BACKGROUND: The 21-gene recurrence score is a useful tool to predict the recurrence risk in patients with early hormone receptor positive (HR + ) and human epidermal receptor-2 negative (HER2-) breast cancer, which helps...BACKGROUND: The 21-gene recurrence score is a useful tool to predict the recurrence risk in patients with early hormone receptor positive (HR + ) and human epidermal receptor-2 negative (HER2-) breast cancer, which helps to determine those patients who may benefit from chemotherapy. Our goal was to assess whether there was a disparity in the use of the 21-gene recurrence score, especially between races and income levels. METHODS: Using the SEER Medicare database, we analyzed breast cancer patients diagnosed from 2012 to 2017. Inclusion criteria were HR + /HER2- phenotype, clinical stages I and II in post-menopausal women, and Stage 1 cancers in premenopausal women. Differences in the application of the 21-gene recurrence score with regard to race and income level were studied using chi-square analysis. RESULTS: Overall, 124 761 patients were included. Of these, 99.1% were females, and 32.9% had 21-gene recurrence score testing. The median age was 70 years (range 27-100). Most patients had invasive ductal carcinoma (86.6%) followed by invasive lobular carcinoma (13.4%), of which 66.0% were stage I and 34.0% as stage II. When comparing subgroups based on testing, White race had a lower application rate (83.8% vs. 84.3%, p = 0.031), compared to African-Americans (8.7% vs. 8.3%, p = 0.031). Similarly, patients with ≥ 10% poverty index showed a lower frequency of testing (46.0% vs. 47.3%, p < 0.001). However, clinically meaningful disparities by race or income were not observed. Underuse of 21-gene recurrence score was more evident among older patients ( ≥ 65, 76.9% vs. 61%, p < 0.001), separated/divorced/widowed individuals (38.7% vs. 28.4%, p < 0.001), and those undergoing mastectomy (39% vs. 29.5%, p < 0.001) compared to breast-conserving surgery. CONCLUSIONS: No clinically significant disparities were observed in race or income level in the application of the 21-gene recurrence score, which is reassuring, particularly as chemotherapy treatment regimens continue to trend appropriately trend toward de-escalation. However, underuse was more evident among older patients, separated/divorced/widowed individuals, and those undergoing mastectomy, highlighting opportunities to improve equity and adherence to guideline-based testing.
Jonsson EL, Fraser Hill WK, Saayman M
… +4 more, Yakaback S, Assadzadeh GE, Gregory McKinnon EJ, Temple-Oberle C
J Surg Oncol
· 2026 Jan · PMID 41190591
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INTRODUCTION: Lymphedema (LE) is chronic swelling due to inadequate lymphatic function, which can occur after therapeutic lymph node dissection (TLND) for melanoma. At our institution, the risk of LE is 12% for axillary...INTRODUCTION: Lymphedema (LE) is chronic swelling due to inadequate lymphatic function, which can occur after therapeutic lymph node dissection (TLND) for melanoma. At our institution, the risk of LE is 12% for axillary and 38% for ilioinguinal lymph node dissection. This study investigated LE rates in patients undergoing TLND with immediate lymphatic reconstruction (ILR) using lymphaticovenous anastomosis (LVA), a microsurgical technique aimed at preventing LE. METHODS: Patients with melanoma requiring TLND were recruited prospectively from the Tom Baker Cancer Center and were consented to undergo ILR at the time of their node dissection. Institutional ethics board approval was obtained (Ethics ID HREBA. cc-20-9426). This study was not a registered clinical trial; the ongoing randomized LYMbR trial (NCT05136079) is registered but does not include this cohort. The main objective was to assess the development of LE, which was defined as a 10% increase in postsurgical limb volume compared with the contralateral limb. In addition, participants completed the Lymphoedema Quality of Life Questionnaire (LYMQoL), a validated LE-specific quality of life patient-reported outcome measure (PROM) before surgery and at each 6-month assessment, to assess for any changes in quality of life related to LE. A direct comparison was made to historical institutional rates of LE after TLND without ILR. Kaplan-Meier analysis assessed overall survival and lymphedema-free survival, while Mann-Whitney U test compared quality of life between patients with and without lymphedema. RESULTS: Between August 2020 and October 2022, 22 patients (14 men and 8 women) with a median age of 68 (range 43-80) were included in the study and underwent TLND for melanoma with ILR. 16 patients underwent ALND, and 6 patients underwent ILND with ILR. There were no complications directly related to the ILR part of the procedure. All disease was at least stage III. At a median follow-up of 34 months (range: 0-51 months), three patients met the criteria for LE, one who underwent ALND and two ILND. Of these three patients, two had regional recurrence and one suffered from a DVT and a postoperative wound infection in the affected limb. LYMQoL scores were equal or better (p = NS) in patients without LE than those with LE across all domains except for mood: function (median IQR 1.0 vs 1.0, p = 0.78), appearance (1.0 vs 1.6, p = 0.19), symptom burden (1.1 vs 1.6, p = 0.52), and mood (1.1 vs 1.0, p = 0.87). CONCLUSION: This study aligns with other cohort studies demonstrating the usefulness of ILR in TLND patients with melanoma, which will be further examined in an ongoing randomized trial (LYMbR - NCT05136079).
Gould LE, Pring ET, Drami I
… +6 more, Constantinides J, Hodges N, Steele CW, Roxburgh CSD, Burns EM, Jenkins JT
J Surg Oncol
· 2025 Dec · PMID 41190571
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AIM: To determine whether high complexity pelvic exenterations alter perineal wound morbidity and to assess risk factors for perineal flap complications following complex rectal cancer surgery. METHODS: A retrospective a...AIM: To determine whether high complexity pelvic exenterations alter perineal wound morbidity and to assess risk factors for perineal flap complications following complex rectal cancer surgery. METHODS: A retrospective analysis of consecutive adults undergoing complex rectal cancer resections with immediate gluteal flap perineal reconstruction between January 2013-July 2021 at a tertiary referral centre. Conventional complex cancer resections were compared with "high complexity" exenterations, including en bloc sacrectomy and extended lateral pelvic side wall excision. Primary outcomes were short-term (wound infection, necrosis, dehiscence) and long-term (sinus, fistula, hernia) perineal flap complications. RESULTS: We identified 194 patients (median 56 years, 60% male) with gluteal flap reconstructions; 163 (84%) for advanced or recurrent rectal cancer. Gluteal artery perforator flaps were predominantly used (176, 92%). Wound infections were more common in the conventional group (23.2% vs. 6.3%, p = 0.001), but no other differences in complications were observed between groups. Obesity (HR 2.70, 95% CI 1.22-5.97, p = 0.014) and total pelvic exenteration (HR 2.13, 95% CI 1.07-4.23, p = 0.031) were associated with short-term complications. Age over 65 years predicted readmission/reoperation (HR 2.66, 95%CI 1.07-6.6, p = 0.040). Ureteric/ileal conduit leaks were associated with long-term complications (HR 3.37, 95% CI 1.21-9.34, p = 0.024). No flap losses occurred. CONCLUSION: Gluteal fasciocutaneous perforator flaps provide reliable perineal reconstruction after complex rectal cancer surgery. The extent of surgery and resulting defect size did not significantly influence perineal wound complication rates.
BACKGROUND: We assessed causes of death in patients with early-onset colorectal cancer (EOCRC) and factors associated with non-CRC-related deaths. METHODS: SEER database was screened between 2000 and 2020 for patients wi...BACKGROUND: We assessed causes of death in patients with early-onset colorectal cancer (EOCRC) and factors associated with non-CRC-related deaths. METHODS: SEER database was screened between 2000 and 2020 for patients with EOCRC. Causes of death were classified into CRC-related and non-CRC-related, and stratified by demographics, disease location, and stage. The main study outcome was the cause of death in EOCRC. RESULTS: A total of 67 353 patients (53.9% male) had EOCRC. In total, 13.2% of 25 441 deaths were unrelated to CRC. The most common cause of non-CRC-related deaths was medical conditions (36.1%), mainly heart disease (16.6%). CRC was more often the cause of death in patients aged < 30 years, female, and stages III and IV disease; whereras medical conditions accounted for more deaths in patients aged 40-50 years, males, and Black. Other primary cancers were more often the cause of death in patients aged 45-50 years, female patients, and Asian patients. Death due to causes other than CRC was significantly more likely when surgery for CRC was performed (OR: 2.35; p = 0.028) and when CRC was one of multiple primary cancers (OR: 3.7; p < 0.001). CONCLUSIONS: Most common causes of non-CRC-related deaths were medical conditions and other primary cancers accounting for more deaths in patients aged 40-50 years, males, Black and Asian patients, and with early-stage CRC.
INTRODUCTION: Breast cancer survival rates are improving, increasing focus on post-treatment quality of life. Oncoplastic breast surgery (OPS), which combines plastic and reconstructive techniques during breast conservat...INTRODUCTION: Breast cancer survival rates are improving, increasing focus on post-treatment quality of life. Oncoplastic breast surgery (OPS), which combines plastic and reconstructive techniques during breast conservation surgery, has emerged as an important approach to optimize both oncologic safety and cosmetic outcomes. However, data comparing complication rates across different OPS levels are limited. METHODS: We conducted a retrospective cohort study using the ACS-NSQIP database (2007-2020) to analyze OPS outcomes using the American Society of Breast Surgeons oncoplastic surgery classification system. OPS techniques are categorized into Level-1, Level-2, and volume-replacement (VR) procedures. Post-operative complications were assessed within 30 days. RESULTS: A total of 9647 patients underwent OPS between 2007 and 2020: 3917 (40.6%) Level-1, 5078 (52.6%) Level-2, and 652 (6.8%) VR surgeries. Mean age differed across groups (61.7, 60.4, and 56.9 years for Level-1, Level-2, and VR, respectively; p < 0.001). Overall complication rates were 3.8% for Level-1, 5.2% for Level-2, and 4.8% for VR, with wound complications more frequent in Level-2 procedures (3.3% vs. 1.7% for Level-1). Compared to Level-1, Level-2 OPS had higher odds of wound complications (OR = 1.472, 95% CI: 1.095-1.979), while VR procedures had lower odds than Level-2 (OR = 0.525, 95% CI: 0.305-0.902), driven mainly by wound dehiscence and superficial surgical site infections, respectively. Operative times increased with complexity (77.7, 110.6, and 171.7 min for Level-1, Level-2, and VR), and length of stay was longest for VR procedures (0.89 vs. 0.05 days for Level-1). BMI ≥ 30 (overall complications, OR = 1.485, 95% CI: 1.203-1.833; p < 0.001; wound complications, OR = 2.202, 95% CI: 1.642-2.951; p < 0.001) and diabetes (overall complications, OR = 1.311, 95% CI: 1.011-1.700; p = 0.041) were independently associated with complications, while smoking was not. VR procedures had lower odds of superficial surgical site infections compared to Level-2 (OR = 0.379, 95% CI: 0.186-0.760; p = 0.006). Level-2 and VR procedures had higher odds of wound dehiscence compared to Level-1 (OR = 1.223, 95% CI: 1.015-1.335; p = 0.039 and OR = 4.274, 95% CI: 1.880-12.154; p = 0.004, respectively). CONCLUSION: The ASBrS classification system predicts post-operative complications and operative times in OPS. More complex procedures, such as Level-2 OPS, have higher wound complication rates and longer operative times. BMI ≥ 30 and diabetes increase risk, while smoking appears less impactful. VR OPS may be advantageous in high-BMI patients. These findings support surgical planning, patient counseling, and shared decision-making.
BACKGROUND: Total mesorectal excision (TME) is the standard surgical treatment for rectal cancer. Transanal local excision (TLE) after neoadjuvant chemoradiotherapy (nCRT) is an organ-preserving option, avoiding morbidit...BACKGROUND: Total mesorectal excision (TME) is the standard surgical treatment for rectal cancer. Transanal local excision (TLE) after neoadjuvant chemoradiotherapy (nCRT) is an organ-preserving option, avoiding morbidity of TME. This study compared TLE versus TME following nCRT. METHODS: We searched Medline, PubMed, Embase, Web of Science, Scopus, Cochrane databases, Google Scholar, and CINHAL to 30 April 2025. Eligible studies were adults with nonmetastatic mid or low rectal cancer treated with nCRT followed by TLE or TME. Outcomes included local recurrence, disease free survival (DFS), overall survival (OS), and postoperative complications. Risk of bias was assessed using Cochrane RoB 2 for randomized trials and Newcastle-Ottawa Scale (NOS) for cohorts. RESULTS: Nineteen studies were included. TLE was associated with higher local recurrence in cohorts (RR = 1.823; 95% CI = 1.222-2.720; p = 0.003), but no difference in RCTs (RR = 1.248; 95% CI = 0.618-2.518; p = 0.537). DFS (HR = 1.121; p = 0.174) and OS (HR = 1.032; p = 0.830) did not differ. Postoperative morbidity was lower after TLE (RR = 0.429; p = 0.005). CONCLUSION: Strengths include robust search, study quality and number of patients, while heterogeneity in nCRT protocol, follow up, and complication reporting are limitations. Higher recurrence in TLE in cohorts but not in RCTs suggests safety of TLE when strict selection criteria are applied. REGISTRATION: PROSPERO CRD420251076513.
OBJECTIVE: Endoscopic submucosal dissection (ESD) is increasingly preferred as an alternative to surgery and as an organ-preserving method for the treatment of rectal lesions. However, its impact on bowel function-partic...OBJECTIVE: Endoscopic submucosal dissection (ESD) is increasingly preferred as an alternative to surgery and as an organ-preserving method for the treatment of rectal lesions. However, its impact on bowel function-particularly the development of low anterior resection syndrome (LARS)-remains poorly understood. This study aimed to evaluate the incidence of LARS following rectal ESD and to identify associated clinical and pathological factors. METHODS: Data from 118 patients who underwent rectal ESD between January 2018 and December 2024 were retrospectively analyzed. Demographic characteristics, lesion location and size, histopathological findings, and LARS scores were recorded. All procedures were performed by the same experienced colorectal surgeon. For functional assessment, patients were contacted by telephone, and the LARS score was administered. RESULTS: Of the patients included in the study, 60.9% were male, with a mean age of 68.2 ± 11.0 years. In total, 93.2% of lesions were located in the rectum, while 6.8% were located in the anal canal or anorectal junction. The mean lesion size was 5.04 ± 3.19 cm. Lymphovascular invasion was detected in four patients. Minor LARS was observed in 3.4% (n = 4) of cases, and no cases of major LARS were identified. All patients with LARS had adenomas located in the lower rectum containing high-grade dysplasia. CONCLUSION: The incidence of LARS after rectal ESD is low and limited to minor symptoms. Lesion location, size, and dysplasia grade may influence LARS development. These findings support ESD as a functionally safe treatment approach. Further validation in larger, prospective studies is warranted. TRIAL REGISTRATION: This study was a retrospective observational analysis.
BACKGROUND AND OBJECTIVES: The indication for sublobar resection is determined based on radiologic findings, but some cases exhibit radiology-pathology discordance. This study aimed to examine the impact of histologic su...BACKGROUND AND OBJECTIVES: The indication for sublobar resection is determined based on radiologic findings, but some cases exhibit radiology-pathology discordance. This study aimed to examine the impact of histologic subtypes on radiology-pathology discordance and their preoperative predictability. METHODS: We reviewed 585 patients with clinical stage IA adenocarcinoma and examined the relationship between radiology-pathology discordance and histologic characteristics, focusing on high-grade components: solid (SOL) or micropapillary (MIP). The predictive ability of radiologic or cytopathologic examinations for those subtypes was evaluated. RESULTS: Radiology-pathology discordance was found in 148 (25.2%) patients and was significantly associated with the presence of histologic high-grade components, with 71.9% and 70.4% of patients with upstaged lymph node and pleural invasion statuses having high-grade components. The preoperative prediction of high-grade components varied between subtypes, and radiographically pure-solid appearance and high maximum standardized uptake value were independent predictors of the SOL subtype, but not MIP. Among pre- or intraoperative cytopathologic examinations, intraoperative touch imprint cytology exhibited superior detection ability for MIP component. CONCLUSIONS: Histologic high-grade components are highly associated with radiology-pathology discordance in early-stage lung adenocarcinoma. Radiologic assessment would be beneficial for predicting the SOL subtype, but not MIP. Alternatively, intraoperative cytologic assessment would complement the detection of MIP subtype.
Emile SH, Horesh N, Garoufalia Z
… +3 more, Oosenbrug M, Boutros M, Wexner SD
J Surg Oncol
· 2025 Dec · PMID 41117358
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BACKGROUND: We assessed predictors of overall (OS) and cancer-specific survival (CSS) in stage I colorectal cancer (CRC). METHODS: Retrospective analysis of patients with stage I colon or rectal adenocarcinomas from the...BACKGROUND: We assessed predictors of overall (OS) and cancer-specific survival (CSS) in stage I colorectal cancer (CRC). METHODS: Retrospective analysis of patients with stage I colon or rectal adenocarcinomas from the SEER database (2010-2020) Survival was assessed using Kaplan-Meier statistics and multivariable Cox regression analyses. The primary outcomes were 5-year OS and CSS. RESULTS: 40,001 patients (51.3% male; mean age: 65.1 ± 12.6 years) were included. Colon and rectal cancers accounted for 75.8% and 24.2%, respectively. Five-year OS and CSS were 83.1% (95% CI: 82.6-83.5%) and 93.2% (95% CI: 92.9-93.5%), respectively. Factors independently associated with worse OS were age (HR: 1.07; p < 0.001), male sex (HR:1.48; p < 0.001), Black race (HR: 1.25; p < 0.001), single, divorced, or widowed status (HR: 1.49, 1.46, and 1.43; p < 0.001), tumor size (HR: 1.001; p = 0.008), poorly differentiated carcinomas (HR: 1.32; p < 0.001), undifferentiated carcinomas (HR:1.44; p = 0.026), perineural invasion (HR: 1.84; p < 0.001), elevated CEA levels (HR: 1.68; p < 0.001), and systemic therapy (neoadjuvant: HR: 1.3; p = 0.032, adjuvant: HR: 2.2; p < 0.001, both: HR: 1.97; p < 0.001). Factors independently associated with worse CSS were age (HR: 1.05; p < 0.001), male sex (HR: 1.32; p < 0.001), Black race (HR: 1.43; p < 0.001), marital status (HR: 1.44, 1.28, and 1.68; p < 0.001), tumor size (HR: 1.003; p < 0.001), poorly differentiated carcinomas (HR: 1.77; p < 0.001), perineural invasion (HR: 2.29; p < 0.001), elevated CEA levels (HR: 2.24; p < 0.001), and systemic therapy (neoadjuvant: HR: 2.53; p = 0.032, adjuvant: HR: 4.22; p < 0.001, both: HR: 3.83; p < 0.001). CONCLUSIONS: Although patients with stage I CRC had excellent survival, single, older, Black, male patients with large, high-grade tumors associated with perineural invasion and elevated CEA levels had a higher mortality risk.
Approximately 50%-60% of patients with colorectal cancer develop metastases, of which most have unresectable metastatic liver disease. Several recent studies highlight the progress of systemic therapy in converting patie...Approximately 50%-60% of patients with colorectal cancer develop metastases, of which most have unresectable metastatic liver disease. Several recent studies highlight the progress of systemic therapy in converting patients with high burden of colorectal liver metastases (CRLM) from unresectable to resectable disease, resulting in median overall survival improvements. The improvement of systemic therapy and the evolving spectrum of surgical techniques is allowing multidisciplinary treatment teams an increasing ability to achieve complete cytoreduction of CRLM and offering an increasing number of patients a chance for long-term survival.
INTRODUCTION: Melanoma is a heterogeneous malignancy, the incidence of which has increased by 20% in the Hispanic population over the past two decades. We aimed to compare the clinical, pathological, and outcome-related...INTRODUCTION: Melanoma is a heterogeneous malignancy, the incidence of which has increased by 20% in the Hispanic population over the past two decades. We aimed to compare the clinical, pathological, and outcome-related characteristics of Hispanic patients with melanoma in Peru (HPP) versus the United States (HPUS). METHODS: Two retrospective cohorts were evaluated: HPP diagnosed with melanoma at a tertiary institution in Lima-Peru and HPUS with melanoma registered in the Surveillance, Epidemiology, and End Results Program during the period 2010-2019. RESULTS: A total of 1136 HPP and 5302 HPUS were included. HPP patients were older (61.17 vs. 56.63 years, p < 0.001), more likely to be male (51.5% vs. 39.6%, p < 0.001), and resided in nonmetropolitan areas (49.6% vs. 3.5%, p < 0.001). HPP had a higher prevalence of primary lesions in the lower extremities (75.5% vs. 36.9%, p < 0.001) and ulceration (65.3% vs. 21.3%, p < 0.001). Histologically, HPP most commonly presented with acral lentiginous melanoma (38.1%), while HPUS had a more superficial spreading type (30.8%, p < 0.001). HPP showed greater Breslow depth (mean: 7.66 vs. 1.51 mm, p < 0.001) and mitotic activity and were diagnosed at more advanced stages: stage III (36.5% vs. 15.0%, p < 0.001). With a median follow-up of 74 months, HPP exhibited worse 5-year overall survival (OS) rates across all stages versus HPUS. CONCLUSIONS: HPP with melanoma exhibit more aggressive pathological features than their HPUS counterparts and are diagnosed at more advanced stages, resulting in poorer OS rates across all stages, and being HPP is a prognostic factor of a worse OS. These findings emphasize the need for further research to deepen our understanding of the molecular factors influencing this diverse biological presentation in Hispanic populations.
BACKGROUND: While peripheral excision margins in cutaneous melanoma are well established, the optimal excision depth remains unclear. In plantar melanoma, the fat pad plays a key functional role, raising concerns about w...BACKGROUND: While peripheral excision margins in cutaneous melanoma are well established, the optimal excision depth remains unclear. In plantar melanoma, the fat pad plays a key functional role, raising concerns about whether full excision is necessary for thin and intermediate-thickness lesions. This study evaluated the association between excision depth and oncologic outcomes in T1-T3 plantar melanoma. METHODS: Patients with primary T1-T3 plantar melanoma who underwent wide excision between 2008 and 2022 were reviewed. They were grouped by excision depth: intra-adiposal (partial fat pad preservation) and suprafascial (complete removal). Oncologic and functional outcomes, assessed via the Foot Function Index (FFI), were compared. RESULTS: Ninety-four patients (40 intra-adiposal, 54 suprafascial) were analyzed (median follow-up, 43 months). Tumor-free margins were achieved in all cases. Baseline characteristics were similar, except for lesion location. Recurrence rates were comparable, and excision depth was not significantly associated with recurrence-free survival. FFI scores from 26 patients (13 per group) tended to be better in the intra-adiposal group, though not statistically significant. CONCLUSIONS: In thin to intermediate-thickness plantar melanoma, intra-adiposal excision may be oncologically safe if tumor-free margins are achieved, potentially offering functional benefits without compromising oncologic outcomes.