A retrospective observational study of leucoreductive strategies to manage patients with acute myeloid leukaemia presenting with hyperleucocytosis.

Acute myeloid leukaemia (AML) patients with hyperleucocytosis have higher early mortality, lower complete remission (CR) and overall survival (OS). Whether different pre-induction leucoreduction strategies can improve outcome is unknown. A single centre retrospective cohort study was conducted on AML patients with a white blood cell count (WBC) >100 × 10(9) /l between 1987 and 1997, and on all AML patients between 1998 and 2006, to determine (a) the effect of four different leucoreductive strategies (leukapheresis, hydroxycarbamide, leukapheresis and hydroxycarbamide or no pre-induction leucoreduction) on early (day 28) mortality, CR, and OS; and (b) whether a high presenting WBC remains a negative predictor of OS in patients surviving induction (first 28 d). In the 1998-2006 cohort (n = 702), higher WBC was associated with higher early mortality and lower OS but its effects were greatly diminished in patients who survived the first 28 d (Hazard Ratio 1·094 vs. 1·002). A WBC of 34·1 × 10(9) /l had the highest sensitivity (75·6%) and specificity (67·4%) for early mortality. None of the four leucoreduction strategies differed significantly in early mortality, CR, or OS in patients with WBC>100 × 10(9) /l (n = 166). The number of leucostatic signs was a significant predictor of early mortality (P < 0·0001) and OS (P = 0·0007). The results suggest that AML patients with hyperleucocytosis should be induced, if eligible, without pre-induction leucoreduction.

Is gastric cancer different in Korea and the United States? Impact of tumor location on prognosis.

PURPOSE: To compare the characteristics and prognoses of gastric cancers by tumor location in Korean and U.S. subjects after curative-intent (R0) resection for gastric cancer (GC). METHODS: Data were collected for all patients who had undergone R0 resection at one U.S. institution (n = 567) and one South Korean institution (n = 1,620). Patients with gastroesophageal junction tumors or neoadjuvant therapy were excluded. Patient, surgical, and pathologic variables were compared by tumor location. Factors associated with disease-specific survival (DSS) were determined via multivariate analysis. RESULTS: In the Korean cohort, significantly more upper third GC (UTG) patients had undifferentiated, diffuse type, and advanced stage cancers compared to lower third GC (LTG) and middle third GC (MTG) patients. In the U.S. cohort, however, T stage was relatively evenly distributed among UTG, MTG, and LTG patients. The independent predictors of DSS in the Korean cohort were T stage, tumor size, retrieved and positive lymph node counts, and age, but in the U.S. cohort, the only independent predictors were T stage and positive lymph node count. Tumor size significantly affected DSS of Korean UTG patients but not U.S. UTG patients. CONCLUSIONS: There were significant differences in tumor characteristics by tumor location within and between both national cohorts. On the basis of these findings, further study to investigate the biological difference between the two countries is needed.

Pilot study of quantitative analysis of background enhancement on breast MR images: association with menstrual cycle and mammographic breast density.

PURPOSE: To perform semiautomated quantitative analysis of the background enhancement (BE) in a cohort of patients with newly diagnosed breast cancer and to correlate it with mammographic breast density and menstrual cycle. MATERIALS AND METHODS: Informed consent was waived after the research ethics board approved this study. Results of 177 consecutive preoperative breast magnetic resonance (MR) examinations performed from February to December 2009 were reviewed; 147 female patients (median age, 48 years; range, 26-86 years) were included. Ordinal values of BE and breast density were described by two independent readers by using the Breast Imaging Reporting and Data System lexicon. The BE coefficient (BEC) was calculated thus: (SI2 · 100/SI1) - 100, where SI is signal intensity, SI2 is the SI enhancement measured in the largest anteroposterior dimension in the axial plane 1 minute after the contrast agent injection, and SI1is the SI before contrast agent injection. BEC was used for the quantitative analysis of BE. Menstrual cycle status was based on the last menstrual period. The Wilcoxon rank-sum or Kruskal-Wallis test was used to compare quantitative assessment groups. Cohen weighted κ was used to evaluate agreement. RESULTS: Of 147 patients, 68 (46%) were premenopausal and 79 (54%) were postmenopausal. The quantitative BEC was associated with the menstrual status (BEC in premenopausal women, 31.48 ± 20.68 [standard deviation]; BEC in postmenopausal women, 25.65 ± 16.74; P = .02). The percentage of overall BE was higher when the MR imaging was performed in women in the inadequate phase of the cycle (<35 days, not 7-14 days; mean BEC, 35.7) compared with women in the postmenopausal group (P = .001). Premenopausal women had significantly higher BEC when compared with postmenopausal women (P = .03). There was no significant difference in the percentage of BE between breast density groups. CONCLUSION: Premenopausal women with breast cancer, and specifically women in the inadequate phase of the cycle, presented with higher quantitative BE than postmenopausal women. No association was found between BE and breast density.

Comparison of disease-specific survival in the United States and Korea after resection for early-stage node-negative gastric carcinoma.

BACKGROUND AND OBJECTIVES: Disease-specific survival (DSS) for GC patients differs in Eastern and Western countries. The aim is to compare outcomes of US and Korean patients following resection of early-stage, node-negative gastric carcinoma (GC). METHODS: All patients (1995-2005) with T1N0 gastric carcinoma, excluding gastroesophageal tumors, were evaluated. DSS was compared by adjusting for prognostic variables from an internationally validated GC nomogram. RESULTS: The cohort included 598 Korean patients and 159 US patients. Age and BMI were significantly higher in US patients. Distal tumor location was more frequent in Korea (60% vs. 52%) and proximal location in the US (19% vs. 5%, P < 0.0001). Five-year DSS did not differ significantly between Korea and the US. After multivariate analysis, DSS of Korean patients persisted, with no significant differences when compared to US patients (HR = 1.2, 95% CI: 0.3-5.2, P = 0.83). CONCLUSIONS: Despite widespread speculations that GC differs in the East and West, when we compare similarly staged, node-negative GC patients, survival did not differ significantly between Korea and the US. This suggests that GC is a heterogeneous disease and when similar subtypes of gastric cancer are compared, these differences disappear. This study suggests more similarities than previously hypothesized between US and Korean GC patients.

A nomogram to predict postresection 5-year overall survival for patients with uterine leiomyosarcoma.

BACKGROUND: The clinical course of patients with uterine leiomyosarcoma (LMS) is difficult to predict with the currently available categorical staging systems of the American Joint Committee on Cancer (AJCC) and the International Federation of Gynecology and Obstetrics (FIGO). The objective of the current study was to develop and validate a novel, clinically relevant, individualized prognostic model for patients with uterine LMS. METHODS: Patients with uterine LMS who presented at the authors' institution from 1982 to 2008 were analyzed. The nomogram model was chosen based on the clinical evidence and statistical significance of the predictors, including age at diagnosis, tumor size, histologic grade, uterine cervix involvement, extrauterine spread, distant metastases, and mitotic index. Five-year overall survival (OS) was the predicted endpoint. The concordance probability (CP) was used as a predictive accuracy measure and compared with the CP of current staging systems. The model was internally validated using 200 bootstrap samples to correct for over fitting. RESULTS: One hundred eighty-five of 270 patients were eligible for the nomogram analysis. The median follow-up was 5.4 years, and the median OS was 3.75 years (95% confidence interval, 3-6 years). The CP of the newly developed nomogram was 0.67 (95% confidence interval, 0.63-0.72). This was superior to predictions based on AJCC and FIGO staging. The bootstrap-validated CP was 0.65 with good calibration accuracy. CONCLUSIONS: The authors developed and internally validated a uterine LMS-specific nomogram to predict 5-year OS. This novel, individualized prognostic model outperforms traditionally used categorical staging systems and may be useful for patient counseling and for better selection of patients for adjuvant therapy trials.

Anterior cruciate ligament reconstruction: MR imaging signs of anterior knee laxity in the presence of an intact graft.

PURPOSE: To determine the accuracy of secondary magnetic resonance (MR) imaging signs of anterior cruciate ligament (ACL) insufficiency in predicting clinical anterior translational knee laxity, in the presence of an intact graft, after ACL reconstruction. MATERIALS AND METHODS: Institutional review board approval was obtained, and the requirement to obtain informed consent was waived. Fifty-two patients with ACL reconstruction and no injury to the contralateral knee were included. Three patients with visible ACL graft tears at MR imaging were excluded. All patients underwent MR imaging of the affected knee, functional assessment with use of the International Knee Documentation Committee (IKDC) score, and arthrometric testing of both the affected and uninjured knee. A side-to-side difference of more than 3 mm at 133 N was considered to be indicative of knee laxity. Two radiologists independently evaluated all MR images for seven signs of anterior knee laxity. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated for each MR imaging sign. RESULTS: Ten patients demonstrated knee laxity at arthrometric testing. Patients with knee laxity at arthrometric testing had significantly lower IKDC scores (P < .03). Sensitivities for all signs were low (0%-50%). Anterior translation of the tibia of more than 7 mm, a posterior cruciate ligament (PCL) angle of less than 100°, and a PCL curvature ratio of more than 0.39 demonstrated high specificity (range, 82%-90%). Uncovering of the posterior horn of the lateral meniscus and the posterior femoral line had a specificity of 97%-100% and a sensitivity of 0%. All signs had a low PPV and high NPV for laxity. All MR imaging signs demonstrated near-perfect interobserver agreement. CONCLUSION: Although MR imaging signs of knee laxity in the presence of an intact ACL graft have a high specificity, the low PPV means that MR imaging is of little value in predicting anterior knee laxity as demonstrated with mechanical testing.

Accuracy of unenhanced MR imaging in the detection of axillary lymph node metastasis: study of reproducibility and reliability.

PURPOSE: To investigate the accuracy, reproducibility, and reliability of unenhanced magnetic resonance (MR) imaging techniques for detecting metastatic axillary lymph nodes in patients with newly diagnosed breast carcinoma. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained. Seventy-four consecutive women with invasive breast carcinoma were recruited to undergo preoperative breast MR imaging. Thirteen patients were excluded, two because they were undergoing preoperative chemotherapy and 11 because of the presence of movement or susceptibility artifacts on images. Thus, 61 patients (mean age, 53 years; range, 33-78 years) were included in this study. Axial T1-weighted MR images without fat saturation and diffusion-weighted (DW) MR images were analyzed by two experienced radiologists, who were blinded to the histopathologic findings. Visual and quantitative analyses of unenhanced MR images were performed. Sensitivity, specificity, and accuracy were calculated. To assess the intraobserver agreement, a second reading was performed. Statistical analysis was conducted on a patient-by-affected side basis. RESULTS: The sensitivity, specificity, and accuracy were 88%, 82%, and 85%, respectively, for axial T1-weighted MR imaging and 84%, 77%, and 80% for DW imaging. Apparent diffusion coefficients (ADCs) were significantly lower in the malignant group (P<.05 for all four readings), with the average of the four readings ranging from 0.333×10(-3) mm2/sec to 2.843×10(-3) mm2/sec. The mean Lin coefficient comparing the mean ADC reading for each observer was 0.959 (95% confidence interval: 0.935, 0.975), suggesting very high interobserver agreement between the two observers in terms of reproducibility of ADCs. The Bland-Altman plot showed good inter- and intraobserver agreement. CONCLUSION: Unenhanced MR imaging techniques showed high accuracy in the preoperative evaluation of axillary status in patients with invasive breast cancer. Results indicate reliable and reproducible assessment with DW imaging, but it is unlikely to be useful in clinical practice.

Detection of urothelial tumors: comparison of urothelial phase with excretory phase CT urography--a prospective study.

PURPOSE: To compare contrast material-enhanced computed tomographic (CT) urography 60 seconds after injection of contrast material (urothelial phase [UP]) after intravenous administration of a diuretic with the standard 5-minute delayed excretory phase (EP) in a high-risk population for upper tract tumors. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained. Eighty CT urographic examinations in 77 patients known to have or at high risk for urothelial malignancy were included. After intravenous administration of a diuretic, dual-phase CT urography was performed at 60 seconds (UP) and 5 minutes (EP) after intravenous administration of contrast material. Two experienced abdominal radiologists independently interpreted each phase more than 1 month apart to minimize recall bias. Urinary tract distention and location and size of all lesions suspected of being urothelial tumors were recorded. Standard of reference was obtained from prospective study interpretation and surgical histopathologic findings. Generalized estimating equations for logistic regression were used to compare performance measures and adjust for the correlation of repeated measures within patients. RESULTS: There were 23 upper and 61 lower urinary tract tumors confirmed in 15 and 32 patients, respectively. For detection of bladder tumors, there was higher sensitivity for the UP than the EP (89.3% [109 of 122] vs 70.5% [86 of 122], respectively; P<.0001). For detection of upper tract tumors, there was higher sensitivity for the UP than the EP (82.6% [38 of 46] vs 69.6% [32 of 46], respectively; P=.0194). Distention of all upper urinary tract segments was better during the EP than the UP (P<.0001). CONCLUSION: UP CT urography after injection of a diuretic has a higher lesion detection rate than the EP for both upper and lower urinary tract tumors, which suggests its possible use as a single-phase protocol for evaluation of the entire urinary tract in patients at high risk for urothelial tumors.

A comparison of surgical complications between immediate breast reconstruction and mastectomy: the impact on delivery of chemotherapy--an analysis of 391 procedures.

PURPOSE: To compare the postoperative complications after immediate breast reconstruction (IBR) versus mastectomy alone and to examine the impact on the delivery of chemotherapy. METHODS: In this prospective series, there were 391 consecutive women who underwent mastectomy (243 mastectomy alone and 148 mastectomy and IBR). The outcome measures were complications (within 3 months after surgery) and time to adjuvant chemotherapy. RESULTS: Compared to the IBR group, patients in the mastectomy alone group were significantly older (P < 0.0001), smokers (P = 0.007) and less likely to have had previous radiation or lumpectomy (P < 0.0001). Overall, the complication rate was significantly greater in the IBR group than mastectomy alone (27.0% vs. 15.6%, P = 0.009). Univariate analyses revealed that mastectomy with IBR [odds ratio (OR) = 2, 95% confidence interval (CI) 1.21-2.30]; bilateral procedure (OR = 1.84, 95% CI 1.07-3.16); previous radiotherapy (OR = 2.4, 95% CI 1.29-4.47); and previous lumpectomy (OR = 1.84, 95% CI 1.11-3.03) were significant predictors of increased complications. With multivariable analysis, none of these variables were significantly associated with increased complications. 106 patients received adjuvant chemotherapy; median time from mastectomy to chemotherapy was 6.8 (0.71-15) weeks in the mastectomy alone group (n = 96) compared to 8.5 (6.3-11) weeks in the IBR group (n = 10) (P = 0.01). CONCLUSIONS: Although the incidence of overall and major postoperative complications was higher after IBR than mastectomy alone, there were no significant relationships in the multivariable analysis. IBR was associated with a modest increase in time to chemotherapy that was statistically but not clinically significant.

Locally advanced prostate cancer: a population-based study of treatment patterns.

UNLABELLED: Study Type--Therapy (practice patterns). Level of Evidence 2b. What's known on the subject? And what does the study add? The treatment of locally advanced prostate cancer varies widely even though there is level one evidence supporting the use of multimodality therapy as compared with monotherapy. This study defines treatment patterns of locally advanced prostate cancer within the United States and identifies predicators of who receives multimodality therapy rather than monotherapy. OBJECTIVE: • To identify treatment patterns and predictors of receiving multimodality therapy in patients with locally advanced prostate cancer (LAPC). PATIENTS AND METHODS: • The cohort comprised patients ≥66 years with clinical stage T3 or T4 non-metastatic prostate cancer diagnosed between 1998 and 2005 identified from the Surveillance, Epidemiology and End Results (SEER) cancer registry records linked with Medicare claims. • Treatments were classified as radical prostatectomy (RP), radiation therapy (RT) and androgen deprivation therapy (ADT) received within 6 and 24 months of diagnosis. • We assessed trends over time and used multivariable logistic regression to identify predictors of multimodality treatment. RESULTS: • Within the first 6 months of diagnosis, 1060 of 3095 patients (34%) were treated with a combination of RT and ADT, 1486 (48%) received monotherapy (RT alone, ADT alone or RP alone), and 461 (15%) received no active treatment. • The proportion of patients who received RP increased, exceeding 10% in 2005. • Use of combined RT and ADT and use of ADT alone fluctuated throughout the study period. • In all 6% of patients received RT alone in 2005. • Multimodality therapy was less common in patients who were older, African American, unmarried, who lived in the south, and who had co-morbidities or stage T4 disease. CONCLUSIONS: • Treatment of LAPC varies widely, and treatment patterns shifted during the study period. • The slightly increased use of multimodality therapy since 2003 is encouraging, but further work is needed to increase combination therapy in appropriate patients and to define the role of RP.

Adjuvant trastuzumab with chemotherapy is effective in women with small, node-negative, HER2-positive breast cancer.

BACKGROUND: Several large, randomized trials established the benefits of adjuvant trastuzumab with chemotherapy. However, the benefit for women with small, node-negative HER2-positive (HER2+) disease is unknown, as these patients were largely excluded from these trials. Therefore, a retrospective, single-institution, sequential cohort study of women with small, node-negative, HER2+ breast cancer who did or did not receive adjuvant trastuzumab was conducted. METHODS: Women with ≤ 2 cm, node-negative, HER2+ (immunohistochemistry 3+ or fluorescence in situ hybridization ≥ 2) breast cancer were identified through an institutional database. A "no-trastuzumab" cohort of 106 trastuzumab-untreated women diagnosed between January 1, 2002 and May 14, 2004 and a "trastuzumab" cohort of 155 trastuzumab-treated women diagnosed between May 16, 2005 and December 31, 2008 were described. Survival and recurrence outcomes were estimated by Kaplan-Meier methods. RESULTS: The cohorts were similar in age, median tumor size, histology, hormone receptor status, hormone therapy, and locoregional therapy. Chemotherapy was administered in 66% and 100% of the "no trastuzumab" and "trastuzumab" cohorts, respectively. The median recurrence-free and survival follow-up was: 6.5 years (0.7-8.5) and 6.8 years (0.7-8.5), respectively, for the "no trastuzumab" cohort and 3.0 years (0.5-5.2) and 3.0 years (0.6-5.2), respectively, for the "trastuzumab" cohort. The 3-year locoregional invasive recurrence-free, distant recurrence-free, invasive disease-free, and overall survival were 92% versus 98% (P = .0137), 95% versus 100% (P = .0072), 82% versus 97% (P < .0001), and 97% versus 99% (P = .18) for the "no trastuzumab" and "trastuzumab" cohorts, respectively. CONCLUSIONS: Women with small, node-negative, HER2+ primary breast cancers likely derive significant benefit from adjuvant trastuzumab with chemotherapy.

A SEER-Medicare population-based study of lymphedema-related claims incidence following breast cancer in men.

Each year there are an estimated 200,000 new breast cancer cases diagnosed in the United States; of these, 1% of cases are in men. Lymphedema can be a devastating complication from breast cancer and its treatment. Currently, almost all lymphedema-related research is based on women and extrapolated to men. We conducted the first population-based study of men with incident breast cancer of any stage, diagnosed from 1998 to 2005, who were 65 years and older in the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. We utilized claims related to lymphedema and lymphedema treatment in our cohort. We defined 'lymphedema-specific' claims to contain the word 'lymphedema' in the Medicare claim description; similarly, 'lymphedema-related' claims were defined as treatments reimbursed for lymphedema but not necessarily containing the word 'lymphedema' in the Medicare claim description. We identified 628 men with incident breast cancer from 1998 to 2005 who were 65 years and older. The cumulative incidence, censored for deaths, of lymphedema-specific claims at 2, 3, 4, and 5 years was 8.0, 9.2, 10.5, and 10.5%, respectively. The median follow-up was 3.4 years and for those without any event was 4.7 years. The cumulative incidence, censored for deaths, of lymphedema-related claims at 2, 3, 4, and 5 years was 26.9, 32.2, 35.4, and 39.8%. Rates for men were similar to analogous rates for women. Lymphedema is a common complication affecting men with breast cancer as well as women and appropriate treatment and rehabilitation strategies need to be implemented for both genders.

Expression of Abl interactor 1 and its prognostic significance in breast cancer: a tissue-array-based investigation.

Abl interactor 1 (Abi1) is an adaptor protein involved in cell migration. Previous in vitro work suggested that Abi1 is a regulator of breast cancer proliferation, migration, and invasion. In the present study, we explore the expression of Abi1 and its downstream effector phospho-Akt (p-Akt) in a series of breast cancers and correlate their expression with clinicopathological and survival data. Using tissue microarrays, 988 patients with invasive breast carcinoma were evaluated by immunohistochemistry. Statistical correlation was performed to determine associations between Abi1 and p-Akt expression and standard breast clinicopathological factors. The prognostic value of Abi1 and p-Akt for disease-free (DFS) and overall survival (OS) was also evaluated. Abi1 expression was demonstrated in 33.7% (314/933) of invasive carcinomas, while p-Akt was expressed in 46.7% (441/944). There was a significant association between Abi1 and p-Akt expression (P=0.001). Abi1 expression showed significant positive correlation with older age at diagnosis and the Ki67 index. Most importantly, it was demonstrated to be an independent predictor of both DFS and OS (HR = 1.6 and 1.5, P<0.001, respectively). There was no association between p-Akt expression and survival. To the best of our knowledge, this is the first study evaluating Abi1 expression in a large group of breast cancers. Our analysis demonstrated that tumors expressing high levels of Abi1 are significantly associated with early recurrence and worse survival on multivariate analysis. This suggests that Abi1 expression has potential as a molecular marker to refine outcome prediction in breast cancer patients.

Analysis of gadobenate dimeglumine-enhanced MR findings for characterizing small (1-2-cm) hepatic nodules in patients at high risk for hepatocellular carcinoma.

PURPOSE: To retrospectively identify magnetic resonance (MR) imaging findings that are associated with hepatocellular carcinoma (HCC) in 1-2-cm nodules detected at surveillance ultrasonography (US) and to propose newer MR imaging diagnostic criteria. MATERIALS AND METHODS: Institutional research ethics board approval was obtained, and informed patient consent was waived. Among 145 consecutive patients who had 1-2-cm nodules that were newly detected at surveillance US, 108 patients underwent gadobenate dimeglumine-enhanced MR imaging. After excluding hemangiomas and unconfirmed nodules, the study sample comprised 96 patients with 116 nodules, including 43 HCCs and 73 benign nodules. MR imaging findings were assessed for signal intensity at each sequence. On the basis of the results of univariate and multivariable logistic regression analyses, several diagnostic criteria were developed by using combinations of MR imaging findings, which were then compared with the American Association for the Study of Liver Diseases (AASLD) practice guideline. RESULTS: Univariate analysis revealed four imaging findings associated with HCC, including arterial phase hyperintensity, portal or delayed phase hypointensity (washout), hyperintensity on T2-weighted images, and hepatobiliary phase hypointensity (P < .001 for each). In the multivariable analysis, arterial phase hyperintensity (adjusted odds ratio [OR], 17.1; P = .003) and washout (adjusted OR, 11.7; P = .007) were associated with HCC. Of the developed criteria, the criteria including nodules fitting the AASLD practice guideline (arterial phase hyperintensity and washout) or nodules having three or more findings were considered most reasonable, showing improved sensitivity (77% [33 of 43] versus 67% [29 of 43], P = .048) and comparable specificity (95% [69 of 73] versus 99% [72 of 73], P = .09), as compared with AASLD practice guideline. CONCLUSION: Alternative MR imaging criteria for diagnosing HCC in 1-2-cm nodules detected at surveillance US that can improve sensitivity compared with the AASLD practice guideline were proposed. A larger study is needed to verify the preliminary criteria in this study. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11101549/-/DC1.

Penile implant utilization following treatment for prostate cancer: analysis of the SEER-Medicare database.

INTRODUCTION: Prostate cancer treatments, including radical prostatectomy (RP) and radiotherapy (RT), may adversely affect erectile function. Penile implant surgery is a well-recognized erectile dysfunction (ED) treatment for prostate cancer survivors who wish to remain sexually active and in whom nonsurgical treatments are ineffective or unpalatable. AIM: To describe the utilization of penile implants after RP or RT for prostate cancer and to identify predictors of such use. METHODS: From Surveillance Epidemiology and End Results cancer registry data linked with Medicare claims, we identified men aged ≥66 years diagnosed with prostate cancer in 1998-2005 who were treated with RP or RT. Utilization of penile implants was identified in Medicare claims. Multivariable logistic regression was used to identify demographic and clinical predictors of implant utilization. MAIN OUTCOME MEASURES: Medicare claim for penile implant surgery, impact of demographic and clinical factors on penile implant surgery utilization. RESULTS: The study group comprised 68,558 subjects, including 52,747 who had RT and 15,811 who had RP as primary prostate cancer treatment. The penile implant utilization rate was 0.8% for the entire group, 0.3% for the RT group, and 2.3% for the RP group. Predictors of penile implant utilization were initial treatment modality, younger age, and African American or Hispanic race, being unmarried and residing in the South or West. CONCLUSIONS: Penile implant utilization after prostate cancer treatment is relatively uncommon in men over 65. Men who are younger, African American or Hispanic, and those who have an RP are more likely than their peers to receive a penile implant after prostate cancer treatment.

Error rates in breast imaging reports: comparison of automatic speech recognition and dictation transcription.

OBJECTIVE: The purpose of this study was to compare the error rates in breast imaging reports generated with automated speech recognition (ASR) technology as opposed to conventional dictation transcription. MATERIALS AND METHODS: Breast imaging reports reviewed from January 2009 to April 2010 during multidisciplinary tumor board meetings at two hospitals were scrutinized for minor and major errors. RESULTS: Of 615 reports obtained, 308 were generated with ASR and 307 with conventional dictation transcription. At least one major error was found in 23% of ASR reports, as opposed to 4% of conventional dictation transcription reports (p < 0.01). Major errors were more common in breast MRI reports (35% of ASR and 7% of conventional reports), the lowest error rates occurring in reports of interventional procedures (13% of ASR and 4% of conventional reports) and mammography reports (15% of ASR and no conventional reports) (p < 0.01). The error rates did not differ substantially between reports generated by staff radiologists and trainees or between reports generated by speakers who spoke English as their first language and those whose native language was not English. After adjustment for academic rank, native language, and imaging modality, reports generated with ASR were 8 times as likely as conventional dictation transcription reports to contain major errors (p < 0.01). CONCLUSION: Reports generated with ASR are associated with higher error rates than reports generated with conventional dictation transcription. The imaging modality used is a predictor of the occurrence of reporting errors. Conversely, native language and academic rank of the speaker do not have a significant influence on error rate.

Identification and quantification of peritoneal metastases in patients with ovarian cancer with multidetector computed tomography: correlation with surgery and surgical outcome.

PURPOSE: The purpose of the study was to determine the performance of a 64-row multidetector computed tomography (MDCT) in identifying peritoneal metastases in ovarian cancer patients undergoing surgical staging or cytoreduction. METHODS: This retrospective study included 76 patients who underwent surgical staging (n = 11) or cytoreduction (n = 65). Patients had MDCT before surgery (mean, 24 [SD, 16.9] days) as well as correlative surgicopathologic data. For the imaging analysis, the peritoneal cavity was divided to 28 segments, which were assessed for absence or presence of disease. Rate of optimal cytoreduction at the time of surgery was recorded. The standard of reference for this study was surgery, unless there was proof of metastasis as assessed by follow-up imaging. Sensitivity and predictive accuracy of CT and surgery compared with the standard of reference were calculated. RESULTS: The overall sensitivity and accuracy were 81.2% and 94.3% for MDCT and 87.4% and 97.2% for surgery (P = 0.14, P = 0.007), respectively. There was no difference in the detection of lesions 1 cm or greater between MDCT and surgery (89.3% and 84.9%, respectively; P = 0.31); however, MDCT was less sensitive than surgery in detecting disease sites of less than 1 cm (65.5% and 92.3%, respectively; P = 0.001). For the subgroup of patients undergoing cytoreduction after neoadjuvant chemotherapy (NAC) (n = 30), sensitivities for MDCT and surgery were similar (80% and 76.9%, respectively [P = 0.71]). Although sensitivity of CT was not altered by NAC (P = 0.92), there was a significant decrease in sensitivity of surgical assessment after NAC (94% vs 76.9%; P = 0.003). CONCLUSIONS: Multidetector computed tomography (MDCT) has similar sensitivity as surgery for peritoneal metastases of 1 cm or greater. The maintained sensitivity of MDCT in detecting peritoneal disease after NAC, which is underestimated at surgery, may help surgical planning and may improve optimal cytoreduction rate in this group of patients.

Comparison of gastric cancer survival following R0 resection in the United States and Korea using an internationally validated nomogram.

OBJECTIVE: To compare disease-specific survival (DSS) between the US and Korea following R0 resection for gastric carcinoma (GC). SUMMARY BACKGROUND DATA: Many studies have described decreased 5-year survival after curative gastrectomy for GC in the West compared with the East. Although clinicopathological presentations of GC are known to vary widely between Eastern and Western countries, including histology, tumor location, and stage at presentation, it remains unclear whether these factors account for differences in survival. METHODS: All patients undergoing curative intent resections (R0) for GC (1995-2005) were evaluated in 2 independent, single-institution prospectively maintained databases from the US (711 patients) and Korea (1646 patients). Patients receiving neoadjuvant chemotherapy were excluded from this analysis. Patient, surgical and pathologic variables were compared. DSS was determined via multivariate analysis using prognostic variables from an internationally validated GC nomogram that estimates the probability of 5- and 9-year survival. RESULTS: Age and body mass index were significantly higher in US patients. Location of tumors was more often proximal in the United States (39% vs. 9%, P < 0.0001) and distal in Korea (54% vs. 33%, P < 0.0001). Korean patients had more early stage tumors (42% vs. 28% stage Ia, P < 0.0001) with a higher number of lymph nodes identified (97% vs. 79%, >or=15 lymph nodes, P < 0.0001). The 5-year DSS was higher in Korea than in the United States. After multivariate analysis, applying factors used in the nomogram, DSS of Korean GC patients remained significantly better than that of US patients (HR = 1.3, 95% CI; 1.0-1.6, P = 0.008). CONCLUSIONS: This study demonstrates better survival for GC patients in Korea compared with the US as determined by multivariate analysis with a validated gastric cancer nomogram. Multiple possibilities can explain this difference.

Comparative effectiveness of prostate cancer surgical treatments: a population based analysis of postoperative outcomes.

PURPOSE: Enthusiasm for laparoscopic surgical approaches to prostate cancer treatment has grown despite limited evidence of improved outcomes compared with open radical prostatectomy. We compared laparoscopic prostatectomy with or without robotic assistance vs open radical prostatectomy in terms of postoperative outcomes and subsequent cancer directed therapy. MATERIALS AND METHODS: Using a population based cancer registry linked with Medicare claims we identified men 66 years old or older with localized prostate cancer who underwent radical prostatectomy from 2003 to 2005. Outcome measures were general medical/surgical complications and mortality within 90 days after surgery, genitourinary/bowel complications within 365 days, radiation therapy and/or androgen deprivation therapy within 365 days and length of hospital stay. RESULTS: Of the 5,923 men 18% underwent laparoscopic radical prostatectomy. Adjusting for patient and tumor characteristics, there were no differences in the rate of general medical/surgical complications (OR 0.93 95% CI 0.77-1.14) or genitourinary/bowel complications (OR 0.96 95% CI 0.76-1.22), or in postoperative radiation and/or androgen deprivation (OR 0.80 95% CI 0.60-1.08). Laparoscopic prostatectomy was associated with a 35% shorter hospital stay (p <0.0001) and a lower bladder neck/urethral obstruction rate (OR 0.74, 95% CI 0.58-0.94). In laparoscopic cases surgeon volume was inversely associated with hospital stay and the odds of any genitourinary/bowel complication. CONCLUSIONS: Laparoscopic prostatectomy and open radical prostatectomy have similar rates of postoperative morbidity and additional treatment. Men considering prostate cancer surgery should understand the expected benefits and risks of each technique to facilitate decision making and set realistic expectations.

Impact of breast density on the presenting features of malignancy.

PURPOSE: To determine the relationship between breast density, presenting features and molecular subtype of cancer, and surgical treatment received. METHODS: Retrospective review of a prospectively maintained database. Eligible patients had stage 1-3 cancer, were treated between 1/2005 and 6/2007, and had estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) measurements and films available for review. Density was classified at presentation as 1-4 using the Breast Imaging Reporting and Data System (BI-RADS) classification. RESULTS: 1,323 patients were included. Significant differences across the four density groups were present in age, race, multicentricity/focality, and presence of an extensive intraductal component (EIC). When density was combined into two groups, after adjustment for age, only an EIC and mammographically occult cancer were significantly more common in the dense groups. Extremely dense breasts (BI-RADS density 4) more commonly had luminal A tumors (p = 0.05), lobular cancers (p = 0.03), multicentricity (p = 0.02), and occult tumors (p < 0.0001). Greater density was associated with increased mastectomy use, with 61% of the extremely dense group having mastectomy versus 43% of those of lesser density (p = 0.01). CONCLUSIONS: Cancers in extremely dense breasts occur in younger women, are more often mammographically occult, and appear to be phenotypically different from those arising in other density groups. The more common use of mastectomy may be related to these features, although density itself is not a selection criterion for mastectomy.