A population-based study of tumor-node relationship,resection margins,and surgeon volume on gastric cancer survival

BACKGROUND: Gastric cancer surgery literature is conflicting. Two European level I randomized controlled trials refute Asian lesser level evidence promoting more radical resections. Population-based study evidence is undefined. METHODS: Using this study design we examined the overall survival, the tumor-node relationship, margins, and surgeon volume on gastric cancer survival in a Canadian province. RESULTS: Between 1991 and 1997, 577 (71 +/- 13 years 60% male) gastric adenocarcinomas were diagnosed in Northern Alberta (population 1.7 million). Respectively, median survival in months for stage I (n = 67) was 77, stage II (n = 55) 75, stage III (n = 155) 12, stage IV (n = 235) 3, and 65 unstaged (n = 65) 4. Five-year survival for T1N0 (n = 28) was 68% versus T1N1 (n = 7) 71% (P = 0.80); for T2N0 (n = 29) 58% versus T2N1 (n = 19) 58% versus T2N3 (n = 7) 29% (P = 0.08); for T3N0 (n = 33) 57%, versus T3N1 (n = 98) 9% versus T3N2 (n = 47) 0% versus T3N3 (n = 8) 0% (P < 0.0001). Median gastrectomy survival (months) in stage III was 15 months margin negative versus 8 months margin positive versus 6 bypass and 5 for no surgery (P = 0.0004). In stage IV it was margin positive 8 versus margin negative 6 (nonsignificant), bypass 3 versus no surgery 2. Five-year survival for surgeons doing fewer than 20 gastrectomies (n = 196 patients) was 29% (median 1.4 years) versus 35% (median 2.3 years; n = 72 patients) for surgeons doing 20 or more (n = 4; P = 0.325). CONCLUSIONS: From these population data we conclude that (1) few patients present with "curable" gastric cancer, (2) node negative or small gastric cancer survival is not influenced by nodal stage, (3) positive margin resection survival is better than bypass or no surgery in stage IV but not stage III disease, and (4) surgeon volume does not appear to influence patient survival.     

TREATMENT OF ABDOMINAL AORTIC ANEURYSM DISEASE IN THE 9TH AND 10TH DECADES OF LIFE

Background : The appropriate management of patients who are older than 80 years of age and who present with an abdominal aortic aneurysm (AAA) remains controversial. While it appears that elective repair can be performed safely, appropriate management of these patients in the emergency situation is unclear. The purpose of the present study was to examine the results obtained in treating this elderly group in the elective and emergency setting, by operation and conservative techniques at St George Hospital, Kogarah. Methods : Between January 1987 and December 1994 85 patients older than 80 years of age were treated for AAA. These patients were divided into four groups: I, elective presentatiodno surgery; II, elective presentatiodelective surgical repair; III, emergency presentatiodsurgical repair; and IV, emergency presentatiodconservative treatment. We examined age, sex, size of AAA, mode of presentation, type of treatment, length of survival and cause of death. Results : The mean age of the total group (n = 85) of patients was 84 years (range: 80–94). The mean AAA diameter for this group was 5.6 cm (95% CI: 5.2–6 cm). The diameters for group I (n= 40), II (n= 22), III (n= 16) and IV (n = 7) were 4.9 cm (4.4–5.5, 95% CI), 5.7 (4.9–6.5 CI), 7.0 (6.1–7.7 CI) and 6.2 (5.2–7.2 CI), respectively. The median survival for groups I, II, III and IV was 18, 38.5, 0.25 and 0 months, respectively. Group II had a longer survival than any other group (P= 0.015). and group IV had a shorter survival than the total group (P= 0,001). However, the length of survival was no different for III versus IV (P= 0.146). Deaths in each group were due to the following reasons. I: cardiopulmonary events (14), rupture (3), malignancy/sepsis (3); II: cardiopulmonary events (3), rupture (thoracic aneurysm) (2). malignancy (1); III: rupture (10), malignancy (1); and (IV): rupture (6), malignancy (1). Conclusions : Elective surgical repair offers the best management option for AAA in patients older than 80 years of age. Death may still occur from progression of aneurysmal disease at other sites. An aggressive surgical approach to the management of haemodynamically unstable patients in this age group is of questionable benefit.     

Palliative Operation for Cancer of the Head of the Pancreas: Significance of Pancreaticoduodenectomy and Intraoperative Radiation Therapy for Survival and Quality of Life

p < 0.05). Among TNM stage III patients, a significant difference in survival was observed between surgical bypass associated with IORT and bypass alone ( p < 0.05); the median survival time of the IORT group was 10 months, whereas that of the control group was 5 months. In addition, HFS of 3 months or longer was achieved in 83.3% of patients who underwent bypass with IORT but in only 25.0% of the patients who underwent surgery alone ( p < 0.01). The addition of IORT to palliative PD neither prolonged survival nor improved HFS. These results show the beneficial effect of palliative PD on QOL, and the efficacy of IORT for survival and QOL was proved in cases with stage III pancreatic cancer who underwent surgical bypass. For patients subjected to palliative PD, however, IORT is not thought to be beneficial for either survival or QOL.     

Surgery of esophageal cancer]

From 1975 through 1988, 257 patients with carcinoma of the thoracic oesophagus have been treated in our department. Operability was 90% (232/257), overall resectability 77% (198/257) and for the operated group 85% (198/232). Hospital mortality was 9.6% but decreased to 3% over the period 1986-1988. There were 65% squamous cell epitheliomas and 35% adenocarcinomas. pTNM staging was as follows: Stage I: 11.6%, Stage II: 23.2%; Stage III: 37.9%; Stage IV: 27.3%. Overall survival was 62.5% after one year, 42.4% after 2 years and 30% after 5 years. According to the pTNM staging 5-year survival was 90% for stage I, 56% for stage II, 15.3% for stage III. There was no 5-year survival for patients with stage IV carcinoma. There were statistically significant differences according to tumour localisation, pathologic type, sex and age. Introducing extensive resection and extended lymphadenectomy seems to improve significantly survival in patients in whom an operation with curative intention was performed. The 1-year survival was 90.8 versus 72%, 2-year survival was 81 versus 46% and 5-year survival was 48.5 versus 41% for respectively radical and non-radical resections. Radical surgery in stage IV carcinoma substantially prolonged median survival from 6 months to 1 year. From this study it can be concluded that in experienced hands, surgery today offers the best chances for optimal staging, potential cure and prolonged high-quality palliation.     

Liver transplantation for hepatocellular carcinoma: a single European centre experience

Background With respect to deficient donor grafts and the risk of tumour recurrence, indication for orthotopic liver transplantation (OLT) is still controversial. OLT offers the only chance for both the tumour and the underlying liver disease to be eliminated in patients with hepatocellular carcinoma (HCC) and cirrhosis. The aim of this study was to assess survival and related factors of recurrence.Patients and methods This retrospective study analyses data from 45 patients with HCC (UICC stage I/II, n=16; III, n=13; IV, n=12) treated with OLT between 1992 and 2002 in our centre. There were 39 primary tumours and two recurrent ones after previous surgical resection. Four perioperative deaths were excluded from analysis.Results Mean follow-up was 50.4 months. Five-year rates after OLT were 64% for overall survival, 78% for disease-specific survival, 73% for recurrence-free survival, and 22% for tumour recurrence. No tumour recurrence has been observed so far in patients with tumours of UICC stage I/II. None of the patient characteristics had a significant impact on survival, while tumour stage was significantly correlated with freedom from recurrence.Conclusion Our results demonstrate that the risk of recurrent HCC in liver transplanted patients is low for small and solitary tumours with no vascular invasion (UICC I/II). Even in advanced tumour stages (UICC III/IV), there is a real chance of cure or at least a survival benefit in selected patients.Presented at the workshop on malignant tumours in organ transplantation, Department of Surgery, Ludwig Maximillians University, Munich, 4–5 April 2003     

Adrenocortical carcinomas: surgical trends and results of a 253-patient series from the French Association of Endocrine Surgeons study group

Because of the rarity of adrenocortical carcinoma, survival rates and the prognosis for patients who have undergone operation are not well known. The purpose of the French Association of Endocrine Surgery was to evaluate these factors over an 18-year period. A trend study was associated to assess changes in the clinical and biochemical presentations as well as the surgical evolution. A total of 253 patients (158 women, 95 men) with a mean age of 47 years were included. Cushing syndrome was the main clinical presentation (30%), and hormonal studies revealed secreting tumors in 66% of the cases. Altogether, 72% (n= 182) of patients underwent resection for cure, and 41.5% (n= 105) of them had an extensive resection because of metastatic cancer. A lymphadenectomy was performed in 32.5% (n= 89) of the cases. The operative mortality was 5.5% (n= 14). Patients were given mitotane as adjuvant therapy in 53.8% of the cases (n= 135). The results of staging were stage I in 16 patients (6.3%), stage II (local disease) in 126 patients (49.8%), stage III (locoregional disease) in 57 patients (22.5%), and stage IV (metastases) in 54 patients (21.3%). Neither tumor staging nor the rate of curative surgery changed during the study period. More subcostal incisions were performed, and the use of mitotane increased significantly. The 5-year actuarial survival rates were 38% overall, 50% in the curative group, 66% for stage I, 58% for stage II, 24% for stage III, and 0% for stage IV. Multivariate analysis showed that mitotane benefited only the group of patients not operated on for cure. A better prognosis was found in patients operated on after 1988 (p= 0.04), in those with precursor-secreting tumors (p= 0.005), and in those at local stages of the disease (p= 0.0003). Thus mitotane benefited only patients not operated on for cure. Curative resection, precursor secretion, recent diagnosis, and local stage were favorably associated with survival.     

Adjuvant chemotherapy with 5-FU,adriamycin, and mitomycin-C (FAM) versus surgery alone for patients with locally advanced gastric adenocarcinoma: A southwest oncology group study

Purpose: To evaluate FAM [5-FU (5-fluorouracil), doxorubicin, mitomycin C] chemotherapy as adjuvant therapy for patients with resected TNM stage I, II, or III gastric carcinoma. Patients and Methods: One hundred ninety-three eligible patients were accrued from 1978 to 1991 in a phase III trial comparing six cycles (1 year) of postoperative FAM chemotherapy with observation only. Results: The median follow-up on this study was 9.5 years. For all patients, no differences (log-rank analysis) in disease-free survival (p=0.45) and overall survival (p=0.57) between FAM therapy (93 cases) and surgery (100 cases) were observed. Quality of surgical resection affected survival irrespective of FAM use. Cases with curative resection, defined in a retrospective review of pathology and surgical reports as cases having no evidence of residual disease in the abdomen and tumor-free margins >1 cm, had superior survival compared to cases not meeting these requirements (p<0.001). FAM was well tolerated with 6% (five of 90) of cases demonstrating grade IV hematologic toxicity. There were two drug-related fatalities (one cardiomyopathy, one hematolytic uremic syndrome). Conclusion: FAM is not effective adjuvant therapy for TNM stage I, II, and III patients with resected gastric cancer. Future adjuvant studies must emphasize prospective surgical quality control to assure enrollment of appropriately staged and resected cases and wide participation to assure adequate case accrual over a reasonable period. Address reprint requests to Southwest Oncology Group (SWOG-7804), Operations Office, 14980 Omicron Drive, San Antonio TX 78245-3217, USA.     

A population-based competing-risks analysis of survival after nephrectomy for renal cell carcinoma

ObjectivesVariability in survival after surgical treatment is observed in patients with renal cell carcinoma (RCC), thereby affirming the heterogeneity of the disease. The aim of our study was to provide a clinically relevant and detailed assessment of survival following surgical excision in patients with RCC of all stages according to age, stage, and grade.Materials and methodsA retrospective population-based analysis of 42,090 patients in the United States who were treated with partial nephrectomy (PN) or radical nephrectomy (RN) for RCC of all stages between the years 1988 and 2008 was performed. Competing-risks Poisson regression analyses focusing on cancer-specific mortality (CSM) or other-cause mortality (OCM) were executed. Stratification was performed according to age groups (≤59, 60–69, 70–79, and ≥80 y), the American Joint Committee on Cancer stage (I, II, III, and IV), and the Fuhrman grade (I–II and III–IV).ResultsIncreasing stage was associated with higher CSM rates (from 2%–9% to 54%–79% for stage I and IV), regardless of age. Similarly, high tumor grade was associated with higher CSM rates (from 2%–64% to 6%–79% for low and high grade). However, OCM was nonnegligible amongst persons aged 70 to 79 years (11%–24%) and ≥80 years (17%–44%), regardless of stage and grade. In subanalyses focusing on stage I RCC, CSM (3%–10%) rates were slightly higher for RN-treated patients, regardless of age and grade. However, in individuals aged 70 to 79 years with high-grade RCC, OCM rates were slightly higher for PN relative to RN (25.5% vs. 23.5%). In those aged ≥80 years, OCM rates were higher for PN compared with RN, both for low-grade (39.4% vs. 32.7%) and high-grade disease (52.0% vs. 42.8%).ConclusionsTumor grade and American Joint Committee on Cancer stage represent important prognostic factors for the prediction of CSM, despite adjustment for patient age. However, OCM rates were nonnegligible in elderly individuals (≥70 y) with low-grade and stage I to III RCC.     

Adrenocortical Carcinoma: Is Prognosis Different in Nonfunctioning Tumors? Results of Surgical Treatment in 31 Patients

From 1980 to 1998 a series of 265 patients with adrenal tumors underwent surgery, with an adrenocortical carcinoma found in 31 (11.7%). Altogether, 17 (54.8%) patients (group A) had Cushing syndrome (n= 15) or virilization (n= 2), and 14 (45.2%) patients (group B) had nonfunctioning adrenal tumors. Tumor staging was as follows: (groups A/B): stage I, n= 5 (3/2), stage II, n= 14 (9/5), stage III, n= 5 (1/4), stage IV, n= 7 (4/3) patients. There were 12 (38.7%) men and 19 (61.3%) women (median age 51 years, range 25–73 years), and the size of the mass ranged from 3.5 to 20.0 cm (median 8.0 cm), with no differences (p= NS) between groups A and B. Two (6.4%) patients (stage IV) did not undergo surgery and received only palliative drug treatment; 6 (19.4%) were treated with debulking surgery; 15 (48.4%) had unilateral adrenalectomy; and 8 (25.8%) had an extended adrenalectomy. Eighteen (58.0%) patients underwent adjuvant postoperative mitotane treatment, and in 8 (25.8%) patients one or more reoperations for recurrence were required. Nine (29.0%) patients are still alive with a mean follow-up of 34 months; 22 (71.0%) died 2 to 60 months (median 20 months) after surgery. The overall 2- and 5-year survival rates were 62.1% and 10.3%, with no difference (p= NS) between groups A and B. The survival rates at the 1- and 3-year follow-ups were 90.3% and 32.3% (stages I and II) and 71.0% and 6.5% (stages III and IV). In conclusion, adrenocortical carcinoma remains a highly malignant tumor, and stage III–IV patients still have a poor prognosis; but nonfunctioning tumors do not seem to be more aggressive.     

Multimodality Treatment of Thymoma: A Prospective Study

Background. Thymomas are a heterogeneous group of tumors. Treatment of invasive lesions is not well standardized. The aim of this study is to propose a clinicopathologically based protocol for multimodality therapy.

Methods. Between 1965 and 1988, we operated on 83 patients with thymoma who did not receive standardized adjuvant therapy. In 1989, on the basis of the retrospective analysis of the data, we started a multimodality therapy protocol and used it for 65 patients. Twelve patients had medullary thymoma (11 stage I and 1 stage II), 13 had mixed type (6 stage I and 7 stage II), and 40 had cortical thymoma (4 stage I, 11 stage II, 12 stage III, and 13 stage IV). We considered three groups. Group I (n = 18 patients), benign thymoma, included stage I and II medullary and stage I mixed thymomas; radical resection with no adjuvant therapy was performed. Group II (n = 22), invasive thymoma, included stage I and II cortical and stage II mixed thymomas; postoperative chemotherapy plus radiotherapy was always administered. Group III (n = 25), malignant thymoma, comprised stage III and IV cortical thymomas and stage III mixed thymomas; resectable stage III lesions were removed, and highly invasive stage III and stage IV lesions underwent biopsy, neoadjuvant chemotherapy, and surgical resection; postoperative chemotherapy and radiotherapy was administered to all patients.

Results. The 8-year survival rate for patients in stages I, II, III, and IV was 95%, 100%, 92%, and 68%, respectively. Patients with medullary thymoma had a 92% 8-year survival rate; those with mixed type, 100%; and those with cortical thymoma, 85%. Group I had an 8-year survival rate of 94%; group II, 100%; and group III, 76%. Survival was compared with that of patients operated on before 1989: differences were not significant for group I; survival improved in group II (100% versus 81%; p = not significant); and group III showed significant improvement (76% versus 43%; p < 0.049).

Conclusions. Multimodality treatment with neoadjuvant chemotherapy and adjuvant chemotherapy plus radiotherapy may improve the results of radical resection and the survival of patients with invasive and malignant thymoma.     

GASTRIC CANCERS IN SINGAPORE: POOR PROGNOSIS ARISING FROM LATE PRESENTATION

Background : Mortality rates from gastric cancer, apart from those derived from Japanese series, remain poor. This paper sought to determine the present outcome of gastric carcinoma in a predominantly Chinese population in Singapore. Prognostic factors useful in predicting survival were also evaluated in this population. Method : All cases of histologically confirmed gastric adenocarcinoma presenting in 1992 were entered into a prospective database. Prognostic factors related to age, sex, site of disease, depth of invasion, histological grade, nodal status and stage of disease were evaluated in patients with resectable disease to determine their utility in predicting survival. Results : Of 1310 consecutive patients with histologically proven adenocarcinomas, 37% had distant metastases at presentation predominantly in the liver (21%) and peritoneal cavity (20%). Sixty-four per cent of patients underwent surgery and in only 51% of these patients was resection of the turnour possible. Stages 111 and IV (T4N2) locally advanced disease were present in 38% of patients. Thus the majority of patients presented with late or metastatic disease (75%, stages 111 and IV). Sixty per cent of patients were alive at I year and 40% at 2 years after resection of the tumour (Kaplan-Meier survival plots). In contrast, no patient survived longer than a year if the tumour was not resectable (P < 0.001, log-rank test). Median survival of patients without surgery was 12 weeks. Median survival for patients with resected stage IV disease was 23 weeks, compared to 18 weeks after surgical bypass. Age, sex, site, depth of invasion and histological grade did not significantly predict survival. Patients with node-negative disease survived longer (2 year, 70%) than those with nodal involvement (2 years, 44%; P = 0.06, log-rank test). Pathologic staging with the TNM system was useful in predicting survival (P < 0.001). Sixty per cent of patients with stage I and II disease were alive at 2 years compared to 54% with stage III disease and 0% with stage IV disease. Conclusion : The prognosis of stomach cancer remains poor, due predominantly to late presentation. Pathologic TNM staging and nodal status were useful in predicting survival outcome after resection. If the tumour were resectable, survival was appreciable even in patients with advanced stage III (2 years, 54%) and stage IV (1 year, 40%) disease. Strategies to improve outcome should focus on early detection of gastric carcinomas.     

Outcomes of free vascularized fibular graft for post-traumatic osteonecrosis of the femoral head

IntroductionOsteonecrosis of the femoral head (ONFH) can occur after traumatic injuries of the hip. Surgical treatment with total hip arthroplasty (THA) may not produce lifelong viability in younger patients. Free vascularized fibular graft (FVFG) has become a reliable method to delay or even avoid THA in this patient population by aiming to correct loss of viable bone through vascularized autologous bone transfer. The purpose of this study was to evaluate the longevity and outcomes of FVFG for traumatic hip injuries resulting in ONFH.MethodsWe performed a retrospective review of our institutional database of patients who had undergone FVFG from 1980-2006 for post-traumatic ONFH and had a minimum follow-up of 5 years. Data collected included demographics, pre-operative Urbaniak ONFH staging, Harris Hip scores (HHS), SF-12 scores, and conversion to THA.ResultsSeventy-two hips in 68 patients met inclusion criteria. Mean follow-up was 11.6 years (range 5.1–33.2 years). Etiology included femoral neck fracture in 36 patients (61%), hip dislocation in 7 (12%), trauma without fracture or dislocation in 11 (19%), and femoral neck nonunion in 5 (8%). The most common stage at presentation was stage IV (48 patients). Graft survival at final follow-up (mean 10.9 years) was 64%, with mean time to conversion to THA of 8.4 years in those that did not survive (36%). There was no difference between THA conversion rates in hips with pre-collapse (Stage I and II) versus impending or post-collapse (Stage III or IV) lesions (p = 0.227). In hips with surviving grafts at final follow-up, mean HHS improved from 56.7 to 77.3 (SD 24.57, range 69–93), a mean improvement of 20.6 (p < 0.001).ConclusionsOur study reveals improvement in HHS in surviving FVFG and an acceptable overall THA conversion rate at mid to long term follow-up in Urbaniak stage I through IV hips. FVFG remains a viable option for treatment in younger patients with pre- and post-collapse (stage IV) ONFH lesions secondary to hip trauma.     

Composite grafting for distal digital amputation with respect to injury type and amputation level

Abstract

Purpose. This study evaluated the composite graft survival rate in distal digital amputations with respect to injury type and amputation level. Methods. Twenty-seven patients with complete fingertip amputations (32 digits) distal to the distal interphalangeal joint who were treated by composite grafting from January 2010 to February 2012 were enrolled. Injury type was classified as clean-cut, blunt-cut, or crush-avulsion. Amputation level was classified according to Ishikawa’s classification: subzones I–IV. Graft survival was categorised as complete, partial, or no survival. Results. The graft was more likely to exhibit complete survival in clean-cut injuries (50%) than in blunt-cut (10%) or crush-avulsion injuries (12.5%). However, when complete and partial survival were combined, there was no significant difference among injury types (clean-cut = 83.3%, blunt-cut = 70.0%; crush-avulsion = 68.8%). Composite grafting in sub-zone I provided good results (complete survival = 50%; partial survival = 50.0%; no survival = 0%). When complete and partial survival were combined, there was no significant difference with respect to amputation level except sub-zone I (II = 70.6%; III = 66.7%; IV = 60%). In sub-zone II, clean-cut injuries exhibited better graft survival than blunt-cut or crush-avulsion injuries. In sub-zones III and IV, no complete graft survival was observed. Conclusion. In conclusion, all types of injuries in sub-zone I and clean-cut injuries in sub-zone II are candidates for composite grafting. Blunt-cut and crush-avulsion injuries in sub-zone II are marginal candidates for composite grafting. Any type of injury in sub-zone III or IV is contraindicated for composite grafting and should be treated by microanastomosis.     

Surgical and Chemotherapy Treatment Outcomes of Goblet Cell Carcinoid: A Tertiary Cancer Center Experience

Background Goblet cell carcinoid (GCC) is a rare malignant tumor with distinct histological and clinical features. Our goals were to review the surgical and chemotherapy outcomes of patients with GCC. Methods We performed a retrospective review of the Mayo Clinic database from 1984 to 2004 with a prospective follow-up of 57 patients with GCC. Results The age at diagnosis (mean ± SE) was 55 ± 13 years. The most common presentations were right lower quadrant pain mimicking appendicitis (70%) and right lower quadrant or pelvic mass (25%). Only patients with T4 lesions had positive mesenteric nodes, with a frequency of 28%. Fifty percent of female patients had metastasis to the ovaries. The disease-specific 5-year survivals for stages I, II, III, and IV were 100%, 76%, 22%, and 14%, respectively; the overall mean survival was 47 ± 3 months. All stage I patients had simple appendectomy. The overall 5-year survival rates for patients with combined stages II to IV who underwent appendectomy versus right hemicolectomy were 43% and 34%, respectively (P = .604). The corresponding survival rates for adjuvant chemotherapy versus no chemotherapy were 32% and 27%, respectively (P = .151). Conclusions The prognosis for patients with GCC tumors correlates well with the American Joint Committee on Cancer stage at initial presentation. Appendectomy alone seems adequate for stage I disease. For staging purposes, right hemicolectomy is appropriate for T4 tumors or stage II to III disease provided that it can be performed with minimal risk. Surgical debulking is a consideration but is controversial. Adjuvant chemotherapy with 5-fluorouracil and leucovorin regimen is minimally effective against GCC.     

Asymptomatic degenerative mitral regurgitation repair: Validating guidelines for early intervention

IntroductionMitral repair for asymptomatic (New York Heart Association [NYHA] class I) degenerative mitral regurgitation (MR) is supported by the guidelines, but is not performed often. We sought to determine outcomes for asymptomatic patients when compared with those with symptoms.MethodsBetween 2004 and 2018, 1027 patients underwent mitral replacement (22) or repair with or without other cardiac surgery (1005), the latter being grouped by NYHA class: I (n = 470; 47%), II (n = 408; 40%), or III/IV (n = 127; 13%). Statistical analyses included propensity score matching and weighting, and multistate models.ResultsThe proportion of patients designated as NYHA class I undergoing surgery increased steadily during this period (P < .001). Overall, 30-day mortality was 0.4%, and zero for patients designated NYHA class I. Unadjusted 10-year survival was significantly greater in patients designated NYHA class I compared with II and III/IV (P < .001). Freedom from reoperation at 10 years was 99.8% overall, and 100% for patients designated NYHA class I. In patients designated as NYHA class I, predischarge and 10-year moderate MR were 0.7% and 20.1%, whereas more than moderate was zero and 0.6%. Preoperative ejection fraction less than 60% was associated with late mortality (P = .025). After covariate-adjustments, freedom from MR and tricuspid regurgitation were not statistically significantly different by NYHA class. However, overall survival was significantly worse in patients with NYHA class III/IV, compared with class II.ConclusionsMitral repair in asymptomatic patients is safe and durable. Careful monitoring until class II symptoms is appropriate. However, repair before ejection fraction decreases below 60% is important for late overall survival.     

Perioperative Morbidity and Mortality in Elderly Gynecological Oncological Patients (≥70 Years) by the American Society of Anesthesiologists Physical Status Classes

Background: We evaluated the morbidity and mortality associated with American Society of Anesthesiologists (ASA) classes III and IV versus ASA classes I and II in elderly women (70 years) undergoing gynecological oncological surgery.Methods: From 1986 to 2000, we retrospectively collected patients 70 years of age undergoing oncological gynecological surgery. The study population consisted of 121 ASA class III and IV patients. The control group consisted of the same number of patients with ASA classes I and II, and these were matched to study patients (1:1) by clinical and surgical data. The morbidity and mortality of patients with ASA status III and IV were analyzed before and after 1992.Results: In ASA class III and IV patients, compared with ASA class I and II, a higher rate of severe morbidity (P = .000) occurred, whereas the median postoperative stay was similar (8 days). No differences between patients with ASA class III and IV and ASA class I and II for median operative time, transfusion rate, or median blood loss were found. Mortality was 3% in ASA classes III and IV.Conclusions: Our study suggests that surgery in elderly gynecological oncological patients aged 70 years with ASA class III or IV results in an acceptable perioperative morbidity and mortality rate.     

Surgery for Ductal Adenocarcinoma of the Pancreatic Head: Staging, Complications, and Survival after Regional versus Extended Lymphadenectomy

The purpose of this study was to evaluate the influence of regional versus extended lymphadenectomy on survival after partial pancreaticoduodenectomy for pancreatic cancer. From October 1988 to December 1991 (Department of Surgery, University of Hamburg) and from January 1992 to March 1998 (Department of Surgery, University of Kiel) 72 patients with histologically proven ductal adenocarcinoma of the pancreatic head were treated. Partial pancreaticoduodenectomy with regional lymphadenectomy was performed in 26 patients. In 46 patients lymphadenectomy was expanded to include extended retroperitoneal lymphatic and connective tissue clearance. Comparing these two groups and including only patients with R0 resections (n= 58) no significant differences in long-term survival could be shown. The following parameters were shown to have a significant or nearly significant influence on long-term survival: (1) stage of the disease: The 5-year survival of patients with stage I/II pancreatic head cancer was 63%, compared to 15% in patients with stage III/IV a + b of the disease (p= 0.0087). (2) Grading: The 1-year survival of patients with well or moderately differentiated tumors was 55%, compared to 0% for patients with poorly differentiated ductal adenocarcinoma (p= 0.0022). (3) N stage: The 5-year survival of patients in N0 stage was 46.9%, compared with 15% for N1 stage patients. The difference was not quite significant (p= 0.081). (4) Portal vein involvement: The 1-year survival was 0% in patients with R0 resections and histologically proven tumor infiltration of the portal vein, compared to 63% for patients with curative resections without portal vein involvement (p= 0.0063). In conclusion our data indicate that extensive retroperitoneal tissue clearance during pancreaticoduodenectomy for ductal pancreatic cancer does not improve survival compared to regional lymphadenectomy restricted to the right side of the mesenteric artery.     

Stage-specific conditional survival in renal cell carcinoma after nephrectomy

ObjectivesConditional survival (CS) represents the probability that a cancer patient will survive some additional number of years, given that the patient has already survived for a certain period of time. CS estimates, therefore, serve as better measures of survival probability compared to standard estimates as they incorporate patient survivorship. Stage-specific CS has not been widely investigated in the context of renal cell carcinoma (RCC) after nephrectomy. We aimed to examine this phenomenon.Materials and methodsWe analyzed retrospective data on a population-based cohort of 87,225 surgically-treated RCC patients extracted from the Surveillance, Epidemiology, and End Results database (2004–2015) and on a similar validation cohort of 1,642 patients from our institution (1995–2015). 5-year cancer-specific CS estimates stratified by stage were obtained using the Kaplan–Meier method. Multivariable Cox regression analyses were performed to evaluate the possible variation in risk of cancer-specific mortality by stage at nephrectomy and with increasing postoperative survivorship.Results5-year cancer-specific survival rates at time of nephrectomy for stage I, II, III, and IV patients in the population-based cohort were 97.4%, 89.9%, 77.9%, and 26.7%, respectively. Improvement in 5-year CS was mainly observed in surviving patients with advanced-stage disease; given 1, 2, 3, 4, and 5 years of survivorship after nephrectomy, the subsequent 5-year cancer-specific survival rates were, respectively, 79.3% (+1.8% increase over previous survival probability), 81.3% (+2.5%), 83.3% (+2.5%), 84.3% (+1.2%), and 85.1% (+1.0%) for stage III, and 34.6% (+29.6%), 42.5% (+22.8%), 49.0% (+15.3%), 55.7% (+13.7%), and 58.6% (+5.2%) for stage IV. A similar trend was established in the validation cohort. Findings were confirmed upon multivariable analyses.ConclusionsCS after nephrectomy for RCC varies dramatically by stage of disease. Gains in CS over time occur primarily among patients with advanced-stage disease. Stage-specific CS estimates can help urologists better plan postoperative surveillance for RCC patients.     

The Benefits of Interferon Treatment in Patients Without Sustained Viral Response After Living Donor Liver Transplantation for Hepatitis C

Although it has been recognized that interferon (IFN) treatment is crucial for recurrent hepatitis C after liver transplantation, its benefits have not been determined among patients without a sustained viral response (SVR).

Methods

Eighty patients who received IFN plus ribavirin treatment after living donor liver transplantation were grouped as follows: group I (n = 18) SVR; group II (n = 25) no-SVR but viral response [VR] positive; Group III (n = 13) no-VR but biochemical response [BR] positive; and group IV (n = 24) no-VR and no-BR.

Results

In groups II and III, not only the histological activity grade and fibrosis stage, but also the serum parameters including transaminases and type IV collagen were stable for 3 years after induction of IFN-based treatment. In group I, the activity grade and fibrosis stage significantly improved (P < .01). In group IV, the fibrosis stage significantly deteriorated (P < .01); the serum transaminases and type IV collagen were significantly higher than the other groups (P < .01). The mean duration of IFN treatment was significantly longer among group II (96 weeks) compared with the other cohorts (P < .05). The 5-year graft survival rate in groups II (91%) and III (100%) were comparable to those of group I (100%); group IV (62%) was significantly lower than the other groups (P < .05).

Conclusion

IFN treatment was beneficial even among subjects with IFN-dependent VR or BR, although they did not achieve SVR.     

Interleukin-6 Blood Level Is Associated With Circulating Carcinoembryonic Antigen and Prognosis in Patients With Colorectal Cancer

Abstarct Background: Interleukin-6 (IL-6) is an important proinflammatory cytokine that has multiple effects on stimulating inflammation and cell growth. Experimental data suggest that carcinoembryonic antigen (CEA) induces the systemic production of IL-6 and that IL-6 may stimulate tumor cell growth at metastatic sites. We tested the hypothesis that blood concentrations of IL-6 are associated with the amount of circulating CEA and with prognosis in patients with colorectal cancer.Methods: CEA and IL-6 concentrations were measured by using enzyme immunoassay in preoperative serum samples from 208 patients with stages I through IV colorectal cancer.Results: Linear regression analysis showed a significant association between serum values of CEA and IL-6 (r = .544; R² = .296; P < .001). Patients with stage III and stage IV disease had a significantly higher IL-6 serum concentration than those with stage I and stage II disease. In patients with stages I through III, 5-year survival was 83% in cases with concentrations of IL-6 at 10 pg/ml or less (n = 94) and 56% in cases with IL-6 concentrations of more than 10 pg/ml (n = 54; P = .001; median follow-up time, 46 months). By using multivariate analysis, an IL-6 concentration of more than 10 pg/ml was an independent prognostic factor of survival (relative risk = 1.820; P = .020).Conclusions: In patients with colorectal cancer, blood concentration of IL-6 is associated with high circulating CEA and advanced stage. Furthermore, an IL-6 concentration of more than 10 pg/ml is an independent negative prognostic marker of survival.Presented at the 52nd Annual Meeting of Society of Surgical Oncology, Orlando, Florida, March 4–7, 1999.