Ciliated Hepatic Foregut Cyst: Definitive Diagnosis Is Critical to the Optimal Treatment Pathway.

Background. Ciliated hepatic foregut cyst (CHFC) is a rare, benign cyst of the liver, derived from the embryonic foregut epithelium. Although CHFCs are typically asymptomatic, some present with nonspecific abdominal symptoms. Imaging modalities alone are insufficient for diagnosis, with intrahepatic cholangiocarcinoma included in the differential due to nonspecific imaging features; definitive diagnosis relies on histologic confirmation. These lesions are often benign; however, larger lesions can have malignant transformation into squamous cell carcinoma (SCC), which carries a poor prognosis, thus making a definitive diagnosis, no matter what size, essential. Here, we present a case of CHFC as well as a comprehensive literature review. Given these data, we propose an algorithm for definitive diagnosis.

Therapeutic Value of Sentinel Lymph Node Biopsy in Patients With Melanoma: A Randomized Clinical Trial.

Importance: Sentinel lymph node (SLN) biopsy is a standard staging procedure for cutaneous melanoma. Regional disease control is a clinically important therapeutic goal of surgical intervention, including nodal surgery. Objective: To determine how frequently SLN biopsy without completion lymph node dissection (CLND) results in long-term regional nodal disease control in patients with SLN metastases. Design, Setting, and Participants: The second Multicenter Selective Lymphadenectomy Trial (MSLT-II), a prospective multicenter randomized clinical trial, randomized participants with SLN metastases to either CLND or nodal observation. The current analysis examines observation patients with regard to regional nodal recurrence. Trial patients were aged 18 to 75 years with melanoma metastatic to SLN(s). Data were collected from December 2004 to April 2019, and data were analyzed from July 2020 to January 2022. Interventions: Nodal observation with ultrasonography rather than CLND. Main Outcomes and Measures: In-basin nodal recurrence. Results: Of 823 included patients, 479 (58.2%) were male, and the mean (SD) age was 52.8 (13.8) years. Among 855 observed basins, at 10 years, 80.2% (actuarial; 95% CI, 77-83) of basins were free of nodal recurrence. By univariable analysis, freedom from regional nodal recurrence was associated with age younger than 50 years (hazard ratio [HR], 0.49; 95% CI, 0.34-0.70; P < .001), nonulcerated melanoma (HR, 0.36; 95% CI, 0.36-0.49; P < .001), thinner primary melanoma (less than 1.5 mm; HR, 0.46; 95% CI, 0.27-0.78; P = .004), axillary basin (HR, 0.61; 95% CI, 0.44-0.86; P = .005), fewer positive SLNs (1 vs 3 or more; HR, 0.32; 95% CI, 0.14-0.75; P = .008), and SLN tumor burden (measured by diameter less than 1 mm [HR, 0.39; 95% CI, 0.26-0.60; P = .001] or less than 5% area [HR, 0.36; 95% CI, 0.24-0.54; P < .001]). By multivariable analysis, younger age (HR, 0.57; 95% CI, 0.39-0.84; P = .004), thinner primary melanoma (HR, 0.40; 95% CI, 0.22-0.70; P = .002), axillary basin (HR, 0.55; 95% CI, 0.31-0.96; P = .03), SLN metastasis diameter less than 1 mm (HR, 0.52; 95% CI, 0.33-0.81; P = .007), and area less than 5% (HR, 0.58; 95% CI, 0.38-0.88; P = .01) were associated with basin control. When looking at the identified risk factors of age (50 years or older), ulceration, Breslow thickness greater than 3.5 mm, nonaxillary basin, and tumor burden of maximum diameter of 1 mm or greater and/or metastasis area of 5% or greater and excluding missing value cases, basin disease-free rates at 5 years were 96% (95% CI, 88-100) for patients with 0 risk factors, 89% (95% CI, 82-96) for 1 risk factor, 86% (95% CI, 80-93) for 2 risk factors, 80% (95% CI, 71-89) for 3 risk factors, 61% (95% CI, 48-74) for 4 risk factors, and 54% (95% CI, 36-72) for 5 or 6 risk factors. Conclusions and Relevance: This randomized clinical trial was the largest prospective evaluation of long-term regional basin control in patients with melanoma who had nodal observation after removal of a positive SLN. SLN biopsy without CLND cleared disease in the affected nodal basin in most patients, even those with multiple risk factors for in-basin recurrence. In addition to its well-validated value in staging, SLN biopsy may also be regarded as therapeutic in some patients. Trial Registration: ClinicalTrials.gov Identifier: NCT00297895.

Hepatic lobe torsion: A rare disease necessitating surgical management.

BACKGROUND: Accessory liver lobes and other congenital liver abnormalities are rare and most often asymptomatic. However, these abnormalities can result in liver torsion, requiring surgical resection. CASE REPORT: We report a case of a 72-year-old woman with hepatic lobe torsion. She presented with an acute onset of chest pain and was discovered to have hypoperfusion of the left lobe of the liver on contrast-enhanced abdominal computed tomography (CT) scan. An exploratory laparotomy revealed left hepatic lobe torsion with irreversible ischemic changes requiring left hepatic lobe resection. CONCLUSION: Even though hepatic torsion is rare, it should be considered in the differential diagnosis for abdominal pain and appropriately imaged so that surgical teams can prepare for the complex surgical procedure.

GIST identified during bariatric surgery: to treat or not to treat?

BACKGROUND: Gastrointestinal stromal tumors (GIST) are rare GI tumors that compose 1% of GI tumors. With the rise in obesity, bariatric surgery is becoming an increasingly common procedure and the incidental GISTs in this population have been noted more often than in the general population. OBJECTIVE: We evaluated and characterized the incidental GISTs in our bariatric surgical population. SETTING: The study was completed at a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited academic hospital system. METHODS: All GISTs identified during Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy between January 1, 2005 and December 31, 2016 were evaluated. Typical demographic, clinicopathologic, treatment, follow-up, and outcome data were recorded. RESULTS: Within the 2655 bariatric surgeries at our institution, 17 GISTs were identified (.64%). Mean age was 54 years; 94% of lesions were identified intraoperatively. Lesions were identified in the fundus (29.4%) or body (70.6%), were unifocal, and <1 cm; 94.1% of resections had clear margins. Histology revealed 88.2% spindle cell and 11.8% mixed histology with <5 mitoses/50 fields, portending a low malignancy potential. Follow-up included the bariatric surgeon and oncology consult; 17.6% were recommended by oncology for computed tomography surveillance. No recurrences were recorded. CONCLUSION: We present the largest cohort to date of incidental GISTs in a bariatric population. A diligent intraoperative examination of the serosa in the left-behind portion of the remnant in bypass and the discarded remnant in sleeves allows the bariatric surgeon the opportunity to leave the patient cancer-free after removal of incidental tumor.

Head and neck cancer PEG site metastases: Association with PEG placement method.

BACKGROUND: Many patients with head and neck cancer (HNC) will require feeding tube placement for nutritional support using percutaneous endoscopic gastrostomy (PEG) tube. Rarely, HNC metastases have been reported at the PEG site, a morbidity associated with a poor outcome. METHODS: Along with a case report, an evaluation of PEG placement methods with metastases from the literature was completed along with a statistical analysis of the literature to determine PEG site metastases and method of placement correlations. RESULTS: The incidence of PEG metastases in patients with HNC with the "pull" method is statistically identical to that of patients receiving any other method for PEG placement. CONCLUSIONS: When considering options for the placement of PEG tubes in patients with HNC, the "pull" method should not be considered as a technique which will put patients at risk for PEG site metastases more than any other method of placement.

Predictive genetic profiles for regional lymph node metastasis in primary cutaneous melanoma: a case-matched pilot study.

Melanoma confers an estimated lifetime risk of one in 50 for 2016. Clinicopathologic staging and sentinel lymph node biopsy (SLNB) have been the standard of care for T2 and T3 lesions. Molecular biomarkers identified in the primary lesion suggestive of metastatic potential may offer a more conclusive prognosis of these lesions. Our purpose was to investigate molecular mutations in primary melanoma that were predictive for micrometastasis as defined by a positive sentinel lymph node (SLN) in a case-controlled manner: nine patients with negative SLN and nine with positive SLN. The two cohorts were statistically identical as shown by a t-test for age (P=0.17), race (P=0.18), Breslow depth (P=0.14), Clark level (P=0.33), host response (P=0.17), ulceration (P=0.50), satellite nodules (P=0.17), lymphovascular invasion (P=0.50), and mitotic activity (P=0.09). While no single gene was significantly associated with SLN status, multivariate analysis using classification and regression tree assessment revealed two unique gene profiles that completely represented regional metastases in our cohort as defined by a positive SLN: PIK3CA (+) NRAS (-) and PIK3CA (-) ERBB4 (-) TP53 (+) SMAD4 (-). These profiles were identified in 89% of the patients with positive SLN; none of these profiles were identified in the SLN-negative cohort. We identified two unique gene profiles associated with positive SLN that do not overlap other studies and highlight the genetic complexity that portends the metastatic phenotype in cutaneous melanoma.

Completion Dissection or Observation for Sentinel-Node Metastasis in Melanoma.

BACKGROUND: Sentinel-lymph-node biopsy is associated with increased melanoma-specific survival (i.e., survival until death from melanoma) among patients with node-positive intermediate-thickness melanomas (1.2 to 3.5 mm). The value of completion lymph-node dissection for patients with sentinel-node metastases is not clear. METHODS: In an international trial, we randomly assigned patients with sentinel-node metastases detected by means of standard pathological assessment or a multimarker molecular assay to immediate completion lymph-node dissection (dissection group) or nodal observation with ultrasonography (observation group). The primary end point was melanoma-specific survival. Secondary end points included disease-free survival and the cumulative rate of nonsentinel-node metastasis. RESULTS: Immediate completion lymph-node dissection was not associated with increased melanoma-specific survival among 1934 patients with data that could be evaluated in an intention-to-treat analysis or among 1755 patients in the per-protocol analysis. In the per-protocol analysis, the mean (±SE) 3-year rate of melanoma-specific survival was similar in the dissection group and the observation group (86±1.3% and 86±1.2%, respectively; P=0.42 by the log-rank test) at a median follow-up of 43 months. The rate of disease-free survival was slightly higher in the dissection group than in the observation group (68±1.7% and 63±1.7%, respectively; P=0.05 by the log-rank test) at 3 years, based on an increased rate of disease control in the regional nodes at 3 years (92±1.0% vs. 77±1.5%; P<0.001 by the log-rank test); these results must be interpreted with caution. Nonsentinel-node metastases, identified in 11.5% of the patients in the dissection group, were a strong, independent prognostic factor for recurrence (hazard ratio, 1.78; P=0.005). Lymphedema was observed in 24.1% of the patients in the dissection group and in 6.3% of those in the observation group. CONCLUSIONS: Immediate completion lymph-node dissection increased the rate of regional disease control and provided prognostic information but did not increase melanoma-specific survival among patients with melanoma and sentinel-node metastases. (Funded by the National Cancer Institute and others; MSLT-II ClinicalTrials.gov number, NCT00297895 .).

Management of periampullary adenocarcinoma by pancreaticoduodenectomy at a regional teaching hospital.

BACKGROUND: Periampullary adenocarcinoma (PA) includes: pancreatic, duodenal and ampullary adenocarcinoma; and cholangiocarcinoma. Pancreaticoduodenectomy (PD) is required for cure of PA. Previous studies demonstrated the likelihood of cure increases when a microscopically negative (R0) margin is achieved. Clearance of the superior mesenteric artery (SMA) margin has been identified as the most critical margin in PD. Some authors have emphasized the importance of certain techniques to clear the SMA margin. Neither the degree to which these techniques have been incorporated nor their impact on margin status and survival has been described. We hypothesized that use of techniques focusing on clearing the SMA margin would result in higher R0 resection rates and improved survival after PD in patients with PA. METHODS: A retrospective study was performed on patients from 1/1/1985 until 7/31/2007. Data on patient demographics, clinical presentation, preoperative treatment, operative technique, margins, and postoperative outcomes were collected. Ninety-three patients were identified for inclusion in the study. Three approximately equal groups were created for analysis. RESULTS: The overall survival (OS) for the entire cohort was 19 months and was not different among the groups studied. Margins were microscopically negative in 81% of cases. The percentage of node-positive cases increased during the time period, as did the number of lymph nodes (LNs) examined (P=0.017). The use of pylorus-preserving PD decreased (P=0.001) while resection of the superior mesenteric/portal vein (SMV/PV) increased during the study period. We observed an increase in descriptions of the clearance of the anterior aspect of the aorta and inferior vena cava (IVC), dissection to the right side of the SMA, dissection to the origin of the SMA and intra-operative identification of the SMA margin. Dissecting to the SMA did not change the likelihood of achieving an R0 margin. OS was improved after R0 resections (R0: 21 months vs. R1/2: 10 months) but this difference was not statistically significant (P=0.099). There was no association between margin status and OS. Changes in the pathology reporting of margins were observed, with statistically significant increases in the percentage of cases in which the SMA, common bile duct and pancreatic neck margins were separately reported. However, the SMA margin was separately reported in only 26% of pathology reports. CONCLUSIONS: The operative techniques used in PD at this institution have changed over time. The increasing frequency of dissection to the SMA and identification of the SMA margin by both surgeon and pathologist suggest an increased attention to the SMA margin. This shift did not result in significant improvements in survival or margin status, but it is consistent with the recognition of the importance of the SMA margin. Our analysis has also identified areas of potential improvement in the ways in which operative and pathology reports for PD are generated.

Videoscopic inguinal lymphadenectomy in malignant melanoma: safe in pregnancy?

Lymphadenectomy is the standard of care for metastatic melanoma in the inguinal lymph node basin. Historically, open surgery was the only treatment option. However, in recent years, videoscopic inguinal lymphadenectomy (VIL) has become a popular approach as it offers a minimally invasive alternative, provides similar oncologic control and reduces wound complications. Even though the VIL approach is being used more frequently, the patient populations that stand to benefit the most from this approach are still under investigation. Despite continued advances in safety for laparoscopic surgery, many surgeons are hesitant to perform these procedures on pregnant women. In this report, we present a successful VIL in a pregnant patient, describe our technique and demonstrate the safety of performing VIL in expectant mothers. To our knowledge, this case represents the first VIL performed in an expectant mother.

What is the risk of diagnostic endoscopic retrograde cholangiopancreatography before cholecystectomy?

Many surgeons prefer to perform endoscopic retrograde cholangiopancreatography (ERCP) before cholecystectomy, specifically in patients at significant risk of having biliary pathology. However, a preoperative diagnostic ERCP, without the use of an endoscopic ultrasound or magnetic retrograde cholangiopancreatoscopy, remains controversial. This is the result of the risk of either performing an unnecessary procedure and/or the development of post-ERCP pancreatitis (PEP). We performed a retrospective review of all surgeon-performed ERCPs at our institution between July 2011 and May 2013. This was done to examine patients who had pericholecystectomy ERCP. We had 550 ERCPs performed at our institution during this time period, 169 of which were pericholecystectomy procedures. We divided the 169 patients who had a diagnostic procedure (Diagnostic group) from those who had known biliary pathology before intervention (Therapeutic group). As a result, 34 patients (20.1%) were placed in the Diagnostic group and 135 patients (79.9%) in the Therapeutic group. Of the 34 Diagnostic patients, four (11.8%) developed PEP. Fifteen (44.1%) had unnecessary procedures, two of which had PEP (2.9%). Of the 135 ERCPs in the Therapeutic group, 18 patients (13.4%) developed PEP. Five of the 11 who had unnecessary procedures developed PEP. Based on the low incidence of complications, diagnostic ERCP has an acceptable rate of pancreatitis and/or unnecessary procedures when performed in highly selected patients and before cholecystectomy when compared with patients undergoing therapeutic ERCP. However, more aggressive use of diagnostic imaging before ERCP should be adopted given the number of unnecessary procedures performed.

Differential lymph node retrieval in rectal cancer: associated factors and effect on survival.

BACKGROUND: Recent publications have identified positive associations between numbers of lymph nodes pathologically examined and five-year overall survival (5-yr OS) in colon cancer. However, focused examinations of relationships between survival of rectal cancer and lymph node counts are less common. We conducted a single institution, retrospective review of rectal cancer resections to determine whether lymph node counts correlated with 5-yr OS and to explore the relationship between lymph node counts and various clinical and pathologic factors. METHODS: A retrospective review of our institutional tumor registry identified 159 patients with AJCC Stage 1, 2, or 3 rectal cancers that underwent surgical resection at our institution over eleven years. Univariate analysis was used to explore the relationship between lymph node counts and age, AJCC Stage, time period of diagnosis, preoperative radiotherapy, and performance of TME. Survival analysis was performed by the Kaplan-Meier method and the Cox proportional hazards model. RESULTS: In univariate analysis, there was an association between increased lymph node counts and age <70, higher stage, and diagnosis during the later portion of the study period [all P-values <0.05]. Lymph node counts were not associated with survival in Kaplan-Meier analysis or in multivariate Cox proportional hazards analysis. CONCLUSIONS: Increasing lymph node counts improve survival and the accuracy of colorectal cancer staging. The body of literature recommends identical minimum lymph node counts in both colon and rectal cancer. In our study, which exclusively examined rectal cancer, we could not demonstrate that increased lymph node counts were associated with improved survival.

Neuroendocrine tumors of the rectum: a 10-year review of management.

Neuroendocrine tumors of the rectum constitute approximately 19 per cent of gastrointestinal neuroendocrine tumors (NETs). The histologic characteristics of the tumor seem to be an indicative prognostic factor. Optimal treatment of NETS of the rectum has been widely debated, but more recent studies suggest that treatment depends upon the size. The medical records of 37 patients with NETS of the rectum were retrospectively reviewed. We reviewed their presentation, surgical treatment, pathology, and outcome. All pathological specimens were reviewed. Neuroendocrine tumors of the rectum were classified as either well-differentiated tumors, well-differentiated neuroendocrine carcinoma, or poorly differentiated neuroendocrine carcinoma. Evaluating tumor size, we found 35/37 patients had tumors less than 1 cm, 1 patient had a tumor between 1 and 2 cm, and one had a tumor greater than 2 cm. Pathologic evaluation of the tumors revealed that 35 of the tumors invaded the submucosa only, one invaded the muscularis propria, and one invaded the perirectal adipose tissue. The histopathologic features of the tumors revealed that 34 of the tumors were well-differentiated NETS with benign features, one tumor had invaded the submucosa, with angioinvasion, and two tumors were neuroendocrine carcinoma. Thirty-five patients underwent local excision. Eleven had reexcisions for positive margins. Two patients had local excision for recurrence, and one patient underwent low anterior resection (4 cm). Twelve patients had negative margins, 25 had positive margins. Eleven patients underwent reexcision. Six had no evidence of residual disease, and five had persistent positive margins and were offered no further treatment. Nineteen patients had positive margins and did not have reexcision. They all had tumors < 1 cm. Despite half of the lesions being resected with final pathologic positive margins, we have seen no significant influence on recurrence or overall survival. This raises the question of margin clearance in early lesions.

Histology, not lymph node involvement, predicts long-term survival in bronchopulmonary carcinoids.

Recently, the incidence of bronchopulmonary carcinoid has increased substantially, whereas survival associated with both subtypes has declined. We reviewed our experience with bronchopulmonary carcinoid to identify factors associated with long-term survival. We reviewed our cancer registry from 1985 to 2009 for all patients undergoing surgical resection for bronchopulmonary carcinoid. Cox regression analysis was used to evaluate prognostic factors. Fifty-two patients met criteria for inclusion. Forty-three patients (82%) presented with typical histology. The likelihood of lymph node metastasis was similar for patients with typical histology and patients with atypical histology. For patients with typical histology, the 5-year survival rates with and without lymph node metastases were 100 per cent and 97 per cent, respectively (P = 0.420). The overall survival rate for patients with typical histology (97% at 5 years; 72% at 10 years) was significantly better than for patients with atypical histology (35% at 5 years, 0% at 10 years) (P < 0.001). Univariate and multivariate analyses demonstrated that long-term survival was associated with histology but not lymph node involvement (hazards ratio = 14.6, 95% confidence interval: 1.7, 125.2). Our data suggests that long-term survival is associated with histology, not lymph node involvement. We found tumor histology to be the strongest predictor of long-term survival in patients with pulmonary carcinoid tumors.

The use of sentinel lymph node biopsy in ductal carcinoma in situ.

Although ductal carcinoma in situ (DCIS) does not require axillary evaluation, controversy exists regarding the use of sentinel lymph node biopsy (SLNB) in patients with DCIS diagnosed by core needle biopsy (CNB). Advocates of concomitant SLNB and lumpectomy cite the low morbidity of SLNB, the high rate of invasive ductal carcinoma in resected specimens, and the positive nodes found in 1 to 2 per cent of patients with resected DCIS despite finding no invasive component. Opponents of this practice cite the complication risk and the improbability of clinically significant axillary recurrence. We therefore proposed to determine our rate of invasive cancer in DCIS diagnosed by CNB and to determine whether SLNB at first operation would decrease return to the operating room. We retrospectively reviewed patients diagnosed with DCIS by CNB from 2003 to 2008. Standard clinicopathological data were collected and analyzed. In 110 patients, the prevalence of invasive cancer on final resection pathology was 13.6 per cent (15 of 110). Of those patients with invasive cancer, 93 per cent (14 of 15) had high-grade DCIS (P = 0.077) by CNB. Seventeen per cent (14 of 82) of patients with high-grade DCIS had invasive cancer. Of 34 patients with SLNB, three (9%) had positive nodes. Fifteen patients required re-excision to obtain negative margins, including 13 patients with invasive cancer. Five patients (4.5%) were spared additional operative intervention by initially performing SLNB. We suggest using concomitant SLNB when a high clinical suspicion of invasive cancer exists, in the presence of a palpable mass, or when mastectomy precludes future SLNB. Intraoperative margin assessment is needed to avoid return to the operating room.

Combined treatment of dendritoma vaccine and low-dose interleukin-2 in stage IV renal cell carcinoma patients induced clinical response: A pilot study.

Vaccination using dendritic/tumor cell hybrids represents a novel and promising cancer immunotherapy. We have developed a technology that can instantly purify the hybrids (dendritomas) from the fusion mixture of dendritic cells (DCs) and tumor cells. Our animal studies and a phase I study of stage IV melanoma patients demonstrated that dendritoma vaccination could be conducted without major toxicity and induced tumor cell-specific immunological and clinical responses. In this pilot study, ten stage IV renal cell carcinoma patients were studied. Dendritomas were made from autologous DCs and tumor cells and administered by subcutaneous injection. After initial vaccination, three escalating doses of IL-2 (3, 6, and 9 million units each) were followed within five days. This treatment regimen was tolerated well without severe adverse events directly related to the dendritoma vaccine. Most adverse events were related to IL-2 administration or pre-existing disease. Patient-specific immune responses were evaluated by flow cytometric measurement of interferon-gamma-producing T-cells before and after vaccination in response to stimulation with tumor antigens. Nine out of nine patients eligible for the analysis showed an increase of IFN-gamma-expressing CD4+ T cells after vaccination(s); while five out of eight patients eligible for the analysis showed an increase of IFN-gamma-expressing CD8+ T cells. Clinical responses were documented in 40% of the patients, three with stabilization of disease and one with a partial response documented by a reduction in tumor size. This pilot study demonstrated that dendritoma vaccines could be administered safely to patients with metastatic renal cell carcinoma, while producing both clinical and immunologic evidence of response.

Differential expression of prognostic factors and effect on survival in young (< or =40) breast cancer patients: a case-control study.

The belief that young women develop more aggressive forms of breast cancer than other women is controversial. The purpose of this study was to determine if women 40 years of age and under with breast cancer have more negative prognostic indicators and a higher 5-year mortality than those women over 40 years of age. From January 1998-December 2002, all women with breast cancer were identified from our tumor registry. Women with metastatic disease at presentation were excluded from our study. The women were divided into two groups, women under 40 (cases) and women 40 and over (controls). Seventy-eight cases were identified and matched to 228 controls. These cohorts were matched 3:1 (cases:controls) based on tumor staging. The data collected on each patient included prognostic factors such as tumor size, tumor type, estrogen and progesterone receptors, Her2/neu, and Ki-67. Information on surgical procedure, postoperative therapy, recurrence, and mortality was also gathered. The mean ages for cases and controls were 35 and 59 years, respectively. The rates of modified radical mastectomy were similar in the two groups, but young women were more likely to have breast reconstruction (33.7% vs 9.8%). The rates of breast conservation therapy were actually lower in the group under 40 (32.5% vs 37.6%). Tumors in the 40 and under group were more frequently estrogen receptor negative (33.8% vs 21.9%: P = 0.046) and progesterone receptor negative (50.0% vs 35.5%: P = 0.033). Younger women also experienced a greater prevalence of Ki-67 (P < 0.001) and higher levels of Her2/neu overexpression (P = 0.013). Women over 40 were more likely to receive hormonal therapy (39.7% vs 36.1%). Women over 40 had a lower overall rate of recurrence. A difference in overall survival does exist between these two groups of women, which trends toward significance. The women 40 and under had a lower overall 5-year survival. The reason for this difference remains unclear. Although we demonstrate a higher percentage of younger women with negative biochemical markers, the only factors independently and significantly related to higher mortality were estrogen receptor negativity and tumor stage at presentation.

Treatment and outcomes of melanoma with a Breslow's depth greater than or equal to one millimeter in a regional teaching hospital.

Local control and regional lymph node evaluation are the primary treatment goals for cutaneous primary melanoma. Historically, primary lesions were excised with large 3- to 5-cm radial margins. Recent clinical trials have suggested that similar survival and recurrence rates can be achieved with smaller margins of excision. In addition to excision of the primary lesion, the presence or absence of nodal metastasis is the single most powerful predictor of survival in patients with melanoma. Based on the available trials, the standard of care for a melanoma 1 mm or greater in depth is a wide local excision with a 2-cm margin and a sentinel lymph node biopsy (SLNB). The application of this standard in regional teaching hospitals is unknown. We performed a retrospective review of a cancer registry at a teaching hospital in South Carolina. This analysis included all patients who underwent surgery for melanoma at our institution between July 1997 and March 2003. Our single inclusion criterion was that the primary melanoma had to be 1 mm or greater in depth. Only 42 per cent of the patients underwent excision with a radial margin >2 cm, and only 60 per cent of the patients underwent SLNB. As time progressed, the use of SLNB at our institution increased; but, even as late as 2003, some patients did not receive SLNB. Adherence to standards did not appear to have an effect on overall survival. In conclusion, the current standard for the treatment of invasive melanoma greater than or equal to 1 mm in thickness is a 2-cm margin of excision and a SLNB. In this regional teaching hospital, surgical treatment and staging of melanoma did not strictly adhere to the standard.