Does surgical delay for radical prostatectomy affect biochemical recurrence? A retrospective analysis from a Canadian cohort

Aim

We sought to explore the impact of surgical wait time (SWT) to robot-assisted radical prostatectomy (RARP) on biochemical recurrence (BCR).

Method

Retrospective review of a prospectively collected database between 2006 and 2015 was conducted on all RARP cases. SWT was defined as period from prostate biopsy to surgery. Primary outcome was the impact on BCR, which was defined as two consecutive PSA ≥ 0.2 ng/dl, or salvage external beam radiation therapy and/or salvage androgen deprivation therapy. Patients were stratified according to D’Amico risk categories. Univariable analysis (UVA) and multivariable analyses (MVA) with a Cox proportional hazards regression model were used to evaluate the effect of SWT and other predictive factors on BCR, in each D’Amico risk group and on the overall collective sample.

Results

Patients eligible for analysis were 619. Mean SWT was 153, 169, 150, and 125 days, for overall, low-, intermediate-, and high-risk patients, respectively. Multivariate analysis on the overall cohort did not show a significant relation between SWT and BCR. On subgroup analysis of D’Amico risk group, SWT was positively correlated to BCR for high-risk group (p = 0.001). On threshold analysis, cut-off was found to be 90 days. SWT did not significantly affect BCR on UVA and MVA in the low- and intermediate-risk groups.

Conclusion

Increased delay to surgery could affect the BCR, as there was a positive association in high-risk group. Further studies with longer follow-up are necessary to assess the impact of wait time on BCR, cancer specific survival and overall survival.

     

What can we learn from patient claims? - A retrospective analysis of incidence and patterns of adverse events after orthopaedic procedures in Sweden

Background  

Objective data on the incidence and pattern of adverse events after orthopaedic surgical procedures remain scarce, secondary to the reluctance for encompassing reporting of surgical complications. The aim of this study was to analyze the nature of adverse events after orthopaedic surgery reported to a national database for patient claims in Sweden.     

A real-world retrospective analysis of the management of metastatic castrate-resistant prostate cancer in Ontario,Canada from 2010 – 2018

PurposeWe sought to quantify mCRPC patient treatment patterns and survival across multiple lines of therapy after prior androgen-receptor-axis-targeted therapy (ARAT) failure.MethodsIndividuals diagnosed with prostate cancer between 2010 and 2018 were identified in the Ontario Cancer Registry (OCR). An algorithm was created to identify patients with mCRPC that was aligned to Prostate Cancer Clinical Trials Working Group 3 criteria (PCWG3) and validated with Canadian clinical experts. In the mCRPC setting, treatment patterns were assessed by line of therapy, and survival was calculated from treatment initiation until death or lost to follow-up.Results64,484 men were diagnosed withprostate cancer in Ontario between 2010 and 2018with 5,588 men assessed to have mCRPC and 2,970 (53%) of those received first-line systemic treatment. Across the first-, second- and third-line of therapy, ARATs (abiraterone and enzalutamide) were the most used therapies. Survival for mCRPC patients treated with ARATs in first-, second- and third-line were 13.0 (95% CI, 11.6 – 14.5), 11.5 (95% CI, 10.1 – 13.4) and 8.9 (95% CI, 7.4 – 10.2) months, respectively. Survival for mCRPC patients treated with taxanes in first, second- and third-line were 16.7 (95% CI, 14.8 – 18.0), 11.3 (95% CI, 10.1 – 12.5) and 7.8 (95% CI, 6.5 – 10.6) months, respectively. No statistical difference in overall survival was found between taxanes and ARATs.ConclusionIn this analysis of a large retrospective cohort of Canadian men with mCRPC, we found that survival in patients treated with ARATs and taxanes was fairly similar across all lines of therapy. Importantly, this trend was maintained in ARAT-exposed patients, where sequential ARAT and taxanes offered similar survival. These data may help inform optimal sequencing of therapies in mCRPC.     

Does delay in surgical debridement increase the risk of infection in open tibia fractures in Saudi patients? A retrospective cohort study

BackgroundInfection is the most common and devastating complication of open fractures, with a reported incidence of 3–40%. Tibia bone along its anteromedial surface has relatively thin soft tissue coverage; hence the open tibia fracture incidence rate ranges from 49.4% to 63.2%. Open fractures are usually classified based on the Gustilo & Anderson classification system, which is used by surgeons as an index for the severity of an injury and as a prognostic tool. Our current practice follows the 6-h rule of irrigation and debridement (I&D). Nevertheless, there is little support for this opinion in the literature. Our study concentrates on identifying the risk factors of infection in open tibia fractures and comparing the rate of infection if surgical irrigation and debridement was delayed.MethodsThe medical records of 389 patients with open fractures were reviewed. Of these cases, 113 patients with open tibia fracture who presented to our Hospital from the period 1997 to 2008 fit the inclusion criteria and were included in a retrospective cohort study.ResultsA total of 113 tibia fractures were reviewed, with an average patient age of 31.70 years; 87.1% of the fractures were high-energy fractures, and the most common mechanism of injury was a motor vehicle accident (62.4%). The data analysis revealed no difference in overall infectious outcome when comparing initial I&D performed within 6 h to when I&D was performed after 6 h (P = 0.201). The data analysis showed a significant relationship between infection and wound closure in first surgery in both univariate and multivariate analysis (P = 0.0003 and P = 0.014), respectively.ConclusionThis study showed no significant evidence to support the 6-h rule, but it did demonstrate a significant relationship between the Gustilo stage and infection, as well as an increased infection rate if external fixation was used or if the wound was left open during the initial irrigation and debridement. We believe that more studies are required to identify the relationship between infection and the delay in irrigation and debridement; a meta-analysis of the currently available data may provide an answer to this question.     

Does HistoScanning™ predict positive results in prostate biopsy? A retrospective analysis of 1,188 sextants of the prostate

Purpose

The role of HistoScanning? (HS) in prostate biopsy is still indeterminate. Existing literature is sparse and controversial. To provide more evidence according to that important clinical topic, we analyzed institutional data from the Martini-Clinic, Prostate Cancer Center, Hamburg.

Methods

Patients who received prostate biopsy and who also received HS were included in the study cohort. A single examiner, blinded to pathological results, re-analyzed all HS data in accordance with sextants of the prostate. Each sextant was considered as an individual case. Corresponding results from biopsy and HS were analyzed. The area under the receiver-operating characteristic curve (AUC) for the prediction of a positive biopsy by HS was calculated. Furthermore, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were assessed according to different HS signal volume cutoffs (>0, >0.2 and >0.5 ml).

Results

Overall, 198 men were identified and 1,188 sextants were analyzed. The AUC to predict positive biopsy results by HS was 0.58. Sensitivity, specificity, PPV and NPV for HS to predict positive biopsy results per sextant, depending on different HS signal volume cutoffs (>0, >0.2 and >0.5 ml) were 84.1, 27.7, 29.5 and 82.9 %, 60.9, 50.6, 28.8 and 79.7 %, and 40.1, 73.3, 33.1 and 78.8 %, respectively.

Conclusions

Positive HS signals do not accurately predict positive prostate biopsy results according to sextant analysis. We cannot recommend a variation of well-established random biopsy patterns or reduction of biopsy cores in accordance with HS signals at the moment.     

Does open-access mammography and ultrasound delay the diagnosis of breast cancer?

There is a consensus that open-access breast imaging for general practitioners is inappropriate since the process omits an expert clinical examination and fine needle aspiration cytology. However, it was decided to test this hypothesis by comparing the outcome of breast referrals in a district with both an open-access imaging and a one-stop clinic. The time from referral to definitive diagnosis in all women with breast cancer was compared over a 12 month period in 1996. Of 1049 women referred for open-access imaging 20 (2%) were found to have breast cancer compared with 91 (9%) of 995 women referred to the one-stop breast clinic. There was a longer interval before the diagnosis of breast cancer was made in cases referred for open-access imaging compared with cases referred to the one-stop breast clinic (mean 63 vs 35 days). However, if patients with advanced disease are excluded the mean interval was 63 vs 44 days. The mean tumour size of breast cancers in cases referred to open-access imaging was smaller (1.5 vs 2.3 cm), there were fewer grade 3 tumours (10% vs 39%), and there was a lower rate of axillary lymph node metastases (20% vs 32%) compared with cases referred to the one-stop breast clinic. The longer interval for the open-access patients was largely due to administrative delay and the 3 patients with a delay of more than 3 months had all had a triple assessment which was false negative. This study does not support the hypothesis that open-access mammography is unsafe and should be withdrawn.     

Which cause of diffuse peritonitis is the deadliest in the tropics? A retrospective analysis of 305 cases from the South-West Region of Cameroon

Backgraound

An occult pneumothorax is a pneumothorax that is not seen on a supine chest X-ray but is detected by computed tomography scanning. However, critical patients are difficult to transport to the computed tomography suite. We previously reported a method to detect occult pneumothorax using oblique chest radiography (OXR). Several authors have also reported that ultrasonography is an effective technique for detecting occult pneumothorax. The aim of this study was to evaluate the usefulness of OXR in the diagnosis of the occult pneumothorax and to compare OXR with ultrasonography.

Methods

All consecutive blunt chest trauma patients with clinically suspected pneumothorax on arrival at the emergency department were prospectively included at our tertiary-care center. The patients underwent OXR and ultrasonography, and underwent computed tomography scans as the gold standard. Occult pneumothorax size on computed tomography was classified as minuscule, anterior, or anterolateral.

Results

One hundred and fifty-nine patients were enrolled. Of the 70 occult pneumothoraces found in the 318 thoraces, 19 were minuscule, 32 were anterior, and 19 were anterolateral. The sensitivity and specificity of OXR for detecting occult pneumothorax was 61.4 % and 99.2 %, respectively. The sensitivity and specificity of lung ultrasonography was 62.9 % and 98.8 %, respectively. Among 27 occult pneumothoraces that could not be detected by OXR, 16 were minuscule and 21 could be conservatively managed without thoracostomy.

Conclusion

OXR appears to be as good method as lung ultrasonography in the detection of large occult pneumothorax. In trauma patients who are difficult to transfer to computed tomography scan, OXR may be effective at detecting occult pneumothorax with a risk of progression.

     

Incidental appendectomy – standard or unnecessary additional trauma in surgery for colorectal cancer? A retrospective analysis of histological findings in 380 specimens

Background Incidental appendectomy is a frequent but non‐standard procedure during surgery for colorectal cancer. Incidental appendectomy during colorectal resections is performed at the discretion of the operating surgeon. Method This retrospective study used data from 1352 consecutive patients who underwent surgery for colorectal cancer between 1993 and 2009 at the Medical University of Vienna. The authors evaluated histopathological results of appendices removed incidentally. In addition, complications and costs of the additional intervention were analyzed. Results Appendectomy had been performed in 314 (23.22%) patients because of appendicitis. Incidental appendectomy had been performed in 380 (28.11%) patients: 86 (22.63%) had a histologically completely normal appendix, a pathologic alteration was found in 289 (76.05%) and a neoplasm was found in seven (1.84%). No complications occurred from the additional surgical procedure. The costs and time effort were negligible. Conclusion Incidental appendectomy is a safe procedure and can be integrated into surgery for colorectal carcinoma to avoid future complications. Pathological findings of the appendix, including neoplasm, are frequent but the clinical relevance remains questionable.     

Does developmental dysplasia of the hip cause a delay in walking?

Developmental dysplasia of the hip (DDH) is commonly supposed to lead to a delay in walking. The authors present a retrospective review of the age of walking in 86 children with established DDH and compare them with an age- and sex-matched group of controls. While the median age of walking was 1 month later than in the control group, this was clinically insignificant, as all walked within the normal time limits. The authors conclude that children with DDH do not present as late walkers.     

Does the minimally invasive complete plantar fasciotomy result in deformity of the Plantar arch? A prospective study

BackgroundComplete plantar fasciotomy has been associated with changes in foot loading, leading to medial longitudinal arch collapse. The purpose of this study is to analyse our clinical experience with percutaneous complete plantar fasciotomy and quantify the possible changes in foot loading measured by the calcaneal pitch angle.MethodsA prospective case series study with patients operated between 2005–2012 was conducted, where AOFAS, Maryland Foot Score (MFS), VAS and radiological calcaneal pitch (CP) were recorded. Postoperative data were collected, where the surgeon evaluated the presence of complications, and an independent investigator performed radiological and scale evaluations follow-up: AOFAS, MFS, VAS and Benton-Weil questionnaire.ResultsA total of 60 patients, 62 feet, with a mean follow-up of 57 months (range 13–107) were studied. The MFS increased a mean of 21 points (p = .001), the AOFAS score a mean of 25 points (p = .001), and the VAS decreased a mean of 8.89 points (p = .001). A total of fifty-seven feet (91.9%) were pain-free at the end of follow-up. The mean CP dropped from 20.2° (range 11–34) preoperatively to 19.3° (range 11–34) at the end of follow-up (p = .05). In 25 feet (40.3%) there were no changes in the calcaneus pitch angle, in 21 feet dropped 1° (33.9%), in 11 dropped 2° (17.8%), 3 feet 3° (4.8%) and 2 feet (3.2%) 4°. Postoperative complications were noted in 4 feet (6.4%), with lateral column pain. The surgery meets the expectations of all patients.ConclusionsPercutaneous total fascia release is safe and does not produce a significant drop in arch height based on the radiological finding. Lack of success after surgery may be explained by other pathologies that might appear like plantar fasciitis. Further studies with gait analysis after total plantar fascia release in patients are needed.     

Does the finding of a indeterminate mass lesion in screening CT result in kidney loss and is postoperative follow-up necessary in renal encocytomas? A retrospective study

OBJECTIVE: Sixteen patients who were operated on with a preoperative diagnosis of renal tumor were diagnosed with renal oncocytoma between 1991 and 2004. The reliability of preoperative diagnosis, the role of screening CT in organ preservation and the need for follow-up for renal oncocytomas are discussed in the light of literature findings. MATERIAL AND METHODS: Among 345 patients diagnosed with renal tumors in the previous 13 years, the clinical and radiological features of the 16 patients with renal oncocytomas and the results during the postoperative follow-up period were evaluated in this retrospective study. The female:male ratio was 4.3. Two of the patients complained of hematuria whereas the other 14 experienced lumbocostal pain. The mean dimensions of the tumors on CT scans were 5.7+/-2.88 cm. Central fibrous scarring existed in three patients. Two patients underwent tumor enucleation, three underwent partial nephrectomy and 11 underwent radical nephrectomy. RESULTS: Screening CT could not achieve a precise preoperative differential diagnosis from malignant renal mass. The organ preservation ratio was approximately 1:3 based on the radiological diagnosis. Screening CT scans showed oncocytomas with diameters greater than those reported in the literature, indicating a need for urgent nephrectomy. No recurrences, metastases or deaths due to renal oncocytoma were observed in the postoperative follow-up period (mean 6.7+/-4 years; range 1-13 years). CONCLUSIONS: Preoperative diagnosis of renal oncocytoma is very difficult. The postoperative follow-up period in our series was 13 years, which is significantly longer than the duration proposed in the literature.     

Is limited surgery justified in the treatment of T1 colorectal cancer?

Background

Surgical treatment of colorectal cancer (CRC) should be aimed primarily at achieving a combination of surgical-oncologic radicalness and the highest possible quality of life. In recent years, surgical therapy for T1 CRC has tended toward less radical interventions. The question regarding changes in survival and recurrence rates still is unanswered.

Methods

A retrospective medical chart review of patients surgically treated in our department for T1 CRC from January 1990 to December 2010 (n = 223) was performed. Charts were reviewed for tumor-specific parameters, local recurrence, distant metastasis, and patient survival. The different treatment options used were strictly separated for a more detailed workup.

Results

Radical resection (RR) was performed for 57.1 %, local resection (LR) for 14.8 %, and an endoscopic approach (EA) for 28.1 % of the study population. After receipt of the histology report, 35.7 % of the patients initially resected nonradically underwent reoperation, mostly using RR. Seven patients experienced a local recurrence over time (3.6 %): one after initial RR, three after LR, and three after EA. Systemic recurrence occurred for nine patients (4.6 %) over time, six of whom had undergone initial RR. High-risk criteria were shown for 20 T1 CRCs. For 60 % (12/20) of the patients, initial RR was performed. Radical reoperation was performed for 75 % of the nonradically treated high-risk tumors. One high-risk patient without reoperation experienced metastatic disease over time. The 5-year overall survival rate was 87.2 %, itemized for the defined subgroups as follows: 83.9 % for RR, 82.8 % for LR, and 58.2 % for EA.

Conclusion

Patients with T1 CRC had a distinctly higher incidence of local recurrence after EA or LR. Explicit workup in terms of risk classification is crucial to reducing the risk of local and systemic recurrence. A nonradical approach should be only a second option for patients with T1 CRC, namely, those solely in clearly low-risk situations or those with distinct comorbidities.     

Disparities in colorectal cancer mortality for rural populations in the United States: Does screening matter?

IntroductionRural compared to urban populations in the US have increased colorectal cancer (CRC) incidence with known disparity in screening rates and mortality. We hypothesize that rural-urban disparities are different at a regional level.MethodsWe assessed screening rates according to the 2016 Behavioral Risk Factor Surveillance System guidelines using state and city-level data for county level estimates and correlating with county CRC mortality data from the National Cancer Institute. We used multivariable modeling to examine associations between rurality, screening rates, and mortality.ResultsHighest screening rate states had the smallest urban-rural disparities; lowest screening rate states had the largest disparities. Percent screened and urban-rural classification correlated significantly with mortality. Rural counties experienced ∼5 more deaths per 100,000 population even controlling for screening rates.ConclusionsNational urban-rural disparities in CRC screening mask greater state/regional disparities, not fully explaining the urban-rural mortality gap. Other factors (i.e. access to care, treatment differences) must be considered.