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OBJECTIVES/SPECIFIC AIMS: Perineal urethral sling placement is an option for men with mild to moderate post-prostatectomy stress urinary incontinence (SUI). However, men with persistent incontinence after sling placement often require secondary artificial urinary sphincter (AUS) placement, made difficult by the sling occupying the proximal bulbar urethra. This proximal section has a thicker corpus spongiosum which may mitigate cuff-induced ischemia and subsequent urethral atrophy. The authors report a series of AUS placements after failed sling, using sling revision or removal to access the proximal urethra. METHODS/STUDY POPULATION: Cutting the sling arms during urethral cuff placement increased urethral exposure and mobility. If feasible, completely removing the sling allowed the most proximal cuff site; but if dissection was felt unsafe, the mesh was left in situ and the cuff placed distally. This study is a retrospective cohort design of patients with SUI who underwent AUS placement after failed sling from 2010 to 2016. Variables included baseline patient characteristics, SUI severity, intraoperative variables, and postoperative outcomes. AUS failure, defined as infection, erosion or urethral atrophy, was analyzed at 12 and 96 months using univariate and multivariable logistic regression. RESULTS/ANTICIPATED RESULTS: Over the study period, 29 patients underwent AUS placement after failed sling. At the time of AUS placement, mean urethral circumference was 6.2 cm and 68% of patients had a 4.5 cm cuff placed; no cases required a 3.5 cm cuff. Seventy-three percent of cases were after transobturator sling placement (27% bone-anchored) and 45% of slings were explanted. AUS failure rate at 12 and 96 months was 17.8% and 45%, respectively; atrophy was the most common indication. Prior transobturator sling placement had lower rates of both 12 month (9.1% vs. 57%, p=0.006) and 96 month (36% vs. 71%, p=0.11) failure, though the latter was not statistically significant. Sling explant was not a significant predictor of 12 month (p=0.12) or 96 month failure (p=0.17). DISCUSSION/SIGNIFICANCE OF IMPACT: Sling revision during AUS placement helps expose the wider proximal urethra, allowing larger cuff size placement. This procedure appears safe, with low rates of erosion and short-term failure—albeit with high rates of long-term urethral atrophy possibly due to more significant dissection causing devascularization. However, sling removal was not a significant predictor of failure. The transobturator sling’s smaller profile may result in less trauma to urethra—possibly explaining the improved outcomes.

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Red blood cell transfusion for hematologic disorders

Hematology ◽

10.1182/asheducation-2015.1.454 ◽

2015 ◽

Vol 2015 (1) ◽

pp. 454-461 ◽

Cited By ~ 13

Author(s):

Chang Liu ◽

Brenda J. Grossman

Keyword(s):

Randomized Clinical Trials ◽

Patient Characteristics ◽

Transfusion Practice ◽

Red Blood Cell Transfusion ◽

Limited Data ◽

Hematopoietic Stem ◽

Specific Patient ◽

Hematologic Disorders ◽

Improved Outcomes ◽

Rbc Transfusion

Abstract Randomized clinical trials (RCTs) have determined, in surgical and critically ill patients, relatively safe hemoglobin (Hb) thresholds of 7-8 g/dL to guide restrictive transfusion of red blood cells (RBCs). However, in patients with various hematologic disorders, strong evidence in support of such an approach is sparse and the optimal transfusion practice is yet to be defined. This review focuses on RBC transfusion practice in three hematologic diseases and a treatment strategy, including autoimmune hemolytic anemia, thalassemia, myelodysplastic syndrome, and hematopoietic stem cell transplantation. These entities manifest in a broad spectrum of anemia, acute or chronic, in patients with different comorbidities and degrees of transfusion requirement. Thus the nuances in the indications of RBC transfusion and the goals to achieve in these specific situations may have been underappreciated. The limited data available highlight the importance of titrating RBC transfusion based on the clinical context and patient characteristics. Future RCTs are necessary to firmly establish the Hb thresholds associated with improved outcomes relevant to these specific patient populations, which will facilitate the personalized decision-making in RBC transfusion.

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A case report of antepartum bladder outlet obstruction following transobturator sling placement

International Urogynecology Journal ◽

10.1007/s00192-009-0965-z ◽

2009 ◽

Vol 21 (3) ◽

pp. 379-381 ◽

Cited By ~ 9

Author(s):

David Shveiky ◽

Andrew I. Sokol ◽

Cheryl B. Iglesia

Keyword(s):

Case Report ◽

Bladder Outlet Obstruction ◽

Outlet Obstruction ◽

Transobturator Sling ◽

Sling Placement

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Does Focus Improve Performance in Elective Surgery? A Study of Obesity Surgery in Sweden

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17186682 ◽

2020 ◽

Vol 17 (18) ◽

pp. 6682 ◽

Cited By ~ 1

Author(s):

Anna Svarts ◽

Luca Urciuoli ◽

Anders Thorell ◽

Mats Engwall

Keyword(s):

Obesity Surgery ◽

Elective Surgery ◽

Patient Characteristics ◽

Multilevel Regression ◽

Positive Effects ◽

Procedural Volume ◽

Improved Outcomes ◽

And Performance ◽

Using Data ◽

The Relationship

Recent studies have found positive effects from hospital focus on both quality and cost. Some studies indicate that certain patient segments benefit from focus, while others have worse outcomes in focused hospital departments. The aim of this study was to establish the relationship between hospital focus and performance in elective surgery. We studied obesity surgery procedures performed in Sweden in 2016 (5152 patients), using data from the Scandinavian Obesity Surgery Registry (SOReg) complemented by a survey of all clinics that performed obesity surgery. We examined focus at two levels of the organization: hospital level and department level. We hypothesized that higher proportions of obesity surgery patients in the hospital, and higher proportions of obesity surgery procedures in the department, would be associated with better performance. These hypotheses were tested using multilevel regression analysis, while controlling for patient characteristics and procedural volume. We found that focus was associated with improved outcomes in terms of reduced complications and shorter procedure times. These positive relationships were present at both hospital and department level, but the effect was larger at the department level. The findings imply that focus is a viable strategy to improve quality and reduce costs for patients undergoing elective surgery. For these patients, general hospitals should consider implementing organizationally separate units for patients undergoing elective surgery.

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Urethrovaginal fistula repair with or without concurrent fascial sling placement: A retrospective review

Canadian Urological Association Journal ◽

10.5489/cuaj.6786 ◽

2020 ◽

Vol 15 (5) ◽

Author(s):

Sarah Neu ◽

Jennifer Locke ◽

Mitchell Goldenberg ◽

Sender Herschorn

Keyword(s):

Patient Characteristics ◽

Urethral Diverticulum ◽

Pelvic Surgery ◽

Study Patient ◽

Complication Rates ◽

Urethrovaginal Fistula ◽

Fascial Sling ◽

Significant Difference ◽

Sling Placement

Introduction: We sought to review outcomes of urethrovaginal fistula (UVF) repair, with or without concurrent fascial sling placement. Methods: All patients diagnosed with UVF at our center from 1988–2017 were included in this study. Patient charts were reviewed from a prospectively kept fistula database, and patient characteristics and surgical outcomes were described. Descriptive statistics were applied to compare complication rates between patients with or without fascial sling placement at the time of UVF repair. Results: A total of 41 cases of UVF were identified, all of which underwent surgical repair. Median age at diagnosis was 49 years (interquartile range [IQR] 35–62). All patients had undergone pelvic surgery. UVF etiology was secondary to stress urinary incontinence (SUI) surgery in 17 patients (41%) and urethral diverticulum repair in seven patients (17%). The most common presenting symptom was continuous incontinence in 19 patients (46%). Nineteen patients had a fascial sling placed at the time of surgery (46%), with no significant difference in complication rates (26% vs. 23%, p=0.79). Two patients had Clavien-Dindo grade I complications (5%) and one had a grade III complication (2%). Four patients had long-term complications (10%), including urinary retention, chronic pain, and urethral stricture. Two patients had UVF recurrence (5%). Median followup after surgery was 21 months (IQR 4–72). Conclusions: UVF should be suspected in patients with continuous incontinence following a surgical procedure. Most UVF surgical repairs are successful and can be done with concurrent placement of a fascial sling.

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An International Comparison of Attitudes Toward Traditional and Modern Medicine in a Chinese and an American Clinic Setting

Evidence-based Complementary and Alternative Medicine ◽

10.1093/ecam/nen065 ◽

2011 ◽

Vol 2011 ◽

pp. 1-9 ◽

Cited By ~ 5

Author(s):

Adam Burke ◽

Tony Kuo ◽

Rick Harvey ◽

Jun Wang

Keyword(s):

United States ◽

Cultural Values ◽

Patient Characteristics ◽

The United States ◽

Modern Medicine ◽

Convenience Sample ◽

Improved Outcomes ◽

Patient Groups ◽

International Comparative ◽

And Gender

Introduction. International comparative research on traditional medicine (TM) offers a useful method for examining differences in patient characteristics and can provide insight into: (i) more universal characteristics which may cross cultures and international borders; (ii) unique characteristics influenced by regional/national factors; and (iii) cultural values of immigrant populations. To explore these issues TM patients from the United States and China were compared.Methods.Data collection took place at two TM college clinics. A convenience sample of 128 patients in China and 127 patients in the United States completed a 28-item questionnaire.Results.There was a marked similarity between the two patient groups in terms of the biological characteristics of age and gender. Musculoskeletal issues were the most common presenting complaints in the United States; while in China TM was used for a more diverse array of conditions. The majority of patients in both countries had initially used allopathic medicine (AM); significantly, more of the United States respondents stopped allopathic treatment after beginning traditional treatment. In comparing the two countries, patients in China were significantly more satisfied with AM and American patients significantly more satisfied with TM. In comparing the two medicines, the patient samples in both countries were significantly more satisfied with TM than AM.Discussion.Although treatment often originated with allopathic providers, many patients sought alternatives presumably to find the best solution to their problems. This tendency toward self-assignment suggests that a pluralistic healthcare system may provide the greatest satisfaction resulting from personal choice and improved outcomes.

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The Characteristics, Treatment Patterns, and Outcomes of Older Adults with Multiple Myeloma

Blood ◽

10.1182/blood-2018-99-118660 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 4463-4463

Author(s):

Mark A. Fiala ◽

Tanya M. Wildes ◽

Mark A. Schroeder ◽

Armin Ghobadi ◽

Keith E. Stockerl-Goldstein ◽

...

Keyword(s):

Older Adults ◽

Multiple Myeloma ◽

Board Of Directors ◽

Research Funding ◽

Performance Status ◽

Patient Characteristics ◽

Treatment Patterns ◽

Advisory Committees ◽

Improved Outcomes ◽

Immunomodulatory Drug

Abstract Background: Advances in the treatment for multiple myeloma (MM) have dramatically improved outcomes for younger patients. Older adults, particularly those 80 years of age or older at diagnosis, have seen more modest gains. MM incidence increases with age, and as more of the population is living later into life, the segment of the MM population over 80 will continue to grow. In this study, we sought to better understand the characteristics, treatment, and outcomes of older patients with MM. Methods: We identified all patients diagnosed with MM at age 80 or older in the Surveillance, Epidemiology, and End Results Program (SEER) database from 2007-2013 to determine incidence and outcomes. Subset analysis was then performed on patients included in the SEER-Medicare linked database who were enrolled in Medicare Parts A, B, and D to further explore patient characteristics and treatment patterns. Results: The incidence of MM increases over age, peaking after age 80. The annual incidence for those aged 65-69, 70-74, 75-79, 80-84 and 85+ was 24.4, 32.7, 39.5, 42.8 and 36.4 per 100,000, respectively. Based on 2010 US population estimates, approximately 4,500 new cases of MM were diagnosed annually 2007-2013 in patients age 80 or older. In that period, 8,093 cases, approximately 1,150 per year, were reported to SEER. The estimated median overall survival (OS) of these patients was 14 months (95% CI 13.2-14.8). The estimated relative 12 month survival was 58.9% (95% CI 57.4-60.4) compared to their peers without cancer. Of the 8,093 cases of MM reported to SEER during the study period, 2,385 were present in the SEER-Medicare linked dataset. Of these, 225 were identified as smoldering MM using a previously established algorithm (Fiala, et al, JCOCCI, 2018) and excluded leaving 2,160 for the analyses. The median age was 84 (range 80-100) and 55% were female. 81% were white, 13% black or African-American, and 6% another race. At disease presentation, 22% had claims indicating hypercalcemia, 61% renal failure or chronic kidney disease, 59% anemia, and 34% MM bone involvement. The estimated median OS was 13.4 months (95% CI 12.2-15.1). Only 52% of patients had claims indicating they received systemic MM treatment within 6 months post-diagnosis. Nearly all that did received novel agents; 38% received bortezomib-based treatment, 41% immunomodulatory drug (IMID)-based, and 14% both. The others received antineoplastic chemotherapies such as melphalan or cyclophosphamide. Interestingly, bortezomib utilization increased incrementally from 25% of patients treated in 2007 to 62% in 2013 while IMID utilization declined from 67% to 49%. The median OS of those receiving treatment was 21 months (95% CI 18.5-23.1) compared to 6.3 months (95% CI 5.3-7.3) for those who did not (p <0.0001). MM treatment was associated with a 26% decrease in hazard for death (aHR 0.74; 95% CI 0.67-0.82; p < 0.0001) independent of age, race, gender, poverty, comorbidities, and proxy measures of performance status. Outcomes improved for patients in more recent years; the hazard for death decreased by 3% (HR 0.97; 95% CI 0.94-0.99; p = 0.0096) each year 2007-2013. This can be attributed to increasing treatment rates. In 2007, only 41% of patients received treatment compared to 61% in 2013. After controlling for MM treatment, the year of diagnosis was no longer a significant predictor of survival. Conclusions: The outcomes of patients with MM over 80 years old are still relatively poor; nearly half of the patients do not receive systemic treatment and for those who do the median OS is just 21 months. The population over 80, when MM incidence peaks, is projected to triple over the next few decades. It is imperative that we improve our understanding of the needs of this vulnerable subgroup of patients of MM. Disclosures Schroeder: Amgen Inc.: Consultancy, Membership on an entity's Board of Directors or advisory committees. Vij:Bristol-Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Karyopharma: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Jazz Pharmaceuticals: Honoraria, Membership on an entity's Board of Directors or advisory committees; Jansson: Honoraria, Membership on an entity's Board of Directors or advisory committees; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

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Is Adherence to the American College of Chest Physicians Recommended Anticoagulation Treatment Duration Associated with Different Outcomes Among Patients with Venous Thromboembolism?

Blood ◽

10.1182/blood.v126.23.1126.1126 ◽

2015 ◽

Vol 126 (23) ◽

pp. 1126-1126 ◽

Cited By ~ 1

Author(s):

Alex C. Spyropoulos ◽

Ron Preblick ◽

Jackie Kwong ◽

Melissa Lingohr-Smith ◽

Jay Lin

Keyword(s):

Venous Thromboembolism ◽

Treatment Duration ◽

Bleeding Risk ◽

Patient Characteristics ◽

Baseline Period ◽

Employment Equity ◽

Minimum Duration ◽

Study Population ◽

Equity Ownership

Abstract Introduction: Venous thromboembolism (VTE) represents a major clinical and economic burden. The American College of Chest Physicians (ACCP) Guideline 9th Edition on the treatment of VTE recommends a minimum duration of anticoagulation (AC) therapy depending on patient risk profiles. The objectives of this study were to evaluate the clinical and economic outcomes associated with adherence to the AC treatment duration recommendation among VTE patients in the real world setting. Methods: Adult patients (≥18 years of age) with at least 1 inpatient diagnosis or 2 outpatient diagnoses on two different dates of deep vein thrombosis (DVT) and/or pulmonary embolism (PE), based on ICD-9-CM codes, were identified from the IMS Pharmetrics Plus database during 1/1/2009 through 3/31/2013. The first VTE diagnosis was defined as the index event. Study patients were required to have continuous insurance coverage during the 12 months before (baseline) and after (follow-up) the index event and no prior VTE diagnosis in the baseline period. They were also required to have received at least one outpatient anticoagulant treatment within 30 days of the initial VTE diagnosis with a minimum medication days of supply of 30 days. ACCP recommend that patients with provoked VTE or unprovoked VTE and high bleeding risks receive AC treatment for at least 3 months and that patients with unprovoked VTE and low or moderate bleeding risks or patients with cancer receive AC treatment for at least 6 months. Patient records in the database including ICD-9-CM codes and RIETE bleeding risk scores were used to group patients into 2 cohorts, one comprised of patients who received AC treatment for a duration as recommended by the ACCP (adherent group, AD) and the other comprised of patients who received AC treatment for a duration less than that recommended by the ACCP (non-adherent group, non-AD). Patient demographics and clinical characteristic were evaluated during the baseline period. Healthcare resource utilization, including hospital admissions, outpatient medical services, and prescription drug usage, were measured during the baseline and follow-up periods. VTE recurrence, defined as hospitalization or ER visit with a VTE diagnosis code, was also measured during the follow-up period. Multivariate regression analysis was utilized to compare clinical and economic outcomes of study cohorts while controlling for key patient characteristics. Results: The study population included 81,827 patients with a mean age (standard deviation) of 55.3 (13.8) years. For the index VTE event, 61% had DVT only, 26% had PE only, and 13% had DVT/PE. Of the study population, the minimum ACCP recommended AC treatment durations were 3 and 6 months for 27% (n=22,157) and 73% (n=59,670) of patients, respectively. Among all patients, 74% (n=60,550) received AC therapy for the ACCP recommended duration. The proportion of patients with VTE risks, including recent hospitalization (17% vs. 9%, p<0.001), recent surgery (9% vs. 6%, p<0.001), index diagnosis of PE only (28% vs. 20%, p<0.001), and index diagnosis of DVT/PE (15% vs. 8%, p<0.001) was greater in the AD cohort than in the non-AD cohort. Furthermore, mean Charlson Comorbidity Index score (1.67 vs. 1.59, p<0.001) and RIETE bleeding risk score (RIETE ≥1: 66% vs. 55%, p<0.001) were higher for the AD cohort compared to the non-AD cohort. The most prevalent anticoagulants used for treatment were warfarin (89% vs. 96%, p<0.001) and low molecular weight heparin (58% vs. 59%, p<0.01). After controlling for key patient characteristics, risks for all-cause hospitalization (Odds ratio (OR): 0.80, confidence interval (CI): 0.77-0.83, p<0.001) and VTE recurrence (OR=0.91, CI: 0.86-0.95, p<0.001) were lower among VTE patients in the AD cohort vs. the non-AD cohort, as were differences in all-cause total healthcare payments (-$3,416, p<0.001) and VTE-related healthcare payments (-$2,139, p<0.001) during the follow-up period. Conclusions: Approximately a quarter of the study population with VTE did not receive treatment with AC therapy for the minimum duration as recommended by the ACCP guideline. Patients who did not receive outpatient AC therapy for the recommended duration had more VTE recurrences, utilized more inpatient services, and had higher healthcare costs than patients who received AC therapy for the ACCP recommended duration. Disclosures Spyropoulos: Daiichi Sankyo, Inc.: Consultancy. Preblick:Daiichi Sankyo, Inc.: Employment, Equity Ownership. Kwong:Daiichi Sankyo, Inc.: Employment, Equity Ownership. Lingohr-Smith:Chimerix, Inc.: Consultancy; Bristol-Myers Squibb: Consultancy; Daiichi Sankyo, Inc: Consultancy; Novosys Health: Employment. Lin:Chimerix, Inc.: Consultancy; Daiichi Sankyo, Inc: Consultancy; Bristol-Myers Squibb: Consultancy; Novosys Health: Employment.

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Pretreatment prognostic factors associated with outcomes for first-line FCR-based treatments in previously untreated CLL.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.6517 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. 6517-6517

Author(s):

William G. Wierda ◽

Susan Mary O'Brien ◽

Stefan Faderl ◽

Alessandra Ferrajoli ◽

Jan Andreas Burger ◽

...

Keyword(s):

Prognostic Factors ◽

High Risk ◽

Performance Status ◽

Absolute Lymphocyte Count ◽

Patient Characteristics ◽

Treatment Modalities ◽

First Line ◽

Liver Size ◽

Improved Outcomes ◽

New Treatment

6517 Background: First-line chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab (FCR) demonstrated improved outcomes, including survival, for fit patients (pts) with CLL. Modifications of this regimen, including intensified rituximab (FCR3), addition of mitoxantrone (FCMR) or addition of alemtuzumab fir high-risk CLL (CFAR), were evaluated but did not improve outcomes in historic comparisons. Methods: We correlated outcomes, including complete remission (CR), time-to-treatment failure (TTF) and overall survival (OS), with new and traditional pretreatment prognostic factors to identify high-risk pts. Results: All pts (N=473) had an NCI-WG indication for treatment and received a first-line FCR-based regimen on trial; the intended treatment was 6 courses. Patient characteristics correlated with outcomes are presented in the table. Factors not associated with outcomes included absolute lymphocyte count; platelet count; performance status; spleen size; liver size; and number of involved lymph node sites. Conclusions: We identified the following as high-risk pretreatment features for patients going on first-line FCR-based therapy: advanced age, presence of 17p del, high B2M (≥4mg/l), and unmutated IGHV gene. Pts with these features should be pursued with new treatment modalities and novel agents in order to improve outcomes. [Table: see text]

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Metastatic neuroblastoma confined to distant lymph nodes (stage 4N) to predict outcome in patients with stage 4 disease: A study from the International Neuroblastoma (NB) Risk Group (INRG) Database.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.10015 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. 10015-10015

Author(s):

Daniel Alexander Morgenstern ◽

Wendy B. London ◽

Derek Stephens ◽

Samuel Louis Volchenboum ◽

Barabara Hero ◽

...

Keyword(s):

Lymph Nodes ◽

Case Series ◽

Patient Characteristics ◽

Response To Therapy ◽

Age At Diagnosis ◽

Response To Treatment ◽

Chi Square ◽

Improved Outcomes ◽

Stage 4 ◽

Pathologic Classification

10015 Background: Patients with metastatic NB typically have a poor prognosis; however case series have suggested that those with 4N disease may have improved outcomes. Methods: Retrospective analysis of data from INRG database for patients diagnosed 1990–2002. 4N patients (INSS stage 4 disease confined to distant lymph nodes) were compared to the balance of stage 4 patients (‘non-4N’), excluding those with missing metastatic site data. 5-yr estimates of overall (OS) and event-free survival (EFS) were calculated ± standard error (Kaplan-Meier method). Patient characteristics were compared by Mann-Whitney or Fisher’s exact/Chi-square tests. Results: 2,250 INSS stage 4 patients with complete data were identified, of whom 146 (6%) had 4N disease. For 4N patients, EFS and OS (5-yr: 77% ± 4%, 85% ± 3%), were significantly better than EFS and OS (5-yr: 35% ± 1%, 42% ± 1%) for non-4N stage 4 patients (p<0.0001). 4N patients were more likely to be younger (median age at diagnosis 1.2 yr vs 2.5 yr for non-4N; p<0.0001) and have tumors with favourable International Neuroblastoma Pathologic Classification (INPC) (63% vs 26%, p<0.0001), differentiating grade (21% vs 8%, p=0.006), lower MKI (p=0.0011) and non-MYCN amplified tumors (89% vs 69%, p<0.0001). Within subgroups defined by age at diagnosis and MYCN status, 4N pattern of disease remained significantly associated with improved outcomes. For patients aged ≥547 days at diagnosis and MYCN non-amplified, 5-yr EFS for 4N patients (n=42) was 63% ± 8% vs 27% ± 2% for non-4N (n=785); OS 74% ± 7% vs 38% ± 2% (both p<0.0001). Within this subgroup, favourable INPC and differentiating grade remained more frequent in the 4N vs non-4N patients (45% vs 10%, p<0.0001; 45% vs 8%, p=0.0017, respectively). Conclusions: 4N represents a subgroup of metastatic patients with better outcome than other INSS stage 4 patients. These findings indicate that the biology and response to treatment of 4N tumors differs from other stage 4 tumors, and different therapies should be considered for this cohort. Future exploration of biological factors determining pattern of metastatic spread and response to therapy is warranted.

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