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Background Approximately one third of all patients with CRC present with, or subsequently develop, colorectal liver metastases (CRLM). The objective of this population-based analysis was to assess the impact of resection of liver only, lung only and liver and lung metastases on survival in patients with metastatic colorectal cancer (mCRC) and resected primary tumor. Methods Ten thousand three hundred twenty-five patients diagnosed with mCRC between 2010 and 2015 with resected primary were identified in the Surveillance, Epidemiology and End Results (SEER) database. Overall, (OS) and cancer-specific survival (CSS) were analyzed by Cox regression with multivariable, inverse propensity weight, near far matching and propensity score adjustment. Results The majority (79.4%) of patients had only liver metastases, 7.8% only lung metastases and 12.8% metastases of lung and liver. 3-year OS was 44.5 and 27.5% for patients with and without metastasectomy (HR = 0.62, 95% CI: 0.58–0.65, P  < 0.001). Metastasectomy uniformly improved CSS in patients with liver metastases (HR = 0.72, 95% CI: 0.67–0.77, P  < 0.001) but not in patients with lung metastases (HR = 0.84, 95% CI: 0.62–1.12, P  = 0.232) and combined liver and lung metastases (HR = 0.89, 95% CI: 0.75–1.06, P  = 0.196) in multivariable analysis. Adjustment by inverse propensity weight, near far matching and propensity score and analysis of OS yielded similar results. Conclusions This is the first SEER analysis assessing the impact of metastasectomy in mCRC patients with removed primary tumor on survival. The analysis provides compelling evidence of a statistically significant and clinically relevant increase in OS and CSS for liver resection but not for metastasectomy of lung or both sites.

Background The objective of the present population-based analysis was to assess survival patterns in patients with resected and metastatic GIST. Methods Patients with histologically proven GIST were extracted from the Surveillance, Epidemiology and End Results (SEER) database from 1998 through 2011. Survival was determined applying Kaplan-Meier-estimates and multivariable Cox-regression analyses. The impact of size and mitotic count on survival was assessed with a generalized receiver-operating characteristic-analysis. Results Overall, 5138 patients were included. Median age was 62 years (range: 18–101 years), 47.3 % were female, 68.8 % Caucasians. GIST location was in the stomach in 58.7 % and small bowel in 31.2 %. Lymph node and distant metastases were found in 5.1 and 18.0 %, respectively. For non-metastatic GIST, three-year overall survival increased from 68.5 % (95 % CI: 58.8–79.8 %) in 1998 to 88.6 % (95 % CI: 85.3–92.0 %) in 2008, cancer-specific survival from 75.3 % (95 % CI: 66.1–85.9 %) in 1998 to 92.2 % (95 % CI: 89.4–95.1 %) in 2008. For metastatic GIST, three-year overall survival increased from 15.0 % (95 % CI: 5.3–42.6 %) in 1998 to 54.7 % (95 % CI: 44.4–67.3 %) in 2008, cancer-specific survival from 15.0 % (95 % CI: 5.3–42.6 %) in 1998 to 61.9 % (95 % CI: 51.4–74.5 %) in 2008 (all P Trend  < 0.05). Conclusions This is the first SEER trend analysis assessing outcomes in a large cohort of GIST patients over a 11-year time period. The analysis provides compelling evidence of a statistically significant and clinically relevant increase in overall and cancer-specific survival from 1998 to 2008, both for resected as well as metastatic GIST.

Background The distinction between right-sided and left-sided colon cancer has recently received considerable attention due to differences regarding underlying genetic mutations. There is an ongoing debate if right- versus left-sided tumor location itself represents an independent prognostic factor. We aimed to investigate this question by using propensity score matching. Methods Patients with resected, stage I - III colon cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) database (2004–2012). Both univariable and multivariable Cox regression as well as propensity score matching were used. Results Overall, 91,416 patients (51,937 [56.8 %] with right-sided, 39,479 [43.2 %] with left-sided colon cancer; median follow-up 38 months) were eligible. In univariable analysis, patients with right-sided cancer had worse overall (hazard ratio [HR] = 1.32, 95 % CI:1.29–1.36, P  < 0.001) and cancer-specific survival (HR = 1.26, 95 % CI:1.21–1.30, P  < 0.001) compared to patients with left-sided cancer. After propensity score matching, the prognosis of right-sided carcinomas was better regarding overall (HR = 0.92, 95 % CI: 0.89 − 0.94, P  < 0.001) and cancer-specific survival (HR = 0.90, 95 % CI:0.87 − 0.93, P  < 0.001). In stage I and II, the prognosis of right-sided cancer was better for overall (HR = 0.89, 95 % CI:0.84–0.94 and HR = 0.85, 95 % CI:0.81–0.89) and cancer-specific survival (HR = 0.71, 95 % CI:0.64 − 0.79 and HR = 0.75, 95 % CI:0.70–0.80). Right- and left-sided colon cancer had a similar prognosis for stage III (overall: HR = 0.99, 95 % CI:0.95–1.03 and cancer-specific: HR = 1.04, 95 % CI:0.99–1.09). Conclusions This population-based analysis on stage I - III colon cancer provides evidence that the prognosis of localized right-sided colon cancer is better compared to left-sided colon cancer. This questions the paradigm from previous research claiming a worse survival in right-sided colon cancer patients.

Background The objective of the present analysis was to assess whether small bowel gastrointestinal stromal tumor (GIST) is associated with worse cancer-specific survival (CSS) and overall survival (OS) compared with gastric GIST on a population-based level. Patients and methods Data on patients aged 18 years or older with histologically proven GIST was extracted from the SEER database from 1998 to 2011. OS and CSS for small bowel GIST were compared with OS and CSS for gastric GIST by application of adjusted and unadjusted Cox regression analyses and propensity score analyses. Results GIST were located in the stomach ( n  = 3011, 59 %), duodenum ( n  = 313, 6 %), jejunum/ileum ( n  = 1288, 25 %), colon ( n  = 139, 3 %), rectum ( n  = 172, 3 %), and extraviscerally ( n  = 173, 3 %). OS and CSS of patients with GIST in the duodenum [OS, HR 0.95, 95 % confidence interval (CI) 0.76–1.19; CSS, HR 0.99, 95 % CI 0.76–1.29] and in the jejunum/ileum (OS, HR 0.97, 95 % CI 0.85–1.10; CSS, HR = 0.95, 95 % CI 0.81–1.10) were similar to those of patients with gastric GIST in multivariate analyses. Conversely, OS and CSS of patients with GIST in the colon (OS, HR 1.40; 95 % CI 1.07–1.83; CSS, HR 1.89, 95 % CI 1.41–2.54) and in an extravisceral location (OS, HR 1.42, 95 % CI 1.14–1.77; CSS, HR = 1.43, 95 % CI 1.11–1.84) were significantly worse than those of patients with gastric GIST. Conclusions Contrary to common belief, OS and CSS of patients with small bowel GIST are not statistically different from those of patients with gastric GIST when adjustment is made for confounding variables on a population-based level. The prognosis of patients with nongastric GIST is worse because of a colonic and extravisceral GIST location. These findings have implications regarding adjuvant treatment of GIST patients. Hence, the dogma that small bowel GIST patients have worse prognosis than gastric GIST patients and therefore should receive adjuvant treatment to a greater extent must be revisited.

Background: There is an ongoing debate about the relationship between breast implants and secondary malignancies. Methods: Breast cancer patients undergoing surgical reconstruction after mastectomy by either implants or autologous flap were identified in the Surveillance, Epidemiology and End Results registry between 1998 and 2002. The occurrence of secondary malignancies at least 1 year after diagnosis was compared between breast reconstruction with implants vs autologous flap. Results: Of 7955 women, 3727 underwent reconstruction using implants and 4228 using autologous flap. The incidence of secondary tumours was similar in both the groups (hazards ratio (HR)=1.02, 95% confidence interval (CI): 0.82–1.26, P =0.880). For lung cancer, a significantly increased risk for implants (HR=2.51, 95% CI: 1.28–4.95, P =0.005) was observed. Conclusions: Except for lung cancer, no association between implants and secondary malignancies including lymphomas was observed.

Background The lymph node ratio (LNR), i.e. the number of positive lymph nodes (LN) divided by the total number of analyzed LN, has been described as a strong outcome predictor in node-positive colon cancer patients. However, most published analyses are constrained by relatively low numbers of analyzed LN. Therefore, the objective of the present study was to evaluate the prognostic impact of LNR in colon cancer patients with high numbers of analyzed LN. Methods One hundred sixty-six colon cancer patients underwent open colon resection. All node-positive patients were analyzed for this study. The number of analyzed LN, of positive LN, the disease-free (DFS) and overall survival (OS) time were prospectively recorded. Patients were dichotomously allocated to a high or a low LNR-group, respectively, with the median LNR (0.125) as a cut-off value. Median follow-up was 34.3 months. Results Fifty-eight patients (34.9%) were node-positive. The median number of analyzed LN was 23 (range 8–54). DFS and OS were significantly shorter in pN2 vs pN1 patients ( p  < 0.001, and p  = 0.001, respectively), and in LNR high vs low patients ( p  = 0.032, and p  = 0.034, respectively). pN2 (vs pN1) disease showed hazard ratios (HR) of 6.2 ( p  < 0.001), and 6.8 ( p  < 0.005; for DFS and OS, respectively), while LNR high (vs low) showed HR of 3.0 ( p  =0.041), and 4.5 ( p  = 0.054). Conclusions LNR is a reasonable outcome predictor in node-positive colon cancer patients. However, LNR is inferior to pN-stage in predicting survival in patients with high number of harvested lymph nodes.

BackgroundAs far as we know, no previous study has determined the relationship between volume and outcomes for shoulder arthroplasty. We hypothesized that surgeons and hospitals with higher caseloads of total shoulder arthroplasties and hemiarthroplasties have better outcomes as measured by decreased mortality rate, shorter length of stay in the hospital, reduced postoperative complications, and routine disposition of patients on discharge.MethodsData on patients undergoing shoulder arthroplasty were extracted from the Nationwide Inpatient Sample databases for the years 1988 through 2000. Logistic regression with generalized estimating equations and multiple linear regression models were used to estimate the adjusted association between surgeon and hospital volume and outcomes for total shoulder arthroplasty and hemiarthroplasty after adjusting for comorbidity, age, race, household income, and sex.ResultsThe mortality rates for patients who had a total shoulder arthroplasty performed by surgeons who did fewer than two procedures per year (0.36%) or who did between two and fewer than four procedures per year (0.32%) were higher than those for patients who had a total shoulder arthroplasty performed by surgeons who did four procedures or more per year (0.20%). The risk-adjusted rate of postoperative complications after hemiarthroplasty was significantly higher for patients managed by surgeons who performed fewer than two procedures per year (1.68%) than for those managed by surgeons with a volume of five procedures or more per year (0.97%). The possibility of postoperative complications when total shoulder arthroplasty was performed in hospitals with a volume of fewer than five procedures (1.44%) or in those with a volume of five to ten procedures per year (1.45%) was significantly higher than that in hospitals where ten procedures or more were performed every year (0.64%). The mean lengths of stay in the hospital after total shoulder arthroplasty and hemiarthroplasty were significantly longer when the operations were performed by surgeons who did fewer than two procedures per year or when they were done in hospitals with a volume of fewer than five procedures per year or with a volume of five to fewer than ten procedures per year than when they were done in hospitals or by surgeons in the highest volume category (p < 0.001).ConclusionsPatients who have a total shoulder arthroplasty or hemiarthroplasty performed by a high-volume surgeon or in a high-volume hospital are more likely to have a better outcome.Level of EvidenceTherapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Background An increasing fraction of gastric cancer patients present with distant metastases at diagnosis. The objective of the present 11-year population-based trend analysis was to assess the survival rates in patients who underwent and in patients who did not undergo palliative gastrectomy. Methods Patients with metastatic gastric cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 1998 and 2009. Time trend and impact of palliative gastrectomy on survival were assessed by both a multivariate Cox proportional hazards model and propensity score matching. Results We identified 8249 patients with stage IV gastric cancer. The rate of metastatic disease increased from 31.0 % in 1998 to 37.5 % in 2009 ( P  < 0.001). The palliative gastrectomy rate dropped from 18.8 to 10.2 % ( P  = 0.004). The median survival for patients who underwent palliative gastrectomy ( N  = 1445, 17.4 %) and for patients who did not undergo palliative gastrectomy ( N  = 6804, 82.4 %) was 7 and 3 months, respectively. There was an increase in median overall survival from 2 months (1998) to 3 months (2009) in the no-gastrectomy group, and from 6.5 to 8 months in the gastrectomy group. The 3-year cancer-specific survival rates were 2.1 % (95 % confidence interval 1.7–2.5 %) for patients who did not undergo palliative gastrectomy and 9.4 % (95 % confidence interval 7.8–11.2 %) for patients who underwent palliative gastrectomy ( P  < 0.001). Palliative gastrectomy was associated with an increased cancer-specific survival in propensity-score-adjusted Cox regression analyses (hazard ratio 0.50, 95 % confidence interval 0.46–0.55, P  < 0.001). Conclusion On a population-based level, only modest improvements in prognosis for metastatic gastric cancer were observed in patients who underwent and in patients who did not undergo palliative gastrectomy. Considering the low rate of midterm survivors in both groups, only a small subgroup of patients benefits from palliative gastrectomy.

Background Molecular lymph node workup with one-step nucleic acid amplification (OSNA) is a validated diagnostic adjunct in breast cancer and also appealing for colon cancer (CC) staging. This study, for the first time, evaluates the prognostic value of OSNA in CC. Patients and methods The retrospective study includes patients with stage I-III CC from three centres. Lymph nodes were investigated with haematoxylin and eosin (H&E) and with OSNA, applying a 250 copies/μL threshold of CK19 mRNA. Diagnostic value of H&E and OSNA was assessed by survival analysis, sensitivity, specificity and time-dependent receiver operating characteristic curves. Results Eighty-seven patients were included [mean follow-up 53.4 months (± 24.9)]. Disease recurrence occurred in 16.1% after 19.8 months (± 12.3). Staging with H&E independently predicted worse cancer-specific survival in multivariate analysis (HR = 10.77, 95% CI 1.07–108.7, p  = 0.019) but not OSNA (HR = 3.08, 95% CI 0.26–36.07, p  = 0.197). With cancer-specific death or recurrence as gold standard, H&E sensitivity was 46.7% (95% CI 21.3–73.4%) and specificity 84.7% (95% CI 74.3–92.1%). OSNA sensitivity and specificity were 60.0% (95% CI 32.3–83.7%) and 75.0% (95% CI 63.4–84.5%), respectively. Conclusions In patients with CC, OSNA does not add relevant prognostic value to conventional H&E contrasting findings in other cancers. Further studies should assess lower thresholds for OSNA (< 250 copies/μL).

Objective To assess the accuracy of sentinel lymph node (SLN) frozen section in a prospective multicenter study of early-stage breast cancer patients. Summary background data The decision to perform an immediate completion axillary node dissection (ALND) is based on results of SLN frozen section. However, SLN frozen sections are not routinely performed in all centers. Moreover, the accuracy of SLN frozen section remains a matter of great debate. Methods Prospective multicenter trial analyzing 659 early stage breast cancer patients (pT1 and pT2 <= 3 cm, cN0) enrolled between January 2000 and December 2003. SLN were intraoperatively examined by frozen section. Final histopathology consisted in performing step sectioning as well as staining with H&E and immunohistochemistry. Results SLN were identified in 98.3% (648/659) of all patients. The accuracy of frozen section was 90.1% (584/648), the sensitivity for SLN macro-metastases 98% (142/145), and the specificity 100%. A total of 47 patients with SLN micro-metastases (n = 36) or isolated tumor cells (n = 11) underwent a delayed completion ALND. In 96% (45/47) of these patients the ALND specimens were free of macro-metastases. Conclusions SLN frozen section provides highly accurate information regarding identification of SLN macro-metastases, a delayed completion ALND can be avoided in 98% of these patients. More importantly, in the present investigation the vast majority (96%) of patients with SLN micro-metastases or isolated tumor cells undergoing delayed completion ALND did not benefit from the second operation as ALND specimens were free of macro-metastases. We strongly recommend the routine use of SLN frozen section in early stage breast cancer patients.