Long-term Risk Of Recurrence Research Articles

Oral D-mannose in recurrent urinary tract infections in women: a pilot study

Background: In recurrent urinary tract infections (UTIs) usual prophylactic antibiotic regimes do not change the long-term risk of recurrence. Our aim was to evaluate the efficacy of D-mannose in the treatment and prophylaxis of recurrent UTIs. Methods: In this randomized cross-over trial female patients were eligible for the study if they had an acute symptomatic UTI and three or more recurrent UTIs during the preceding 12 months. Suitable patients were randomly assigned to antibiotic treatment with trimethoprim/sulfamethoxazole or to a regimen of oral D-mannose 1 g 3 times a day, every 8 hours for 2 weeks, and subsequently 1 g twice a day for 22 weeks. They received the other intervention in the second phase of the study, with no further antibiotic prophylaxis. The primary endpoint was evaluation of the elapsed time to recurrence; secondary endpoints were evaluation of bladder pain (VASp) and urinary urgency (VASu). Results: The results for quantitative variables were expressed as mean values and SD as they were all normally distributed (Shapiro–Wilk test). In total, 60 patients aged between 22 and 54 years (mean 42 years) were included. Mean time to UTI recurrence was 52.7 days with antibiotic treatment, and 200 days with oral D-mannose ( p < 0.0001). Conclusions: Mean VASp, VASu score, and average numbers of 24-hour voidings decreased significantly. D-mannose appeared to be a safe and effective treatment for recurrent UTIs in adult women. A significant difference was observed in the proportion of women remaining infection free versus antibiotic treatment.

Cryoablation versus radiofrequency ablation of atrioventricular nodal reentrant tachycardia

Ablation of the slow pathway is an established cure for atrioventricular nodal reentrant tachycardia (AVNRT). Periprocedural damage to the conduction system is a major concern during AVNRT ablation, and cryoablation (CRYO) has been suggested to improve the procedural safety compared to standard radiofrequency (RF) ablation, without reducing the procedural success. We performed a systematic review and meta-analysis of studies comparing CRYO with RF ablation of AVNRT. We searched PubMed, CENTRAL, the BioMed Central, EMBASE, CardioSource, clinicaltrials.gov, and ISI Web of Science (January 1980 to July 2013). No language restriction was applied. Two independent reviewers screened titles and abstracts to identify studies that compared the procedural outcomes of AVNRT ablation with either CRYO or RF energy. Two independent reviewers assessed the risk of bias according to the Cochrane Collaboration, and extracted patient, study characteristics, and procedural outcome data. Results are expressed as odds ratio (OR) or as weighted mean difference (WMD) with their 95% confidence interval (CI). Fourteen studies (5 prospective randomized and 9 observational) with 2,340 patients (mean age range 13 to 53years, 1,522 (65%) females) were included in the analysis. RF ablation was performed in 1,262 (54%) patients, while CRYO in 1,078 (46%) patients. Acute success (abolition of dual atrioventricular node physiology or single echo beats) was achieved in 88% of patients treated with RF versus 83% of those treated with CRYO (OR = 0.72, 95% CI 0.46 to 1.13; P = 0.157). RF ablation was associated with shorter total procedure time (WMD = -13.7min, 95% CI -23 to -4.3min; P = 0.004), but slightly longer fluoroscopy time (WMD = +4.6min 95% CI +1.7 to +7.6min; P = 0.002). Permanent atrioventricular block occurred in 0.87% RF cases and in no CRYO case (OR = 3.60, 95% CI 1.09 to 11.81; P = 0.035). Over a median follow-up of 10.5months (range 6 to 12months), freedom from recurrent AVNRT was 96.5% in the RF group versus 90.9% in the CRYO group (OR = 0.40, 95% CI 0.28 to 0.58; P < 0.001). At meta-regression analysis, no clinical or procedural variable had a significant interaction with the results above. In patients undergoing AVNRT ablation, RF significantly reduces the risk of long-term arrhythmia recurrence compared to CRYO, but is associated with a higher risk of permanent atrioventricular block.

Omitting Adjuvant Radiotherapy in Endometrial Cancer Increases the Rate of Locoregional Recurrences but Has no Effect on Long-Term Survival

In 2 prospective nationwide studies, the Danish Endometrial Cancer Study demonstrated that postoperative radiotherapy (RT) could be omitted in low- and intermediate-risk stage I patients without loss of survival when evaluated after 5 years. In the present study, we evaluated the consequence of this decision on the long-term risk of recurrence and death. From 1998 to 1999, 1166 patients newly diagnosed with uterine carcinoma were included. Of these, 586 were low-risk, 231 intermediate-risk, and 78 high-risk stage I. Low- and intermediate-risk patients received standard primary surgery (hysterectomy and bilateral salpingo-oophorectomy), and no postoperative RT was given. Long-term recurrence and survival rates were estimated. After 14 years, 6.3% of low-risk and 22% of intermediate-risk patients had relapsed compared with 32% of high-risk patients. Recurrences were dominated by locoregional relapse in the low and intermediate risk, whereas non-locoregional relapses were prominent in high risk. After locoregional relapse, 1.5% of low and 4.3% of intermediate risk experienced a second relapse dominated by non-locoregional relapses. After curative-intended treatment of vaginal recurrence in the low- and intermediate-risk patients, 100% had complete remission after the first vaginal recurrence, whereas only 74% was cured after the first or the second recurrence. The increased recurrence rate, however, does not seem to affect survival because the survival rate did not change compared to earlier Danish population-based data. We conclude that omitting RT in early stage endometrial cancer increase local recurrences, but without affecting long-term survival.

Low Long-Term Risk of Foot Ulcer Recurrence After Nerve Decompression in a Diabetes Neuropathy Cohort

Use of nerve decompression in diabetic sensorimotor polyneuropathy is a controversial treatment characterized as being of unknown scientific effectiveness owing to lack of level I scientific studies. Herein, long-term follow-up data have been assembled on 65 diabetic patients with 75 legs having previous neuropathic foot ulcer and subsequent operative decompression of the common peroneal and tibial nerve branches in the anatomical fibro-osseous tunnels. The cohort's previously reported low recurrence risk of less than 5% annually at a mean of 2.49 years of follow-up has persisted for an additional 3 years, and cumulative risk is now 2.6% per patient-year. Nine of 75 operated legs (12%) have developed an ulcer in 4,218 months (351 patient-years) of follow-up. Of the 53 contralateral legs without decompression, 16 (30%) have ulcerated, of which three have undergone an amputation. Fifty-nine percent of patients are known to be alive with intact feet a mean of 60 months after decompression. The prospective, objective, statistically significant finding of a large, long-term diminution of diabetic foot ulcer recurrence risk after operative nerve decompression compares very favorably with the historical literature and the contralateral legs of this cohort, which had no decompression. This finding invites prospective randomized controlled studies for validation testing and reconsideration of the frequency and contribution of unrecognized nerve entrapments in diabetic sensorimotor polyneuropathy and diabetic foot complications.

Preliminary Results of High-Dose Single-Fraction Radiotherapy for the Management of Chordomas of the Spine and Sacrum

En bloc wide-margin excision significantly decreases the risk of chordoma recurrence. However, a wide surgical margin cannot be obtained in many chordomas because they arise primarily in the sacrum, clivus, and mobile spine. Furthermore, these tumors have shown resistance to fractionated photon radiation at conventional doses and numerous chemotherapies. To analyze the outcomes of single-fraction stereotactic radiosurgery (SRS) in the treatment of chordomas of the mobile spine and sacrum. Twenty-four patients with chordoma of the sacrum and mobile spine were treated with high-dose single-fraction SRS (median dose, 2400 cGy). Twenty-one primary and 3 metastatic tumors were treated. Seven patients were treated for postoperative tumor recurrence. In 7 patients, SRS was administered as planned adjuvant therapy, and in 13 patients, SRS was administered as neoadjuvant therapy. All patients had serial magnetic resonance imaging follow-up. The overall median follow-up was 24 months. Of the 24 patients, 23 (95%) demonstrated stable or reduced tumor burden based on serial magnetic resonance imaging. One patient had radiographic progression of tumor 11 months after SRS. Only 6 of 13 patients who underwent neoadjuvant SRS proceeded to surgery. This decision was based on the lack of radiographic progression and the patient's preference. Complications were limited to 1 patient in whom sciatic neuropathy developed and 1 with vocal cord paralysis. High-dose single-fraction SRS provides good tumor control with low treatment-related morbidity. Additional follow-up is required to determine the long-term recurrence risk.

Identifying clinically relevant prognostic subgroups in node-positive postmenopausal HR+ early breast cancer patients treated with endocrine therapy: A combined analysis of 2,485 patients from ABCSG-8 and ATAC using the PAM50 risk of recurrence (ROR) score and intrinsic subtype.

506 Background: Most postmenopausal women with node positive HR+ EBC receive adjuvant chemotherapy. We hypothesized that a molecular-based characterization of residual risk after endocrine therapy using the ROR score and IS may identify node-positive patient subgroups with limited long-term recurrence risk after endocrine therapy better than clinical-pathological risk assessment by clinical treatment score (CTS) alone. Methods: Long-term follow-up and tissue samples were obtained from 2,485 postmenopausal HR+ patients from the ABCSG-8 (N=1,478) and transATAC (N=1,007) trials. The PAM50 test was conducted on RNA extracted from paraffin blocks using the NanoString nCounter Analysis system. The ability of ROR, IS and ROR-defined risk groups (ROR-RG) to add prognostic information to CTS was assessed by the likelihood ratio test in a prospectively defined analysis plan. Results: Patients in the combined data set were grouped by the number of positive nodes into 1 (N1), 2 (N2), or 2 or 3 (N2-3),Baseline hazards for these subgroups were similar in the two trials. ROR score, IS and ROR-RG added statistically significant prognostic information (10-year distant recurrence risk) beyond CTS in all groups. In patients with one positive node, the absolute 10-year risk of distant recurrence was 6.6% [95% CI: 3.3%-12.8%] in the PAM-50-low risk group (40% of patients) and 8.4 % [5.3%-13.3%] in the Luminal A subgroup (69% of patients). Conclusions: The results of this combined analysis demonstrate that a significant proportion of N1 EBC patients have very limited long term recurrence risk and suggest the same for some N2 patients. The PAM50 ROR score, IS and ROR-RG reliably provide additional prognostic information beyond CTS and may be useful in deciding which women with node-positive HR+ EBC can be spared adjuvant chemotherapy. [Table: see text]

Hidradenocarcinoma of the Finger

Hidradenocarcinoma is a rare adnexal neoplasm representing the malignant counterpart of hidradenoma derived from eccrine sweat glands. Misdiagnosis of this disease is common due to the wide variety of histological patterns and rarity of this malignancy. We report an 87-year-old man presenting with a rare case of biopsy-proven hidradenocarcinoma of the finger. There is no standard care of treatment of hidradenocarcinoma, especially of those tumors in rare locations such as the fingers, given its rarity, variable tumor behavior and histology. Although limited treatment strategies exist, detailed data including TNM, location, histologic type and grade, and patient age should be gathered for optimal treatment strategy. The literature supports a 3-fold approach to these malignancies involving margin-free resection, sentinel lymph node biopsy to evaluate possible metastasis, and long-term follow-up given high risk of recurrence. Our treatment strategy involved a 4-fold, multidisciplinary approach involving reconstruction to optimize tumor-free remission and hand function.

Short- and long-term risk of colorectal adenoma recurrence among whites and blacks

It is unclear whether the higher burden from colorectal cancer among blacks is due to an increased biological susceptibility. To determine whether non-Hispanic blacks (blacks) have a higher risk of adenoma recurrence than non-Hispanic whites (whites) after removal of colorectal adenoma. Secondary analysis of the Polyp Prevention Trial (PPT) data. United States. Patients were 1668 self-identified whites and 153 blacks who completed the 4-year trial. Of these, 688 whites and 55 blacks enrolled in a posttrial, passive Polyp Prevention Trial Continued Follow-up Study (PPT-CFS) and underwent another colonoscopy. Recurrence and location of the adenoma and advanced adenoma by race-ethnicity during PPT and cumulative recurrence over a mean follow-up of 8.3 years (range, 4.9-12.4 years) among PPT-CFS enrollees. Blacks had similar risk of recurrence of adenoma (39.2% vs 39.4%; incidence risk ratio [RR] = .98; 95% CI, .80-1.20) and advanced adenoma (8.5% vs 6.4%; RR = 1.18; 95% CI, .68-2.05) as whites at the end of PPT. Recurrence risk did not differ by colon subsite. Among PPT-CFS enrollees, the cumulative recurrence rate over a maximal follow-up period of 12 years was similar for blacks and whites for adenoma (67.3% vs 67.0%; RR = 1.01; 95% CI, .84-1.21) and advanced adenoma (14.5% vs 16.9%; RR = 1.03; 95% CI, .60-1.79). There were few blacks in the long-term follow-up study. Adenoma and advanced adenoma recurrence did not differ by race. Our study does not support more frequent surveillance colonoscopies for blacks with a personal history of adenoma as an intervention to reduce colorectal cancer disparity.

Arterial stiffness predicts risk for long-term recurrence in patients with type 2 diabetes admitted for acute coronary event

Objectivesto investigate the predictive value of arterial stiffness (AS) estimation for long-term recurrences in patients with type 2 diabetes (DM2) following acute coronary event. Patients and methodsprospective observational study involving 119 DM2 patients without history of coronary heart disease admitted with ST-segment elevation myocardial infarction (STEMI). Medical history, anthropometrics, smoking, HbA1c, lipid profile, troponine-I levels, and left ventricular ejection fraction (LVEF) were recorded. Carotid-femoral pulse wave velocity (cf-PWV) was measured 1 month after discharge. Patients were followed up for 36 months or to reach an end-point: cardiovascular death, acute coronary event, angioplasty or hospitalization for acute heart failure. To facilitate analysis, patients were divided into two groups according to cf-PWV, using the accepted cut-off value of 12m/s. Resultsoverall, 34 patients had a recurrence. In Kaplan–Meier analysis patients with cf-PWV>12m/s had mean time-to-event 353±43 days compared to 505±115 days for patients with cf-PWV≤12m/s, log rank=0.0252. In multivariate analysis factors independently associated with recurrence were age (66.53±6.87 vs. 61.54±10.77 years, p=0.015), LVEF (41.66±8.21 vs. 47.58±8.11%, p=0.001) and cf-PWV (13.94±2.91 vs. 12.35±2.77m/s, p=0.008). ConclusionsAS estimation in patients with DM2 after STEMI discriminate patients at higher risk for 3-year recurrence, and maybe valuable for distinguishing patients likely to require a more rigorous therapeutic intervention.

Endovascular treatment of haemoptysis: Medium and long-term assessment

To assess the short, medium and long-term results of bronchial artery embolisation (BAE) and identify the factors favouring the recurrence of haemoptysis. This is a retrospective study, between January 2001 and June 2010, comprising 53 consecutive patients with BAE. The mean age was 53.8 years. There were 15 women (28.30%) and 38 men (71.69%). The aetiologies of haemoptysis were dominated by the residual signs of pulmonary tuberculosis: 18 cases (33.96%), bronchial dilations: 12 cases (22.64%) and aspergilloma: five cases (9.43%). The bronchial arteriography showed signs of bronchial hypervascularisation in 92.45% of the cases. Forty-six patients had a first embolisation (86.79%) with immediate efficacy in 84.90% of the cases (n=45). This efficacy was noted after more than 3 years in 60.08% of the cases. Short (< 30 days) and medium-term (> 30 days and < 3 years) recurrence of haemoptysis were noted in 17.39% and 8.69% of the cases respectively. A statistically significant correlation between aspergilloma and the immediate recurrence was found (P=0.013). The risk of medium and long-term recurrence (> 3 years) was correlated with age. The survival without recurrence was statistically higher when the age was less than 60 years (P=0.0041). BAE is an effective treatment. Aspergilloma is a major risk factor in the recurrence of haemoptysis. Repeated embolisation may be proposed for these patients.

Comparison of the Long-Term Risk of Recurrence and Other Clinical Outcomes in GIST Patients Receiving Imatinib as Adjuvant Therapy—A Retrospective Chart Extract-Based Approach

PurposeTo compare characteristics of patients, the risk of recurrence, and mortality among adult patients with primary resectable gastrointestinal stromal tumor (GIST) receiving short-term (6–12 months) versus long-term (≥ 24 months) imatinib therapy.MethodsDetailed information on primary resectable KIT-positive GIST patients initiated on imatinib adjuvant therapy was retrospectively collected for short- and long-term imatinib patients from 318 US oncologists using an online data collection form. Patient characteristics were compared using Wilcoxon and Chi-square tests. Disease recurrence and mortality rates were compared using multivariate Cox proportional hazard models.ResultsAmong the 406 short-term and 406 long-term imatinib patients, the median follow-up was 916 and 970 days, respectively. While patients generally had similar demographic characteristics, the short-term group had a higher prevalence of cardiovascular and ischemic heart diseases and patients in the long-term group had a higher pre-surgery risk profile. This finding was consistent with the main reason reported by oncologists for prescribing adjuvant imatinib over longer duration, i.e., patient risk profile. Disease recurrence [5.9 versus 1.2 %, (p < .001)] and mortality rates [7.1 % versus 2.0 %, (p < .001)] were higher in short- versus long-term patients. The adjusted risk of recurrence was 5.30 times (p < .001) higher, and mortality risk was 4.02 times (p < .001) higher in short- versus long-term patients.ConclusionsPatient risk profile is an important factor in oncologists’ decisions to prescribe adjuvant imatinib. Despite the higher risk profile observed in long-term patients, the long-term use of imatinib was associated with a reduction in long-term risk of disease recurrence and mortality.

Long‐term adjuvant therapy for the prevention of postoperative endometrioma recurrence: a systematic review and meta‐analysis

Ovulation seems crucial in the pathogenesis of ovarian endometriomas. Therefore, suppression of ovulation should be protective against cyst relapse after excision. The objective of this systematic review was to assess the effect of long-term postoperative medical treatment on the risk of endometrioma recurrence. A MEDLINE search was conducted to identify all the comparative studies published in the last 12 years in the English language literature on the relation between long-term postoperative adjuvant therapy and risk of endometrioma recurrence. Of the 12 articles assessed in detail, four were finally selected based on surgery for endometriotic cysts, postoperative medical treatment use for ≥ 12 months vs. expectant management, and ultrasonographic and/or histological diagnosis of endometrioma recurrence. A total of 965 women were enrolled, 726 of whom were in three cohort studies and 239 in one randomized controlled trial. Oral contraceptives (OCs) were always used as postoperative adjuvant treatment. The absolute effect of postoperative OC use was assessed by comparing "always" and "never" users. A recurrent endometrioma was identified in 33 of 423 (8%) "always" OC users and in 117 of 341 (34%) women who underwent expectant management (pooled odds ratio 0.12; 95% confidence interval 0.05-0.29). To define the effect of duration of use, "always" users were compared with "ever" users, and "ever" with "never" users, with a pooled odds ratio of, respectively, 0.21 (95% confidence interval 0.11-0.40) and 0.39 (95% confidence interval 0.23-0.66). Postoperative OC use dramatically decreased the risk of ovarian endometrioma recurrence, especially in women who used OCs regularly and for prolonged periods.

Recurrence of major depressive disorder and its predictors in the general population: results from The Netherlands Mental Health Survey and Incidence Study (NEMESIS)

Knowledge of the risk of recurrence after recovery from major depressive disorder (MDD) in the general population is scarce. Data were derived from 687 subjects in the general population with a lifetime DSM-III-R diagnosis of MDD but without a current major depressive episode (MDE) or dysthymia. Participants had to be at least 6 months in remission, and were recruited from The Netherlands Mental Health Survey and Incidence Study (NEMESIS), using the composite international diagnostic interview (CIDI). Recency and severity of the last MDE were assessed retrospectively at baseline. Recurrence of MDD was measured prospectively during the 3-year follow-up. Kaplan-Meier survival curves were used to measure time to recurrence. Determinants of time to recurrence were analyzed using proportional hazard models. The estimated cumulative recurrence of MDD was 13.2% at 5 years, 23.2% at 10 years and 42.0% at 20 years. In bivariate analysis, the following variables predicted a shorter time to recurrence: younger age, younger age of onset, higher number of previous episodes, a severe last depressive episode, negative youth experiences, ongoing difficulties before recurrence and high neuroticism. Multivariably, younger age, a higher number of previous episodes, a severe last depressive episode, negative youth experiences and ongoing difficulties remained significant. In this community sample, the long-term risk of recurrence was high, but lower than that found in clinical samples. Subjects who had had an MDE had a long-term vulnerability for recurrence. Factors predicting recurrence included illness- and stress-related factors.

Importance of recurrence rating, morphology, hernial gap size, and risk factors in ventral and incisional hernia classification

There is limited evidence on the natural course of ventral and incisional hernias and the results of hernia repair, what might partially be explained by the lack of an accepted classification system. The aim of the present study is to investigate the association of the criteria included in the Wuerzburg classification system of ventral and incisional hernias with postoperative complications and long-term recurrence. In a retrospective cohort study, the data on 330 consecutive patients who underwent surgery to repair ventral and incisional hernias were analyzed. The following four classification criteria were applied: (a) recurrence rating (ventral, incisional or incisional recurrent); (b) morphology (location); (c) size of the hernial gap; and (d) risk factors. The primary endpoint was the occurrence of a recurrence during follow-up. Secondary endpoints were incidence of postoperative complications. Independent association between classification criteria, type of surgical procedures and postoperative complications was calculated by multivariate logistic regression analysis and between classification criteria, type of surgical procedures and risk of long-term recurrence by Cox regression analysis. Follow-up lasted a mean 47.7 ± 23.53 months (median 45 months) or 3.9 ± 1.96 years. The criterion "recurrence rating" was found as predictive factor for postoperative complications in the multivariate analysis (OR 2.04; 95 % CI 1.09-3.84; incisional vs. ventral hernia). The criterion "morphology" had influence neither on the incidence of the critical event "recurrence during follow-up" nor on the incidence of postoperative complications. Hernial gap "width" predicted postoperative complications in the multivariate analysis (OR 1.98; 95 % CI 1.19-3.29; ≤5 vs. >5 cm). Length of the hernial gap was found to be an independent prognostic factor for the critical event "recurrence during follow-up" (HR 2.05; 95 % CI 1.25-3.37; ≤5 vs. >5 cm). The presence of 3 or more risk factors was a consistent predictor for "recurrence during follow-up" (HR 2.25; 95 % CI 1.28-9.92). Mesh repair was an independent protective factor for "recurrence during follow-up" compared to suture (HR 0.53; 95 % CI 0.32-0.86). The ventral and incisional hernia classification of Dietz et al. employs a clinically proven terminology and has an open classification structure. Hernial gap size and the number of risk factors are independent predictors for "recurrence during follow-up", whereas recurrence rating and hernial gap size correlated significantly with the incidence of postoperative complications. We propose the application of these criteria for future clinical research, as larger patient numbers will be needed to refine the results.

Altemeier’s procedure for rectal prolapse: analysis of long‐term outcome in 60 patients

Altemeier's procedure (perineal rectosigmoidectomy) is the operation of choice for rectal prolapse in the elderly. The aims of this prospective observational study were to evaluate its long-term actuarial recurrence risk and the influence of the length of rectosigmoid resection and associated levatorplasty on recurrence rate and continence. The perioperative and long-term data for all patients undergoing Altemeier's procedure since 1992 were analysed with regard to mortality, morbidity, continence, anorectal function and recurrence rate. Sixty patients [median age 77 years (35-98)] underwent rectosigmoid resection [median length of bowel 14 (6-60) cm] with associated levatorplasty in 21 (35%). Overall mortality and morbidity were 1.6 and 11.6%, respectively. Manometry showed increased anal sphincter basal pressure and maximal squeeze pressure. We observed a decrease in postoperative rectal compliance (P=0.002). Age, gender, prolapse duration before surgery, levatorplasty and length of resection had no statistically significant relationship with recurrence. Continence improved in 62% and was stable over a median follow-up of 48 (1-186) months. Continence was positively related to a short length of bowel resection, but not to decreased rectal compliance. Actuarial recurrence was 14% at 4 years. The long-term recurrence rate after the Altemeier procedure was low and not linked to resection length or to levatorplasty. Improvement in continence was stable over time.

Clinical Features, Management, and Prognosis of Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is an acute coronary event of uncertain origin. Clinical features and prognosis remain insufficiently characterized. A retrospective single-center cohort study identified 87 patients with angiographically confirmed SCAD. Incidence, clinical characteristics, treatment modalities, in-hospital outcomes, and long-term risk of SCAD recurrence or major adverse cardiac events were evaluated. Mean age was 42.6 years; 82% were female. Extreme exertion at SCAD onset was more frequent in men (7 of 16 versus 2 of 71; P<0.001), and postpartum status was observed in 13 of 71 women (18%). Presentation was ST-elevation myocardial infarction in 49%. Multivessel SCAD was found in 23%. Initial conservative management (31 of 87) and coronary artery bypass grafting (7 of 87) were associated with an uncomplicated in-hospital course, whereas percutaneous coronary intervention was complicated by technical failure in 15 of 43 patients (35%) and 1 death. During a median follow-up of 47 months (interquartile range, 18-106 months), SCAD recurred in 15 patients, all female. Estimated 10-year rate of major adverse cardiac events (death, heart failure, myocardial infarction, and SCAD recurrence) was 47%. Fibromuscular dysplasia of the iliac artery was identified incidentally in 8 of 16 femoral angiograms (50%) undertaken before closure device placement and in the carotid arteries of 2 others with carotid dissection. SCAD affects a young, predominantly female population, frequently presenting as ST-elevation myocardial infarction. Although in-hospital mortality is low regardless of initial treatment, percutaneous coronary intervention is associated with high rates of complication. Risks of SCAD recurrence and major adverse cardiac events in the long term emphasize the need for close follow-up. Fibromuscular dysplasia is a novel association and potentially causative factor.

Risk of disease recurrence and mortality in gastrointestinal stromal tumor (GIST) patients receiving short-term versus long-term imatinib adjuvant therapy: A chart review analysis.

e20511 Background: The benefits of long-term (36 months) use of adjuvant imatinib (IM) in high risk GIST patients (pts) have been demonstrated in a recent multicenter, prospective clinical trial that compared efficacy and safety of 3 years vs 1 year IM treatment. However, in clinical practice, there is no consensus on the optimal IM treatment duration after surgery. The objective of this retrospective observational study was to compare the risk of recurrence and survival among primary resectable Kit positive GIST pts treated with adjuvant IM for a short vs an extended period of time in a real-world setting. Methods: Information on adult pts with primary resectable Kit positive GIST initiating imatinib ≤84 days after surgery was collected from 248 U.S. oncologists using an online data collection form. Detailed pt information following first GIST diagnosis, including demographic, GIST-related characteristics (e.g., risk profile), comorbidity profile, IM treatment characteristics, disease recurrence and mortality was collected for pts with short-term (6-12 months) and long-term IM use (≥24 months). Disease recurrence and mortality rates were estimated from the 1st surgery date to the 1st evidence of recurrence, mortality, or end of observation period. Multivariate Cox proportional hazard models were used to compare recurrence and mortality rates between short vs long term IM use pts. Results: Among the 246 short-term and 395 long-term IM pts, the median follow up was 884 and 963 days, respectively. The average age was similar [59.0 (10.4) vs 58.1 (9.5); p=.23] but short-term pts had less males [57.7% vs 69.6% (p&lt;.01)] and a lower Miettinen risk score [0.3 vs 0.4, p&lt; .01)] than long-term pts. Disease recurrence [7.3 vs 1.8%, (p&lt; .01)] and mortality rates [6.9% vs 2.3%, (p &lt; .01)] were also higher in short- vs long-term pts. The adjusted risk of recurrence was 4.77 times [95% CI: 1.98 – 11.48, (p&lt;.01)] higher and mortality risk was 3.44 times [CI: 1.53 – 7.75, (p&lt;.01)] higher in short- vs long-term pts. Conclusions: Use of IM over an extended period of time is associated with a reduction in long-term risk of disease recurrence and mortality.

A Close Surgical Margin After Radical Prostatectomy is an Independent Predictor of Recurrence

The term close surgical margin refers to a tumor extending to the inked margin of the specimen without reaching it. Current guidelines state that a close surgical margin should simply be reported as negative. However, this recommendation remains controversial and relies on limited evidence. We evaluated the impact of close surgical margins on the long-term risk of biochemical recurrence after radical prostatectomy. We identified 1,195 consecutive patients who underwent radical prostatectomy and lymphadenectomy for localized prostate cancer at our institution from 1993 to 1999. In 894 of these patients associations between margin status and location, Gleason score, pathological stage, preoperative prostate specific antigen, prostate weight and age with the risk of biochemical recurrence were examined. Of these 894 patients 644 (72%) had negative margins and of these patients 100 (15.5%) had close surgical margins. In the group with prostate specific antigen failure, median time to recurrence was 3.5 years. In the group without recurrence median followup was 9.9 years. Cumulative recurrence-free survival differed significantly among positive, negative and close surgical margins (p <0.001). On multivariate analysis a close surgical margin constituted a significant, independent predictor of recurrence (HR 2.1, 95% CI 1.04-4.33). Gleason score and positive margins were the strongest prognostic factors. In this cohort close surgical margins were independently associated with a twofold risk of postoperative biochemical recurrence. Further evaluation of the clinical significance of close surgical margins is indicated as they might be an indicator of local recurrence and of relevance when considering salvage therapy.

Patients with a history of infection and voiding dysfunction are at risk for recurrence after successful endoscopic treatment of vesico ureteral reflux and deserve long-term follow up

Aim of the Study:Subureteral endoscopic injection of a bulking agent is an attractive alternative to open surgery or antibiotic prophylaxis for vesico ureteral reflux (VUR). Little information is available about long-term risk of recurrence after an initially successful treatment. Aim of this paper was to review short- and long-term success rate of endoscopic treatment in a single Center series after risk stratification of individual patients.Materials and Methods:The records of 126 patients who underwent Deflux injection for primary VUR were examined. Indications to treatment were an unvaried high grade VUR (IV-V) at 1 year from diagnosis and/or and recurrent urinary tract infection (UTI) on antibiotic prophylaxis even in the presence of mild grade VUR (III grade). Gender, age and mode of diagnosis, infections (UTI), voiding dysfunctions, VUR grade and side, renal function, number of treatments were correlated to outcome. Long-term evaluation was planned at a minimum of 1 year from the last negative post-injection cystogram (MCUG). A new MCUG and DMSA scan were also offered to those complaining new UTI episodes. Late recurrences were correlated to history and grade of reflux. Data were analyzed with Graph Pad Instat software; the Chi-square test was used for univariate comparisons, the Fisher's exact test for categorical variables.and multiple regression tests for factors influencing outcome.Results:M/F ratio was 62 to 64; median age at diagnosis was 28 months. VUR affected 198 renal units. Preinjection VUR grade was I in 1, II in 27, III in 107, IV in 59, and V in 4 units. Reduced DMSA uptake was evidenced in 51 units and scarring in 24. Median age at treatment was 34.5 months, for persistent high grade VUR (IV–V) in 55 patients and recurrent IVU in 92. Two hundred sixty seven injections were performed on 198 ureters. Complete resolution was documented by MCUG at 3-5 months in 68%, low grading < II in 20%, persistence or unsignificant reduction in 11%. Preoperative recurrent UTI, higher grade VUR, and bilaterality were correlated to a poorer surgical outcome. Among 80 successfully treated cases, 12 complained of persistent UTI. Recurrence of VUR was demonstrated in 31% of them. Deteriorated uptake or additional scarring in 25% was independent from VUR recurrence. Preoperative recurrent UTI and voiding dysfunction correlated significantly to late outcome.Conclusions:Preoperative recurrent IVU, together with high-grade reflux, seem to correlate to lower success rate of Deflux injection for primary VUR. Even after successful endoscopic treatment, long-term surveillance may be needed among these cases, mainly if voiding dysfunction is also recorded. Late recurring VUR must be actively excluded in case of new IVU episodes.

Papillary Thyroid Carcinoma Patients Assessed to Be at Low or Intermediary Risk After Primary Treatment Are at Greater Risk of Long Term Recurrence If They Are Thyroglobulin Antibody Positive Or Do Not Have Distinctly Low Thyroglobulin at Initial Assessment

In papillary thyroid carcinoma (PTC), recurrences during long-term follow-up (R-LTFU) occur even in those who appear to have an excellent prognosis after initial thyroid surgery and usually, radioactive iodine (i.e., "primary treatment"). Initial studies that predict R-LTFU are not well defined. Values for serum thyroglobulin (Tg) measurements when serum thyrotropin (TSH) is >30 μU/mL, as a result of either recombinant TSH or L-thyroxine withdrawal, referred to here as stimulated Tg (STg), have been previously evaluated. The aim of the current study was to determine the parameters associated with R-LTFU in patients with PTC categorized as having low-risk disease 9 to 12 months after their primary treatment. This was a retrospective study of 469 patients with PTC with a mean follow-up 5.8±3.9 years. Study patients had to have no uptake in the first postablative diagnostic (131)iodine whole body scan (WBS) performed 9-12 months after primary treatment, a normal cervical ultrasonography (C-US), and STg of <2 ng/mL if their test for antithyroglobulin antibody (anti-Tg) was negative. The first two criteria were required for patients with a positive anti-Tg test, and their nominal serum Tg concentrations were not analyzed. Twelve patients developed recurrences (2.6%) in cervical region. Greater tumor size, higher STg, and positive anti-Tg tests at initial evaluation were associated with greater R-LTFU. The recurrence rates were 1.5% (7/450) and 26% (5/19), respectively, in patients with negative and positive anti-Tg tests at initial evaluation. Recurrence-free survival was lower in the patients with initial lymph node metastases, positive anti-Tg tests, and STg of ≥0.3 ng/mL at the first postablative WBS (p=0.022, 0.001, 0.035, respectively, by log-rank test). Regression analysis in patients who were anti-Tg negative revealed that STg ≥0.3 ng/mL at this first WBS was the only parameter related to recurrence (p=0.031, odds ratio: 10.30, confidence interval: 1.23-83.3). Patients with PTC traditionally categorized as low risk during their first 9 to 12 months after primary treatment have a greater risk of R-LTFU if their postablative STg is ≥0.3 ng/mL, or they have positive anti-Tg, even at this early stage. Periodic C-US is important in these patients and should probably be more frequent in patients with PTC who have positive anti-Tg tests or STg ≥0.3 ng/mL in the first year after diagnosis.