A multivariable model based on calcification, nodule size, nuclear atypia, and tobacco use may predict the risk of thyroid cancer requiring a total thyroidectomy in patients with thyroid nodules of indeterminate cytology.

This study is consistent with previous research showing that breast-conserving surgery after neoadjuvant chemotherapy does not reduce breast cancer-specific survival. In fact, patients undergoing breast-conservation after neoadjuvant therapy appeared to have better survival than patients undergoing mastectomy without radiation.

The testing of oDX in BC has significantly increased since first implemented. Results from additional studies such as TAILORx will clarify the current discordant practice patterns between low oDX RSs and adjuvant chemotherapy recommendations.

Background Esophagectomy is associated with significant morbidity. Optimizing perioperative fluid administration is one potential strategy to mitigate morbidity. We sought to investigate the relationship of intraoperative fluid (IOF) administration to outcomes in patients undergoing transhiatal esophagectomy with particular attention to malnourished patients, who may be more susceptible to the effects of fluid overload. Material and methods Patients who underwent transhiatal esophagectomy from 2000–2013 were identified from a retrospective database. IOF rates (mL/kg/hr) were determined and their relationship to outcomes compared. To examine the impact of malnutrition, we stratified patients based on median preoperative serum albumin and compared outcomes. Results and discussion 211 patients comprised the cohort. 74% of patients underwent esophagectomy for esophageal adenocarcinoma. Linear regression analyses were performed comparing independent perioperative variables to four outcomes variables: length of stay, complications per patient, major complications, and Clavien-Dindo classification. IOF rate was significantly associated with three of four outcomes on univariate analysis. Significantly more patients with a preoperative albumin level ≤3.7 g/dL who received more than the median IOF rate experienced more severe complications. Conclusions Increased intraoperative fluid administration is associated with perioperative morbidity in patients undergoing transhiatal esophagectomy. Patients with lower preoperative albumin levels may be particularly sensitive to the effects of volume overload.

BackgroundThe objective of this study is to describe the system and technical factors that enabled our moderate size transhiatal esophagectomy program to achieve low mortality rates.MethodsA retrospective chart review was conducted on 200 consecutive patients who underwent transhiatal esophagectomy at Robert Wood Johnson University Hospital. Primary outcomes included operative times, estimated blood loss, frequency and nature of complications, and lengths of stay in the hospital and the intensive care unit.ResultsIn general, surgical outcomes tended to improve over the course of this study. We identified decreased operative time, intra-operative blood loss, frequency of complications, and lengths of intensive care unit and hospital stay as the program matured. Through coordinated actions of the surgical and anesthesia teams, all intraoperative injuries were responded to in an effective, emergent fashion and all but one patient was saved. This resulted in an inhospital and 30-day mortality rate of only 0.5%.ConclusionsOur study suggests that a dual attending approach, focus on avoiding “failure to rescue”, increased volume, and a surgeon driven commitment to quality improvement may lead to low mortality rates after transhiatal esophagectomy.

Introduction Human injury or infection induces systemic inflammation with characteristic neuro-endocrine responses. Fluctuations in autonomic function during inflammation are reflected by beat-to-beat variation in heart rate, termed heart rate variability (HRV). In the present study, we determine threshold doses of endotoxin needed to induce observable changes in markers of systemic inflammation, we investigate whether metrics of HRV exhibit a differing threshold dose from other inflammatory markers, and we investigate the size of data sets required for meaningful use of multi-scale entropy (MSE) analysis of HRV. Methods Healthy human volunteers (n=25) were randomized to receive placebo (normal saline) or endotoxin/lipopolysaccharide (LPS): 0.1, 0.25, 0.5, 1.0, or 2.0 ng/kg administered intravenously. Vital signs were recorded every 30 minutes for 6 hours and then at 9, 12, and 24 hours after LPS. Blood samples were drawn at specific time points for cytokine measurements. HRV analysis was performed using EKG epochs of 5 minutes. MSE for HRV was calculated for all dose groups to scale factor 40. Results The lowest significant threshold dose was noted in core temperature at 0.25ng/kg. Endogenous TNF-α and IL-6 were significantly responsive at the next dosage level (0.5ng/kg) along with elevations in circulating leukocytes and heart rate. Responses were exaggerated at higher doses (1 and 2 ng/kg). Time domain and frequency domain HRV metrics similarly suggested a threshold dose, differing from placebo at 1.0 and 2.0 ng/kg, below which no clear pattern in response was evident. By applying repeated-measures ANOVA across scale factors, a significant decrease in MSE was seen at 1.0 and 2.0 ng/kg by 2 hours post exposure to LPS. While not statistically significant below 1.0 ng/kg, MSE unexpectedly decreased across all groups in an orderly dose-response pattern not seen in the other outcomes. Conclusions By usingrANOVA across scale factors, MSE can detect autonomic change after LPS challenge in a group of 25 subjects using EKG epochs of only 5 minutes and entropy analysis to scale factor of only 40, potentially facilitating MSE’s wider use as a research tool or bedside monitor. Traditional markers of inflammation generally exhibit threshold dose behavior. In contrast, MSE’s apparent continuous dose-response pattern, while not statistically verifiable in this study, suggests a potential subclinical harbinger of infectious or other insult. The possible derangement of autonomic complexity prior to or independent of the cytokine surge cannot be ruled out. Future investigation should focus on confirmation of overt inflammation following observed decreases in MSE in a clinical setting.

Randomized controlled trials (RCTs) have challenged the need for routine radiation therapy (RT) in women ≥ age 70 with favorable early stage breast cancer (BC) due to modest improvement in local control and no survival benefit. We studied practice patterns in RT among elderly women in the United States. We analyzed data from the National Cancer Database (NCDB) of women ≥age 70 diagnosed with T1 or T2 and N0 invasive BC treated with breast conservation surgery (BCS) between 2004 and 2014. Patients were divided into four groups: (1) no RT, (2) partial breast irradiation (PBI); (3) hypofractionation (HF); and (4) conventional whole breast RT (CWBI). Univariable and multivariable analyses (MVA) were performed to compare characteristics among the four RT groups. A subgroup analysis of women with favorable disease (T1N0 ER + HER2‐) was also performed with similar statistical comparisons. Of the 66,126 meeting eligibility, 9,570 (14.5%) had PBI, 16,340 (24.7%) had HF, and 40,117 (60.7%) had CWBI. Only 99 patients (0.15%) had RT omitted. Omission of RT increased marginally from 0.04% in 2004 to 0.24% in 2014. MVA identified older age (OR 1.18, CI 1.08‐1.28), more comorbidities (Charlson‐Deyo Score of 1) (OR 3.36, CI 1.29‐8.72), and no hormone therapy (OR 22.07, CI 5.79‐84.07) as more likely to have RT omitted. The use of HF increased from 3.9% to 47.0%, P < .001 with a concomitant decrease in CWBI from 88% to 41%, P < .001. MVA identified older age, treatment location, and omission of chemotherapy as associated with HF. No significant differences from the larger cohort were found among the T1N0 subgroup analysis. Despite RCT evidence, omission of RT was rare in the United States, suggesting that more effective outreach methods to disseminate clinical guideline information may be needed.

Background: Follicular neoplasm (Bethesda IV cytology) requires thyroid lobectomy for diagnosis. Approximately 15-30% of cases are ultimately malignant, requiring reoperative completion thyroidectomy. We sought to reassess whether intraoperative frozen section (FS) reduces the need for reoperative thyroidectomy in these cases. Methods:A retrospective chart review of fine needle aspiration (FNA) results showing follicular neoplasm from 2003 to 2012 was performed. Our practice is to offer thyroid lobectomy with FS for these patients; with suspicious FS, surgery proceeded to total thyroidectomy. FS suspicious for papillary thyroid carcinoma (PTC) was based on nuclear features (nuclear grooves/atypia, pseudo-nuclear inclusions) and for follicular thyroid carcinoma (FTC) was based on capsular/vascular invasion. Results:A total of 148 patients with follicular neoplasm on FNA were identified, of which 79 underwent FS. Fifteen had suspicious FS with 12 having malignancy on final pathology, for a positive predictive value of 80%. Nine showed features suspicious for PTC, of which eight had PTC. Six showed features suspicious for FTC, of which four had malignancy on final pathology. Of the 64 patients with unremarkable FS, 49 had benign final pathology, for a negative predictive value of 77%. Twelve (19%) patients required reoperation. Seven of 19 patients (37%) with malignancy avoided reoperation due to FS. Risk of malignancy with follicular neoplasm diagnosis was 34% (51/148), while risk of malignancy with follicular neoplasm and suspicious FS was 80%. Conclusions:Risk of malignancy with follicular neoplasm and suspicious FS is 80%. FS may avoid reoperative completion thyroidectomy in up to a third of patients.