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Complete surgical resection at the time of primary presentation is likely to afford the best chance for long-term survival. With long-term follow-up, it is clear that recurrence will continue to occur, and a 5-year disease-free interval is not a cure. Patients with an incomplete initial resection, age less than 50 years, and high-grade tumors are candidates for investigational adjuvant therapy.

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The management of a substernal goiter is a problem which has challenged surgeons since its first description in 1749. While the overall incidence in the United States has decreased with the routine use of iodized salt, the development of large multinodular substernal goiters in the rest of the world is still common. In addition, even in those regions where they are less common, knowledge of their treatment is important as they can represent up to 7% of mediastinal tumors. Certainly, the majority are large, benign masses found in the superior and anterior mediastinum, although from 3 to 15% can be malignant in nature. The presenting symptoms generally relate to the compressive nature of the mass on nearby structures. Up to 90% of patients report some form of respiratory symptoms in association with these masses. Diagnostic evaluation should include chest x-ray and computed tomographic (CT) scan. Needle aspiration biopsy should be avoided due to its dangerous substernal location. The treatment is surgical, as medical therapy is generally unsuccessful. Perioperative management should include careful evaluation of the airway as the extent of compression and deviation caused by the mass can lead to a difficult intubation. The vast majority of substernal goiters can be removed via a cervical incision; occasionally sternotomy or thoracotomy is necessary. Although rare, tracheomalacia secondary to prolonged compression of the trachea by the mass needs to be watched for postoperatively. Overall, the results of surgical treatment are excellent, as morbidity and mortality are minimal and patients can expect full relief of symptoms secondary to these mediastinal masses.

Summary Background 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov , NCT03471494 . Findings Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding National Institute for Health Research Global Health Research Unit.

Data documenting the isolated effect of systemic hyperinsulinemia on whole body and skeletal muscle leucine carbon kinetics in humans are limited. Using steady-state [14C]leucine kinetics, 10 normal volunteers were studied in the baseline postabsorptive state and then under euglycemic, hyperinsulinemic (71 +/- 5 microU/ml), and euleucinemic conditions. Systemic hyperinsulinemia resulted in a significant decrease in whole body and forearm leucine rate of appearance (Ra) by 17 and 37%, respectively, (P less than 0.0003, 0.03), without a significant change in the nonoxidized rate of disappearance for either (P = 0.23, 0.66). The baseline contribution of total body skeletal muscle (TBSM) leucine Ra and rate of disappearance (Rd) to whole body leucine Ra and Rd was 27 +/- 6 and 24 +/- 5%, respectively. During hyperinsulinemia TBSM Ra decreased by 34%, whereas whole body Ra decreased by 16%. We conclude that the primary effect of insulin in the whole body and skeletal muscle is to decrease leucine release from protein without a significant effect on leucine incorporation into protein. This antiproteolytic effect of insulin is more pronounced in skeletal muscle than in other tissues in the body.

As 30-day mortality and survival are similar to those observed in younger patients, a PD can be offered to carefully selected octogenarians.

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