Post-treatment sarcoma in breast cancer patients

Background: Many patients treated for breast cancer with radiotherapy will survive their disease and be at risk for treatment-related sarcoma for many years. Methods: In order to identify patients with post-treatment sarcoma and define this disease, we examined the records of 99 patients treated for sarcoma with a history of antecedent breast carcinoma. Of these patients, 51 were felt to have a sarcoma unrelated to breast cancer treatment and 48 were felt to have a treatment-related sarcoma (secondary to lymphedema and/or radiation). Results: Lymphangiosarcoma of the extremity was the most common histologic subtype of post-treatment sarcoma, accounting for 22 of 48 cases (46%). Twenty-six patients (54%) developed nonlymphangiosarcoma post-treatment sarcoma; all of these were radiation-associated sarcomas. The median latency interval between the diagnosis of breast cancer and the development of sarcoma was 11 years (range 4–44) and was not different between the two groups. However, patients with nonlymphangiosarcoma were significantly younger when diagnosed with breast cancer than were those with lymphangiosarcoma of the extremity (median 43 vs. 51 years, p<0.001). The survival of all 48 patients was poor: 5-year survival was 29%. Five-year survival of patients with other types of post-treatment sarcoma was just as poor as those with lymphangiosarcoma of the extremity (30% vs. 28%, p=0.98). Conclusions: Patients who develop sarcoma after treatment for breast cancer have a poor prognosis whether it occurs as Stewart-Treves syndrome or other types of post-treatment sarcoma. Younger patients may be at higher risk than are older patients for the development of nonlymphangiosarcoma post-treatment sarcoma.Presented at the 46th Annual Cancer Symposium of the Society of Surgical Oncology, Los Angeles, March 18–21, 1993.     

Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida

BackgroundPatients with diverticulitis have a 20% risk of requiring urgent/emergent treatment. Since morbidity and mortality rates differ between elective and urgent/emergent care, understanding associated disparities is critical. We compared factors associated with treatment setting for diverticulitis and evaluated disparities regarding access to Minimally Invasive Surgery (MIS) and development of complications.MethodsThe Florida Inpatient Discharge Dataset was queried for patients diagnosed with diverticulitis. Three multivariate models were utilized: 1) elective vs urgent/emergent surgery, 2) MIS vs open and 3) presence of complications.ResultsThe analysis included 12,654 patients. Factors associated with increased odds of urgent/emergent care included being uninsured or covered by Medicaid, African American, obese, or more comorbid. MIS was associated with reduced odds of complications. Patients treated by high-volume or colorectal surgeons had increased odds of receiving MIS.ConclusionsPatients were more likely to receive MIS if they were treated by a colorectal surgeon, or a high-volume surgeon (colorectal, or general surgeon). Additionally, patients that were older, had increased comorbidities, or did not have health insurance were less likely to receive MIS.     

成人原发性肾肉瘤

目的　探讨成人原发性肾肉瘤的诊断、治疗及预后。　方法　１９８５ ～１９９５ 年共收治肾脏肿瘤３５３ 例,其中成人原发性肾肉瘤７ 例,占１９ ％ 。采用回顾性研究。　结果　７ 例均行外科手术治疗。术后病理确诊平滑肌肉瘤３ 例、横纹肌肉瘤２ 例、梭形细胞肉瘤１ 例、低分化肉瘤１ 例。术中死亡１ 例。术后随访３ ～６０ 个月,平均生存１４ 个月。　结论　成人原发性肾肉瘤高度恶性,以平滑肌肉瘤最常见。早期诊断和外科手术切除是目前唯一提高疗效的方法,但总体预后较差。     

伴病理性骨折的原发恶性骨肿瘤保肢手术疗效评价

目的探讨保肢手术对伴病理性骨折的原发恶性骨肿瘤的治疗效果。方法伴病理性骨折的原发恶性肿瘤患者29例,所有患者均接受规律化疗及保肢手术。对所有患者按照骨折类型、骨折时间、手术的类型进行分组。分析各临床因素与术后原位复发率与肺转移率的关系。结果平均随访18个月(10~45个月),仅2例由于复发需要截肢(6%),5例发生肺转移(17%),最终死亡。结论伴病理性骨折的原发恶性骨肿瘤并不是患者行保肢手术的禁忌证,广泛切除重建和辅助化疗可以作为保肢治疗的方案之一。     

Treatment and outcomes of patients with primary breast sarcoma

Background

Surgery is the main treatment for primary breast sarcoma (PBS). Here we characterize this disease and determine factors associated with use of adjuvant therapy.

Methods

Records of patients with PBS from 1986 to 2006 were reviewed. Overall survival (OS) was estimated by Kaplan-Meier. Relationships between patient variables and OS were determined using univariate Cox proportional hazard models.

Results

Thirteen patients with PBS were identified; 10 patients underwent mastectomy, and 3 underwent partial mastectomy. Six patients underwent axillary staging; none were positive. Patients with tumors >5 cm were more likely to undergo radiation therapy (P <.05). Local recurrence occurred in 7 patients. Metastatic disease was present in 2 patients at diagnosis, and 6 patients developed metastatic disease; all 8 patients died from their disease. Five patients remained disease free. Five-year OS was 67% (83% for tumors <5 cm and 42% for tumors >5 cm). Tumor size was significantly associated with OS (relative risk = 1.1/1 cm increase in size > 5 cm).

Conclusions

Treatment for PBS is excision to clear margins. Axillary staging is not indicated. Tumor size >5 cm is the only significant prognostic indicator of overall survival.     

Refusal of surgery for colon cancer: Sociodemographic disparities and survival implications among US patients with resectable disease

BackgroundWe aimed to identify factors associated with refusal of surgery among patients with colon cancer.MethodsThis 2004–2016 NCDB retrospective study identified AJCC stage I-III colon cancer patients who were recommended surgery. Multivariable logistic regression defined adjusted odds ratios of refusing treatment, with sociodemographic and clinical covariates. Treatment propensity-adjusted Cox proportional hazard ratios defined differential survival stratified by clinical stage, controlling for potential confounders.ResultsOf 170,594 patients recommended surgery, 1116 refused. Increased rates of surgery refusal were associated with older age, African American race, CDCC>3, and female sex. Decreased rates of surgery refusal were associated with higher income and private insurance. Stratifying by stage, refusal rates among African Americans remained disparately high. Refusal of surgery was associated with worse overall survival.ConclusionsDisparate rates of refusal of surgery for resectable colon cancer by race and other sociodemographic factors highlight potential treatment adherence reinforcement beneficiaries, necessitating further study of shared decision-making.     

成人原发性肾肉瘤的诊治及预后

目的探讨成人原发性肾肉瘤的诊断、治疗以及影响预后的因素。方法1996年至2005年收治成人原发性肾肉瘤15例，占同期收治794例肾肿瘤患者的1．9％。男6例，女9例。年龄36～68岁，平均50岁。临床表现为腹部肿块10例，腹部疼痛2例，健康体检发现后腹膜占位2例，肉眼血尿1例。肿瘤直径6．8～22．5cm，平均13．4cm，均为单发。临床分期Ⅱ期6例、Ⅲ期5例、Ⅳ期4例。15例影像学表现具有肾恶性肿瘤的特征，但与肾癌或错构瘤鉴别困难。结果11例行根治性肾切除术，4例因无法根治而行单纯肾切除术或肿瘤部分切除术。术后病理诊断为平滑肌肉瘤6例、脂肪肉瘤3例、低分化肉瘤3例、纤维肉瘤2例、滑膜肉瘤1例。13例随访3个月～8年，死亡10例，生存最长者为8年（脂肪肉瘤），最短者为3个月（术前已肝转移）。11例接受根治性肾切除术者平均生存期33个月，4例行单纯肾切除术或肿瘤部分切除术者平均生存期8个月；平滑肌肉瘤组平均生存期22个月，脂肪肉瘤组为46个月，低分化肉瘤组为15个月。结论腹部肿块是成人原发性肾肉瘤最常见的临床表现，是否可以进行根治性手术、病理类型是影响预后的重要因素。     

Racial Disparities in Esophageal Cancer Treatment and Outcomes

Purpose Blacks have a higher mortality rate than whites from esophageal cancer, but the reasons underlying this disparity remain unclear. In this study, we used a national sample of patients with resectable esophageal cancer to assess the extent to which racial inequalities in care can explain outcome disparities. Methods We identified all non-Hispanic white and black patients diagnosed with T0–T2, node-negative esophageal cancer between 1988 and 2003 from the Surveillance, Epidemiology, and End Results registry. Racial differences in esophageal-specific survival were assessed using the Kaplan-Meier method. We performed Cox regression to test for racial differences in survival after adjusting for potential confounders and to assess the extent to which disparities can be explained by later diagnosis or treatment inequalities. Results A total of 1522 patients were included in the study. Blacks had worse esophageal-specific survival rates than whites (37% vs 60% 5-year survival; P < .0001). Blacks were more likely to be diagnosed at a more advanced stage and to have squamous cell tumors, but were less likely to undergo surgery. In multivariate regression controlling for age, sex, marital status, histology, and tumor location, black race was associated with worse survival. When tumor status, surgery, and radiotherapy were added to the model, race was no longer significantly associated with survival. Conclusion These data suggest that blacks are at greater risk of death from esophageal cancer. While the disparity is due in part to differences in tumor histology, diagnosis at an earlier stage and higher rates of surgery among blacks could reduce this survival disparity.     

手术切除加行射频消融术在肝脏原发性未分化胚胎性肉瘤外科治疗中的意义

目的 研究根治性切除+射频消融术治疗原发性肝脏未分化胚胎性肉瘤的根治效果.方法 回顾性分析2005年1月-2015年2月中国人民解放军总医院肝胆外科17例肝脏原发性未分化胚胎性肉瘤患者的诊断、治疗和预后.所有17例患者均行外科手术切除,其中8例患者加行切缘组织的射频消肖融治疗(S+ RFA组),另外9例患者仅行手术切除病灶(S组).结果 所有病例均经术后病理证实为原发性肝脏未分化胚胎性肉瘤.与S组患者相比,S+ RFA组手术时间较长(P =0.0449);但术后肝功能(转氨酶、胆红素水平)和术中出血量的差异无统计学意义.回访时间4 ～38个月,其中9例患者死亡;S+RFA组患者病死率33.3％(3/9),S组患者病死率75.0％(6/8).Kaplan-Meier生存曲线法分析,两组患者总生存期差异无统计学意义(P＞0.05).S组和S+ RFA组患者24个月无病生存率分别为0和56.8％,中位生存期分别为15个月和29个月(P =0.0476).结论 手术切除+肝脏射频消融术能进一步保证原发性肝脏未分化胚胎性肉瘤切缘的阴性率,进而降低肿瘤的复发和转移,结合全身化疗等综合治疗,能够明显延长原发性肝脏未分化胚胎性肉瘤患者的生存期、降低肿瘤复发转移率.     

Effect of perioperative blood transfusion on recurrence and survival in 232 primary high-grade extremity sarcoma patients

Background: Allogeneic blood transfusion (BT) has been implicated as an unfavorable factor influencing cancer recurrence and overall survival. Methods: To investigate this, 232 consecutive localized, high-grade extremity soft tissue sarcoma (STS) patients admitted between January 1, 1983, and December 31, 1989, were analyzed from our prospective database by univariable and Cox multivariable statistical methods. Results: Twenty-eight patients developed a local recurrence (LR). Factors found significantly unfavorable for the rate of developing an LR by uni- and multivariable tests were age >60 years and positive microscopic margin. Eighty-nine patients developed a distant metastasis (DM) and 72 patients died of their tumor. Median follow-up of survivors was 48 months. Unfavorable factors for DM and tumor mortality (TM) by univariable analysis included large size, deep tumor (that involved or was below the superficial fascia), positive microscopic margin, invasion of a vital structure, operative blood loss, duration of operation, and perioperative BT (whole blood or packed cells -24 to +48 h of curative operation). Multivariable analysis found large size, deep tumor, and positive margin significant independent unfavorable factors for DM and TM. The effect of BT was not a significant independent prognosticator for LR, DM, or TM by multivariable analysis (p=0.26, 0.56, 0.08, respectively), The only factor that was found to be significant in a multivariable analysis of factors contributing to postmetastasis survival was time <6 months until metastasis (p=0.008). BT had no significant impact on postmetastasis survival (p=0.42). There was a significant association between BT and deep, large tumors. As the size of deep tumors increased from <5, 5<10, 10<15, or15 cm, the amount transfused was 15, 16, 49, and 68% (p<0.00001). Also, BT was significantly (p<0.005) associated with low hematocrit at initial diagnosis, blood loss during surgery, and the length of the surgical procedure. Conclusions: These data emphasize the importance of size, depth, and margin on distant recurrence and death for localized high-grade extremity STS. In the absence of a randomized trial, the impact of allogeneic blood transfusion would appear to be due to its strong association with large size and deep tumor invasion. This study also highlights the importance of a multivariable analysis and long-term follow-up to better define this controversial question.Presented at the 46th Annual Cancer Symposium of the Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

加速康复外科在老年腹股沟疝无张力修补日间手术中的应用

目的探讨加速康复外科（ERAS）在老年腹股沟疝日间手术无张力修补中的有效性。 方法前瞻性选取2017年7月至2018年6月,绍兴市人民医院行腹股沟疝无张力修补日间手术80例老年患者纳入本随机对照研究,按SPSS 19.0随机数字表法分为试验组和对照组,每组患者40例。试验组进入日间手术流程,围手术期采用ERAS方法处理;对照组采用常规日间手术处理。观察2组间相关手术并发症、手术康复情况和卫生经济学指标。 结果最终试验组37例,对照组38例完成了研究。试验组术后恶心呕吐、术后6 h切口疼痛VAS评分分别为1（2.7%）、23.96,明显低于对照组7（18.4%）、51.67,差异有统计学意义（χ²=4.862、Z=－5.643,P=0.027、<0.001）;试验组术后尿潴留、阴囊水肿、血肿/血清肿及局部感觉异常分别为1（2.7%）、2（5.4%）、0、3（8.1%）,与对照组5（13.2%）、5（13.2%）、1（2.6%）、3（7.9%）比较,差异均无统计学意义（P>0.05）。试验组术后住院时间、住院费用及完成日间手术例数分别为（1.65±0.48）d、（9304.83±613.28）元、37（100.00%）,与对照组（2.45±0.80）d、（10 817.53±1473.48）元、27（71.05%）均明显少于对照组,差异均有统计学意义（t=－5.270、t=－5.776、χ²=12.551,P=0.028、<0.001、<0.001）。 结论ERAS理念应用于老年腹股沟疝无张力修补日间手术中,使患者痛苦更小、恢复更快、医疗费用更省,不增加并发症发生率,有较大的推广和应用价值。     

Pioneering women in American pediatric surgery

Women were among the pioneers in American pediatric surgery in its early decades. Once in practice, Benjy Brooks (Houston) and Jessie Ternberg (St. Louis) became identified with the specialty in their adopted communities, and Rowena Spencer in her hometown of New Orleans. Louise Schnaufer in Philadelphia, Kathryn Anderson in Washington, D.C., and Patricia Donahoe in Boston were all prominent surgeons at leading children's specialty hospitals in the country. Schnaufer was the unsung stalwart in general and thoracic surgery at the Children's Hospital of Philadelphia. Anderson became Surgeon-in-Chief in Los Angeles, and later the first woman leader of both professional societies in pediatric surgery as well as first woman President of the American College of Surgeons. Donahoe developed a spectacular academic career and became one of the outstanding surgical scientists in the country.Each faced gender discrimination at several stages of their careers: medical school enrollments that limited spots for women; widespread bias against women training in surgery and pediatric surgery; and the absence of woman role models and mentors. It is instructive and inspiring to review their individual stories that play an important part of the history of the specialty.     

Solo hand surgery

Unassisted hand surgery is being undertaken by necessity for both elective and emergency cases, due to hospital resource restrictions. The authors outline the principles of local anesthesia, surgeon-controlled tourniquet techniques, and a number of new instruments which allow a surgeon to work in comfort and safety, unassisted. The traditional surgical instruments designed for the days when trained surgical assistants were available to hold them are no longer suitable. We are entering a new era of surgical design with safer instruments that can complement our skills rather than challenge them. There are significant cost savings and efficiency when hand procedures are undertaken in the emergency and outpatient clinic settings.     

基于SEER数据库分析手术在Ⅳ期胆囊癌治疗中的作用

目的 探究手术对Ⅳ期胆囊癌患者预后的影响。方法 从美国SEER数据库筛选2010年1月1日至2015年12月31日间诊断的4 627例Ⅳ期胆囊癌患者,根据是否进行手术治疗分为手术组（3 535例）和非手术组（1 092例）。倾向得分匹配后共得到1 344例,其中手术组和未手术组各672例。采用Cox风险回归模型分析Ⅳ期胆囊癌患者预后的独立风险因素,通过Kaplan-Meier法进行总体和各亚组生存分析和亚组分析,绘制生存曲线并计算中位生存时间（median survival time,MST）。结果 Cox回归模型提示原发灶部位、肿瘤分级、N分期、M分期、放疗、化疗、婚姻状况和手术（HR 0.590,95%CI 0.517~0.672,P<0.001）是Ⅳ期胆囊癌患者预后的独立危险因素。手术组中位（四分位间距）生存时间长于未手术组[7（14）个月 vs 3（8）个月,P<0.001],1年[31.6% vs 16.3%,P<0.001]、3年[9.4% vs 1.4%,P<0.001]生存率均高于未手术组,差异均有统计学意义。亚组分析显示,对于所有原发灶部位、M分期、放疗情况、化疗情况的亚组的Ⅳ期胆囊癌,手术均能改善患者的生存时间和生存结局。结论 手术可以改善Ⅳ期胆囊癌患者的预后情况,且是影响预后的独立危险因素之一。     

Treatment of undifferentiated embryonal sarcoma of the liver in children—single center experience

Background

Undifferentiated embryonal sarcoma of the liver (UESL) represents less than 5% of all malignant hepatic tumors in childhood. It is considered an aggressive neoplasm with an unfavorable prognosis. The aim of this paper is to present a single center experience in the treatment of children with UESL.

Materials and methods

Ten children with UESL were treated between 1981 and 2012. Age at diagnosis ranged from 4 months to 17 years (median age, 6 years and 9 months). Surgery after neoadjuvant chemotherapy (CHT) was performed in 7 patients, and in 3 patients primary surgery was done. Adjuvant chemotherapy was administered in all 10 patients (CYVADIC, CAV, CAV/ETIF/IF + ADM, CDDP/PLADO). Right hemihepatectomy was performed in 1 patient, extended right hemihepatectomy in 6, and partial resection of the right lobe (segments V-VI, segment V) in 2 patients. One patient with unresectable tumor affecting both lobes was listed for liver transplantation (LTx).

Results

Follow-up from diagnosis ranged from 50 to 222 months (mean 138 months). Among 9 patients treated with partial liver resection, distant metastases/local recurrence was not observed in any, and disease-free survival in this group is 100% (9 patients alive). The patient that underwent liver transplantation died of multiorgan failure 4 months postoperatively.However, this patient was misdiagnosed as having hepatoblastoma (HBL) and received PLADO chemotherapy. The overall survival rate is 90%.

Conclusion

Excellent results with long-term survival can be achieved in children with UESL with conventional therapy, including a combination of neoadjuvant and adjuvant chemotherapy and surgery, even in large extensively growing tumors.     

单中心23年胆道外科腹腔镜手术中转开腹的原因分析

目的分析解放军总医院23年间胆道外科行腹腔镜手术中转开腹的情况,分析其中转开腹的常见疾病和原因。 方法根据相关纳入标准回顾性分析解放军总医院胆道外科1992年4月至2014年12月期间收治的连续348例腹腔镜手术中转开腹患者的临床资料,描述胆道外科腹腔镜手术的整体中转开腹情况,进而分析其中转开腹的常见病因及原因。 结果(1)解放军总医院胆道外科1992年4月起至2014年12月止23年间收治腹腔镜手术中转开腹患者共348例,总体中转开腹率为2.96%(348/11 767);其中11例患者有上腹手术史,其中转开腹率为25.58%(11/43)。(2)在所有患者中,最常见的中转开腹疾病是胆囊良性疾病和肝外胆管结石,分别占77.30%和16.67%。胆囊良性疾病的中转开腹率为2.41%,肝外胆管结石的中转开腹率为14.61%。(3)胆道外科腹腔镜手术常见中转开腹原因是粘连,占93.97%;其次是出血和癌变,分别占2.59%和2.30%,因损伤所致的中转开腹仅占1.15%。(4)对于胆囊良性疾病和肝外胆管结石患者而言,粘连是其最常见的中转开腹原因,分别占97.40%和98.28%。 结论胆道外科腹腔镜手术应严格掌握适应证,尤其是既往有上腹手术史的患者;如遇到无法控制的出血和损伤情况应及时中转开腹,以保证手术的安全。     

Concomitant upper extremity soft tissue sarcoma limb-sparing resection and functional reconstruction: assessment of outcomes and costs of surgery

Background

The purpose of this study is to investigate functional outcomes and cost impacts of immediate functional reconstruction performed in conjunction with limb-sparing resection of upper extremity soft tissue sarcomas.

Methods

Patients undergoing simultaneous limb-sparing upper extremity soft tissue sarcoma resection and functional reconstruction between December 1998 and March 2004 were retrospectively identified, their medical records reviewed, and costs of surgery analyzed. Functional outcomes and patient satisfaction were assessed via patient surveys and the Toronto Extremity Salvage Score (TESS).

Results

Thirteen patients met the inclusion criteria. Average follow-up was 43.3 months. Reconstructions included rotational innervated muscle flaps (n = 6), free innervated myocutaneous flaps (n = 1), and tendon transfers or grafts (n = 6). Overall survival was 85 % (n = 11) and disease-free survival was 77 % (n = 10). Average total cost of surgery was $26,655. Patients undergoing reconstruction for hand and forearm sarcomas had significantly higher total costs of surgery than those undergoing reconstruction for elbow and upper arm sarcomas. Survey response rate was 91 % (n = 10). Average TESS score was 76. Of the patients who worked preoperatively, 88 % returned to work postoperatively, and all patients who returned to work currently use their affected limb at work.

Conclusions

Patients undergoing immediate functional reconstruction for upper extremity soft tissue sarcoma resection achieved very good to excellent functional outcomes with quick recovery times and a high return-to-work rate following immediate functional reconstruction, thereby minimizing surgical cost impacts. Immediate functional reconstruction in the same surgical setting is thus a viable strategy following upper extremity soft tissue sarcoma resection.

Electronic supplementary material

The online version of this article (doi:10.1007/s11552-013-9567-9) contains supplementary material, which is available to authorized users.     

新疆地区70例艾滋病相关型卡波西肉瘤患者临床特征及预后分析

目的 分析新疆艾滋病相关型卡波西肉瘤(AIDS-KS)患者的临床特征,探讨抗反转录病毒治疗(HAART)及系统性化疗等对患者预后的影响.方法 连续收集2008年1月至2013年6月新疆维吾尔自治区第六人民医院收治的70例AIDS-KS患者的临床资料,采用回顾性研究的方法对人群特点、KS进展情况、病变部位及范围、治疗及预后等进行总结分析,并采用t检验和x2检验比较不同治疗组的疗效及预后.结果 70例AIDS-KS患者的平均年龄为(40±10)岁,男女比例2.5∶1,其中66例(94.29％)为维吾尔族,23例(32.9％)疾病进展评分为快速.KS临床症状主要有斑片、结节等,且头颈、躯干、四肢和内脏均有累及.治疗组总病死率为7.7％ (4/52),而未治疗组的12例患者中4例死亡,与治疗组比较差异有统计学意义(x2=5.861,P＜0.05).单纯HAART组和HAART序贯化疗组治疗半年后CD4+T淋巴细胞计数较治疗前明显上升(t=35.258和42.528,P＜0.01),而采用其他治疗方案的患者和未治疗的患者CD4+T淋巴细胞计数较治疗前无显著变化或下降.HAART序贯化疗组、化疗序贯HAART组和单纯化疗组中的所有患者对KS治疗均有效,而单纯HAART组的治疗有效率为86.4％ (19/22),且45.5％ (10/22)的患者在HAART后出现免疫重建炎症反应综合征(IRIS),KS症状加重.结论 AIDS-KS多发生于中青年,以维吾尔族男性多见,病灶部位多样化,部分呈快速进展.HAART联合系统性化疗疗效较好,且可降低IRIS的发生率,值得临床推广应用.     

Efficacy of video-based education program in improving metabolic surgery perception among patients with obesity and diabetes

Background

Metabolic surgery remains underutilized despite its efficacy and safety. Poor perception of surgery has been cited as one of the major reasons.