A single-center experience with inflammatory breast cancer, 1985-2003

HYPOTHESIS: "Up-front" surgery improves survival in inflammatory breast cancer (IBC). DESIGN: Retrospective cohort, 1985-2003. SETTING: Tertiary referral center. PATIENTS: Consecutive patients with a primary occurrence of IBC. MAIN OUTCOME MEASURES: All-cause and disease-free survival. RESULTS: One-hundred fifty-six patients were identified with IBC; 28 patients with metastatic disease were excluded from further analysis. The mean age of the remaining 128 patients was 53 years; 57% of women were postmenopausal. One hundred twenty-two patients had clinically apparent IBC. Tumors were palpable in 83 patients (mean diameter, 9.1 cm). Neoadjuvant chemotherapy was the initial therapy in 106 patients, while surgery was the initial therapy in 22 patients. The overall median survival was 37 months, with a median disease-free interval of 23 months. The 5-year survival was 42%, with a disease-free survival of 21%. Univariate analysis of recurrence identified previous hormone therapy (relative risk [RR], 0.50; P = .03), menopause (RR, 0.55; P = .01), and palpable adenopathy (RR, 1.57; P = .04) as significant factors. Univariate survival analysis highlighted previous hormone therapy (RR, 0.48; P = .04), radiotherapy (RR, 0.39; P = .02), sequence of therapy (P = .001), family history (RR, 0.47; P = .01), and palpable adenopathy (RR, 2.22; P<.001) as being important. Multivariate analysis of recurrence identified menopausal status as the key factor. Adenopathy at the initial examination was associated with decreased length of survival, while radiotherapy was associated with better survival. CONCLUSIONS: Survival from IBC remains poor. Although adenopathy and radiotherapy affected survival by multivariate analysis, the sequence of therapy was not associated with improved outcome.     

Risk factors for short- and long-term survival of primary cadaveric renal allografts in pediatric recipients: a UNOS analysis

BACKGROUND: Pediatric kidney graft survival rates have improved in the United States. This study evaluates early and late risk factors for cadaveric graft loss in pediatric recipients. METHODS: From January 1994 to December 2002, 2,597 primary cadaveric kidney-alone transplants (donor age 5-45 years, recipient age 2-20 years) were reported to the United Network for Organ Sharing (UNOS). The analysis includes follow-up information based on OPTN data as of October 14, 2003. Odds ratio of early graft loss and relative risk of late graft loss are estimated using logistic regression and Cox proportional hazards model, respectively. RESULTS: Graft survival rates significantly improved during 1999-2002 (95% and 79% at 1-year and 3-years, respectively) compared with those of 1994-1998 (88% and 76% at 1-year and 3-years, respectively) (log rank P=0.02). After adjusting for other variables, the factors that significantly affected early transplant outcome adversely within 3 months posttransplant were prolonged cold ischemia time (>36 hours, odds ratio [OR]=3.38 vs. 0-36 hours) and young recipient age (2-5 years old, OR=2.02 vs. 6-12 years). Beyond 3 months, significant risk factors were African-American recipients (relative risk [RR]=1.93 vs. others), teenage recipients (13-20 yrs, RR=1.50 vs. 6-12 yrs), and patients with focal glomerulosclerosis (FGS) (RR=1.27 vs. others). CONCLUSIONS: The short-term graft survival rate of pediatric cadaveric kidney transplants has significantly improved, yet the long-term outcome has changed little. The long-term outcomes for teenagers (13-20 yrs), patients with FGS, and African-Americans lag significantly behind other groups. In order to improve long-term graft survival in these high-risk patients, newer preventive or treatment strategies must be developed.     

肝门部胆管癌的手术治疗：附41例报告

目的:探讨肝门部胆管癌手术疗效及其预后的相关因素。方法:对近7年来收治的经病理诊断确诊的41例肝门部胆管癌患者的临床资料进行回顾性分析。结果:41例肝门部胆管癌患者中，术前影像检查联合诊断正确率为95.1%；行手术切除32例，总手术切除率为78.1%，其中根治性切除15例，姑息性切除17例；胆管内引流术9例。全组住院期间死亡2例，病死率4.9%。手术切除组中位生存时间和1，3，5年生存率分别为28个月和70.0%，40.0%，23.3％,内引流组为8个月和44.4%，11.1%，0，手术切除组患者的生存率优于引流组（P<0.05和P<0.05）。其中施行R0有14例，占46.7%，其中位生存时间和1，3，5年生存率为52个月和85.7%，64.3%，35.7%，不同手术级别的术后疗效存在差别（P<0.05）。Bismuth分型以Ⅱ型生存率最高，有7例，占18.0%，其中位生存时间和1，3，5年生存率为72个月和85.7%，71.4%，42.9%;不同病理类型切除率中以乳头腺癌和高分化腺癌为最高的切除率分别为77.8% 和78.3%，其1，3，5年的生存率分别为77.8%，44.4%，33.3%和73.9%，65.2%，17.4%；低分化癌为20%,0,0。结论:肝门部胆管癌手术治疗的预后主要与肿瘤的临床病理特征和手术方式相关，根治性切除是改善肝门部胆管癌长期生存和预后的关键因素。     

Metastasectomy in renal cell carcinoma: A multicenter retrospective analysis

OBJECTIVE: In 60-70% of patients with renal cell carcinoma (RCC), metastases develop in the course of the disease. In the present analysis, the surgical management of metastases is described, and survival data are presented. This retrospective analysis may help in the management of future cases. Due to the retrospective nature of the data, no comparison between surgical and nonsurgical management is possible. METHODS: Between 1985 and 1995, 152 resections of RCC metastases were performed in 101 patients at four Dutch Hospitals. Thirty-five and 6 patients had metastases resected 2 and 3 times, respectively. In most patients, the primary tumor was resected (n = 95). Resections were performed for metastases at different locations: lung n = 54, bone n = 42, lymph nodes n = 18, cerebrum n = 12 and locations in the spinal canal, thyroid, bowel, and testis. Skin excisions were excluded from the analysis. Solitary metastases were resected in 40 patients. RESULTS: Median survival after the initial metastasectomy was 28 months. Initial tumor stage, grade, or size were not related to metastasis location or survival. The number of initially resected pulmonary metastases was of no influence on survival, however, multiple consecutive resections were related with longer survival. Patients with solitary metastases (n = 40) did not show longer survival after the first metastasectomy compared to no solitary lesions. Better survival was found for lung metastases compared to other tumor locations (p = 0.0006, log rank test) and for patients that were clinically tumor free after metastasectomy (p = 0.0230, log rank test). Additional immuno- or radiotherapy did not independently influence survival. Time interval between primary tumor resection and metastasectomy correlated positively with survival: a tumor-free interval of more than 2 years between primary tumor and metastasis was accompanied by a longer disease-specific survival after metastasectomy. Eleven patients were free of disease after metastasectomy with a median time of 47 (14-65) months. The median time of hospital admittance for metastasectomy was 9 days (4-64). Lethal complications were found in 2 patients. Long-term (>5 years) disease-free survival was achieved in 7% of patients whereas 14% of patients were free of disease with a minimal follow-up of 45 months. CONCLUSIONS: (1) Surgical management of metastases could be performed with short hospital stay, and low complication rates were found. (2) Disease-free survival was found in 14 and 7%, with follow-ups of at least 45 and 60 months, respectively. (3) The longest survival was found after surgery for pulmonary lesions. (4) Resection of solitary metastases did not result in longer survival compared to resection of nonsolitary lesions. (5) An interval shorter than 2 years between primary tumor and metastases was correlated with a shorter disease-specific survival.     

Preoperative Neutrophil-to-Lymphocyte Ratio as a Prognostic Predictor after Curative Resection for Hepatocellular Carcinoma

BACKGROUND: This study was designed to evaluate the impact of an elevated preoperative neutrophil-to-lymphocyte ratio (NLR) on outcome after curative resection for hepatocellular carcinoma (HCC). METHODS: Patients undergoing resection for HCC from January 1994 to May 2007 were identified from the hepatobiliary database. Demographics, laboratory analyses, and histopathology data were analyzed. RESULTS: A total of 96 patients were identified with a median age at diagnosis of 65 (range, 15-85) years. The 1-, 3-, and 5-year overall survival rates were 80%, 58%, and 52%, respectively. Although the presence of microvascular invasion, NLR >or=5, and R1 resection margin were adverse predictors of overall survival, there were no independent predictors identified on multivariate analysis. The 1-, 3-, and 5-year disease-free survival rates were 74%, 63%, and 57%, respectively. Preoperative tumor biopsy, NLR >or= 5, multiple liver tumors, microvascular invasion, and R1 resection margin were all predictors of poorer disease-free survival. Multivariate analysis showed that a NLR >or= 5 and R1 resection margin were independent predictors of poorer disease-free survival. The median disease-free survival of those with a NLR >or= 5 was 8 months compared with 18 months for those with a NLR < 5. CONCLUSION: Preoperative NLR >or= 5 was an adverse predictor of disease-free and overall survival.     

Gender differences in long-term survival of patients with colorectal cancer

BACKGROUND: Significant differences exist in the immunological response to surgery. This raises the possibility that gender differences exist concerning the outcome after curative colorectal cancer resection. METHODS: To study this hypothesis, a database of patients with colorectal cancer was analysed prospectively. RESULTS: Some 894 patients were included, 500 (55.9 per cent) were men and 394 (44.1 per cent) were women. Median follow-up was 54.5 months for the entire group and 63.3 months for survivors. The mean(s.e.m.) patient age was 65.3(0.4) years (women 66.1(0.6), men 64.7(0.5) years; P < 0.05). Women lived significantly longer after cancer resection than men (57.8(1.5) versus 52.0(1.3) months; P < 0.05, log rank 0.009). Disease-free survival was significantly longer in women than in men (51.6(1.7) versus 46.0(1.4) months; P < 0.05). Subgroup analysis revealed significant gender differences in Union Internacional Contra la Cancrum (UICC) stages I (n = 195, log rank 0.01) and UICC IV (n = 38, log rank 0.021). Survival analysis after rectal cancer resection revealed significant advantages for women (log rank 0.02), while no gender differences were detected when comparing patients after resection for colonic cancer. Moreover, patients older than 50 years (n = 635) showed significant gender-related survival differences (log rank 0.015). CONCLUSION: Significant gender differences following curative rectal cancer resection were observed. In women disease-free and overall survival were significantly longer. Whether or not these gender differences are related to gender-specific immune functions or to other gender-related local or systemic factors remains to be determined.     

Does Additional Doxorubicin Chemotherapy Improve Outcome in Patients with Hepatocellular Carcinoma Treated by Liver Transplantation?

The aim of this prospective randomized study was to determine whether additional doxorubicin chemotherapy improves outcome in patients with hepatocellular carcinoma (HCCA) treated by liver transplantation. Stratification parameters were tumor stage (UICC I-IVa), gender, age 50 years, α-fetoprotein 20 ng/mL, cirrhosis and HbsAg status. For pre-operative chemotherapy doxorubicin (15 mg/m²) was given biweekly, intra-operative chemotherapy was a single dose administered before surgical manipulation. Post-operative chemotherapy from day 10 was as given preoperatively for a total dosage of 300 mg/m². Outcome parameters were overall survival (OS) and disease-free survival. Of the 75 consecutive patients who received liver transplantation for treatment of HCCA, 62 patients were enrolled. Thirty-four patients were randomized in the chemotherapy group; 28 patients were in the control group and transplanted only. OS rates at 5 years were 38% in the chemotherapy group and 40% in the control group, disease-free survival rates at 5 years 43% and 53%, respectively. Tumor stage and vascular invasion were identified as independent risk factors for recurrence of disease. Doxorubicin chemotherapy did not improve organ survival and disease-free survival in patients undergoing liver transplantation for HCCA.     

Prostate cancer stage shift has eliminated the gap in disease-free survival in black and white American men after radical prostatectomy

PURPOSE: The initiation of prostate specific antigen (PSA) testing has led to increased public awareness, early detection and a stage shift in prostate cancer. We have previously reported that black American men have worse disease-free survival independently of pathological or clinical factors. We tested the stage shift effects on disease-free survival in our cohort of patients treated with radical prostatectomy. MATERIALS AND METHODS: A total of 1,042 consecutive patients underwent radical prostatectomy performed by Wayne State University full-time faculty. The cohort was divided by the year of surgery as before (585 men in group 1) or after (457 in group 2) 1996. Clinicopathological and disease-free survival data were obtained from the Karmanos Cancer Institute multidisciplinary prostate cancer database. RESULTS: Improvements in clinical stage, preoperative PSA and biopsy Gleason score were observed in group 2 (p = 0.0001). Pathological organ confined disease increased in group 2 versus 1 in the 2 races, including 89 of 153 (58%) from 66 of 178 (37%) in black men and 189 of 304 (62%) from 194 of 407 (48%) in white men (p = 0.003 and 0.001, respectively). Calculated cancer recurrence-free median probability in group 1 at 42 months was 81% and 68% in white and black men, respectively (log rank test p = 0.001). These differences became insignificant in group 2 patients at 42 months with a median probability of 90% and 88% in white and black men, respectively (log rank test p = 0.39), representing a net increase in disease-free survival of 20% in black men. Specimen Gleason score, PSA and pathological stage were independent predictors of survival in the 2 groups. In contrast, race was an independent predictor only in group 1. CONCLUSIONS: The increased rate of pathological organ confined disease is translating into improved disease-free survival rates. These early data suggest that the survival gap in black and white American men is narrowing and may become statistically insignificant.     

20-year experience with elderly donors in living renal transplantation

PURPOSE: This study evaluates the impact of living renal donors (LD) aged 60 years and older on graft performance and patient survival in an old-for-young constellation. PATIENTS AND METHODS: We analyzed 144 consecutive LDs between January 1983 and December 2002 (19 patients 60+/125 controls). RESULTS: Mean donor age in the 60+ group was 63.7 (+/- 2.6) years and 43.7 (+/- 9.0) years for the <60 group. Mean recipient age was 42.4 (+/- 15.2) years versus 32.6 (+/- 15.3) years HLA-A, -B, and DR-mismatches were 3.16 (+/- 1.3) for the 60+ group and 3.13 (+/- 1.7) for the controls (P = NS). Rejection episodes in the first year following LD did not differ (53% versus 33%, P =.25). Mean serum creatinine for 65+ versus <65 after 1, 3, and 12 months was 1.91 +/- 1.2 versus 1.48 +/- 0.85 mg/dL (P =.16), 1.82 +/- 0.89 versus 1.29 +/- 0.35 mg/dL (P <.05) and 1.80 +/- 0.31 versus 1.37 +/- 0.38 mg/dL (P <.05) and mean creatinine clearance at 12 months 62 versus 82 mL/min (P =.06). Censored 1-, 3-, and 5-year graft survival was 100% versus 95% (P = NS), 100% versus 93% (P = NS) and 100% versus 83% (P = NS) with no significant difference in the log-rank test for Kaplan Meier. CONCLUSION: No impact of donor age was found for graft survival but function of the 65+ kidneys at 3 and 12 months was reduced. Living renal donors 60+ are acceptable for carefully allocated recipients.     

Malignant fibrous histiocytoma of the extremities and trunk: an institutional review

BACKGROUND: Malignant fibrous histiocytoma (MFH) is the most common subtype of soft-tissue sarcoma. Detailed understanding of this tumor type may lead to improved therapeutic strategies. METHODS: An institutional review was performed on all patients with primary MFH of the extremities and trunk operated on between 1988 and 2000. RESULTS: Ninety-seven patients with histologically confirmed MFH (G1, n=8; G2, n=25; G3, n=64) were analyzed. Local recurrence was 31% after a median of 13 months. Distant metastases occurred in 29 patients (30%). After a median follow-up of 4.5 years, 54 patients were alive without evidence of disease; median survival time was 84 months at a cumulative 5-year survival rate of 70%. Tumor size significantly influenced disease-free survival (T2 vs T1, P<.01, risk ratio [RR] 6.0), as did tumor depth (subfascial tumors, P<.01, RR 3.1) and presence of positive lymph nodes (P=.02, RR 6.9). Positive microscopic margins and subfascial tumors were associated with an increased local recurrence rate (RR 4.8, P<.001 and RR 3.5, P=.02, respectively). Significant multivariate risk factors of distant metastases were tumor size, depth, and grade. Though not performed in a randomized fashion, a subgroup analysis indicated that adjuvant radiation therapy significantly reduced local tumor failure. CONCLUSION: We conclude that aggressive, albeit limb-preserving resection of MFH, should be performed at initial operation to minimize risk of local recurrence; a strict follow-up especially of subfascial tumors should be performed.     

Pulmonary metastatic melanoma -- the survival benefit associated with positron emission tomography scanning.

OBJECTIVE: Positron emission tomography (PET) scanning is more sensitive at detecting metastatic disease than conventional radiological techniques. For patients with pulmonary metastatic melanoma, we investigate if PET scanning to detect occult extra pulmonary disease prior to thoracotomy and metastectomy is associated with improved survival compared to patients staged by conventional radiology. METHODS: Between November 1984 and December 1999, 121 patients (90 males, 31 females) have undergone a thoracotomy and pulmonary metastectomy for metastatic melanoma. The age range was 19-84 years (mean 57, median 59). In every case all palpable nodules were removed and the diagnosis confirmed histologically. A total of 68 (56%) patients had a PET scan preoperatively, 53 (44%) underwent conventional or nuclear imaging. Patients with only radiologically isolated pulmonary disease are included. RESULTS: Survival is 100% complete and totals 238 pt/years (mean 2.2 years, median 1.4 years). Survival (+/-SE) at 1, 3, 5 and 7 years for all patients is 68% (+/-4.5) (n=67), 36.6% (+/-5.2) (n=27), 22.1% (+/-4.8) (n=15) and 13.5% (+/-4.2) (n=7), respectively. Survival (+/-SE) was significantly better at 3 and 5 years in patients who underwent a PET scan preoperatively (Log rank P=0.002). There was no significant difference in survival by 7 years. CONCLUSIONS: There is a significant survival benefit associated with excluding extra pulmonary disease using a PET scan prior to thoracotomy and metastectomy. We recommend that PET scanning be used in the investigation of patients with pulmonary metastatic melanoma prior to metastectomy.     

Risk factors for liver metastases after curative surgical procedures for gastric cancer: a prospective study of 208 patients treated with surgical resection

BACKGROUND: The aim of this study was to evaluate the risk of liver metastases after radical surgical treatment for gastric cancer, the potential risk factors involved, and the sensitivity of serum tumor markers during followup. STUDY DESIGN: A total of 208 patients who had undergone curative resection for primary gastric cancer and a prospective followup protocol were studied. The association between clinicopathologic variables and hepatic recurrence was investigated using standard univariate methods and multivariate Cox regression analysis. RESULTS: Mean followup time (+/- SD) for the entire patient population was 51 +/- 38 months (median 52 months) and was 88 +/- 24 months (median 81 months) for disease-free patients. Recurrence of gastric cancer was documented in 109 of 208 patients (52.4%). Liver metastases were found in 28 of 208 patients (13.5%); in most of these patients (82.1%) diagnosis was made within 2 years after surgical treatment. The estimated cumulative risk of liver metastases after 5 years was 16.4%. Cox regression analysis identified lymph node involvement (adjusted relative risk [RR] = 6.28, 95% confidence interval [CI] = 2.11 to 18.70, p = 0.001), preoperative positivity for CEA, CA 19-9, or CA 72-4 (RR = 5.18, 95% CI = 1.75 to 15.37, p = 0.003), and intestinal histotype (RR = 3.08, 95% CI = 1.06 to 8.96, p = 0.039) as independent predictors of hepatic recurrence. In 27 of 28 cases hepatic recurrence was associated with an increase in CEA, CA 19-9, or CA 72-4 serum levels above the cutoff, either before or at the time of the clinical diagnosis (sensitivity 96.4%). CONCLUSIONS: Preoperative positivity for serum tumor markers, lymph node involvement, and intestinal histotype are risk factors for liver metastases after radical surgical treatment for gastric cancer. Postoperative measurement of serum tumor markers may be useful for an early diagnosis of hepatic recurrence during followup.     

Treatment strategy for hepatic metastases of colorectal cancer

Over the past 25 years, 125 patients with colorectal liver metastases underwent 167 hepatectomies in our department. The 1-, 3-, and 5-year survival rates after the initial hepatectomy were 90%, 58%, and 51%, respectively, and those after repeated hepatectomy were 88%, 60%, and 42%, respectively. The predictive factors significantly associated with poor prognosis after initial hepatectomy were maximal diameter of metastasis (> or = 5 cm), distribution pattern in the liver (multiple bilobar), number of nodules (> or = four), and presence of extrahepatic metastases. A disease-free interval of > 6 months after initial hepatectomy was a significant factor for prolongation of survival after repeat hepatectomy. Patients with hilar node metastases at the initial hepatectomy did not receive a survival benefit from hepatectomy, while 5 patients underwent repeat hepatectomy with lymphadenectomy for remnant liver and hilar node metastases with a disease-free interval of > 8 months and 4 of them survived for > 5 years. Our treatment strategies for colorectal hepatic metastases are as follows: 1) hepatectomy is the first choice for < 4 liver metastases without extrahepatic disease; 2) a careful evaluation for liver resection is performed for patients with > or = 4 liver metastases receiving hepatic arterial infusion chemotherapy because of the high frequency of hepatic and/or extrahepatic recurrence after initial hepatectomy; 3) the presence of hilar node metastases at the initial hepatectomy should be excluded from surgical indications; 4) simultaneous single metastasis limited to the lung is an indication for lung resection; and 5) a suitable indication for repeat hepatectomy for hepatic recurrence is patients with a longer disease-free interval. Aggressive surgery based on the optimum patient selection can contribute to clinical benefit, including long-term survival in patients with colorectal liver metastases.     

p53 nuclear accumulation is not associated with decreased disease-free survival in patients with node positive transitional cell carcinoma of the bladder

PURPOSE: Although the majority of patients with node positive transitional cell carcinoma of the bladder have disease progression, a definitive subset is cured by surgery only. Nuclear accumulation of p53 has been associated with disease progression in patients with superficial transitional cell carcinoma and decreased survival in those with muscle invasive disease. We determined whether p53 status would predict survival in a cohort with nodal metastasis. MATERIALS AND METHODS: We explored the comprehensive database of all 199 radical cystectomies performed at our institution between July 1988 and September 1999. The 59 patients in this database with node positive pathology comprise our study. We performed immunohistochemical analysis of specimens using the MAB1801 antibody with greater than 20% lymph node and primary tumor nucleus staining deemed positive. Additional covariates measured included patient age, sex, pathological disease stage, adjuvant chemotherapy and nodal stage. Disease-free survival curves were generated for the various covariates and compared using the log rank test. The Cox proportional hazards technique was used to determine covariate adjusted p53 survival. RESULTS: In the cohort overall median disease-free survival was only 21 months, although 18% of patients were disease-free at 5 years. There was evidence of p53 nuclear accumulation in 54% of cases and complete agreement of nodal with bladder p53 nuclear accumulation. No significant baseline differences were noted in the covariates with respect to p53 nuclear accumulation. For stratum specific disease-free survival univariate and multivariate analyses revealed that only pathological stages p0-p2b versus p3-p4 (hazards ratio 2.86, p = 0.03), and nodal stages N2 versus N1 and N3 versus N1 (hazards ratio 3.84, p = 0.01 and hazards ratio 13.3, p = 0.0002, respectively) were significantly associated with prolonged disease-free survival, while p53 nuclear accumulation was not. CONCLUSIONS: Despite credible evidence for p53 nuclear accumulation prognostication in patients with in situ and invasive transitional cell carcinoma, this marker is not predictive of disease-free survival in node positive disease.     

Kidney transplants in African Americans and non-African Americans: equivalent outcomes with living but not deceased donors

BACKGROUND: The outcome differences between ethnic groups after kidney transplantation have led to the characterization of African Americans (AA) as having high immune risk. Several multicenter clinical trials have reported better outcomes when AA receive higher doses of immunosuppression (I/S), suggesting pharmacokinetic (PK) and pharmacodynamic (PD) differences. However, the donor source has not been cited as an risk factor for outcome. METHODS: Patient and graft survival rates of 469 AA were compared with 308 non-African Americans (nAA) who received kidney transplants between January 1, 1995 and December 31, 2002, and were followed-up through December 31, 2003. Gender, age, and I/S protocol were not different between the groups. Based on outcomes, open and laparoscopic donor groups were combined for analysis. Deceased donor kidneys comprised 49% of the AA kidneys but only 32% of the nAA kidneys (P < .000). Kaplan-Meier survival statistics were used for both patient and graft survival. RESULTS: Patient survival rates for AA compared with nAA at 1, 3, 5, and 7 years were not statistically different for living (log rank statistic, 1 df, P = .56) versus deceased donor kidneys (log rank statistic, 1 df, P = .15). Kidney graft survival rates for AA compared with nAA at 1, 3, 5, and 7 years for living donor were similar (log rank statistic, 1 df, P = .493), but significantly different for deceased donor kidneys (log rank statistic, 1 df, P = .026). CONCLUSIONS: The majority of living donation occurred between ethnically similar donor-recipient pairs, whereas deceased donors tended to be nAA. The difference demonstrated by donor source suggests that antigens may be more dissimilar or uniquely different between ethnic groups.     

Impact of triple negative phenotype on breast cancer prognosis

Triple negative (TN) [estrogen receptor (ER), progesterone receptor (PgR)] (ER-/PgR-/Her2/neu-) breast cancer (BC) is an aggressive disease without tumor-specific treatment options. Our objective is to evaluate the relative contribution of combined Her2/neu (Her2) and hormone receptor (HR) status to BC progression. A prospective primary BC cohort of 1550 patients at our institution, stage I-IV, from 1998 to 2003 were categorized by HR and Her2 status into ER+/PgR+/Her2- (HR+/Her2-) (n = 1134), ER+/PgR+/Her2+ [triple positive (TP)] (n = 138), ER-/PgR-/Her2- (TN) (n = 183), and ER-/PgR-/Her2+ (HR-/Her2+) (n = 95). Clinical variables were chart abstracted and vital and disease status updated annually. Log-rank tests and Cox regression analyses were used to assess associations with survival. Patient age ranged from 21 to 88 years and average length of follow-up was 4.24 years. Overall survival at 5 years was 94% (HR+/Her2-), 91% (TP), and 81% (TN and HR-/Her2+) (log rank test = 22.22, p < 0.001). Disease-specific survival at 5 years was 98% (HR+/Her2-), 93% (TP), 88% (TN), and 86% (HR-/Her2+) (log rank test = 25.85, p < 0.001) and 5-year relapse-free survival was 95% (HR+/Her2-), 89% (TP), 84% (TN), and 76% (HR-/Her2+) (log rank test = 20.29, p < 0.001). In a model adjusted for age, race, TNM stage, and treatment using HR+/Her2- patients as the reference group, recurrence risk was 1.98 for TP (95% CI = 1.02 to 3.84), 2.32 for TN (95% CI = 1.32 to 4.08), and 4.25 for HR-/Her2+ patients (95% CI = 2.33, 7.75). A hierarchy of BC phenotypes defined by HR and Her2 status exists with progressively worse disease outcomes by category.     

Patient and technique survival of diabetics on peritoneal dialysis: one-center's experience and review of the literature

BACKGROUND: Diabetes is the leading cause of end-stage renal disease (ESRD). This retrospective study investigated the long-term patient and technique survival and sought to identify the predictors of mortality in diabetic patients receiving PD. METHODS: Patients, aged 17 years or more who commenced home PD between January 31, 1994, and December 31, 2001 were included. Clinical data were available for 358 patients out of 418 total patients who started PD during this period. They were followed until cessation of PD, death, or to January 31, 2003. Survival probabilities were generated according to the Kaplan-Meier method, and multivariate Cox proportional hazards models were used to assess predictors of survival. RESULTS: A total of 358 patients were enrolled in the study. Among them, 139 patients (38.8%) were diabetics. The 1-, 2-, 3- and 5-year patient survival rates were 91%, 76%, 66% and 47% in diabetics and 94%, 89%, 84% and 69% in non-diabetics, respectively. Median actuarial patient survival for diabetic patients (51.8 months; 95% CI 36.0 a 67.5 months) was significantly shorter than that of non-diabetic patients (log rank 14.117, p < 0.001). Death-censored technique survival rates at 1-, 2-, 3- and 5-year were 90%, 83%, 67% and 58% in diabetic, and 94%, 87%, 77% and 70% in non-diabetic patients, respectively. Similar to patient survival, the median technique survival time was significantly shorter for diabetic patients (63.9 months; 95% CI 35.7 - 92.2 months) than that of non-diabetic patients (log rank 4.884, p = 0.027). Multivariate Cox regression analysis showed that advancing age was the only independent predictor of death in the diabetic patients, whereas higher age and wider pulse pressure were associated with mortality in non-diabetic patients. CONCLUSION: Long-term patient and technique survival for diabetic patients on PD seem to be improved compared to our previous report and other studies. The mortality of diabetic patients was predicted predominantly by advancing age. PD remains a viable form of long-term renal replacement therapy for diabetic patients with ESRD.     

The effect of radiosurgery during management of aggressive meningiomas

BACKGROUND: Aggressive (atypical or malignant) meningiomas are difficult tumors to manage. We review the local control and survival rates of patients with aggressive meningiomas after multi-modality therapy that included stereotactic radiosurgery (SRS). METHODS: Thirty patients had SRS for treatment of malignant (n = 12) or atypical (n = 18) meningiomas. There were 17 (57%) males and 13 (43%) females with an average age of 58 years. The mean number of prior surgical resections was two. The median imaging follow-up was 2.3 (0.1-11.4) years; median clinical follow-up was 3.8 (0.25-11.5) years. RESULTS: After SRS, the overall median time until progression of neurologic signs was 48.0 (+/-6.51) months. Median time to neurologic progression was significantly worse for patients treated late after recurrence versus early after craniotomy. Atypical meningiomas had 5- and 10-year overall actuarial survival rates of 59% (+/-13), while malignant meningiomas had 5- and 10-year overall actuarial survival rates of 59% (+/-16) and 0%. These curves were not significantly different from one another. Atypical meningiomas had a 5-year progression-free survival (PFS) of 83% (+/-7%), while malignant meningiomas had a 5-year PFS of 72% (+/-10) (p = 0.018). On multivariate analysis, early SRS and smaller tumor volumes were associated with better PFS, while younger age was associated with better survival. One patient had an adverse radiation effect after SRS. CONCLUSIONS: Stereotactic radiosurgery is an important adjuvant management strategy for residual tumors identified early after craniotomy and partial resection. Aggressive use of early boost radiosurgery following craniotomy and radiation therapy is recommended for patients with malignant meningiomas.     

Transrectal high-intensity focused ultrasound in the treatment of localized prostate cancer: a multicenter study

We report a multicenter trial with transrectal high-intensity focused ultrasound (HIFU) in the treatment of localized prostate cancer. A total of 72 consecutive patients with stage T1c-2NOM0 prostate cancer were treated using the Sonablate 500TM HIFU device (Focus Surgery, Indianapolis, USA). Biochemical recurrence was defined according to the criteria recommended by the American Society for Therapeutic Radiology and Oncology Consensus Panel. The median age and prostate specific antigen (PSA) level were 72 years and 8.10 ng/ml, respectively. The median follow-up period for all patients was 14.0 months. Biochemical disease-free survival rates in all patients at 1 and 2 years were 78% and 76%, respectively. Biochemical disease-free survival rates in patients with stage T1c, T2a and T2b groups at 2 years were 89, 67% and 40% (p = 0.0817). Biochemical disease-free survival rates in patients with Gleason scores of 2-4, 5-7 and 8-10 at 2 years were 88, 72% and 80% (p = 0.6539). Biochemical disease-free survival rates in patients with serum PSA of less than 10 ng/ml and 10-20 ng/ml were 75% and 78% (p = 0.6152). No viable tumor cells were noted in 68% of patients by postoperative prostate needle biopsy. Prostatic volume was decreased from 24.2 ml to 14.0 ml at 6 months after HIFU (p < 0.01). No statistically significant differences were noted in International Prostate Symptom Score, maximum urinary flow rate and quality of life analysis with Functional Assessment of Cancer Therapy. HIFU therapy appears to be minimally invasive, efficacious and safe for patients with localized prostate cancer with pretreatment PSA levels less than 20 ng/ml.     

Kidney graft survival in Italy and factors influencing it

PURPOSE: National registry data are often a suitable basis for examination of transplant outcomes. Using data supplied by the Italian National Transplant Registry, established in 1995, we performed the first nationwide analysis of this kind. METHODS: A retrospective analysis of 4893 recipients of cadaveric kidneys transplanted in all Italian centers from 1995 through 2000 was done to study 5-year graft survival. The association between some donor and recipient variables and outcomes in renal transplantation was analyzed. Graft survival was 93% at 3 months, 89% at 1 year, 82% at 3 years, and 80% at 5 years after transplantation. RESULTS: A significant association between graft survival and donor age (old vs young, relative risk [RR] = 1.62, 95% CI 1.27-2.06) and recipient age (old vs young, RR = 1.25, 95% CI 1.02-1.53). Graft survival was also associated with cold ischemia time (24-36 hours, RR= 1.39, 95% CI 1.05-1.85 and >36 hours, RR= 1.94, 95% CI 1.32-2.86 vs 0-24 hours) and donor/recipient sex mismatch (female/male vs male/male, RR= 1.50, 95% CI 1.17-1.93). CONCLUSION: The quality of kidney transplantation in Italy is satisfactory and is comparable to that in other developed countries. Furthermore, our experience confirms that both donor and recipient factors are major determinants of renal allograft function.