The incidence and surgical management of paratubal cysts in a pediatric and adolescent population

Purpose

The aim of this study is to determine the incidence of paratubal cysts (PTCs) in a pediatric and adolescent population.

Methods

An institutional review board-approved retrospective chart review was performed between the years of 1998 and 2008 at a single children's hospital. Inclusion criteria were met if pathology reports demonstrated diagnosis of PTC, hydrosalpinx, or hydatid of morgagni.

Results

One hundred ten patients had confirmed diagnoses of hydatid of morgagni, hydrosalpinx, or PTC. The incidence of PTCs was 7.3%. Mean age of PTC diagnosis was 13.7 ± 2.82 years, with 12.6% diagnosed premenarchal. Mean age menarche was 11.7 ± 1.34 years among pubertal females. The age of menarche and diagnosis of PTC correlated (Pearson, 0.54) (P < .0001). There was a small correlation between body mass index and size of PTC (r = 0.36; P ≤ .001).

Conclusion

The incidence of PTCs was 7.3% in this pediatric and adolescent population. In addition, this is the first study to confirm presence of PTCs in prepubertal females. Surgeon should be aware of these benign cysts because they are frequently a source of abdominal pain in young girls. As nonphysiologic cysts, these will not resolve spontaneously and may increase in size and/or be at risk for adnexal torsion. Ultimately, surgical management is required for definitive resolution.     

Adjuvant oral etoposide plus cisplatin (EoP) following sequential doxorubicin/cyclophosphamide (AC) and docetaxel (T) in early breast cancer patients with 4 or more positive lymph nodes (10 years follow-up)

Background and objectives

Previous reports suggest that including cisplatin plus etoposide in the adjuvant treatment may improve the outcomes in patients with early breast cancer.

Patients and Methods

Forty-one patients with early breast cancer and 4 or more positive lymph nodes were treated with 3 cycles of EoP (oral etoposide plus cisplatin) in addition to 3 cycles of AC (doxorubicin plus cyclophosphamide) and 3 cycles of T (docetaxel) (Group 1). Toxicity and survival results were compared to those with similar disease characteristics who were treated with 4 cycles of AC plus 4 cycles of T (Group 2) during the same period.

Results

There were no long-term side effects related to EoP. While median disease-free and overall survivals were not reached in Group 1, they were 107 ± 13 (p = 0.387) months and 123 ± 5 months (p = 0.618) in Group 2. Likewise 10-year disease-free survivals (DFS) were 59.3% and 44.7% respectively.

Conclusions

The trend towards improvement in survival with adjuvant AC + T + EoP when compared to AC + T needs to be studied in randomized trial.     

The validity of complex breast cysts after surgery

Background

Breast cysts are the most common cause of benign breast masses. Simple breast cysts do not need further evaluation, but complex breast cysts require additional assessment due to the potential presence of malignancy. However, these complex cysts have rarely been examined and quantified according to the associated cancer detection rate. Our study is the first investigation to evaluate the malignancy rate of complex breast cysts identified by histopathological results.

Methods

Imaging findings of complex cysts were correlated retrospectively with clinical and pathologic outcomes. We detected a malignancy rate of 14%. Sonographic criteria of a complex cyst such as thick cyst wall (P = .0006), lobulation (P = .01), and hyperechogenicity (P = .04) were predictive of neoplasm. Two or more criteria combined were associated with a 13.6-fold higher risk of malignancy (P <.0001).

Conclusion

Based on our results we reinforce the importance of adequate assessment of complex breast cysts to prevent a missed or delayed diagnosis of malignancy.     

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.     

Prediction of progression-free survival rates after bevacizumab plus interferon versus interferon alone in patients with metastatic renal cell carcinoma: comparison of a nomogram to the Motzer criteria

Background

The combination of bevacizumab plus interferon (BEV + IFN) for treatment of metastatic renal cell carcinoma (mRCC) is associated with improved progression-free survival (PFS) in a phase 3 study.

Objective

To develop a novel model for prediction of individual PFS using data from the randomized, controlled phase 3 trial of BEV + IFN or interferon alone. The ability of the Motzer criteria for prediction of PFS was also assessed.

Design, setting, and participants

Pretreatment parameters of 628 patients were included in the Cox regression model predicting PFS at 6, 12, 18, and 24 mo. BEV + IFN was administered to 337 patients; 291 patients received interferon alone. The developed model and the Motzer criteria were internally validated using Harrell's concordance index and calibrated.

Results and limitations

Median PFS was 10.2 versus 4.6 mo (p < 0.001) for patients receiving BEV + IFN or interferon alone, respectively. The novel model relying on age, Karnofsky performance status, baseline albumin, alkaline phosphatase, and time from primary diagnosis to treatment resulted in the highest discrimination (area under the curve [AUC]: 72.8, 75.0, 72.8, and 70.8% at 6, 12, 18, and 24 mo). The AUC of the Motzer criteria risk groups was 63.7, 61.8, 58.6, and 51.8% for the same time points. Comparison of discriminatory ability between the developed model and the Motzer criteria showed statistically significant differences (all p ≤ 0.02). An external validation of the new model is warranted.

Conclusions

The developed model identified prognostic factors of PFS in mRCC patients treated with BEV + IFN or interferon alone and quantified individual risk of PFS. Relative to the Motzer criteria, the novel model demonstrated better discriminatory properties. The model may serve clinicians in identifying patients who can benefit the most from BEV + IFN versus interferon alone.     

Induction With Basiliximab in Renal Transplantation

Introduction

The use of monoclonal antibodies in renal transplantation for induction therapy has been associated with a marked reduction in acute rejection rates with an impact on graft and patient survivals.

Objective

We sought to evaluate the efficacy of renal transplant induction protocols using Basiliximab based on the rates of acute rejection episodes (ARE) and delayed graft function (DGF) of infectious complications in the first 6 months posttransplant, as well as patient and graft survivals.

Methods

We retrospectively evaluated all renal transplants performed between 2000 and 2008 that were primary grafts from cadaveric heart-beating donors, into recipients with a panel reactive antibody titer <5% and who were treated with an immunosuppression scheme based on cyclosporine, mycophenolate mofetil/mycophenolic acid plus corticosteroids, with (group 1) or without basiliximab (group 2).

Results

We enrolled 52 recipients in group 1 (induction with basiliximab) and 189 in group 2 (without basiliximab). The baseline characteristics were similar among the groups, except for time on dialysis which was longer in group 1 and the number of HLA matches, which was lower in group 1. The ARE rate was lower among group 1 (7.8% vs 27.8%; P = .001); rates of DGF and infectious complications were similar. There was no significant difference in graft and patient survivals.

Conclusion

In this study, induction with basiliximab was associated with a reduced rate rate of ARE, despite a lower number of HLA matches and a longer previous time on dialysis. The use of this induction modality was not associated with a greater rate of infectious complications.     

Tumor growth in urinary diversion: a multicenter analysis

Background

The risk estimation of secondary tumors after different types of urinary diversion with intestinal segments is possible only for ureterosigmoidostomy owing to the lack of follow-up studies of other forms of urinary diversions.

Objective

We calculated the prevalence of secondary tumors associated with different forms of urinary diversion, relating the number of reported tumors to the number of performed diversions in German clinics.

Design, setting, and participants

We analyzed the operative records of 44 German clinics for urinary diversions performed from 1970 to 2007 and registered all reported secondary tumors up to 2009.

Measurements

For statistical comparison of the different tumor prevalences, Fisher exact test was used. Additionally, we compared tumor locations and latency periods in different forms of urinary diversions.

Results and limitations

In 17 758 urinary diversions, 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (2.58%) and cystoplasty (1.58%) was significantly higher than in other continent forms of urinary diversion (p < 0.0001). The risk in orthotopic (ileo-)colonic neobladders (1.29%) was significantly higher (p = 0.0001) than in ileal neobladders (0.05%). The difference between ileocecal pouches (0.14%) and ileal neobladders was not significant (p = 0.46), and the tumor risk with ileal conduits was minimal (0.02%).

Conclusions

Ureterosigmoidostomies, cystoplasties, and probably orthotopic (ileo-)colonic neobladders bear a significantly increased tumor risk compared with the general population and necessitate regular endoscopic evaluation from at least the fifth postoperative year. Regular endoscopy is not imperative after ileal neobladders and conduits, but with catheterizable ileocecal pouches, it is recommended in the presence of symptoms such as hydronephrosis, chronic urinary infection, and hematuria.     

Natural course and outcome of cystic lesions in the pancreas

Background

The number of patients identified with cysts of the pancreas is increasing. The current study was undertaken to assess the natural course and malignant potential of pancreatic cysts.

Methods

From 1995 to 2008, radiology records were reviewed for the presence of cystic lesions of the pancreas (CLP) characteristics, patient demographics, and follow-up.

Results

Eighty-two patients met the study inclusion criteria, with a mean age at time of diagnosis of 64.4 ± 16.7 years. Mean cyst size was 1.36 ± 1.05 cm, with 75.6% of patients having a solitary cyst. Thirteen patients underwent surgery. Operative intervention was statistically related to symptomatic, loculated cysts with the presence of calcifications (all P <.05). Malignancy was statistically related to symptomatic (P <.05), loculated cysts (P <.01), and male gender (P <.05).

Conclusions

Our data show that most pancreatic cysts found on radiographic imaging are asymptomatic, solitary, and small and can be followed safely radiographically.     

Trauma: the impact of repeat imaging

Background

Patients referred to trauma centers often undergo an extensive diagnostic work-up before transfer. The purpose of our study was to quantify and examine the effects of repeat imaging in this population.

Methods

A prospective cohort study of 410 patient transfers was performed. Repeat imaging was conducted at the discretion of the accepting surgeon for multiple reasons. Two groups were compared, those who did and those who did not require repeat imaging.

Results

Overall, 53% of referrals received repeat imaging, at an average cost of $2,985 per patient. This group was older (42 vs 37 y; P < .05), more severely injured (injury severity score, 12 vs 9; P < .05), and experienced longer delays before transfer (244 vs 192 min; P < .05). By using logistic regression analysis, injury severity score was found to be an independent predictor of the need for repeat imaging (P = .003).

Conclusions

Severely injured trauma patients often receive films that ultimately require duplication, resulting in transfer delay, unnecessary morbidity, and increased resource use. Targeted education and development of centralized radiology systems could alleviate some of the burden of unnecessary imaging.     

Intraoperative bone marrow puncture in breast cancer patients: Prospective assessment of adverse side-effects

Background and aim

In breast cancer patients, intraoperative bone marrow puncture (BMP) with positive detection of disseminated tumor cells has been reported to predict unfavorable clinical outcome due to increased risk of recurrence. In this study, we prospectively assessed BMP-associated untoward side-effects.

Methods

Fifty-eight consecutive breast cancer patients were prospectively explored after intraoperative BMP for postoperative pain (visual analogue scale, VAS) and complications in terms of infection, hematoma, and sensibility disorder. Furthermore, the impact of BMP on hospital stay duration was analyzed in 254 patients.

Results

In all subgroups analyzed, during five postoperative days patients complained about minor pain only at the site of BMP (VAS < 1) while the corresponding pain scores were significantly higher for the area of the operated breast. Post-BMP iliac crest hematomas were encountered in 13 out of 58 patients (22.4%) who were significantly older (p = 0.04), less frequently smokers (p = 0.02), and presented with higher body mass index (p = 0.01) than controls. Within the area of BMP no signs of infection or sensibility disorders were observed. Comparison of patients with and without BMP did not show any significant difference in postoperative hospital stay duration.

Conclusion

Referring to the potential clinical benefit of intraoperative BMP its prospectively assessed adverse side-effects appear relatively mild and thus acceptable.     

Diabetes mellitus and hip fracture: a study of 5966 cases

Introduction

Diabetes mellitus, and especially type II diabetes, is a widespread and increasing problem in the western world due to the high rates of obesity. It has also been shown in previous studies that diabetics have impaired fracture healing. The aim of this study was to see exactly what role diabetes plays in hip fracture because it is a partially modifiable disease, and to see whether there are any changes that we could make to our practice to improve patient outcome.

Methods

We analysed the characteristics and outcomes for 477 hip fracture patients who were known to be diabetic at the time of admission, against 5489 non-diabetic hip fracture patients.

Results

At the time of admission the diabetic patients were more likely to be using walking aids [268/477 (56%) versus 2455/5489 (45%), p < 0.0001], have a more restricted walking ability and a higher mean ASA grade (2.9 versus 2.6, p < 0.0001). Diabetics patients were more likely to develop cardiac post-operative complications [26/477 (5.5%) versus 146/5489 (2.7%), p = 0.0008] and to develop pressure ulcers [34/477 (7.1%) versus 171/5489 (3.1%), p < 0.0001]. Hospital stay was increased for those with diabetes (25 days versus 21days, p 0.006). No difference in surgical complications was seen between groups. At one year, recovery of function was similar for diabetic patients compared to those without diabetes.

Conclusion

These findings show diabetics are at an increased risk of specific complications and have a longer length of hospital stay but generally make a normal recovery thereafter.     

Sunitinib in urothelial cancer: clinical, pharmacokinetic, and immunohistochemical study of predictors of response

Background

Sunitinib has activity in patients with metastatic urothelial cancer (UC), but most patients do not respond.

Objective

To identify predictors of response to sunitinib.

Design, setting, and participants

Seventy-seven patients with advanced UC received sunitinib on one of two schedules at a single institution. Blood pressure (BP), immunohistochemistry (IHC), and pharmacokinetic (PK) results were correlated with response to sunitinib.

Measurements

BP was assessed on day 1 and 28 of each cycle and on day 14 of cycle 1. IHC was performed on 55 samples from 38 cases using mammalian target of rapamycin and hypoxia-inducible factor (HIF) pathway marker antibodies. Blood samples for PK analysis were collected from 15 patients at three time points. Response was assessed using Response Evaluation Criteria in Solid Tumors criteria.

Results and limitations

Sunitinib-induced hypertension predicted improved response when hypertension was categorized as a discrete (p = 0.02) or continuous variable (p = 0.005 [systolic BP] and p = 0.007 [diastolic BP]). The odds ratio of response was 12.5 (95% confidence interval, 1.95-246.8) for grade 3/4 hypertension compared with grade 0. Response was associated with low HIF-1α expression in primary (p = 0.07) tissue. A nonstatistically significant trend was seen for an association between greater drug concentration and best response. A correlation between expression markers within the same pathways was identified, phosphorylated-4EBP1 and phosphorylated-S6 (p = 6.5 × 10⁻⁹), and vascular endothelial growth factor receptor 2 and HIF-1α (p = 0.008). Results are limited by small numbers.

Conclusions

Clinical and molecular biomarkers of response to sunitinib may have clinical relevance and require prospective validation. There is an urgent need for predictive biomarkers to guide the management of UC.     

Preoperative sonographic evaluation is a useful method of detecting contralateral patent processus vaginalis in pediatric patients with unilateral inguinal hernia

Background/purpose

To analyze the value of ultrasound scan (US) in the preoperative identification of a contralateral patent processus vaginalis (CPPV), the authors investigated the presence of CPPV by US in children with clinically diagnosed unilateral inguinal hernias.

Methods

Three hundred forty-eight patients (168 boys and 180 girls) with unilateral inguinal hernia underwent US examination using a 7.5-MHz linear transducer. If a CPPV was visible as a hydrocele owing to the inflow of physiologic ascites into a processus vaginalis on straining, then US scanning was performed while the patient was at rest and while inducing straining by standing or crying. A groin with a hydrocele in the inguinal canal on straining was diagnosed as a CPPV and was explored bilaterally through surgery. The US findings were compared with surgical results.

Results

In 348 patients, 78 cases (22.4%) were diagnosed by US as patients with a CPPV; these patients underwent bilateral surgery. Seventy-four of 78 cases (94.9%) were confirmed surgically as patients with CPPV.

Conclusions

A CPPV was detected correctly by US in 74 of 348 patients (21.3%) with clinically diagnosed unilateral inguinal hernias. US is a noninvasive and accurate method for evaluating the presence of a CPPV.     

Isolated skin recurrence following salvage mastectomy for intramammary recurrence (after initial breast conservation therapy): is it a fatal event?

Aims

The authors analyzed the outcome of patients with Isolated Skin Recurrence After Salvage Mastectomy (ISRASM) performed after conservative treatment for breast carcinoma, taking into account initial tumor characteristics, intramammary recurrence (first recurrence) characteristics, local skin recurrence (second recurrence) characteristics, and the type of treatment at each stage of the breast cancer continuum.

Methods

Forty-two patients who had ISRASM between 1976 and 2007 were included in this retrospective study. Twenty-six factors were studied in univariate and multivariate analyses.

Results

Mean Overall Survival (OS) was 70.3 (±4.1) months. The 5-year OS rate was 66.6%. 31% of patients did not present any recurrence, 52% had locoregional recurrence and 14% metastatic recurrence following ISRASM. Univariate analysis showed that 4 prognostic factors were significantly related to OS and/or Disease-Free Survival (DFS): (1) initial chemotherapy after primary breast cancer (P = 0.09 and 0.01 respectively), (2) presence of emboli at the site of intramammary recurrence (first recurrence) (P = 0.02 and 0.03), (3) interval between first and second surgery of less than 3 years (P = 0.09 and 0.0003), and (4) inflammatory skin involvement at ISRASM (P = 0.005 and 0.17). Multivariate analysis showed that presence of emboli at the site of intramammary recurrence was significantly related to OS and that an interval between first and second recurrence of less than 3 years was significantly related to DFS.

Conclusion

Our results show that ISRASM affects a group of breast cancer patients with predominantly local rather than metastatic disease. Prognostic factors depend on characteristics at initial breast cancer, first recurrence and second recurrence. Evidence-based guidelines are still required for ISRASM management.     

Does the difference in donor and recipient weight influence renal graft survival?

Introduction

Grafts from older donors or those in recipients with a greater body mass index (BMI) as compared with the donor may develop hyperfiltration syndrome that shortens renal graft survival.

Objectives

To assess whether the differences in weight and BMI between donor and recipient correlated with renal function, proteinuria, or graft survival among recipients of grafts from expanded criteria donors.

Materials and methods

We undertook a prospective, observational study in 180 recipients of grafts from expanded criteria donors performed between 1999 and 2006. All grafts had been biopsied previously for viability. The recipients underwent immunosuppression with basiliximab, late introduction of tacrolimus, mycophenolate mofetil and steroids. The study population was divided into three groups, depending on the tertile of the donor-to-recipient weight ratio (<1, n = 64; 1-1.2, n = 56; >1.2, n = 60), and the donor-to-recipient BMI ratio (<0.97, n = 59; 0.97-1.13, n = 60; >1.13, n = 60). The glomerular filtration rate was estimated from the modified diet in renal disease (MDRD) equation.

Results

The mean age of the donors was 63.54 years and of the recipients, 58.38 years. The proportion of male-to-female donors was 52:48 and recipients 57.8:42.2 (P = NS). No significant differences in overall graft survival were observed between the tertiles. There was a negative correlation between the donor-to-recipient weight ratio and serum creatinine value at 1 (P < .001), 3 (P = .013), and 12 months (P = .005) after transplantation, and a positive correlation with the MDRD at 1 month (P < .001). No relation was noted between weight and proteinuria at 1 (P = .25), 3 (P = .51), or 12 months (P = .90). The results were similar after analyzing the ratio of the BMI to creatinine, MDRD or proteinuria, as well as in cases of a female donor to a male recipient.

Conclusions

Differences in weights between the donor and the recipient did not appear to affect graft survival or proteinuria among patients receiving grafts from expanded criteria donors, though it may be related to renal function during the early posttransplant stages.     

Regurgitant jet evaluation using three-dimensional echocardiography and magnetic resonance

Background

Three-dimensional assessment of regurgitant jet volume is the prerequisite for stratifying valve insufficiency. However, systematic comparison of three-dimensional methods is lacking. Therefore, we evaluated magnetic resonance imaging and three-dimensional echocardiography experimentally.

Methods

An insufficiency chamber (22 × 18.5 × 27 cm; ostia 10, 16, and 20 mm; regurgitant volumes 2.3 to 25 mL) within experimental circulation (BioMedicus pump, tubes, pulsatile flow 0.2 to 1.9 L/min) was used for three-dimensional echocardiography (HP Sonos 2500) and magnetic resonance imaging (Siemens Magnetom Vision). Doppler flowmeter served as a gold standard. Segmentation used thresholding and surface integration of velocity vectors. Jet volume was evaluated qualitatively by polynom fitting.

Results

Jet volume calculated by magnetic resonance (r = 0.99, p < 0.0001) and by echocardiography (r = 0.99, p < 0.0001) correlated identically to the gold standard. Jet volume derived from imaging correlated with each other by r = 0.98 (p < 0.0001). Polynom fits indicated a more paraboloid shape of magnetic resonance jet volume.

Conclusions

Experimentally, three-dimensional echocardiography and magnetic resonance imaging possess identical accuracy for determining regurgitant jet volume. Magnetic resonance imaging seems to provide qualitatively better image data for three-dimensional reconstruction.     

Anatomic features of enhancing renal masses predict malignant and high-grade pathology: a preoperative nomogram using the RENAL Nephrometry score

Background

Counseling patients with enhancing renal mass currently occurs in the context of significant uncertainty regarding tumor pathology.

Objective

We evaluated whether radiographic features of renal masses could predict tumor pathology and developed a comprehensive nomogram to quantitate the likelihood of malignancy and high-grade pathology based on these features.

Design, setting, and participants

We retrospectively queried Fox Chase Cancer Center's prospectively maintained database for consecutive renal masses where a Nephrometry score was available.

Intervention

All patients in the cohort underwent either partial or radical nephrectomy.

Measurements

The individual components of Nephrometry were compared with histology and grade of resected tumors. We used multiple logistic regression to develop nomograms predicting the malignancy of tumors and likelihood of high-grade disease among malignant tumors.

Results and limitations

Nephrometry score was available for 525 of 1750 renal masses. Nephrometry score correlated with both tumor grade (p < 0.0001) and histology (p < 0.0001), such that small endophytic nonhilar tumors were more likely to represent benign pathology. Conversely, large interpolar and hilar tumors more often represented high-grade cancers. The resulting nomogram from these data offers a useful tool for the preoperative prediction of tumor histology (area under the curve [AUC]: 0.76) and grade (AUC: 0.73). The model was subjected to out-of-sample cross-validation; however, lack of external validation is a limitation of the study.

Conclusions

The current study is the first to objectify the relationship between tumor anatomy and pathology. Using the Nephrometry score, we developed a tool to quantitate the preoperative likelihood of malignant and high-grade pathology of an enhancing renal mass.     

Retrospective study of the surgical management and outcome of nonrhabdomyosarcoma soft tissue sarcomas of the groin and axilla in children

Purpose

The incidence of pediatric nonrhabdomyosarcoma soft tissue sarcomas (NRSTSs) of the groin and axilla is unknown, and the optimal surgical approach to these patients is unclear.

Methods

We conducted a retrospective study of patients treated at St Jude Children's Research Hospital from January 1962 to March 2007 for NRSTSs of the groin and axilla. Demographic variables, tumor pathology, clinical management, and outcome were reviewed.

Results

Of the 300 patients treated for NRSTSs, only 10 had tumors of the axilla or groin (6 of whom had synovial sarcoma). Surgical interventions included wide resection of the tumor (n = 7), marginal resection (n = 1), subtotal resection (n = 1), and biopsy only (n = 1). Six patients underwent lymph node sampling; all were negative for tumor. Short- and long-term surgical complications were rare. Four patients received adjuvant chemotherapy (n = 3) and/or radiotherapy (n = 2). At a median follow-up of 8.5 years, 7 of the 10 were surviving free of disease. Two of these patients died of tumor progression (1 with metastases at diagnosis and 1 with an unresectable tumor at diagnosis), and one patient who was free of NRSTS died of secondary breast carcinoma.

Conclusions

Pediatric NRSTSs of the axilla and groin are rare, but outcomes are similar to those of other patients with NRSTS. Wide local excision of the tumor with preservation of good limb function should be the surgical goal and may be sufficient therapy in some cases.