ASA Annual Meeting

SAN DIEGO – The few trauma patients who will survive a high-risk thoracotomy procedure for cardiac arrest can be predicted by the presence of cardiac motion as detected by a quick and inexpensive bedside ultrasound, a prospective study conducted at a level I trauma center showed.

Focused assessment with sonography in trauma (FAST) was 100% sensitive and 62% specific in predicting those who would survive or be eligible for organ donation after receiving a resuscitative thoracotomy for traumatic cardiac arrest, said Dr. Kenji Inaba of the department of surgery at the University of Southern California Medical Center in Los Angeles.

Ryan McVay/Thinkstock

Resuscitative thoracotomy, said Dr. Inaba, is a salvage procedure performed after cardiac arrest. It is a “high-risk, resource-intensive procedure, with a low quantitative yield. And yet, patients do survive.” Previous retrospective studies found that of those receiving resuscitative thoracotomy for traumatic arrest, 7.4% survived, with more than 90% of survivors retaining neurologic function; an additional 4.2% of recipients were potentially eligible for organ donation. Thus, a tool to identify potential survivors among those who present in post-traumatic cardiac arrest would help avoid unnecessary use of a procedure with such risks and resource burdens.

FAST, an inexpensive procedure that is standard for other indications in trauma, has been effective in identifying potential survivors in thoracotomy for nontrauma cardiac arrests, Dr. Inaba said at the annual meeting of the American Surgical Association.

The technique “has near-universal availability, can be performed immediately at the bedside without moving the patient, and yields real-time results with no radiation involved,” he said.

For the current prospective study, the specific aim was to examine the ability of FAST to differentiate survivors and potential organ donors from those who would not survive resuscitative thoracotomy among those presenting in traumatic cardiac arrest. Dr. Inaba and his associates examined the predictive value of cardiac motion and the presence of pericardial fluid for survival, as well as the adequacy of the FAST study for each patient.

The single-center study, conducted from 2010 to 2014, enrolled 187 patients (mean age, 31; 84.5% male) presenting in traumatic arrest who received resuscitative thoracotomy in the emergency department and also received a FAST. The scans were performed by emergency medicine residents under direct faculty supervision. Of the 187 patients studied, 6 (3.2%) survived, 3 (1.6%) became organ donors, and 178 (95.2%) died but were not organ donor eligible.

Cardiac motion was detected by FAST in 54 (28.9%) individuals in the total study population; among these were all nine of the survivors and donors, yielding a sensitivity of 100% and a specificity of 73.7% for survival (P < .001). All 16 of the patients with pericardial fluid detected by FAST died, as did all 7 patients in whom the study was deemed inadequate. Put simply, Dr. Inaba said, “no cardiac motion equals no survival.”

If thoracotomies had been performed only on patients in the study group who had cardiac motion on FAST, more than half of the unsuccessful resuscitative thoracotomies would have been avoided, Dr. Inaba noted. The study, he said, has particular application for lower-volume trauma centers, which must carefully weigh the prolonged use of limited resources required in a resuscitative thoracotomy.

Dr. David Spain, chief of trauma and critical care surgery at Stanford (Calif.) University, asked whether the study captured the mechanism of injury. Though the study did not do so, said Dr. Inaba, he and his colleagues realized that a subset of patients who went immediately to the operating room were not included in the study, a potential limitation. This group of patients included those with a penetrating cardiac injury – a possible reason, he said, why no patients among the survivors had a cardiac injury.

The authors reported no relevant financial disclosures.

SAN DIEGO – The few trauma patients who will survive a high-risk thoracotomy procedure for cardiac arrest can be predicted by the presence of cardiac motion as detected by a quick and inexpensive bedside ultrasound, a prospective study conducted at a level I trauma center showed.

Focused assessment with sonography in trauma (FAST) was 100% sensitive and 62% specific in predicting those who would survive or be eligible for organ donation after receiving a resuscitative thoracotomy for traumatic cardiac arrest, said Dr. Kenji Inaba of the department of surgery at the University of Southern California Medical Center in Los Angeles.

Ryan McVay/Thinkstock

Resuscitative thoracotomy, said Dr. Inaba, is a salvage procedure performed after cardiac arrest. It is a “high-risk, resource-intensive procedure, with a low quantitative yield. And yet, patients do survive.” Previous retrospective studies found that of those receiving resuscitative thoracotomy for traumatic arrest, 7.4% survived, with more than 90% of survivors retaining neurologic function; an additional 4.2% of recipients were potentially eligible for organ donation. Thus, a tool to identify potential survivors among those who present in post-traumatic cardiac arrest would help avoid unnecessary use of a procedure with such risks and resource burdens.

FAST, an inexpensive procedure that is standard for other indications in trauma, has been effective in identifying potential survivors in thoracotomy for nontrauma cardiac arrests, Dr. Inaba said at the annual meeting of the American Surgical Association.

The technique “has near-universal availability, can be performed immediately at the bedside without moving the patient, and yields real-time results with no radiation involved,” he said.

For the current prospective study, the specific aim was to examine the ability of FAST to differentiate survivors and potential organ donors from those who would not survive resuscitative thoracotomy among those presenting in traumatic cardiac arrest. Dr. Inaba and his associates examined the predictive value of cardiac motion and the presence of pericardial fluid for survival, as well as the adequacy of the FAST study for each patient.

The single-center study, conducted from 2010 to 2014, enrolled 187 patients (mean age, 31; 84.5% male) presenting in traumatic arrest who received resuscitative thoracotomy in the emergency department and also received a FAST. The scans were performed by emergency medicine residents under direct faculty supervision. Of the 187 patients studied, 6 (3.2%) survived, 3 (1.6%) became organ donors, and 178 (95.2%) died but were not organ donor eligible.

Cardiac motion was detected by FAST in 54 (28.9%) individuals in the total study population; among these were all nine of the survivors and donors, yielding a sensitivity of 100% and a specificity of 73.7% for survival (P < .001). All 16 of the patients with pericardial fluid detected by FAST died, as did all 7 patients in whom the study was deemed inadequate. Put simply, Dr. Inaba said, “no cardiac motion equals no survival.”

If thoracotomies had been performed only on patients in the study group who had cardiac motion on FAST, more than half of the unsuccessful resuscitative thoracotomies would have been avoided, Dr. Inaba noted. The study, he said, has particular application for lower-volume trauma centers, which must carefully weigh the prolonged use of limited resources required in a resuscitative thoracotomy.

Dr. David Spain, chief of trauma and critical care surgery at Stanford (Calif.) University, asked whether the study captured the mechanism of injury. Though the study did not do so, said Dr. Inaba, he and his colleagues realized that a subset of patients who went immediately to the operating room were not included in the study, a potential limitation. This group of patients included those with a penetrating cardiac injury – a possible reason, he said, why no patients among the survivors had a cardiac injury.

The authors reported no relevant financial disclosures.

SAN DIEGO – The few trauma patients who will survive a high-risk thoracotomy procedure for cardiac arrest can be predicted by the presence of cardiac motion as detected by a quick and inexpensive bedside ultrasound, a prospective study conducted at a level I trauma center showed.

Focused assessment with sonography in trauma (FAST) was 100% sensitive and 62% specific in predicting those who would survive or be eligible for organ donation after receiving a resuscitative thoracotomy for traumatic cardiac arrest, said Dr. Kenji Inaba of the department of surgery at the University of Southern California Medical Center in Los Angeles.

Ryan McVay/Thinkstock

Resuscitative thoracotomy, said Dr. Inaba, is a salvage procedure performed after cardiac arrest. It is a “high-risk, resource-intensive procedure, with a low quantitative yield. And yet, patients do survive.” Previous retrospective studies found that of those receiving resuscitative thoracotomy for traumatic arrest, 7.4% survived, with more than 90% of survivors retaining neurologic function; an additional 4.2% of recipients were potentially eligible for organ donation. Thus, a tool to identify potential survivors among those who present in post-traumatic cardiac arrest would help avoid unnecessary use of a procedure with such risks and resource burdens.

FAST, an inexpensive procedure that is standard for other indications in trauma, has been effective in identifying potential survivors in thoracotomy for nontrauma cardiac arrests, Dr. Inaba said at the annual meeting of the American Surgical Association.

The technique “has near-universal availability, can be performed immediately at the bedside without moving the patient, and yields real-time results with no radiation involved,” he said.

For the current prospective study, the specific aim was to examine the ability of FAST to differentiate survivors and potential organ donors from those who would not survive resuscitative thoracotomy among those presenting in traumatic cardiac arrest. Dr. Inaba and his associates examined the predictive value of cardiac motion and the presence of pericardial fluid for survival, as well as the adequacy of the FAST study for each patient.

The single-center study, conducted from 2010 to 2014, enrolled 187 patients (mean age, 31; 84.5% male) presenting in traumatic arrest who received resuscitative thoracotomy in the emergency department and also received a FAST. The scans were performed by emergency medicine residents under direct faculty supervision. Of the 187 patients studied, 6 (3.2%) survived, 3 (1.6%) became organ donors, and 178 (95.2%) died but were not organ donor eligible.

Cardiac motion was detected by FAST in 54 (28.9%) individuals in the total study population; among these were all nine of the survivors and donors, yielding a sensitivity of 100% and a specificity of 73.7% for survival (P < .001). All 16 of the patients with pericardial fluid detected by FAST died, as did all 7 patients in whom the study was deemed inadequate. Put simply, Dr. Inaba said, “no cardiac motion equals no survival.”

If thoracotomies had been performed only on patients in the study group who had cardiac motion on FAST, more than half of the unsuccessful resuscitative thoracotomies would have been avoided, Dr. Inaba noted. The study, he said, has particular application for lower-volume trauma centers, which must carefully weigh the prolonged use of limited resources required in a resuscitative thoracotomy.

Dr. David Spain, chief of trauma and critical care surgery at Stanford (Calif.) University, asked whether the study captured the mechanism of injury. Though the study did not do so, said Dr. Inaba, he and his colleagues realized that a subset of patients who went immediately to the operating room were not included in the study, a potential limitation. This group of patients included those with a penetrating cardiac injury – a possible reason, he said, why no patients among the survivors had a cardiac injury.

The authors reported no relevant financial disclosures.

SAN DIEGO – Graduates of U.S. surgical residency training are generally very satisfied with their postgraduate choices, whether they opt for fellowships or not.

However, the 20% who opt to practice as general surgeons rather than pursuing subspecialty and fellowship training are more confident of their skills as they emerge from residency. “Specialty training does not result in greater confidence,” said Dr. Mary Klingensmith, professor of surgery and vice chair for education at Washington University, St. Louis. She discussed these results and other insights drawn from a nationwide survey of surgical residency graduates at the annual meeting of the American Surgical Association.

Dr. Klingensmith noted that there is a growing deficit of general surgeons, with a 25% decline in practicing general surgeons over the last 2 decades and an additional 18% decline projected over the next 20 years. A need existed, she said, for a systematic survey of recent graduates to identify the factors that play into the decision to pursue postgraduate training rather than enter directly into practice as a general surgeon.

A survey developed by American Board of Surgery (ABS) directors and executive staff was sent to all allopathic general surgery (GS) graduates from 2009 to 2013. Of 5,512 graduates, 3,354 (61%) responded. About three-quarters of respondents were specialist surgeons (SS).

The analysis of survey results conducted by Dr. Klingensmith and her colleagues compared the general to the specialist surgeons’ responses, and linked the surveys to the ABS database, which provided demographic characteristics that included residency program type, performance on board exams, and the postgraduate fellowship pursued, if any.

Surgeons were surveyed about their level of confidence in the independent practice of 16 common general procedures, including such “bread and butter” procedures as laparoscopic appendectomy and cholecystectomy, herniorrhaphy, and screening colonoscopies. Respondents were also asked to indicate how confident they were performing less common procedures, including tracheostomies, arterioveneous (AV) fistulas for dialysis, laparoscopic Nissen fundoplications, thyroidectomies, and laparoscopic colon resections.

Responses on a five-point Likert scale were sorted by type of subspecialty training, if any. After the most confident group – pediatric surgeons – general surgeons were significantly more likely to feel confident in their surgical skills than were the other specialist surgeons (P < .0001). Essentially all general surgery respondents were “very” or “mostly” confident of their ability to perform such common procedures as laparoscopic appendectomies and cholecystectomies, as well as ventral herniorrhaphies. Confidence decreased for specialists and nonspecialists alike for the more complex and less common surgeries. Overall, 94% of general surgeons and 90% of specialist surgeons were very or mostly confident of their abilities.

For general surgeons, factors influencing their choices included the opportunity for a broad scope of practice (63%), the influence of a mentor (56%), readiness to be done with training (26%), and being confident with the amount of training received (26%). For the specialists, the most influential factors included high degree of interest in the chosen specialty (57%), interest in improving specific skills (35%), and the opportunity to increase confidence and experience (35%). Both groups felt they’d made the right decision overall: 94% of general surgery graduates and 90% of those pursuing fellowships were very or somewhat satisfied with their career choices.

Study limitations included the risk of nonresponder bias, and the fact that only the most common procedures were included in the survey. Also, no outcome data were available to validate self-perceptions of competence, said Dr. Klingensmith.

The survey and its analysis “have implications that are enormous for the workforce needs of the country, and it’s clear that lack of confidence is an issue for a small but likely significant number of trainees,” said discussant Dr. J. David Richardson of the University of Louisville (Ky.). Greater opportunities for general surgery rotations, as well as stronger general surgery mentorship during residency, may help increase the number of general surgeons entering practice in the future, said Dr. Klingensmith.

The complete manuscript of this study and its presentation at the American Surgical Association’s 135th Annual Meeting, April 2015, in San Diego, California, are anticipated to be published in the Annals of Surgery pending editorial review.

SAN DIEGO – Graduates of U.S. surgical residency training are generally very satisfied with their postgraduate choices, whether they opt for fellowships or not.

However, the 20% who opt to practice as general surgeons rather than pursuing subspecialty and fellowship training are more confident of their skills as they emerge from residency. “Specialty training does not result in greater confidence,” said Dr. Mary Klingensmith, professor of surgery and vice chair for education at Washington University, St. Louis. She discussed these results and other insights drawn from a nationwide survey of surgical residency graduates at the annual meeting of the American Surgical Association.

Dr. Klingensmith noted that there is a growing deficit of general surgeons, with a 25% decline in practicing general surgeons over the last 2 decades and an additional 18% decline projected over the next 20 years. A need existed, she said, for a systematic survey of recent graduates to identify the factors that play into the decision to pursue postgraduate training rather than enter directly into practice as a general surgeon.

A survey developed by American Board of Surgery (ABS) directors and executive staff was sent to all allopathic general surgery (GS) graduates from 2009 to 2013. Of 5,512 graduates, 3,354 (61%) responded. About three-quarters of respondents were specialist surgeons (SS).

The analysis of survey results conducted by Dr. Klingensmith and her colleagues compared the general to the specialist surgeons’ responses, and linked the surveys to the ABS database, which provided demographic characteristics that included residency program type, performance on board exams, and the postgraduate fellowship pursued, if any.

Surgeons were surveyed about their level of confidence in the independent practice of 16 common general procedures, including such “bread and butter” procedures as laparoscopic appendectomy and cholecystectomy, herniorrhaphy, and screening colonoscopies. Respondents were also asked to indicate how confident they were performing less common procedures, including tracheostomies, arterioveneous (AV) fistulas for dialysis, laparoscopic Nissen fundoplications, thyroidectomies, and laparoscopic colon resections.

Responses on a five-point Likert scale were sorted by type of subspecialty training, if any. After the most confident group – pediatric surgeons – general surgeons were significantly more likely to feel confident in their surgical skills than were the other specialist surgeons (P < .0001). Essentially all general surgery respondents were “very” or “mostly” confident of their ability to perform such common procedures as laparoscopic appendectomies and cholecystectomies, as well as ventral herniorrhaphies. Confidence decreased for specialists and nonspecialists alike for the more complex and less common surgeries. Overall, 94% of general surgeons and 90% of specialist surgeons were very or mostly confident of their abilities.

For general surgeons, factors influencing their choices included the opportunity for a broad scope of practice (63%), the influence of a mentor (56%), readiness to be done with training (26%), and being confident with the amount of training received (26%). For the specialists, the most influential factors included high degree of interest in the chosen specialty (57%), interest in improving specific skills (35%), and the opportunity to increase confidence and experience (35%). Both groups felt they’d made the right decision overall: 94% of general surgery graduates and 90% of those pursuing fellowships were very or somewhat satisfied with their career choices.

Study limitations included the risk of nonresponder bias, and the fact that only the most common procedures were included in the survey. Also, no outcome data were available to validate self-perceptions of competence, said Dr. Klingensmith.

The survey and its analysis “have implications that are enormous for the workforce needs of the country, and it’s clear that lack of confidence is an issue for a small but likely significant number of trainees,” said discussant Dr. J. David Richardson of the University of Louisville (Ky.). Greater opportunities for general surgery rotations, as well as stronger general surgery mentorship during residency, may help increase the number of general surgeons entering practice in the future, said Dr. Klingensmith.

The complete manuscript of this study and its presentation at the American Surgical Association’s 135th Annual Meeting, April 2015, in San Diego, California, are anticipated to be published in the Annals of Surgery pending editorial review.

SAN DIEGO – Graduates of U.S. surgical residency training are generally very satisfied with their postgraduate choices, whether they opt for fellowships or not.

However, the 20% who opt to practice as general surgeons rather than pursuing subspecialty and fellowship training are more confident of their skills as they emerge from residency. “Specialty training does not result in greater confidence,” said Dr. Mary Klingensmith, professor of surgery and vice chair for education at Washington University, St. Louis. She discussed these results and other insights drawn from a nationwide survey of surgical residency graduates at the annual meeting of the American Surgical Association.

Dr. Klingensmith noted that there is a growing deficit of general surgeons, with a 25% decline in practicing general surgeons over the last 2 decades and an additional 18% decline projected over the next 20 years. A need existed, she said, for a systematic survey of recent graduates to identify the factors that play into the decision to pursue postgraduate training rather than enter directly into practice as a general surgeon.

A survey developed by American Board of Surgery (ABS) directors and executive staff was sent to all allopathic general surgery (GS) graduates from 2009 to 2013. Of 5,512 graduates, 3,354 (61%) responded. About three-quarters of respondents were specialist surgeons (SS).

The analysis of survey results conducted by Dr. Klingensmith and her colleagues compared the general to the specialist surgeons’ responses, and linked the surveys to the ABS database, which provided demographic characteristics that included residency program type, performance on board exams, and the postgraduate fellowship pursued, if any.

Surgeons were surveyed about their level of confidence in the independent practice of 16 common general procedures, including such “bread and butter” procedures as laparoscopic appendectomy and cholecystectomy, herniorrhaphy, and screening colonoscopies. Respondents were also asked to indicate how confident they were performing less common procedures, including tracheostomies, arterioveneous (AV) fistulas for dialysis, laparoscopic Nissen fundoplications, thyroidectomies, and laparoscopic colon resections.

Responses on a five-point Likert scale were sorted by type of subspecialty training, if any. After the most confident group – pediatric surgeons – general surgeons were significantly more likely to feel confident in their surgical skills than were the other specialist surgeons (P < .0001). Essentially all general surgery respondents were “very” or “mostly” confident of their ability to perform such common procedures as laparoscopic appendectomies and cholecystectomies, as well as ventral herniorrhaphies. Confidence decreased for specialists and nonspecialists alike for the more complex and less common surgeries. Overall, 94% of general surgeons and 90% of specialist surgeons were very or mostly confident of their abilities.

For general surgeons, factors influencing their choices included the opportunity for a broad scope of practice (63%), the influence of a mentor (56%), readiness to be done with training (26%), and being confident with the amount of training received (26%). For the specialists, the most influential factors included high degree of interest in the chosen specialty (57%), interest in improving specific skills (35%), and the opportunity to increase confidence and experience (35%). Both groups felt they’d made the right decision overall: 94% of general surgery graduates and 90% of those pursuing fellowships were very or somewhat satisfied with their career choices.

Study limitations included the risk of nonresponder bias, and the fact that only the most common procedures were included in the survey. Also, no outcome data were available to validate self-perceptions of competence, said Dr. Klingensmith.

The survey and its analysis “have implications that are enormous for the workforce needs of the country, and it’s clear that lack of confidence is an issue for a small but likely significant number of trainees,” said discussant Dr. J. David Richardson of the University of Louisville (Ky.). Greater opportunities for general surgery rotations, as well as stronger general surgery mentorship during residency, may help increase the number of general surgeons entering practice in the future, said Dr. Klingensmith.

The complete manuscript of this study and its presentation at the American Surgical Association’s 135th Annual Meeting, April 2015, in San Diego, California, are anticipated to be published in the Annals of Surgery pending editorial review.

SAN DIEGO – Radiation may benefit women with ductal carcinoma in situ (DCIS) who have breast-conserving surgery if their tumor margins are close or positive; however, wide tumor margins alone also may convey the same protection from local recurrence, Dr. Kimberly Van Zee reported at the annual meeting of the American Surgical Association.

Dr. Van Zee and her colleagues on the breast surgery service at New York’s Sloan Kettering Cancer Center examined the data from a large institutional database of DCIS patients to assess the relative benefit of radiation for various margin widths. They discovered that after adjusting for the other variables, patients with the widest tumor margins saw very little reduction in risk of 10-year recurrence when radiation was added – only 6%. However, this was still a significant difference and represented a hazard ratio of 0.54. Radiation gave patients with positive margins an absolute 18% risk reduction, for a hazard ratio of 0.10.

“We know that radiation reduces risk in all subsets of women with DCIS undergoing breast-conserving surgery,” she said. “But we really wanted to evaluate the relationship between margin width and recurrence and find the best margin width for DCIS with breast-conserving surgery.”

Over 20% of breast cancers are DCIS, and though overall mortality is low, as many as one in three patients will have local recurrence of their cancer. Radiation reduces the risk of local recurrence by about 50%, but it does not reduce the already low mortality associated with DCIS, she said.

Since radiation for DCIS may be associated with an increased risk for cardiovascular disease and certain rare malignancies, Dr. Van Zee said she and her colleagues were interested in identifying those women who were already at low risk for recurrence and would see little increased benefit from radiation.

Dr. Van Zee and her associates conducted a retrospective review of a prospectively collected database of women with DCIS who received treatment at Sloan Kettering Cancer Center between 1978 and 2010. The database contained multiple patient- and procedure-specific variables that were also factored into multivariable analysis in order to evaluate the relationships between margin width and recurrence, and to account for the contribution of radiation to reducing the risk of recurrence in women who received breast-conserving surgery for DCIS.

Overall, the database contained data for nearly 3,000 patients. Of the 2,996 studied, 72% were over the age of 50 and about 67% were postmenopausal. In 87% of cases, the diagnosis was made radiologically rather than clinically, and 60% of the patients had low or intermediate nuclear grade disease.

Dr. Van Zee and her colleagues assessed the 10-year recurrence rate for the 2,788 women whose excision margin width was known. Only 3% of these women had positive margins, and 75% had margin widths greater than 2 mm.

On multivariable analysis, wider margin width was associated with a significantly decreased 10-year risk of recurrence, but only for individuals who had not received radiation (P less than .0001). The hazard ratios for recurrence became progressively lower as margins widened, dropping to 0.31 for a margin of 10 mm or more.

Dr. Van Zee noted that the study was limited by its retrospective nature and the relatively small number of cases with positive margins. Also, cases with positive or close margins usually had more limited or focal disease at the margins, so recurrence rate estimates for this group may have underestimated risk of recurrence for those who had more significant disease.

During the discussion following her presentation, Dr. Van Zee noted that multiple factors are related to the risk of local recurrence, and that nomograms exist to help calculate risk and guide the decision to recommend radiation in women with close margins.

Dr. Patrick Borgen, chairman of the department of surgery at Maimonides Medical Center, New York, remarked that “biology beats technique. A growing wealth of information exists that there is a reservoir of DCIS that will progress so slowly as not to be significant. Is the next step in refining our approach better class prediction using genomic profiling?”

Dr. Van Zee agreed that genomic profiling will play a role, but noted that a study comparing DCIS score and multiple clinical variables would be expensive and archival pathology specimens would be difficult to obtain. Studies will mostly have to be prospective, she said.

The complete manuscript of this study and its presentation at the American Surgical Association’s 135th Annual Meeting, April 2015, in San Diego, California, are anticipated to be published in the Annals of Surgery pending editorial review.

This article was updated May 11, 2015.

SAN DIEGO – Radiation may benefit women with ductal carcinoma in situ (DCIS) who have breast-conserving surgery if their tumor margins are close or positive; however, wide tumor margins alone also may convey the same protection from local recurrence, Dr. Kimberly Van Zee reported at the annual meeting of the American Surgical Association.

Dr. Van Zee and her colleagues on the breast surgery service at New York’s Sloan Kettering Cancer Center examined the data from a large institutional database of DCIS patients to assess the relative benefit of radiation for various margin widths. They discovered that after adjusting for the other variables, patients with the widest tumor margins saw very little reduction in risk of 10-year recurrence when radiation was added – only 6%. However, this was still a significant difference and represented a hazard ratio of 0.54. Radiation gave patients with positive margins an absolute 18% risk reduction, for a hazard ratio of 0.10.

“We know that radiation reduces risk in all subsets of women with DCIS undergoing breast-conserving surgery,” she said. “But we really wanted to evaluate the relationship between margin width and recurrence and find the best margin width for DCIS with breast-conserving surgery.”

Over 20% of breast cancers are DCIS, and though overall mortality is low, as many as one in three patients will have local recurrence of their cancer. Radiation reduces the risk of local recurrence by about 50%, but it does not reduce the already low mortality associated with DCIS, she said.

Since radiation for DCIS may be associated with an increased risk for cardiovascular disease and certain rare malignancies, Dr. Van Zee said she and her colleagues were interested in identifying those women who were already at low risk for recurrence and would see little increased benefit from radiation.

Dr. Van Zee and her associates conducted a retrospective review of a prospectively collected database of women with DCIS who received treatment at Sloan Kettering Cancer Center between 1978 and 2010. The database contained multiple patient- and procedure-specific variables that were also factored into multivariable analysis in order to evaluate the relationships between margin width and recurrence, and to account for the contribution of radiation to reducing the risk of recurrence in women who received breast-conserving surgery for DCIS.

Overall, the database contained data for nearly 3,000 patients. Of the 2,996 studied, 72% were over the age of 50 and about 67% were postmenopausal. In 87% of cases, the diagnosis was made radiologically rather than clinically, and 60% of the patients had low or intermediate nuclear grade disease.

Dr. Van Zee and her colleagues assessed the 10-year recurrence rate for the 2,788 women whose excision margin width was known. Only 3% of these women had positive margins, and 75% had margin widths greater than 2 mm.

On multivariable analysis, wider margin width was associated with a significantly decreased 10-year risk of recurrence, but only for individuals who had not received radiation (P less than .0001). The hazard ratios for recurrence became progressively lower as margins widened, dropping to 0.31 for a margin of 10 mm or more.

Dr. Van Zee noted that the study was limited by its retrospective nature and the relatively small number of cases with positive margins. Also, cases with positive or close margins usually had more limited or focal disease at the margins, so recurrence rate estimates for this group may have underestimated risk of recurrence for those who had more significant disease.

During the discussion following her presentation, Dr. Van Zee noted that multiple factors are related to the risk of local recurrence, and that nomograms exist to help calculate risk and guide the decision to recommend radiation in women with close margins.

Dr. Patrick Borgen, chairman of the department of surgery at Maimonides Medical Center, New York, remarked that “biology beats technique. A growing wealth of information exists that there is a reservoir of DCIS that will progress so slowly as not to be significant. Is the next step in refining our approach better class prediction using genomic profiling?”

Dr. Van Zee agreed that genomic profiling will play a role, but noted that a study comparing DCIS score and multiple clinical variables would be expensive and archival pathology specimens would be difficult to obtain. Studies will mostly have to be prospective, she said.

The complete manuscript of this study and its presentation at the American Surgical Association’s 135th Annual Meeting, April 2015, in San Diego, California, are anticipated to be published in the Annals of Surgery pending editorial review.

This article was updated May 11, 2015.

SAN DIEGO – Radiation may benefit women with ductal carcinoma in situ (DCIS) who have breast-conserving surgery if their tumor margins are close or positive; however, wide tumor margins alone also may convey the same protection from local recurrence, Dr. Kimberly Van Zee reported at the annual meeting of the American Surgical Association.

Dr. Van Zee and her colleagues on the breast surgery service at New York’s Sloan Kettering Cancer Center examined the data from a large institutional database of DCIS patients to assess the relative benefit of radiation for various margin widths. They discovered that after adjusting for the other variables, patients with the widest tumor margins saw very little reduction in risk of 10-year recurrence when radiation was added – only 6%. However, this was still a significant difference and represented a hazard ratio of 0.54. Radiation gave patients with positive margins an absolute 18% risk reduction, for a hazard ratio of 0.10.

“We know that radiation reduces risk in all subsets of women with DCIS undergoing breast-conserving surgery,” she said. “But we really wanted to evaluate the relationship between margin width and recurrence and find the best margin width for DCIS with breast-conserving surgery.”

Over 20% of breast cancers are DCIS, and though overall mortality is low, as many as one in three patients will have local recurrence of their cancer. Radiation reduces the risk of local recurrence by about 50%, but it does not reduce the already low mortality associated with DCIS, she said.

Since radiation for DCIS may be associated with an increased risk for cardiovascular disease and certain rare malignancies, Dr. Van Zee said she and her colleagues were interested in identifying those women who were already at low risk for recurrence and would see little increased benefit from radiation.

Dr. Van Zee and her associates conducted a retrospective review of a prospectively collected database of women with DCIS who received treatment at Sloan Kettering Cancer Center between 1978 and 2010. The database contained multiple patient- and procedure-specific variables that were also factored into multivariable analysis in order to evaluate the relationships between margin width and recurrence, and to account for the contribution of radiation to reducing the risk of recurrence in women who received breast-conserving surgery for DCIS.

Overall, the database contained data for nearly 3,000 patients. Of the 2,996 studied, 72% were over the age of 50 and about 67% were postmenopausal. In 87% of cases, the diagnosis was made radiologically rather than clinically, and 60% of the patients had low or intermediate nuclear grade disease.

Dr. Van Zee and her colleagues assessed the 10-year recurrence rate for the 2,788 women whose excision margin width was known. Only 3% of these women had positive margins, and 75% had margin widths greater than 2 mm.

On multivariable analysis, wider margin width was associated with a significantly decreased 10-year risk of recurrence, but only for individuals who had not received radiation (P less than .0001). The hazard ratios for recurrence became progressively lower as margins widened, dropping to 0.31 for a margin of 10 mm or more.

Dr. Van Zee noted that the study was limited by its retrospective nature and the relatively small number of cases with positive margins. Also, cases with positive or close margins usually had more limited or focal disease at the margins, so recurrence rate estimates for this group may have underestimated risk of recurrence for those who had more significant disease.

During the discussion following her presentation, Dr. Van Zee noted that multiple factors are related to the risk of local recurrence, and that nomograms exist to help calculate risk and guide the decision to recommend radiation in women with close margins.

Dr. Patrick Borgen, chairman of the department of surgery at Maimonides Medical Center, New York, remarked that “biology beats technique. A growing wealth of information exists that there is a reservoir of DCIS that will progress so slowly as not to be significant. Is the next step in refining our approach better class prediction using genomic profiling?”

Dr. Van Zee agreed that genomic profiling will play a role, but noted that a study comparing DCIS score and multiple clinical variables would be expensive and archival pathology specimens would be difficult to obtain. Studies will mostly have to be prospective, she said.

The complete manuscript of this study and its presentation at the American Surgical Association’s 135th Annual Meeting, April 2015, in San Diego, California, are anticipated to be published in the Annals of Surgery pending editorial review.

This article was updated May 11, 2015.

SAN DIEGO – A technique that causes tumors to glow allowed surgeons to identify pulmonary adenocarcinomas accurately and quickly in the operating room, according to findings presented at the annual meeting of the American Surgical Association.

The molecular imaging technique, dubbed an “optical biopsy,” was 100% accurate in identifying pulmonary adenocarcinomas in wedge resection of lung nodules. Using an agent derived from fireflies, Dr. Sunil Singhal and his associates at the University of Pennsylvania, Philadelphia, tagged a ligand specific to lung adenocarcinoma and infused patients with the preparation before surgery so that cancerous nodules would light up in the operating room.

About 800,000 surgeries for cancer are performed in the United States annually, and surgery remains the most effective overall treatment since it affords the opportunity for complete resection and accurate staging, but technical challenges presist in many cancer surgeries, including the difficulty of ensuring negative margins, identifying in situ disease, and ascertaining which lymph nodes are malignant, Dr. Singhal noted.

“We depend on our hands, eyes and intuition,” he said. “This is fallible.”

The molecular imaging technique developed by Dr. Singhal and his colleagues has the potential to improve surgical precision by giving surgeons a clear visual indication of which tissue is malignant and needs to be excised. The technique identifies a receptor specific to a particular type of cancer cell and tags an appropriate ligand with a molecule that glows – a fluorophore – before surgery. With uptake of the tagged ligand, the tumor cells glow visibly and are clearly identified during surgery.

The small proof-of-principle study used fluorescein bound to a folate ligand for folate receptor alpha (FRalpha). This receptor is specific to pulmonary adenocarcinoma, the most commonly diagnosed cancer among the approximately 250,000 solitary pulmonary nodules detected as incidental findings on CT scans.

The 30 solitary pulmonary nodules in the study underwent a wedge resection and an optical biopsy, since patients had all received the fluorescein-tagged ligand infusion before surgery. Nineteen of the tumors fluoresced and were provisionally identified as pulmonary adenocarcinoma. Of the 11 that did not fluoresce, five were later identified as benign, three were other types of lung cancer, and three represented metastatic disease.

All nodules also were subject to frozen section, with provisional identification of 13 as lung adenocarcinoma, 8 as cancer of unknown origin, 6 as benign, 2 as metastatic renal adenocarcinoma, and 1 as a nonadenocarcinoma lung cancer.

One of the nodules read as benign on frozen section had been correctly identified as pulmonary adenocarcinoma by optical biopsy, which had 100% positive predictive value for pulmonary adenocarcinoma in this series, according to Dr. Singhal.

He stressed, however, that this technique should not be viewed as a replacement for pathology, but rather as an adjunct.

“If the tumor glows, we predict lung adenocarcinoma. If the tumor does not glow, we have no information and we follow the standard of care,” he said.

Going forward, Dr. Singhal and his colleagues plan to identify other candidate ligands for tagging, as well as developing fluorophores in a variety of colors. These could be infused simultaneously and allow differentiation between various tumor types. They also are developing materials that glow in the near-infrared spectrum and are detectable by specialized cameras.

Discussant Dr. Fabrizio Michelassi, chairman of the department of surgery at Weill Cornell Medical College and surgeon-in-chief at New York-Presbyterian/Weill Cornell Medical Center, asked whether the technique would be useful in identifying malignant sites in a diffusely inflamed field. Addressing the examples of Barrett’s esophagus and Crohn’s disease, Dr. Singhal affirmed the utility of optical biopsy in these conditions.

“As long as you have blood supply to that location, you can use whatever molecular contrast agent you want,” he said.

Dr. David Harpole, vice chief of the division of surgical services at Duke University Medical Center, applauded Dr. Singhal and his colleagues for taking a pertinent clinical problem to the laboratory. “Rapid intraoperative assessment of suspicious nodules is important,” he said, calling for a multi-institutional prospective cohort analysis to move the work forward.

The investigators reported no relevant financial disclosures. The study was supported by the National Institutes of Health, the Department of Defense, and the Veterans Health Administration.

SAN DIEGO – A technique that causes tumors to glow allowed surgeons to identify pulmonary adenocarcinomas accurately and quickly in the operating room, according to findings presented at the annual meeting of the American Surgical Association.

The molecular imaging technique, dubbed an “optical biopsy,” was 100% accurate in identifying pulmonary adenocarcinomas in wedge resection of lung nodules. Using an agent derived from fireflies, Dr. Sunil Singhal and his associates at the University of Pennsylvania, Philadelphia, tagged a ligand specific to lung adenocarcinoma and infused patients with the preparation before surgery so that cancerous nodules would light up in the operating room.

About 800,000 surgeries for cancer are performed in the United States annually, and surgery remains the most effective overall treatment since it affords the opportunity for complete resection and accurate staging, but technical challenges presist in many cancer surgeries, including the difficulty of ensuring negative margins, identifying in situ disease, and ascertaining which lymph nodes are malignant, Dr. Singhal noted.

“We depend on our hands, eyes and intuition,” he said. “This is fallible.”

The molecular imaging technique developed by Dr. Singhal and his colleagues has the potential to improve surgical precision by giving surgeons a clear visual indication of which tissue is malignant and needs to be excised. The technique identifies a receptor specific to a particular type of cancer cell and tags an appropriate ligand with a molecule that glows – a fluorophore – before surgery. With uptake of the tagged ligand, the tumor cells glow visibly and are clearly identified during surgery.

The small proof-of-principle study used fluorescein bound to a folate ligand for folate receptor alpha (FRalpha). This receptor is specific to pulmonary adenocarcinoma, the most commonly diagnosed cancer among the approximately 250,000 solitary pulmonary nodules detected as incidental findings on CT scans.

The 30 solitary pulmonary nodules in the study underwent a wedge resection and an optical biopsy, since patients had all received the fluorescein-tagged ligand infusion before surgery. Nineteen of the tumors fluoresced and were provisionally identified as pulmonary adenocarcinoma. Of the 11 that did not fluoresce, five were later identified as benign, three were other types of lung cancer, and three represented metastatic disease.

All nodules also were subject to frozen section, with provisional identification of 13 as lung adenocarcinoma, 8 as cancer of unknown origin, 6 as benign, 2 as metastatic renal adenocarcinoma, and 1 as a nonadenocarcinoma lung cancer.

One of the nodules read as benign on frozen section had been correctly identified as pulmonary adenocarcinoma by optical biopsy, which had 100% positive predictive value for pulmonary adenocarcinoma in this series, according to Dr. Singhal.

He stressed, however, that this technique should not be viewed as a replacement for pathology, but rather as an adjunct.

“If the tumor glows, we predict lung adenocarcinoma. If the tumor does not glow, we have no information and we follow the standard of care,” he said.

Going forward, Dr. Singhal and his colleagues plan to identify other candidate ligands for tagging, as well as developing fluorophores in a variety of colors. These could be infused simultaneously and allow differentiation between various tumor types. They also are developing materials that glow in the near-infrared spectrum and are detectable by specialized cameras.

Discussant Dr. Fabrizio Michelassi, chairman of the department of surgery at Weill Cornell Medical College and surgeon-in-chief at New York-Presbyterian/Weill Cornell Medical Center, asked whether the technique would be useful in identifying malignant sites in a diffusely inflamed field. Addressing the examples of Barrett’s esophagus and Crohn’s disease, Dr. Singhal affirmed the utility of optical biopsy in these conditions.

“As long as you have blood supply to that location, you can use whatever molecular contrast agent you want,” he said.

Dr. David Harpole, vice chief of the division of surgical services at Duke University Medical Center, applauded Dr. Singhal and his colleagues for taking a pertinent clinical problem to the laboratory. “Rapid intraoperative assessment of suspicious nodules is important,” he said, calling for a multi-institutional prospective cohort analysis to move the work forward.

The investigators reported no relevant financial disclosures. The study was supported by the National Institutes of Health, the Department of Defense, and the Veterans Health Administration.

SAN DIEGO – A technique that causes tumors to glow allowed surgeons to identify pulmonary adenocarcinomas accurately and quickly in the operating room, according to findings presented at the annual meeting of the American Surgical Association.

The molecular imaging technique, dubbed an “optical biopsy,” was 100% accurate in identifying pulmonary adenocarcinomas in wedge resection of lung nodules. Using an agent derived from fireflies, Dr. Sunil Singhal and his associates at the University of Pennsylvania, Philadelphia, tagged a ligand specific to lung adenocarcinoma and infused patients with the preparation before surgery so that cancerous nodules would light up in the operating room.

About 800,000 surgeries for cancer are performed in the United States annually, and surgery remains the most effective overall treatment since it affords the opportunity for complete resection and accurate staging, but technical challenges presist in many cancer surgeries, including the difficulty of ensuring negative margins, identifying in situ disease, and ascertaining which lymph nodes are malignant, Dr. Singhal noted.

“We depend on our hands, eyes and intuition,” he said. “This is fallible.”

The molecular imaging technique developed by Dr. Singhal and his colleagues has the potential to improve surgical precision by giving surgeons a clear visual indication of which tissue is malignant and needs to be excised. The technique identifies a receptor specific to a particular type of cancer cell and tags an appropriate ligand with a molecule that glows – a fluorophore – before surgery. With uptake of the tagged ligand, the tumor cells glow visibly and are clearly identified during surgery.

The small proof-of-principle study used fluorescein bound to a folate ligand for folate receptor alpha (FRalpha). This receptor is specific to pulmonary adenocarcinoma, the most commonly diagnosed cancer among the approximately 250,000 solitary pulmonary nodules detected as incidental findings on CT scans.

The 30 solitary pulmonary nodules in the study underwent a wedge resection and an optical biopsy, since patients had all received the fluorescein-tagged ligand infusion before surgery. Nineteen of the tumors fluoresced and were provisionally identified as pulmonary adenocarcinoma. Of the 11 that did not fluoresce, five were later identified as benign, three were other types of lung cancer, and three represented metastatic disease.

All nodules also were subject to frozen section, with provisional identification of 13 as lung adenocarcinoma, 8 as cancer of unknown origin, 6 as benign, 2 as metastatic renal adenocarcinoma, and 1 as a nonadenocarcinoma lung cancer.

One of the nodules read as benign on frozen section had been correctly identified as pulmonary adenocarcinoma by optical biopsy, which had 100% positive predictive value for pulmonary adenocarcinoma in this series, according to Dr. Singhal.

He stressed, however, that this technique should not be viewed as a replacement for pathology, but rather as an adjunct.

“If the tumor glows, we predict lung adenocarcinoma. If the tumor does not glow, we have no information and we follow the standard of care,” he said.

Going forward, Dr. Singhal and his colleagues plan to identify other candidate ligands for tagging, as well as developing fluorophores in a variety of colors. These could be infused simultaneously and allow differentiation between various tumor types. They also are developing materials that glow in the near-infrared spectrum and are detectable by specialized cameras.

Discussant Dr. Fabrizio Michelassi, chairman of the department of surgery at Weill Cornell Medical College and surgeon-in-chief at New York-Presbyterian/Weill Cornell Medical Center, asked whether the technique would be useful in identifying malignant sites in a diffusely inflamed field. Addressing the examples of Barrett’s esophagus and Crohn’s disease, Dr. Singhal affirmed the utility of optical biopsy in these conditions.

“As long as you have blood supply to that location, you can use whatever molecular contrast agent you want,” he said.

Dr. David Harpole, vice chief of the division of surgical services at Duke University Medical Center, applauded Dr. Singhal and his colleagues for taking a pertinent clinical problem to the laboratory. “Rapid intraoperative assessment of suspicious nodules is important,” he said, calling for a multi-institutional prospective cohort analysis to move the work forward.

The investigators reported no relevant financial disclosures. The study was supported by the National Institutes of Health, the Department of Defense, and the Veterans Health Administration.