Pancreatic Metastasectomy—an Analysis of Survival Outcomes and Prognostic Factors

Background

The pancreas and peripancreatic region may be a site of metastasis from distant sites. Recent data suggest that pancreatic metastasectomy may achieve long-term survival. We seek to examine our experience with this metastasectomy by reporting the perioperative and survival outcomes.

Methods

Patients undergoing resection of isolated pancreatic metastasis were identified from a prospective pancreatic surgical database at the Department of Gastrointestinal Surgery, North Shore campus of the University of Sydney between January 2004 and June 2015 and selected for retrospective review. Data on operative morbidity and mortality were reported. Survival analysis was performed using the Kaplan–Meier method.

Results

Fifteen patients underwent pancreatic metastasectomy after a median disease-free interval of 63 months (range 0 to 199). Pancreatoduodenectomy was performed in six patients (40 %), distal pancreatectomy with or without splenectomy in three patients (20 %), and pancreatectomy with other visceral organ resection in six patients (40 %). Major complications occurred in six patients (40 %) without mortality. The median survival was 40 months (95 % CI 24.3 to 53.7), and 1-, 3-, and 5-year survival were 76, 48, and 31 % respectively. Cox proportional hazard model identified margin negative resection (hazard ratio (HR) 10.5; P?=?0.044) as a predictor of improved survival.

Conclusion

Long-term survival may be achieved in selected patients with pancreatic metastasis through pancreatic metastasectomy with acceptable morbidity. Selection of patients should be individualized and based on their primary disease origin, biological behavior of the tumor, resectability of the tumor, and the relative effectiveness of systemic or targeted therapies.

     

What Are the Prognostic Factors for Radiographic Progression of Knee Osteoarthritis? A Meta-analysis

Background

A previous systematic review on prognostic factors for knee osteoarthritis (OA) progression showed associations for generalized OA and hyaluronic acid levels. Knee pain, radiographic severity, sex, quadriceps strength, knee injury, and regular sport activities were not associated. It has been a decade since the literature search of that review and many studies have been performed since then investigating prognostic factors for radiographic knee OA progression.

Questions/purposes

The purpose of this study is to provide an updated systematic review of available evidence regarding prognostic factors for radiographic knee OA progression.

Methods

We searched for observational studies in MEDLINE and EMBASE. Key words were: knee, osteoarthritis (or arthritis, or arthrosis, or degenerative joint disease), progression (or prognosis, or precipitate, or predictive), and case-control (or cohort, or longitudinal, or follow-up). Studies fulfilling the inclusion criteria were assessed for methodologic quality according to established criteria for reviews on prognostic factors in musculoskeletal disorders. Data were extracted and results were pooled if possible or summarized according to a best-evidence synthesis. A total of 1912 additional articles were identified; 43 met our inclusion criteria. The previous review contained 36 articles, thus providing a new total of 79 articles. Seventy-two of the included articles were scored high quality, the remaining seven were low quality.

Results

The pooled odds ratio (OR) of two determinants showed associations with knee OA progression: baseline knee pain (OR, 2.38 [95% CI, 1.74–3.27) and Heberden nodes (OR, 2.66 [95% CI, 1.46–8.84]). Our best-evidence synthesis showed strong evidence that varus alignment, serum hyaluronic acid, and tumor necrosis factor-α are associated with knee OA progression. There is strong evidence that sex, former knee injury, quadriceps strength, smoking, running, and regular performance of sports are not associated with knee OA progression. Evidence for the majority of determined associations, however, was limited, conflicting, or inconclusive.

Conclusions

Baseline knee pain, presence of Heberden nodes, varus alignment, and high levels of serum markers hyaluronic acid and tumor necrosis factor-α predict knee OA progression. Sex, knee injury, and quadriceps strength, among others, did not predict knee OA progression. Large variation remains in definitions of knee OA and knee OA progression. Clinical studies should use more consistent definitions of these factors to facilitate data pooling by future meta-analyses.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-015-4349-z) contains supplementary material, which is available to authorized users.     

Are There Prognostic Factors for One-Year Outcome After Total Knee Arthroplasty? A Systematic Review

Background

Preoperative factors predicting outcome for pain, physical function and quality of life after total knee arthroplasty (TKA) have not been clearly identified.

Subtotal Thyroidectomy: A Reliable Method to Achieve Euthyroidism in Graves’ Disease. Prognostic Factors

Background Subtotal thyroidectomy is a widely accepted surgical procedure for Graves’ disease. The purpose of this work is to evaluate functional long-term results and determine predictive prognostic factors of postoperative thyroid function. Study design This is a retrospective study conducted on 202 patients with Graves’ disease undergoing subtotal thyroidectomy during the period 1979–2002. Predictive prognostic factors of final thyroid status were investigated by logistic ordinal regression, and probability of hypothyroidism during the years of follow-up was obtained by the Kaplan–Meier method. Results Surgery controlled hyperthyroidism in 196 out of 202 patients (97%). The probability of hypo-, eu-, and hyperthyroidism at 5 years was 62.1%, 35.5%, and 2.4%, respectively. No statistical change in thyroid function occurred in the follow-up after 60 months. Multivariate analysis by a logistic ordinal regression analysis showed that weight of the remnant, age, and gender seemed to influence long-term thyroid function. The higher rates of euthyroidism were obtained when the remnant weight was between 6 and 8 g. No recurrence or persistence of hyperthyroidism occurred with remnant weights under 5 g. Conclusions Subtotal thyroidectomy controlled hyperfunction symptoms in 97% of our patients. Cure (euthyroidism) of Graves’ disease patients should be attempted by leaving a thyroid tissue remnant between 6 and 8 g. Even more significant, our results suggest that euthyroidism rates could be improved by leaving a smaller remnant in elderly women and greater remnants in young men.     

What Risk Factors Are Associated With Musculoskeletal Injury in US Army Rangers? A Prospective Prognostic Study

Background

Musculoskeletal injury is the most common reason that soldiers are medically not ready to deploy. Understanding intrinsic risk factors that may place an elite soldier at risk of musculoskeletal injury may be beneficial in preventing musculoskeletal injury and maintaining operational military readiness. Findings from this population may also be useful as hypothesis-generating work for particular civilian settings such as law enforcement officers (SWAT teams), firefighters (smoke jumpers), or others in physically demanding professions.

Questions/purposes

The purposes of this study were (1) to examine whether using baseline measures of self-report and physical performance can identify musculoskeletal injury risk; and (2) to determine whether a combination of predictors would enhance the accuracy for determining future musculoskeletal injury risk in US Army Rangers.

Methods

Our study was a planned secondary analysis from a prospective cohort examining how baseline factors predict musculoskeletal injury. Baseline predictors associated with musculoskeletal injury were collected using surveys and physical performance measures. Survey data included demographic variables, injury history, and biopsychosocial questions. Physical performance measures included ankle dorsiflexion, Functional Movement Screen, lower and upper quarter Y-balance test, hop testing, pain provocation, and the Army Physical Fitness Test (consisting of a 2-mile run and 2 minutes of sit-ups and push-ups). A total of 320 Rangers were invited to enroll and 211 participated (66%). Occurrence of musculoskeletal injury was tracked for 1 year using monthly injury surveillance surveys, medical record reviews, and a query of the Department of Defense healthcare utilization database. Injury surveillance data were available on 100% of the subjects. Receiver operator characteristic curves and accuracy statistics were calculated to identify predictors of interest. A logistic regression equation was then calculated to find the most pertinent set of predictors. Of the 188 Rangers (age, 23.3 ± 3.7 years; body mass index, 26.0 ± 2.4 kg/m²) remaining in the cohort, 85 (45.2%) sustained a musculoskeletal injury of interest.

Results

Smoking, prior surgery, recurrent prior musculoskeletal injury, limited-duty days in the prior year for musculoskeletal injury, asymmetrical ankle dorsiflexion, pain with Functional Movement Screen clearing tests, and decreased performance on the 2-mile run and 2-minute sit-up test were associated with increased injury risk. Presenting with one or fewer predictors resulted in a sensitivity of 0.90 (95% confidence interval [CI], 0.83–0.95), and having three or more predictors resulted in a specificity of 0.98 (95% CI, 0.93–0.99). The combined factors that contribute to the final multivariable logistic regression equation yielded an odds ratio of 4.3 (95% CI, 2.0–9.2), relative risk of 1.9 (95% CI, 1.4–2.6), and an area under the curve of 0.64.

Conclusions

Multiple factors (musculoskeletal injury history, smoking, pain provocation, movement tests, and lower scores on physical performance measures) were associated with individuals at risk for musculoskeletal injury. The summation of the number of risk factors produced a highly sensitive (one or less factor) and specific (three or more factors) model that could potentially be used to effectively identify and intervene in those persons with elevated risk for musculoskeletal injury. Future research should establish if screening and intervening can improve musculoskeletal health and if our findings among US Army Rangers translate to other occupations or athletes.

Level of Evidence

Level II, prognostic study.     

Prognostic Factors Affecting Postmastectomy Locoregional Recurrence in Patients with Early Breast Cancer: Are Intrinsic Subtypes Effective?

Background  

Many studies have investigated the association between the molecular subtypes of breast cancer and survival. The aim of this study was to identify the effects of intrinsic subtypes of breast cancer and the other clinicopathological factors on postmastectomy locoregional recurrence (LRR) in patients with early breast cancer.     

Tumor Existence and Tumor Size as Prognostic Factors in Hepatitis B Virus–Related Cirrhosis Patients Who Underwent Liver Transplantation

Background

Hepatitis B virus (HBV)–related chronic liver disease is one of the most common indications for liver transplantation (LT). Patient data in our unit were collected to evaluate the impact of liver tumor on outcomes in patients with HBV-related cirrhosis who underwent LT.

Methods

HBV transplantation patients in our hospital from August 2002 to March 2012 were analyzed and compared according to LT indications: decompensated cirrhosis (DEC) or hepatocellular carcinoma (HCC). For HCC patients, receiver operating characteristic (ROC) curve analysis was used to determine the cutoff tumor size for prognosis, namely the maximum tumor diameter. According to the cutoff size, patients were divided into 2 groups: large-size HCC and small-size HCC. The correlations among other clinicopathologic factors were also investigated. Potential prognostic factors were evaluated with the use of Cox proportional hazards model analysis.

Results

The 1-, 3-, and 5-year overall survival rates of the 111 HBV-related patients were 76.2%, 43.2%, and 32.9%, respectively. Patients with HCC had significantly poorer overall survival than those with only DEC (P < .05). The mean tumor size was 5.97 cm, and ROC analysis indicated that the cutoff tumor size for prognosis was 4.25 cm, with sensitivity and specificity of 62.8% and 81.0%, respectively (area under the ROC curve, 0.760; 95% CI, 0.644–0.877; P < .001). According to this cutoff point, 31 patients had large tumor size (≥4.25 cm) and 33 had small tumor size (<4.25 cm). Patients with small tumor size had significantly better overall survival than those with large tumor size (P < .05). Univariate analysis showed that only the tumor size (risk ratio, 1.14; P < .001) was significantly associated with the overall survival.

Conclusions

Tumor existence and tumor size are prognostic factors in HBV-related cirrhosis. With the use of a tumor size cutoff value of 4.25 cm, patients with large-size tumors have significantly poorer overall survival than those with small-size tumors.     

Identification of Prognostic Factors Associated with Early Mortality after Surgical Resection for Pancreatic Cancer—Under-analysis of Cumulative Survival Curve

Background The cumulative survival curve after surgery for advanced pancreatic cancer is characterized by a steep downward slope in the early postoperative period. The aim of this investigation was to identify the characteristics associated with early mortality in patients undergoing pancreatic resection for pancreatic cancer. Methods Thirty-seven patients with extended radical pancreatectomy combined with intraoperative radiation therapy were studied. The cumulative survival curve in this series was depicted using the Kaplan-Meier method. Assuming that there were two distinct survival curves, below and above the breakpoint, each part of the curve was modeled as an exponential distribution. Three parameters, the breakpoint, the high hazard rate below the breakpoint, and the low hazard rate above the breakpoint were estimated by the maximum likelihood method. Prognostic factors associated with early mortality after surgery were evaluated using univariate and multivariate Cox proportional hazards regression analyses. Results The breakpoint of the survival curve was estimated at 41 months. The short-survival group (SSG) was defined as deceased earlier than 41 months after surgery, and included 31 patients (83.8 %). The long-survival patient group (LSG) consisted of 6 patients who were alive more than 41 months after surgery. Eighteen SSG patients (58.1 %) died of hepatic metastases, whereas no LSG patients died of hepatic metastases. Abdominal pain and/or back pain during clinical course was identified by multivariate analysis as a prognostic factor for patients undergoing pancreatic resection. Conclusions The high hazard rate in the early postoperative period was closely linked with death due to liver metastases. The preoperative presence of local pain was a prognostic factor associated with early mortality.     

Analysis of Prognostic Factors in Extraosseous Ewing Sarcoma Family of Tumors: Review of St. Jude Children’s Research Hospital Experience

Background

Advances in the treatment of Ewing sarcoma family of tumors (ESFT) are the result of improvements in systemic and local therapies. Clinical data of extraosseous ESFT are scarce.

Methods

A retrospective analysis of all patients with extraosseous ESFT treated at St. Jude Children??s Research Hospital (SJCRH) from June 1982 to August 2009.

Results

Forty-six patients with extraosseous ESFT were identified. The mean age at diagnosis was 13.8?years. The majority of patients were male and white. The most common site of primary tumor was the trunk. Twelve patients had subcutaneous tumors. The median tumor size was 8?cm. Six patients (13?%) had metastatic disease at diagnosis. A total of 59?% of patients were alive at the time of analysis, with a median follow-up from diagnosis of 15.3?years. Fifteen-year estimates of survival and event-free survival (EFS) for all patients were 53.3?±?9.4 and 50?±?9.1?%, respectively. Fifteen-year estimates of survival and EFS with localized disease were 61.4?±?9.8 and 57.6?±?9.7?%, respectively. Stage and subcutaneous ESFT were significant predictors of outcome. There was no significant difference in patient??s demographics and tumor characteristics between patients with skeletal ESFT and extraosseous Ewing sarcoma. The outcome for patients with localized extraosseous Ewing sarcoma was similar to that reported for all localized ESFT patients treated at SJCRH.

Conclusions

The outcome for localized patients treated with extraosseous ESFT was similar to that reported for all ESFT patients treated on protocols at SJCRH. Patients with subcutaneous ESFT had a favorable prognosis when compared to their counterparts.     

Prognostic and treatment-predictive factors-is there a difference?

The terms risk factor, prognostic factor and predictive factor are often imprecisely used. We defined a prognostic factor as a patient characteristic that identifies subgroups of untreated patients having different outcomes, and a factor predictive of treatment effect as a patient characteristic that identifies subgroups of treated patients having different (as a consequence of treatment) outcomes. To illustrate this, theoretical graphical examples were constructed and data from the literature on prostate cancer were used to substantiate the theoretical examples. In most situations, but not necessarily always, a prognostic factor is also pre- dictive of the effect of specific treatments. Whether a prognostic factor is also predictive of treatment effect or not can only be assessed in a valid comparative setting such as in a randomized trial. A factor that is predictive for treatment effect may not be predictive for another treatment. Prostate Cancer and Prostatic Diseases (2000) 3, 265-268     

Prognostic Indications for Hürthle Cell Cancer

Hürthle cell carcinoma (HCC) has been reported to have variable clinical behavior. The objective of this study was to determine the important prognostic factors in patients with HCC. It was a retrospective investigation of 33 patients with HCC treated in our institution from 1976 to 2002. The average age of our 33 patients with HCC was 55.2 years (range 20–82 years; 23 women, 10 men). Fifteen patients (45.5%) presented with a T2 tumor, 7 (21.2%) with a T3 tumor, and 8 (24.2%) with a T4 tumor; the tumor stage was unknown in three patients. Coexisting papillary carcinoma occurred in six patients (18%), 9% of whom presented with metastatic disease. Twelve patients (36.4%) had metastases, four of whom (12.2%) had persistent HCC, and 8 (24.2%) developed recurrent HCC (range 1–9 years). Eight of these twelve patients (66.7%) died from the HCC. The average follow-up time was 5.5 years (range 1–16 years). Altogether, 3 of 23 women and 5 of 10 men died from their HCC (p < 0.05). Of the 22 patients with T2-T3 tumors, 5 (22.7%) developed metastases and 1 patient died; 5 of 8 patients (62.5%) with T4 tumors developed metastases and died (p < 0.01). Patients who were treated by less than total thyroidectomy had a worse prognosis by univariate analysis (p < 0.01) but not by multivariate analysis. Survival time for patients with persistent disease was shorter than for those with recurrent disease (p < 0.05). Multivariate analysis, however, revealed no difference for extent of operation or those with persistent and recurrent disease. The cause-specific survivals were 74% and 49% at 5 and 10 years, respectively. Disease-free survivals were 65.0% and 40.5% at 5 and 10 years, respectively. Our findings show that gender and stage of disease influence the prognosis of patients with HCC.This article was presented at the International Association of Endocrine Surgeons meeting, Uppsala, Sweden, June 14–17, 2004.     

Prognostic nomogram for microvascular decompression–treated trigeminal neuralgia

Neurosurgical Review - This study aimed to establish an effective prognostic nomogram for microvascular decompression (MVD)–treated trigeminal neuralgia (TN). The nomogram was based on a...