RESUMO
BACKGROUND: Palpable nodes were exclusionary in American College of Surgeons Oncology Group (ACOSOG) Z0011, while SINODAR-ONE excluded those with positive axillary nodes by palpation and ultrasound. To determine whether clinical nodal status should be exclusionary in those fulfilling pathologic criteria for ACOSOG Z0011 and similar trials, this study analyzed the accuracy and implications of clinical nodal positivity. METHODS: Patients ≥ 18 years old with cT1-T2, cN0-cN1, M0 breast cancer were identified in the National Cancer Database between 2004 and 2019. Subset characteristics of cN1 and cN0 were compared with respect to final pathologic nodal status and overall survival (OS). RESULTS: Of 57,823 patients identified, 77.0% were cT1 and 23.0% were cT2. Of the 93.9% of patients who were staged as cN0, 16.7% were pN1; of the remaining 6.1% staged as cN1, 9.6% were found to be pN0. Among cN1/pN0 patients, 14.9% underwent axillary dissection without sentinel node biopsy. There was no difference in adjusted OS for patients staged as cN0 versus cN1 who were found to be pN1 (HR 1.13, 95% CI 0.93-1.37, p = 0.22), a finding that persisted on subset analysis in those with two positive nodes (HR 0.91, 95% CI 0.62-1.33, p = 0.63). CONCLUSIONS: Clinical nodal stage does not affect OS in pN1 patients. Clinical nodal assessment can both overstage patients and result in unnecessary axillary surgery. These data suggest that cN1 patients who are otherwise candidates for a Z0011-like paradigm should still be considered eligible. Their final candidacy should be determined by surgical lymph node pathology and not preoperative clinical status.
RESUMO
INTRODUCTION: The National Defense Authorization Act of 2017 indicated the need for a national strategy to improve trauma care among military treatment facilities (MTFs). Part of the proposed strategy to improve trauma outcomes was to convert identified MTFs into verified trauma centers. The American College of Surgeons (ACS) verifies trauma centers through an evaluation process based on available resources at a facility. It has been proven that trauma centers, specifically those verified by the ACS, have improved trauma outcomes. In 2017, we implemented steps to become a level III trauma program, according to the standards for designation by the state and verification through the ACS. The goal of this retrospective review is to evaluate the impact of this implementation with regard to both patient care and the MTF. MATERIALS AND METHODS: Data from a single-MTF trauma registry from 2018, at the initiation of the trauma program, to present were reviewed. Outcomes were selected based upon the ACS verification criteria. Specifically, emergency department length of stay (ED LOS), nonsurgical admissions, injury severity score, diversion rates, and time to operating room were reviewed. Statistical analyses were performed using Student's t-tests. Institutional review board (IRB) approval was not required for this study as it was performed as a quality improvement project using deidentified data. RESULTS: ED LOS decreased significantly after implementation of the trauma program from an average of 6.43 h in 2018 to 4.73 h in 2019 and 4.6 h in 2020 (P < .04). Nonsurgical admissions decreased significantly from 57.8% in 2018, with rates of <20% in all subsequent years (P < .01). The average injury severity score increased from 5.61 in 2018 to 7.52 in 2020 (P < .01) and 7.27 in 2021 (P < .01). Diversion rates also decreased from >5% in 2018 to 0% in 2021. CONCLUSIONS: The establishment of a trauma program in accordance with the standards of the ACS for verification improved metrics of care for trauma patients at our MTF. This implementation as part of the local trauma system also led to increased injury severity seen by the MTF, which enhances readiness for its providers.
