The American Joint Committee on Cancer was founded in 1959. Over the last 60 years, the organization has been dedicated to expanding and promoting the TNM cancer staging system.

Cytoreductive surgery (CRS) plus Hyperthermic intraperitoneal chemotherapy (HIPEC) is an effective measure for peritoneal carcinomatosis. The cisplatin (CP) applied in HIPEC carries a risk of kidney injury. This study aims to investigate CP-induced nephrotoxicity post HIPEC and to explore its risk factors.From January 2012 to July 2013, 99 patients undergoing CRS + HIPEC were retrospectively reviewed. Patients were divided into CP and Non-CP HIPEC groups. The RIFLE classification was used to assess the severity of acute kidney injury (AKI). Renal and hepatic function, concentrations of tumor markers, and postoperative outcomes were compared between groups.47 (47.5%) patients were in the CP HIPEC group, with 52 (52.5%) patients in the Non-CP HIPEC group. 11 (11.1%) patients developed AKI, with 10 of them from the CP HIPEC group. Two patients with CP-contained HIPEC developed acute renal failure. Plasma levels of both urea nitrogen and creatinine were significantly increased in the CP HIPEC group compared with the Non-CP HIPEC group (P < 0.01). However, postoperative pain (scaled score, 4.2 vs. 3.8; P = 0.279), length of hospital stay (18.1 vs. 20.2 days; P = 0.285), hospital costs ($1 3182 vs. $12 640; P = 0.465) and incidence of postoperative complication (25.5% vs. 17.3%; P = 0.337) were similar in both groups, with comparable 3-year overall survival observed (38.6% vs. 31.8%, P = 0.319). A multivariate analysis indicated that use of CP was an independent risk factor for AKI (P = 0.017, 95% CI: 1.277–4.155).Application of CP during HIPEC is associated with an increased risk of nephrotoxicity, without promising long-term survival benefit.

Journal of Surgical OncologyVolume 116, Issue 8 p. 983-983 EDITORIAL The prognosis for prognostic tools Frederick L. Greene MD, FACS, Corresponding Author Frederick L. Greene MD, FACS fgreene@med.unc.edu orcid.org/0000-0002-1690-7139 Levine Cancer Institute, Charlotte, North Carolina Correspondence Frederick L. Greene, MD, FACS, Levine Cancer Institute, 1021 Morehead Medical Drive, Charlotte, NC 28204. Email: fgreene@med.unc.eduSearch for more papers by this author Frederick L. Greene MD, FACS, Corresponding Author Frederick L. Greene MD, FACS fgreene@med.unc.edu orcid.org/0000-0002-1690-7139 Levine Cancer Institute, Charlotte, North Carolina Correspondence Frederick L. Greene, MD, FACS, Levine Cancer Institute, 1021 Morehead Medical Drive, Charlotte, NC 28204. Email: fgreene@med.unc.eduSearch for more papers by this author First published: 02 August 2017 https://doi.org/10.1002/jso.24773Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume116, Issue8December 15, 2017Pages 983-983 RelatedInformation

The American Joint Committee on Cancer (AJCC) staging manual has become the benchmark for classifying patients with cancer, defining prognosis, and determining the best treatment approaches. Many view the primary role of the tumor, lymph node, metastasis (TNM) system as that of a standardized classification system for evaluating cancer at a population level in terms of the extent of disease, both at initial presentation and after surgical treatment, and the overall impact of improvements in cancer treatment. The rapid evolution of knowledge in cancer biology and the discovery and validation of biologic factors that predict cancer outcome and response to treatment with better accuracy have led some cancer experts to question the utility of a TNM-based approach in clinical care at an individualized patient level. In the Eighth Edition of the AJCC Cancer Staging Manual, the goal of including relevant, nonanatomic (including molecular) factors has been foremost, although changes are made only when there is strong evidence for inclusion. The editorial board viewed this iteration as a proactive effort to continue to build the important bridge from a "population-based" to a more "personalized" approach to patient classification, one that forms the conceptual framework and foundation of cancer staging in the era of precision molecular oncology. The AJCC promulgates best staging practices through each new edition in an effort to provide cancer care providers with a powerful, knowledge-based resource for the battle against cancer. In this commentary, the authors highlight the overall organizational and structural changes as well as "what's new" in the Eighth Edition. It is hoped that this information will provide the reader with a better understanding of the rationale behind the aggregate proposed changes and the exciting developments in the upcoming edition. CA Cancer J Clin 2017;67:93-99. © 2017 American Cancer Society.

In this era of multidisciplinary management of the patient with cancer, there is a critical need for accurate information related to the patient, tumor characteristics, and treatment received or planned to facilitate the quality of care delivered. Staging has been a core component of cancer care for decades, and the rapidly evolving pace of oncology calls for measures to improve the quality of cancer staging. The Institute of Medicine report on improving the quality of cancer care noted that “in order to continue to advance the high-quality cancer care delivery system, measurement and assessment of progress in improving the delivery of cancer care, public reporting of information gathered, and development of innovative strategies to facilitate performance improvement will be needed.”1 This charge from the Institute of Medicine calls for adherence to existing quality indicators (QIs) or measures (QMs), practice guidelines, and the creation of new QIs or QMs when none exist. The American Joint Committee on Cancer (AJCC) is engaged in several efforts to improve the quality of cancer staging. QIs are well-defined, quantifiable targets that allow for the assessment of structure, process, and outcome with regard to care.2-4 QIs must be measurable, actionable, and based on evidence.5 In addition, QIs should serve as benchmarks for the comparison of different metrics associated with care across many institutions.5 Among several important QIs and QMs for the care of the patient with cancer, accurate and complete documentation of cancer stage has critical implications for the patient, clinician, and public health scientists. Clinicians involved in the care of the patient with cancer, cancer registries, and other users of staging data look to the AJCC to formulate and revise the rules for cancer staging in the United States. Established in 1959, the AJCC has been collaborating with the Union for International Cancer Control since 1982 to provide a unified anatomic staging system for cancer worldwide.6 Updates to the staging system are performed periodically by convening the best expertise in the field and using the highest available level of evidence. Previous editions of the AJCC staging system have included nonanatomic prognostic factors within the TNM framework for some disease sites.7 Expansion of staging to include widely accepted pertinent prognostic factors for many other disease sites is also currently under consideration in the ongoing efforts to develop the 8th edition of the AJCC staging system. Accurate staging allows the clinician to offer patients treatment recommendations based on practice guidelines and to discuss prognosis. Cancer stage also serves as an important inclusion, exclusion, and/or stratification criterion for clinical trials. In addition to other variables, data elements with which to derive disease stage are abstracted into the National Cancer Data Base (NCDB), the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database, and the Center for Disease Control's (CDC's) National Program of Cancer Registries (NPCR). These data elements allow for research into disease outcomes and trends over time based on stage of disease when necessary and are informative in the formulation of guidelines, targeted population cancer control efforts, and allocation of resources. Importantly, staging facilitates national and international collaborative cancer research efforts, and allows clinicians from different cultural and language backgrounds to communicate and share data regarding cancer. This is especially important as the global burden of cancer cases continues to rise, especially in low-income and middle-income countries.8 Despite the fundamental role of cancer staging, timely and accurate stage assignment with appropriate documentation can be difficult to achieve in practice. First, ambiguities in portions of the AJCC staging manual leave interpretation of staging rules to the clinician or registrar, either of whom may be incorrect. Critical to improving quality staging data are cancer registrars, who are personnel with specialized training to abstract pertinent information with regard to the history, diagnosis, treatment, and surveillance for every patient with cancer in the United States. Registrars are employed at hospitals, state cancer control departments, or at the federal level and abstract information from patient medical records into hospital cancer registries, state cancer registries, the NCDB, the SEER database, and the CDC's NPCR. Given the vital role played by registrars in the collection of cancer data, their understanding and accurate interpretation of staging rules are crucial to improving the quality of staging data. Second, clinicians and registrars may not be familiar with the most recent changes to disease site-specific staging systems because there may be a time lag to the adoption of such revisions between the date when the newly published manual takes effect and consistent use of the new rules. Although the magnitude of the problem associated with the timeliness of uptake of new revisions in the latest editions of the staging manual has not been formally evaluated, our anecdotal experience based on queries in the American College of Surgeons’ cancer staging forum (CAnswer Forum; cancerbulletin.facs.org/forums/help), hosted by the AJCC, points to the existence of such a problem. Barriers to adherence, such as a lack of awareness and lack of familiarity,9 may increase inaccuracies in staging data. In addition, apathy to the value of staging by some clinicians may facilitate inaccurate staging or promote a lack of documentation. In preparation for the transition to mandatory direct abstraction of AJCC staging data in 2016, the AJCC engaged the National Cancer Registrars Association to assess registrars’ understanding of AJCC staging by administering knowledge-based tests to 1342 cancer registrars in 2013.10 We found significant gaps in knowledge and currently are working closely with our partners to improve registrars’ understanding of AJCC staging. The quality of retrospective outcomes studies using databases and clinical trials that use stage as a stratification factor may be hampered if assignment of stage is not accurate. Multipronged approaches are needed to increase the quality and accuracy of staging data. As part of ongoing activities by the AJCC regarding the 8th edition of the staging system, the AJCC has established the following core groups to oversee various aspects of the quality improvement process: the Content Harmonization Core, Evidence Based Medicine and Statistics Core (EBMS), Precision Medicine Core (PMC), and Data Collection Core. The Content Harmonization Core, comprised of experts in cancer staging (and chaired by coauthor J.E.G.), has begun to critically revisit and revise the “Purposes and Principles of Cancer Staging”7 chapter of the staging manual, which includes a general discussion of staging along with detailed rules for applying the AJCC staging system. The goal of this effort is to critically appraise the current fundamental rules for staging cancer in terms of relevance and clarity; when appropriate, new concepts that are pertinent to staging cancer such as the role of imaging in cancer staging will be introduced. In addition, ensuring the consistent use of terms and definitions across chapters and a reduction in ambiguities are some of the goals for the next edition of the AJCC staging system. The newly created EBMS core is collaborating with disease site experts to ensure that the highest levels of available evidence are used to inform changes to the staging system. Toward this end, the EBMS is providing recommendations to guide disease site expert panels about the levels of evidence needed to effect new changes to the staging system to ensure that changes made are based on both clinical and statistical validity. As our understanding of cancer biology matures and computational and statistical modeling continue to improve, clinically relevant prognostic models have and will continue to be created to serve as useful clinical decision aids.11 Realizing the importance of prognostic models as adjuncts to or independent of traditional staging, the PMC, comprised of clinicians, data scientists, statisticians, and modelers, has been established. The PMC is charged with devising guidelines for the evaluation of prognostic models that include anatomic and nonanatomic factors such as biomarkers and pertinent clinical variables for possible endorsement by the AJCC. The work of the PMC is partly informed by a study commissioned by the AJCC to examine the quality of existing cancer prognostic calculators and nomograms (unpublished data). This study highlighted the generally poor quality of existing prognostic tools. The AJCC is also exploring opportunities for collaboration with data scientists and computational modelers outside of the PMC to build prognostic tools when there is a need. The Data Collection Core is collaborating with clinicians and the registry community to identify important data items that need to be collected by hospital registries to inform future revisions to the staging system. With funding from the CDC's NPCR, the AJCC offers self-study modules consisting of multiple lessons, Webinars, and discussion forums to educate registrars about staging. Volunteer physicians who are members of the AJCC offer lessons on anatomy and clinical information pertinent to staging to cancer registrars. In addition, the AJCC hosts an online forum, CAnswer Forum (cancerbulletin.facs.org/forums/help), where clinicians and registrars from around the world seek answers to staging-related questions. Given the crucial role of institutional databases, the NCDB, and SEER registries to outcomes studies, clinician engagement and support of registrar education will help to improve the quality of abstracted data. The AJCC anticipates that multimedia approaches to the dissemination of cancer staging systems including delivery by print, Web, and applications (“apps”) will enhance the receipt of such information to myriad users of cancer staging data. Integration of cancer staging rules into electronic health records may ease information accessibility and improve the quality of staging data. Avenues to help realize these goals for the upcoming 8th edition of the AJCC staging system currently are being explored. In addition, stakeholders such as hospitals, accreditation bodies, and payers can and should play a critical role in the quest for high-quality staging data. In an effort to streamline the reporting of staging data and to improve data quality, the College of American Pathologists has sponsored a National Quality Forum-endorsed measure that recommends the reporting of pT category (pathologic tumor), pN category (regional lymph node), and histologic grade for all pathology reports from patients with resected breast cancer.12 The expansion of such a National Quality Forum measure to include other disease sites may improve the quality of staging data reported by pathologists and potentially enhance the quality of cancer care delivered. Complete and accurate staging data should be a QM promulgated by all stakeholders involved in the care of the patient with cancer. The AJCC and its partner organizations are committed to Improving the quality of cancer staging.

The T N M staging system created by a surgeon in the 1950s continues to be a major benchmark for assessing long-term outcomes in adult solid tumors. Although several major changes have occurred in this anatomical staging system, the tenets of TNM staging remain constant. Recently molecular markers and biologic modifiers have been added to this anatomical staging system to create a more robust outcomes tool. (C) 2014 Wiley Periodicals, Inc.

At Carolinas Medical Center, before 2008, axillary sentinel lymph nodes (SLNs) from breast cancer patients were evaluated with a single hematoxylin and eosin–stained slide. In 2008, the protocol changed to include a limited step sectioning at 500 μm. In this study, we compared the intraoperative and permanent section pathologic findings for SLN biopsies from 2006 to 2007 to those from 2009 to 2010. We hypothesized that evaluating 2 slides would increase the detection of micrometastases and isolated tumor cells (ITCs) on permanent sections and correspondingly decrease the sensitivity of intraoperative touch preparation cytology (IOTPC). From 2006 to 2007, 140 (23.5%) of 597 of SLN permanent sections contained tumor cells: 92 macrometastases (65.7%), 36 micrometastases (25.7%), and 12 ITCs 0.2 mm or less (8.6%). The sensitivity of IOTPC for 2006 to 2007 was 51.4% for any tumor cells and 71.7% for macrometastases. From 2009 to 2010, 160 (21.9%) of 730 SLN permanent sections were positive for any tumor cells: 76 macrometastases (47.5%), 55 micrometastases (34.4%), and 29 ITCs (18.1%). The sensitivity of IOTPC for 2009 to 2010 was 39.4% for any tumor cells and 76.3% for macrometastases. With limited step sectioning, we observed an approximately 10% increase in the detection of both micrometastases and ITCs in SLN. The increased detection of ITCs on permanent sections reached statistical significance (P = .018). However, under current clinical guidelines, patients with limited SLN involvement may not be required to undergo completion axillary lymph node dissection. The ability to detect SLN tumor deposits less than 2 mm must be balanced with the clinical utility of doing so.

As surgeons, we grew up learning about postoperative complications in the forum known as the Morbidity and Mortality (M&M) conference. We learned that certain genre of complications, such as intra-abdominal infections, myocardial ischemia, pneumonia, and deep venous thrombosis, portend especially detrimental outcomes for our surgical patients. The concept of the M&M conference developed from the seminal work of Dr. Ernest Amory Codman who, in the early 1900s working at Massachusetts General Hospital, recognized that in order to learn from our mistakes and improve patient care we had to discuss unsuccessful outcomes, quantify and catalogue these misadventures, and follow the course of our patients. These tenets espoused by Codman were not embraced by his fellow Boston physicians and he was invited to remove himself from the environment of the medical staff and hospital! Codman’s early endeavors into developing databases and reporting outcomes served, however, as the basis for the quality initiatives first developed by the American College of Surgeons (ACS) during the infancy of that organization in the second decade of the twentieth century. Subsequently, the creation of risk-adjusted instruments, such as the Veterans Administration (VA)initiated National Surgical Quality Improvement Program (NSQIP) launched in the early 1990s and the ACS–NSQIP promulgated to all hospitals more recently, has provided analytic tools not only to evaluate the consequences of surgical complications during the immediate postoperative period but to assess the ultimate effects of these events on the entire course of an illnesses, such as cancer. As an important derivative from the ACS–NSQIP, the Surgical Risk Calculator recently has been launched to facilitate the computation of the likelihood of 30-day outcomes for a large number of surgical procedures given the presence of preoperative comorbidities. The late Shukri Khuri, working with his VA colleagues using the VA-NSQIP database, showed that the 30-day complication rate is a robust factor in determining both short(30-day) and long-term survivals for all patients undergoing eight common operations. Although not directed previously to cancer patients, Khuri’s work suggested that the ‘‘inflammatory response’’ resulting from postoperative complications was a detrimental factor in determining long-term survival and was independent of patients’ preoperative risks. The importance of this work had obvious implications for patients with malignancy. The prognosis of cancer is dependent on adequate staging of patients. More recently, molecular markers along with anatomical staging have been added to the taxonomy of outcomes of cancer patients. Unfortunately, the role of comorbidities, although championed by some, continues to be unrecognized as a major factor in the outcomes of cancer patients. Along with this, we have generally failed to understand the importance of the postoperative complication on the future of our cancer patient. Perhaps complicated outcomes are associated with other factors. The adverse effect of blood transfusion has been delineated as a reason for reduced survival in cancer patients, perhaps as a consequence of reduced immunocompetence resulting from transfusion. Obviously patients with postoperative complications may have an increased This is an editorial to the article available at doi: 10.1245/s10434013-3267-0.

57 Background: A woman with a known BRCA mutation has a lifetime risk for the development of breast cancer of up to 80%. Carolinas Medical Center cares for approximately 600 breast cancer patients annually with genetic testing offered to those patients whose history meets commonly established criteria. This study seeks to document the follow-up patients with BRCA mutations most commonly undertake at our facility. Methods: This study is a retrospective review of all patients who underwent genetic testing at Carolinas Medical Center and who were found to be positive for a mutation in the BRCA gene. Since 1996 our genetics group has tested 2056 individuals, of these 246 (12%) carry a mutation of the BRCA-1 and/or BRCA-2 gene. 102 of these 246 patients (41%) had no evidence of cancer at the time of genetic testing. 144 of these 246 patients (59%) did carry a diagnosis of cancer at the time of genetic testing. Results: Of the 246 patients who tested positive for a deleterious mutation in the BRCA gene 204 (83%) had documented follow-up after their diagnosis. 140 of those 204 patients (69%) had documented initial follow-up appointments to discuss their diagnosis. 63 patients of the 140 (45%) who sought initial consultation met with a surgeon. 73 of these 140 patients (52%) had their initial consultation with a Gyn/Oncologist. 3 patients had their initial consultation with a medical oncologist and the remaining patient with their primary care physician. Documentation was available for 131 of the 204 patients (64%) in regards to follow up related to their risk of breast cancer development, 129 of those patients were being followed by a high risk breast provider. 126 of the 204 patients (62%) with long term follow-up were being followed by a Gyn/Oncologist secondary to their increased risk for ovarian cancer. This data includes all patients regardless of the decisions they made concerning surveillance or prophylactic surgery. Conclusions: The majority of the patients at Carolinas Medical Center who have tested positive for a BRCA mutation have sought long term follow-up with both a high risk breast provider and a Gyn/Oncologist in regards to their increased risk for the development of both breast and ovarian cancer.

BACKGROUND:Thyroidectomy has traditionally been performed as an inpatient hospital procedure, but low risk and high patient tolerance make it acceptable as an outpatient procedure.STUDY DESIGN:All thyroidectomies performed by a single surgeon between March 2003 and June 2009 were retrospectively and prospectively reviewed as planned outpatient or planned inpatient operations, noting the patient's American Society of Anesthesiologists (ASA) classification, success of completion as an outpatient procedure, time to same-day discharge, postoperative emergency room visit, hospital admission, and complications.RESULTS:Overall, 1,136 of 1,242 thyroidectomies were planned as outpatient procedures and 1,063 (93.6%) were successfully completed as such. Including 1 outpatient procedure initially planned as an inpatient procedure, 1,064 outpatient procedures were performed, of which 613 were total and 451 less-than-total thyroidectomies. These outpatient procedures had a mean time to day-surgery discharge of 2 hours and 42 minutes. Of discharged outpatients, a postoperative emergency room visit within 30 days occurred in 83 cases (7.8%), with subsequent hospital admission in 25 of these patients (2.3%). Excluding 153 cases of isolated and self-limited asymptomatic hypocalcemia (14.4%), substantial complications occurred in 122 discharged outpatients (11.5%), including 56 symptomatic hypocalcemias (5.2%), 39 transient recurrent laryngeal nerve injuries (3.7%), 4 permanent recurrent laryngeal nerve injuries (0.4%), and 2 hematomas (0.19%). None of the patients with postoperative hematoma required bedside decompression and only 1 occurred within 24 hours of the outpatient procedure. Discharged outpatient thyroidectomy patients were younger (53 years versus 60 years; p < 0.0001) and healthier (2.3 ASA versus 3.0 ASA; p < 0.0001) than planned inpatient thyroidectomies.CONCLUSIONS:Outpatient thyroidectomy in experienced hands is safe and reasonable with favorable patient acceptance and the potential for substantial health care cost savings.

BACKGROUND: Axillary lymph node status remains the most important prognostic factor in breast cancer. Established staging systems emphasize the absolute number of positive nodes, without regard for the total number of lymph nodes examined. We sought to confirm that a ratio of positive nodes to total nodes examined (LNR) has prognostic value beyond the current TNM classification for women with node-positive breast cancer.STUDY DESIGN: Using the Duke University Medical Center breast cancer tumor registry, we identified women diagnosed with node-positive breast cancer between 1985 and 2005 (n = 1,788). Variables analyzed for impact on disease-free survival (DFS) included the number of positive nodes, N classification, and the calculated LNR. Based on LNR, the patients were divided into low(<= 0.2), intermediate- (>0.2 and <= 0.65), and high- (>0.65) risk groups. Kaplan-Meier survival analysis was performed with groups compared by the log-rank test. Values of p < 0.05 were considered significant.RESULTS: For all patients, the 10-year actuarial DFS rates for the low-, intermediate-, and high-risk LNR groups were 69%, 60%, and 45%, respectively. The DFS curves for the 3 LNR groups were significantly different (p < 0.0001). Furthermore, when patients were stratified by pN status, the DFS curves for the LNR groups remained significantly different. The LNR discerned groups of patients with divergent survival probabilities across all pN groups.CONCLUSIONS: Our data show that LNR has prognostic value in assessing breast cancer survival beyond the current TNM classification. This study supports the inclusion of LNR for enhanced risk stratification beyond traditional pN classification. (J Am Coll Surg 2010;210:797-807. (C) 2010 by the American College of Surgeons)

Journal of Surgical OncologyVolume 97, Issue 2 p. 97-98 Guest Editorial Is volume the most important predictor of outcome in cancer management? Frederick L. Greene MD, Corresponding Author Frederick L. Greene MD [email protected] Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina Chair, Commission on Cancer, American College of Surgeons.Chairman, Department of Surgery, Carolinas Medical Center, P. O. Box 32861, Charlotte, NC 28232. Fax: 704-355-5619.Search for more papers by this author Frederick L. Greene MD, Corresponding Author Frederick L. Greene MD [email protected] Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina Chair, Commission on Cancer, American College of Surgeons.Chairman, Department of Surgery, Carolinas Medical Center, P. O. Box 32861, Charlotte, NC 28232. Fax: 704-355-5619.Search for more papers by this author First published: 26 July 2007 https://doi.org/10.1002/jso.20833Citations: 1 AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. REFERENCES 1 Chang AE: Improving surgical outcomes for cancer in the United States. J Surg Oncol 2007; 95: 91–92. 2 Finlayson EV, Goodney PP, Birkmeyer JD: Hospital volume and operative mortality in cancer surgery. Arch Surg 2003; 138: 721–726. 3 Begg CB, Cramer LD, Hoskins WJ, et al.: Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998; 280: 1747–1751. 4 American College of Surgeons: Bariatric Surgery Center Network Accreditation Program. http://www.facs.org/cqi/bscn/index.html (accessed April 12, 2007). 5 Fong Y, Gonen M, Rubin D, et al.: Long-term survival is superior after resection for cancer in high-volume centers. Ann Surg 2005; 242: 540–547. 6 Guller U, Safford S, Pietrobon R, et al.: High hospital volume is associated with better outcomes for breast cancer surgery: Analysis of 233,247 patients. World J Surg 2005; 29: 994–1000. 7 Metreveli RE, Sahm K, Abdel-Misih R, et al.: Major pancreatic resections for suspected cancer in a community-based teaching hospital: Lessons learned. J Surg Oncol 2007; 95: 201–206. Citing Literature Volume97, Issue21 February 2008Pages 97-98 ReferencesRelatedInformation

Lymph node (LN) evaluation in colorectal cancer has been shown to be an important prognostic indicator of outcome as well as paramount for appropriate staging. The purpose of our study was to assess the effect of lymph node evaluation on outcomes for rectal cancer patients. Consecutive cases of rectal cancer with 5 years of follow-up reported to the American College of Surgeons National Cancer Database from 1993-1996 were analyzed. Variables included extent of regional LN examination as well as the effect of age, education, rural versus urban residence, and case volume on lymph node retrieval. Analysis was performed using Cox Proportional Hazard Regression Modeling with forward step-wise methodology for determining hazard of mortality at 5-year follow-up. The study included 37,789 patients. Of these 57.2% were male and 91.8% were Caucasian. The average age was 66.4 years (range: 17-102 years). Less than 8 LN’s were obtained in 43% of cases, 8-12 LN’s were obtained in 27%, and >12 LN’s in 30%. Age, patient education status, rural versus urban residence, and hospital annual case volume had a significant impact (p=0.0001) on regional LN examination. However, extent of regional lymph node examination was not a significant predictor of hazard of death. Although patient age, education status, rural or urban residence, and case volume have an impact on the number of LN’s harvested during rectal resection for cancer, this does not impact the 5 year hazard of death.

Hope, William W. MD; Lincourt, Amy PhD; Lang, Nicholas MD; Stewart, Andrew MA; Sing, Ronald DO; Greene, Frederick MD, FACS; Heniford, Todd B. MD, FACS Author Information