Adjuvant external beam radiation for medullary thyroid carcinoma.

BACKGROUND: Adjuvant radiation is rarely used to treat medullary thyroid carcinoma (MTC). We hypothesized that external beam radiation therapy (EBRT) would improve overall survival (OS) in MTC patients. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database identified patients who underwent total thyroidectomy and lymph nodes excision for MTC between 1988 and 2004. The Kaplan-Meier method was used for univariate comparisons of OS. Multivariate Cox proportional hazards models controlled for gender, age, lymph node status, tumor size, extent of disease, and EBRT. RESULTS: After 12 years, EBRT did not significantly improve OS (log rank, P < 0.14). In node-positive patients, univariate analysis demonstrated an OS benefit with EBRT (log rank, P < 0.05). In a multivariate model of node-positive patients, only increasing age (P < 0.001) and tumor size (P < 0.001) significantly influenced OS. CONCLUSIONS: The OS benefit attributed to EBRT in node-positive patients by univariate analysis could not be duplicated when controlling for known prognostic factors.

An evaluation of lymph node yield and lymph node ratio in well-differentiated thyroid carcinoma.

It is unknown whether the number of lymph nodes harvested (lymph node yield, LNY) or the proportion of metastatic lymph nodes resected (metastatic lymph node ratio, MLNR) influence survival in well-differentiated thyroid carcinoma (WDTC). We hypothesized that overall survival in WDTC is influenced by the LNY and MLNR. We used the Surveillance, Epidemiology, and End Results database to identify all patients with primary, nonmetastatic WDTC who underwent thyroidectomy with at least one lymph node removed between 1988 and 2004. Kaplan-Meier survival curves for LNY and MLNR were compared using the log rank test. Multivariate Cox proportional hazards models included tumor and patient-specific factors. WDTC patients that met entry criteria totaled 9926. In the univariate model, LNY and MLNR had a significant impact on survival (P < 0.001). In multivariate analysis, increasing LNY was associated with poorer survival in all patients (P = 0.001) and node-negative patients (P = 0.03), but not for node-positive patients (P = 0.27). MLNR did not influence survival in node-positive patients (P = 0.84). Among patients with WDTC treated with thyroidectomy and lymphadenectomy, increasing LNY and MLNR were associated with decreased survival. The decrease in survival associated with increasing LNY, even in node-negative patients, indicates that nodal understaging is inconsequential to WDTC survival.

Medullary carcinoma of the breast: a population-based perspective.

Prognostic factors specific to medullary carcinoma of the breast (MCB) are unknown. Our objective was to identify patient and tumor factors predictive of overall survival (OS) in a large cohort of MCB patients. The Surveillance, Epidemiology, and End Results database was used to identify patients with MCB diagnosed from 1988 to 2004. Patient, tumor, and treatment factors were compared by univariate analysis via the Kaplan­Meier method and survival differences detected using the log-rank test. A multivariate Cox proportional hazards model controlled for patient age, race, type of surgery, radiotherapy, tumor size, number of lymph node metastases (LNM), lymph node yield (LNY), estrogen receptor (ER) and progesterone receptor (PR) status, and extent of disease. On univariate analysis of 3,348 patients, factors influencing OS included age, race, tumor size, ER status, type of surgery, radiotherapy, LNM, LNY, and extent of disease (P<0.001). On multivariate analysis, advancing age (P<0.001), black race (P<0.001), regional metastases (P<0.001), distant metastases (P<0.001), increasing tumor size (P<0.001), ER positivity (P=0.003), and increasing LNM (P<0.001) were associated with decreased OS. An OS benefit was seen in PR-positive patients (P=0.002) and in those with increasing LNY (P<0.001). Even among node-negative patients, increasing LNY was associated with improved OS (P<0.001). Tumor size, LNM, regional and distant metastases, PR status, age, and race are important prognostic factors in MCB. ER positivity was associated with decreased OS, which may reflect inaccuracy in diagnosing MCB or a significant biologic variant. The improved OS seen with increasing LNY in node-negative patients suggests MCB may be currently understaged.

Survival in 12,653 breast cancer patients with extensive axillary lymph node metastasis in the anthracycline era.

Institutional data are conflicting regarding the prognosis of breast cancer patients with extensive (≥10) axillary lymph node (ALN) metastases. We hypothesized that overall survival (OS) and disease specific survival (DSS) improved after the introduction of anthracycline-based therapy in 1997. We used the Surveillance, Epidemiology, and End results (SEER) database to identify breast cancer patients with ≥10 ALN metastases diagnosed between 1988 and 2004. Patients were categorized according to whether they were diagnosed prior to the FDA approval of anthracyclines (pre-anthracycline era, pre-AE) or after approval (post-anthracycline era, post-AE). Univariate analyses of OS and DSS were performed using the Kaplan-Meier method and differences assessed via the log rank test. Anthracycline era as an independent predictor of OS and DSS was evaluated using Cox proportional hazards models with patient age, hormone receptor status, tumor size, use of radiation therapy, and number of metastatic ALNs as covariates. Entry criteria were met by 12,653 patients. Of these, 5,655 (44.7%) and 6,998 (55.3%) were treated in the pre-AE and post-AE, respectively. On univariate analysis, post-AE patients experienced significantly improved rates of OS (P<0.001) and DSS (P<0.001) relative to pre-AE patients. On multivariate analysis, treatment in the post-AE favorably influenced both OS (Hazard Ratio [HR] 0.90, 95% Confidence Interval [CI] 0.84-0.96) and DSS (HR 0.84, CI 0.79-0.91). Both OS and DSS are poor in patients with extensive ALN metastases. Patients with advanced breast cancer treated in the post-AE demonstrated superior OS and DSS.

Disparities in the use of radiation therapy in patients with local-regionally advanced breast cancer.

BACKGROUND: Radiation therapy (RT) is indicated for the treatment of local-regionally advanced breast cancer (BCa). HYPOTHESIS: We hypothesized that black and Hispanic patients with local-regionally advanced BCa would receive lower rates of RT than their white counterparts. METHODS: The Surveillance Epidemiology and End Results database was used to identify white, black, Hispanic, and Asian patients with invasive BCa and ≥10 metastatic lymph nodes diagnosed between 1988 and 2005. Univariate and multivariate logistic regression evaluated the relationship of race/ethnicity with use of RT. Multivariate models stratified for those undergoing mastectomy or lumpectomy. RESULTS: Entry criteria were met by 12,653 patients. Approximately half of the patients did not receive RT. Most patients were white (72%); the remainder were Hispanic (10.4%), black (10.3%), and Asian (7.3%). On univariate analysis, Hispanics (odd ratio [OR] 0.89; 95% confidence interval [CI], 0.79-1.00) and blacks (OR 0.79; 95% CI, 0.70-0.89) were less likely to receive RT than whites. On multivariate analysis, blacks (OR 0.76; 95% CI, 0.67-0.86) and Hispanics (OR 0.80; 95% CI, 0.70-0.90) were less likely than whites to receive RT. Disparities persisted for blacks (OR 0.74; 95% CI, 0.64-0.85) and Hispanics (OR 0.77; 95% CI, 0.67-0.89) who received mastectomy, but not for those who received lumpectomy. CONCLUSIONS: Many patients with local-regionally advanced BCa do not receive RT. Blacks and Hispanics were less likely than whites to receive RT. This disparity was noted predominately in patients who received mastectomy. Future efforts at improving rates of RT are warranted. Efforts at eliminating racial/ethnic disparities should focus on black and Hispanic candidates for postmastectomy RT.

Negligible effect of selective preoperative biliary drainage on perioperative resuscitation, morbidity, and mortality in patients undergoing pancreaticoduodenectomy.

OBJECTIVE: To examine the effect of selective preoperative biliary drainage (BD) on perioperative resuscitation, morbidity, and mortality in patients undergoing pancreaticoduodenectomy. Biliary drainage prior to pancreaticoduodenectomy remains controversial. Proponents argue that it facilitates referral to high-volume tertiary centers, while detractors maintain that it increases surgical morbidity and mortality. DESIGN: Retrospective analysis of single-institution tumor registry database. SETTING: University medical center. PATIENTS: From October 1, 2003, to May 31, 2008, 90 patients underwent pancreaticoduodenectomy for periampullary mass lesions. MAIN OUTCOME MEASURES: Clinicopathologic data were reviewed and analyzed among patients who did and did not receive BD for their association with perioperative outcomes. chi(2) Analysis, independent-samples t tests, and Mann-Whitney U tests were used as appropriate. RESULTS: Fifty-six patients (62%) underwent BD, and 34 (38%) did not. Intraoperative bile cultures were positive for 1 or more species of microorganisms in 88% of stented patients (35 of 40). There were no significant differences in fluid requirements, transfusion requirements, or surgery duration between patients who did and did not undergo BD. Estimated blood loss was increased in patients who received BD (625 mL vs 525 mL in patients who did not undergo BD; P = .03), while reoperation was significantly more common in nonstented patients (4% vs 15% in patients who did not undergo BD; P = .02). Intensive care unit stay, overall length of stay, pancreatic leak/abscess/fistula, infectious complications, postoperative percutaneous drainage, hospital readmission, and 30- and 90-day mortality were not significantly different between the 2 groups. CONCLUSIONS: Although preoperative biliary stents may complicate the intraoperative management and lessen the postoperative complications of patients undergoing pancreaticoduodenectomy, only estimated blood loss and reoperation were significantly different in this cohort. Further study may reveal patient subgroups who may specifically benefit or suffer from preoperative biliary stenting. Currently, selective preoperative BD appears appropriate in the multidisciplinary management of patients with periampullary lesions.