Patrice Wendling

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.

SAN ANTONIO – Lymphovascular invasion, not sentinel lymph node status, was strongly associated with recurrence and death from Merkel cell carcinoma in a series of 153 patients with clinically localized disease.

Patients without lymphatic vascular invasion (LVI) of their primary tumors did not develop recurrence or die, said Dr. Ryan Fields of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York.

Although sentinel lymph node (SLN) status was not associated with recurrence or death from Merkel cell carcinoma (MCC), patients with a positive SLN were more likely to receive subsequent treatment including complete lymph node dissection, nodal radiation therapy, and/or chemotherapy.

Dr. Fields suggested that one explanation for the surprising lack of association with SLN status may be the additional treatment received by SLN-positive patients was so effective as to interrupt the metastatic cascade and prevent recurrence or death from MCC.

During a discussion of the study, Dr. Kelly McMasters, professor and chair of surgery at the University of Louisville in Kentucky, expressed doubt that adjuvant therapy was so effective as to skew the results and asked whether clinicians should biopsy their next MCC patient or whether this may simply lead them to overtreat their patients.

Dr. Fields acknowledged that the results are puzzling and said that all patients with MCC continue to be offered SLN biopsy at Memorial Sloan-Kettering, where the study was performed. He added that surgeons there are also trying to capture information on LVI to determine in which patients LVI could be used in lieu of SLN biopsy as a prognostic marker.

There is no universally accepted staging system for MCC, a rare cutaneous cancer that has a propensity for lymphatic spread. SLN biopsy has been used in an effort to provide more accurate staging and to guide subsequent treatment, although most studies have been small and did not look at outcome at the time of SLN status, he explained.

A previous analysis of 251 MCC patients treated from 1970 to 2002 at Memorial Sloan-Kettering reported that disease stage was the only independent predictor of survival and that stage-specific survival was decreased in patients with node-positive disease (J. Clin. Oncol. 2005;23:2300-9).

In the current analysis from 1996 to 2010, a total of 153 patients with stage I or II MCC underwent SLN biopsy, of which 45 (29%) were positive and 108 (71%) were negative.

The primary tumor was 2 cm or less (clinical stage I) in 122 patients and more than 2 cm (clinical stage II) in 31 patients. LVI was present in the primary tumor in 75 patients, absent in 69, and unknown in 9.

A positive SLN biopsy was significantly associated with stage II vs. stage I tumors (45% vs. 25%, P = .02), and with LVI vs. LVI absence (55% vs. 4%, P less than .01). Notably, 26% of positive SLNs occurred in tumors 1 cm or less, observed Dr. Fields.

After a median follow-up of 41 months, 16 nodal or distant recurrences occurred, 11 patients died of MCC, and 27 patients died of other causes.

"This highlights the fact that overall survival, which has been used quite a bit as an end point in Merkel cell cancers, is a poor end point measure in this population," Dr. Fields said.

Importantly, there were no nodal recurrences in SLN-positive patients who went on to receive adjuvant nodal radiation therapy after completion lymph node dissection or therapeutic radiotherapy alone.

Only two of the 32 SLN-positive patients (6%) who received no adjuvant chemotherapy developed a distant recurrence, suggesting that unproven adjuvant chemotherapy would be unlikely to benefit this patient population, Dr. Fields said.

Among the 108 patients with a negative SLN, 99 received no further treatment. Of these, 8% experienced a recurrence, which corresponds to a 15% false-negative rate for the SLNB procedure in MCC, he said.

When patients were stratified by tumor characteristics, there was no significant association between SLN-positive and SLN-negative patients in nodal/distant recurrence (P = .86) or death from MCC (P = .89). The association was significantly between stage II and stage I tumors for death (P =.05), but not for recurrence (P = .26).

In contrast, the presence of LVI was significantly associated with both nodal/distant recurrence and death from MCC (both P less than .001), Dr. Fields said. The 2-year confidence intervals of recurrence or death from MCC for LVI-positive patients were 30% and 15%, respectively.

Dr. Fields and his coauthors reported no study support or relevant conflicts of interest.

SAN ANTONIO – Lymphovascular invasion, not sentinel lymph node status, was strongly associated with recurrence and death from Merkel cell carcinoma in a series of 153 patients with clinically localized disease.

Patients without lymphatic vascular invasion (LVI) of their primary tumors did not develop recurrence or die, said Dr. Ryan Fields of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York.

Although sentinel lymph node (SLN) status was not associated with recurrence or death from Merkel cell carcinoma (MCC), patients with a positive SLN were more likely to receive subsequent treatment including complete lymph node dissection, nodal radiation therapy, and/or chemotherapy.

Dr. Fields suggested that one explanation for the surprising lack of association with SLN status may be the additional treatment received by SLN-positive patients was so effective as to interrupt the metastatic cascade and prevent recurrence or death from MCC.

During a discussion of the study, Dr. Kelly McMasters, professor and chair of surgery at the University of Louisville in Kentucky, expressed doubt that adjuvant therapy was so effective as to skew the results and asked whether clinicians should biopsy their next MCC patient or whether this may simply lead them to overtreat their patients.

Dr. Fields acknowledged that the results are puzzling and said that all patients with MCC continue to be offered SLN biopsy at Memorial Sloan-Kettering, where the study was performed. He added that surgeons there are also trying to capture information on LVI to determine in which patients LVI could be used in lieu of SLN biopsy as a prognostic marker.

There is no universally accepted staging system for MCC, a rare cutaneous cancer that has a propensity for lymphatic spread. SLN biopsy has been used in an effort to provide more accurate staging and to guide subsequent treatment, although most studies have been small and did not look at outcome at the time of SLN status, he explained.

A previous analysis of 251 MCC patients treated from 1970 to 2002 at Memorial Sloan-Kettering reported that disease stage was the only independent predictor of survival and that stage-specific survival was decreased in patients with node-positive disease (J. Clin. Oncol. 2005;23:2300-9).

In the current analysis from 1996 to 2010, a total of 153 patients with stage I or II MCC underwent SLN biopsy, of which 45 (29%) were positive and 108 (71%) were negative.

The primary tumor was 2 cm or less (clinical stage I) in 122 patients and more than 2 cm (clinical stage II) in 31 patients. LVI was present in the primary tumor in 75 patients, absent in 69, and unknown in 9.

A positive SLN biopsy was significantly associated with stage II vs. stage I tumors (45% vs. 25%, P = .02), and with LVI vs. LVI absence (55% vs. 4%, P less than .01). Notably, 26% of positive SLNs occurred in tumors 1 cm or less, observed Dr. Fields.

After a median follow-up of 41 months, 16 nodal or distant recurrences occurred, 11 patients died of MCC, and 27 patients died of other causes.

"This highlights the fact that overall survival, which has been used quite a bit as an end point in Merkel cell cancers, is a poor end point measure in this population," Dr. Fields said.

Importantly, there were no nodal recurrences in SLN-positive patients who went on to receive adjuvant nodal radiation therapy after completion lymph node dissection or therapeutic radiotherapy alone.

Only two of the 32 SLN-positive patients (6%) who received no adjuvant chemotherapy developed a distant recurrence, suggesting that unproven adjuvant chemotherapy would be unlikely to benefit this patient population, Dr. Fields said.

Among the 108 patients with a negative SLN, 99 received no further treatment. Of these, 8% experienced a recurrence, which corresponds to a 15% false-negative rate for the SLNB procedure in MCC, he said.

When patients were stratified by tumor characteristics, there was no significant association between SLN-positive and SLN-negative patients in nodal/distant recurrence (P = .86) or death from MCC (P = .89). The association was significantly between stage II and stage I tumors for death (P =.05), but not for recurrence (P = .26).

In contrast, the presence of LVI was significantly associated with both nodal/distant recurrence and death from MCC (both P less than .001), Dr. Fields said. The 2-year confidence intervals of recurrence or death from MCC for LVI-positive patients were 30% and 15%, respectively.

Dr. Fields and his coauthors reported no study support or relevant conflicts of interest.

SAN ANTONIO – Lymphovascular invasion, not sentinel lymph node status, was strongly associated with recurrence and death from Merkel cell carcinoma in a series of 153 patients with clinically localized disease.

Patients without lymphatic vascular invasion (LVI) of their primary tumors did not develop recurrence or die, said Dr. Ryan Fields of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York.

Although sentinel lymph node (SLN) status was not associated with recurrence or death from Merkel cell carcinoma (MCC), patients with a positive SLN were more likely to receive subsequent treatment including complete lymph node dissection, nodal radiation therapy, and/or chemotherapy.

Dr. Fields suggested that one explanation for the surprising lack of association with SLN status may be the additional treatment received by SLN-positive patients was so effective as to interrupt the metastatic cascade and prevent recurrence or death from MCC.

During a discussion of the study, Dr. Kelly McMasters, professor and chair of surgery at the University of Louisville in Kentucky, expressed doubt that adjuvant therapy was so effective as to skew the results and asked whether clinicians should biopsy their next MCC patient or whether this may simply lead them to overtreat their patients.

Dr. Fields acknowledged that the results are puzzling and said that all patients with MCC continue to be offered SLN biopsy at Memorial Sloan-Kettering, where the study was performed. He added that surgeons there are also trying to capture information on LVI to determine in which patients LVI could be used in lieu of SLN biopsy as a prognostic marker.

There is no universally accepted staging system for MCC, a rare cutaneous cancer that has a propensity for lymphatic spread. SLN biopsy has been used in an effort to provide more accurate staging and to guide subsequent treatment, although most studies have been small and did not look at outcome at the time of SLN status, he explained.

A previous analysis of 251 MCC patients treated from 1970 to 2002 at Memorial Sloan-Kettering reported that disease stage was the only independent predictor of survival and that stage-specific survival was decreased in patients with node-positive disease (J. Clin. Oncol. 2005;23:2300-9).

In the current analysis from 1996 to 2010, a total of 153 patients with stage I or II MCC underwent SLN biopsy, of which 45 (29%) were positive and 108 (71%) were negative.

The primary tumor was 2 cm or less (clinical stage I) in 122 patients and more than 2 cm (clinical stage II) in 31 patients. LVI was present in the primary tumor in 75 patients, absent in 69, and unknown in 9.

A positive SLN biopsy was significantly associated with stage II vs. stage I tumors (45% vs. 25%, P = .02), and with LVI vs. LVI absence (55% vs. 4%, P less than .01). Notably, 26% of positive SLNs occurred in tumors 1 cm or less, observed Dr. Fields.

After a median follow-up of 41 months, 16 nodal or distant recurrences occurred, 11 patients died of MCC, and 27 patients died of other causes.

"This highlights the fact that overall survival, which has been used quite a bit as an end point in Merkel cell cancers, is a poor end point measure in this population," Dr. Fields said.

Importantly, there were no nodal recurrences in SLN-positive patients who went on to receive adjuvant nodal radiation therapy after completion lymph node dissection or therapeutic radiotherapy alone.

Only two of the 32 SLN-positive patients (6%) who received no adjuvant chemotherapy developed a distant recurrence, suggesting that unproven adjuvant chemotherapy would be unlikely to benefit this patient population, Dr. Fields said.

Among the 108 patients with a negative SLN, 99 received no further treatment. Of these, 8% experienced a recurrence, which corresponds to a 15% false-negative rate for the SLNB procedure in MCC, he said.

When patients were stratified by tumor characteristics, there was no significant association between SLN-positive and SLN-negative patients in nodal/distant recurrence (P = .86) or death from MCC (P = .89). The association was significantly between stage II and stage I tumors for death (P =.05), but not for recurrence (P = .26).

In contrast, the presence of LVI was significantly associated with both nodal/distant recurrence and death from MCC (both P less than .001), Dr. Fields said. The 2-year confidence intervals of recurrence or death from MCC for LVI-positive patients were 30% and 15%, respectively.

Dr. Fields and his coauthors reported no study support or relevant conflicts of interest.

SAN ANTONIO – Lymphovascular invasion, not sentinel lymph node status, was strongly associated with recurrence and death from Merkel cell carcinoma in a series of 153 patients with clinically localized disease.

Patients without lymphatic vascular invasion (LVI) of their primary tumors did not develop recurrence or die, said Dr. Ryan Fields of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York.

Although sentinel lymph node (SLN) status was not associated with recurrence or death from Merkel cell carcinoma (MCC), patients with a positive SLN were more likely to receive subsequent treatment including complete lymph node dissection, nodal radiation therapy, and/or chemotherapy.

Dr. Fields suggested that one explanation for the surprising lack of association with SLN status may be the additional treatment received by SLN-positive patients was so effective as to interrupt the metastatic cascade and prevent recurrence or death from MCC.

During a discussion of the study, Dr. Kelly McMasters, professor and chair of surgery at the University of Louisville in Kentucky, expressed doubt that adjuvant therapy was so effective as to skew the results and asked whether clinicians should biopsy their next MCC patient or whether this may simply lead them to overtreat their patients.

Dr. Fields acknowledged that the results are puzzling and said that all patients with MCC continue to be offered SLN biopsy at Memorial Sloan-Kettering, where the study was performed. He added that surgeons there are also trying to capture information on LVI to determine in which patients LVI could be used in lieu of SLN biopsy as a prognostic marker.

There is no universally accepted staging system for MCC, a rare cutaneous cancer that has a propensity for lymphatic spread. SLN biopsy has been used in an effort to provide more accurate staging and to guide subsequent treatment, although most studies have been small and did not look at outcome at the time of SLN status, he explained.

A previous analysis of 251 MCC patients treated from 1970 to 2002 at Memorial Sloan-Kettering reported that disease stage was the only independent predictor of survival and that stage-specific survival was decreased in patients with node-positive disease (J. Clin. Oncol. 2005;23:2300-9).

In the current analysis from 1996 to 2010, a total of 153 patients with stage I or II MCC underwent SLN biopsy, of which 45 (29%) were positive and 108 (71%) were negative.

The primary tumor was 2 cm or less (clinical stage I) in 122 patients and more than 2 cm (clinical stage II) in 31 patients. LVI was present in the primary tumor in 75 patients, absent in 69, and unknown in 9.

A positive SLN biopsy was significantly associated with stage II vs. stage I tumors (45% vs. 25%, P = .02), and with LVI vs. LVI absence (55% vs. 4%, P less than .01). Notably, 26% of positive SLNs occurred in tumors 1 cm or less, observed Dr. Fields.

After a median follow-up of 41 months, 16 nodal or distant recurrences occurred, 11 patients died of MCC, and 27 patients died of other causes.

"This highlights the fact that overall survival, which has been used quite a bit as an end point in Merkel cell cancers, is a poor end point measure in this population," Dr. Fields said.

Importantly, there were no nodal recurrences in SLN-positive patients who went on to receive adjuvant nodal radiation therapy after completion lymph node dissection or therapeutic radiotherapy alone.

Only two of the 32 SLN-positive patients (6%) who received no adjuvant chemotherapy developed a distant recurrence, suggesting that unproven adjuvant chemotherapy would be unlikely to benefit this patient population, Dr. Fields said.

Among the 108 patients with a negative SLN, 99 received no further treatment. Of these, 8% experienced a recurrence, which corresponds to a 15% false-negative rate for the SLNB procedure in MCC, he said.

When patients were stratified by tumor characteristics, there was no significant association between SLN-positive and SLN-negative patients in nodal/distant recurrence (P = .86) or death from MCC (P = .89). The association was significantly between stage II and stage I tumors for death (P =.05), but not for recurrence (P = .26).

In contrast, the presence of LVI was significantly associated with both nodal/distant recurrence and death from MCC (both P less than .001), Dr. Fields said. The 2-year confidence intervals of recurrence or death from MCC for LVI-positive patients were 30% and 15%, respectively.

Dr. Fields and his coauthors reported no study support or relevant conflicts of interest.

SAN ANTONIO – Lymphovascular invasion, not sentinel lymph node status, was strongly associated with recurrence and death from Merkel cell carcinoma in a series of 153 patients with clinically localized disease.

Patients without lymphatic vascular invasion (LVI) of their primary tumors did not develop recurrence or die, said Dr. Ryan Fields of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York.

Although sentinel lymph node (SLN) status was not associated with recurrence or death from Merkel cell carcinoma (MCC), patients with a positive SLN were more likely to receive subsequent treatment including complete lymph node dissection, nodal radiation therapy, and/or chemotherapy.

Dr. Fields suggested that one explanation for the surprising lack of association with SLN status may be the additional treatment received by SLN-positive patients was so effective as to interrupt the metastatic cascade and prevent recurrence or death from MCC.

During a discussion of the study, Dr. Kelly McMasters, professor and chair of surgery at the University of Louisville in Kentucky, expressed doubt that adjuvant therapy was so effective as to skew the results and asked whether clinicians should biopsy their next MCC patient or whether this may simply lead them to overtreat their patients.

Dr. Fields acknowledged that the results are puzzling and said that all patients with MCC continue to be offered SLN biopsy at Memorial Sloan-Kettering, where the study was performed. He added that surgeons there are also trying to capture information on LVI to determine in which patients LVI could be used in lieu of SLN biopsy as a prognostic marker.

There is no universally accepted staging system for MCC, a rare cutaneous cancer that has a propensity for lymphatic spread. SLN biopsy has been used in an effort to provide more accurate staging and to guide subsequent treatment, although most studies have been small and did not look at outcome at the time of SLN status, he explained.

A previous analysis of 251 MCC patients treated from 1970 to 2002 at Memorial Sloan-Kettering reported that disease stage was the only independent predictor of survival and that stage-specific survival was decreased in patients with node-positive disease (J. Clin. Oncol. 2005;23:2300-9).

In the current analysis from 1996 to 2010, a total of 153 patients with stage I or II MCC underwent SLN biopsy, of which 45 (29%) were positive and 108 (71%) were negative.

The primary tumor was 2 cm or less (clinical stage I) in 122 patients and more than 2 cm (clinical stage II) in 31 patients. LVI was present in the primary tumor in 75 patients, absent in 69, and unknown in 9.

A positive SLN biopsy was significantly associated with stage II vs. stage I tumors (45% vs. 25%, P = .02), and with LVI vs. LVI absence (55% vs. 4%, P less than .01). Notably, 26% of positive SLNs occurred in tumors 1 cm or less, observed Dr. Fields.

After a median follow-up of 41 months, 16 nodal or distant recurrences occurred, 11 patients died of MCC, and 27 patients died of other causes.

"This highlights the fact that overall survival, which has been used quite a bit as an end point in Merkel cell cancers, is a poor end point measure in this population," Dr. Fields said.

Importantly, there were no nodal recurrences in SLN-positive patients who went on to receive adjuvant nodal radiation therapy after completion lymph node dissection or therapeutic radiotherapy alone.

Only two of the 32 SLN-positive patients (6%) who received no adjuvant chemotherapy developed a distant recurrence, suggesting that unproven adjuvant chemotherapy would be unlikely to benefit this patient population, Dr. Fields said.

Among the 108 patients with a negative SLN, 99 received no further treatment. Of these, 8% experienced a recurrence, which corresponds to a 15% false-negative rate for the SLNB procedure in MCC, he said.

When patients were stratified by tumor characteristics, there was no significant association between SLN-positive and SLN-negative patients in nodal/distant recurrence (P = .86) or death from MCC (P = .89). The association was significantly between stage II and stage I tumors for death (P =.05), but not for recurrence (P = .26).

In contrast, the presence of LVI was significantly associated with both nodal/distant recurrence and death from MCC (both P less than .001), Dr. Fields said. The 2-year confidence intervals of recurrence or death from MCC for LVI-positive patients were 30% and 15%, respectively.

Dr. Fields and his coauthors reported no study support or relevant conflicts of interest.

SAN ANTONIO – Lymphovascular invasion, not sentinel lymph node status, was strongly associated with recurrence and death from Merkel cell carcinoma in a series of 153 patients with clinically localized disease.

Patients without lymphatic vascular invasion (LVI) of their primary tumors did not develop recurrence or die, said Dr. Ryan Fields of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York.

Although sentinel lymph node (SLN) status was not associated with recurrence or death from Merkel cell carcinoma (MCC), patients with a positive SLN were more likely to receive subsequent treatment including complete lymph node dissection, nodal radiation therapy, and/or chemotherapy.

Dr. Fields suggested that one explanation for the surprising lack of association with SLN status may be the additional treatment received by SLN-positive patients was so effective as to interrupt the metastatic cascade and prevent recurrence or death from MCC.

During a discussion of the study, Dr. Kelly McMasters, professor and chair of surgery at the University of Louisville in Kentucky, expressed doubt that adjuvant therapy was so effective as to skew the results and asked whether clinicians should biopsy their next MCC patient or whether this may simply lead them to overtreat their patients.

Dr. Fields acknowledged that the results are puzzling and said that all patients with MCC continue to be offered SLN biopsy at Memorial Sloan-Kettering, where the study was performed. He added that surgeons there are also trying to capture information on LVI to determine in which patients LVI could be used in lieu of SLN biopsy as a prognostic marker.

There is no universally accepted staging system for MCC, a rare cutaneous cancer that has a propensity for lymphatic spread. SLN biopsy has been used in an effort to provide more accurate staging and to guide subsequent treatment, although most studies have been small and did not look at outcome at the time of SLN status, he explained.

A previous analysis of 251 MCC patients treated from 1970 to 2002 at Memorial Sloan-Kettering reported that disease stage was the only independent predictor of survival and that stage-specific survival was decreased in patients with node-positive disease (J. Clin. Oncol. 2005;23:2300-9).

In the current analysis from 1996 to 2010, a total of 153 patients with stage I or II MCC underwent SLN biopsy, of which 45 (29%) were positive and 108 (71%) were negative.

The primary tumor was 2 cm or less (clinical stage I) in 122 patients and more than 2 cm (clinical stage II) in 31 patients. LVI was present in the primary tumor in 75 patients, absent in 69, and unknown in 9.

A positive SLN biopsy was significantly associated with stage II vs. stage I tumors (45% vs. 25%, P = .02), and with LVI vs. LVI absence (55% vs. 4%, P less than .01). Notably, 26% of positive SLNs occurred in tumors 1 cm or less, observed Dr. Fields.

After a median follow-up of 41 months, 16 nodal or distant recurrences occurred, 11 patients died of MCC, and 27 patients died of other causes.

"This highlights the fact that overall survival, which has been used quite a bit as an end point in Merkel cell cancers, is a poor end point measure in this population," Dr. Fields said.

Importantly, there were no nodal recurrences in SLN-positive patients who went on to receive adjuvant nodal radiation therapy after completion lymph node dissection or therapeutic radiotherapy alone.

Only two of the 32 SLN-positive patients (6%) who received no adjuvant chemotherapy developed a distant recurrence, suggesting that unproven adjuvant chemotherapy would be unlikely to benefit this patient population, Dr. Fields said.

Among the 108 patients with a negative SLN, 99 received no further treatment. Of these, 8% experienced a recurrence, which corresponds to a 15% false-negative rate for the SLNB procedure in MCC, he said.

When patients were stratified by tumor characteristics, there was no significant association between SLN-positive and SLN-negative patients in nodal/distant recurrence (P = .86) or death from MCC (P = .89). The association was significantly between stage II and stage I tumors for death (P =.05), but not for recurrence (P = .26).

In contrast, the presence of LVI was significantly associated with both nodal/distant recurrence and death from MCC (both P less than .001), Dr. Fields said. The 2-year confidence intervals of recurrence or death from MCC for LVI-positive patients were 30% and 15%, respectively.

Dr. Fields and his coauthors reported no study support or relevant conflicts of interest.

SAN ANTONIO – Lymphovascular invasion, not sentinel lymph node status, was strongly associated with recurrence and death from Merkel cell carcinoma in a series of 153 patients with clinically localized disease.

Patients without lymphatic vascular invasion (LVI) of their primary tumors did not develop recurrence or die, said Dr. Ryan Fields of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York.

Although sentinel lymph node (SLN) status was not associated with recurrence or death from Merkel cell carcinoma (MCC), patients with a positive SLN were more likely to receive subsequent treatment including complete lymph node dissection, nodal radiation therapy, and/or chemotherapy.

Dr. Fields suggested that one explanation for the surprising lack of association with SLN status may be the additional treatment received by SLN-positive patients was so effective as to interrupt the metastatic cascade and prevent recurrence or death from MCC.

During a discussion of the study, Dr. Kelly McMasters, professor and chair of surgery at the University of Louisville in Kentucky, expressed doubt that adjuvant therapy was so effective as to skew the results and asked whether clinicians should biopsy their next MCC patient or whether this may simply lead them to over treat their patients.

Dr. Fields acknowledged that the results are puzzling and said that all patients with MCC continue to be offered SLN biopsy at Memorial Sloan-Kettering, where the study was performed. He added that surgeons there are also trying to capture information on LVI to determine in which patients LVI could be used in lieu of SLN biopsy as a prognostic marker.

There is no universally accepted staging system for MCC, a rare cutaneous cancer that has a propensity for lymphatic spread. SLN biopsy has been used in an effort to provide more accurate staging and to guide subsequent treatment, although most studies have been small and did not look at outcome at the time of SLN status, he explained.

A previous analysis of 251 MCC patients treated from 1970 to 2002 at Memorial Sloan-Kettering reported that disease stage was the only independent predictor of survival and that stage-specific survival was decreased in patients with node-positive disease (J. Clin. Oncol. 2005;23:2300-9).

In the current analysis from 1996 to 2010, a total of 153 patients with stage I or II MCC underwent SLN biopsy, of which 45 (29%) were positive and 108 (71%) were negative.

The primary tumor was 2 cm or less (clinical stage I) in 122 patients and more than 2 cm (clinical stage II) in 31 patients. LVI was present in the primary tumor in 75 patients, absent in 69, and unknown in 9.

A positive SLN biopsy was significantly associated with stage II vs. stage I tumors (45% vs. 25%, P = .02), and with LVI vs. LVI absence (55% vs. 4%, P less than .01). Notably, 26% of positive SLNs occurred in tumors 1 cm or less, observed Dr. Fields.

After a median follow-up of 41 months, 16 nodal or distant recurrences occurred, 11 patients died of MCC, and 27 patients died of other causes.

"This highlights the fact that overall survival, which has been used quite a bit as an end point in Merkel cell cancers, is a poor end point measure in this population," Dr. Fields said.

Importantly, there were no nodal recurrences in SLN-positive patients who went on to receive adjuvant nodal radiation therapy after completion lymph node dissection or therapeutic radiotherapy alone.

Only two of the 32 SLN-positive patients (6%) who received no adjuvant chemotherapy developed a distant recurrence, suggesting that unproven adjuvant chemotherapy would be unlikely to benefit this patient population, Dr. Fields said.

Among the 108 patients with a negative SLN, 99 received no further treatment. Of these, 8% experienced a recurrence, which corresponds to a 15% false-negative rate for the SLNB procedure in MCC, he said.

When patients were stratified by tumor characteristics, there was no significant association between SLN-positive and SLN-negative patients in nodal/distant recurrence (P = .86) or death from MCC (P = .89). The association was significantly between stage II and stage I tumors for death (P =.05), but not for recurrence (P = .26).

In contrast, the presence of LVI was significantly associated with both nodal/distant recurrence and death from MCC (both P less than .001), Dr. Fields said. The 2-year confidence intervals of recurrence or death from MCC for LVI-positive patients were 30% and 15%, respectively.

Dr. Fields and his coauthors reported no study support or relevant conflicts of interest.

SAN ANTONIO – Lymphovascular invasion, not sentinel lymph node status, was strongly associated with recurrence and death from Merkel cell carcinoma in a series of 153 patients with clinically localized disease.

Patients without lymphatic vascular invasion (LVI) of their primary tumors did not develop recurrence or die, said Dr. Ryan Fields of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York.

Although sentinel lymph node (SLN) status was not associated with recurrence or death from Merkel cell carcinoma (MCC), patients with a positive SLN were more likely to receive subsequent treatment including complete lymph node dissection, nodal radiation therapy, and/or chemotherapy.

Dr. Fields suggested that one explanation for the surprising lack of association with SLN status may be the additional treatment received by SLN-positive patients was so effective as to interrupt the metastatic cascade and prevent recurrence or death from MCC.

During a discussion of the study, Dr. Kelly McMasters, professor and chair of surgery at the University of Louisville in Kentucky, expressed doubt that adjuvant therapy was so effective as to skew the results and asked whether clinicians should biopsy their next MCC patient or whether this may simply lead them to over treat their patients.

Dr. Fields acknowledged that the results are puzzling and said that all patients with MCC continue to be offered SLN biopsy at Memorial Sloan-Kettering, where the study was performed. He added that surgeons there are also trying to capture information on LVI to determine in which patients LVI could be used in lieu of SLN biopsy as a prognostic marker.

There is no universally accepted staging system for MCC, a rare cutaneous cancer that has a propensity for lymphatic spread. SLN biopsy has been used in an effort to provide more accurate staging and to guide subsequent treatment, although most studies have been small and did not look at outcome at the time of SLN status, he explained.

A previous analysis of 251 MCC patients treated from 1970 to 2002 at Memorial Sloan-Kettering reported that disease stage was the only independent predictor of survival and that stage-specific survival was decreased in patients with node-positive disease (J. Clin. Oncol. 2005;23:2300-9).

In the current analysis from 1996 to 2010, a total of 153 patients with stage I or II MCC underwent SLN biopsy, of which 45 (29%) were positive and 108 (71%) were negative.

The primary tumor was 2 cm or less (clinical stage I) in 122 patients and more than 2 cm (clinical stage II) in 31 patients. LVI was present in the primary tumor in 75 patients, absent in 69, and unknown in 9.

A positive SLN biopsy was significantly associated with stage II vs. stage I tumors (45% vs. 25%, P = .02), and with LVI vs. LVI absence (55% vs. 4%, P less than .01). Notably, 26% of positive SLNs occurred in tumors 1 cm or less, observed Dr. Fields.

After a median follow-up of 41 months, 16 nodal or distant recurrences occurred, 11 patients died of MCC, and 27 patients died of other causes.

"This highlights the fact that overall survival, which has been used quite a bit as an end point in Merkel cell cancers, is a poor end point measure in this population," Dr. Fields said.

Importantly, there were no nodal recurrences in SLN-positive patients who went on to receive adjuvant nodal radiation therapy after completion lymph node dissection or therapeutic radiotherapy alone.

Only two of the 32 SLN-positive patients (6%) who received no adjuvant chemotherapy developed a distant recurrence, suggesting that unproven adjuvant chemotherapy would be unlikely to benefit this patient population, Dr. Fields said.

Among the 108 patients with a negative SLN, 99 received no further treatment. Of these, 8% experienced a recurrence, which corresponds to a 15% false-negative rate for the SLNB procedure in MCC, he said.

When patients were stratified by tumor characteristics, there was no significant association between SLN-positive and SLN-negative patients in nodal/distant recurrence (P = .86) or death from MCC (P = .89). The association was significantly between stage II and stage I tumors for death (P =.05), but not for recurrence (P = .26).

In contrast, the presence of LVI was significantly associated with both nodal/distant recurrence and death from MCC (both P less than .001), Dr. Fields said. The 2-year confidence intervals of recurrence or death from MCC for LVI-positive patients were 30% and 15%, respectively.

Dr. Fields and his coauthors reported no study support or relevant conflicts of interest.

SAN ANTONIO – Lymphovascular invasion, not sentinel lymph node status, was strongly associated with recurrence and death from Merkel cell carcinoma in a series of 153 patients with clinically localized disease.

Patients without lymphatic vascular invasion (LVI) of their primary tumors did not develop recurrence or die, said Dr. Ryan Fields of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York.

Although sentinel lymph node (SLN) status was not associated with recurrence or death from Merkel cell carcinoma (MCC), patients with a positive SLN were more likely to receive subsequent treatment including complete lymph node dissection, nodal radiation therapy, and/or chemotherapy.

Dr. Fields suggested that one explanation for the surprising lack of association with SLN status may be the additional treatment received by SLN-positive patients was so effective as to interrupt the metastatic cascade and prevent recurrence or death from MCC.

During a discussion of the study, Dr. Kelly McMasters, professor and chair of surgery at the University of Louisville in Kentucky, expressed doubt that adjuvant therapy was so effective as to skew the results and asked whether clinicians should biopsy their next MCC patient or whether this may simply lead them to over treat their patients.

Dr. Fields acknowledged that the results are puzzling and said that all patients with MCC continue to be offered SLN biopsy at Memorial Sloan-Kettering, where the study was performed. He added that surgeons there are also trying to capture information on LVI to determine in which patients LVI could be used in lieu of SLN biopsy as a prognostic marker.

There is no universally accepted staging system for MCC, a rare cutaneous cancer that has a propensity for lymphatic spread. SLN biopsy has been used in an effort to provide more accurate staging and to guide subsequent treatment, although most studies have been small and did not look at outcome at the time of SLN status, he explained.

A previous analysis of 251 MCC patients treated from 1970 to 2002 at Memorial Sloan-Kettering reported that disease stage was the only independent predictor of survival and that stage-specific survival was decreased in patients with node-positive disease (J. Clin. Oncol. 2005;23:2300-9).

In the current analysis from 1996 to 2010, a total of 153 patients with stage I or II MCC underwent SLN biopsy, of which 45 (29%) were positive and 108 (71%) were negative.

The primary tumor was 2 cm or less (clinical stage I) in 122 patients and more than 2 cm (clinical stage II) in 31 patients. LVI was present in the primary tumor in 75 patients, absent in 69, and unknown in 9.

A positive SLN biopsy was significantly associated with stage II vs. stage I tumors (45% vs. 25%, P = .02), and with LVI vs. LVI absence (55% vs. 4%, P less than .01). Notably, 26% of positive SLNs occurred in tumors 1 cm or less, observed Dr. Fields.

After a median follow-up of 41 months, 16 nodal or distant recurrences occurred, 11 patients died of MCC, and 27 patients died of other causes.

"This highlights the fact that overall survival, which has been used quite a bit as an end point in Merkel cell cancers, is a poor end point measure in this population," Dr. Fields said.

Importantly, there were no nodal recurrences in SLN-positive patients who went on to receive adjuvant nodal radiation therapy after completion lymph node dissection or therapeutic radiotherapy alone.

Only two of the 32 SLN-positive patients (6%) who received no adjuvant chemotherapy developed a distant recurrence, suggesting that unproven adjuvant chemotherapy would be unlikely to benefit this patient population, Dr. Fields said.

Among the 108 patients with a negative SLN, 99 received no further treatment. Of these, 8% experienced a recurrence, which corresponds to a 15% false-negative rate for the SLNB procedure in MCC, he said.

When patients were stratified by tumor characteristics, there was no significant association between SLN-positive and SLN-negative patients in nodal/distant recurrence (P = .86) or death from MCC (P = .89). The association was significantly between stage II and stage I tumors for death (P =.05), but not for recurrence (P = .26).

In contrast, the presence of LVI was significantly associated with both nodal/distant recurrence and death from MCC (both P less than .001), Dr. Fields said. The 2-year confidence intervals of recurrence or death from MCC for LVI-positive patients were 30% and 15%, respectively.

Dr. Fields and his coauthors reported no study support or relevant conflicts of interest.

SAN ANTONIO – Patients with thin melanomas and positive deep margins on initial biopsy had the same incidence of sentinel lymph node metastasis as those with thicker melanomas, according to the results of a retrospective analysis of 260 patients with melanoma.

At least one positive sentinel lymph node was detected in 6 of 73 patients (8%) with a melanoma Breslow thickness of less than 0.8 mm and positive deep margins vs. 17 of 187 patients (9%) with a melanoma Breslow thickness of 0.8-2.0 mm, regardless of margin status (P = .82).

Immunohistochemistry was the most common method of identifying positive sentinel nodes in both the thin and thick melanoma groups (5 cases vs. 10 cases, respectively), Dr. Victor Koshenkov said at a symposium sponsored by the Society of Surgical Oncology.

The decision to perform sentinel node biopsy is largely driven by tumor thickness. When the initial biopsy of a thin melanoma shows positive deep margins, many clinicians will treat these cases as potentially thicker melanomas and perform sentinel lymph node (SLN) biopsy. There are few data on the impact of positive deep margins on surgical decision making, prognosis, and outcome, even though positive deep margins are the most common cause of incompletely measured or indeterminate tumor thickness, said Dr. Koshenkov of the department of surgery at Atlantic Health Memorial Hospital in Morristown, N.J.

He presented data from a retrospective analysis of 260 adult patients who underwent wide excision plus SLN biopsy for cutaneous melanoma from January 2004 to May 2010.

Demographics were not statistically different between the two groups, except for tumor site and Clark’s level, he said. In 53% of patients in the thicker melanoma group, the extremities were the primary tumor site vs. 38% in the thin melanoma group (P = .042), while 40% had Clark’s level IV-V vs. 22% in the thin melanoma group (P less than .001).

Multivariate regression analysis revealed that only female gender (P = .046; odds ratio, 2.68) and Clark’s level IV-V (P = .024; OR, 3.54) were significantly associated with an increased risk of positive SLNs. Belonging to the thin melanoma group versus the thicker melanoma group was not significant (P = .66; OR, 1.29) Dr. Koshenkov said.

The presence of residual disease approached, but did not reach, statistical significance (P = .062; OR, 2.60). Residual disease was found in about 20% of both groups. Only 4 of the 73 patients (5.5%) with positive SLNs in the thin melanoma group required further reexcision with wide margins.

Only 1 of the 23 sentinel node–positive patients went on to have additional positive nodes on completion of lymph node dissection, he said.

"Patients with thin melanomas and positive deep margins on initial biopsy have an incidence of SLN metastasis statistically no different than patients with thicker melanomas," Dr. Koshenkov concluded. "Thus, we believe that thin melanomas with positive deep margins should be treated with wide excision and a sentinel lymph node biopsy. Of course, these findings should be tested and verified in larger, multi-institutional databases."

During a discussion of the study, the audience questioned the ability to make almost a practice-changing conclusion based on the small number of patients and the low incidence of positive SLNs in the thicker melanoma group. Dr. Koshenkov replied that the reason the rate of sentinel node positivity was lower than predicted in this group was that a larger proportion of patients had melanomas 0.8-1 mm in depth, rather than 1-2 mm in depth.

Another attendee remarked that before concluding that every patient with a positive deep margin on initial biopsy needs to undergo SLN biopsy, it is important to know how many patients with positive sentinel nodes had a positive deep margin as their only indication or whether factors such as mitotic rate or ulceration played a role. Dr. Koshenkov said mitotic rate was not analyzed because it was not regularly included in the pathology report at the time of the review, and that ulceration and Clark's level IV were factored into the multivariate analysis.

The authors said they had no relevant financial disclosures.

SAN ANTONIO – Patients with thin melanomas and positive deep margins on initial biopsy had the same incidence of sentinel lymph node metastasis as those with thicker melanomas, according to the results of a retrospective analysis of 260 patients with melanoma.

At least one positive sentinel lymph node was detected in 6 of 73 patients (8%) with a melanoma Breslow thickness of less than 0.8 mm and positive deep margins vs. 17 of 187 patients (9%) with a melanoma Breslow thickness of 0.8-2.0 mm, regardless of margin status (P = .82).

Immunohistochemistry was the most common method of identifying positive sentinel nodes in both the thin and thick melanoma groups (5 cases vs. 10 cases, respectively), Dr. Victor Koshenkov said at a symposium sponsored by the Society of Surgical Oncology.

The decision to perform sentinel node biopsy is largely driven by tumor thickness. When the initial biopsy of a thin melanoma shows positive deep margins, many clinicians will treat these cases as potentially thicker melanomas and perform sentinel lymph node (SLN) biopsy. There are few data on the impact of positive deep margins on surgical decision making, prognosis, and outcome, even though positive deep margins are the most common cause of incompletely measured or indeterminate tumor thickness, said Dr. Koshenkov of the department of surgery at Atlantic Health Memorial Hospital in Morristown, N.J.

He presented data from a retrospective analysis of 260 adult patients who underwent wide excision plus SLN biopsy for cutaneous melanoma from January 2004 to May 2010.

Demographics were not statistically different between the two groups, except for tumor site and Clark’s level, he said. In 53% of patients in the thicker melanoma group, the extremities were the primary tumor site vs. 38% in the thin melanoma group (P = .042), while 40% had Clark’s level IV-V vs. 22% in the thin melanoma group (P less than .001).

Multivariate regression analysis revealed that only female gender (P = .046; odds ratio, 2.68) and Clark’s level IV-V (P = .024; OR, 3.54) were significantly associated with an increased risk of positive SLNs. Belonging to the thin melanoma group versus the thicker melanoma group was not significant (P = .66; OR, 1.29) Dr. Koshenkov said.

The presence of residual disease approached, but did not reach, statistical significance (P = .062; OR, 2.60). Residual disease was found in about 20% of both groups. Only 4 of the 73 patients (5.5%) with positive SLNs in the thin melanoma group required further reexcision with wide margins.

Only 1 of the 23 sentinel node–positive patients went on to have additional positive nodes on completion of lymph node dissection, he said.

"Patients with thin melanomas and positive deep margins on initial biopsy have an incidence of SLN metastasis statistically no different than patients with thicker melanomas," Dr. Koshenkov concluded. "Thus, we believe that thin melanomas with positive deep margins should be treated with wide excision and a sentinel lymph node biopsy. Of course, these findings should be tested and verified in larger, multi-institutional databases."

During a discussion of the study, the audience questioned the ability to make almost a practice-changing conclusion based on the small number of patients and the low incidence of positive SLNs in the thicker melanoma group. Dr. Koshenkov replied that the reason the rate of sentinel node positivity was lower than predicted in this group was that a larger proportion of patients had melanomas 0.8-1 mm in depth, rather than 1-2 mm in depth.

Another attendee remarked that before concluding that every patient with a positive deep margin on initial biopsy needs to undergo SLN biopsy, it is important to know how many patients with positive sentinel nodes had a positive deep margin as their only indication or whether factors such as mitotic rate or ulceration played a role. Dr. Koshenkov said mitotic rate was not analyzed because it was not regularly included in the pathology report at the time of the review, and that ulceration and Clark's level IV were factored into the multivariate analysis.

The authors said they had no relevant financial disclosures.

SAN ANTONIO – Patients with thin melanomas and positive deep margins on initial biopsy had the same incidence of sentinel lymph node metastasis as those with thicker melanomas, according to the results of a retrospective analysis of 260 patients with melanoma.

At least one positive sentinel lymph node was detected in 6 of 73 patients (8%) with a melanoma Breslow thickness of less than 0.8 mm and positive deep margins vs. 17 of 187 patients (9%) with a melanoma Breslow thickness of 0.8-2.0 mm, regardless of margin status (P = .82).

Immunohistochemistry was the most common method of identifying positive sentinel nodes in both the thin and thick melanoma groups (5 cases vs. 10 cases, respectively), Dr. Victor Koshenkov said at a symposium sponsored by the Society of Surgical Oncology.

The decision to perform sentinel node biopsy is largely driven by tumor thickness. When the initial biopsy of a thin melanoma shows positive deep margins, many clinicians will treat these cases as potentially thicker melanomas and perform sentinel lymph node (SLN) biopsy. There are few data on the impact of positive deep margins on surgical decision making, prognosis, and outcome, even though positive deep margins are the most common cause of incompletely measured or indeterminate tumor thickness, said Dr. Koshenkov of the department of surgery at Atlantic Health Memorial Hospital in Morristown, N.J.

He presented data from a retrospective analysis of 260 adult patients who underwent wide excision plus SLN biopsy for cutaneous melanoma from January 2004 to May 2010.

Demographics were not statistically different between the two groups, except for tumor site and Clark’s level, he said. In 53% of patients in the thicker melanoma group, the extremities were the primary tumor site vs. 38% in the thin melanoma group (P = .042), while 40% had Clark’s level IV-V vs. 22% in the thin melanoma group (P less than .001).

Multivariate regression analysis revealed that only female gender (P = .046; odds ratio, 2.68) and Clark’s level IV-V (P = .024; OR, 3.54) were significantly associated with an increased risk of positive SLNs. Belonging to the thin melanoma group versus the thicker melanoma group was not significant (P = .66; OR, 1.29) Dr. Koshenkov said.

The presence of residual disease approached, but did not reach, statistical significance (P = .062; OR, 2.60). Residual disease was found in about 20% of both groups. Only 4 of the 73 patients (5.5%) with positive SLNs in the thin melanoma group required further reexcision with wide margins.

Only 1 of the 23 sentinel node–positive patients went on to have additional positive nodes on completion of lymph node dissection, he said.

"Patients with thin melanomas and positive deep margins on initial biopsy have an incidence of SLN metastasis statistically no different than patients with thicker melanomas," Dr. Koshenkov concluded. "Thus, we believe that thin melanomas with positive deep margins should be treated with wide excision and a sentinel lymph node biopsy. Of course, these findings should be tested and verified in larger, multi-institutional databases."

During a discussion of the study, the audience questioned the ability to make almost a practice-changing conclusion based on the small number of patients and the low incidence of positive SLNs in the thicker melanoma group. Dr. Koshenkov replied that the reason the rate of sentinel node positivity was lower than predicted in this group was that a larger proportion of patients had melanomas 0.8-1 mm in depth, rather than 1-2 mm in depth.

Another attendee remarked that before concluding that every patient with a positive deep margin on initial biopsy needs to undergo SLN biopsy, it is important to know how many patients with positive sentinel nodes had a positive deep margin as their only indication or whether factors such as mitotic rate or ulceration played a role. Dr. Koshenkov said mitotic rate was not analyzed because it was not regularly included in the pathology report at the time of the review, and that ulceration and Clark's level IV were factored into the multivariate analysis.

The authors said they had no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

SAN ANTONIO – Patients with thin melanomas and positive deep margins on initial biopsy had the same incidence of sentinel lymph node metastasis as those with thicker melanomas, according to the results of a retrospective analysis of 260 patients with melanoma.

At least one positive sentinel lymph node was detected in 6 of 73 patients (8%) with a melanoma Breslow thickness of less than 0.8 mm and positive deep margins vs. 17 of 187 patients (9%) with a melanoma Breslow thickness of 0.8-2.0 mm, regardless of margin status (P = .82).

Immunohistochemistry was the most common method of identifying positive sentinel nodes in both the thin and thick melanoma groups (5 cases vs. 10 cases, respectively), Dr. Victor Koshenkov said at a symposium sponsored by the Society of Surgical Oncology.

The decision to perform sentinel node biopsy is largely driven by tumor thickness. When the initial biopsy of a thin melanoma shows positive deep margins, many clinicians will treat these cases as potentially thicker melanomas and perform sentinel lymph node (SLN) biopsy. There are few data on the impact of positive deep margins on surgical decision making, prognosis, and outcome, even though positive deep margins are the most common cause of incompletely measured or indeterminate tumor thickness, said Dr. Koshenkov of the department of surgery at Atlantic Health Memorial Hospital in Morristown, N.J.

He presented data from a retrospective analysis of 260 adult patients who underwent wide excision plus SLN biopsy for cutaneous melanoma from January 2004 to May 2010.

Demographics were not statistically different between the two groups, except for tumor site and Clark’s level, he said. In 53% of patients in the thicker melanoma group, the extremities were the primary tumor site vs. 38% in the thin melanoma group (P = .042), while 40% had Clark’s level IV-V vs. 22% in the thin melanoma group (P less than .001).

Multivariate regression analysis revealed that only female gender (P = .046; odds ratio, 2.68) and Clark’s level IV-V (P = .024; OR, 3.54) were significantly associated with an increased risk of positive SLNs. Belonging to the thin melanoma group versus the thicker melanoma group was not significant (P = .66; OR, 1.29) Dr. Koshenkov said.

The presence of residual disease approached, but did not reach, statistical significance (P = .062; OR, 2.60). Residual disease was found in about 20% of both groups. Only 4 of the 73 patients (5.5%) with positive SLNs in the thin melanoma group required further reexcision with wide margins.

Only 1 of the 23 sentinel node–positive patients went on to have additional positive nodes on completion of lymph node dissection, he said.

"Patients with thin melanomas and positive deep margins on initial biopsy have an incidence of SLN metastasis statistically no different than patients with thicker melanomas," Dr. Koshenkov concluded. "Thus, we believe that thin melanomas with positive deep margins should be treated with wide excision and a sentinel lymph node biopsy. Of course, these findings should be tested and verified in larger, multi-institutional databases."

During a discussion of the study, the audience questioned the ability to make almost a practice-changing conclusion based on the small number of patients and the low incidence of positive SLNs in the thicker melanoma group. Dr. Koshenkov replied that the reason the rate of sentinel node positivity was lower than predicted in this group was that a larger proportion of patients had melanomas 0.8-1 mm in depth, rather than 1-2 mm in depth.

Another attendee remarked that before concluding that every patient with a positive deep margin on initial biopsy needs to undergo SLN biopsy, it is important to know how many patients with positive sentinel nodes had a positive deep margin as their only indication or whether factors such as mitotic rate or ulceration played a role. Dr. Koshenkov said mitotic rate was not analyzed because it was not regularly included in the pathology report at the time of the review, and that ulceration and Clark’s level IV were factored into the multivariate analysis.

The authors said they had no relevant financial disclosures.

SAN ANTONIO – Patients with thin melanomas and positive deep margins on initial biopsy had the same incidence of sentinel lymph node metastasis as those with thicker melanomas, according to the results of a retrospective analysis of 260 patients with melanoma.

At least one positive sentinel lymph node was detected in 6 of 73 patients (8%) with a melanoma Breslow thickness of less than 0.8 mm and positive deep margins vs. 17 of 187 patients (9%) with a melanoma Breslow thickness of 0.8-2.0 mm, regardless of margin status (P = .82).

Immunohistochemistry was the most common method of identifying positive sentinel nodes in both the thin and thick melanoma groups (5 cases vs. 10 cases, respectively), Dr. Victor Koshenkov said at a symposium sponsored by the Society of Surgical Oncology.

The decision to perform sentinel node biopsy is largely driven by tumor thickness. When the initial biopsy of a thin melanoma shows positive deep margins, many clinicians will treat these cases as potentially thicker melanomas and perform sentinel lymph node (SLN) biopsy. There are few data on the impact of positive deep margins on surgical decision making, prognosis, and outcome, even though positive deep margins are the most common cause of incompletely measured or indeterminate tumor thickness, said Dr. Koshenkov of the department of surgery at Atlantic Health Memorial Hospital in Morristown, N.J.

He presented data from a retrospective analysis of 260 adult patients who underwent wide excision plus SLN biopsy for cutaneous melanoma from January 2004 to May 2010.

Demographics were not statistically different between the two groups, except for tumor site and Clark’s level, he said. In 53% of patients in the thicker melanoma group, the extremities were the primary tumor site vs. 38% in the thin melanoma group (P = .042), while 40% had Clark’s level IV-V vs. 22% in the thin melanoma group (P less than .001).

Multivariate regression analysis revealed that only female gender (P = .046; odds ratio, 2.68) and Clark’s level IV-V (P = .024; OR, 3.54) were significantly associated with an increased risk of positive SLNs. Belonging to the thin melanoma group versus the thicker melanoma group was not significant (P = .66; OR, 1.29) Dr. Koshenkov said.

The presence of residual disease approached, but did not reach, statistical significance (P = .062; OR, 2.60). Residual disease was found in about 20% of both groups. Only 4 of the 73 patients (5.5%) with positive SLNs in the thin melanoma group required further reexcision with wide margins.

Only 1 of the 23 sentinel node–positive patients went on to have additional positive nodes on completion of lymph node dissection, he said.

"Patients with thin melanomas and positive deep margins on initial biopsy have an incidence of SLN metastasis statistically no different than patients with thicker melanomas," Dr. Koshenkov concluded. "Thus, we believe that thin melanomas with positive deep margins should be treated with wide excision and a sentinel lymph node biopsy. Of course, these findings should be tested and verified in larger, multi-institutional databases."

During a discussion of the study, the audience questioned the ability to make almost a practice-changing conclusion based on the small number of patients and the low incidence of positive SLNs in the thicker melanoma group. Dr. Koshenkov replied that the reason the rate of sentinel node positivity was lower than predicted in this group was that a larger proportion of patients had melanomas 0.8-1 mm in depth, rather than 1-2 mm in depth.

Another attendee remarked that before concluding that every patient with a positive deep margin on initial biopsy needs to undergo SLN biopsy, it is important to know how many patients with positive sentinel nodes had a positive deep margin as their only indication or whether factors such as mitotic rate or ulceration played a role. Dr. Koshenkov said mitotic rate was not analyzed because it was not regularly included in the pathology report at the time of the review, and that ulceration and Clark’s level IV were factored into the multivariate analysis.

The authors said they had no relevant financial disclosures.

SAN ANTONIO – Patients with thin melanomas and positive deep margins on initial biopsy had the same incidence of sentinel lymph node metastasis as those with thicker melanomas, according to the results of a retrospective analysis of 260 patients with melanoma.

At least one positive sentinel lymph node was detected in 6 of 73 patients (8%) with a melanoma Breslow thickness of less than 0.8 mm and positive deep margins vs. 17 of 187 patients (9%) with a melanoma Breslow thickness of 0.8-2.0 mm, regardless of margin status (P = .82).

Immunohistochemistry was the most common method of identifying positive sentinel nodes in both the thin and thick melanoma groups (5 cases vs. 10 cases, respectively), Dr. Victor Koshenkov said at a symposium sponsored by the Society of Surgical Oncology.

The decision to perform sentinel node biopsy is largely driven by tumor thickness. When the initial biopsy of a thin melanoma shows positive deep margins, many clinicians will treat these cases as potentially thicker melanomas and perform sentinel lymph node (SLN) biopsy. There are few data on the impact of positive deep margins on surgical decision making, prognosis, and outcome, even though positive deep margins are the most common cause of incompletely measured or indeterminate tumor thickness, said Dr. Koshenkov of the department of surgery at Atlantic Health Memorial Hospital in Morristown, N.J.

He presented data from a retrospective analysis of 260 adult patients who underwent wide excision plus SLN biopsy for cutaneous melanoma from January 2004 to May 2010.

Demographics were not statistically different between the two groups, except for tumor site and Clark’s level, he said. In 53% of patients in the thicker melanoma group, the extremities were the primary tumor site vs. 38% in the thin melanoma group (P = .042), while 40% had Clark’s level IV-V vs. 22% in the thin melanoma group (P less than .001).

Multivariate regression analysis revealed that only female gender (P = .046; odds ratio, 2.68) and Clark’s level IV-V (P = .024; OR, 3.54) were significantly associated with an increased risk of positive SLNs. Belonging to the thin melanoma group versus the thicker melanoma group was not significant (P = .66; OR, 1.29) Dr. Koshenkov said.

The presence of residual disease approached, but did not reach, statistical significance (P = .062; OR, 2.60). Residual disease was found in about 20% of both groups. Only 4 of the 73 patients (5.5%) with positive SLNs in the thin melanoma group required further reexcision with wide margins.

Only 1 of the 23 sentinel node–positive patients went on to have additional positive nodes on completion of lymph node dissection, he said.

"Patients with thin melanomas and positive deep margins on initial biopsy have an incidence of SLN metastasis statistically no different than patients with thicker melanomas," Dr. Koshenkov concluded. "Thus, we believe that thin melanomas with positive deep margins should be treated with wide excision and a sentinel lymph node biopsy. Of course, these findings should be tested and verified in larger, multi-institutional databases."

During a discussion of the study, the audience questioned the ability to make almost a practice-changing conclusion based on the small number of patients and the low incidence of positive SLNs in the thicker melanoma group. Dr. Koshenkov replied that the reason the rate of sentinel node positivity was lower than predicted in this group was that a larger proportion of patients had melanomas 0.8-1 mm in depth, rather than 1-2 mm in depth.

Another attendee remarked that before concluding that every patient with a positive deep margin on initial biopsy needs to undergo SLN biopsy, it is important to know how many patients with positive sentinel nodes had a positive deep margin as their only indication or whether factors such as mitotic rate or ulceration played a role. Dr. Koshenkov said mitotic rate was not analyzed because it was not regularly included in the pathology report at the time of the review, and that ulceration and Clark’s level IV were factored into the multivariate analysis.

The authors said they had no relevant financial disclosures.

DETROIT – Preinjury use of warfarin, but not aspirin or clopidogrel, significantly increased the risk of death in a retrospective analysis of 3,488 trauma patients.

Overall, mortality was 13.6% for patients on warfarin (Coumadin), aspirin, clopidogrel (Plavix), or various combinations, compared with 6.2% for patients not on these medications.

When mortality data were broken down by drug, warfarin demonstrated a mortality of 24% vs. 6% for controls.

After they adjusted for the potential confounders of age and injury severity score, the researchers found that the relative risk of a patient on warfarin dying during hospitalization as a result of their injury remained significant at 3.9, first-year resident Dr. Travis Arnold reported on behalf of his colleagues and lead author Dr. Carrie Jahraus at Albany (N.Y.) Medical College.

Surprisingly, aspirin and clopidogrel were not significantly associated with increased mortality at 12.3% and 9.3%, respectively, when adjusted for confounders.

"With aspirin and, [perhaps] clopidogrel, there may be some protective mechanism that we don’t fully understand," senior author Dr. Daniel Bonville said in an interview, adding that other groups have found similar results for the two agents.

All of the drugs increased the risk of intracranial hemorrhage when compared with controls (50% vs. 30%). The adjusted relative risk was 3.2 for warfarin, 1.9 for patients on warfarin plus clopidogrel, and 1.6 for those on aspirin or other combinations.

A total of 3,488 trauma patients were identified in the Albany Medical College database from September 2004 to December 2007. Of these, 456 patients were on some form of anticoagulation or antiplatelet therapy including 91 patients on warfarin alone, 228 on aspirin, 43 on clopidogrel, and 94 on various combinations. The mean warfarin international normalized ratio (INR) level was within the therapeutic window at 2.4, with 95% of patients falling between 2.2 and 2.6, Dr. Arnold said.

The percentage of patients in the treatment and control groups who experienced a blunt trauma was similar at 99% vs. 93%, respectively, as was the percentage with Injury Severity Scores greater than 15 (55% vs. 50%, respectively).

Hospital length of stay greater than 10 days was similar at 30% for the treatment group vs. 24% for controls, and remained similar after adjustment, Dr. Arnold said.

The percentage of patients discharged to home was significantly lower at 48% among patients on warfarin and antiplatelet agents vs. 74% for controls (P less than .01). This difference disappeared when adjusted for age.

When the researchers compared the subgroup of 191 patients who had intracranial hemorrhage with controls, only warfarin increased mortality (29% vs. 6%, adjusted RR 3.1) and the need for craniotomy (15% vs. 7%, adjusted RR 2.2), Dr. Arnold said.

He concluded that warfarin continues to be a necessary evil for many patients with coronary artery disease or history of stroke and advocated for greater patient education by primary care providers on the risks of anticoagulants.

Invited discussant Dr. Mark Hemmila, with the University of Michigan, Ann Arbor, said it is fortunate that only warfarin increases the risk of mortality given how difficult it is to reverse the effects of aspirin and clopidogrel, but that he would rank clopidogrel ahead of Coumadin and aspirin in terms of dangerousness. He asked Dr. Arnold to speculate on why no effect was observed and how the researchers recommend evaluating patients on warfarin.

Dr. Arnold said if a patient is on warfarin and has significant trauma and an elevated INR, warfarin reversal is initiated prior to obtaining computed tomography imaging. Factor VII is used, although they are transitioning more to the prothrombin complex. He said it is unclear why no impact on mortality was observed for aspirin given the large number of aspirin users in the study and that an effect would likely have been observed had there been more clopidogrel patients.

A recent analysis of 1.2 million patients in the American College of Surgeons’ National Trauma Data Bank reported that warfarin was associated with an increased risk of death, regardless of type of injury, indication for anticoagulation, or comorbidities. In all, 9.3% of warfarin-users died from their injuries vs. 4.8% of nonusers (Arch. Surg. 2011 [doi:10.1001/archsurg.2010.313]).

The researchers disclosed no conflicts of interest.

DETROIT – Preinjury use of warfarin, but not aspirin or clopidogrel, significantly increased the risk of death in a retrospective analysis of 3,488 trauma patients.

Overall, mortality was 13.6% for patients on warfarin (Coumadin), aspirin, clopidogrel (Plavix), or various combinations, compared with 6.2% for patients not on these medications.

When mortality data were broken down by drug, warfarin demonstrated a mortality of 24% vs. 6% for controls.

After they adjusted for the potential confounders of age and injury severity score, the researchers found that the relative risk of a patient on warfarin dying during hospitalization as a result of their injury remained significant at 3.9, first-year resident Dr. Travis Arnold reported on behalf of his colleagues and lead author Dr. Carrie Jahraus at Albany (N.Y.) Medical College.

Surprisingly, aspirin and clopidogrel were not significantly associated with increased mortality at 12.3% and 9.3%, respectively, when adjusted for confounders.

"With aspirin and, [perhaps] clopidogrel, there may be some protective mechanism that we don’t fully understand," senior author Dr. Daniel Bonville said in an interview, adding that other groups have found similar results for the two agents.

All of the drugs increased the risk of intracranial hemorrhage when compared with controls (50% vs. 30%). The adjusted relative risk was 3.2 for warfarin, 1.9 for patients on warfarin plus clopidogrel, and 1.6 for those on aspirin or other combinations.

A total of 3,488 trauma patients were identified in the Albany Medical College database from September 2004 to December 2007. Of these, 456 patients were on some form of anticoagulation or antiplatelet therapy including 91 patients on warfarin alone, 228 on aspirin, 43 on clopidogrel, and 94 on various combinations. The mean warfarin international normalized ratio (INR) level was within the therapeutic window at 2.4, with 95% of patients falling between 2.2 and 2.6, Dr. Arnold said.

The percentage of patients in the treatment and control groups who experienced a blunt trauma was similar at 99% vs. 93%, respectively, as was the percentage with Injury Severity Scores greater than 15 (55% vs. 50%, respectively).

Hospital length of stay greater than 10 days was similar at 30% for the treatment group vs. 24% for controls, and remained similar after adjustment, Dr. Arnold said.

The percentage of patients discharged to home was significantly lower at 48% among patients on warfarin and antiplatelet agents vs. 74% for controls (P less than .01). This difference disappeared when adjusted for age.

When the researchers compared the subgroup of 191 patients who had intracranial hemorrhage with controls, only warfarin increased mortality (29% vs. 6%, adjusted RR 3.1) and the need for craniotomy (15% vs. 7%, adjusted RR 2.2), Dr. Arnold said.

He concluded that warfarin continues to be a necessary evil for many patients with coronary artery disease or history of stroke and advocated for greater patient education by primary care providers on the risks of anticoagulants.

Invited discussant Dr. Mark Hemmila, with the University of Michigan, Ann Arbor, said it is fortunate that only warfarin increases the risk of mortality given how difficult it is to reverse the effects of aspirin and clopidogrel, but that he would rank clopidogrel ahead of Coumadin and aspirin in terms of dangerousness. He asked Dr. Arnold to speculate on why no effect was observed and how the researchers recommend evaluating patients on warfarin.

Dr. Arnold said if a patient is on warfarin and has significant trauma and an elevated INR, warfarin reversal is initiated prior to obtaining computed tomography imaging. Factor VII is used, although they are transitioning more to the prothrombin complex. He said it is unclear why no impact on mortality was observed for aspirin given the large number of aspirin users in the study and that an effect would likely have been observed had there been more clopidogrel patients.

A recent analysis of 1.2 million patients in the American College of Surgeons’ National Trauma Data Bank reported that warfarin was associated with an increased risk of death, regardless of type of injury, indication for anticoagulation, or comorbidities. In all, 9.3% of warfarin-users died from their injuries vs. 4.8% of nonusers (Arch. Surg. 2011 [doi:10.1001/archsurg.2010.313]).

The researchers disclosed no conflicts of interest.

DETROIT – Preinjury use of warfarin, but not aspirin or clopidogrel, significantly increased the risk of death in a retrospective analysis of 3,488 trauma patients.

Overall, mortality was 13.6% for patients on warfarin (Coumadin), aspirin, clopidogrel (Plavix), or various combinations, compared with 6.2% for patients not on these medications.

When mortality data were broken down by drug, warfarin demonstrated a mortality of 24% vs. 6% for controls.

After they adjusted for the potential confounders of age and injury severity score, the researchers found that the relative risk of a patient on warfarin dying during hospitalization as a result of their injury remained significant at 3.9, first-year resident Dr. Travis Arnold reported on behalf of his colleagues and lead author Dr. Carrie Jahraus at Albany (N.Y.) Medical College.

Surprisingly, aspirin and clopidogrel were not significantly associated with increased mortality at 12.3% and 9.3%, respectively, when adjusted for confounders.

"With aspirin and, [perhaps] clopidogrel, there may be some protective mechanism that we don’t fully understand," senior author Dr. Daniel Bonville said in an interview, adding that other groups have found similar results for the two agents.

All of the drugs increased the risk of intracranial hemorrhage when compared with controls (50% vs. 30%). The adjusted relative risk was 3.2 for warfarin, 1.9 for patients on warfarin plus clopidogrel, and 1.6 for those on aspirin or other combinations.

A total of 3,488 trauma patients were identified in the Albany Medical College database from September 2004 to December 2007. Of these, 456 patients were on some form of anticoagulation or antiplatelet therapy including 91 patients on warfarin alone, 228 on aspirin, 43 on clopidogrel, and 94 on various combinations. The mean warfarin international normalized ratio (INR) level was within the therapeutic window at 2.4, with 95% of patients falling between 2.2 and 2.6, Dr. Arnold said.

The percentage of patients in the treatment and control groups who experienced a blunt trauma was similar at 99% vs. 93%, respectively, as was the percentage with Injury Severity Scores greater than 15 (55% vs. 50%, respectively).

Hospital length of stay greater than 10 days was similar at 30% for the treatment group vs. 24% for controls, and remained similar after adjustment, Dr. Arnold said.

The percentage of patients discharged to home was significantly lower at 48% among patients on warfarin and antiplatelet agents vs. 74% for controls (P less than .01). This difference disappeared when adjusted for age.

When the researchers compared the subgroup of 191 patients who had intracranial hemorrhage with controls, only warfarin increased mortality (29% vs. 6%, adjusted RR 3.1) and the need for craniotomy (15% vs. 7%, adjusted RR 2.2), Dr. Arnold said.

He concluded that warfarin continues to be a necessary evil for many patients with coronary artery disease or history of stroke and advocated for greater patient education by primary care providers on the risks of anticoagulants.

Invited discussant Dr. Mark Hemmila, with the University of Michigan, Ann Arbor, said it is fortunate that only warfarin increases the risk of mortality given how difficult it is to reverse the effects of aspirin and clopidogrel, but that he would rank clopidogrel ahead of Coumadin and aspirin in terms of dangerousness. He asked Dr. Arnold to speculate on why no effect was observed and how the researchers recommend evaluating patients on warfarin.

Dr. Arnold said if a patient is on warfarin and has significant trauma and an elevated INR, warfarin reversal is initiated prior to obtaining computed tomography imaging. Factor VII is used, although they are transitioning more to the prothrombin complex. He said it is unclear why no impact on mortality was observed for aspirin given the large number of aspirin users in the study and that an effect would likely have been observed had there been more clopidogrel patients.

A recent analysis of 1.2 million patients in the American College of Surgeons’ National Trauma Data Bank reported that warfarin was associated with an increased risk of death, regardless of type of injury, indication for anticoagulation, or comorbidities. In all, 9.3% of warfarin-users died from their injuries vs. 4.8% of nonusers (Arch. Surg. 2011 [doi:10.1001/archsurg.2010.313]).

The researchers disclosed no conflicts of interest.