,General Surgery,Cincinnati, OH, USA

Introduction:  The oncologic safety of minimally invasive surgery for colon cancer has been well established, however the role for a minimally invasive approach to rectal cancer has yet to be fully defined. Though current evidence to support the use of laparoscopic and robotic approaches is limited, these approaches are being adopted broadly into clinical practice. We sought to describe national practice patterns in different surgical approaches and operative outcomes for rectal cancer in the US. 

Methods:  The 2010 National Cancer Database (NCDB) was queried for surgical cases of rectal cancer. Surgical approach was classified as open, laparoscopic, or robotic. Patient, tumor, and hospital characteristics were examined for variation in approach. Oncologic efficacy was studied by examining whether harvest of ≥ 12 lymph nodes (controlling for radiation use) and negative surgical margins were achieved. We used propensity-score matching to compare laparoscopic or robotic surgery to open surgery, while controlling for case-mix differences. 

Results: We identified 9,253 patients, of which 68.6% had open, 26.4% laparoscopic, and 5.0% robotic surgery. Patients who underwent a minimally invasive approach were more likely to have private insurance, higher income, and be operated on in higher volume, urban hospitals. Patients who underwent open operations were more likely to have elevated CEA levels, higher histologic grade and more advanced pathologic stage. Patients who had robotic surgery were more likely to receive preoperative radiation compared to other approaches (p = 0.01). In unadjusted analysis, patients who had a minimally invasive approach had a lower incidence of positive resection margin, a shorter length of stay and a lower readmission rate compared to open surgery, however there were no differences in lymph nodes harvested or 30-day mortality (Table 1). After propensity score matching on age, gender, radiation use, tumor grade, and pathologic T and N stage, the laparoscopic approach was associated with a 2.6% decrease in the incidence of positive margin when compared to open surgery (p = 0.02), whereas the robotic approach was not associated with a difference in margin status when compared to open surgery. 

Conclusion: Minimally invasive approaches for rectal cancer resections are more commonly performed in high volume, urban, academic centers on privately insured patients. Patients with more advanced tumors are being resected by an open approach. Examination of a matched cohort of patients indicates that the laparoscopic approach may lead to improvements in resection margin status, though longer follow-up will be needed to determine whether this translates into better long-term survival.

 

34.07 Multimodality Therapy Improves Survival in Resected Early Stage (IB-II) Gastric Cancer

Posted on December 22, 2014

J. Datta1, M. T. McMillan1, L. Ruffolo1, R. Mamtani2, J. A. Drebin1, D. L. Fraker1, G. C. Karakousis1, R. Roses1  2University Of Pennsylvania,Medicine (Oncology),Philadelphia, PA, USA 1University Of Pennsylvania,Surgery,Philadelphia, PA, USA

Introduction:  Multimodality therapy (MT) is a recommended component of treatment for early stage gastric adenocarcinoma (ESGA). Compliance with these guidelines, and the impact of MT on survival in ESGA has not been extensively explored. We examined (1) temporal trends in sequencing of MT, (2) factors associated with MT use, and (3) effect of MT receipt on overall survival (OS) in resected ESGA.

Methods:  The National Cancer Data Base was queried for stage IB-II GA patients undergoing gastrectomy (1998-2011). Multivariate models were developed to identify factors associated with adjuvant chemoradiotherapy (ACRT) or perioperative chemotherapy (PC) receipt and to compare risk-adjusted OS by treatment group.

Results: Of 7,357 resected ESGA patients (median age 68 years, 69.1% male), 50.6%, 25.5%, and 23.9% received surgery only (SO), PC, and ACRT, respectively. Utilization of MT rose consistently between 1998 and 2011, increasing by 42.4% (p<0.001). While ACRT use increased only modestly (12.0%–23.5%, p=0.02), receipt of PC increased dramatically (8.0%–38.8%, p<0.001). Predictors of ACRT receipt were multifactorial, but most strongly associated with age<56 years (OR 3.31, 95% CI 2.62-4.17) and non-proximal tumor location (OR 2.78, 95% CI 2.42-3.19). Proximal tumor location (OR 3.79, 95% CI 3.26-4.41) and AJCC clinical stage IIB (OR 2.42, 95% CI 1.99-2.92) were the strongest predictors of PC use. Younger, white, higher-income, and less comorbid patients were also significantly more likely to receive PC (all p<0.01). Hospital-based selection of MT varied significantly by geographic region and academic affiliation (all p≤0.01). Survival analyses included 1,275 patients with a minimum follow-up of 5 years. Median, 1-yr, and 5-yr survival was 44.8 months, 75.0%, and 46.0% respectively. In this cohort, median survival was significantly longer for patients selected to receive MT (i.e. ACRT or PC) compared with those undergoing SO (47.1 vs. 43.3 months; p<0.001). R1 resection (HR 2.08, 95% CI 1.56-2.76), pathologic lymph node positivity (HR 1.91, 95% CI 1.65-2.22), and tumor T-classification 3/4 (HR 1.75, 95% CI 1.50-2.04) were strongly predictive of worse risk-adjusted OS. On stage-stratified Cox regression analysis, utilization of MT was independently associated with improved OS in both stage IB and II GA (IB: HR 0.65; p=0.002; II: HR 0.73; p=0.003).

Conclusion: Adoption of MT in ESGA is steadily increasing nationally, but remains incomplete. Patient-, tumor-, and hospital-related factors influence selection of MT sequence. In ESGA, MT receipt is independently associated with improved survival compared with undergoing SO.

 

34.08 Routine Somatostatin Analogue Use Decreases Pancreatic Fistulas After Whipple: A Meta-Analysis

Posted on December 22, 2014

K. Mahendraraj1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 3Saint George’s University,Department Of Surgery,Grenada, Grenada, Grenada

Introduction:
Pancreatic fistulas remain one of the most common and detrimental complications following the Whipple operation (pancreaticoduodenectomy). The prophylactic use of somatostatin analogues (SA) for the prevention of pancreatic fistulas is controversial. This meta-analysis aimed to assess the effectiveness of SA in preventing pancreatic fistulas among the conflicting data from published randomized controlled trials.

Methods:
A comprehensive search of  PUBMED, Embase and both the Cochrane and NIH Clinical Trial Registries was completed using the keywords ‘somatostatin’, ‘octreotide’, ‘fistula’, and ‘randomized controlled trial (RCT)’. Citations of relevant review articles were examined. Data on patient recruitment, intervention and outcome were extracted from the included trials and analyzed. 42 full-text articles were identified in this manner, and 22 of these were excluded for lack of randomization, inadequate blinding and incomplete outcome data. Only RCTs which were completed and had an endpoint of ‘pancreatic fistula’ were included. The risk ratio (RR) was calculated with 95% confidence intervals.

Results:
20 RCTs involving 2,596 patients who underwent pancreaticoduodenectomy were identified. 1,312 patients (50.5%) were randomized to receive SA while 1,284 patients (49.5%) received either a placebo or no intervention. The incidence of pancreatic fistula was 32% lower in the SA group (RR 0.68, 95% CI 0.54-0.86;p=0.001). The proportion of these fistulas that were clinically significant is not clear. On subgroup analysis, there was no significant difference in perioperative mortality between the two groups (RR 0.80, 95% CI 0.56-1.16; p=0.24), but there was a 30% lower incidence of overall complications in the SA group (RR 0.70, 95% CI 0.60-0.82; p=0.03). Significant heterogeneity was found among the identified trials with regard to the definition of fistula, dosage of octreotide, starting time and duration of treatment.

Conclusion:
The use of SA following pancreaticoduodenectomy significantly reduces both pancreatic fistula and overall complication rates, with no effect on perioperative mortality. Available data suggests a role for routine prophylactic SA use to improve patient outcomes following major pancreatic resection. Further clarification of the effects of these drugs is required through additional large, adequately powered randomized controlled trials with low risk of bias.

34.09 The Role of Intraoperative Pathologic Assessment in the Surgical Management of DCIS

Posted on December 22, 2014

M. R. Decker1, H. B. Neuman1, A. Trentham-Dietz3, N. K. LoConte4, M. A. Smith3, R. S. Punglia2, C. C. Greeberg1, L. G. Wilke1  1University Of Wisconsin Hospital & Clinics,Department Of Surgery,Madison, WI, USA 2Dana Farber Cancer Institute,Radiation Oncology,Boston, MA, USA 3University Of Wisconsin School Of Medicine & Public Health,Population Health Sciences,Madison, WI, USA 4University Of Wisconsin Hospital & Clinics,Carbone Cancer Center,Madison, WI, USA

Introduction: The elevated number of repeat operations for the treatment of ductal carcinoma in situ (DCIS) is costly for patients and the medical community, financially and psychologically.  Intraoperative pathologic assessment of DCIS may lead to reduction in these additional surgeries. This study examines the relationship between intraoperative pathologic assessment and subsequent operations after a diagnosis of DCIS.

Methods: SEER-Medicare patients diagnosed with DCIS from 1999 to 2007 who underwent lumpectomy without axillary surgery, as their initial surgical procedure, were eligible.  All subsequent breast surgical procedures were identified.  Use of intraoperative pathology (frozen section or touch preparation) during the initial surgery was assessed.  Multivariable logistic regression was used to describe the relationship between the use of intraoperative pathologic assessment and any subsequent mastectomy or lumpectomy within 90 days of the initial operation. 

Results: Of 8,259 DCIS patients who underwent lumpectomy without axillary surgery, 3,510(43%) underwent a subsequent mastectomy or lumpectomy. Claims for intraoperative pathologic assessment were present for 2,172 (26%) patients.  On univariate analysis, patients with intraoperative pathology during their initial surgery were more likely to have additional breast surgery than patients without intraoperative pathology (28% vs 25%, p=0.009). However, multivariable analysis demonstrated that intraoperative pathologic assessment had no statistically significant relationship with ocurrance of subsequent breast surgery (Adjusted OR 1.06 (95%CI: 0.93-1.19), p = 0.387). Only tumor size >2cm (AOR 2.28 (95%CI: 1.99 ­-2.60), p<0.001), poorly differentiated tumor grade (AOR 1.36 (95%CI: 1.13 -1.63), p<0.001 ), and patient residence in a rural area (AOR 1.20 (95%CI: 1.01 to 1.43), p=0.034) were associated with greater likelihood of subsequent surgery. 

Conclusion: The use of intraoperative pathologic assessment during lumpectomy from 1999-2007 was not associated with a reduction in subsequent breast operations in women with DCIS. Surgery in 2014 for DCIS has not changed from 2000, as there are no novel intraoperative tools that have been developed or standardization of margin assessment implemented.  These results highlight a need to identify cost-effective tools and strategies to facilitate surgical decision making and reduce the number of subsequent operations for women with intraductal disease.

34.10 Small Cell Gastric Carcinoma is a Lethal Diagnosis: A Clinical Outcomes Study from the SEER Database

Posted on December 22, 2014

B. L. Siracuse1,4, K. Mahendraraj1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada 4Duke University,Durham, NC, USA

Introduction:  Small cell gastric carcinoma (SCGC) is an aggressive neuroendocrine malignancy that comprises less than 0.1% of all gastric carcinomas. No large patient series exist and clinical information regarding SCGC is derived from limited case studies. This study sought to examine the demographic and clinical factors in a large cohort of SCGC patients in order to compare clinical outcomes of SCGC to the more common gastric adenocarcinoma (GA).

Methods:  Demographic and clinical data on 71,607 patients with gastric cancer was abstracted from the SEER database (1973-2010). 207 SCGC and 71,400 GA patients formed the study populations. Abstracted data was analyzed using Chi square tests, t-tests, and multivariate analysis. Kaplan-Meier analysis was used to compare long-term survival between the groups.

Results: SCGC comprised 0.3% of all gastric cancers identified. The mean age of SCGC and GA patients was similar (68±12 vs.70±13 years, p=0.03) and both cancers were more common in males (64.7% and 66.0%, p<0.001) and Caucasians (70.4% and 65.6%, p<0.001). SCGC was more often undifferentiated (66.9%vs.2.9%, p<0.001) and had more lymph node positivity (59.6% vs. 55.9%, p=0.01) and metastatic disease than GA (64.5% vs. 46.1%, p<0.001). SCGC had lower mean survival times than GA (1.00±1.78 vs. 2.02±3.91 years, p=0.03). Mean survival time for SCGC patients treated with radiation was inferior to GA, but SCGC patients benefited more from surgery than GA patients (2.20±0.61 vs. 1.23±0.04 years, p<0.001). Multivariate analysis identified tumor size greater than 2 cm (OR=2.1, CI=1.9-2.4), regional (OR=2.8, CI=2.6-3.0) or distant disease (OR=2.1, CI=1.9-2.4), lymph node positivity (OR=1.6, CI=1.4-1.8), undifferentiated grade (OR=1.3, CI=1.1-1.4), Caucasian race (OR=2.0, CI=1.8-2.2), and male gender (OR=1.2, CI=1.1-1.3) as independently associated with increased mortality for SCGC, p<0.001. A survival advantage for SCGC was seen in patients treated with surgery alone (OR=0.5, CI=0.4-0.6) or in combination with radiation (OR=0.23, CI=0.2-0.3), p<0.001.

Conclusion: SCGC is a rare and often lethal gastric malignancy that presents most often in Caucasian males in their seventh decade of life, with larger tumor size, more undifferentiated histology, greater lymph node positivity, and higher rates of metastatic disease than GA. The majority of SCGC was untreated presumably due to advanced disease, but when treatment was employed, surgical resection resulted in a greater survival advantage than similarly treated GA. The combination of surgery and radiation was associated with the longest survival compared to other treatment modalities for SCGC, and should therefore be considered in patients with operable disease.

35.01 Is Incisional Negative Pressure Wound Therapy Associated with Decreased Surgical Site Infections?

Posted on December 22, 2014

K. Chopra1, N. N. Semsarzadeh1, K. K. Tadisina1, J. Maddox1, D. P. Singh1  1University Of Maryland School Of Medicine,Division Of Plastic Surgery,Baltimore, MARYLAND, USA

Introduction:  Negative pressure therapy has been increasingly used to treat open wounds over the past two decades. More recently, studies have reported the use of negative pressure therapy over closed incisions to decrease surgical site occurrences including infection and dehiscence. To assess cumulative status of reported findings, we conducted a meta-analysis of the current literature to evaluate the effectiveness of incisional negative pressure wound therapy (iNPWT) in lowering the incidence of surgical site infections (SSIs) as compared to standard dressings. 

Methods:  PubMed, the Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched through August 2014 for publications comparing iNPWT to standard incisional care. A meta-analysis including 4631 participants from 14 published studies was performed. A fixed effects meta-analytical model was used to assess between-study heterogeneity and effect size, and funnel plots were used to assess publication bias.

Results: The overall rates of surgical site infection in the incisional negative pressure wound therapy group and control groups were 6.61% and 9.36%, respectively. Individual Odds Ratios or relative SSI likelihood rates by incision site location were 56% (p = 0.01) for the abdomen, 37% (p = 0.002) for the chest, 19% (p = 0.0001) for the groin, and 55% for the lower extremity (p = 0.022). The use of iNPWT was found to decrease SSI rate by 56% across all incision site regions considered together (p < 0.0001). However, a sensitivity analysis of heterogeneity (i.e., sub-group analysis) resulted in the three groin area studies being dropped and a final result that yielded an odds ratio of 0.504 (p = 0.0001), indicating a 50% reduction in SSI rate with iNPWT relative to standard care. Additionally, 9 of the 14 studies reported dehiscence rates among the two groups. Overall rates of dehiscence in the iNPWT and control groups were 5.32% and 10.68%, respectively. Heterogeniety was very high (I2 = 84%) and consequently data were not considered for further analysis. However, the effect size, Odds Ratio = 0.5 (CI 0.30 to 0.85), was significant, suggesting a correlation between iNPWT and lower dehiscence.

Conclusion: The results of the quantitative meta-analysis suggest that iNPWT is an effective method for reducing SSIs. It also appears that iNPWT may be associated with a decreased incidence of dehiscence although the evidence is still inconclusive. 

 

35.02 Fateful or Fruitful? ICP Monitoring in Elderly Patients with TBI is Associated with Worse Outcomes

Posted on December 22, 2014

Q. N. Dang2, J. Simon2, J. Catino1,3, I. Puente1,3, F. Habib1,3, L. Zucker1, M. Bukur1,3  1Delray Regional Medical Center,Trauma And Surgical Critical Care,Delray Beach, FL, USA 2Larkin Community Hospital,Surgery,South Miami, FL, USA 3Broward General Hospital,Trauma And Surgical Critical Care,Fort Lauderdale, FL, USA

Introduction:  In an expanding elderly population, Traumatic Brain Injury (TBI) remains a significant cause of death and disability. Guidelines for management of TBI, according to the Brain Trauma Foundation (BTF) include intracranial pressure (ICP) monitoring. Whether or not ICP monitoring contributes to outcomes in the elderly patients with TBI has not been explored. 

Methods:  This is a retrospective study extracted from the National Trauma Database 2007-2008 Research Datasets. Patients were included if age > 55 and they met BTF indications for ICP monitoring. Patients that had non-survivable injuries (any body AIS = 6), were dead on arrival, had withdrawal of care, or LOS < 48 hours were excluded. Outcomes were then stratified based upon ICP monitoring. The primary outcomes were in-hospital mortality as well as favorable discharge (to home or rehab facility). Logistic regression was used to analyze the effect of ICP monitoring on outcomes. 

Results: A total of 4437 patients were included with 11.1% having an ICP monitor placed. Patients requiring an ICP monitor were younger overall, more likely to present hypertensive, had higher injury severity, and more likely to require operative intervention. Median GCS (3) and Head AIS (4) were similar between groups. Of those patients with ICP monitoring, overall mortality was significantly higher (table) and they were less likely to have favorable discharge status. Craniotomy itself was not associated with increased mortality (p = 0.450)

Conclusion: Our findings suggest that the use of ICP monitoring according to BTF Guidelines in elderly TBI patients does not provide outcomes superior to treatment without monitoring. The ideal group to benefit from ICP monitor placement remains to be elucidated. 

 

35.03 Increased Age Predicts Failure to Rescue

Posted on December 22, 2014

G. Barmparas1, J. Murry1, M. Martin2, D. A. Wiegmann3, K. R. Catchpole1, B. L. Gewertz1, E. Ley1  1Cedars-Sinai Medical Center,Division Of Acute Care Surgery And Surgical Critical Care / Department Of Surgery,Los Angeles, CA, USA 2Madigan Army Medical Center,Department Of Surgery,Tacoma, WA, USA 3University Of Wisconsin,Madison College Of Engineering,Madison, WI, USA

Introduction:   Failure to rescue (FTR), defined as any death following the development of in-hospital complications, has become an important quality measure. The purpose of this investigation was to examine whether older patients are at higher risk of FTR following traumatic injuries.

Methods:   National Trauma Databank (NTDB) datasets 2007-2011 were queried. Patients ≥ 16 years admitted to centers reporting ≥ 80% of AIS and/or ≥ 20% of comorbidities, with ≥ 200 subjects in the NTDB and who had any reported complication were reviewed. Those who survived (non-FTR) were compared to those who did not (FTR) using a forward logistic regression model.

Results: Of 3,313,117 eligible patients, 218,986 (6.6%) met inclusion criteria and had at least one complication reported. Of these, 201,358 (91.2%) survived their complication (non-FTR) and 17,628 (8.8%) died (FTR). A forward logistic regression identified 22 variables as predictors of FTR. Of those, age 65 to 89 years was the strongest predictor (AOR [95% CI]: 6.58 [6.11, 7.08], p<0.001), followed by the need for mechanical ventilation (AOR [95% CI]: 2.99 [2.81, 3.17], p<0.001) and ICU admission (AOR [95% CI]: 2.61 [2.40, 2.84], p<0.001). Using age group 16 to 45 years as the reference group, the adjusted risk for FTR increased with increasing age in a stepwise fashion [AOR [95% CI]: 1.94 [1.80, 2.09] for age 46 to 65 years, 6.78 [6.19, 7.42] for age 66 to 89 years and 27.58 [21.81, 34.87] for age ≥ 90 years]. The adjusted risk of FTR also increased in a stepwise fashion with increasing number of complications, reaching AOR (95% CI) of 2.25 (2.07, 2.45), p<0.001 for ≥ 4 complications.

Conclusion: The risk of failure to rescue increases with age and number of complications.  Strategies which track this quality measure to encourage early recognition and treatment of complications in the elderly are necessary.

35.04 The Impact of Preexisting Opioid Use on Injury Mechanism, Type, and Outcome

Posted on December 22, 2014

W. Wilson1, S. O’Mara1,2, J. Opalek2, U. Pandya1,2  1Ohio University,Heritage College Of Osteopathic Medicine,Athens, OH, USA 2Grant Medical Center,Trauma Services,Columbus, OH, USA

Introduction: The prevalence of prescription narcotic use in the U.S. is on the rise. Opioid use and its impact on the management of trauma patients has yet to be thoroughly studied. The aim of this study is to determine the prevalence of pre-injury opioid use and its influence on specific outcomes amongst the trauma patient population.  

Methods: A retrospective review of all trauma patients presenting to a Level I Trauma Center was performed from January 1, 2010 to December 31, 2010.  Patients who died within 24 hours of presentation and those with incomplete medication data were excluded.  Electronic medical record review of history and physical documentation and urine drug screen records were used to determine pre-injury opioid status.  Pre-existing narcotic use, demographic data, injury mechanism and severity, injury type, and outcome variables were analyzed.

Results:A total of 3953 patients met inclusion criteria.  Among our sample, 644 (16.3%) were positive for pre-injury opioid use. Patients in the pre-injury opioid group were older (48 years vs. 41 years) and more likely to be female (37.9% vs. 30.6%).  The mechanism of injury was more often falls (32.8% vs. 22.0%).  Patients on narcotics were more likely to be admitted (82.6% vs. 77.4 %) despite having overall lower injury severity.  Analysis of less severely injured patients (ISS < 15) found a significantly increased length of stay (3.7 days vs. 2.9 days) in the narcotics group.  Evaluation of injury type revealed that head injury, abdominal injury and lower extremity/pelvic injuries were predictive of increased length of stay in these patients. 

Conclusion:There is a considerable prevalence of pre-injury opioid use in the trauma population.  These patients have unique characteristics and causes of injury.   Pre injury opioid use is predictive of increased hospital admission rate and increased length of stay, with important ramifications for patient care and health care costs.
 

35.05 A Restrictive Transfusion Strategy is Safe in Patients with Isolated Traumatic Brain Injury

Posted on December 22, 2014

A. Nguyen2, D. Plurad1, A. Kaji3, S. Bricker1, A. Neville1, F. Bongard1, B. Putnam1, D. Kim1  1Harbor-UCLA Medical Center,Division Of Trauma/Acute Care Surgery/Surgical Critical Care,Torrance, CA, USA 2Harbor-UCLA Medical Center,Department Of Surgery,Torrance, CA, USA 3Harbor-UCLA Medical Center,Department Of Emergency Medicine,Torrance, C, USA

Introduction: The optimal transfusion threshold for patients with traumatic brain injury (TBI) is not well defined. The purpose of this study was to examine the impact of a liberal versus restrictive transfusion strategy (RTS) on outcomes in patients with TBI. We hypothesized that a RTS is not associated with mortality in TBI patients.

Methods: We performed a retrospective cohort analysis of adult patients with TBI over a 40-month period. Patients with an Abbreviated Injury Scale (AIS) ≥3 in 2 or more regions outside of the head and those patients who did not undergo transfusion were excluded. Liberal transfusion strategy (LTS) patients received packed red blood cells for a hemoglobin ≤10 mg/dL whereas as RTS patients were not transfused until their Hb was ≤7 mg/dL. Multivariate logistic regression analysis was performed to identify independent predictors of mortality.

Results: Of 103 patients, 61 patients (59%) underwent a LTS and 42 patients (41%) underwent a RTS. Both groups were similar in age, gender, injury severity, and head AIS scores. There was no difference in the number of patients with severe TBI between the RTS and LTS groups (50% vs. 46%, p=0.7). On unadjusted analysis, there was no difference in mortality (31% vs. 38%, p=0.5) or complications (20% vs. 18%, p=0.8) between groups. On multivariate logistic regression analysis, age (OR=1.03; 95%CI=1.00-1.05, p=0.02), head AIS (OR=2.4; 95%CI=1.2-5.1, p=0.02), and subarachnoid hemorrhage (OR=3.6; 95%CI=1.3-10.3, p=0.02) were the only independent predictors of mortality.

Conclusion: A restrictive transfusion strategy may be safe in patients following isolated TBI. Prospective multicenter studies are required before any definitive recommendations regarding a restrictive transfusion strategy can be set forth.

 

35.06 Outcomes of Supracondylar/Intercondylar Humerus Fractures in Adults

Posted on December 22, 2014

W. K. Roache1, A. Harris2  1Howard University College Of Medicine,Washington, DC, USA 2University Of Florida,Jacksonville,Gainesville, FL, USA

Introduction:
Distal humerus fractures in adults are rare (0.5-2% of all fractures) and are approximately 30% of all humeral fractures. Supracondylar/intercondylar fractures are even less common, having only a 0.31% incidence. These injuries often occur from high-energy trauma, particularly in the young adult, and often present as open fractures with complex fracture patterns. These fractures in adults can be debilitating and difficult injuries to treat and frequently require operative management to create a stable platform to allow for early range of motion (ROM).

Methods:
A retrospective analysis was completed on a consecutive series of skeletally mature adults treated at a Level I Trauma Center with a radiologically visible supracondylar/intercondylar humerus fracture during the period from Feb. 2006 to May 2013. Exclusion criteria were patients with still maturing epiphyseal plates, supracondylar humerus fractures that were not inter-articular, and patients treated non-operatively. Postoperative data such as date of union, status of infection, range of motion (ROM), further complications, subsequent surgeries, status of physical therapy or occupational therapy (PT/OT), and comorbidities was gathered from postoperative and clinic visit notes. Postoperative elbow ROM was measured by tracking the arc of the forearm from full extension to flexion.

Results:
High-energy mechanisms accounted for injuries in 81% of the cases treated. Using the AO/OTA classification, 42% had a C2 and 39% had a C3 fracture pattern, with 53% of the cases being open fractures and 50% of the cases being polytrauma. Operative management, however, is not without risks. Complications were seen in 57% of the cases, with the major issues being elbow stiffness (54% of all complications) and infection (17%), often related to a compromised soft tissue envelope. In cases of infection, all were associated with open fractures. In cases of post union stiff elbow, 54% were associated with an open fracture, while only 41% of functional elbow cases involved open fractures. However, all cases of frozen elbow involved open fractures. Mean time from injury to operative fixation was 28.8 hours sooner in cases resulting in functional elbows than stiff elbows. Of the patients who regained full ROM, 91% started aggressive PT/OT immediately after surgery.

Conclusion:
The combination of soft tissue damage and comminution may lead to arthrofibrosis and the formation of heterotopic bone. It appears clear however that the ability to regain functional range of motion or better is associated with early operative intervention and more importantly, immediate participation in therapy driven modalities. Aggressive physical/occupational therapy was extremely important in restoring ROM, while nearly all patients who achieved full ROM performed immediate therapy postoperatively. Secondary interventions (manipulation; HO excision) appear to prove beneficial in restoring functional motion if stiffness does occur.

32.04 Prognostic Relevance of Lymph Node Ratio and Total Lymph Node Count for Small Bowel Adenocarcinoma

Posted on December 22, 2014

T. Tran1, M. Dua1, G. Poultsides1, J. Norton1, B. Visser1  1Stanford University School Of Medicine,Surgery,Stanford, CA, USA

Introduction:  Nodal metastasis is a known prognostic factor for small bowel adenocarcinoma (SBA). Like many gastrointestinal malignancies, inadequate lymph node evaluation may adversely influence survival and lead to understaging. The objective of this study is to evaluate the number of lymph node (LN) that should be retrieved and the impact of lymph node ratio (LNR) on survival.   

Methods:  The Surveillance, Epidemiology, and End Results database was queried to identify patients diagnosed with SBA and treated with curative surgical resection from 1988 to 2010. Patients who did not undergo lymphadenectomy (Nx) or had distant metastases (M1) were excluded from our analysis. The greatest survival difference for duodenal and jejunoileal tumors was determined using cut-point analysis and maximum log-rank test χ2 statistic. Survival was estimated using Kaplan-Meier method and compared using log-rank test. Multivariate cox proportional hazard model was utilized to identify independent predictors of survival. 

Results: A total of 2773 patients underwent surgical resection with lymphadenectomy for SBA from 1988 to 2010. Duodenal and jejunoileal adenocarcinomas each consisted of 50% of all small intestine tumors (n=1387 and n=1386, respectively). There were 1371 patients (49.4%) with negative nodal metastases (N0), whereas 928 (33.5%) and 474 patients (17.1%) had N1 and N2 metastases, respectively. Median LN examined for duodenal and jejunoileal adenocarcinomas were 9 and 8, respectively. Cut-point analysis demonstrated that harvesting at least 9 for jejunoileal and 5 for duodenal tumors resulted in the greatest survival difference. However, there was a significant survival difference for each additional LN examined up to 11 for duodenal and 20 for jejunoileal tumors. Increasing LNR was associated with decreased overall median survival (LNR=0, 71 months; LNR 0-0.2, 35 months; LNR 0.21-0.4, 25 months, and LNR > 0.4, 16 months; p<0.001).  This inverse pattern of survival in relation to LNR was observed in the entire cohort (see figure, p<0.001) and each subsite. Multivariate analysis revealed extent of lymph node retrieval, T-stage, and lymph node positivity were independent predictors of survival.  

Conclusion: LNR has a profound impact on survival in SBA. In order to achieve adequate staging, we recommend retrieving a minimum of 5 and 9 LN for duodenal and jejunoileal tumors.   

 

32.05 Wider Sentinel Lymph Node Diameter Is A Predictor Of Positivity For Cutaneous Melanoma

Posted on December 22, 2014

J. S. Merkow1, A. Paniccia1, E. Jones1, T. Jones1, M. Hodges1, J. Byers1, K. Lewis1, R. Gonzales1, W. Robinson1, N. Kounalakis1, R. Stovall1, C. Gajdos1, N. Pearlman1, M. McCarter1  1University Of Colorado Denver,Aurora, CO, USA

Introduction: The prognostic implication of a positive SLN is powerful. There are multiple studies that have identified factors such as Breslow thickness, presence of ulceration, regression, and age as predictors of a positive SLN.  However, there are no studies to date that have specifically looked at the size of a SLN and its relationship to positivity.  THE PURPOSE of this study was to determine if lymph node size was indeed associated with a positive SLN.

Methods: Retrospective review of an institutional prospectively maintained database of patients undergoing SLNB for cutaneous melanoma between February 1995 to January 2013. The diameters of the largest sentinel lymph nodes were measured at the time of histopathologic analysis and the widest of the three diameters (length, width, or height) was used for the analysis. A nodal diameter of 1.5 cm, included in two interquartile ranges of maximal nodal size in both positive and negative SLN, was used as the cut off value for a multivariate logistic regression model.

Results: A thousand and seventeen patients underwent SLN biopsy. Of these, 826 (81%) had complete information on SLN measurements and were included in the final analysis. Negative SLN biopsy was obtained in 677 patients (82%) vs. 149 (18%) with positive SLN biopsy. Patients with positive SLN biopsy were younger with median age of 50 years (38-59) vs. 53 years (43-61, p=0.032) and had a deeper primary lesion of 2 mm (1.3-3.2) vs. 1.4 mm (1-2.2, p<0.001). Gender and other tumor characteristics including ulceration, mitosis, regression, lymphovascular invasion, type of melanoma, and location were not statistically different between the two groups. The largest SLN diameter was 1.9 cm (1.5-2.2) in the positive SLN group and 1.6 cm (1.2-2.2) in the negative SLN group (1.2-2.2, p=0.030). A SLN with a diameter wider than 1.5 cm was found to have an 87% increased odds of being positive for nodal metastasis after adjusting for age, sex, and depth of primary lesion (p=0.005).

Conclusion: A sentinel lymph node biopsy is considered the standard of care for melanoma. Here we demonstrated that a wider sentinel lymph node size is associated with significant increased odds for a positive biopsy result that is independent from the depth of primary lesion. Sentinel lymph nodes wider than 1.5 cm are more likely to be positive than not.

 

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