National Utilization, Survival, and Costs Analysis of Treatment Options for Stage I Non-Small Cell Lung Cancer: A SEER-Medicare Database Analysis.

RATIONALE AND OBJECTIVES: To compare utilization, outcomes, and costs of surgery, radiation therapy, and percutaneous ablation for the treatment of stage I non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Using 2006-2016 Medicare-linked Surveillance, Epidemiology, and End Results (SEER) databases, stage I NSCLC patients who underwent surgery, radiotherapy, or percutaneous ablation were identified using relevant billing codes. National utilization rates were determined. Overall survival for treatment arms were compared using log-rank test and Cox-proportional hazard modeling. Mean direct costs for each treatment strategy during the first year after diagnosis were compared using Analysis of Variance. RESULTS: A total of 15,847 Stage I NSCLC patients were identified; mean age at diagnosis was 75.5 years (minimum age = 66 years) and 59.2% were female. A total of 10,732 patients (67.7%) underwent only surgery, 5013 (31.6%) only radiotherapy, and 102 (0.6%) only ablation. Utilization of surgery and ablation decreased while radiotherapy utilization increased from 2007 to 2015 (p < 0.0001). Compared to the ablation group, overall survival was greater for the surgery group (HR: 0.7, 95% CI of HR: 0.6-0.9, p = 0.0047) and lower for the radiotherapy group (HR: 1.4, 95% CI of HR: 1.1-1.8, p = 0.002). The mean first year cost of therapy for ablation = $11,976) was significantly less (p < 0.05) than for radiotherapy ($15,447) and surgery ($22,669). CONCLUSION: In Medicare patients with stage I NSCLC, the utilization of radiation therapy has increased and surgery has declined, while utilization of percutaneous ablation has remained uniformly low. Although overall survival is best for surgery, then ablation, and then radiation therapy, first year treatment costs are lowest for ablation.

Effect of Metacarpal Fixation Configuration on Strength and Fracture Gap Displacements in a Cadaveric Model of Externally Fixed Distal Radius Fractures.

Background: The purpose of the study was to determine the biomechanical effect of distal pin configuration in unilateral external fixation of distal radius fracture in a cadaveric model. Methods: A standardized 2-part extra-articular distal radius fracture model with dorsal comminution was created in 6 matched pairs of cadaveric upper extremities. Specimens within each matched pair were randomly assigned to either 4 or 6 cortices of distal pin metacarpal fixation. Cyclic, compressive loads were applied to the palmar hand. Results: No significant differences were detected in maximum forces. Six-cortex metacarpal fixation showed significantly lower magnitude of actuator displacement at 100 N cyclic loading. The difference in construct stiffness did not translate to disparities in angular and translational interfragmentary displacement at the fracture gap. Conclusions: Utilizing only 4 cortices and sparing the middle finger metacarpal avoids the need for a more transverse orientation required with 6-cortex fixation, which may otherwise impede thumb motion.

Yttrium-90 dosimetry and implications on tumour response and survival after radioembolisation of chemo-refractory hepatic metastases from breast cancer.

PURPOSE: The aim of the study was to evaluate the effects of tumour dose on tumour response and overall survival (OS) in patients with chemo-refractory metastatic breast cancer (MBC) to the liver undergoing yttrium-90 radioembolisation (Y90 RE). MATERIALS AND METHODS: In 20 consecutive patients with chemo-refractory MBC to the liver undergoing 33 total Y90 RE resin treatments, volumes of interest were drawn around the five largest tumours of the targeted liver lobe on post-Y90 RE Bremsstrahlung single-photon emission computed tomography/computed tomography using MIM software v.6.9 (MIM Software, Cleveland, Ohio, USA) and dose-volume histograms were calculated. Response Evaluation Criteria in Solid Tumours (RECIST) was used to determine tumour response at 3 months. Receiver operating characteristics (ROC) curves were used to determine thresholds for various dosimetry parameters. Kaplan-Meier estimation was used to determine OS. RESULTS: Overall, 11 of 33 (33%) Y90 RE treatments resulted in complete or partial response according to RECIST criteria with a median OS of 20.97 months compared to 11.73 months for nonresponders (P = 0.003). Mean tumour dose, defined as the aggregate tumour dose of up to the five largest tumours in the targeted lobe, was the most predictive of tumour response with the highest area under the ROC curve of 0.967. Mean tumour dose >70 Gy had 91% sensitivity and 100% specificity for predicting tumour response. Patients with mean tumour dose >70 Gy experienced a median OS of 16.1 months vs. 12.8 months for those who did not (P = 0.008). CONCLUSION: For patients with chemo-refractory breast cancer with liver metastases, achieving a mean tumour dose >70 Gy is a significant predictor of tumour response and prolonged OS.

Predictors of Survival after Yttrium-90 Radioembolization of Chemotherapy-Refractory Hepatic Metastases from Breast Cancer.

PURPOSE: To determine predictors of survival after transarterial radioembolization of hepatic metastases from breast cancer. MATERIALS AND METHODS: Twenty-four patients with chemotherapy-refractory hepatic metastases from breast cancer who underwent radioembolization from 2013 to 2018 were evaluated based on various demographic and clinical factors before and after treatment. Overall survival (OS) was estimated by Kaplan-Meier method. Log-rank analysis was performed to determine predictors of prolonged OS from the time of first radioembolization and first hepatic metastasis diagnosis. RESULTS: Median OS times were 35.4 and 48.6 months from first radioembolization and time of hepatic metastasis diagnosis, respectively. Radioembolization within 6 months of hepatic metastasis diagnosis was a positive predictor of survival from first radioembolization, with median OS of 38.9 months vs 22.1 months for others (P = .033). Estrogen receptor (ER)-positive status predicted prolonged survival (38.6 months for ER+ vs 5.4 months for ER-; P = .005). The presence of abdominal pain predicted poor median OS: 12.8 months vs 38.6 months for others (P < .001). The presence of ascites was also a negative predictor of OS (1.7 months vs 35.4 months for others; P = .037), as was treatment-related grade ≥ 2 toxicity at 3 months (5.4 months vs 38.6 months for others; P = .017). CONCLUSIONS: In patients with metastatic breast cancer, radioembolization within 6 months of hepatic metastasis diagnosis and ER+ status appear to be positive predictors of prolonged survival. Conversely, baseline abdominal pain, baseline ascites, and treatment-related grade ≥ 2 toxicity at 3 months after treatment appear to be negative predictors of OS.

Trisomy 18 and Congenital Heart Disease: Single-Center Review of Outcomes and Parental Perspectives.

BACKGROUND: In patients with trisomy 18, congenital heart surgery is controversial due to anticipated poor patient outcome. Data are lacking regarding clinical outcomes and family opinions about care received. METHODS: A retrospective chart review of patients with trisomy 18 and congenital heart disease from 2005 to 2017 was performed. Patients were grouped into those receiving cardiac intervention (surgery or cardiac catheterization) versus medical management. A telephone survey was used to assess completeness of family counseling provided prior to treatment selection and parental opinions on the care received. RESULTS: Seventeen infants were assessed. In the medical management group (n = 7), there were five deaths at a median age of 1.5 months (range: 1.2-4.1 months) and two survivors aged 29 and 44 months at latest follow-up. In the intervention group (n = 10), cardiac surgery was performed in nine patients at a median age of 4.3 months (0.2-23.4 months) and weight of 3.2 kg (1.5-12.2 kg); catheter intervention was performed in one patient at one week of age. At latest follow-up, seven intervention patients are alive at a median age of 50 months (5-91 months). Survey respondents (n = 12) unanimously stated that their child's quality of life was improved by their specific treatment strategy, that the experience of the parents was enhanced, and that they would choose the same treatment course again. CONCLUSIONS: Surgical repair may be associated with favorable early outcomes and may be judiciously offered in selected circumstances. In this limited experience, parental perceptions were positive regarding the quality of care and overall experience independent of the chosen treatment strategy or eventual outcome.