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Tan W.,Cancer Center | Boughey J.C.,Mayo Medical School | McNeil R.B.,Biostatistics Unit | Coppola K.E.,Mayo Medical School | And 3 more authors.
Oncologist | Year: 2010

Long-term outcomes and hence the role of adjuvant therapy in patients with small (≤1 cm), node-negative breast cancer remain unclear. This study's objective was to evaluate whether human epidermal growth factor receptor (HER)-2 status is an independent, poor prognostic marker in patients with these tumors and to identify a subgroup of patients with these small tumors who might benefit from adjuvant systemic therapy. All patients with a diagnosis of a node-negative breast tumor measuring ≤1 cm and available HER-2 test results between January 1, 2001, and December 31, 2005, at the three Mayo Clinic sites were identified. Clinicopathologic data were compared in three groups: HER-2-, HER-2-, and triple-negative (TN) tumors. Of the 421 tumors identified, 364 (86.5%) were HER-2+, 28 (6.7%) were HER-2[1], and 29 (6.9%) were TN. The median follow-up time was 1,015 days (range, 1-2,549 days). Groups were balanced in terms of patient age and tumor histology. Eleven patients with HER-2 tumors (3.0%), seven with HER-2- tumors (25.0%), and eight with TN tumors (27.6%) received adjuvant chemotherapy. Follow-up data were available for 357, 28, and 28 patients in the three groups, respectively. Death rates in the three groups were 6.4% (23 of 357) (one recurrencerelated death), 0% (0 of 28), and 7.1% (2 of 28) (one recurrence-related death), respectively. During followup, the tumor recurred in nine patients: four were HER-2 tumors (1.1%), two were HER-2+ tumors (7.1%), and three were TN tumors (10.7%). Patients with small, node-negative breast tumors have an excellent prognosis, but HER-2+and TN tumors appear to have a higher recurrence rate, warranting consideration for broad use and optimization of systemic adjuvant treatments. © AlphaMed Press.


Li C.,Oncology | Aragon Han P.,Oncology | Lee K.C.,Oncology | Lee L.C.,Oncology | And 12 more authors.
Journal of Clinical Endocrinology and Metabolism | Year: 2013

Background: Existing evidence is controversial regarding the association between BRAF mutation status and aggressive features of papillary thyroid cancer (PTC). Specifically, no study has incorporated multiple surgical practices performing routine central lymph node dissection (CLND) and thus has patients who are truly evaluable for the presence or absence of central lymph node metastases (CLNMs). Methods: Consecutive patientswhounderwent total thyroidectomy and routine CLND at 4 tertiary endocrine surgery centers were retrospectively reviewed. Descriptive and bivariable analyses examined demographic, patient, and tumor-related factors. Multivariable analyses examined the odds of CLNM associated with positive BRAF status. Results: In patients with classical variant PTC, bivariate analysis found no significant associations between BRAF mutation and aggressive clinicopathologic features; multivariate analysis demonstrated that BRAF status was not an independent predictor of CLNM. When all patients with PTC were analyzed, including those with aggressive or follicular subtypes, bivariate analysis showed BRAF mutation to be associated with LNM, advanced American Joint Committee on Cancer (AJCC) stage, and histologic subtype. Multivariable analyses showed BRAF, age, size, and extrathyroidal extension to be associated with CLNM. Conclusion: Although BRAF mutation was found to be an independent predictor of central LNM in the overall cohort of patients with PTC, this relationship lost significance when only classical variant PTC was included in the analysis. The usefulness of BRAF in predicting the presence of LNM remains questionable. Prospective studies are needed before BRAF mutation can be considered a reliable factor to guide the treatment of patients with PTC, specifically whether to perform prophylactic CLND. Copyright © 2013 by The Endocrine Society.


Pockaj B.A.,Mayo Medical School | Wasif N.,Mayo Medical School | Dueck A.C.,Mayo Medical School | Wigle D.A.,Mayo Medical School | And 7 more authors.
Annals of Surgical Oncology | Year: 2010

Patients with metastatic or stage IV breast cancer have limited therapeutic options, and the mainstay of treatment remains systemic chemotherapy. Traditionally, the role of surgery has been confined to strict palliation. Improvements in the efficacy of chemotherapeutic regimens, coupled with the use of hormonal and targeted therapy, have resulted in an expansion of surgical resection beyond simple palliation. Several single-institution studies have reported improved survival and even long-term cures after surgical resection for oligometastatic stage IV breast cancer. Similarly, provocative new data suggest that removal of the primary tumor in some patients may confer a survival advantage. The aim of this review is to summarize studies in the medical literature pertaining to the use of surgical resection in patients with stage IV breast cancer. We believe there is enough evidence to challenge conventional thinking about the role of surgery in stage IV breast cancer and to consider a new multimodality treatment paradigm to optimize patient outcomes. It is time to conduct a carefully designed randomized trial to see whether surgery in stage IV breast cancer does indeed warrant a second look. © 2010 Society of Surgical Oncology.


Lin S.-Y.,Section of Anesthesiology | Huang H.-A.,Section of General Surgery | Lin S.-C.,Pingtung Christian Hospital | Huang Y.-T.,Kaohsiung Armed Forces General Hospital | And 2 more authors.
European Journal of Anaesthesiology | Year: 2016

BACKGROUND Despite growing evidence that an educational anæsthesia video can effectively reduce perioperative anxiety, the ideal medium for addressing perioperative anxiety is unclear. OBJECTIVE The purpose of this study was to investigate the effect of viewing an anæsthetic patient information video on anxiety levels in patients scheduled to undergo surgery. DESIGN A randomised controlled trial. SETTING Pingtung Christian Hospital (PTCH), Taiwan. PATIENTS One hundred patients were randomised to either an experimental group (n=50) or a control group (n=50). INTERVENTIONS At the preoperative clinic, the experimental group watched the an 8 minute educational anæsthetic video, whereas the control group received a standard 8-min verbal briefing on anæsthesia after preoperative assessment. MAIN OUTCOMES MEASURES The Chinese version of the Spielberger state trait anxiety inventory, which included a state scale (STAI-S) and a trait scale (STAI-T), was performed in the preoperative clinic (T1) before anæsthetic preassessment, at the preoperative holding area just before surgery (T2) and again on the third day after surgery (T3). Scores for overall satisfaction with medical care were obtained on the third day after surgery. For two time interval comparisons, effect size was used to standardise the extent of change as measured by STAI-S. RESULTS After the educational intervention, state anxiety was lower in the experimental group than in the control group at both T2 (42.9±6.5 vs. 45.0±12.7) and T3 (40.2±5.3 vs. 48.8±8.5). Compared with control group, the experimental group had a larger effect size at T2 and T3 (-0.65 and-0.36, respectively). Overall satisfaction was significantly higher in the experimental group than in the control group (P<0.05). CONCLUSION Perioperative anxiety was significantly reduced and overall patient satisfaction increased after viewing a preoperative educational anæsthesia video compared with a standard verbal briefing on anæsthesia. Copyright © 2016 European Society of Anæsthesiology. All rights reserved.


Chen I.-C.,Section of Cardiology | Yu C.-C.,Section of General Surgery | Wu Y.-H.,Tainan Municipal Hospital | Chao T.-H.,National Cheng Kung University
Acta Cardiologica Sinica | Year: 2016

Background: Inflammation plays an important role in the pathogenesis of cardiovascular disease in patients with advanced chronic kidney disease (CKD). Neutrophil-to-lymphocyte ratio (NLR), an inflammatory biomarker, has not been evaluated in patients who have advanced CKDwith peripheral artery disease (PAD) undergoing percutaneous transluminal angioplasty (PTA), especially in Taiwan. Methods: We retrospectively evaluated 148 advanced CKD (creatinine clearance rate ≤30 mL/min/1.73 m2) identified from a prospective registry in our hospital (303 PTA cases in total). Kaplan-Meier analysis with log-rank test was used to study event-free survival, and all univariables (p value < 0.1) were put into multivariate Cox regression analysis. Results: During the mean follow-up time of 8.6 ± 7.8 months, 35.1% of the cases achieved primary composite endpoint (all-cause mortality or major amputation), 25.5% underwent death from any cause, and 14.9% underwent major or minor amputation. Rutherford grade 6, either NLR or NLR ≥ 3.76, and a history of hypertension had a positively prognostic impact on the occurrence of primary composite endpoint, whereas higher albumin level (≥ 3.0mg/dL) and technical success had a significantly protective effect. History of hypertension, either NLR or NLR ≥ 3.76, and age were associated with all-cause mortality. In addition, Rutherford 6, higher albumin level (≥ 3.0 mg/dL), technical success, NLR, and age could predict the occurrence of major amputation. Conclusions: NLR, but not C-reactive protein or platelet-lymphocyte ratio, is an important prognostic predictor of allmajor clinical outcomes in patients with advanced CKD and PAD receiving PTA. Further studies are warranted to establish a better strategy and healthcare program in this clinical setting. © 2016, Republic of China Society of Cardiology. All rights reserved.


Carcoforo P.,Section of General Surgery | Raiji M.T.,Georgetown University | Langan R.C.,Georgetown University | Lanzara S.,Section of General Surgery | And 9 more authors.
Journal of Cancer | Year: 2012

One in twelve American women will develop breast cancer, with infiltrating lobular carcinoma (ILC) comprising approximately 15% of these cases. The incidence of ILC has been increasing over the last several decades. It has been hypothesized that this increase is associated with combined replacement hormonal therapy. Although pathologically distinct from infiltrating ductal carcinoma (IDC), ILC is treated in the same manner as IDC. However, ILC demon-strates significantly different patterns of late local recurrence and distant metastasis. The in-cidence of extra-hepatic gastrointestinal metastases is reported to be 6% to 18%, with stomach being most common. Herein, we present a brief review of the literature and a typical case involving ILC initially presenting as a small bowel obstruction. Evidence suggests that the late clinical patterns of ILC are distinctly separate from IDC and physicians need be cognizant of its late local recurrence and unique late metastatic pattern. Different follow up strategy should be entertained in patients with ILC. © Ivyspring International Publisher.


Scarcello E.,Unit of Vascular Surgery | Ferrari M.,Unit of Vascular Surgery | Rossi G.,CNR Institute of Clinical Physiology | Berchiolli R.,Unit of Vascular Surgery | And 3 more authors.
Annals of Vascular Surgery | Year: 2010

Background: In patients with ruptured abdominal aortic aneurysm (RAAA) and shock, the time lag between the onset of the symptoms due to RAAA and the presence of a full developed shock syndrome was evaluated to assess its prognostic meaning. This time lag was called time before shock (TBS). Methods: Ninety-four patients operated on between 2002 and 2007 have been retrospectively analyzed regarding TBS and the following parameters: presence of shock, severity of bleeding, age, comorbidities, and gender. According to TBS, on a 10-hour cutoff value, three groups of patients were distinguished: patients with TBS of 10 or less (short TBS), patients with TBS greater than 10 (long TBS), and patients without shock. The relationship of these variables with intraoperative and 30-day mortality was analyzed by both univariate and multivariate analyses. Results: In the univariate analysis, patients with short TBS presented with four-fold mortality compared to patients without shock (p=0.000), whereas the increase in mortality of the patients with long TBS was nonsignificant (p=0.448). The mortality in patients with shock (presence of shock) was 3.7 times higher than in patients without shock (p=0.001). The mortality related to massive bleeding was 3.7 times higher than that associated with moderate bleeding (p=0.001). An increased mortality with borderline significance level was observed in patients older than 75 years (p=0.052). The relationship of mortality to the presence of comorbidities and gender was not significant. In the multivariate analysis, the mortality among the patients with short TBS was clearly highest, after either massive or moderate bleeding. In the logistic model with TBS, the Wald test showed as significant both short TBS (p=0.001) and severity of bleeding (p=0.033) but not age (p=0.103) and long TBS (p=0.0401). The model with TBS presented a better performance than that with shock, showing higher sensitivity, higher values of Youden's J, and a greater proportion of the total variation in mortality. Through the model with TBS, two groups of patients (those 75 years or younger with massive bleeding and those older than 75 years with moderate bleeding), both with short TBS, presented with a high risk of death not predicted by the model with shock. Conclusion: TBS seems to complete the information given by the parameter "presence of shock," and its evaluation allows a more effective judgment of the risk of death, at emergency admission of patients with RAAA. © 2010.


Burke C.R.,University of Michigan | Henke P.K.,University of Michigan | Hernandez R.,University of Michigan | Rectenwald J.E.,University of Michigan | And 6 more authors.
Annals of Vascular Surgery | Year: 2010

Background: Although aortofemoral bypass (AFB) has historically been the treatment of choice for aortoiliac occlusive disease (AIOD), rates of AFB have declined, while utilization of aortoiliac angioplasty and stenting (AS) has increased dramatically. The objective of the current study was to determine the effect of these trends on treatment outcomes in a contemporary single-institution experience with AIOD. Methods: Between 1997 and 2007, 118 AFB and 174 AS procedures were performed in 161 men (55.1%) and 131 women at a single university teaching hospital. Patient outcomes were retrospectively reviewed and analyses were performed using chi-squared/Fisher's exact test and ANOVA. Ankle-brachial index (ABI) interactions between procedure type and Trans-Atlantic Inter-Society Consensus (TASC) category were calculated using a General Linear Model. A reduced Cox model was used to determine the impact of patency, presenting symptoms, duplex surveillance, and procedure type on amputations and revisions. Kaplan-Meier estimates for survival, freedom from amputation, and freedom from revision were used to evaluate long-term outcomes. Results: There was no difference between AFB and AS groups with respect to 30-day mortality (0.8% and 1.1%, p = 0.64), myocardial infarction (1.7% and 1.1%, p = 0.53), cerebrovascular accident (0.0% and 1.1%, p = 0.35), or renal failure requiring hemodialysis (3.4% and 1.2%, p = 0.19). AFB was associated with increased surgical complication rates including the need for emergency surgery (6.8% and 1.7%, p = 0.029), infection/sepsis (16.1% and 2.3%, p < 0.001), transfusion (16.1% and 5.7%, p = 0.004), and lymph leak (8.5% and 0.6%, p = 0.001). The difference between preprocedural and postprocedural ABI was greater for AFB than AS (R, 0.39 and 0.18, p < 0.001; L, 0.41 and 0.15, p < 0.001). This difference was maintained when patients were stratified by TASC category. Conclusion: There were no differences between the AFB and AS groups with respect to long-term rates of mortality, amputation, or revision procedures. AFB continues to be performed safely, despite the case numbers in this series correlating with a lower-volume hospital. Morbidities associated with major open surgery in this series were counterbalanced by greater improvements in ABI. Patients and practitioners should continue to entertain both procedure types as viable alternatives for the treatment of AIOD. © 2010 Annals of Vascular Surgery Inc.


Laird A.M.,Section of General Surgery | Gauger P.G.,Section of General Surgery | Miller B.S.,Section of General Surgery | Doherty G.M.,Section of General Surgery
World Journal of Surgery | Year: 2012

Background Prophylactic central lymph node dissection (CLND) accompanying total thyroidectomy for papillary thyroid cancer (PTC) remains controversial. Our hypothesis is that CLND may help select patients who benefit from postoperative radioactive iodine (RAI). Methods A total of 119 patients who were clinically nodenegative underwent total thyroidectomy/bilateral CLND for papillary thyroid cancer (PTC) > 1 cm during 2002-2010. Pathology results, RAI results, and outcomes were compared between node-positive (NP) and node-negative (NN) patients. Results NP and NN patients were similar in age, gender, tumor size, and MACIS score. Median number of nodes excised was six. The rate of permanent hypocalcemia was 1.7% without permanent recurrent laryngeal nerve injuries. Thirteen of 52 (25%) NN patients and 24 of 67 (36%) NP patients had suspicious nodes by intraoperative inspection. The node assessment negative predictive value was 75%; positive predictive value was 36%. Fifty-six percent (67/118) were NP; 100 patients were treated with RAI. Fourteen of 62 NP patients had abnormal postoperative RAI scans aside from the thyroid remnant versus 4 of 38 NN patients (23 vs. 11%, p = 0.18). Median 1-year stimulated thyroglobulin (Tg) level was 0.0 for both (range 0.0-1.2, NN; 0.0-22.7, NP; p = 0.1). NP patients received higher doses of RAI (150 vs. 30 mCi, p < 0.001). Rate of recurrent or persistent disease was 3.4%. Conclusions Few node-negative patients have abnormal RAI scans outside of the thyroid bed. Node-positive patients had greater variability in stimulated 1-year Tg levels after higher doses of RAI. CLND may identify the patients most likely to have persistently elevated stimulated Tg after initial therapy for PTC. © Société Internationale de Chirurgie 2011.


PubMed | Section of General Surgery
Type: Review | Journal: Anesthesiology clinics | Year: 2016

Traumatic brain injury (TBI) represents a wide spectrum of disease and disease severity. Because the primary brain injury occurs before the patient enters the health care system, medical interventions seek principally to prevent secondary injury. Anesthesia teams that provide care for patients with TBI both in and out of the operating room should be aware of the specific therapies and needs of this unique and complex patient population.

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