Carcinosarcoma of the hand.

Carcinosarcomas are rare malignant tumors derived of both epithelial and mesenchymal elements. Herein, we report an elderly man originally diagnosed with a squamous cell carcinoma of the hand. Upon excision, the tumor was found to be a more aggressive carcinosarcoma. Immunohistochemical stains revealed that the sarcoma component of the lesion was vimentin positive, whereas the primary carcinoma tumor cells were positive for p63 and CK903. Both components were negative for CD34 and D2-40. This tumor was found to have angiolymphatic invasion and eventually metastasized to the axillary lymph nodes and lungs.

The use of neoadjuvant platinum-based chemotherapy in locally advanced breast cancer that is triple negative: retrospective analysis of 144 patients.

Triple-negative breast cancers comprise about 20 % of breast cancers. They have poor prognosis and have no standard therapy. The aim of this study was to evaluate pathologic complete response (pCR), progression-free survival (PFS), and overall survival (OS) in patients with TNBC treated with neoadjuvant platinum-based chemotherapy. This is a retrospective study of one hundred and forty-four women with TNBC treated with neoadjuvant platinum-containing chemotherapy for locally advanced breast cancer at the University of Miami between January 1, 1999, and January 1, 2011. The medical record was reviewed to obtain data on clinical characteristics, including ethnicity, race, age, clinical stage, treatment regimen, and vital status. This study was approved by the University of Miami IRB. All patients had locally advanced breast cancer with at least one of the following features at presentation: T3, T4, N2, and N3. The mean tumor size by palpation was 9.4 cm. The clinical T-stage at presentation was 1.4 % T1, 8.3 % T2, 52.8 % T3, and 37.5 % T4 (19.4 % T4d). The nodal status by physical exam at presentation was 23 % N0, 37.5 % N1, 34 % N2, and 5.5 % N3. pCR in breast and axilla was seen in 31 %. PFS and OS were 55 and 59 %, respectively, at 7 years. Cisplatin offered a survival advantage over carboplatin in both PFS (P = 0.007) and OS (P = 0.018). Node positivity was the most important predictor of survival. Cisplatin/docetaxel neoadjuvant therapy was well tolerated and an effective therapy in locally advanced TNB.

Predictors of incidental gallbladder cancer in patients undergoing cholecystectomy for benign gallbladder disease.

BACKGROUND AND OBJECTIVES: Discovery of incidental gallbladder cancer (IGC) has become more frequent due to adoption of laparoscopy. Gallbladder spillage during operation can disseminate cancer and worsen the prognosis. METHODS: Patients who underwent laparoscopic or open cholecystectomy for benign gallbladder disease January 1996 to August 2011 at two tertiary care facilities were reviewed. Unmatched controls were randomly selected in 2:1 ratio. Preoperative variables were compared between the two groups. RESULTS: Sixty-seven patients with IGC were identified and compared to 134 controls. Mean age was 68 for index cases and 49 for controls; 70% of cases and 75% of controls were female. Multivariate analysis showed that higher risk of IGC was significantly associated with age ≥ 65 (OR = 10.61, P < 0.0001), dilated bile ducts (OR = 4.76, P = 0.0028), and presence of gallbladder wall thickening (OR = 4.39, P = 0.0003). This model yielded a very good area under the curve of receiver operating characteristic (AUC = 0.83) for discriminating the patients with IGC from controls. CONCLUSIONS: IGC is more likely to be found in patients when age is ≥65, with dilated bile ducts and gallbladder wall thickening. Preoperative suspicion of gallbladder cancer should prompt the surgeon to be more careful not to perforate the gallbladder during laparoscopic approach, and to have a lower threshold for conversion if necessary.

Impact of surgery-radiation interval on locoregional outcome in patients receiving neo-adjuvant therapy and mastectomy.

Delays in the initiation of radiation are increasingly common for medically underserved patients. We evaluated the impact of delay in initiation of postmastectomy radiation (PMRT) in breast cancer patients treated with neo-adjuvant therapy (NAT) in a cohort of medically underserved patients with multiple barriers to timely care. We retrospectively reviewed medical records of 248 consecutively treated patients. Clinical stage was 34.4% II, 65.6% III. The median interval from surgery to PMRT was 11.9 weeks; 22.2% started PMRT within 8 weeks of surgery, 52% within 12 weeks, and 67.3% within 16 weeks. The cumulative 5-year incidence of locoregional recurrence (LRR) was 5.8% (95% CI: 3.2-9.7). There was no significant difference in locoregional outcome among patients starting PMRT within 8 weeks versus >8 weeks (p = 0.634), ≤ 12 versus >12 weeks (p = 0.332), or ≤ 16 versus >16 weeks (p = 0.549) after surgery. Although timely initiation of PMRT remains a priority, the locoregional control benefit of PMRT appears to be maintained up to at least 16 weeks, and in those without early locoregional recurrence, PMRT should be offered despite such a delay.

Effects of Recorded versus Live Teleconference Didactic Lectures on Medical Student Performance in the Surgery Clerkship.

OBJECTIVE: Due to the COVID-19 pandemic, numerous institutions converted medical education didactics to electronic formats including both live teleconference didactics and recorded faculty lectures. This study aims to compare the effect of recorded versus live teleconference didactic lectures on medical student examination scores during the surgery clerkship. DESIGN: Medical students completing the Surgery Clerkship received a weekly series of didactic lectures taught by faculty via a teleconference (2020-2021 academic year) or recorded format (2021-2022 academic year). Performance outcomes included weekly quizzes, National Board of Medical Examiners (NBME) Surgery Shelf Exam, and clerkship Objective Structured Clinical Examination (OSCE) scores. SETTING: University of Miami Miller School of Medicine. PARTICIPANTS: All second- (MS2) and third-year (MS3) medical students completing the Surgery Clerkship over two academic years (n = 312). RESULTS: Students who received live teleconference lectures (n = 156) demonstrated higher average scores on weekly quizzes (89%) and the NBME shelf exam (76%) compared to those receiving recorded lectures (n = 156; 71% quiz, 70% shelf exam), both p < 0.001. There was a significant association with performance in the highest quartile (Q1) of weekly quiz scores and receiving live lectures (40% vs. recorded lectures 1%, p < 0.001). Comparing only MS3 students, mean weekly quiz scores and Q1 achievement were significantly higher (both p < 0.001) in the teleconference cohort with no significant difference in NBME shelf exam performance (p = 0.971). No difference in OSCE performance was observed between groups. CONCLUSION: These results suggest that synchronous teleconferences may be more effective than recorded lectures for achieving institutional learning objectives on the surgery clerkship without any negative impact on NBME shelf exam or clinical evaluation parameters. This information should be used to inform future institutional clerkship design and educational initiatives.

Examination Scores but not Clinical Performance Correlate With Duration of Preclinical Didactic Time: A Synchronous Comparison of Second- Versus Third-Year Medical Students on the Surgery Clerkship.

OBJECTIVE: Numerous institutions have reduced preclinical didactic time to facilitate earlier clinical exposure during the second year of medical education. However, the effects that shortened preclinical education may have on performance in the surgery clerkship are unclear. This study aims to compare the clinical and examination performance of second- (MS2) and third-year (MS3) students synchronously completing an identical surgery clerkship. DESIGN: All students completing the surgery clerkship (identical didactics, examinations, clinical rotations, etc.) were included. MS3s received 24 months of preclinical education, whereas MS2s received 14 months. Performance outcomes included weekly quizzes based on lectures, NBME Surgery Shelf Exam, numeric clinical evaluations, objective structured clinical examination (OSCE) scores, and overall clerkship grades. SETTING: University of Miami Miller School of Medicine. PARTICIPANTS: All second- (MS2) and third-year (MS3) medical students completing the Surgery Clerkship over 1 year (n = 395). RESULTS: There were 199 MS3 (50%) and 196 MS2 (50%) students. MS3s demonstrated higher median shelf exams (77% vs 72% MS2s), weekly quiz score averages (87% vs 80% MS2s), clinical evaluations (96% vs 95% MS2s), and overall clerkship grades (89% vs 87% MS2s), all p < 0.020. There was no difference in median OSCE performance (both 92%; p = 0.499). A greater proportion of MS3 students performed in the highest 50% of weekly quiz scores (57% vs 43% MS2), NBME shelf exams (59% vs 39% MS2), and overall clerkship grades (45% vs 37% MS2), all p < 0.010. No significant difference in the proportion of students placing in the top 50% of clinical parameters including the OSCE (48% MS3 vs 46% MS2; p = 0.106) and clinical evaluations (45% MS3 vs 38%; p = 0.185) was observed. CONCLUSIONS: Although the duration of preclerkship education may correspond to examination scores, MS2s and MS3s perform similarly on clinical metrics. Future strategies to enhance available preclinical didactic time and preparation for examinations are needed.

Implementation of a Surgical Problem-Based Learning Curriculum: A One-Year Single-Center Experience.

BACKGROUND: Problem-Based Learning (PBL) has become an integral part of medical student education for preclinical curricula, but few studies have evaluated the benefits of a PBL curriculum for clinical education. This study aims to assess the 1-year experience after implementing a resident-led PBL program for the third-year (MS3) surgery clerkship and compare students' self-reported preparedness following PBL sessions to traditional faculty-led lectures. METHODS: Surgical faculty and residents developed a PBL curriculum to address common topics in surgical education. Pandemic requirements necessitated a switch from in-person to virtual sessions during the experience. Students enrolled in the MS3 surgical clerkship were asked to participate in a survey. Demographics and clerkship data were obtained. Quality of PBL and faculty-led lectures were assessed using a ten-point Likert scale, and standard statistical analyses were performed. RESULTS: During the study period, 165 students rotated through surgery, of which 129 (78%) responded to the survey (53% female, 59% white). PBLs were held in-person (53%), exclusively virtual (32%) or hybrid (15%) platforms. In-person PBLs were preferred to faculty-led lectures for preparing students for NBME examinations (6.9 vs 6.0), oral examinations (7.8 vs 6.3), and surgical cases (6.3 vs 5.8), all P < .001. Virtual PBLs were also preferred to lectures for preparing students for NBME examinations (6.8 vs 5.8, P < .001) and surgical cases (5.6 vs 4.8, P = .05). CONCLUSIONS: PBL is a valuable adjunct for medical student education. Resident-led PBLs were preferred to faculty-led lectures for preparing students for examinations and clerkship experiences and may be useful adjuncts to clinical education.

Adjuvant therapy of gastrointestinal stromal tumors.

PURPOSE OF REVIEW: The treatment of gastrointestinal stromal tumors (GISTs) with tyrosine kinase inhibitors (TKIs), such as imatinib and sunitinib, has produced improved outcomes and survival. However, patients with high-risk tumors still have unacceptably high rates of recurrence and disease progression. In the current review, we examine the various strategies for optimizing the treatment of GISTs. RECENT FINDINGS: Extended duration of treatment (36 months) with adjuvant imatinib resulted in improved recurrence-free survival and overall survival, whereas discontinuation of the TKI led to relapse of disease in most high-risk patients. High-dose therapy of imatinib was beneficial for patients with KIT exon 9 mutations. Patients with KIT exon 11 mutations experienced the most improvement in outcomes from adjuvant imatinib. SUMMARY: The extended duration of TKI treatment, dose optimization, mutation status, and the effects of TKI discontinuation have recently been examined in more detail. As our understanding of TKI therapy grows, an individualized approach to each patient should lead to better outcomes.

The Role of Perioperative Chemotherapy in the Management of Colloid Carcinoma of the Pancreas.

OBJECTIVES: Colloid carcinoma (CC) of the pancreas is associated with an improved prognosis compared with pancreatic ductal adenocarcinoma (PDAC), yet studies on the optimal management of these rare lesions are lacking. METHODS: Patients with CC or PDAC treated from 2004 to 2014 were identified in the National Cancer Database. Clinicopathologic characteristics were compared between groups and stratified by disease stage. Survival analysis evaluating the role of perioperative chemotherapy was performed. RESULTS: A total of 1295 CC patients (11%) and 10,855 PDAC patients (89%) were identified. Pancreatic ductal adenocarcinoma was associated with a higher likelihood of mortality compared with CC (hazard ratio, 1.35; 95% confidence interval, 1.25-1.45; P < 0.001). When stratifying by stage, perioperative chemoradiation improved overall survival in early stage (I/IIA) PDAC but had no effect in CC patients. However, for node-positive disease (stage IIB), median overall survival was improved with adjuvant chemoradiation for both CC patients (22 vs 13 months; P < 0.001) and PDAC patients (20 vs 11 months; P < 0.001) compared with surgery alone. CONCLUSIONS: Surgery alone may be sufficient for the management of node-negative (I/IIA) CC lesions in contrast to conventional PDAC, whereas CC patients with stage IIB disease have a survival benefit from perioperative chemoradiation.

Surgical clerkship: Do examination scores correlate with clinical performance?

BACKGROUND: This study aims to determine if there are correlations between clinical performance and objective grading parameters for medical students in the third-year surgery clerkship. METHODS: Clerkship grades were compiled from 2016 to 2020. Performance on clinical rotations, NBME shelf exam, oral exam, and weekly quizzes were reviewed. Students were divided into quartiles (Q1-Q4) based on clinical performance. Standard statistical analysis was performed. RESULTS: There were 625 students included in the study. Students in Q1+Q2 were more likely than those in Q3+Q4 to score in the top quartile on the shelf exam (29% vs. 19%, p = 0.002), oral exam (24% vs. 17%, p = 0.032), and quizzes (22% vs. 15%, p = 0.024). However, there was negligible correlation between clinical performance and performance on objective measures: shelf exam (R2 = 0.027, p < 0.001), oral exam (R2 = 0.021, p < 0.001), and weekly quizzes (R2 = 0.053, p = 0.092). CONCLUSIONS: Clinical performance does not correlate with objective grading parameters for medical students in the third-year surgery clerkship.

Medical Student Education During COVID-19: Electronic Education Does Not Decrease Examination Scores.

BACKGROUND: During the COVID-19 emergency, medical students were mandated to remain home, creating challenges to providing education remotely for third-year clinical rotations. This study aims to assess student reception and investigate objective outcomes to determine if online learning is a suitable alternative. METHODS: Medical students enrolled in the third-year surgical clerkship during COVID-19 were asked to participate in a survey. 19 of 27 (70%) students participated. Content, faculty-led lectures, and resident-led problem-based learning (PBL) sessions were assessed using a ten-point Likert scale. National Board of Medical Examiners (NBME) examination, weekly quiz, and oral examination scores were compared to previous years. Student t-tests compared the groups. RESULTS: The median age was 25 years. Comparing in-person to electronic sessions, there was no difference in effectiveness of faculty sessions preparing students for NBME (6.2 vs. 6.7, P = .46) or oral examinations (6.4 vs. 6.8, P = .58); there was also no difference in resident-led PBL sessions preparing students for NBME (7.2 vs. 7.2, P = .92) or oral examinations (7.4 vs. 7.6, P = .74). Comparing this group to students from the previous academic year, there was no difference in weekly quiz (85.3 vs. 87.8, P = .13), oral examination (89.8 vs. 93.9, P = .07), or NBME examination (75.3 vs. 77.4, P = .33) scores. DISCUSSION: Surgical medical didactic education can effectively be conducted remotely through faculty-led lectures and resident-led PBL sessions. Students did not have a preference between in-person and electronic content in preparation for examinations. As scores did not change, electronic education may be adequate for preparing students for examinations in times of crisis such as COVID-19.

Developments in the use of ultrasound for thyroid cancer.

PURPOSE OF REVIEW: This article reviews the recent developments in neck ultrasound for thyroid cancer published in the last 18 months, with emphasis on the emerging role of surgeon-performed ultrasound in clinical endocrine practice. RECENT FINDINGS: Ultrasound has evolved beyond the simple differentiation of solid and cystic thyroid nodules and their measurement. Although no single ultrasound feature has the highest accuracy in distinguishing between benign and malignant thyroid lesions, the combination of several ultrasound characteristics (e.g. hypoechogenicity, irregular borders and microcalcifications) within such thyroid nodules may have a stronger correlation for thyroid cancer. Based on these ultrasound features and risk for thyroid malignancy, the need for ultrasound-guided fine needle aspiration, preoperative staging, lymph node mapping and extent of surgery can subsequently be determined and performed. Furthermore, ultrasound has an additional value intraoperatively and in the postoperative surveillance of patients treated for thyroid cancer. Surgeon-performed ultrasound has recently become indispensible in clinical practice where endocrine surgeons have integrated this versatile imaging modality in the evaluation and treatment of patients with thyroid cancer. SUMMARY: Ultrasound is an essential modality in the evaluation of thyroid malignancy. Surgeon-performed ultrasound has proved invaluable in the preoperative, intraoperative and postoperative setting. Future developments in ultrasound may lead to further improvement in the diagnostic accuracy of this modality.

The Major Pre- and Postmenopausal Estrogens Play Opposing Roles in Obesity-Driven Mammary Inflammation and Breast Cancer Development.

Many inflammation-associated diseases, including cancers, increase in women after menopause and with obesity. In contrast to anti-inflammatory actions of 17ß-estradiol, we find estrone, which dominates after menopause, is pro-inflammatory. In human mammary adipocytes, cytokine expression increases with obesity, menopause, and cancer. Adipocyte:cancer cell interaction stimulates estrone- and NFκB-dependent pro-inflammatory cytokine upregulation. Estrone- and 17ß-estradiol-driven transcriptomes differ. Estrone:ERα stimulates NFκB-mediated cytokine gene induction; 17ß-estradiol opposes this. In obese mice, estrone increases and 17ß-estradiol relieves inflammation. Estrone drives more rapid ER+ breast cancer growth in vivo. HSD17B14, which converts 17ß-estradiol to estrone, associates with poor ER+ breast cancer outcome. Estrone and HSD17B14 upregulate inflammation, ALDH1 activity, and tumorspheres, while 17ß-estradiol and HSD17B14 knockdown oppose these. Finally, a high intratumor estrone:17ß-estradiol ratio increases tumor-initiating stem cells and ER+ cancer growth in vivo. These findings help explain why postmenopausal ER+ breast cancer increases with obesity, and offer new strategies for prevention and therapy.

Evolving management of positive regional lymph nodes in melanoma: Past, present and future directions.

Sentinel lymph node (SLN) biopsy has become the standard of care for lymph node staging in melanoma and the most important predictor of survival in clinically node-negative disease. Previous guidelines recommend completion lymph node dissection (CLND) in cases of positive SLN; however, the lymph nodes recovered during CLND are only positive in a minority of these cases. Recent evidence suggests that conservative management (i.e. observation) has similar outcomes compared to CLND. We sought to review the most current literature regarding the management of SLN in metastatic melanoma and to discuss potential future directions.

Role of surgeon-performed ultrasound in predicting malignancy in patients with indeterminate thyroid nodules.

BACKGROUND: Certain ultrasound features can predict malignancy in patients with thyroid nodules. The purpose of this study was to determine the value of surgeon-performed ultrasound (SUS) in predicting thyroid malignancy in patients with indeterminate fine-needle aspiration (FNA) cytology. METHODS: 477 consecutive patients with dominant thyroid nodules were referred to our institution from 2002 to 2007. Of these, 180/477(38%) were judged to have indeterminate cytology: follicular neoplasm (FN, n = 108), Hürthle neoplasm (HN, n = 29), and suspicious for papillary thyroid cancer (SPTC, n = 43). SUS characteristics for thyroid nodules were recorded in a prospective database prior to thyroidectomy. Variables analyzed included patients' age and sex, nodule size, shape, echogenicity, consistency, borders, multiplicity/multicentricity, and presence of microcalcifications. SUS features of thyroid nodules were correlated with final pathology. The accuracy of individual SUS features as well as the presence of two or more adverse features in predicting malignancy was also examined. RESULTS: There were 144 females and 36 males. Mean age was 52 years (range 17-87 years). Mean tumor size was 2.7 cm (range 0.65-6.6 cm). Overall, final pathology revealed cancer in 92/180 (51%) patients. Malignancy was present in 40/108 (37%) FN, 12/29 (41%) HN, and 40/43 (93%) SPTC. Nodule borders (irregular), shape (height > width), hypoechogenicity, and presence of microcalcifications were significantly associated with malignancy. The presence of 2 or >/=3 adverse SUS thyroid nodule features was associated with a >/=55% or >/=78% risk of malignancy, respectively. CONCLUSION: Adverse thyroid nodule features seen on SUS may predict malignancy and help determine the initial extent of thyroidectomy in patients with indeterminate FNA cytology.

Improved preoperative planning for directed parathyroidectomy with 4-dimensional computed tomography.

BACKGROUND: Four-dimensional computed tomography (4D-CT) provides both functional and highly detailed anatomic information about parathyroid tumors. The purpose of this study was to compare 4D-CT with sestamibi imaging and ultrasonography as methods for the accurate preoperative localization of hyperfunctioning parathyroid glands before parathyroidectomy. METHODS: A study of 75 patients with primary hyperparathyroidism was performed at a tertiary-care institution. Sestamibi imaging, ultrasonography, and 4D-CT were performed on each patient preoperatively. Results of the imaging studies were compared with operative findings, pathologic data, and biochemical measurements to assess the sensitivity and specificity of each of the imaging modalities. RESULTS: 4D-CT demonstrated improved sensitivity (88%) over sestamibi imaging (65%) and ultrasonography (57%), when the imaging studies were used to localize (lateralize) hyperfunctioning parathyroid glands to 1 side of the neck. Moreover, when used to localize parathyroid tumors to the correct quadrant of the neck (ie, right inferior, right superior, left inferior, or left superior), the sensitivity of 4D-CT (70%) was significantly higher than sestamibi imaging (33%) and ultrasonography (29%). CONCLUSION: 4D-CT provides significantly greater sensitivity than sestamibi imaging and ultrasonography for precise (quadrant) localization of hyperfunctioning parathyroid glands. This allows improved preoperative planning, particularly for the case of reoperation. In addition to the data that are provided, we present a novel classification scheme for use in parathyroid localization.

Adrenocortical carcinoma.

ACC is a rare clinical entity that carries a poor prognosis; early diagnosis and complete surgical resection are associated with the improvement in patient survival. Even with appropriated diagnosis and treatment, most patients will develop recurrence and succumb to ACC because of the underlying tumor biology, the difficulty of achieving a complete resection, and the lack of effective systemic therapies. Despite its many drawbacks, mitotane continues to be a mainstay in the treatment of high-risk patients with ACC, especially those with recurrent or metastatic disease. Recent findings suggest that mitotane, combined with conventional chemotherapeutic agents, may improve survival for such patients.

Risk factors for locoregional failure in patients with inflammatory breast cancer treated with trimodality therapy.

PURPOSE: To compare patterns of local and regional failure between patients with inflammatory breast cancer (IBC) and non-IBC in patients treated with trimodality therapy. MATERIALS AND METHODS: We reviewed records of 463 patients with stage II/III breast cancer, including IBC, who completed trimodality therapy from January 1999 to December 2009. RESULTS: The median follow-up was 46.3 months (range, 4-152 months). Clinical stage was 29.4% (n = 136) II, 56.4% (n = 261) non-IBC III, 14.2% (n = 66) IBC, 30.5% (n = 141) cN0/Nx, and 69.5% (n = 322) N1-N3c. All the patients received neoadjuvant therapy and mastectomy (98%, n = 456 with axillary dissection), and all had postmastectomy radiation therapy to the chest wall with or without supraclavicular nodes (82.5%, n = 382) with or without axilla (6%, n = 28). The median chest wall dose was 60.4 Gy. Patients with IBC presented with larger tumors (P < .001) and exhibited a poorer response to neoadjuvant therapy: after surgery, fewer patients with IBC were ypN0 (P = .003) and more had ≥ 4 positive nodes (P < .001). Four-year cumulative incidence of locoregional recurrence was 5.9%, with 25 locoregional events, 9 of which had a regional component. On multivariate analysis, triple-negative disease (hazard ratio [HR] 7.75, P < .0001) and residual pathologic nodes (HR 7.10, P < .001) were associated with an increased risk of locoregional recurrence, but IBC was not. However, on multivariate analysis, the 4-year cumulative incidence of regional recurrence specifically was significantly higher in IBC (HR 9.87, P = .005). CONCLUSION: In this cohort of patients who completed trimodality therapy, the patients with IBC were more likely to have residual disease in the axilla after neoadjuvant therapy and were at greater risk of regional recurrence. Future study should focus on optimizing regional nodal management in IBC.

Number of lymph nodes removed during modified radical neck dissection for papillary thyroid cancer does not influence lateral neck recurrence.

BACKGROUND: This study examines the relationship between the number of lymph nodes removed during modified radical neck dissection and the incidence of disease recurrence. METHODS: A retrospective review of 117 patients with papillary thyroid cancer and lateral neck involvement (levels 2-5) who underwent modified radical neck dissection was performed. Data were analyzed for patient demographics, operative procedure, lymph node involvement, complications, radioactive iodine therapy, and disease recurrence. RESULTS: Of 117 patients who underwent modified radical neck dissection, the median follow-up of the entire study group was 25 months (range, 1-256 months). Recurrent disease was found in 8% of patients, with a median time to recurrence of 35 months. The median number of lymph nodes removed during modified radical neck dissection was similar in recurrent and nonrecurrent patients (P = .78). There was also no difference in the median number of positive lymph nodes removed (P = .14) between these 2 groups. On multivariate analysis, however, the number of positive lymph nodes (odds ratio, 1.16 [95% confidence interval, 1.01-1.34]) and tumor size (odds ratio, 1.60 [95% confidence interval, 1.03-2.49]) were independent predictors of recurrence of disease after modified radical neck dissection. CONCLUSION: Recurrence of papillary thyroid cancer after modified radical neck dissection is unrelated to the number of lymph nodes removed. This study suggests that attempts to maximize the number of lymph nodes removed during modified radical neck dissection for papillary thyroid cancer may not be necessary.

Higher chest wall dose results in improved locoregional outcome in patients receiving postmastectomy radiation.

PURPOSE: Randomized trials demonstrating decreased locoregional recurrence (LRR) and improved overall survival (OS) in women receiving postmastectomy radiation therapy (PMRT) used up to 50 Gy to the chest wall (CW), but in practice, many centers boost the CW dose to ≥60 Gy, despite lack of data supporting this approach. We evaluated the relationship between CW dose and clinical outcome. METHODS AND MATERIALS: We retrospectively reviewed medical records of 582 consecutively treated patients who received PMRT between January 1999 and December 2009. We collected data on patient, disease, treatment characteristics, and outcomes of LRR, progression-free survival (PFS) and OS. RESULTS: Median follow-up from the date of diagnosis was 44.7 months. The cumulative 5-year incidence of LRR as first site of failure was 6.2%. CW dose for 7% (43 patients) was ≤50.4 Gy (range, 41.4-50.4 Gy) and 93% received >50.4 Gy (range, 52.4-74.4 Gy). A CW dose of >50.4 Gy vs. ≤50.4 Gy was associated with lower incidence of LRR, a 60-month rate of 5.7% (95% confidence interval [CI], 3.7-8.2) vs. 12.7% (95% CI, 4.5-25.3; p = 0.054). Multivariate hazard ratio (HR) for LRR controlling for race, receptor status, and stage was 2.62 (95% CI, 1.02-7.13; p = 0.042). All LRR in the low-dose group occurred in patients receiving 50 to 50.4 Gy. Lower CW dose was associated with worse PFS (multivariate HR, 2.73; 95% CI, 1.64-4.56; p < 0.001) and OS (multivariate HR, 3.88; 95% CI, 2.16-6.99; p < 0.001). CONCLUSIONS: The addition of a CW boost above 50.4 Gy resulted in improved locoregional control and survival in this cohort patients treated with PMRT for stage II-III breast cancer. The addition of a CW boost to standard-dose PMRT is likely to benefit selected high-risk patients. The optimal technique, target volume, and patient selection criteria are unknown. The use of a CW boost should be studied prospectively, as has been done in the setting of breast conservation.