Introduction: Completion lymph node dissection (CLND) for melanoma after positive sentinel lymph node biopsy (SLNB) was recently shown to improve regional but not overall survival, likely due to the majority of patients harboring no further nodal disease. We sought to determine predictors of non-sentinel node (NSN) positivity. Methods: Retrospective review of prospectively collected data on melanoma patients undergoing SLNB. Results: 116 patients underwent 119 CLNDs. The incidence of NSN positivity was 17.6%; the average number of positive NSNs in those cases was 1.5. Cervical and inguinofemoral location were most likely to yield positive NSN(s) (40% each). Conversely, the axilla was least likely at 18% (p < 0.001). The average number of nodes harvested was 13 for NSN negative cases and 20 for NSN positive cases (p = 0.005). Tumor thickness increased the probability of positive NSN(s) (OR 1.2, p = 0.02). Conclusions: Tumor thickness and nodal basin were predictors of NSN metastasis, factors that could help determine which patients may benefit from CLND. Further, CLNDs with fewer nodes may inadequately clear residual nodal disease. (C) 2018 Elsevier Inc. All rights reserved.

Background: In a province-wide audit of patients undergoing treatment for rectal cancer in British Columbia in 1996, the 4-year rate of pelvic recurrence for stage m rectal cancer was 27%. The management guidelines were changed in 2002 to include adjuvant short-course preoperative radiation and total mesorectal excision surgical techniques. Education workshops were held to implement the protocol change.Methods: We performed a provincial audit of rectal cancer cases for patients treated in the year after the protocol change, and we compared the pelvic recurrence rates with those from the audit performed in 1996.Results: During a 12-month period beginning Oct. 1, 2003, a total of 367 patients underwent radical resection of rectal cancer with a curative intent. Preoperative adjuvant radiotherapy was used in 54% of cases (197/367). Median follow-up was 34.5 months, and 91% of patients were followed for at least 2 years. Relative to the 1996 cohort, there was a decreasing trend in 2-year overall pelvic recurrence rates in the 2003/04 cohort (9.6% v. 6.9%) and a significant decrease in recurrence among patients with stage m cancers (18.2% v. 9.2%; p = 0.020). Use of adjuvant radiation increased significantly (37% v. 65%; p < 0.001), and negative radial margins were achieved in 87% (319/367) of cases.Conclusion: The rates of pelvic recurrence were improved after changes in the management guidelines advocating increased use of total mesorectal excision surgery and preoperative radiation. Knowledge translation with an integrated strategy among surgeons and medical and radiation oncologists was successful in improving population outcomes among patients with rectal cancer.

Background Laparoscopic splenectomy has become the preferred surgical procedure for the management of idiopathic thrombocytopenic purpura (ITP). However, there studies have directly compared the incidence of recurrent ITP secondary to missed accessory spleens in open versus laparoscopic splenectomy. Methods Open and laparoscopic splenectomies performed for ITP at 4 sites over 18 years were analyzed. The incidence of recurrent disease secondary to missed accessory spleens was compared between the open and laparoscopic splenectomy groups. Results A total of 105 splenectomies (54 open/51 laparoscopic) were performed. Accessory spleens were identified in 6 laparoscopic and 6 open cases (P = .57). Recurrent disease occurred in 27.6% of open and 14.6% of laparoscopic cases (P = .222). There were no cases of recurrent ITP secondary to a missed accessory spleen in either group. Conclusions The incidence of missed accessory spleens causing recurrent disease is similar when splenectomy is performed either open or laparoscopically.

Survival and recurrence rates for all rectal cancers in BC in 1996 were suboptimal relative to re- ports from other centres. From chart reviews, questionnaire mail-outs, and telephone calls, we now report possible factors which could result in suboptimal outcomes, including suboptimal staging investigations, surgical procedures, and adjuvant radiation and chemotherapy. Staging investigations performed within 3 months of diagnosis were as follows: chest X-ray in 65% of pa- tients, barium enema or colonoscopy in 74% of patients, CT scan in 21% of patients, ultrasound in 42% of pa- tients, and endorectal ultrasound in 3% of patients. Adequacy of resection was judged by use of total mesorectal excision as the preferred surgical resection technique and by pathologic assess- ment of the radial resection margin. Whether total mesorectal excision was performed could not be reliably determined from operative reports. Radial resection margins were as- sessed in only 48% of pathology reports. Adjuvant radiation was given in 60% and adjuvant chemotherapy in 60% of stage 2 and stage 3 tumors. These data show that in BC there is suboptimal cancer staging by use of staging investigations and pathol- ogy reporting. Surgical techniques and use of adjuvant therapy are also suboptimal. As such, we have iden- tified potential opportunities for im- proving outcome including improved use of staging investigations preop- eratively, improved use of preopera- tive adjuvant radiation, postopera- tive adjuvant chemotherapy, and improved surgical techniques and pathology reporting

Purpose: Rectal cancer outcome depends on stage, technical aspects of surgical excision. and use of adjuvant chemoradiation. Here, we examine effects of positive resection margin and tumor distance from the anus in stage 2 and 3 cancers on 4-year disease-specific Survival and recurrence.Methods: We reviewed all 495 rectal cancer patients registered in British Columbia in 1996.Results: There were 481 cases analyzed: 29 in situ, 134 stage 1, 107 stage 2, 100 stage 3, 83 stage 4, and 28 unknown stage. Survival was significantly affected by presence of positive resection margin in stage 2 and 3 cancers. P = 0.0001. Lower tumor distance from the anus for stage 2 and 3 cancers worsened Survival. P = 0.0007, and overall recurrence, P = 0.016, but not local recurrence, P = 0.11. Adjuvant postoperative combined radiation and chemotherapy in stage 2 and 3 cancers significantly improved survival, P = 0.070 and local recurrence, P = 0.018, but not overall recurrence, P = 0.19.Conclusions: Presence of positive resection margin and tumor distance from the anus affect survival, local recurrence, and overall recurrence. Adjuvant postoperative combined radiation and chemotherapy improved our outcomes. Our local recurrence rates for rectal cancers are worse than currently reported standards of less than 10%. Improved surgical excision and use of adjuvant preoperative radiation and chemotherapy may improve outcome. (C) 2002 Excerpta Medica, Inc. All rights reserved.

Background: Short course neoadjuvant radiation has been shown to provide improved local control of rectal cancer in a clinical trial population even in the presence of standardized surgical techniques. However, this use of hypofractionated radiotherapy has been limited in North America owing to concerns over toxicity.Methods: Patients considered to have locally advanced rectal carcinoma received a radiation dose of 25 Gy given in five fractions to the posterior pelvis. Definitive surgery was then performed within 2 weeks. Retrospective analysis was performed.Results: Sixty-three patients, of whom 60 were assessable, were treated with preoperative short course radiotherapy at the British Columbia Cancer Agency between 1991 and 1998, and 97% proceeded to R0 resection. Local recurrence developed in 3 patients (5%). Five-year actuarial overall and relapse-free survival rates for the group were 71% and 69%, respectively. The actuarial rates of relapse-free survival by stage at 5 years were stage I 83%, stage II 75%, stage III 62%, and stage 4 0%. Eleven patients (18%) experienced a postoperative complication.Conclusion: Short course preoperative radiotherapy for operable rectal cancer can be delivered to a general population and produce high pelvic control rates with acceptable toxicity. (C) 2002 Excerpta Medica, Inc. All rights reserved.

In his 2001 presidential address to the Canadian Association of General Surgeons, the author offers advice to young surgeons, based on his lifetime experience as a surgical educator, researcher and practitioner. He offers the following samples of wisdom for young surgeons: they should be prepared for a lifetime of learning and be willing and able to adapt to new advances; they should listen to their patients as they describe their presenting complaints and not be tempted to interrupt; they should take time in an emergency situation and remember that split-second decisions can affect the patient for a lifetime; they should be willing to take advice from fellow professionals; they should take time to maintain a quality family life and take adequate time away from the workplace; they should be active be a role model in their community; and, finally, they should get involved and adopt an advocacy role in their profession.

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The role of lymph node metastases in rectal cancer, their preoperative diagnosis, and their surgical and postoperative management are reviewed in this article. The results of traditional surgical approaches with and without adjuvant radiotherapy (XRT) and chemotherapy (CT) are detailed and contrasted with the results of mesorectal excision (MRE) in the high-risk patient with rectal cancer. A proposal is presented for a clinical trial to incorporate the improved surgical results of MRE on local, regional, and distant recurrence with selected use of XRT or CT.

A Head and Neck Sarcoma Registry was established by the Society of Head and Neck Surgeons to review treatment results of a rare tumor by surgeons with special interest in this anatomic site. Two hundred fourteen patients were analyzed. There were 194 adult tumors and 20 pediatric tumors. The major sites included parotid and neck, 20%; face and forehead, 18%; maxilla and palate, 13%; scalp, 12%; mandible, 11%; paranasal sinuses, 7%; larynx, 2%; and oral cavity, 5%. Eighty-four percent were resectable. The disease-free survival was 56%; overall survival was 70% at 5 years. Major determinants of survival were adequacy of resection (margins free of tumor) and tumor type. Survival differed according to tumor cell type (tumor grade was not available). Patients with chondrosarcoma and dermatofibrosarcoma had survival approaching 100%. Patients with malignant fibrous histiocytoma (MFH) and fibrosarcoma (FSA) had intermediate survival of 60% to 70%. The worst survival, < 50% at 5 years, occurred in patients with osteosarcoma, angiosarcoma, and rhabdomyosarcoma in decreasing order. This suggests a rationale for identifying high-risk patients for prospective adjuvant protocols. This study emphasizes the value of recording uncommon tumors to provide relevant information for future study and possibly therapy.

Twelve patients (weight 107-178 kg and age range 19-43 years) were investigated following ileo-gastrostomy for morbid obesity. A number of variables were studied prospectively, pre- and postoperatively, to determine the cause of weight loss--previously attributed to malabsorption or decreased caloric intake. Weight loss of 10.9-36.5 kg, mean 22.9 kg, occurred. Three-day calorie counts demonstrated a postoperative decrease in daily caloric consumption of 320-3870, mean 1975 cal. Analysis of body compartment composition after derivation of lean body mass (from calculation of total body water with tritiated water) showed a mean decrease in adipose tissue of 17.7 kg. Postoperative weight loss, mainly fat, could not all be accounted for by decreased caloric consumption or steatorrhoea (72-h stool fat increased by a mean of 30 g). Pulmonary studies showed no significant change in respiratory quotient, but a large decrease in both postoperative utilization of oxygen and the production of carbon dioxide. This may indicate an alternate, anaerobic, energy cycle utilization. Other statistically significant variables included a large fall in cholesterol, LDH cholesterol and triglycerides, and smaller decrease in HDL cholesterol. Changes in gastro-intestinal (GI) hormones and cell counts in stomach and small intestine were also measured and will be reported later.

One hundred and three women were examined independently for presymptomatic breast disease by two nurses and two surgeons who recorded physical findings and their recommendations for further clinical workup. Agreement between the observers beyond what would have been expected by chance was assessed by a new extension of the statistic κ which allows multi-level scales of measurement, more than two observers (not necessarily the same for each subject), and comparisons between and within subsets of observers. Agreement between nurses and between the nurse-surgeon pairs was not significantly better than would have been expected by chance. Agreement within surgeon pairs was only slightly better than chance (overall κ for physical findings and recommendations being 0.42 and 0.32 respectively). Agreement between surgeons was generally better for physical findings than for recommendations and was best for the finding of fibrocystic disease. Future studies to compare the performance of nurses or other allied health professionals with surgeons should, therefore, be designed to allow assessement of the reliability of the standard group.

The presence of glucocorticoid receptors was examined in 100 primary and 22 metastatic human breast cancer lesions. Aliquots of cytosol were incubated in vitro with tritiated cortisol and dexamethasone with and without competing steroids. Two different types of glucocorticoid receptors were detected. One is similar to transcortin; it sediments at 4 S in the ultracentrifuge, has a dissociation constant in the same range (10(-8) M), and does not bind fluorinated corticosteroids. While every tumor showed cortisol binding, very high activity (greater than 1000 fmoles/g tissue) was detected in 38% of primaries and in 59% of metastases. Plasma transcortin could be excluded as the source of binding activity. The other receptor binds both natural and fluorinated corticosteroids, has a higher affinity (Kd 10(-9) M), and sediments at 8 S. It was present in 23% of tumors and its quantity (26 to 995 fmoles/g) was much less than that of cortisol binder (50 to 6000 fmoles/g). While there was no correlation between the two glucocorticoid receptors, 80% of dexamethasone receptor-positive cases also had estrogen receptor. The results indicate that a significant proportion of these tumors could be subject to glucocorticoid influence.

SUMMARY The presence of glucocorticoid receptors was examined in 100 primary and 22 metastatic human breast cancer lesions. Aliquots of cytosol were incubated in vitro with tritiated cortisol and dexamethasone with and without corn peting steroids. Two different types of glucocorticoid re ceptors were detected. One is similar to transcortin; it sedi rnents at 4 S in the ultracentrifuge, has a dissociation con stant in the same range (i08 M), and does not bind fluori nated corticosteroids. While every tumor showed cortisol binding, very high activity (>1000 fmoles/g tissue) was de tected in 38% of primaries and in 59% of metastases. Plasma transcortin could be excluded as the source of binding activity. The other receptor binds both natural and fluorinated corticosteroids, has a higher affinity (K,@ i0@ M), and sediments at 8 S. It was present in 23% of tumors and its quantity (26 to 995 fmoles/g) was much less than that of cortisol binder (50 to 6000 fmoles/g). While there was no correlation between the two glucocorticoid receptors, 80% of dexarnethasone receptor-positive cases also had estro gen receptor. The results indicate that a significant propor tion of these tumors could be subject to glucocorticoid influence.