Radiation therapy as part of local control of metastatic neuroblastoma: the St Jude Children's Research Hospital experience

Purpose

The purpose of the study was to compare outcomes of pediatric patients with high-risk metastatic neuroblastoma who received radiotherapy (RT) with those of patients who did not.

Patients and methods

We reviewed the records of 63 patients with newly diagnosed metastatic neuroblastoma treated at our institution (1989-2001) to investigate their characteristics at presentation, dose and field of RT, treatment response, and failure patterns.

Results

Seventeen patients received RT, and 46 did not. In the RT group, a greater percentage of patients had residual disease before consolidation than did those in the no-RT group (88.2% vs 69.6%, P = .008). Gross total resection was achieved less often in the RT group (65% vs 89%, P = .055), but the 5-year cumulative incidences of local failure were similar (35.3% ± 12.4% vs 32.6% ± 7.1%). Although there was no difference in 5-year event-free survival, overall survival was better in the no-RT group (47.8% ± 7.2% vs 23.5% ± 9.2%, P = .026).

Conclusion

The addition of RT to the therapy of a group of patients with more residual locoregional disease appeared to improve the local failure rate to approximately that of patients with less residual disease. Radiotherapy may provide even greater benefit to those with less residual disease before consolidation.     

Management of the primary tumor in patients with metastatic pancreatic neuroendocrine tumor: a contemporary single-institution review

Background

Pancreatic nonfunctioning neuroendocrine tumors (PNFNETs) are an uncommon malignancy and often present with metastatic disease. There is a lack of information on the management of the primary tumor in patients who present with unresectable synchronous hepatic metastases.

Methods

A retrospective review (2001-2008) of PNFNETs was conducted. Patients were divided into 3 groups: PNFNET without evidence of hepatic metastasis (group A), PNFNET with metastatic disease involving less than 50% of the liver (group B), and PNFNET with metastatic disease involving more than 50% of the liver (group C). Clinical data and outcomes were analyzed.

Results

Thirty-five patients with PNFNET were identified (group A = 15, group B = 11, group C = 9). Resection of the pancreatic tumor was performed in 26 patients. With a mean follow-up period of 30 months, death from disease progression occurred in 1 patient in group A, none in group B, and in 7 in group C.

Conclusions

In selected patients, resection of the primary pancreatic tumor even in the setting of unresectable but limited hepatic metastases may be indicated.     

Comparative study of resection and radiofrequency ablation in the treatment of solitary colorectal liver metastases

Background

We compared outcomes in patients with solitary colorectal liver metastases treated by either hepatic resection (HR) or radiofrequency ablation (RFA).

Methods

A retrospective analysis from a prospective database was performed on 67 consecutive patients with solitary colorectal liver metastases treated by either HR or RFA.

Results

Forty-two patients underwent HR and 25 patients underwent RFA. The 5-year overall and local recurrence-free survival rates after HR (50.1% and 89.7%, respectively) were higher than after RFA (25.5% and 69.7%, respectively) (P = .0263 and .028, respectively). In small tumors less than 3 cm (n = 38), the 5-year survival rates between HR and RFA were similar, including overall (56.1% vs 55.4%, P = .451) and local recurrence-free (95.7% vs 85.6%, P = .304) survival rates. On multivariate analysis, tumor size, metastases treatment, and primary node status were significant prognostic factors.

Conclusions

HR had better outcomes than RFA for recurrence and survival after treatment of solitary colorectal liver metastases. However, in tumors smaller than 3 cm, RFA can be recommended as an alternative treatment to patients who are not candidates for surgery because the liver metastases is poorly located anatomically, the functional hepatic reserve after a resection would be insufficient, the patient's comorbidity inhibits a major surgery, or extrahepatic metastases are present.     

Primary gastrointestinal tract lymphoma in the pediatric patient: review of 265 patients from the SEER registry

Objective

The objective of this study is to determine outcomes of pediatric patients with primary gastrointestinal tract lymphoma (PGTL) and the impact of surgery or radiation on survival.

Methods

The Surveillance, Epidemiology, and End Result database was queried from 1973 to 2006 for patients younger than 20 years with PGTL.

Results

265 patients with PGTL were identified. Overall 5- and 10-year survivals were 84% and 83%, respectively. Tumors of the stomach (9%) and rectum/anus (2%) had the worst and best 10-year survivals, respectively (59% vs 100%, P = .023). There was no significant difference in 10-year survival for patients younger than 10 years of age who had surgical extirpation (83% vs 85% no surgery, P = .958) or radiotherapy (76% vs 85% no radiotherapy, P = .532). However, there was a significantly decreased 10-year survival in patients 10 years or older who had surgical extirpation (79% vs 100% no surgery, P = .013) or radiotherapy (49% vs 87% no radiotherapy, P = .001). Under multivariate analysis, tumor location was an independent predictor of improved survival (small bowel, HR 0.21, P = .002; large bowel, HR 0.23, P = .004).

Conclusion

We found no significant survival advantage for surgical extirpation or radiotherapy in patients younger than 10 years with PGTL, whereas either treatment modality was associated with lower survival in patients 10 years or older.     

Resection of pulmonary metastases in pediatric patients with Ewing sarcoma improves survival

Background

Ewing sarcoma (ES) is the second most common bone tumor in children, and survival of those with metastatic ES has not improved. Previous studies have shown a survival benefit to whole lung irradiation in patients with pulmonary metastases and may be given either before, after, or instead of surgical pulmonary metastasectomy (PM). The contribution of surgery compared with irradiation in ES has not previously been studied.

Methods

A retrospective review of patients younger than 21 years (median age, 16 years) treated at a single institution (1990-2006) was performed. Kaplan-Meier survival curves were compared using log-rank test and a multivariate Cox proportional hazards model. P ≤ .05 was regarded as significant.

Results

Eighty patients with ES were identified. Of these, 31 (39%) had pulmonary metastases. Nine patients had incomplete details of their full treatment regimen, but the following groups could be defined from the remainder: resection alone (n = 5), radiation alone (n = 3), radiation and resection (n = 3), or chemotherapy alone (n = 11). There were 24 deaths overall, with a median overall survival (OS) of 2.7 (95% confidence interval [CI], 1.7-5.2) years. Patients who had PM had the best OS (80%), whereas those who underwent radiation to the lung without PM compared with chemotherapy only for pulmonary metastasis both had similar OS of 0% at 5 years (P = .002). Patients who had radiation followed by PM for lung metastasis had a 5-year OS of 65%. Patients with PM had a longer OS compared with those without lung resection (P < .0001).

Conclusion

These data suggest a possible benefit for ES patients who undergo surgical resection of lung metastases.     

Psychometric properties of an integrated assessment of technical and communication skills

Purpose

The Integrated Procedural Performance Instrument (IPPI) consists of clinical scenarios in which bench-top models are positioned to simulated patients. Trainees are required to perform technical skills while engaging with the patient. The purpose of this study was to determine whether an IPPI format examination could discriminate between different levels of trainees.

Methods

Sixteen fourth-year medical students and 16 first-year surgery residents participated in 4 IPPI scenarios. Videotaped performances were scored by 2 blinded independent clinician raters on previously validated instruments: checklist of technical skills, Global Rating Scale of technical skills, and communication scale. We conducted separate mixed design analyses of variance (level × cases) on the 3 scales.

Results

Residents performed better than medical students on the checklist (74% vs 60%, P < .05), the Global Rating Scale of technical skills (75% vs 56%, P < .01), and the coherence communication subscale (79% vs 69%, P < .05).

Conclusions

An IPPI examination discriminated between students' and residents' technical skills and coherence in communication skills. It also highlighted a potential gap in the training of residents' communication skills.     

Excellent local tumor control regardless of extent of surgical resection after treatment on the Chicago Pilot II protocol for neuroblastoma

Background

Our aim was to investigate the impact of the extent of surgical resection on local recurrence and survival in high-risk patients treated with the Chicago Pilot II protocol.

Methods

Retrospective chart review was performed on 30 patients enrolled in the Chicago Pilot II protocol between 1995 and 2003. Variables studied were location of tumor, extent of resection, timing and location of recurrence, MYCN amplification, surgical complications, event-free survival, and overall survival (OS). Operative reports and postoperative meta-iodobenzylguanidine scans were used to assess extent of resection. Complete resection (CR) was defined as no gross residual tumor including primary and nodal disease.

Results

Three-year event-free survival and OS of this cohort of 30 patients was 58% and 82%, respectively. Only 1 patient developed a local recurrence, whereas metastatic recurrent disease was observed in 13 (43%) of the 30; and this subset had a significantly worse OS (23% vs 94%, P = .001). The most common relapse location was in bone. Patients with incomplete resection (IR) (11/30) and CR (19/30) had recurrence rates of 64% (7/11) and 32% (6/19, P = .12), respectively. Event-free survival was significantly better for patients with CR (68%) vs IR (27%; P = .05; odds ratio, 2.9). Overall survival rates for patients with CR vs IR were 68% vs 55%, respectively (P = .25).

Conclusions

Recurrence rate was the significant determinant of survival. Patients with CR had lower recurrence rates; however, they did not have improved local control. Final outcome of patients with unfavorable neuroblastoma will be determined by metastatic recurrence, not by extent of resection.     

Location of pulmonary metastasis in pediatric osteosarcoma is predictive of outcome

Background

The 3-year survival after pulmonary metastasectomy for osteosarcoma (OS) is approximately 30%. Resection of metastatic disease can prolong life in pediatric patients with OS. Our objective is to assess the outcome of pediatric patients with pulmonary metastases located centrally as compared with peripheral lesions.

Methods

A retrospective review of patients 0 to 21 years old with a diagnosis of OS with pulmonary metastases on computed tomographic scan between 1985 and 2000 was completed. Demographics, metastasis location, survival, morbidity, and mortality were evaluated.

Results

Of 115 patients who had pulmonary metastasis secondary to OS, there were 96 wedge resections and 13 lobectomy/pneumonectomies in 84 patients. The morbidity of wedge resection was 9% and lobectomy/pneumonectomy was 8%. There were no deaths from surgery. The median survival for patients undergoing lobectomy compared with wedge resection was 0.61 and 1.14 years, respectively, but did not reach statistical significance. The median overall survival for the entire cohort was 0.75 years. The median overall survival after initial detection of metastatic disease was 1.06 years among the patients with peripheral disease, compared with 0.38 years in patients with central disease (P = .008).

Conclusion

Patients with central pulmonary metastases in OS have a very poor prognosis, even after operative treatment, compared with those with peripheral disease. Patients with central lesions may benefit from other nonsurgical treatment options.     

Can we accept donors who have suffered a resuscitated cardiac arrest?

Introduction and aims

The shortage of donor organs has prompted increased acceptance of hearts from donors with more comorbidities. With increasing frequency, hearts are being offered from patients who have undergone a resuscitated cardiac arrest (RCA). Our aim was to compare the rate of complications in the postoperative and follow-up periods, depending on whether the transplanted organ came from a donor who had undergone an RCA.

Materials and methods

We included all 604 heart transplantations (HTs) performed in our center from 1987 to 2009, including 25 recipients who received an organ from a donor who had undergone RCA. We considered RCA to be an in-hospital cardiac arrest that was resuscitated from the onset, with a duration of <30 minutes, and with total recovery of cardiac and hemodynamic function. We analyzed ischemia time, incidence of acute graft failure (AGF), intubation period, recovery room stay, and long-term survival. The statistical methods were Student t and chi-square tests.

Results

There were no differences in baseline characteristics, except that patients in the RCA group were younger (47 ± 13 vs 51 ± 11 years; P = .50). There were also no differences between the RCA group and the other patients in ischemia time (151 ± 50 vs 154 ± 53 minutes; P = .826), incidence of AGF (33% vs 24.7%; P = .311), hours of intubation (76 ± 204 vs 72 ± 249; P = .926), days of recovery room stay (6 ± 7 vs 8 ± 6; P = .453), or survival after HT (53 ± 54 vs 53 ± 52 months; P = .982).

Conclusions

Patients receiving a heart from a patient with an in-hospital RCA and subsequent hemodynamic stability have a similar outcomes to other HT patients.     

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.     

Patterns of severe injury in pediatric car crash victims: Crash Injury Research Engineering Network database

Background/Purpose

Motor vehicle crashes (MVCs) account for 50% of pediatric trauma. Safety improvements are typically tested with child crash dummies using an in vitro model. The Crash Injury Research Engineering Network (CIREN) provides an in vivo validation process. Previous research suggest that children in lateral crashes or front-seat locations have higher Injury Severity Scale scores and lower Glasgow Coma Scale scores than those in frontal-impact crashes. However, specific injury patterns and crash characteristics have not been characterized.

Methods

Data were collected from the CIREN multidisciplinary crash reconstruction network (10 pediatric trauma centers). Injuries were examined with regard to crash direction (frontal/lateral), restraint use, seat location, and change in velocity at impact (ΔV). Injuries were limited to Abbreviated Injury Scale (AIS) scores of 3 or higher and included head, thoracic, abdominal, pelvic, spine, and long bone (orthopedic) injuries. Standard age groupings (0-4, 5-9, 10-14, and 15-18 years) were used. Statistical analyses used Fisher's Exact test and multiple logistic regressions.

Results

Four hundred seventeen MVCs with 2500 injuries were analyzed (males = 219, females = 198). Controlling for ΔV and age, children in lateral-impact crashes (n = 232) were significantly more likely to suffer severe injuries to the head and thorax as compared with children in frontal crashes (n = 185), who were more likely to suffer severe spine and orthopedic injuries. Children in a front-seat (n = 236) vs those in a back-seat (n = 169) position had more injuries to the thoracic (27% vs 17%), abdominal (21% vs 13%), pelvic (11% vs 1%), and orthopedic (28% vs 10%) regions (P < .05 for all). Seat belts were protective for pelvic (5% vs 12% unbelted) and orthopedic (15% vs 40%) injuries (odds ratio = 3, P < .01 for both).

Conclusion

A reproducible pattern of injury is noted for children involved in lateral-impact crashes characterized by head and chest injuries. The Injury Severity Scale scores were higher for children in front-seat positions. Increased lateral-impact safety measures such as mandatory side curtain airbags may decrease morbidity. Furthermore, continued public education for positioning children in the back seat of cars is warranted.     

São Paulo Lung Transplantation Waiting List: Patient Characteristics and Predictors of Death

Introduction

Nowadays, lung transplantation (LTx) allocation in Brazil is based mainly on waiting time. There is a need to evaluate the equity of the current lung allocation system.

Objectives

We sought to (1) determine the characteristics of registered patients on the waiting list and (2) identify predictors of death on the list.

Materials and Methods

We analyzed the medical records as well as clinical and laboratory data of 164 patients registered on the waiting list from 2001 to June 2008. Predictors of mortality were obtained using Cox proportional hazards analysis.

Results

Patients who were registered on the waiting list showed a mean age of 36.1 ± 15.0 vs. 42.2 ± 15.7 years, considering those who did versus did not, die on the list, respectively (P = .054). Emphysema was the most prevalent underlying disease among the patients who did not die on the list (28.8%); its prevalence was low among the patients who died on the list (6.5%; P = .009). The following variables correlated with the probability of death on the waiting list: emphysema or bronchiectasis diagnosis (hazard ratio [HR] = 0.15; P = .002); activated partial thromboplastin time > 30 seconds (HR = 3.28; P = .002); serum albumin > 3.5 g/dL (HR = 0.41; P = .033); and hemoglobin saturation > 85% (HR = 0.44; P = .031).

Conclusions

Some variables seemed to predict death on the LTx waiting list; these characteristics should be used to improve the LTx allocation criteria in Brazil.     

Is there a role for surgery in the management of metastatic urothelial cancer? The M. D. Anderson experience

Purpose

Although rarely curative, chemotherapy remains the mainstay of treatment for metastatic urothelial cancer. The role of surgery for metastatic disease is not well established for urothelial cancer, but is sometimes undertaken in the face of persistent or recurrent disease that can be surgically resected.

Materials and Methods

We identified 31 patients with metastatic urothelial cancer undergoing metastasectomy with the intent of rendering them free of disease. All gross disease was completely resected in 30 patients (97%). The most frequently resected location was lung in 24 cases (77%), followed by distant lymph nodes in 4 (13%), brain in 2 (7%) and a subcutaneous metastasis in 1 (3%).

Results

Median survival from diagnosis of metastases and from time of metastasectomy was 31 and 23 months, respectively. The 5-year survival from metastasectomy was 33%. Median time to progression following metastasectomy was 7 months. Five patients were alive and free of disease for more than 3 years after metastasectomy.

Conclusions

The results in this highly selected cohort, with 33% alive at 5 years after metastasectomy, suggest that resection of metastatic disease is feasible and may contribute to long-term disease control especially when integrated with chemotherapy. Further prospective studies should be undertaken to better characterize the selection criteria and benefit from this intervention.     

The impact of surgical excision in chest wall rhabdomyosarcoma: a report from the Children's Oncology Group

Aims

Rhabdomyosarcoma (RMS) is the most common soft tissue tumor of childhood. Patient age, size, histologic finding, and site of the tumor are primary determinants of prognosis in RMS. Chest wall RMS is a site in which the limitations of surgical excision are realized. We aim to determine the impact of surgical excision in chest wall RMS.

Methods

A retrospective chart review was conducted of all 130 pediatric patients enrolled in the Intergroup Rhabdomyosarcoma Study (IRS) with chest wall rhabdomyosarcoma from the first (I) through fourth (IV) IRS with follow-up to June 2005. Median follow-up was 12.1 years (4.6-27.2 years).

Results

There was a significant improvement in failure-free survival (FFS) and overall survival (OS) between the first IRS study, I, and IRS-IV. The estimated FFS and OS at 5 years in IRS I was 30% and 40%, respectively, compared to 68% and 78%, respectively, in IRS-IV (P = .03 and P = .05, respectively). There was no association between histologic finding or size and FFS or OS. However, all patients who presented without metastasis had an FFS and OS of 49% and 61%, respectively, compared with metastatic patients, 7% and 7%, respectively (P < .001). Five-year FFS of group I, II, and III patients was 52%, 52%, and 45%, respectively, and OS was 65%, 60%, and 59%, respectively. There was no significant difference in 5-year FFS or OS in patients who had a complete resection (group I), complete resection with positive microscopic margins (group II), or biopsy or partial resection only (group III). In groups I to III patients, the local and regional failure rate at 5 years is 25% and 6%, respectively.

Conclusions

The most significant impact on outcome in chest wall RMS patients is metastatic disease at diagnosis. The locoregional failure rate is high but does not appear to impact survival. Alternative treatment strategies are needed for chest wall RMS, but aggressive surgical excision may not be necessary.     

Outcomes of intestinal failure—a comparison between children with short bowel and dysmotile intestine

Background

We investigated whether mortality, intestinal adaptation, and liver function differ between intestinal failure (IF) patients with either short bowel (SB) or bowel dysmotility (DM).

Patients and methods

Twenty-six consecutive patients with SB (n = 20) or DM (n = 6) treated between 2000 and 2007 were retrospectively assessed. Intestinal failure was defined as less than 25% of age-adjusted small intestinal length or dependence on parenteral nutrition (PN) more than 6 months.

Results

Median age-adjusted small intestinal length (17% vs 45%) and gestational age (35 vs 40 weeks) were (P < .05) shorter, whereas proportion of the remaining colon (86% vs 0%) was (P < .05) higher in the SB group relative to the DM group. Overall survival was 92%. Median peak serum bilirubin (80 vs 25 μmol/L) and rate of cholestasis (11/20 vs 0/6) were higher (P < .05) in the SB group. Short bowel rather than DM as an etiology of IF predicted weaning off PN (RR, 39.3; 95% confidence interval [CI], 1.43-526; P < .01) and development of cholestasis (risk ration [RR], 18.3; 95% CI, 0.658-127; P < .05). Three SB children developed liver failure and two died, whereas neither of these occurred in the DM group.

Conclusions

Children with SB are more likely to wean off PN but more prone to cholestatic liver disease than those with DM as an etiology of IF.     

Gastric malignancies in breast cancer survivors: Pathology and outcomes

Background

As the number of breast cancer survivors increases, the appearance of second malignancies and unusual metastatic patterns likely also is increasing. In particular, we and others have observed gastric malignancies in breast cancer survivors.

Methods

We reviewed 3 regional hospital system tumor databases, comprising 19,049 analytic breast cancer cases, to determine the number, types, and outcomes of subsequent gastric malignancies.

Results

Twenty-eight patients developed subsequent gastric malignancies, representing .15% of breast cancer survivors; 82% of patients had gastric symptoms. Overall survival for the cohort was 39%. Twenty-four patients (86%) had gastric primaries and 13 died of their second cancers. Four patients had gastric metastases; all had lobular histology in both their primary tumors and metastatic lesions. Five patients had gastrointestinal stromal tumors; all patients underwent resection and currently are alive.

Conclusion

Gastric symptoms in breast cancer survivors may represent malignant lesions, often second primaries. All gastric metastases in our series were of lobular histology.     

Antiviral prophylaxis versus preemptive therapy to prevent cytomegalovirus infection and related death in liver transplantation: a retrospective study with propensity score matching

Background

Cytomegalovirus (CMV), the most significant viral infection in liver transplant recipients, is addressed by 2 methods: Preemptive therapy (PT) or universal prophylaxis (UP).

Methods

We analyzed medical records including at least 1 year follow-up of patients who underwent liver transplantation from 2006 to 2009 in 3 tertiary hospitals. PT was used in 2 hospitals (PT group), whereas UP with valganciclovir for 3 months was adopted in the other hospital (UP group). The 2 groups were matched using propensity scoring by perioperative variables. We performed a 1:1 comparison of the efficacy of UP and PT.

Results

We analyzed 634 liver transplant patients, including 562 matched subjects. Baseline characteristics and underlying liver status were comparable. CMV immunoglobulin G of recipients was positive in 98.9% of the PT group and 99.3% of the UP group. CMV viremia episodes that required administration of an antiviral agent occurred in 26 (9.3%) PT and 37 (13.2%) UP subjects (P = .18). CMV-related mortalities were similar (0.7% vs 1.8%; P = .45), but all-cause mortality was higher in the PT group (18.5% vs 13.2%; P = .08).

Conclusion

The efficacy of PT was similar to UP to prevent CMV disease and related mortality among a group at moderate risk for CMV infection.     

Computed tomographic scan of the chest underestimates the number of metastatic lesions in osteosarcoma

Purpose

Survival in osteosarcoma correlates with complete resection of primary and metastatic disease. The feasibility of complete pulmonary metastasectomy using thoracoscopy has been raised. Because palpation is not possible, minimally invasive techniques require preoperative radiological enumeration and localization of metastases not presenting at the lung surface. We hypothesized that computed tomographic (CT) scanning underestimated the number of pulmonary metastases in these patients.

Methods

Institutional review board approval was obtained. We determined the association between the number of lesions identified by CT scanning and the number of metastases found at thoracotomies for metastatic osteosarcoma from May 1996 to October 2004. Correlations between CT findings and pathology results were computed using the Kendall τ-b correlation coefficient. Depth, in millimeters, from the pleural surface was measured for those lesions seen on CT scan.

Results

We analyzed 54 consecutive thoracotomies performed in 28 patients for whom complete imaging was available. Computed tomographic scanning was performed a median of 20 days before thoracotomy (range, 1-85 days). Correlation between the number of lesions identified by CT and the number of metastases resected at surgery was poor, with a Kendall τ-b correlation coefficient of 0.45 (P < .001). In 19 (35%) of 54 thoracotomies, CT scanning underestimated the number of pathologically proven, viable and nonviable metastases found by the surgeon. Accounting for viable metastases only, correlation between the number of lesions identified by CT and the number of metastases resected at surgery was 0.50 (P < .001), and CT scanning underestimated the number of viable metastases present in 14 (26%) of 54 thoracotomies. Many lesions (32%) were pleural-based, but nearly half (47%) were 5 mm or deeper from the pleural surface of the lung.

Conclusions

Even in the era of modern CT scanning, only a very rough correlation exists between CT findings and the number of lesions identified at thoracotomy. In more than one third of thoracotomies in our series, metastases would have been missed by any tactic besides manual palpation of the lung during open thoracotomy. Minimal access procedures should not be the approach of choice if the goal is resection of all pulmonary metastases in osteosarcoma.     

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.