Surgical challenges associated with intensive treatment protocols for high-risk neuroblastoma

Background

High-risk neuroblastoma (NB; age, >1 year; INSS stage 4) is associated with a poor outcome. At our institution, the current dose-intensive high-risk Children's Oncology Group protocol for advanced NB appears to have a higher surgical complication rate as compared with previous protocols.

Methods

All stage 4 patients (n = 51) entered in high-risk protocols between 1995 and 2005 were analyzed. Patients in the current high-risk protocol, Children's Oncology Group A3973 (n = 22), were compared with those in the 2 previous protocols, CCG 3891 and POG 9341 (n = 29).

Results

Patients were comparable in their mean age and tumor markers, including Shimada histology, MYCN amplification, 1p deletion, tumor origin, and extent of metastasis. However, transfusion requirement (86% vs 45%; P = .0019), postoperative infection rate (32% vs 3%; P = .02), and other postoperative issues including nutritional support (45% vs 3%; P = .0001) were significantly higher with the current protocol. No perioperative mortality was noted in either group, and the extent of resectability and margins were similar. Importantly, with the current protocol, the survival rate was higher (P = .0022) and the recurrence rate was significantly lower (P = .0003).

Conclusions

Despite higher surgical morbidity associated with the current high-risk protocol (2.59 vs 0.86 complications/person; P < .01), the recurrence rate is lower and interim survival rate is improved for patients with high-risk NB. Therefore, the higher surgical complication rates associated with the current high-risk protocol are acceptable.     

Implications of MYCN amplification in patients with stage 4 neuroblastoma who undergo intensive chemotherapy

Background/Purpose

This study aims to clarify the implications of MYCN amplification in patients with high-risk neuroblastomas treated with 2 different regimens of induction chemotherapy established by the Japan Study Group for Advanced Neuroblastoma.

Methods

Between 1985 and 2003 in Japan, 392 patients with stage 4 neuroblastomas who were older than 12 months were treated with 2 regimens of induction chemotherapy (the combination of cyclophosphamide [CTX], cisplatin [CDDP], pirarubicin, and vincristine or etoposide). Regimen 91A3 or 98A3 (A3) (CTX 2400 mg/m², CDDP 125 mg/m²) was a higher dose combination of CTX and CDDP than regimen 85A1 or 91A1 (A1) (CTX 1200 mg/m², CDDP 90 mg/m²). The 392 cases were classified into 3 groups (A, 1 copy; B, 2-9 copies; C, more than 10 copies) based on the MYCN amplification status by a Southern blot analysis.

Results

The 5-year overall survival rate (5-YS) was 41.1% for all 392 cases. Regarding the MYCN amplification status, the 5-YS was 46.6% for A group (n = 227), 22.7% for B group (n = 26), and 36.0% for C group (n = 139). A flouresence in situ hybridization analysis showed the presence of the cells with more than 10 copies in cases with 2 to 9 copies based on the Southern blot findings. Of the 227 patients in a group, the 5-YS was 46.7% for the 70 cases treated by A3 and 47.0% for 154 cases treated by A1 (nonsignificant). The 5-YS of the 210 patients with stem cell transplantation (SCT) (51.%) was significantly better than that of the 127 patients without SCT (41.1%) (P < .05).

Conclusions

Regarding the MYCN amplification status, the tumor aggressiveness might thus be different between 2 and 9 copies and a single copy of MYCN. In neuroblastomas with 2 and 9 copies of MYCN based on a Southern blot analysis, the MYCN amplification status should be analyzed using the flouresence in situ hybridization method. Induction chemotherapy followed by SCT according to the Japan Study Group for Advanced Neuroblastoma protocol improved the outcome of neuroblastomas with MYCN amplification; however, obtaining a further improvement in the long-term survival of stage 4 neuroblastomas may therefore require the development of an even more effective treatment modality.     

Efficacy of complete resection for high-risk neuroblastoma: a Children's Cancer Group study

Background/purpose

Previous reports indicate that complete resection of high-risk neuroblastoma improves outcome but may entail high surgical complication rates. The authors evaluated the effect of complete primary site resection on event-free survival (EFS), overall survival (OS), and complication rates in patients entered on a high-risk neuroblastoma treatment protocol.

Methods

A total of 539 eligible patients with high-risk neuroblastoma were entered on protocol CCG-3891. Patients were assigned randomly to continuation chemotherapy or autologous bone marrow transplantation. Surgical resection was performed at diagnosis or after induction chemotherapy. Surgeons assessed resection as complete (CR), minimal residual (<5%, MR), or partial (PR). Incomplete resections received secondary resection or 10 Gy of external beam radiation. Patients were evaluated for EFS, OS, and complications of surgery based on completeness of overall best resection.

Results

The proportion of patients resectable at diagnosis was 27% for CR and 14% for MR. This improved after chemotherapy to 45% and 25%. Complication rates based on completeness of resection were 29%, 38%, and 36% for CR, MR, and PR, respectively. Estimated 5-year EFS rate was 30% ± 3% for patients who achieved CR (n = 210) compared with 25% ± 3% (P = .1010) for those with less than CR (n = 258).

Conclusions

Resectability improved after neoadjuvant chemotherapy. Complete resection did not increase complications. There was a small survival benefit for complete resection. This study suggests that complete resection may still be important in the current era of intense chemotherapy and transplant.     

Clinicopathologic characteristics and prognosis of synchronous multifocal gastric carcinomas

Background

We sought to define differences between multifocal and solitary gastric carcinoma to decrease the risk of missing a cancer while resecting another more evident carcinoma.

Methods

We retrospectively examined clinicopathologic characteristics of multifocal gastric carcinoma including anatomic distribution and postoperative survival.

Results

Multifocal gastric carcinoma was seen more frequently when patients were older and when the largest tumor was small and at an early stage. More than half of accessory lesions were located near the main tumor. No significant difference in postoperative survival was seen between patients with multifocal and solitary carcinoma, whether early or advanced.

Conclusions

The entire stomach should be examined carefully before and during resection, especially when local or endoscopic surgery is performed.     

Impact of Donor Age on Renal Allograft Function and Survival

Background

The lack of cadaveric donors coupled with a rapidly growing number of potential recipients have stimulated the implementation of several strategies, including the acceptance of older donors, to increase the organ pool and reduce the waiting list for kidney transplantation. However several studies have demonstrated higher incidences of delayed graft function and poor graft outcomes among kidneys harvested from older donors.

Objective

The objective of this study was to evaluate the influence of donor age on the function and long-term survival of renal allografts.

Patients

We performed a retrospective review of the clinical data from 441 adult kidney transplantation from cadaveric heart-beating donors performed in our unit from May 1989 to May 2007.

Results

Recipients of kidney allografts from older donors were significantly older (49.2 vs 43.7 years; P < .0001) and had a higher incidence of delayed graft function (15.1% vs 5.4%; P = .005). Renal function was superior following kidney transplantation using younger donors not only at 3 months (P < .0001) and 12 months (P < .0001) posttransplantation, but also upon long-term follow-up at 60 months (P < .0001) and 96 months (P = .030). Allograft survival censored for death with a functioning graft and patient survival were not different when comparing older versus younger donors. Multivariate analysis confirmed the lack of correlation between donor age and allograft failure.

Conclusion

Donor age showed no influence on allograft survival. However, kidney allografts from older donors displayed lower first year and long-term renal function.     

Identifying the best candidate for radical prostatectomy among patients with high-risk prostate cancer

Background

The current role of radical prostatectomy (RP) in patients with high-risk disease remains controversial.

Objective

To identify which high-risk prostate cancer (PCa) patients might have favorable pathologic outcomes when surgically treated.

Design, setting, and participants

We evaluated 1366 patients with high-risk PCa (ie, at least one of the following risk factors: prostate-specific antigen [PSA] >20 ng/ml, cT3, biopsy Gleason 8-10) treated with RP and pelvic lymph node dissection (PLND) at eight European centers between 1987 and 2009. A favorable pathologic outcome was defined as specimen-confined (SC) disease—namely, pT2-pT3a, node negative PCa with negative surgical margins.

Intervention

All patients underwent radical retropubic prostatectomy and PLND.

Measurements

Univariable and multivariable logistic regression models tested the association between predictors and SC disease. A logistic regression coefficient-based nomogram was developed and internally validated using 200 bootstrap resamples. The Kaplan-Meier method was used to depict biochemical recurrence (BCR) and cancer-specific survival (CSS) rates.

Results and limitations

Overall, 505 of 1366 patients (37%) had SC disease at RP. All preoperative variables (ie, age and PSA at surgery, clinical stage, and biopsy Gleason sum) were independent predictors of SC PCa at RP (all p ≤ 0.04). Patients with SC disease had significantly higher 10-yr BCR-free survival and CSS rates than patients without SC disease at RP (66% vs 47% and 98 vs 88%, respectively; all p < 0.001). A nomogram including PSA, age, clinical stage, and biopsy Gleason sum demonstrated 72% accuracy in predicting SC PCa. This study is limited by its retrospective design and by the lack of an external validation of the nomogram.

Conclusions

Roughly 40% of patients with high-risk PCa have SC disease at final pathology. These patients showed excellent long-term outcomes when surgically treated, thus representing the ideal candidates for RP as the primary treatment for PCa. Prediction of such patients is possible using a nomogram based on routinely available clinical parameters.     

Laparoscopic versus open reduction of intussusception in children: a single-institution comparative experience

Background

The role of laparoscopic surgery in treating intussusception has been controversial. This study reviews our institution's experience with the laparoscopic approach (LAP) compared to the open surgical approach (OPEN).

Methods

Retrospective analysis of all patients undergoing surgery for intussusception at our center from January 2002 to February 2006. Statistical assessment included Student's t test and χ² analysis.

Results

A total of 41 patients required operation for intussusception (18 LAP, 23 OPEN). Mean age was 22 months for LAP and 11 months for OPEN (P = .17). In the LAP group, 28% (5/18) were converted to an open procedure. Operative times and complications were not significantly different. Pathologic lead points were found in 33% (6/18) LAP and 35% (8/23) OPEN patients (P = 1.0). Time to full feeds was significantly shorter (LAP vs OPEN: 3.4 ± 2.7 vs 5.6 ± 3.4 days, P = .02). Length of stay was shorter (LAP vs OPEN: 4.8 ± 3.5 vs 9.1 ± 7.5 days, P = .03).

Conclusions

Intussusception can be treated safely and effectively using a LAP with a significant decrease in time to full feeds and length of stay. The LAP should be considered as the initial approach for stable patients with intussusception requiring operative intervention.     

Oncologic outcomes after resection of rectal cancer: Laparoscopic versus open approach

Background

This study examined outcomes of laparoscopic and open rectal cancer surgery in a community hospital setting.

Methods

A community health care system cancer registry was reviewed retrospectively (2004-2007) for rectal cancer patients undergoing surgical treatment. Primary end points were rates of recurrence and survival.

Results

Both open and laparoscopic resection groups had similar demographic, treatment, and tumor characteristics. Most patients in the open resection and laparoscopic resection populations experienced no recurrence (79% vs 83%, respectively; P = .5). Overall, the groups had similar mean (88% vs 96%, respectively; P = .4) and disease-free (21 and 23 months, respectively; P = .5) survival.

Conclusions

In a community hospital setting, laparoscopic resection of rectal cancer was found to be as safe and effective as open resection in selected patients.     

Routine adrenalectomy in patients with locally advanced renal cell cancer does not offer oncologic benefit and places a significant portion of patients at risk for an asynchronous metastasis in a solitary adrenal gland

Background

The indications for the removal of the ipsilateral adrenal gland in patients with renal cell carcinoma (RCC) and the long-term outcomes have not been well studied.

Objective

We evaluated the risk of synchronous and asynchronous adrenal involvement in patients with RCC and the effect of adrenalectomy on recurrence and survival in a large, single-institution cohort.

Design, setting, and participants

From 1970 to 2006, 4018 consecutive patients with RCC treated by surgical extirpation (radical nephrectomy [RN]: 3107; partial nephrectomy [PN]: 911) from Mayo Clinic were studied for adrenal involvement. Risk of asynchronous adrenal metastasis and cancer-specific survival (CSS) were also compared between those who underwent concomitant ipsilateral adrenalectomy (n = 1541) and those who did not (n = 2477) using multivariate Cox models.

Intervention

Surgical removal of the adrenal gland at the time of kidney tumor resection.

Measurements

Primary outcome is cancer specific survival; secondary outcomes are incidence of synchronous and asynchronous adrenal metastases.

Results and limitations

Median postoperative follow-up among those still alive was 8.2 yr (interquartile range [IQR]: 5.3-13.6). Synchronous ipsilateral adrenal involvement was rare (n = 88; 2.2%). Ipsilateral adrenalectomy at the time of nephrectomy did not lower the risk of subsequent adrenal metastasis (hazard ratio [HR]: 0.96; 95% confidence interval [CI], 0.64-1.42) or improve CSS (HR: 1.08; 95% CI, 0.95-1.22). The development of asynchronous adrenal metastasis occurred in 147 patients (3.7%) at a median of 3.7 yr (IQR: 1.2-7.7) after initial surgery. The risk of developing an ipsilateral versus a contralateral asynchronous adrenal metastasis was equivalent at 10 yr in those who did not undergo adrenalectomy at initial surgery. This study is limited by its single-institution, nonrandomized nature.

Conclusions

Routine ipsilateral adrenalectomy in patients with high-risk features does not appear to offer any oncologic benefit while placing a significant portion of patients at risk for metastasis in a solitary adrenal gland. Therefore, adrenalectomy should only be performed with radiographic or intraoperative evidence of adrenal involvement.     

The clinical significance of human leukocyte antigen antibody development in kidney transplantation

Background

This retrospective study uses the LAT-M (One Lambda Inc., Calif) screen assay to reexamine the impacts (a), of pretransplant human leukocyte antigen (HLA) antibody on long-term graft survival; (b) posttransplant HLA antibody on long-term graft survival and (c) immunosuppressive regimen on posttransplant HLA antibody development.

Patients and methods

Pretransplant sera from 222 renal transplant recipients and posttransplant sera from 216 renal transplant recipients were studied for the impact of HLA antibody on long-term graft survival.

Results

Among the patients who did not display pretransplant HLA antibodies, 85% enjoyed 5-year and 59% 10-year graft survival, whereas the patients who tested positive were 83% and 83% (P = .5596). Among the patients who did not show posttransplant HLA antibodies, 99% enjoyed 5-, 91% 10-, and 65% 15-year graft survival, whereas for the 44 patients who tested positive they were 59%, 44%, and 30%, respectively (P < .0001). Patients prescribed cyclosporine + myfortic (odds ratio 0.17, P = .05) or FK + Cellcept (odds ratio 0.36, P = .04) showed the lowest posttransplant HLA antibody development.

Conclusion

Both regimens improve graft survival.     

Primary surgery for oropharyngeal cancer

Objective

The development of new techniques for transoral resection has led to a renewed interest in primary surgical treatment of oropharyngeal squamous cell cancer (SCCA). We reviewed our experience with primary surgery for oropharyngeal SCCA to identify factors associated with survival.

Study Design

Case series with chart review.

Setting

Tertiary medical center.

Subjects and Methods

Patients who underwent primary surgical treatment of oropharyngeal SCCA from 1985 to 2002 were analyzed. Patients who failed nonoperative treatment or had distant metastases at presentation were excluded.

Results

A total of 105 patients met study criteria. The majority of patients (91%) had advanced stage disease (III/IV). All patients received postoperative radiation; chemotherapy was used in eight patients. Five-year disease-free survival was 83 percent for stage I, 67 percent for stage II, 56 percent for stage III, and 43 percent for stage IV disease. Crude local control rates were 94 percent for T1 disease, 90 percent for T2 disease, 81 percent for T3 disease, and 80 percent for T4 disease; crude regional control rates were 100 percent for N0 disease, 90 percent for N1 disease, 84 percent for N2 disease, and 82 percent for N3 disease. Cox proportional hazards models revealed that nodal stage (hazard ratio [HR] 2.3, P = 0.02) and black race (HR 2.6, P = 0.004) were the only significant predictors of disease-free survival.

Conclusion

Primary surgical treatment of oropharyngeal SCCA is effective in achieving excellent locoregional control and permits deintensification of adjuvant therapy, even in patients with advanced stage disease. Nodal status and race are the primary determinants of disease-free survival. These data provide useful information for counseling and treatment planning.     

The impact of gross total resection on local control and survival in high-risk neuroblastoma

Background/purpose

Gross total resection of the primary tumor in treatment of high-risk neuroblastoma remains controversial. Furthermore, there are few reports of the effect of primary tumor resection on local control as opposed to overall survival. The authors reviewed their institutional experience to assess the effect of primary tumor resection on local control and overall survival.

Methods

A total of 141 patients were treated on protocol between November 1, 1979 and June 25, 2002 and are the subject of this report. Gross total resection was assessed by review of operative notes, postoperative computerized axial tomograms, and postoperative meta-iodobenzyl guanidine (MIBG)¹ scans when available.

Results

The median age was 3.3 years, and all patients were International Neuroblastoma Staging System (INSS) stage 4 with 79% having metastases to cortical bone. The primary site was the adrenal gland in 74%, the central abdominal compartment in 13%, the posterior mediastinum in 7%, and other sites in 6%. Gross total resection was accomplished in 103 (73%) but was more than 90% for the last 3 protocols. Five kidneys were lost overall. The probability of local progression was 50% in unresected patients compared with 10% in patients undergoing gross total resection (P < .01). Overall survival rate in resected patients was 50% compared with 11% in unresected patients (P < .01).

Conclusions

Our data indicate that local control and overall survival rate are correlated with gross total resection of the primary tumor in high-risk neuroblastoma. Gross total resection should be part of the management of stage 4 neuroblastoma in patients greater than 1 year of age.     

Long-term cancer-specific survival in patients with high-risk, non-muscle-invasive bladder cancer and tumour progression: a systematic review

Context

Some studies report that tumour progression in patients with non-muscle-invasive bladder cancer (NMIBC) is associated with a poor prognosis. However, no systematic evidence is available.

Objective

The aim of the study was to systematically review literature to determine the long-term cancer-specific survival in patients with high-risk NMIBC (T1G3, multifocal, highly recurrent, or carcinoma in situ) having tumour progression.

Evidence acquisition

A systematic review was conducted by searching PubMed and the Cochrane library for studies published between 2006 and 2011. Additional studies were identified by scanning reference lists of relevant papers. We attempted to retrieve missing data by contacting the corresponding author. Keywords used included bladder cancer, high-risk, high grade, carcinoma in situ, non-muscle invasive bladder cancer, progression, and survival. Studies were included when they met the following criteria: inclusion of at least 75 patients having high-risk NMIBC, patients were initially treated conservatively with transurethral resection of the bladder tumour and intravesical instillations, a median follow-up of at least 48 mo, and reporting data on progression to muscle-invasive bladder cancer (MIBC) and death resulting from bladder cancer (BCa).

Evidence synthesis

Literature was systematically reviewed, and 19 trials were included, producing a total of 3088 patients, of which 659 (21%) showed progression to MIBC and 428 (14%) died as a result of BCa after a median follow-up of 48-123 mo. Survival after progression from high-risk NMIBC to MIBC was 35%. Progression to MIBC and BCa-related death in high-risk NMIBC were found to be relatively early events, occurring mainly within 48 mo. Finally, even in cases of early cystectomy in patients with high-risk NMIBC, a relevant proportion of these patients appear not be cured of their disease.

Conclusions

This study provides systematically gathered evidence showing a poor prognosis for patients with high-risk NMIBC and tumour progression.     

Resectability and operative morbidity after chemotherapy in neuroblastoma patients with encasement of major visceral arteries

Background/Purpose

Image-defined vessel encasement is a significant risk factor for surgical complications and incomplete resection for intermediate-risk tumors. We sought to examine the impact of vessel encasement on complications or resectability in intermediate-risk or high-risk patients after neoadjuvant chemotherapy.

Methods

We retrospectively reviewed 207 consecutive patients with circumferential encasement of the renal vessels, celiac axis, and/or superior mesenteric artery (SMA) who underwent resection between 1991 and 2009. Specifically, we evaluated resection rates, complications, and outcome.

Results

Median age at diagnosis was 3.0 years, and 79% of patients had stage 4 disease. Of known MYCN status, 23.4% had MYCN amplification. Vessel encasement included renal vessels, celiac axis, or SMA alone in 107, 7, and 4 patients, respectively. Both the renal vessels and celiac axis were encased in 5 patients, renal vessels and SMA in 7 patients, and celiac axis and SMA in 14 patients. Sixty-three patients had all 3 vessels encased. The gross total resection (GTR) rate was 94%. No operative or postoperative deaths occurred. The overall complication rate was 34.8% (n = 72). Overall 5-year survival (±SEM) was 67.4% (±7.4%).

Conclusion

Encasement of major visceral arteries in patients with neuroblastoma who have received chemotherapy does not preclude gross total resection.     

Periprocedural complications by Child-Pugh class in patients undergoing transcatheter arterial embolization or chemoembolization to treat unresectable hepatocellular carcinoma at a VA medical center

Background

For patients with compensated cirrhosis, transcatheter arterial embolization with and without additive chemotherapy has been shown to improve survival. The aim of this study was to compare periprocedural complications in a population with hepatitis C virus-related hepatocellular carcinoma to evaluate for differences in complications by severity of liver disease.

Methods

Patients with unresectable hepatocellular carcinoma treated by transcatheter arterial embolization with or without additive chemotherapy procedures from 2003 to 2006 were retrospectively reviewed and compared by Child-Pugh (CP) class. A total of 141 embolizations were done in 76 patients.

Results

Complication rates were seen in 27% of CP class A and 17% of CP class B patients. There was no significant difference in the grade of complications between the 2 groups or between procedure types. Survival rate was dependent on the degree of liver dysfunction (3-year CP class A, 49%; CP class B, 13%; P = .0048).

Conclusion

Embolization procedures to treat hepatitis C virus-related hepatocellular carcinoma can be performed safely with low morbidity and mortality rates, even in patients with a compromised hepatic reserve.     

Why Not to Use Kidney Grafts From Elderly Donors

Background

Kidney transplantation is widely recognized as the best treatment in patients who require renal replacement therapy. Although considered a clinical and surgical triumph, it is also a source of frustration because of lack of donor organs and the growth of waiting lists. Strategies need to be developed to increase the supply of organs. One measure is use of expanded criteria for donation.

Objective

To evaluate the effect of donor age on cadaver graft survival.

Materials and Methods

We reviewed the medical records for 454 patients who underwent kidney transplantation with cadaver donors from April 1987 to December 2003.

Results

Donor age had a significant effect on kidney transplant survival. Survival of grafts from donors aged 16 to 40 years (mean, 143.30 months) was significantly greater compared with that of grafts from donors older than 40 years (66.46 months) (P = .005). The HLA matching and cold ischemia time did not significantly affect transplant survival (P = .98 and P = .16, respectively).

Conclusions

Kidneys from cadaver donors older than 40 years significantly compromised graft survival, generating a negative effect via early return of recipients to waiting lists and increasing the rate of repeat transplantation, risk of death, and unnecessary costs.     

Prevalence of the Metabolic Syndrome in Kidney Transplantation

Objectives

We investigated the prevalence of the metabolic syndrome (MS) in kidney transplantation patients and assessed its development based on plasma adiponectin levels and the results of an oral glucose tolerance test (OGTT).

Methods

We performed a cross-sectional study of 94 recipients with stable graft function who underwent kidney transplantation between January 1999 and October 2008. The presence of MS was determined using National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) criteria with body mass index (BMI) used in place of waist circumference. In addition, we measured plasma adiponectin level and performed a 75-g oral GTT.

Results

Fourteen (14.9 %) recipients suffered from MS for a mean period of 46.7 months (range, 1-106) after transplantation. BMI at the time of transplantation was significantly greater in the MS group (23.4 ± 3.24 vs 20.1 ± 2.50; P < .0001), whereas plasma adiponectin level was significantly lower (11.95 ± 5.13 vs 17.71 ± 8.47; P = .0158). The insulinogenic index values were similar, whereas the homeostatic model assessment of insulin resistance was greater in the MS group (2.598 ± 1.918 vs 1.340 ± 0.934; P = .0002).

Conclusion

The level of adiponectin, which was lower in kidney transplant recipients who developed MS, was negatively correlated with insulin sensitivity. We concluded that a low adiponectin level may correlate with the prevalence of MS in kidney transplantation in association with impaired insulin sensitivity.     

Influence of early graft function after renal transplantation and its impact on long-term graft and patient survival

Objective

To determine whether early graft function after transplantation impacted graft and patient survivals.

Materials and methods

Between 1981 and 2008, we performed 1308 renal transplantations. Poor early graft function was defined as a Cockroft-Gault glomerular filtration rate < 60 mL/min or less at 1 and 3 months posttransplant. Patients who lost their kidney or died within the first 12 months after transplantation were excluded from the study. Multivariate statistical analysis used Cox proportional hazards models.

Results

Of the 1308 patients 994 (78.8%) displayed poor early graft function at 1 month after transplantation (glomerular filtration rate < 60 mL/min), while 268 (21.2%) showed normal function (glomerular filtration rate ≥ 60 mL/min). The 2- and 6-year graft survival rates among the poor early graft function group were 96.8% and 85.8%, respectively, while those among the control group were 97.0% and 88.3%, respectively. The 2- and 6-year patient survival rates in the poor early graft function were 98.5% and 89.8% versus 98.9% and 96.3% in the control group. Similar results were observed at 3 months posttransplant. Controlling for patient age, donor age, HLA-AB and -DR mismatches, cold ischemia time, acute rejection episodes, cyclosporine therapy, and waiting time for transplantation, we did not observe early graft function to be a risk factor for graft survival or patient survival. Glomerular filtration rate at 2, 5, and 6 years after kidney transplantation was significantly lower in the poor early graft function than in the control group.

Conclusion

This study suggested that the quality of early graft function had no significant effect on graft and patient survival rate, but did have a significant influence on long-term renal function.     

Neoplasias de páncreas y periampulares: morbimortalidad, resultados funcionales y supervivencia a largo plazo

Aims

To evaluate postoperative morbidity and mortality, pancreatic function and long-term survival in patients with surgically treated pancreatic or periampullar tumours.

Patients and methods

Cohort study including 160 patients consecutively operated on: 80 pancreaticoduodenectomies (PD), 30 distal pancreatectomies (DP), 7 total pancreatectomies, 4 central pancreatic resections and 3 ampullectomies. The tumour was not resected in 36 patients. Pancreatic function was evaluated by oral glucose tolerance test, faecal fat excretion and elastase.

Results

Resectability rate was 77.5%. In resected patients (n=124), 38.7% had complications with a pancreatic fistula rate of 6.4% and a mortality rate of 4%. In PD, endocrine function worsened in 41% and 58.6% had steatorrhoea; these figures in DP were 53.6% and 21.7% respectively. In the 36 non-resected patients, postoperative morbidity was 27.7% and mortality 8.3%. Two and five-year survival rates in resected patients with pancreatic cancer were 42% and 9% respectively; in malignant ampulloma 71% and 53%; in mucinous adenocarcinomas 83% and 33%; in duodenal adenocarcinoma 100% and 75%; and in distal cholangiocarcinoma 50% and 50%.

Conclusions

Morbidity associated with resective pancreatic surgery is still high, but perioperative mortality is low. Endocrine and exocrine disturbances are very common depending on the type of resection. Despite the associated morbidity and functional disorders, surgery provides long-term survival in selected cases.     

Objective measures of renal mass anatomic complexity predict rates of major complications following partial nephrectomy

Background

The association between tumor complexity and postoperative complications after partial nephrectomy (PN) has not been well characterized.

Objective

We evaluated whether increasing renal tumor complexity, quantitated by nephrometry score (NS), is associated with increased complication rates following PN using the Clavien-Dindo classification system (CCS).

Design, setting, and participants

We queried our prospectively maintained kidney cancer database for patients undergoing PN from 2007 to 2010 for whom NS was available.

Interventions

All patients underwent PN.

Measurements

Tumors were categorized into low- (NS: 4-6), moderate- (NS: 7-9), and high-complexity (NS: 10-12) lesions. Complication rates within 30 d were graded (CCS: I-5), stratified as minor (CCS: I or 2) or major (CCS: 3-5), and compared between groups.

Results and limitations

A total of 390 patients (mean age: 58.0 ± 11.9 yr; 66.9% male) undergoing PN (44.6% open, 55.4% robotic) for low- (28%), moderate- (55.6%), and high-complexity (16.4%) tumors (mean tumor size: 3.74 ± 2.4 cm; median: 3.2 cm) from 2007 to 2010 were identified. Tumor size, estimated blood loss, and ischemia time all significantly differed (p < 0.0001) between groups; patient age, body mass index (BMI), and operative time were comparable. When stratified by CCS, minor and major complication rates for all patients were 26.7% and 11.5%, respectively. Minor complication rates were comparable (26.6 vs 24.9 vs 32.8%; p = 0.45), whereas major complication rates differed (6.4 vs 11.1 vs 21.9%; p = 0.009) among tumor complexity groups. Controlling for age, gender, BMI, type of surgical approach, operative duration, and tumor complexity, prolonged operative time (odds ratio [OR]: 1.01; confidence interval [CI], 1.0-1.02) and high tumor complexity (OR: 5.4; CI, 1.2-24.2) were associated with the postoperative development of a major complication. Lack of external validation is a limitation of this study.

Conclusions

Increasing tumor complexity is associated with the development of major complications after PN. This association should be validated externally and integrated into the decision-making process when counseling patients with complex renal tumors.