Surgical resection of grade II astrocytomas in the superior frontal gyrus

OBJECTIVE: Surgery in the superior frontal gyrus partially involving the supplementary motor area (SMA) may be followed by contralateral transient weakness and aphasia initially indistinguishable from damage to the primary motor cortex. However, recovery is different, and SMA deficits may resolve completely within days to weeks. No study has assessed the distinct postoperative deficits after tumor resection in the SMA on a homogeneous patient group. METHODS: Twenty-four patients with World Health Organization Grade II astrocytomas in the superior frontal gyrus consecutively treated by surgery were studied. Degree and duration of postoperative deficits were evaluated according to tumor location and boundaries via magnetic resonance imaging scans, intraoperative neuromonitoring results, and extent of tumor resection. RESULTS: Postoperatively, motor deficits were evident in 21 of 24 and speech deficits in 9 of 12 patients. Motor function quickly recovered in 11 and speech function in 3 patients. None of the 12 patients in whom the posterior tumor resection line was at a distance of more than 0.5 cm from the precentral sulcus experienced persistent motor deficits. Eight of these patients developed typical SMA syndrome with transient initiation difficulties. Seven of 12 patients in whom the tumor extended to the precentral sulcus still had motor deficits at the 12-month follow-up assessment. CONCLUSION: Surgery for Grade II gliomas in the superior frontal gyrus is more likely to result in permanent morbidity when the resection is performed at a distance of less than 0.5 cm from the precentral gyrus or positive stimulation points. Therefore, cortical mapping of motor and speech function, in critical cases under local anesthesia with the patient as his or her own monitor, is recommended; resection should be tailored to obtain good functional outcome and maintain quality of life.     

Surgical resection improves survival in the treatment of early gastric lymphomas

Gastric lymphomas are a relatively rare form of malignancy and controversy about their optimum treatment still exists. To date, there have been no studies directly comparing results of medical therapy alone versus a combination of surgery plus medical therapy. We reviewed our experience in the three teaching hospitals of the University of Massachusetts Medical School to determine the role of surgery in the management of early gastric lymphoma. Statistics were evaluated by means of chi-square, log-rank, and Kaplan-Meier curve analysis where appropriate. Using tumor registry data, 39 patients were treated for early disease at our medical school from 1980 to 1998. Patients treated with surgery plus chemotherapy and radiation had a 90% 5-year survival compared to patients who received chemotherapy and radiation alone (55% 5-year survival; P < 0.01). When we compared all patients on an intention-to-treat basis (patients preoperatively thought to have early-stage disease), there was still a significant survival benefit with the addition of surgery to their management. Because this is an uncommon disease, there are no large prospective studies examining treatment. Based on our retrospective experience, surgical resection should be considered an important adjunct in the treatment of gastric lymphomas in early-stage disease. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.     

A population-based study of the incidence and survival rates in patients with pilocytic astrocytoma

OBJECT: The incidence of pilocytic astrocytomas and the rate of patient survival were analyzed in a population-based study in the canton of Zürich, Switzerland. METHODS: Between 1980 and 1994, 987 astrocytic and oligodendroglial tumors were diagnosed, of which 55 (5.5%) were pilocytic astrocytomas. The incidence rate, adjusted to the World Standard Population, was 4.8 per 1 million per year. The mean age at clinical diagnosis was 19.6 +/- 12.7 years, and the male/female ratio was 1.12. The most frequent tumor sites were the cerebellum (40%), followed by supratentorial locations (35%), the optic pathway and hypothalamus (11%), and the brainstem (9%). The mean follow-up period was 12 years. Observed survival rates were 100% at 5 years and 95.8% at 10 years after diagnosis (relative survival rate at 10 years: 96.8%). Seven patients (13%) received postoperative radiotherapy, but this did not significantly affect survival. In all patients the tumors were histologically classified as WHO Grade I, except in two patients who had anaplastic pilocytic astrocytoma (Grade III), one of whom died after 7 years, whereas the other was still alive after 10 years. CONCLUSIONS: This population-based study shows that, because of the benign biological behavior of pilocytic astrocytomas and advances in microneurosurgery, the survival rates for patients with these tumors are excellent, regardless of postoperative radiotherapy.     

Surgical resection of a pineal tumor containing elements of germinoma and astrocytoma

A 15-year-old boy presented with hydrocephalus due to a pineal tumor presumed to be a germinoma. After a shunting procedure, gross total tumor resection was carried out via an occipital transtentorial approach. Histopathological examination of the tissue demonstrated that, in addition to the expected germinoma, the tumor also contained areas of astrocytoma and areas that, taken in isolation as in a needle biopsy, could have been diagnosed as pineocytoma. The diagnosis and therapy of a pineal tumor of mixed histological types such as this lesion would be seriously compromised by "conventional" empiric radiation and even a stereotactic needle biopsy may not have provided an adequate tissue sample.     

Surgical resection of gliomas WHO grade II and III located in the opercular region

Summary Background. Surgery in the opercular region especially in the dominant hemisphere impose a major challenge for the neurosurgeon due to the close vicinity to functional important motor and speech areas. The purpose of the present study is to analyse on a homogenous patient group pre- and postoperative functional deficits with regard to different speech qualities (e.g. aphasia, apraxia), and to correlate these data with MR and intraoperative monitoring results. Method. Fourteen patients with suspected low grade astrocytomas in the opercular region consecutively treated by surgery were eligible for this study (histology revealed 3 WHO grade III tumours). Degree and duration of postoperative deficits were retrospectively evaluated according to tumour location and boundaries on MR, intraoperative neuromonitoring results and extent of tumour resection. Findings. Postoperatively, 8 patients showed speech or language disturbances, in 4 patients combined with motor deficits mainly of the contralateral upper extremity. Fifty percent of the neuropsychologically tested patients exhibited speech apraxia while the other 50% had a true aphasic syndrome. Recovery of the latter deficits was in general faster and more complete. The severity and duration of postoperative deficits was in good correlation with the distance of the resection margin to the next positive stimulation point(s), and a distance of more than 0.5cm proved to avoid major impairments. The distribution of functional important stimulation points in relation to the tumour extension was not predictable, and – unexpectedly – up to 50% of these sites were found overlaying the tumour. Interpretation. Surgery for WHO grade II and III gliomas in the opercular region can result in speech apraxia or an aphasic syndrome with or without concomitant motor deficits. Intraoperative cortical electrical stimulation is essential in resecting tumours in the opercular region to avoid permanent morbidity.     

Tension-free repair versus watchful waiting for men with asymptomatic or minimally symptomatic inguinal hernias: a cost-effectiveness analysis

BACKGROUND: Watchful waiting (WW) has been shown to be an acceptable option in men with asymptomatic or minimally symptomatic inguinal hernias when clinical and patient-reported outcomes are considered. Although WW is likely to be less costly initially when compared with tension-free repair (TFR) because of the cost of the operation, it is not clear whether WW remains the least costly option when longer-term costs are considered. STUDY DESIGN: We conducted a cost-effectiveness analysis of a randomized controlled trial at six community and academic centers. We examined costs, quality-adjusted life-years (QALY), and cost-effectiveness at 2 years of followup. Costs were assessed by applying Medicare reimbursement rates to patients' health-care use, which was obtained by contacting patients' health-care providers. Quality of life was assessed using the Short Form-36 version 2 health-related quality-of-life survey. Of the 724 men randomized, 641 were available for the economic analysis: 317 were randomized to TFR and 324 were randomized to watchful waiting. RESULTS: At 2 years, TFR patients had $1,831 higher mean costs than WW patients (95% CI, $409-$3,044), with 0.031 higher QALY (95% CI, 0.001-0.058). The cost per additional QALY for TFR patients was $59,065 (95% CI, $1,358-$322,765). The probability that TFR was cost-effective at the $50,000 per QALY level was 40%. CONCLUSION: At 2 years, WW was a cost-effective treatment option for men with minimal or no hernia symptoms.     

Independent association of extent of resection with survival in patients with malignant brain astrocytoma

OBJECT: With recent advances in the adjuvant treatment of malignant brain astrocytomas, it is increasingly debated whether extent of resection affects survival. In this study, the authors investigate this issue after primary and revision resection of these lesions. METHODS: The authors retrospectively reviewed the cases of 1215 patients who underwent surgery for malignant brain astrocytomas (World Health Organization [WHO] Grade III or IV) at a single institution from 1996 to 2006. Patients with deep-seated or unresectable lesions were excluded. Based on MR imaging results obtained < 48 hours after surgery, gross-total resection (GTR) was defined as no residual enhancement, near-total resection (NTR) as having thin rim enhancement of the resection cavity only, and subtotal resection (STR) as having residual nodular enhancement. The independent association of extent of resection and subsequent survival was assessed via a multivariate proportional hazards regression analysis. RESULTS: Magnetic resonance imaging studies were available for review in 949 cases. The mean age and mean Karnofsky Performance Scale (KPS) score at time of surgery were 51 +/- 16 years and 80 +/- 10, respectively. Surgery consisted of primary resection in 549 patients (58%) and revision resection for tumor recurrence in 400 patients (42%). The lesion was WHO Grade IV in 700 patients (74%) and Grade III in 249 (26%); there were 167 astrocytomas and 82 mixed oligoastrocytoma. Among patients who underwent resection, GTR, NTR, and STR were achieved in 330 (35%), 388 (41%), and 231 cases (24%), respectively. Adjusting for factors associated with survival (for example, age, KPS score, Gliadel and/or temozolomide use, and subsequent resection), GTR versus NTR (p < 0.05) and NTR versus STR (p < 0.05) were independently associated with improved survival after both primary and revision resection of glioblastoma multiforme (GBM). For primary GBM resection, the median survival after GTR, NTR, and STR was 13, 11, and 8 months, respectively. After revision resection, the median survival after GTR, NTR, and STR was 11, 9, and 5 months, respectively. Adjusting for factors associated with survival for WHO Grade III astrocytoma (age, KPS score, and revision resection), GTR versus STR (p < 0.05) was associated with improved survival. Gross-total resection versus NTR was not associated with an independent survival benefit in patients with WHO Grade III astrocytomas. The median survival after primary resection of WHO Grade III (mixed oligoastrocytomas excluded) for GTR, NTR, and STR was 58, 46, and 34 months, respectively. CONCLUSIONS: In the authors' experience with both primary and secondary resection of malignant brain astrocytomas, increasing extent of resection was associated with improved survival independent of age, degree of disability, WHO grade, or subsequent treatment modalities used. The maximum extent of resection should be safely attempted while minimizing the risk of surgically induced neurological injury.     

Surgical resection improves median overall survival with marginal improvement in long-term survival when compared with definitive radiotherapy in Merkel cell carcinoma: A propensity score matched analysis of the National Cancer Database

Background

Definitive radiotherapy has been suggested as a treatment alternative to surgical resection in Merkel cell carcinoma (MCC).

Lung resection for non-small-cell lung cancer in patients older than 70: mortality, morbidity, and late survival compared with the general population

BACKGROUND: Operative mortality and morbidity in elderly patients operated on for non-small-cell lung cancer are acceptable. However, risk factors for hospital mortality and the benefits for the patients in the long term are insufficiently defined, and survival compared with the general population is not known. METHODS: From January 1989 to October 2001, 126 consecutive patients older than 70 years of age underwent resection for non-small-cell lung cancer. Each patient was scaled according to the Charlson Comorbidity Index. Postoperative events were divided into minor and major complications. Risk factors for complications and long-term survival were assessed by univariate and multivariate logistic regression analysis. Survival was compared with the yearly expected survival rates of the general population. RESULTS: The hospital mortality was 3.2%. Minor complications occurred in 71 (57%) patients, major complications, in 16 (13%) patients. No risk factor was predictive for major complications. However, a Charlson comorbidity grade of 3 to 4 was predictive for major complications (odds ratio, 12.6; 95% confidence interval, 1.5 to 108.6). Our study showed a 5- and 10-year survival rate of 37% (95% confidence interval, 23 to 51) and 15% (95% confidence interval, 8 to 22). Smoking (odds ratio, 2.3), chronic obstructive pulmonary disease (odds ratio, 2.1), and pathologic stage IIIA (odds ratio, 2.2) or IIIB (odds ratio, 11.9) were risk factors for long-term survival. The observed survival was lower than the expected survival, but the difference decreased with increasing time after pulmonary resection. CONCLUSIONS: Pulmonary resection for non-small-cell lung cancer in patients older than 70 years shows acceptable morbidity and mortality. The Charlson index is a better predictor of complications than individual risk factors. In time survival is no longer correlated with the disease but follows the same pattern as the general population.     

Watchful waiting as a treatment strategy for patients with a ventral hernia appears to be safe

Purpose

Due to risks of postoperative morbidity and recurrence some patients with a ventral hernia are not offered surgical repair. There is limited data on the rate and consequences of a watchful waiting (WW) strategy for these patients. The objective of this cohort study was to analyse outcomes for patients with a ventral hernia who underwent watchful waiting, in terms of later requirement for hernia repair.

Methods

All patients (≥18 years) electively referred to our out-patient clinic from 1 January 2009 to 1 July 2014 with incisional, umbilical or epigastric hernia were included. Information on patient characteristics and whether patients underwent WW or surgery was obtained from hospital files and the Danish National Patient Register. A 100 % follow-up was obtained.

Results

The analyses comprised 569 patients with incisional hernia (WW = 58.1 %) and 789 patients with umbilical/epigastric hernia (WW = 43.2 %). Kaplan–Meier analyses estimated that the probability for patients who underwent watchful waiting to receive later surgical repair was 19 % for incisional hernias and 16 % for umbilical/epigastric hernias after 5 years. The probability of requiring emergency repair when in the WW group was 4 % for both incisional and umbilical/epigastric hernias after 5 years. There were no significant differences in 30-day readmission, reoperation or mortality rates between the WW patients who later underwent elective hernia repair and patients who were initially offered surgery (p > 0.05), for both incisional and umbilical/epigastric hernias.

Conclusions

Watchful waiting appears to be a safe strategy in the treatment of incisional, umbilical and epigastric hernias.

     

Surgical treatment of neuroendocrine metastases to the liver: a plea for resection to increase survival

BACKGROUND: Hepatic metastases from neuroendocrine tumors have a protracted natural history and are associated with endocrinopathies. Resection is indicated for symptom control. Previous reports have suggested improvement in survival for patients undergoing debulking procedures. STUDY DESIGN: The records of all consecutive patients undergoing resection of hepatic metastases from neuroendocrine tumors between 1977 and 1998 were reviewed. Tumors were classified according to histology, endocrine activity, and primary location. Patients lost to followup before 1 year were excluded. Followups were based on outpatient evaluations and were updated by correspondence. The Kaplan-Meier method was used to generate survival and recurrence curves, and the log-rank test was used for comparison. RESULTS: A total of 170 patients fulfilled the inclusion criteria, of whom 73 were men. Mean age (+/-SD) was 57 (+/-11.5) years. Carcinoid (n = 120) and nonfunctioning islet cell tumors (n = 18) predominated; the ileum (n = 85) and the pancreas (n = 52) were the most common primary sites. Major hepatectomy (one or more lobes) was performed in 91 patients (54%). The postoperative complication rate was 14%, and two patients died (1.2%). Operation controlled symptoms in 104 of 108 patients, but the recurrence rate at 5 years was 59%. Operation decreased 5-hydroxyindoleacetic acid levels considerably, and no patient experienced carcinoid heart disease postoperatively. Recurrence rate was 84% at 5 years. Overall survival was 61% and 35% at 5 and 10 years, respectively, with no difference between carcinoid and islet cell tumors. CONCLUSIONS: Hepatic resection for metastatic neuroendocrine tumors is safe and achieves symptom control in most patients. Debulking extends survival, although recurrence is expected. Hepatic resection is justified by its effects on survival and quality of life.     

Progression delay in men with mild symptoms of bladder outlet obstruction: a comparative study of phytotherapy and watchful waiting

To determine the effect of phytotherapy (Serona repens) on the clinical progression in men with mild symptoms of bladder outlet obstruction (BOO). A total of 189 patients with mild symptoms of BOO, recruited from four different European clinics, were included in the analysis. Age, prostate specific antigen (PSA), international prostate symptom score (IPSS), quality of life (QOL), maximum urinary flow rate (Qmax) and total prostate and transitional zone volume were recorded. Clinical progression was defined as change from the mild-IPSS group into the moderate or severe group or the occurrence of urinary retention and need of surgery. Cumulative progression rate was 1, 7, 9 and 16% at 6, 12, 18 and 24 month, respectively, for the active group (Serona repens) as compared to 6, 13, 15 and 24% for the watchful waiting group. (P=0.03) significant improvements in the Qmax, IPSS and QOL were seen in the group receiving Serona repens. Serona repens significantly reduced the clinical progression rates in men with mild symptoms of BOO. It also led to improvements in urinary symptoms, QOL scores and urinary flow rates.     

Feasibility study: watchful waiting for localized low to intermediate grade prostate carcinoma with selective delayed intervention based on prostate specific antigen, histological and/or clinical progression

PURPOSE: We assessed the feasibility of a watchful waiting protocol with selective delayed intervention using clinical, prostate specific antigen (PSA) or histological progression as treatment indications for clinically localized prostate cancer. MATERIALS AND METHODS: In this prospective, single arm cohort study patients with favorable clinical parameters (stage T1b to T2b N0M0, Gleason score 7 or less and PSA 15 ng./ml. or less) are conservatively treated with watchful waiting. When a patient meets disease progression criteria, arbitrarily defined by the 3 parameters of the rate of PSA increase, clinical progression or histological upgrade on repeat prostate biopsy, appropriate treatment is implemented. Patients are followed every 3 months for the first 2 years and every 6 months thereafter. Serum PSA measurement and digital rectal examination are done at each visit and repeat prostate biopsy is performed 18 months after study enrollment. RESULTS: Since November 1995, the study has accrued 206 patients with a median followup of 29 months (range 2 to 66). Of these men 137 remain on the surveillance protocol with no disease progression, while 69 were withdrawn from study for various reasons. There was clinical, PSA and histological progression in 16, 15 and 5 cases, respectively. The estimated actuarial probability of remaining on the surveillance protocol was 67% at 2 years and 48% at 4. The probability of remaining progression-free was 81% and 67% at 2 and 4 years, respectively. CONCLUSIONS: A policy of watchful waiting with selectively delayed intervention based on predefined criteria of disease progression is feasible. This strategy offers the benefit of an individualized approach based on the demonstrated risk of clinical or biochemical progression with time and, thus, it may decrease the burden of therapy in patients with indolent disease, while providing definitive therapy for those with biologically active disease.     

早期及延迟腹腔镜胆囊切除对急性胆囊炎患者的疗效分析

目的对早期行腹腔镜切除术和推迟行腹腔镜切除术治疗急性胆囊炎的临床疗效进行对照研究。方法将2014年1月至2015年12月期间收治的100名急性胆囊炎伴胆囊结石患者随机分为两组:一组为50例急性发作的胆囊炎患者在入院3 d内行腹腔镜胆囊切除,作为早期手术组;另一组为50例急性发作的胆囊炎患者药物保守治疗3个月后行手术切除,作为推迟手术组,比较两组患者的各项指标。患者的年龄、性别、体温、白细胞计数、ALT等一般资料,用(x珋±s)表示,t检验进行比较;术后并发症发生率、中转开腹率,使用χ~2检验进行比较;采取SPSS19.0统计学软件进行分析,以P0.05为差异有统计学意义。结果两组在中转开腹率、术后并发症及术后24 h疼痛评分之间的差异无统计学意义(P0.05);但在平均住院时间、恢复工作所需方面,早期手术组分别为(6.9±2.1)d、(12.4±3.7)d明显短于推迟手术组(14.5±5.3)d、(25.8±2.9)d;差异均有统计学意义(t=6.109、13.062,P0.05)。结论在临床经验丰富的医师进行手术的前提下,急性胆囊炎患者早期行腹腔镜胆囊切除相较推迟腹腔镜切除患者而言,在医疗及经济效益等层面上更具优势。