Annals Of Surgical Oncology Research Articles

Society of Surgical Oncology Distinguished Service Award: Honoring David P. Winchester, M.D.

It is a distinct honor and singular privilege for me to introduce the Society of Surgical Oncology’s inaugural Distinguished Service Awardee, David P. Winchester, M.D. (Fig. 1). Let me walk you through this remarkable man’s life, and you will readily see why he was chosen to be the first recipient of one of our Society’s highest honors. David was born and raised in Illinois by his mother, Virginia, and father, Allan. In 1959 he received his Bachelor of Arts from Northwestern University in Evanston, Illinois. While in college David married his high school sweetheart, Marilyn, and started a long-term partnership that is still going strong, now for more than 55 years (Fig. 2). This in itself is somewhat remarkable considering that 55 years ago his surprise choice of an ideal honeymoon destination for Marilyn and him was St. Louis, Missouri. David graduated in 1963 from Northwestern University Medical School and then did his internship at Evanston Hospital in Evanston, Illinois. Following his surgical internship, David served in the U.S. Army and was deployed to Vietnam in 1966 as a Captain in the Medical Corps. This was certainly a harbinger of a life committed to both service and improving the lives of others. David returned home to complete his general surgery residency at Northwestern University Medical Center, followed by a surgical oncology fellowship at the University of Texas MD Anderson Hospital and Tumor Institute. David has been an attending surgeon for 40 years at Evanston Hospital, where he has also served in many leadership positions, including Head of Surgical Oncology and Chief of the Division of General Surgery. In 1995 he was chosen to be Chairman of the Department of Surgery at Evanston Northwestern Health Care, and he remained in that leadership position until 2007. During that time, David was a Professor of Surgery at Northwestern University Medical School and currently holds that same academic title at the University of Chicago Pritzker School of Medicine. David’s academic accomplishments during the early part of his career are extraordinary and what you would envision for a leading figure in academic surgery. David has authored or co-authored more than 200 peer-reviewed publications and also has ten book chapters and five books to his credit. He has been a member of numerous editorial boards of both surgical and oncology journals including: Cancer, the Journal of Surgical Oncology, the International Journal of Radiation Oncology, Biology and Physics, and, of course, our Society’s journal, the Annals of Surgical Oncology. David has had bestowed upon him numerous awards, medals, named lectureships, and an endowed chair in his name, the David P. Winchester, MD, Chair of Surgical Oncology, with the first chair holder being his accomplished son, David J. Winchester, MD. One of David’s proudest academic achievements is being awarded on multiple occasions (1990, 1993, 1998, 2006, and 2007) the Outstanding Faculty Teacher of the year in the Department of Surgery at Northwestern University Feinberg School of Medicine recognizing his enduring dedication to education and surgical training. David has had a long-term commitment to the mission and values of the Society of Surgical Oncology for decades and has served on its Executive Council for 10 years, named Secretary in 1993 through 1996 and served as our President in 1997–1998. While most individuals would have sat on their laurels, David was just getting started, and, therefore, it is what he has accomplished following his term as SSO president that truly distinguishes this surgical leader. First let me quickly summarize his tenure at the American College of Society of Surgical Oncology 2013

Reply to “Anti-cytokeratin CAM5.2 Recognized CK8 Mainly, but not CK18: Comment on ‘Early Assessment of Axillary Response with 18F-FDG PET/CT During Neoadjuvant Chemotherapy in Stage II–III Breast Cancer: Implications for Surgical Management of the Axilla. Ann Surg Oncol. 2013;20(7):2227–35’”

We agree with Chao and Han that uncertainty exists about the cytokeratins recognized by the CAM5.2 antibody in immunohistochemistry. It has become clear from immunoblot experiments that CAM5.2 is specific for cytokeratin 8 and to a lesser extent for the closely related cytokeratin 7, but not for cytokeratin 18. Nevertheless, CAM5.2 is generally accepted to be suitable for detection of metastatic breast cancer in (sentinel) lymph nodes because almost all breast carcinomas also strongly express cytokeratin 7.

Induction of breast cancer progression and metastasis by HOXB9 gene’s activation by sequence specific binding factors.

26 Background: HOXB9 is a member of class I HOX genes and is known to be overexpressed in human breast cancer and related to EMT, tumor angiogenesis, and radio-resistance (PNAS 2010), being significant prognostic factor in breast cancer patients. (Ann Surg Oncol 2012). Methods: We analyzed the upstream promoter region to determine the critical sequence for HOXB9 transcription. The multiple lengths of HOXB9 promoter region were cloned into pGL3 luciferase vector and each of them were checked by luciferase assay. Then made E2F1 overexpressed cell-lines: MCF7, MCF10A and MDA-MB231 to check HOXB9 gene expression. ChIP assay performed using E2F1 induced MCF7 cell-line model and EMSA made with T47D cells and E2F1 antibody. Results: We demonstrated luciferase activity of MDA-MB231 cells and overexpressed HOXB9 was determined at the region from -404 to -392 bps, showing that the mentioned region plays the critical role for the transcription of HOXB9. Computer prediction system for the binding ability to critical sequence raised several candidate: E2F1, PAX-5, P53, ETS-1, NFY-A, Sp-1, which are known to be related with cancer progression and we confirmed these genes could induce HOXB9. E2F1 overexpressed breast cancer cell-lines indicate high expression of HOXB9 show the correlation between E2F1 and HOXB9 expression. Luciferase assay method done by constructing pGL3 with HOXB9 critical sequence and analyzed using wild-type MCF7 and E2F1 induced MCF7 cells showed high luciferase activity of HOXB9 critical sequence plasmid in E2F1 induced MCF7 cell-line by compare to WT. ChIP assay and EMSA assay methods performed using E2F1 overexpressed MCF7 and T47D cell-lines model revealed high precipitation rate with E2F1 antibody and HOXB9 expression than negative control. Conclusions: HOXB9 is plays the role as the accelerator of breast cancer progression and discovering the properties of the gene and related factors will help to understand new signaling pathways of breast cancer development. E2F1 is a strong candidate direct binds to HOXB9 critical sequence and correlates with HOXB9 expression. Manipulating of E2F1 expression may regulate HOXB9 and reduce cancer progression and metastasis.

SPIO-enhanced MR imaging at 3T for the detection of metastases in sentinel nodes in patients with breast cancer.

1107 Background: We previously demonstrated the usefulness of SPIO-enhanced MR imaging at 1.5T for the detection of metastases in sentinel nodes localized by computed tomography lymphography (CT-LG) in patients with breast cancer (Ann Surg Oncol 2011, ASCO 2012). The aim of this study was to evaluate the accuracy of MR imaging at 3T with SPIO enhancement for the detection of metastases in sentinel nodes. Methods: This study included 60 patients with breast cancer and clinically negative nodes. Sentinel nodes identified by CT-LG were evaluated prospectively using SPIO-enhanced MR imaging at 3T. A node was considered non-metastatic if it showed a homogenous low signal intensity and metastatic if the entire node or a focal area did not show a low signal intensity on MR imaging. Sentinel nodes located by CT-LG were removed, and imaging results and histopathological findings were compared. Results: The mean patient age was 54.2 years (range, 33-78). Sentinel nodes were identified by CT-LG successfully in 59 (98.3%) of 60 patients. The mean number of sentinel nodes identified by CT-LG was 1.43 (range, 1-3). All 16 patients with positive sentinel nodes definitively diagnosed by pathology demonstrated metastases on SPIO-enhanced MR imaging. Five (31.3%) of them had micrometastases. Forty-one of 43 patients with negative sentinel nodes definitively diagnosed by pathology were non-metastatic on imaging studies. The sensitivity, specificity and accuracy of MR imaging for the diagnosis of sentinel node metastases were 100%, 95.3%, and 96.6%, respectively. No adverse events were associated with either CT or MR imaging. Conclusions: SPIO-enhanced MR imaging at 3T is useful for accurate diagnosis of sentinel node metastases, and therefore sentinel node biopsy may be avoided for most patients with breast cancer.

Reply to “Commentary to Matsuda et al., Ann Surg Oncol (2013) 20:856–863,” by Karl Kodeda and Richard J. Heald (doi:10.1245/s10434-013-2951-4)

Reply to “Commentary to Matsuda et al., Ann Surg Oncol (2013) 20:856–863,” by Karl Kodeda and Richard J. Heald (doi:10.1245/s10434-013-2951-4)

Commentary to Matsuda et al., Ann Surg Oncol, Sep 18, 2012 [Epub Ahead of Print

Commentary to Matsuda et al., Ann Surg Oncol, Sep 18, 2012 [Epub Ahead of Print

PC-FACS

PC-FACS

Abstract P4-09-08: HOXB9, a gene promoting tumor angiogenesis and proliferation, is significantly associated with poor clincal outcomes in ER-positive breast cancer patients

Abstract Background: Studies have suggested that HOXB9 expression in breast cancer cells promotes cellular invasiveness, metastatic ability, and tumor neovascularization in the surrounding tissue in in vitro and in vivo assays. These findings imply that HOXB9 overexpression may alter tumor-specific cell fates and the tumor stromal microenvironment, contributing to breast cancer progression (Hayashida et al., PNAS 2010). We previously reported that clinical outcomes were significantly decreased in HOXB9-positive patients (Seki et al., Ann Surg Oncol. 2012). In this study, it was demonstrated that HER2 type and basal-like breast cancers were more associated with HOXB9 positivity than the luminal type. Therefore, it is required to identify more detail clinicopathological features most likely to be associated with HOXB9 overexpression. We investigated the correlation between HOXB9 overexpression and clinicopathological variables, and clinical outcomes in estrogen receptor (ER)-positive breast cancer patients. Patients and methods: A consecutive series of 118 ER-positive breast cancer patients who underwent surgical treatment were examined. HOXB9 expression was analyzed immunohistochemically using the anti-human HOXB9 polyclonal antibody. Immunostaining of Ki-67 and CD31 were also performed to evaluate tumor proliferation and angiogenesis. Results: The median age was 59 years and median observation period was 62 months. Of 118 tumor specimens immunostained for HOXB9, 49 specimens (41.5%) were positive staining. Univariate logistic regression revealed high nuclear grade (p < 0.001), lymph node metastasis (p = 0.019), the number of micro vessel density (p < 0.001) and the Ki-67 ratio (p = 0.019) as significant variables associated with HOXB9 positive. The disease-free survival (DFS) was significantly decreased in HOXB9-positive patients (HR = 4.262, 95% CI = 1.531 — 11.869, p = 0.006) A Multivariate analysis indicated that HOXB9 expression was the only independent prognostic factor for DFS (HR = 3.380 95% CI=1.160 — 9.849, p = 0.026). Conclusions: Our results suggest that HOXB9 expression promoting the cellular proliferation and the angiogenesis in tumor microenvironment is a significant prognostic factor for clinical outcomes in ER-positive breast cancer patients. Further study might help to determine the application of anti-angiogenic therapy for metastatic ER-positive breast cancer patients. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-09-08.

Abstract OT2-1-03: The Z11 design for breast cancer patients undergoing a mastectomy

Abstract Background: The diagnostic work-up and treatment of axillary lymph nodes in breast cancer patients is an ongoing topic of research. The ACOSOG-Z0011 study demonstrated no additional value of complementary axillary lymph node dissection (cALND) in case of limited axillary sentinel lymph node (SLN) metastases in breast cancer patients undergoing breast conserving therapy1. It is questionable whether these results can be applied to patients undergoing a mastectomy2. Trial design: A prospective non-inferiority randomized multicenter trial was designed. Breast cancer patients with cT1-2N0 disease treated with mastectomy and limited axillary SLN metastases will be randomized for follow-up versus complementary axillary treatment. To assess the Quality of Life and morbidity benefits of this experimental treatment, 3 validated questionnaires will be used: QLQ-C30, QLQ-BR 23 and Lymph-ICF3-5. Eligibility criteria: – Women with histological confirmed cT1-2 invasive unilateral breast carcinoma– Clinical node negative: no palpable nodes in physical examination and the axillary ultrasound without signs of lymph node metastases (cyto-/histology if indicated)– Sentinel lymph node biopsy must contain at least one and a maximum of 3 (micro)metastases– Neoadjuvant systemic therapy is allowed Specific aims: Primary endpoint is the axillary recurrence rate. The number of delayed axillary dissections will be registered. Secondary endpoints are distant-disease free survival, overall survival, local recurrence, morbidity and Quality of Life. Statistical methods: Based on 5-year axillary recurrence free survival rate, a failure rate of 0.98 among controls and a true failure rate of 0.96 for study subjects are considered acceptable. Overall, 1114 patients will be included to be able to reject the null hypothesis that the failure rate for experimental and control subjects is inferior by at least 5% (D = −5%) with probability of 0.8 and alpha of 5%. Present accrual and target accrual: This study is expected to start in late 2012 after approval by the Ethical Medical Committee.

Pretest genetic counseling informs patients withBRCAmutation

When patients with breast cancer received pretest genetic counseling before undergoing definitive surgery for breast cancer, they showed fewer signs of distress. At the same time, patients who were offered counseling after surgery improved their informed decision-making, while both groups were better informed, according to a study by researchers at the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida. The study, funded by the American Cancer Society, was published in the Annals of Surgical Oncology.1 The researchers note that patients with breast cancer with certain risk factors likely would benefit from pretest genetic counseling and genetic testing at or near the time of their initial diagnosis. Although some health care providers may fear that these efforts could increase distress for patients at this time, few studies to date have actually examined the impact of such pretest genetic counseling, according to lead coauthor Susan Vadaparampil, PhD, MPH, an associate member of the Health Outcomes and Behavior Program at H. Lee Moffitt. She and her colleagues developed a study to determine how pretest counseling impacts cancer knowledge, psychosocial development, and decision-making about genetic testing for patients with breast cancer. They analyzed 103 patients, 87 of whom had undergone surgery and 16 of whom had not. The patients ranged in age from 24 years to 69 years. They met with master's degree-level, trained genetic health professionals to obtain a risk assessment based on their personal and family genetic history. At the same time, they received information about hereditary breast and ovarian cancer as well as the limitations of genetic testing. The study found that both the before-surgery and aftersurgery groups experienced increases in cancer knowledge after pretest genetic counseling. At the same time, the before-surgery group reported decreases in cancer-related distress and intrusive thoughts. Furthermore, informed decision-making in the after-surgery group improved. Dr. Vadaparampil stresses that before-surgery genetic counselors may need to focus on perceived risks of genetic testing and how they might align with patients' values. Reference

Preliminary decision-tree analysis of costs to payors associated with a pancreatic multidisciplinary clinic.

118 Background: Multidisciplinary clinics (MDC) are well-established formats for delivering thorough oncologic evaluation and treatment. Although much evidence identifies an association between MDCs and superior clinical outcomes, their effect on total costs to payors is not well described. We performed a preliminary decision analysis of likely costs associated with a pancreatic MDC versus other settings, referring to known changes in diagnosis resulting from our pancreatic MDC (Pawlik, Ann Surg Oncol.2008; 15(8):2081-8). Methods: We extracted cost data from previous decision-analyses to determine expected cancer treatment costs for patients with resectable (Ljungman, World J Surg. 2011; 35:662-670), locally advanced (Murphy, Cancer. 2011;118:1119-1129), and metastatic disease (Attard. J Clin Oncol. 2012 [suppl 4; abstr 199]), using the most updated studies available. We then mapped these costs to a decision-analysis, modeling staging patterns that change after referral to the MDC. The expected cost of each disease stage was multiplied by its frequency of occurrence for both scenarios. A unique Markov analysis with consistent assumptions was not available at submission, but will be at the time of the meeting. Results: From the literature, an initial diagnosis of resectable disease was associated with the highest cost, and metastatic disease with the lowest. The percentage of patients managed for each disease stage in both clinic settings are indicated in the table. Because the MDC scenario resulted in a lower frequency of resectable and a higher frequency of metastatic staging at initial diagnosis, costs were 4.7% lower in the MDC scenario. Conclusions: In this preliminary analysis, the MDC showed potential to achieve up to 4.7% in cost-savings over treatment in conventional clinic settings, suggesting that the MDC setting for pancreatic cancer may be cost-saving to payors. [Table: see text]

Robotic Thyroidectomy: Must We Drive a Luxury Sedan to Arrive at Our Destination Safely?

Robotic Thyroidectomy: Must We Drive a Luxury Sedan to Arrive at Our Destination Safely?

1426P - Pain Palliation of Bone Metastases Using Magnetic Resonance Guided Focused Ultrasound - Multi-Center Multi-trial Results

ABSTRACT Introduction Magnetic Resonance guided Focused Ultrasound (MRgFUS) is a non-invasive, non-ionizing treatment for thermal ablation of tumors. The technology uses high intensity focused ultrasound ablation combined with continuous MR imaging to denervate pain. Precise targeting of the lesion and real time monitoring of tissue temperature rise are cornerstones of the technique. We present here results of multiple multi-center studies evaluating the safety and effectiveness of MRgFUS for painful bone metastases. Methods 93 patients with painful bone metastases underwent MRgFUS in 14 medical centers worldwide. Treated lesions had to be remote from nervous structures or joints. Effectiveness of pain palliation was evaluated with a standardized 11-point pain rating scale (0-no pain/10-worst pain) and by monitoring changes in pain-relieving medication. A reduction of 2 points or more was considered a significant response. Safety events were recorded and evaluated by severity. Results of 31 patients treated in initial safety studies were previously reported by Liberman et al (Ann Surg Oncol. 2009 Jan; 16(1):140-6). Results 107 procedures were performed, targeting 96 lesions in 93 patients. 3 patients were treated twice targeting a different lesion; another 11 patients underwent a second treatment due to large lesions. Patients were followed-up for a period of 3 months. Pain response was relatively rapid: within 3 days, on average, the clinical endpoint was met and maintained. Pain scores averaged 6.9 pre-treatment, decreased to 4.5 within 3 days post-treatment, to 3.3 at one month post-treatment, and further decreased to 2.6 at three month follow-up. There were no serious adverse events related to the treatment. 2 patients had mild skin erythema following the treatment and 5 patients (5%) had pain progression. Our updated results are similar to early reports. Conclusions The presented results clearly show that MRgFUS can provide a quick, effective and safe palliative therapy for patients suffering from painful bone metastases. Current results are consistent with initial reported results. Randomized trials are being conducted in patients as a first line treatment of painful bone metastases vs. radiation therapy and in patients who failed radiation therapy vs. sham. Disclosure L. Shay Levi: I work in InSightec as the global bone applications specialist. InSightec is the company sponsered these clinical trials. All other authors have declared no conflicts of interest.

Bradycardia Associated With Drug-Eluting Beads Loaded With Irinotecan (DEBIRI) Infusion for Colorectal Liver Metastases

Intra-arterial injection of drug-eluting beads loaded with irinotecan (DEBIRI) is a new treatment option being investigated, with encouraging results, for unresectable colorectal liver metastases that are refractory to systemic chemotherapy (Martin et al., Ann Surg Oncol 18:192-198, 2011). Toxicity related to DEBIRI has also been described (Martin et al., Cardiovasc Intervent Radiol 33:960-966, 2010). Nevertheless, experience and literature related to DEBIRI remain limited, and experience with this treatment is expected to increase. The purpose of this article is to describe bradycardia occurring during DEBIRI administration, which has not been reported thus far.

OC-105 Impact of AJCC 7th edition TNM staging on a historical oesophago-gastric cancer resection dataset

IntroductionThe revised AJCC1 TNM staging systems for oesophageal and gastric cancer were published in 2010 and have been adopted in many units since that time. However, such changes in staging...

SPIO-enhanced MR imaging for axillary staging to avoid sentinel node biopsy in patients with breast cancer.

1103 Background: We previously demonstrated the usefulness of SPIO-enhanced MR imaging for the detection of metastases in sentinel nodes localized by computed tomography (CT) lymphography (CT-LG) in patients with breast cancer (Ann Surg Oncol, 2011). These techniques have evolved and we report our most recent results of axillary staging using them. Methods: Previously unreported 87 consecutive patients with breast cancer and clinically negative nodes were enrolled in this study. Sentinel nodes identified by CT-LG were evaluated prospectively using SPIO-enhanced MR imaging. A node was considered non-metastatic if it showed a homogenous low signal intensity and metastatic if the entire node or a focal area did not show a low signal intensity on MR imaging. Sentinel nodes located by CT-LG were removed, and imaging results and histopathological findings were compared. Results: The mean patient age was 54.9 years (range, 34-77). Sentinel nodes were identified by CT-LG and removed successfully in all patients. The mean number of sentinel nodes identified by CT-LG was 1.16 (range, 1-2). Twenty of 22 patients with positive sentinel nodes definitively diagnosed by pathology demonstrated metastases on SPIO-enhanced MR imaging. Fifty-eight of 65 patients with negative sentinel nodes definitively diagnosed by pathology were non-metastatic on imaging studies. The sensitivity, specificity and accuracy of MR imaging for the diagnosis of sentinel node metastases were 91%, 89%, and 90%, respectively. Two patients whose metastases were not detected had micrometastases. No adverse events were associated with either CT or MR imaging. Conclusions: SPIO-enhanced MR imaging provided accurate axillary staging, and therefore sentinel node biopsy may not be necessary for most patients with breast cancer.

Abstract 41: Identification of CXCL5/ENA-78 regulating the interaction of cholangiocarcinoma and cancer-associated fibroblasts

Abstract Background and Aims: Tumor-stromal interaction has been recognized to be essential for understanding tumor development. Cholangiocarcinoma shows very poor prognosis and have fibrous tumor stroma. Hepatic stellate cells are well-known to have a major role in hepatic fibrogenesis. Therefore, we have focused on the interaction of cholangiocarcinoma and hepatic stellate cells and reported their positive interaction (Ann Surg Oncol 2009, 2011). The aim of this study is to identify the key protein which is important for the interaction of cholangiocarcinoma cells and hepatic stellate cells and examine its functional role in tumor progression. Methods: Using co-culture model and proteomic analysis, we analyzed the secreted factors which were considered to be important for their interaction. The functional role of CXCL5 was examined in vitro and clinical significance was validated using human intrahepatic carcinoma samples by immunohistochemistry. Results: Using SELDI-TOF-MS and qTOF-MS/MS analysis, we identified CXCL5 which was remarkably increased when they were co-cultured. CXCL5 which was mainly produced by cholangiocarcinoma cell lines (HuCCT1 and RBE) promoted the invasion, and migration of them in the autocrine fashion. These effects were significantly decreased by inhibition of CXCR2 which was a receptor of CXCL5. IL1β was found to up-regulate in hepatic stellate cells when they were co-cultured by cytokine array analysis, we also found that IL1β accelerated the production of CXCL5 in cholangiocarcinoma cells. In human intrahepatic cholangiocarcinoma, immunohistochemical study showed that there was a significant correlation between stromal myofibroblasts and CXCL5 produced by cholangiocarcinoma cells. Since CXCL5 is identified as epithelial neutrophil activating factor-78 (ENA-78), we researched the presence of CD66b positive immune cells which have been recently reported to be tumor-associated neutrophils. CD66b positive immune cells are more abundant in CXCL5 high expression group. In addition, high CXCL5 expression group showed worse survival than low expression group. Conclusion: We conclude that CXCL5 is important for the interaction of cholangiocarcinoma and stromal myofibroblasts and that the strategies to inhibit tumor-stromal cell interactions may be beneficial in cholangiocarcinoma. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 41. doi:1538-7445.AM2012-41

Classification of Parathyroid Cancer

Parathyroid cancer is rare and often has a poor outcome. There is no classification system that permits prediction of outcome in patients with parathyroid cancer. This study was designed to validate two prognostic classification systems developed by Talat and Schulte in 2010 ("Clinical Presentation, Staging and Long-term Evolution of Parathyroid Cancer," Ann Surg Oncol 2010;17:2156-74) derived from a retrospective literature review of 330 patients. This study contains 82 formerly unreported patients with parathyroid cancer. Death due to disease was the primary end point, and recurrence and disease-free survival were the secondary end points. Data acquisition used a questionnaire of predefined criteria. Low risk was defined by capsular and soft tissue invasion alone; high risk was defined by vascular or organ invasion, and/or lymph node or distant metastasis. A differentiated classification system further classified high-risk cancer into vascular invasion alone (class II), lymph node metastasis or organ invasion (class III), and distant metastasis (class IV). Statistical analyses included risk analysis, Kaplan-Meier analysis, and receiver-operating characteristic (ROC) analysis. Follow-up ranged 2-347 months (mean 76 months). Mortality was exclusive to the high- risk group, which also predicted a significant risk of recurrence (risk ratio 9.6; 95% confidence interval 2.4-38.4; P < 0.0001), with significantly lower 5-year disease-free survival (χ(2) = 8.7; P < 0.005 for n = 45). The differentiated classification also provided a good prognostic model with an area under the ROC curve of 0.83 in ROC analysis, with significant impairment of survival between classes (98.6%, 79.2%, 71.4%, 40.0%, P < 0.05 between each class). This study confirms the validity of both classification systems for disease outcome in patients with parathyroid cancer.

Cardiophrenic lymph node dissection (CPLND) in the surgical management of ovarian cancer: Surgical evolution from using VATS to direct approach via incised/resected diaphragm

Objective: CPLND in 12 ovarian cancer patients using video-assisted thoracic surgery (VATS) was well established in our previous study (Lim et al, 2009, Ann Surg Oncol). The objective of this study was to describe the development and experience for CPLND via incised/resected diaphragm in patients with ovarian cancer.

Building the IJSO: An International Editorial Perspective

Building the IJSO: An International Editorial Perspective