Complete Pathologic Response after Combined Modality Treatment for Rectal Cancer and Long-Term Survival: A Meta-Analysis

Background

Complete pathologic response (CPR) after neoadjuvant chemoradiotherapy (combined modality treatment, CMT) for rectal cancer seems associated with improved survival compared to partial or no response (NPR). However, previous reports have been limited by small sample size and single-institution design.

Methods

A systematic literature review was conducted to detect studies comparing long-term results of patients with CPR and NPR after CMT for rectal cancer. Variables were pooled only if evaluated by 3 or more studies. Study end points included rates of CPR, local recurrence (LR), distant recurrence (DR), 5-year overall survival (OS), and disease-free survival (DFS).

Results

Twelve studies (1,913 patients) with rectal cancer treated with CMT were included. CPR was observed in 300 patients (15.6%). CPR and NPR patient groups were similar with respect to age, sex, tumor size, distance of tumor from the anus, and stage of disease before treatment. Median follow-up ranged from 23 to 46?months. CPR patients had lower rates of LR [0.7% vs. 2.6%; odds ratio (OR) 0.45, 95% confidence interval (CI) 0.22?C0.90, P?=?0.03], DR (5.3% vs. 24.1%; OR 0.15, 95% CI 0.07?C0.31, P?=?0.0001), and simultaneous LR?+?DR (0.7% vs. 4.8%; OR 0.32, 95% CI 0.13?C0.79, P?=?0.01). OS was 92.9% for CPR versus 73.4% for NPR (OR 3.6, 95% CI 1.84?C7.22, P?=?0.002), and DFS was 86.9% versus 63.9% (OR 3.53, 95% CI 1.62?C7.72, P?=?0.002).

Conclusions

CPR after CMT for rectal cancer is associated with improved local and distal control as well as better OS and DFS.     

Pulmonary veno-occlusive disease: the role of CT

Objective

The authors sought to evaluate the diagnostic accuracy of high-resolution computed tomography (HRCT) in the detection of pulmonary veno-occlusive disease (PVOD) in patients with pre-capillary pulmonary arterial hypertension (PAH) of unknown aetiology, and to identify the role of CT in diagnosis and therapy.

Materials and methods

The CT scans of 96 patients were retrospectively reviewed and assessed for specific HRCT findings: ground-glass opacities, septal lines and mediastinal lymph nodal enlargement (short diameter ≥1 cm). According to the HRCT findings, patients were divided into PVOD-suspicious and not PVOD-suspicious. Subsequently, a clinical-instrumental evaluation was performed, and the response to therapy and histopathological reports were evaluated.

Results

Radiological evaluation based on HRCT findings revealed 29 patients as PVOD-suspicious and 67 as not PVOD-suspicious. The final diagnosis was PVOD in 22 patients and idiopathic PAH in 74 patients. The CT scan showed 95.5 % sensitivity, 89 % specificity, 72.5 % positive predictive value, and 98.5 % negative predictive value, with a diagnostic accuracy of 90.5 % in identifying patients with PVOD.

Conclusions

Chest CT can be considered a screening test in the assessment of patients with PAH of unknown aetiology, and the radiologist can help the clinician to identify patients with CT findings that make PVOD highly probable.     

Vardenafil for the treatment of erectile dysfunction: a critical review of the literature based on personal clinical experience

OBJECTIVE: To critically review the literature on vardenafil in the treatment of erectile dysfunction while integrating the clinical findings with the personal experience of the authors. METHODS: Analysis of published full-length papers that were identified through Medline search from January 2000 through May 2004. Abstracts published in peer-reviewed journals from the same period were also considered. RESULTS: Efficacy, tolerability and safety, as reported in the peer-reviewed literature compares well with the authors' personal experience. Authors' personal observations include discussions on potency, selectivity, selection of initial dose, counselling for patients characteristically considered difficult-to-treat (diabetes, prostatectomy, depression), including the determination of the maximal efficacious dose and the possible role of daily dosing, optimisation of the use of vardenafil according to its pharmacokinetic and pharmacodynamic profiles (onset and reliability), and management of ED patients with or at risk for cardiovascular disease. CONCLUSIONS: Extensive experience with vardenafil as reported in peer reviewed literature confirms the important role of vardenafil in the management of patients with ED. The development of each physician's own experience with vardenafil is key to optimise overall satisfaction of this therapy by the patient and his partner.     

Analysis of risk factors for tumor recurrence after liver transplantation for hepatocellular carcinoma: key role of immunosuppression.

To confirm recent observations about the relationship between immunosuppression and the recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT), we retrospectively analyzed 70 consecutive HCC patients who underwent LT and received cyclosporine (CsA)-based immunosuppression. CsA trough blood levels, measured with the same technique (fluorescence polarization immunoassay), were analyzed at different time points after transplantation. The exposure to the drug was calculated with the trapezoidal rule in each patient. CsA was associated with steroids in 26 patients and steroids and azathioprine in 44 patients. HCC recurred in 7 patients (10.0%). Different immunosuppressive schedules (CsA and steroids vs. CsA, steroids, and azathioprine) or the cumulative dosage of steroids and azathioprine did not influence HCC recurrence that was associated instead with CsA exposure (278.3 +/- 86.4 ng/mL in recurrent vs. 169.9 +/- 33.3 in tumor-free patients; P < 0.001); CsA exposure above 189.6 ng/mL was related to HCC recurrence at the receiver operating characteristic analysis (ROC). The relationship between CsA exposure; various clinical (sex, age, viral- vs. non-viral-related cirrhosis, preoperative vs. incidental diagnosis of HCC, alpha-fetoprotein [AFP] blood level), pathologic (pathologic tumor staging [pT] stage, presence of Milan criteria), and histologic (grading, presence of microvascular tumor invasion) parameters; and tumor recurrence were assessed. AFP (P = 0.032), microvascular tumor invasion (P = 0.044), and CsA exposure (P < 0.001) influenced recurrence-free survival at the univariate analysis; CsA exposure was the only independent prognostic determinant at multivariate analysis (P < 0.001). High CsA exposure favors tumor recurrence; CsA blood levels should be kept to the effective minimum in HCC patients. In the presence of pathologic and histologic risk factors, specific immunosuppressive protocols should be considered.     

Portal vein thrombosis after intraportal hepatocytes transplantation in a liver transplant recipient

Hepatocytes transplantation is viewed as a possible alternative or as a bridge therapy to liver transplantation for patients affected by acute or chronic liver disorders. Very few data regarding complications of hepatocytes transplantation is available from the literature. Herein we report for the first time a case of portal vein thrombosis after intraportal hepatocytes transplantation in a liver transplant recipient. A patient affected by acute graft dysfunction, not eligible for retransplantation, underwent intraportal infusion of 2 billion viable cryopreserved ABO identical human allogenic hepatocytes over a period of 5 h. Hepatocytes were transplanted at a concentration of 14 million/ml for a total infused volume of 280 ml. Doppler portal vein ultrasound and intraportal pressure were monitored during cell infusion. The procedure was complicated, 8 h after termination, by the development of portal vein thrombosis with liver failure and death of the patient. Autopsy showed occlusive thrombosis of the intrahepatic portal vein branches; cells or large aggregates of epithelial elements (polyclonal CEA positive), suggestive for transplanted hepatocytes, were co-localized inside the thrombus.     

Intramedullary nailing versus external fixation in Gustilo type III open tibial shaft fractures: a meta-analysis of randomised controlled trials

Open tibial shaft fractures are the most common of long-bone open fractures. Management of the fracture is either by intramedullary nailing (IMN) or by external fixation (EF). Since the literature does not indicate clearly which is more effective, a meta-analysis was conducted to establish which approach is more suitable to treat Gustilo type III fractures. MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE and CINAHL databases were searched for randomised controlled trials (RCT) describing IMN and EF treatment of Gustilo type III fractures. As of 15 November 2012, five RCT involving 239 patients had been published; the outcomes examined in this study are their surgical complications. Data analysis led complications to be grouped into infection, fracture healing problems (non-union, malunion) and “other complications” (vascular injury, revision surgery, soft tissue damage, mechanical failure and tibial malalignment). IMN was associated with lower rates of infection and fracture healing problems; the differences between the two approaches for “other complications” were not significant. The data indicate that IMN is the treatment of choice for Gustilo type III fractures.     

Hemostatic Step-by-Step Procedure to Control Presacral Bleeding During Laparoscopic Total Mesorectal Excision

Background  A new procedure of hemostasis during laparoscopic total mesorectal excision is described. Methods  In our surgical department, from January 2004 to December 2007, 128 patients underwent laparoscopic total mesorectal excision. Among them, 47 patients underwent laparoscopic anterior resection after preoperative radiotherapy, 68 patients underwent laparoscopic anterior resection without preoperative radiotherapy, and 13 patients underwent laparoscopic abdominal perineal amputation. Results  In seven laparoscopic rectal surgery cases, we encountered unstoppable presacral bleeding, not amenable by conventional hemostatic solutions. In these cases we applied a simple staging hemostatic procedure. We first performed local compression: tamponing with a small gauze or absorbable fabric hemostat. If bleeding did not stop, we localized an epiploic or omental scrap and excised it by using bipolar forceps and use it as a plug on the tip of a grasping forceps. This plug is then put on the bleeding source and monopolar coagulation is applied by electrified dissecting forceps through the interposed grasping forceps. If bleeding did not stop, we used a little scrap of bovine pericardium graft and tacked it to the bleeding site using endoscopic helicoidal protack. Conclusions  Our experience suggests that this hemostatic step-by-step procedure is a valid option to control persistent presacral hemorrhages.     

Effect of cervical dynamics on adjacent segment degeneration after anterior cervical fusion with cages

The objective of this study is to evaluate the effect of anterior cervical discectomy and fusion (ACDF) on the motion of the cervical spine and dynamic stress (tendency to kyphosis) on adjacent segments and on the overall spinal alignment which may predispose to symptomatic disc diseases at other levels. Twenty consecutive patients underwent ACDF with a mean follow-up of 28 months (range 13-38). Preoperative and postoperative clinical assessments were done by using the neck disability index (NDI) and the Japanese Orthopedic Association (JOA) score. In all cases, at the last follow-up control, a neuro-radiographic assessment [cervical spine static and dynamic X-ray and magnetic resonance imaging (MRI)] was done. The angle of the operated disc space, the disc space angle of contiguous segments, and their range of motion (ROM) and the kyphotic Cobb angle (C2-7) were measured by computer software. The study was done at Sant'Andrea Hospital, Rome, Italy in the period from November 2003 to November 2005. We observed that: the mean Cobb angle improved significantly (p < 0.001) from 3.4 degrees (kyphosis) to postoperative 14.5 degrees . This normalization of angle showed a direct effect on improvement of myelopathic patients, but it had a statistically nonsignificant effect on adjacent segments degeneration (ASD). The mean segmental ROM of adjacent segments did not show significant instability. The mean was 11.1 degrees at upper and 10.2 degrees at lower levels (close to normal). In six cases, the ROM was higher than normal: five of these patients demonstrated symptomatic adjacent segment pathology. Postoperative improvement of mean JOA and NDI scores was statistically significant (p < 0.001). Anyway, symptomatic ASD was observed in five patients (20%): in four of them, the higher disc spaces and in one, the lower disc spaces were involved. In four cases, the preoperative MRI showed slight and asymptomatic disc degeneration at the same levels involved subsequently. This ASD was significantly related to the increased ROM at the segments involved. Follow-up X-rays showed solid fusion with absence of movement in all but one case (at 13-month follow-up), who showed slight movement in the operated level in spite of clinical improvement. The follow-up MRI showed, in all cases, good decompression in the treated levels. Compensatory increase in ROM of the contiguous motion segments in patients subjected to ACDF may lead to ASD especially in those cases with asymptomatic adjacent subclinical degenerative disease. If these preliminary results will be confirmed by larger series, it could be reasonable in young selected patients with soft disc herniation to adopt total disc arthroplasty instead of fusion after cervical micro-discectomy.