Typical carcinoids and neuroendocrine carcinomas of the stomach: differing clinical courses and prognoses

Background

Gastric endocrine tumors are usually classified as 3 types of well-differentiated endocrine tumors (typical carcinoids or carcinoids) and poorly differentiated carcinomas (neuroendocrine carcinomas [NECs]).

Methods

From 1993 to 2008, 97 patients (73 men and 24 women) were diagnosed with gastric neuroendocrine tumors at the Asan Medical Center.

Results

Of the 45 patients with typical carcinoids, 37 underwent surgery (eg, endoscopic resection). Of the 52 patients with NECs, 43 underwent surgery (eg, radical gastrectomy). One patient died of recurrence of the typical carcinoids, whereas 26 patients with NECs died of related diseases (P < .05). The rates of survival and recurrence did not significantly differ by type of typical carcinoid (P > .05).

Conclusions

Regardless of the type, carcinoids that are not yet advanced can be effectively treated with minimal endoscopic or laparoscopic surgery. However, all NECs and advanced carcinoids should be treated with radical gastrectomy.     

Pleurectomy/decortication plus chemotherapy: outcomes of 40 cases of malignant pleural mesothelioma

Malignant pleural mesothelioma still has a dismal prognosis. Despite good patient selection and a multimodality approach, local disease control remains a problem. Whether submitted to pleurectomy/decortication or to extrapleural pneumonectomy, disease progression occurred in all 40 patients in this study. The role of radio-chemotherapy remains uncertain. Between 1985 and 2002, 40 patients underwent pleurectomy/decortication in combination with intracavitary chemotherapy. Pleurectomy was performed to remove all gross tumour, or to achieve significant debulking. Partial or total pleurectomy of the visceral pleura depended on the extent of the tumour. Systemic chemotherapy was administered when disease progression occurred. All 40 patients had disease progression, due in all cases to local recurrence. The Kaplan-Meyer method was used for statistical evaluation. Treatment was relatively well tolerated and quality of life satisfactory. Until disease progression, no important chest pain, pleural effusion, or dyspnoea occurred. Overall survival was 28% at 2 years and 17% at 3 years. Histological sub-type is the only significant prognostic factor for survival. Low morbidity and mortality and good quality of life after treatment make pleurectomy/decortication with intracavitary and systemic chemotherapy not only a radical approach in early stages, but also a good palliative treatment in advanced malignant pleural mesothelioma, especially in patients who are unsuitable for extrapleural pneumonectomy.     

Induction chemotherapy,extrapleural pneumonectomy,and adjuvant radiotherapy for malignant pleural mesothelioma: experience of Guy’s and St Thomas’ hospitals

Purpose  

The treatment of malignant pleural mesothelioma (MPM) remains controversial. We present a prospective study of patients treated at our institution with neoadjuvant chemotherapy, extrapleural pneumonectomy (EPP), and radical radiotherapy.     

Intraoperative ischemia and long-term events after minimally invasive coronary surgery

Background

Concern has been raised about the effects of prolonged left anterior descending (LAD) artery occlusion during minimally invasive direct coronary artery bypass graft surgery (MIDCABG). We sought to assess the impact of myocardial dysfunction during MIDCABG on long-term outcome and the protective role of collateral circulation on myocardial ischemia.

Methods

Myocardial function was evaluated in 92 patients by intraoperative transesophageal echocardiography during MIDCABG.

Results

Wall motion score index increased during LAD occlusion (p < 0.00l) and reverted after LAD reopening (p < 0.001 versus occlusion and p = not significant versus baseline). The change in wall motion score index (occlusion versus baseline) was higher in patients with multivessel disease (p < 0.05) and in patients with LAD Thrombolysis in Myocardial Infarction study classification flow grade 2 or less without collateral circulation (p < 0.05). Myocardial stunning was documented in 12 patients (13%). The 5-year adverse event rate (including death, myocardial infarction, and revascularization) was 12%. By multivariate Cox regression analysis, multivessel disease, but not perioperative ischemia or stunning, was the only predictor of event-free survival.

Conclusions

During MIDCABG anterior wall dysfunction is transient, with prompt recovery after completion of the anastamosis in most cases; myocardial stunning can be documented in a minority of patients. Flow either antegrade or retrograde in the LAD territory plays a protective role against the development of ischemia. Multivessel disease, but not perioperative ischemia or stunning, predicts long-term event-free survival.     

Clinical Impact of Extrapleural Pneumonectomy for Malignant Pleural Mesothelioma

Background  

The clinical impact of extrapleural pneumonectomy in malignant pleural mesothelioma is poorly investigated.     

Desmoplastic small round cell tumor in children: a new therapeutic approach

Purpose

Desmoplastic small round cell tumor (DSRCT) is a rare, highly aggressive malignancy with distinctive histologic and immunohistochemical features occurring in a young population with a male predominance. The tumor appears to arise as masses in the abdominal cavity without a clear visceral origin. Five patients with DSRCT were treated as usual with combined chemoradiation and surgery. In addition, in our center, patients underwent autologous bone marrow transplant (BMT), which is a novel approach to this disease.

Methods

Charts of 5 patients (4 males, mean age of 11 years) treated between 2000 and 2007 were reviewed. The diagnosis of DSRCT was made on the basis of clinical examination, computed tomographic scan, and explorative laparotomy with biopsy, and biochemical markers were negative. All patients were treated with aggressive chemoradiation and surgery. Three patients also had autologous BMT.

Results

Three patients (BMT recipients) responded to treatment. The responding patients had surgery with the intent of removing all disease. Two patients died of their cancer, neither of whom underwent BMT.

Conclusion

The patients DSRCT are sensitive to an aggressive combination of chemotherapy, surgical debulking, and radiation therapy, followed by autologous BMT. It appears that this new multifaceted treatment offers good palliation, which may prolong survival and a possible cure.     

Prospective study of antibiotic protocols for managing surgical site infections in children

Purpose

We adopted antibiotic (Ab) protocols for managing surgical site infections in children and assessed their effectiveness.

Methods

We used our protocols on 1313 children between 2004 and 2005. All wounds were monitored for 30 days and classified as clean, clean-contaminated, contaminated, or dirty-infected. Infections were defined as superficial, deep, or organ/space. A retrospective study involving 721 children who had surgery in 2003 was also performed. χ² Statistical analysis was performed.

Results

Postprotocol, all Abs were administered accurately by anesthesiologists and infections developed in only 22 cases (1.7%): 0.2% (clean), 2.6% (clean-contaminated), 5.8% (contaminated), and 20.8% (dirty-infected), respectively; 21 were superficial or deep and 1 was organ/space. Age at surgery and sex did not influence incidence, neither did length of surgery for clean-contaminated, contaminated, and dirty-infected wounds; clean wounds were excluded because all surgery was minor. Overall, incidence of infections was 1.2% for elective surgery and 4.5% for emergency surgery (P < .01). Preprotocol, only 67% had Ab and infections developed in 27 cases (3.7%), which is significantly higher than in postprotocol (P < .01).

Conclusions

Accurate administration of Ab and careful supervision by an infection control team appear to be effective for preventing wound infections in children.     

The impact of tumor multifocality on outcomes in patients treated with radical nephroureterectomy

Background

The prognostic impact of multifocal upper-tract urothelial carcinoma (UTUC) is poorly understood.

Objective

To investigate the association between tumor multifocality and clinicopathologic features and outcomes of UTUC in patients managed by radical nephroureterectomy (RNU).

Design, setting, and participants

The study included 2492 patients treated with either open or laparoscopic RNU. Tumor and patient characteristics included tumor stage, tumor grade, lymph node status, lymphovascular invasion (LVI), tumor architecture, tumor location, unifocal or multifocal disease, gender, age, history of bladder cancer (BCa), Eastern Cooperative Oncology Group (ECOG) performance status (PS), and adjuvant chemotherapy. tumor multifocality of UTUC was defined as the synchronous presence of multiple tumors in the renal pelvis or ureter.

Intervention

All patients were treated with either open or laparoscopic RNU.

Measurements

Univariable and multivariable models tested the effect of tumor multifocality on disease progression and cancer-specific mortality.

Results and limitations

Five hundred ninety patients (23.7%) had tumor multifocality at the time of RNU. The median follow-up was 45 mo (interquartile range [IQR]: 0-101). Tumor multifocality was significantly associated with a history of previous BCa (p = 0.032), lymph node involvement (p = 0.036), tumor location in the ureter (p = 0.003), higher tumor stage (p < 0.001), higher tumor grade (p < 0.001), sessile tumor architecture (p = 0.003), and LVI (p = 0.001). In organ-confined patients, tumor multifocality was an independent predictor of both disease progression (hazard ratio [HR]: 1.43; p = 0.019) and cancer-specific mortality (HR: 1.46; p = 0.027). When assessed in all patients, tumor multifocality was associated with both disease progression and cancer-specific mortality in univariable (p = 0.005 and p = 0.006, respectively) but not in multivariable analyses (p = 0.468 and p = 0.798, respectively). The main limitation is the retrospective design of the study.

Conclusions

Tumor multifocality is an independent prognosticator of disease progression and cancer-specific mortality in patients with organ-confined UTUC treated with RNU. Multifocal organ-confined patients with UTUC may need closer follow-up. Integration of tumor multifocality with other factors may help identify those patients who would benefit from multimodal therapy.     

Pleural biopsy: a reliable method for determining the diagnosis but not subtype in mesothelioma

Background

Survival after tri-modality therapy with extrapleural pneumonectomy (EPP) and postoperative chemoradiotherapy is longer for patients with epithelial MPM versus mixed or sarcomatoid subtypes, leading some to decline aggressive therapy for patients with nonepithelial histology. However, pathologic diagnosis of malignant pleural mesothelioma (MPM) and subclassification into one of the three histologic subtypes (epithelial, mixed, sarcomatoid) can be challenging. Pleural biopsy has been proposed as the diagnostic gold standard. We investigated the accuracy of open pleural biopsy for diagnosis and subtype identification in MPM.

Methods

Patients with suspected MPM routinely undergo open pleural biopsy to establish diagnosis. Those diagnosed definitively by pleural biopsy or cytology are offered pleurectomy or EPP dependent on stage and cardiorespiratory status. We reviewed medical records for all patients undergoing EPP at our institution, comparing tissue and subtype diagnosis at initial diagnostic biopsy versus definitive resection.

Results

Between 1988 and 2000, 305 of 332 consecutive patients undergoing EPP had MPM. One patient diagnosed with MPM at pleural biopsy was misclassified. Subtype analysis at pleural biopsy proved correct in 80% (226/282). Most patients (174/192) with epithelial subtype at final diagnosis were diagnosed correctly at pleural biopsy. However, 44% (45/103) with pathologic diagnosis of nonepithelial subtype at resection were initially misdiagnosed with the epithelial subtype. The sensitivity of pleural biopsy for epithelial MPM was 97% with a specificity of 56%.

Conclusions

Open pleural biopsy is accurate and should be considered the gold standard diagnostic method for MPM. It is less sensitive for determining histologic subclass, particularly with nonepithelial subtypes.     

Extrapleural pneumonectomy in children

Background/Purpose

Extrapleural pneumonectomy (EPP) is an en bloc resection of the pleura, lung, diaphragm, and pericardium. EPP in the pediatric population has not been reported in the literature. We report our experience of using EPP in children to treat a variety of malignancies that involve the pleural surface.

Methods

We performed a retrospective review of all children treated through EPP at our institution. Data were obtained from patient charts and a pediatric database. All patients underwent en bloc resection of the pleura, lung, diaphragm, and pericardium and reconstruction.

Results

Four patients underwent EPP from 2000 to 2004 for inflammatory myofibroblastic tumor, spindle cell sarcoma, metastatic neuroblastoma, and malignant mesothelioma. The patients' ages were from 6 to 11 years. The patient with metastatic neuroblastoma had recurrent disease in the left chest 1 year after EPP and died of sepsis; the patient with mesothelioma died of disease extension into the abdomen 1.5 years later. The other 2 patients are free of disease.

Conclusions

EPP can be performed with curative intent in selected pediatric patients with pleural-based malignancies. EPP should be included in the armamentarium of the pediatric thoracic surgeon and evaluated in larger studies.     

Risk factors for readmission after neonatal cardiac surgery

Background

Repeat hospitalizations place a significant burden on health care resources. Factors predisposing infants to unplanned hospital readmission after congenital heart surgery are unknown.

Methods

This is a single-center, case-control study. Cases were rehospitalized or died within 30 days of discharge following an arterial switch operation (ASO) or Norwood procedure (NP) between 1992 and 2002. Controls underwent an ASO or NP between 1992 and 2002, and were neither readmitted nor died within 30 days of discharge. Patients and controls were matched by gender, year of birth, and procedure. Potential risk factors examined included indices of medical status at the time of discharge, determinants of access to health care, and provider characteristics.

Results

Forty-eight patients were readmitted; 19 of 498 (3.8%) following an ASO and 29 of 254 (11.4%) after a NP (p < 0.001). Six infants died within 30 days of discharge; 1 after an ASO and 5 after a NP. In multivariate analysis, predictors of readmission or death were: residual hemodynamic problem(s) (odds ratio [OR] 4.10 [1.18, 14.3], p = 0.026); an intensive care unit stay greater than 7 days (OR 5.17 [1.12, 23.9] p = 0.035) (ASO); residual hemodynamic problem(s) (OR 5.84 [1.98, 17.2], p = 0.001); and establishment of full oral intake less than 2 days before discharge (OR 5.83 [1.83, 18.6], p = 0.003) (NP). Combining both groups, living in a low income Zip Code (< $30,000/annum) was associated with a lower likelihood of readmission (OR 0.25 [0.07, 0.85], p = 0.027).

Conclusions

Residual hemodynamic problem(s) predispose to hospital readmission after the ASO and NP. Low socioeconomic status may reduce the likelihood of readmission even when problems arise.     

Laparoscopic improves perioperative outcomes of antireflux surgery at US academic centers

Background

Open and laparoscopic antireflux surgeries are standard for the treatment of gastroesophageal reflux disease (GERD). The in-hospital outcomes of laparoscopic and open antireflux procedures were analyzed and compared at US academic medical centers.

Methods

Using International Classification of Diseases, Ninth Revision, Clinical Modification codes for 5,737 patients with GERD that underwent open (n = 1,377) or laparoscopic (n = 4,360) antireflux surgery were identified from the University Health-System Consortium Database over a 3-year period (2004-2007). Demographic and outcome data measured included length of stay, overall complications, in-hospital mortality, observed-to-expected mortality ratio (risk-adjusted mortality), and hospital costs.

Results

Laparoscopic antireflux procedures offered significantly lower mean length of stay, in-hospital morbidity, and hospital costs. Both procedures had a low observed to expected in-hospital mortality. Open surgery was associated with significantly higher procedure-related and pulmonary complications.

Conclusions

In the context of US academic centers, approximately three quarters of antireflux procedures are being performed using the laparoscopic approach. These data suggest that laparoscopy has improved in-hospital outcomes when compared with open surgery and is preferred for the surgical treatment of GERD.     

Pneumonectomy for nontuberculous mycobacterial infections

Background

Pneumonectomy is considered in the treatment of nontuberculous mycobacterial infections when an entire lung is affected. However, this procedure carries high morbidity. We report on our experience in using pneumonectomy for treating patients with nontuberculous mycobacterial infections.

Methods

Between 1983 and 2002, 53 patients infected with nontuberculous mycobacteria underwent 55 pulmonary resections. Of these patients, 11 (3 men, 8 women) underwent pneumonectomy (5 right, 6 left). Median age was 57 years (range, 43 to 69 years). Mycobacterium avium complex disease occurred in 10 patients and Mycobacterium abscessus disease in 1. Indications for pneumonectomy included multiple cavities in one lung and destruction of an entire lung. The bronchial stump was covered with a latissimus dorsi muscle flap in 7 patients and with an intercostal pedicle flap in 2.

Results

Operating time ranged from 142 to 477 minutes (median, 360 minutes). The median intraoperative blood loss was 555 mL (range, 130 to 1,245 mL). There was no operative mortality. Bronchopleural fistula occurred in 3 patients. All fistulas were observed after right pneumonectomy, and were treated by reclosure of the bronchus. Empyema occurred in 1 patient, who was treated with irrigation. All patients achieved sputum-negative status after surgery. Two late deaths occurred. One patient died of respiratory failure 11 months after surgery. A second patient, the only patient who had recurrent disease, died of respiratory failure 4 years postoperatively.

Conclusions

Despite bronchial stump protection, right pneumonectomy carries a risk for bronchopleural fistula. Nonetheless, pneumonectomy can result in high cure rates in patients with nontuberculous mycobacterial infections.     

Results of multimodal treatment for desmoplastic small round cell tumors

Purpose:

Desmoplastic small round cell tumors (DSRCTs) are rare aggressive neoplasms that frequently present with large symptomatic intraabdominal masses. We examined the effects of multimodal therapy including induction chemotherapy, aggressive surgical debulking, and external beam radiotherapy on patients with DSRCT.

Methods:

Institutional Review Board permission was obtained. Sixty-six patients were diagnosed by histology, immunohistochemistry, and or cytogenetics as having DSRCT at our institution from July 1, 1972, to July 1, 2003. Data were collected on patient demographics, presenting symptoms, tumor location and extent, treatment regimen, and overall survival.

Results:

A majority of patients were male (91%), Caucasian (85%), and with a median age of 19 (7-58) years old at diagnosis. The most common presenting complaint was an intraabdominal mass (64%). In 63 patients (96%), the primary tumor was located in the abdomen or pelvis. Thirty-three (50%) had positive lymph nodes and 27 (41%) had distant parenchymal metastases at diagnosis. Overall, 3- and 5-year survivals were 44% and 15%, respectively. Twenty-nine of these patients (44%) underwent induction chemotherapy (P6), surgical debulking, and radiotherapy. Three-year survival was 55% in those receiving chemotherapy, surgery, and radiotherapy vs 27% when all 3 modalities were not used (P < .02). Gross tumor resection was highly significant in prolonging overall survival; 3-year survival was 58% in patients treated with gross tumor resection compared to no survivors past 3 years in the nonresection cohort (P < .000 01). Ten patients (15%) have no evidence of disease with a median follow-up of 2.4 years (range, 0.4-11.2 years).

Conclusions:

Multimodal therapy results in improved survival in patients with DSRCT. Aggressive surgical resection of these extensive intraabdominal neoplasms correlates with improved patient outcome.     

Use of angioembolization as an effective technique for the management of pediatric solid tumors

Purpose

In oncology practice, angioembolization has been reported for tumor reduction before surgery, treatment of life-threatening conditions, and for palliative care. Nevertheless, the overall experience with angioembolization for the treatment of tumors is limited. We report our experience in 7 nonvascular solid pediatric tumors.

Materials and Methods

A retrospective review was carried out of medical records from pediatric patients (0-18 years) with solid nonvascular tumors who underwent angioembolization in the last 5 years at our institution.

Results

Seven patients underwent embolization: 2 neuroblastomas, 1 metastatic paraganglioma, 1 hepatoblastoma, 1 myofibroblastic tumor, 1 osteosarcoma, and 1 undifferentiated sarcoma. The reason for angioembolization was preparation for surgery (3), treatment of a life-threatening event (1), or palliative care (3). Each case is presented and discussed. The outcome was subsequent complete surgical resection in 3 cases, tumor vanished in 1 case, symptom control was achieved in 1, and the other 2 patients improved their survival and quality of life, however, died of disease progression.

Conclusions

Tumor angioembolization may enter the treatment algorithm for selected patients who have to face difficult or unwarranted surgical procedures or have diseases where conventional therapies have failed.     

Fascia iliaca compartment block reduces emergence agitation by providing effective analgesic properties in children

Study Objective

To determine whether fascia iliaca compartment block (FICB) reduces emergence agitation.

Design

Prospective, randomized, blinded clinical trial.

Setting

Operating room and Postanesthesia Care Unit (PACU) of a university hospital.

Patients

64 ASA physical status 1 and 2 pediatric patients aged three to 7 years, scheduled for orthopedic surgery involving the anterior or lateral thigh.

Interventions

Patients enrolled in the FICB group received FICB immediately after the operation, while control group patients received intravenous (IV) patient/parent-controlled analgesia (PCA) with fentanyl.

Measurements

Severity of agitation and pain were evaluated using the Pediatric Agitation and Emergence Delirium (PAED) scale and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). Data were collected at 10-minute intervals in the PACU. The results were analyzed using the t-test.

Main Results

PAED scores in the FICB group were significantly lower than those of the control group on arrival at the PACU (7.3 ± 2.9 vs 10.4 ± 3.2, P < 0.001). The FICB group also had significantly lower CHEOPS pain scores than the control group, both on arrival at the PACU and 10 minutes after arrival (6.4 ± 1.5 vs 10.4 ± 1.8, P < 0.001 and 6.7 ± 1.6 vs 8.0 ± 1.4, P = 0.009, respectively).

Conclusion

In children having surgery on the thigh, FICB effectively reduced the severity of emergence agitation and postoperative pain during the immediate postoperative period.     

Pleuro-pneumo-phreno-pericardiectomy with pericardial and diaphragmatic plasty]

Aim of the paper is to evaluate 43 extrapleural pneumonectomy performed from 1988 to May 2000. Criteria for extrapleural pneumonectomy were pleural biopsy by thoracoscopy, potentially completely resectable unilateral disease by computed tomography and predicted postresection forced expiratory volume >1,3 L/sec. The resections regarded 33 pleural mesothelioma, 9 pleural lung-carcinosis and 1 pleural melanoma effusion. The perioperative mortality rate was 2,2% (1 death) and morbidity 21,4%.     

Principal strain orientation in the normal human left ventricle

Background

Methods that can improve the accuracy of application of directed intervention in the treatment of coronary artery disease deserve investigation. Magnetic resonance imaging with tissue tagging allows for noninvasive, quantitative determination of regionally varying minimum principal strain. Because the directional vector of minimum principal strain has been shown to be sensitive to ischemic involvement, my colleagues and I sought to fully characterize the normal range of vector direction in the in vivo human left ventricle at rest and during inotropic stimulation.

Methods

Tagged magnetic resonance imaging image sets were acquired in 20 healthy volunteers at rest and during dobutamine infusion. Strain was computed from the measured displacement data by using finite element software. Orientation of minimum principal strain was characterized by measuring the angle (principal strain angle) between the minimum principal strain vector and the local circumferential-longitudinal plane. Values of this angle were computed in 6 ventricular regions and globally.

Results

Resting values of the principal strain angle were small in every region, confirming that maximal normal myocardial contraction occurs primarily in the circumferential-longitudinal plane. Angles were similar during dobutamine infusion. Comparisons between ventricular walls, both at rest and with dobutamine, revealed no marked regional differences in the principal strain angle.

Conclusions

The direction of maximal myocardial contraction is known to change with ischemic injury to the myocardium and can be a sensitive, regionally varying index of myocardial ischemia. The critical first step in the clinical application of this technology is to accurately characterize normal ranges of principal strain angles.     

Thoracoscopy in pediatric pleural empyema: a prospective study of prognostic factors

Purpose

The indications for thoracoscopy remain imprecise in cases of pleural empyema. This study aimed to identify preoperative prognostic factors to help in the surgical decision.

Methods

From 1996 to 2004, 50 children with parapneumonic pleural empyema underwent thoracoscopy either as the initial procedure (n = 26) or after failure of medical treatment (n = 24). Using multivariate analysis, we tested the prognostic value of clinical and bacteriological data, the ultrasonographic staging of empyema, and the delay before surgery. Outcome measures were technical difficulties, postoperative complications, time to apyrexia, duration of drainage, and length of hospitalization.

Results

The clinical and bacterial data did not significantly predict the postoperative course. Echogenicity and the presence of pleural loculations at ultrasonography were not independent significant prognostic factors. A delay between diagnosis and surgery of more than 4 days was significantly correlated (P < .05) with more frequent surgical difficulties, longer operative time, more postoperative fever, longer drainage time, longer hospitalization, and more postoperative complications, such as bronchopleural fistula, empyema relapse, and persistent atelectasia.

Conclusion

The main prognostic factor for thoracoscopic treatment of pleural empyema is the interval between diagnosis and surgery. A 4-day limit, corresponding to the natural process of empyema organization, is significant. The assessment of loculations by ultrasonography alone is not sufficient to predict the postoperative course.