Comparison of oncological outcomes after segmental ureterectomy or radical nephroureterectomy in urothelial carcinomas of the upper urinary tract: results from a large French multicentre study

Study Type – Therapy (multi‐centre retrospective cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Upper urinary tract urothelial carcinomas (UUT‐UCs) are rare tumours. Because of the aggressive pattern of UC, radical nephroureterectomy (RNU) with bladder cuff removal remains the ‘gold‐standard’ treatment. However, conservative strategies, such as segmental ureterectomy (SU) or endourological management, have also been developed in patients with imperative indications. Some teams are now advocating the use of conservative management more commonly in cases of elective indications of UUT‐UCs. Due to the paucity of cases of UUT‐UC, only limited data are available on the oncological outcomes afforded by conservative management. We retrospectively investigated the oncological outcomes after SU and RNU in a large multi‐institutional database. Overall, 52 patients were treated with SU and 416 with RNU. There was no statistical difference between the RNU and SU groups for the 5‐year probability of cancer‐specific survival, recurrence‐free survival and metastasis‐free survival. The type of surgery was not a significant prognostic factor in univariate analysis. The results were the same in a subgroup analysis of only unifocal tumours of the distal ureter with a diameter of <2 cm and of low stage (≤T2). Our results suggest that oncological outcomes after conservative treatment with SU are comparable to RNU for the management of UUT‐UC in select cases.

OBJECTIVE

• ? To compare recurrence‐free survival (RFS), metastasis‐free survival (MFS) and cancer‐specific survival (CSS) after segmental ureterectomy (SU) vs radical nephroureterectomy (RNU) for urothelial carcinoma (UC) of the upper urinary tract (UUT‐UC) located in the ureter.

PATIENTS AND METHODS

• ? We performed a multi‐institutional retrospective review of patients with UUT‐UC who had undergone RNU or SU between 1995 and 2010.
• ? Type of surgery, Tumour‐Node‐Metastasis status, tumour grade, lymphovascular invasion and positive surgical margin were tested as prognostic factors for survival.

RESULTS

• ? In all, 52 patients were treated with SU and 416 with RNU. The median (range) follow‐up was 26 (10–48) months.
• ? The 5‐year probability of CSS, RFS and MFS for SU and RNU were 87.9% and 86.3%, respectively (P= 0.99); 37% and 47.9%, respectively (P= 0.48); 81.9% and 85.4%, respectively (P= 0.51).
• ? In univariable analysis, type of surgery (SU vs RNU) failed to affect CSS, RFS and MFS (P= 0.94, 0.42 and 0.53, respectively).
• ? In multivariable analyses, pT stage and pN stage achieved independent predictor status for CSS (P= 0.005 and 0.007, respectively); the positive surgical margin and pT stage were independent prognostic factors of RFS and MFS (P= 0.001, 0.04, 0.009 and 0.001, respectively).
• ? The main limitation of the study is its retrospective design, which is due to the rarity of the disease.

CONCLUSIONS

• ? Short‐term oncological outcomes after conservative treatment with SU are comparable to RNU for the management of UUT‐UC in select cases and should be considered an option.
• ? In every other case, RNU still represents the ‘gold standard’ for the treatment of UUT‐UC.

     

Facial Nerve Schwannomas of the Cerebellopontine Angle: The Mayo Clinic Experience

Background There is often controversy regarding the optimal management for patients with facial nerve schwannomas (FNSs) of the cerebellopontine angle (CPA).Methods The clinical and radiological outcomes in 14 patients with CPA FNS were retrospectively reviewed.Results Patients underwent resection with anatomic nerve preservation (n = 3), facial-hypoglossal nerve anastomosis (n = 4), gamma knife radiosurgery (GKS) (n = 6), or observation (n = 1). A total of 83% of tumors that underwent GKS were stable or decreased in size. No patient who underwent resection showed evidence of tumor recurrence; the tumor under observation remained unchanged with normal facial function at the time of the last follow-up. Facial function was decreased in 57%, stable in 14%, and improved in 29% of those who underwent microsurgery. A total of 67% of patients who underwent GKS had stable facial function. Serviceable hearing was maintained in 50% of patients in the GKS group and 67% of the tumor resection group. Mean and median follow-up was 48 and 43 months, respectively (range, 12 to 95 months).Conclusion Observation should be the primary management when encountered with FNS of the CPA in those with good neurologic function. Microsurgery or radiosurgery may be used in those with poor facial function or tumor progression.     

Axon counts of potential nerve transfer donors for peroneal nerve reconstruction

BACKGROUND:

The common peroneal nerve is the most commonly injured nerve in the lower limb. Nerve transfer using expendable donor nerves is emerging in the literature as an alternative surgical procedure to traditional treatments.

OBJECTIVE:

To identify potential donors of motor axons from the tibial nerve that can be transferred to the common peroneal nerve branches.

METHODS:

Using 10 human cadaveric lower extremities, all motor nerve branches of the tibial nerve were identified and biopsied. These were compared with the motor branches to tibialis anterior and extensor hallucis longus (branches of the deep peroneal nerve).

RESULTS:

The most suitable donor nerves with respect to cross-sectional area to tibialis anterior (cross sectional area [mean ± SD] 0.255±0.111 mm) was the motor branch to lateral gastrocnemius (0.256±0.105 mm). When comparing the total number of axons, the branch to the tibialis anterior had a mean of 3363±1997 axons. The branch to the popliteus was most similar, with 3317±1467 axons. The most suitable donor nerves for the motor branch to extensor hallucis longus (cross sectional area 0.197±0.302 mm) with respect to cross-sectional area was the motor branch to flexor hallucis longus (0.234±0.147 mm). When comparing the total number of axons, the branch to the extensor hallucis longus had an average of 2062±2314 axons. The branch to the lateral gastrocnemius was most similar with 2352±1249 axons and was a suitable donor.

CONCLUSION:

Nerve transfers should be included in the armamentarium for lower extremity reinnervation, as it is in the upper limb.     

The neoadjuvant rectal score and a novel magnetic resonance imaging based neoadjuvant rectal score are stage independent predictors of long-term outcome in locally advanced rectal cancer

Aim

Neoadjuvant rectal (NAR) score is an early surrogate for longer-term outcomes in rectal cancer undergoing radiotherapy and resection. In an era of increasing organ preservation, resection specimens are not always available to calculate the NAR score. Post-treatment magnetic resonance imaging (MRI) re-staging of regression is subjective, limiting reproducibility. We explored the potential for a novel MRI-based NAR score (mrNAR) adapted from the NAR formula.

Methods

Locally advanced rectal cancer patients undergoing neoadjuvant therapy (nCRT) and surgery were retrospectively identified between 2008 and 2020 in a single cancer network. mrNAR was calculated by adapting the NAR formula, replacing pathological (p) stages with post-nCRT MR stages (ymr). Cox regression assessed relationships between clinicopathological characteristics, NAR and mrNAR with overall survival (OS) and recurrence-free survival (RFS).

Results

In total, 381 NAR and 177 mrNAR scores were calculated. On univariate analysis NAR related to OS (hazard ratio [HR] 2.05, 95% confidence interval [CI] 1.33–3.14, p = 0.001) and RFS (HR 2.52, 95% CI 1.77–3.59, p = 0.001). NAR 3-year OS <8 was 95.3%, 8–16 was 88.6% and >16 was 80%. mrNAR related to OS (HR 2.96, 95% CI 1.38–6.34, p = 0.005) and RFS (HR 2.99, 95% CI 1.49–6.00, p = 0.002). 3-year OS for mrNAR <8 was 96.2%, 8–16 was 92.4% and >16 was 78%. On multivariate analysis, mrNAR was a stage-independent predictor of OS and RFS. mrNAR corresponded to NAR score category in only 15% (positive predictive value 0.23) and 47.5% (positive predictive value 0.48) of cases for categories <8 and >16, respectively.

Conclusions

Neoadjuvant rectal score is validated as a surrogate end-point for long-term outcomes. mrNAR categories do not correlate with NAR but have stage-independent prognostic value. mrNAR may represent a novel surrogate end-point for future neoadjuvant treatments that focus on organ preservation.     

Obstetric and long‐term kidney outcomes in renal transplant recipients: a 40‐yr single‐center study

Female renal transplant recipients of childbearing age may ask what the outcomes are for pregnancy and whether pregnancy will affect graft function. We analyzed obstetric and transplant outcomes among renal transplant recipients in our center who have been pregnant between 1973 and 2013. A case?cohort study was performed identifying 83 pairs of pregnant and non‐pregnant controls matched for sex, age, transplant vintage, and creatinine. There were 138 pregnancies reported from 89 renal transplant recipients. There were live births in 74% of pregnancies with high prevalence of prematurity (61%), low birth weight (52%), and pre‐eclampsia (14%). Lower eGFR (OR 0.98; p = 0.05) and higher uPCR (OR 1.86; p = 0.02) at conception were independent predictors for poor composite obstetric outcome. Lower eGFR (OR 0.98; p = 0.04), higher uPCR (OR 1.50; p = 0.04), and live organ donation (OR 0.35; p = 0.02) were predictors of ≥20% loss of eGFR between immediately pre‐pregnancy and one yr after delivery. There was no difference in eGFR at one, five, and 10 yr in pregnant women compared with non‐pregnant controls and a pregnancy was not associated with poorer 10‐yr transplant or 20‐yr patient survival. Despite high rates of obstetric complications, most women had successful pregnancies with good long‐term transplant function.     

Umbilical Negative Pressure Dressing for Transumbilical Appendectomy in Childern

Methods:This study was a retrospective chart review of 1377 patients (2–20 years) undergoing laparoscopic appendectomy for acute appendicitis in 2 tertiary care referral centers from January 2007 through December 2012. Twenty-two different operative technique/dressing variations were documented. The 6 technique/dressing groups with >50 patients were assessed, including a total of 1283 patients.Results:The surgical site infection rate of the 220 patients treated with TULAA and application of an umbilical vacuum dressing with dry gauze is 1.8% (95% CI, 0.0–10.3%). This compares to an infection rate of 4.1% (95% CI, 1.3–10.5%) in 97 patients with dry dressing without vacuum. In the 395 patients who received an umbilical vacuum dressing with gauze and bacitracin, the surgical site infection rate was found to be 4.3% (95% CI, 2.7–6.8%).Conclusions:Application of an umbilical negative-pressure dressing with dry gauze lowers the rate of umbilical site infections in patients undergoing transumbilical laparoscopic-assisted appendectomy for acute appendicitis.     

False‐positive Extra‐Mammary Findings in Breast MRI: Another Cause for Concern

Breast magnetic resonance imaging (MRI) has been repeatedly shown to have a high false‐positive rate for additional findings in the breast resulting in additional breast imaging and biopsies. We hypothesize that breast MRI is also associated with a high rate of false‐positive findings outside of the breast requiring additional evaluation, interventions, and delays in treatment. We performed a retrospective review of all breast MRIs performed on breast cancer patients in 2010 at a single institution. MRI reports were analyzed for extra‐mammary findings. The timing and yield of the additional procedures was also analyzed. Three hundred and twenty‐seven breast cancer patients (average age = 53.53 ± 11.08 years) had a breast MRI. Incidental, extra‐mammary findings were reported in 35/327 patients (10.7%) with a total of 38 incidental findings. The extra‐mammary findings were located in the liver (n = 21, 60.0%), thoracic cavity (n = 12, 34.3%), kidneys (n = 1, 2.9%), musculoskeletal system (n = 3, 8.6%), and neck (n = 1, 2.9%). Eighteen of the 35 patients (51.4%) received additional radiographic imaging, 3 (8.6%) received additional laboratory testing, 2 (5.7%) received additional physician referrals and 2 (5.7%) received a biopsy of the finding. The average time to additional procedures in these patients was 14.5 days. None of the incidental, extra‐mammary findings were associated with breast cancer or other malignancy. Breast MRI was associated with a high rate (10.7%) of extra‐mammary findings, which led to costly additional imaging studies, referrals, and tests. These findings were not associated with breast cancer or other malignancies. Extra‐mammary findings highlight an unrecognized adverse consequence of breast MRI.