The Width of the Surgical Margin Does Not Influence Outcomes in Extremity and Truncal Soft Tissue Sarcoma Treated With Radiotherapy.

BACKGROUND AND OBJECTIVES: It is unclear whether the quantitative width of the surgical margin influences outcomes in patients with extremity and truncal soft tissue sarcoma (STS) treated with radiotherapy (RT). METHODS: We performed a retrospective review of 382 patients with localized extremity or truncal STS who underwent limb-sparing surgery and RT from 1983 to 2010, and we analyzed the significance of resection margin status and quantitative margin width on outcomes. RESULTS: Surgical margins were positive in 68 (18%) patients and negative in 314 (82%) patients. For those patients with a reported quantitative margin width (n = 235), the width of the negative margin was ≤1 mm (n = 128), >1 mm and ≤5 mm (n = 79), and >5 mm (n = 28). At a median follow-up of 82 months, the local recurrence rates were 5.4% and 11.8% for margin-negative and margin-positive patients, respectively. There were no differences in the rates of local or distant recurrence nor of any survival outcome based on the quantitative width of the surgical margin, provided that it was negative. CONCLUSIONS: In patients undergoing RT and limb-sparing surgery for STS, achieving a negative margin is essential for optimizing both local control and survival. However, the absolute quantitative width of the negative margin does not significantly influence outcome, and so attempts at wide margins of resection appear to be unnecessary. Importantly, the conclusions drawn from this study must not be applied to those patients undergoing surgery alone as the local treatment of their STS, in which case wider margins of resection may be necessary. IMPLICATIONS FOR PRACTICE: In patients undergoing radiation therapy and limb-sparing surgery for soft tissue sarcoma, the quantitative width of the negative margin does not influence outcome, and so attempts at wide margins of resection appear to be unnecessary, especially when such attempts compromise the functional outcome. Importantly, the conclusions drawn from this study must not be applied to those patients undergoing surgery alone as the local treatment of their soft tissue sarcoma, in which case wider margins of resection may be necessary.

The impact of neoadjuvant therapy for gastroesophageal adenocarcinoma on postoperative morbidity and mortality.

BACKGROUND AND OBJECTIVES: We sought to study the impact of neoadjuvant therapy (NAT) on postoperative complications following surgical resection of adenocarcinomas of the stomach and gastroesophageal junction (GEJ). METHODS: We compared the postoperative outcomes of 308 patients undergoing a surgery-first approach and 145 patients undergoing NAT followed by curative-intent surgery for adenocarcinomas of the stomach and GEJ from 1995-2014. RESULTS: Patients receiving NAT were more likely to be younger, have tumors of the GEJ, to undergo esophagogastrectomy and D2 lymphadenectomy, and to have more advanced stage disease than patients undergoing surgery first. There were no differences in overall 30-day morbidity or mortality rates between the groups, yet patients undergoing surgery first were more likely to have higher-grade complications than those undergoing NAT. Age >65 years, higher ASA score, concomitant splenectomy, more advanced tumor stage, and year of surgery were independent risk factors for postoperative morbidity, but receipt of NAT was not an independent predictor of postoperative morbidity. CONCLUSIONS: Despite having more advanced disease and undergoing higher-risk surgical procedures, patients with adenocarcinomas of the stomach or GEJ who receive NAT prior to surgery are no more likely to suffer postoperative complications than patients treated with a surgery-first approach. J. Surg. Oncol. 2016;113:560-564. © 2016 Wiley Periodicals, Inc.

Availability of expanded programme of immunization services provided to children in a rural Pakistani village.

OBJECTIVES: To evaluate the immunization status of children under 5 years age, living in the Nurpur Shahan area and to identify various factors which influenced the rate of immunization. METHODS: A cross sectional study was conducted in which mothers of children under 5 years of age were questioned about the immunization of their children and the immunization services provided in the area. Systematic random sampling was used and the collected data was analyzed using SPSS v. 10.0. RESULTS: The overall immunization rate in the children of Nurpur Shahan was 77.4%. This study found strong correlations to immunization rates in children. Increased educational status of the mother, greater maternal immunization during pregnancy, and home delivery of vaccines, were all directly linked to higher rates of immunization amongst children. Lack of awareness, followed by inadequate facilities were the most commonly cited reasons for discontinuing the programme or abstaining from it altogether. CONCLUSION: The EPI coverage in Nurpur Shahan is quite well established, but still left room for improvement. Factors that encouraged higher immunization rates were more educated mothers, better awareness and availability of door-to-door services.

Adjuvant Therapy Completion Rates in Patients with Gastric Cancer Undergoing Perioperative Chemotherapy Versus a Surgery-First Approach.

Delayed recovery after gastrectomy may preclude the administration of adjuvant therapy in a significant percentage of patients who undergo elective gastrectomy as the initial therapy for gastric cancer. Clinicopathologic and treatment variables of 155 patients undergoing potentially curative gastrectomy for stages Ib-IIIc gastric adenocarcinoma from 2001 to 2014 were analyzed, and rates of receipt of chemotherapy and radiotherapy in patients treated with either a surgery-first approach (SURG) or neoadjuvant therapy followed by surgery followed by postoperative therapy (PERIOP) were compared. SURG patients (n = 93) were older and more likely to have distal tumors and to undergo distal gastrectomy and D1 lymphadenectomy than PERIOP patients (n = 62). The distribution of ASA scores was similar between groups. SURG patients were less likely than PERIOP patients to complete at least one cycle of chemotherapy (56 vs 100%, P = 0.001) and all recommended chemotherapy and radiation therapy (44 vs 66%, P = 0.013). These findings were consistent for SURG patients treated during different time periods throughout the study and for patients of poorer performance status. A significantly higher percentage of gastric cancer patients treated with perioperative chemotherapy receive some or all of the recommended components of multimodality therapy than patients treated with a surgery-first approach.

Predictors of Lymph Node Metastasis in Western Early Gastric Cancer.

BACKGROUND: The application of endoscopic and local resection for early gastric cancer (EGC) is limited by the risk of regional lymph node (LN) metastasis. We sought to determine the incidence and predictors of LN metastasis in a contemporary cohort of Western patients with early gastric cancer. METHODS: Sixty-seven patients with pT1 gastric adenocarcinoma underwent radical surgery without neoadjuvant therapy at our institution between 1995 and 2011, and clinicopathologic factors predicting LN metastasis were analyzed. RESULTS: LN metastases were present in 15/67 (22 %) pT1 tumors, including 1/23 (4 %) T1a tumors and 14/44 (32 %) T1b tumors. Tumor size, site, degree of differentiation, macroscopic tumor sub-classification, perineural invasion status, and depth of submucosal tumor penetration did not predict LN metastasis. The presence of lymphovascular invasion (LVI) and positive nodal status by endoscopic ultrasound (EUS) were the only factors that predicted LN metastasis on multivariate analysis. T1a tumors without LVI had a 0 % rate of positive LN, whereas T1b tumors with LVI had a 64.3 % rate of positive LN. CONCLUSIONS: EGC limited to the mucosa, without evidence of LVI, and N0 on EUS, may be considered for limited resection. However, any EGC with submucosal invasion, LVI, or positive nodes on EUS should undergo radical resection with lymphadenectomy.

Factors influencing readmission after curative gastrectomy for gastric cancer.

BACKGROUND: The incidence of, and associated risk factors for, readmission after potentially curative gastrectomy for patients with gastric cancer has not been well studied. We sought to determine the 30-day readmission rate as well as the potential risk factors for readmission at our institution in patients undergoing gastrectomy for gastric cancer with curative intent. STUDY DESIGN: We performed a retrospective analysis of all patients undergoing potentially curative gastrectomy for gastric cancer from 1995 to 2011. The 30-day hospital readmission rate was determined, and potential clinicopathologic risk factors for readmission were examined. RESULTS: Readmission to the hospital within 30 days occurred in 14.6% (61 of 418) of patients, including 6 patients who were readmitted more than once. The most common reasons for readmission included nutritional difficulties (n =12, 20%), intra-abdominal fluid collections (n = 11, 18%), and small bowel obstruction (n = 6, 10%). Factors associated with a higher 30-day readmission rate included type of resection (total gastrectomy, 23% vs subtotal gastrectomy, 13% vs esophagogastrectomy, 9%, p = 0.016), pre-existing cardiovascular disease (17%, p = 0.05), and history of a major postoperative complication (24%, p < 0.001). Factors not associated with a higher readmission rate included advanced age, pre-existing pulmonary disease, T or N stage, extent of lymph node dissection, receipt of neoadjuvant chemotherapy or radiotherapy, length of stay of the index hospitalization, and destination and level of support on discharge. CONCLUSIONS: Readmission after potentially curative gastrectomy for gastric cancer is common. Patients with pre-existing cardiovascular disease, those who suffer major postoperative complications, and those undergoing total gastric resections are at especially high risk for readmission, and strategies designed to support these high-risk patients on discharge are warranted.

Prognostic value of myogenic differentiation in undifferentiated pleomorphic sarcomas of soft tissue.

Patients with pleomorphic soft tissue sarcomas with myogenic differentiation (MD) are thought to have a worse prognosis than those without MD. In this study, we sought to determine the prognostic significance of MD in a restricted cohort of patients with high-grade undifferentiated pleomorphic sarcoma (UPS) of the extremities or trunk that were uniformly treated at a single institution. Thirty-eight patients met the inclusion criteria: (1) extremity or truncal soft tissue UPS, (2) histologic high grade, (3) size of 8 cm or more, (4) received protocol treatment. Immunohistochemical stains were performed on each tumor for 3 muscle markers: muscle-specific actin, smooth muscle actin, and desmin. A tumor was classified as having MD if it showed positive staining for at least 1 muscle marker. We correlated the line of differentiation with outcome using χ(2) and Kaplan-Meier analysis. MD was identified in 15 tumors and non-MD in 23 tumors. There were no significant differences between the myogenic and nonmyogenic groups in terms of age, sex, tumor size, tumor grade, or follow-up. The overall survival (OS) and disease-specific survival (DSS) were both 86.7% for patients with myogenic sarcomas. The OS and DSS were both 91.3% for those with nonmyogenic sarcomas. There was no significant difference between groups for OS or DSS in χ(2) testing (P = .649) or on Kaplan-Meier curve/log-rank testing (P = .541). In this homogenous group of patients with large, high-grade, extremity or truncal UPS who received neoadjuvant chemoradiotherapy, MD did not predict a worse survival than non-MD.

Career outcomes of nondesignated preliminary general surgery residents at an academic surgical program.

PURPOSE: There remains a debate as to whether nondesignated preliminary (NDP) positions in surgery ultimately translate into successful surgical careers for those who pursue them. We sought to identify the success with which our NDP residents were able to transition to their desired career and what, if any, factors contributed to their success. METHODS: The records of all NDP residents accepted into the Massachusetts General Hospital General Surgery Residency Program from 1995 to 2010 were examined and long-term follow-up was completed. RESULTS: Thirty-four NDP residents were identified, including 26.5% US graduates and 73.5% international medical graduates. At the end of the initial preliminary year, 30 (88%) got placed in a postgraduate residency program, whereas 4 (12%) pursued other career paths. Of those who got placed, 25 (83%) attained surgical residency positions, including 17 (57%) who continued as preliminary residents at our institution and 8 (27%) who got placed in categorical surgical positions at other programs. After multiple preliminary years, 15 of 17 achieved a categorical position, of which, 93% were in surgical fields. Overall, 64.7% of all entering NDP residents eventually went on to have careers in general surgery (50%) or surgical subspecialties (14.7%), and 24 of 34 (71%) fulfilled their desired career goals. No factor predicted success. From 1995 to 2012 there have been 15 midlevel (11 postgraduate year 4) vacancies in our program, 4 of which were filled by preliminary residents, 2 from our program and 2 from elsewhere. All have gone on to board certifications and careers in surgery. CONCLUSIONS: More than 70% of NDP residents in our program successfully transitioned to their desired career paths, many achieving categorical surgical positions and academic surgical careers, thus demonstrating the benefit of this track to both residency programs and trainees.