Other indicators were not significantly associated with DSS afteradjusting for the number of positive LNs and other clinical/pathological factors. Multivariate cut-point analyses identified theLN ratio cut point threshold as 0.12, 0.13, and 0.21 for the neck,axilla, and groin, respectively, corresponding to a minimum of 9, 8,and 5 LNs removed per positive node. The greatest differences in5-year DSS (p � 0.0001) were noted when these thresholds wereapplied: 57% versus 29% following neck dissection, 70% versus 48%following axillary dissection, and 66% versus 42% following groindissection. Incremental improvements in DSS were observed whenadditional LNs were removed. Conclusion: LN ratio is the bestindicator of extent of LN dissection regardless of anatomic region inthis cohort of melanoma patients. Improved DSS is associated withincreased number of LN removed per positive node. These data offerguidelines for defining adequate LN dissections in melanoma pa-tients.

ONCOLOGY VII: CLINICAL OUTCOMES

QS114. BREAST SPECIMEN ORIENTATION. Manuel Molina,Sarah Beth Snell, Merce Jorda, Eli Avisar; University ofMiami, Miami, FL

Background: Breast conserving therapy has been shown to resultin identical survival rate than modified radical mastectomy whentreating breast cancer. The local recurrence rate however is signifi-cantly higher if the resection margins are positive for tumor andre-excision or completion mastectomy is necessary in those cases.During the lumpectomy, a pathology consultation about marginsinvolvement is commonly sought. A reliable way of communicationbetween pathology and surgery is of paramount importance in orderto minimize the need for a second surgery. In those cases where asecond surgery for positive margins is necessary, that same reliableway of communication is essential to ensure a successful re-excisionwith minimal tissue loss. For sake of communication, the contour ofthe lumpectomy specimen is commonly divided into six sides,namely, superficial, deep, superior, inferior, medial and lateral. Inaddition orienting stitches are placed on the specimen at the time ofsurgery (short stitch - superior, long stitch - lateral, etc. . .) to allowre-orientation by the pathologist in the same anatomic position atthe time of his reading. Despite those efforts, a disorientation of thespecimen may occur, leading to incomplete resection or on the con-trary to unnecessary surgery. The aim of this study was to assess therate of agreement on the orientation between surgeons andpathologists. Methods: Lumpectomy specimens were routinely ori-ented with one short stitch superior and one long stitch lateral. Anadditional easily identifiable prolene suture was placed by the sur-geon on one of the six sides, according to a randomization list. Whileperforming the gross assessment of the specimens, the pathologistwas asked to describe the location of the prolene stitch. The resultswere recorded on a datasheet and the specimen disorientation ratecalculated. Additional information on the three dimensions of thespecimens and on presence of skin and/or muscle was recorded.Results: One hundred and twenty two lumpectomy specimens wereentered in this prospective study. The average specimen volume was95.5 cm3. Twenty specimens had a segment of skin and four had apiece of muscle. The additional stitches were evenly divided betweenthe superficial, deep, superior, inferior, medial and lateral sides ofthe specimens. The overall rate of specimen disorientation was31.1% (C.I. 23.1 - 40.2).The side specific specimen disorientation ratewere 43%, 40%, 35%, 29%, 28% and 14% for the deep, superficial,lateral, medial, superior and inferior surfaces respectively but therewas no statistical difference. Furthermore, the presence of skin ormuscle on the specimen did not contribute to a better specimenorientation. Specimen volumes however were very significantly as-sociated with orientation. Specimen with volumes less than 20 cm3had a disorientation rate of 78% while larger specimen had a disori-

entation rate of 20% (p�0.001). Conclusions: Specimen orientationwith two stitches placed on two of the surfaces is associated with asignificant disorientation rate. Joint specimen orientation by thesurgeon and the pathologist or better orientation techniques arenecessary in order to minimize the specimen disorientation.

QS115. THE USE OF DIAGNOSTIC PROCEDURES IN PA-TIENTS WITH LOCOREGIONAL PANCREATIC CAN-CER. Brannon R. Hyde, William H. Nealon, Courtney M.Townsend, Yong-fang Kuo, Jean L. Freeman, Taylor S.Riall; UT Medical Branch Galveston, Galveston, TX

Objective: Different procedures have been used for the diagnosisand assessment of resectability in patients with locoregional pancre-atic cancer. This study evaluates trends in the use of diagnosticprocedures in Medicare patients. Methods: We used the SEER-Medicare linked data to evaluate trends in the use of each diagnosticprocedure over four intervals (1992-1994, 1995-1997, 1998-2000, and2001-2002). Procedures performed between 6 months before to 3months after the diagnosis, but before surgical resection were in-cluded. The procedures evaluated were computed tomography (CT),magnetic resonance imaging (MRI), endoscopic ultrasound (EUS),endoscopic retrograde cholangiopancreatography (ERCP), and theplacement of endoscopic biliary stents (ES) or percutaneous biliarydrains (PBD). Results: 6,008 patients with locoregional pancreaticcancer were identified. The usage of all procedures except PBDincreased over the four time periods in patients with locoregionalpancreatic cancer. The use of CT increased from 85.2% to 92.1%(P�0.0001). The patterns of increase were similar but more strikingfor EUS (1.8% to 19.1%, P�0.0001), MRI (1.2% to 14.8%, P�0.0001),ERCP (48.45% to 60.4%, P�0.0001), and ES (34.2% to 51.3%,P�0.0001). The use of PBD remained constant at approximately14%. Resection rates over the same time period increased from 21.2%to 28.2% Conclusions: There has been a significant increase in theusage of multiple diagnostic procedures in patients with pancreaticcancer over the past decade. This is especially true for new technol-ogies such as endoscopic ultrasound. With advances in technology,further studies are needed to determine the optimal diagnostic algo-rithm that minimizes non-therapeutic operations and cost withoutsacrificing accuracy.

QS116. SURVIVAL AFTER TOTAL PANCREATECTOMYVERSUS PANCREATICODUODENECTOMY FORPANCREATIC ADENOCARINOMA. Hari Nathan1,Mark B. Slidell2, John L. Cameron1, Christopher L. Wolf-gang1, Barish Edil1, Joseph Herman1, Michael A. Choti1,Richard D. Schulick1, Timothy M. Pawlik1; 1The Johns Hop-kins Hospital, Baltimore, MD; 2Georgetown University Hos-pital, Washington, DC

Introduction: Many surgeons perceive total pancreatectomy (TP)for pancreatic adenocarcinoma to be associated with an increasedperi-operative morbidity and a worse long-term outcome com-pared with pancreaticoduodenectomy (PD). Specifically, there is aconcern that complete endocrine and exocrine insufficiency follow-ing TP leads to inferior survival following surgery. National dataon the relative survival of patients (pts) undergoing TP vs PDhave not been previously reported. The purpose of the currentstudy was to analyze the peri-operative and long-term outcomes ofpts undergoing TP vs PD using a large, population-based data set.Methods: The Surveillance, Epidemiology, and End Results(SEER) database was used to identify 6449 pts who underwentsurgical resection of pancreatic adenocarcinoma between 1988-2004 (TP, n�619 vs PD, n�5830). Descriptive statistics werecompared using the rank-sum test, chi-squared test or a non-parametric test for trend, as appropriate. Mortality rates at 30days after diagnosis were calculated. Long-term mortality riskswere compared using Kaplan-Meier curves and Cox proportional

314 ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS