Median Postoperative Survival Time Research Articles

Recurrent spontaneous pneumothorax in four surgically treated Japanese Spitz dogs

AbstractFour Japanese Spitz dogs between 5 and 11 months old were presented for acute dyspnoea. Thoracic radiographs and CT identified bilateral pneumothorax and pulmonary cavitary lesions. The median lesion size was 30 mm (range 7‒50 mm). After initial stabilisation, one dog underwent median sternotomy, while three dogs underwent intercostal thoracotomy. Surgical exploration found grossly haemorrhagic pulmonary bullous lesions in all cases. Histopathology revealed blood‐filled cavities with interstitial fibrosis and pneumocyte hyperplasia. Dyspnoea recurred in all dogs postoperatively, with recurrence of lesions confirmed either radiographically or via CT in three of four cases. The median time from surgery to recurrence of pneumothorax was 9 days (range 5‒15 days). The mortality rate was 100%, and the median postoperative survival time was 22 days (range 5‒558 days). This report aims to raise awareness of this group of dogs presenting with spontaneous pneumothorax at a young age and with high recurrence rates despite surgery, contrary to the literature.

Clinical outcomes following total en bloc spondylectomy for spinal metastases from lung cancer

BackgroundThe current guidelines for the treatment of non-small cell lung cancer encourage local curative treatment for selected patients with oligometastases. This study evaluated the surgical results of total en bloc spondylectomy (TES) for isolated spinal metastases originating from lung cancer in carefully selected patients. MethodsWe retrospectively reviewed 14 patients (7 men and 7 women) who underwent TES for spinal metastases originating from lung cancer between 2000 and 2017. The primary outcome measure was the postoperative overall survival time. The histological types included adenocarcinoma (n = 12), pleomorphic carcinoma (n = 1), and small cell lung carcinoma (SCLC) (n = 1 patient). We assessed postoperative survival using Kaplan–Meier analysis and the log-rank test. ResultsThe median postoperative survival time was 83.0 months (6–162 months) in 13 patients with non-small cell lung carcinoma (NSCLC) and 6 months in 1 patient with SCLC. The 3-, 5-, and 10-year overall survival rates in patients with NSCLC were 61.5%, 53.8%, and 15.4%, respectively. Poor postoperative performance status (PS) and Frankel grade, and preoperative irradiation to the vertebrae to be resected were significantly associated with short-term survival after TES in patients with NSCLC (p < 0.05). ConclusionsThe surgical results of TES for spinal metastases of lung cancer were relatively favorable among carefully selected patients. TES may be indicated for spinal metastases of lung cancer in patients with controlled primary lung cancer, NSCLC histology, prospect of good postoperative PS, and preferably no irradiation to the target vertebrae.

Effectiveness of gelatin matrix with human thrombin for reducing blood loss in palliative decompressive surgery with posterior spinal fusion for metastatic spinal tumors

BackgroundThis study aimed to investigate the effect of gelatin matrix with human thrombin (GMHT) on blood loss and survival time in patients with metastatic spinal tumors treated with palliative decompression surgery with posterior spinal fusion. MethodsWe retrospectively reviewed 67 consecutive patients with metastatic spinal tumors who underwent palliative decompression surgery with posterior spinal fusion. We compared patients in whom GMHT was not used during surgery with those in whom GMHT was used. The following baseline characteristics were evaluated: age, height, weight, sex, metastatic tumor diagnosis, medical history, use of antiplatelet drug, use of anticoagulant drug, use of NSAIDs, smoking, preoperative PLT value, preoperative APTT, preoperative PT-INR, Karnofsky Performance Status score, Charlson comorbidities index score, the percentage of patients who received perioperative chemotherapy, main tumor level, Frankel category, revised Tokuhashi score, spinal instability neoplastic score (SINS), number of fusion segments, operation time, intraoperative blood loss, drainage blood loss, red blood cell transfusion, hemoglobin level, total protein (TP), albumin values, total blood loss (TBL), hidden blood loss, postoperative bed rest and postoperative survival time. Perioperative complications were assessed. ResultsAge, height, weight, sex, metastatic tumor diagnosis, medical history, use of antiplatelet drug, use of anticoagulant drug, use of NSAIDs, smoking, preoperative PLT value, preoperative APTT, preoperative PT-INR, CCI score, main level of tumors, SINS score, preoperative Tokuhashi score and number of fusion segments did not differ significantly between the two groups. Operation time, intraoperative blood loss, postoperative drainage blood loss, and TBL were significantly decreased in the group with GMHT than in the group without GMHT. The total number of perioperative complications was significantly lesser in the group with GMHT than in the group without GMHT. The median postoperative survival time was significantly longer in the GMHT group than in the group without GMHT. ConclusionGMHT should be considered a valid option for the treatment of patients with metastatic spinal tumors with a short life expectancy.

Mixed neuroendocrine-non-neuroendocrine neoplasm of the gallbladder: case report and literature review

BackgroundMixed neuroendocrine–non-neuroendocrine neoplasms (MiNENs) of the gallbladder are rare malignancies. Here we presented two cases and reviewed the related literature.Case presentationOur two patients were postoperatively diagnosed with gallbladder MiNENs, which pathologically consisted of a large cell neuroendocrine carcinoma and papillary adenocarcinoma. After cholecystectomy, one patient had a survival time of 30 months, while the other remained alive through 12 months of follow-up. In the literature, a total of 72 cases of gallbladder MiNENs were identified, and with our two patients included, we calculated a male-to-female ratio of 0.22 and a mean age of 64.5 years for the 74 reported cases. About one-half of these patients were found to have gallstones and presented with abdominal pain or discomfort in a relatively early stage. The preoperative diagnosis of these 74 cases mainly relied on abdominal ultrasound, contrast-enhanced computed tomography (CT) scanning, and magnetic resonance imaging or positron emission tomography/CT. However, the final diagnosis was established based upon the pathological evidence and expression of synaptophysin (Syn) and/or chromogranin A identified by immunohistochemical staining or neurosecretory granules detected by electron microscopy. Fifty-eight patients (78.4%) underwent various operations including simple cholecystectomy (n = 14), en bloc cholecystectomy (n = 9), standard or non-standard radical cholecystectomy (n = 25), or extended radical cholecystectomy (n = 6). The mean size of the resected gallbladder masses was 50.8 ± 36.1 mm (n = 63) with regional lymph node metastasis in 37 patients (52.1%), liver invasion or staging greater than T3 in 33 patients (45.8%), and hepatic metastasis in 26 patients (35.1%). The postoperative median survival time was 36 ± 11.42 months (95% confidence interval, 13.62 to 58.38 months). The log-rank analysis did not find that postoperative adjuvant chemotherapy contributed to a longer survival time relative to that among the patients who did not receive chemotherapy (numbers of patients, 15 versus 43; survival times, 36 months versus 30 months, p > 0.05).ConclusionsOur two cases and the cases in the literature suggest that MiNENs of the gallbladder predominantly occur in women; are associated with early lymph node metastasis, local hepatic invasion, and hepatic metastasis; and can be managed by various surgeries as well as chemotherapy combined with somatostatin analogs.

Hyperlactatemia as a Risk Stratification for Postinfarction Ventricular Septal Rupture.

Surgical repair for postinfarction ventricular septal rupture (VSR) is a challenging operation, especially in the acute phase with unstable hemodynamics. We retrospectively examined the value of measuring lactate, which can be a quantitative indicator of end-organ ischemia caused by multiple factors including ineffective cardiac output, for risk stratification in patients undergoing surgical repair. From April 2008 to December 2018, 33 consecutive patients were admitted to our hospital with a diagnosis of VSR and underwent VSR repair surgery within 24 hours of admission. We categorized patients into 3 groups based on the distribution of preoperative blood lactate level: <5 mmol/L (n = 16), 5 to 10 mmol/L (n = 11), and >10 mmol/L (n = 6). There was no intraoperative death, but the prognosis for patients with lactate >10 mmol/L was extremely poor, with a median postoperative survival time of only 23 days [25th percentile 6, 75th percentile 30]. Five of 6 patients (83%) died within 30 days after surgery. The risk-adjusted hazard ratio (95% confidence interval) for mortality per 1 SD (0.41-unit) increase in log-transformed preoperative lactate level (equivalent to a 4.10-fold increase) was 2.85 (1.57 to 5.19). Patients with lactate 5 to 10 mmol/L had 3.95-fold and those with lactate >10 mmol/L had 6.03-fold higher risk of mortality than those with lactate <5 mmol/L. Elevation of preoperative serum lactate is significantly associated with mortality in patients who underwent VSR repair. The findings of this study highlight the value of measuring lactate level for risk stratification.

Comparison of outcomes between medical and surgical treatment in dogs with prostatic adenocarcinoma: a retrospective study

BackgroundProstatic cancer is uncommon in dogs. Dogs with prostatic carcinoma have been reported to have a poor prognosis. Information regarding prognosis with various surgery options as well as prognosis with surgical vs. medical treatment is lacking. This retrospective study compares the outcomes of medical management to surgical treatment in dogs with prostatic adenocarcinoma and assesses the surgical outcomes of patients who underwent total prostatectomy (TP) and prostatocystectomy (TPC). The medical records of 41 dogs with prostatic adenocarcinoma, between February 2008 and June 2019, were reviewed for information on signalment, clinical signs in the initial evaluation, preoperative diagnostic imaging findings, treatment type (non-surgical or surgical), surgery type, postoperative complications, adjunctive medical therapy, and survival time. The dogs were divided into non-surgical (n = 12) or surgical (n = 29) groups. The surgical group was subdivided into the TP (n = 20) and TPC (n = 9) subgroups.ResultsAge was not significantly different between the surgical (median 13.1 years [8.4–15.4] years) and the non-surgical groups (median 10.8 [7.7–15.3] years). Body weight (BW) was also not significantly different between the surgical (median 6.8 kg [2.4–34.5 kg]) and non-surgical groups (median 6.4 kg [3.7–9.12 kg]). The overall median survival time (MST) from the initial evaluation was significantly longer in the surgical than in the non-surgical group (337 vs. 90.5 days). The postoperative MST was significantly longer in the TP group than in the TPC subgroup (510 vs. 83 days). As TPC was performed in cases of tumor progression, its postoperative complications were severe, resulting in a shorter MST. Ten (50%) and 6 patients (30%) in the TP subgroup postoperatively showed mild and severe urinary incontinence, respectively, whereas all patients in TPC subgroup did show severe incontinence.ConclusionResults of the study suggest that surgical treatment of prostatic carcinoma results in longer survival times over medical management alone. In particular, TP might be recommended for improving survival time and quality of life in canine prostatic adenocarcinoma that does not infiltrate the bladder. Early detection is key for a survival advantage with surgical treatment.

Comparison of 8spheres polyvinyl alcohol microsphere and gelatin sponge particle efficacy for transcatheter arterial chemoembolization in stages A to B patients with hepatocellular carcinoma.

This study aimed to compare the clinical efficacy and prognostic analysis results of 8spheres polyvinyl alcohol (PVA) microspheres (8SM) with gelatin sponge (GS) particles for transcatheter arterial chemoembolization (TACE) in patients with stages A-B hepatocellular carcinoma (HCC). Data were collected from 172 patients who underwent TACE at Harbin Medical University Cancer Hospital from January 2014 to July 2020. Patients were divided into two groups: TACE group using 8SM plus lipiodol (8spheres PVA group, N = 89) and TACE group using GS particles plus lipiodol (the GS group, N = 83). Subsequently, we compared the liver function, blood count, alpha-fetoprotein (AFP), and other parameters of patients in each group before and after interventional embolization. We also calculated the patient's progression-free survival and overall survival in these groups. The postoperative liver function indices, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in the 8spheres PVA group, were worse than in the GS group. The postoperative median survival time was 19 ± 3.06 months and no significant difference in survival time was observed in GS group (26 ± 3.19 months) (P = 0.509). Multivariate analysis showed that targeted therapy (P = 0.051), maximum tumor diameter <5 cm (P = 0.018), age ≥60 years (P = 0.018), and AFP <120.5 μg/L (P = 0.007) significantly improved the overall survival rate of patients. Postoperative liver function indices of patients with HCC treated with GS particles were better than those treated with 8SM; thus, GS particles are more suitable for patients with poor liver function.

Selective Radical Resection for Unresectable Pancreatic Cancer

&lt;p&gt;Background and Objective: &amp;nbsp;For inefficiency of chemotherapy and radiation against pancreatic cancer, resection rate for primary unresectable pancreatic cancer remains very low. This study was carried out to evaluate the safety and value of radical resection for unresectable pancreatic cancer (UPC).&lt;/p&gt;&#x0D; &lt;p&gt;Methods: &amp;nbsp;Clinical data were analyzed retrospectively. In unresectable group, 360&amp;deg; resection of the involved artery sheath, resection and reconstruction of the involved artery, resection and reconstruction of the involved vein as well as resection and reconstruction of combined organs were performed. Operation time, intraoperative blood loss, ICU transitional treatment, pancreatic fistula, bleeding, reoperation and survival time were analyzed for two groups.&lt;/p&gt;&#x0D; &lt;p&gt;Results: &amp;nbsp;Operation time and intraoperative blood loss were greatly increased in the unresectable group. The incidence of intractable diarrhea and abdominal hemorrhage in the unresectable group were higher. However, the rate of ICU transitional therapy, delayed gastric emptying and reoperation were lower. Grade-C pancreatic fistula occurred in neither group.&lt;/p&gt;&#x0D; &lt;p&gt;Conclusion: &amp;nbsp;Surgical treatment through stringent selection for patients with unresectable pancreatic cancer is a safer technique and median post-operative survival time is similar to patients with resectable pancreatic cancer.&lt;/p&gt;

Selective Radical Resection for Unresectable Pancreatic Cancer

Background and Objective: For inefficiency of chemotherapy and radiation against pancreatic cancer, resection rate for primary unresectable pancreatic cancer remains very low. This study was carried out to evaluate the safety and value of radical resection for unresectable pancreatic cancer (UPC). Methods: Clinical data were analyzed retrospectively. In unresectable group, 360° resection of the involved artery sheath, resection and reconstruction of the involved artery, resection and reconstruction of the involved vein as well as resection and reconstruction of combined organs were performed. Operation time, intraoperative blood loss, ICU transitional treatment, pancreatic fistula, bleeding, reoperation and survival time were analyzed for two groups. Results: Operation time and intraoperative blood loss were greatly increased in the unresectable group. The incidence of intractable diarrhea and abdominal hemorrhage in the unresectable group were higher. However, the rate of ICU transitional therapy, delayed gastric emptying and reoperation were lower. Grade-C pancreatic fistula occurred in neither group. Conclusion: Surgical treatment through stringent selection for patients with unresectable pancreatic cancer is a safer technique and median post-operative survival time is similar to patients with resectable pancreatic cancer.

Surgical Outcome and Long-Term Survival of Conversion Surgery for Advanced Gastric Cancer.

The present study aims to report the surgical outcome and long-term survival of conversion surgery and clarify its role in advanced gastric cancer. A total of 95 primary advanced gastric adenocarcinoma patients who underwent systemic chemotherapy and conversion surgery were reviewed retrospectively. The survival of conversion surgery was analyzed by Cox regression and the Kaplan-Meier method. Surgical outcomes were analyzed according to the Clavien-Dindo classification. The median survival time (MST) of the 95 patients was 26.8months, and the postoperative MST was 19.3months. The MSTs of the patients in categories 1, 2, 3, and 4 were 28.8, 25.5, 43.6, and 11.3months, respectively. The MSTs of the patients who underwent R0 resection (47 cases) and R1/2 resection (48 cases) were 49.3months and 21.9months, respectively. The MST of patients treated with total gastrectomy was shorter (21.9months) than that of patients who underwent proximal (55.0months) or distal (46.3months) gastrectomy. Patients who received more than 6 cycles of induction chemotherapy had a longer MST than patients who received 3-5 cycles or 1-2 cycles (MST: 55.0months versus 21.1months versus 21.7months). The incident postoperative complications and postoperative mortality rates were 10.5% and 1.1%, respectively. Advanced gastric cancer patients may obtain a survival benefit from conversion surgery, except category 4. Performing a sufficient number of cycles of induction chemotherapy (usually ≥ 6 cycles) is recommended. Surgical oncologists should perform R0 resection and avoid total gastrectomy.

Additional treatment prolonged survival of pulmonary artery sarcoma after surgical resection.

BackgroundPulmonary artery sarcoma is too rare for a randomized controlled trial or cohort study. We aimed to perform a retrospective analysis on the therapeutic effect of adjuvant therapy on postoperative survival time.MethodsMedline and EMBASE database were searched for articles on pulmonary artery sarcoma published between 1923 and 2018. Age, gender, postoperative overall survival, therapeutic approach, tumor extension, tumor localization, status of resection margins, metastasis, surgical method were extracted as parameters to analyze postoperative overall survival.ResultsA total of 162 articles and 275 cases are included in analysis. Median postoperative overall survival time was 31 months. Patients who received adjuvant and/or neo-adjuvant therapy were associated with improved survival [hazard ratio (HR) =0.64, P=0.017, 95% confidence interval (CI): 0.45–0.92]. Patients with complete resection or without metastasis had longer postoperative overall survival compared with incomplete resection (HR =0.55, P=0.002, 95% CI: 0.37–0.79) or with metastasis (HR =6.01, P=0.000, 95% CI: 3.33–10.67). Subgroup analysis suggested chemotherapy was related with longer postoperative overall survival (HR =0.63, P=0.015, 95% CI: 0.43–0.91), especially for patients with incomplete resection (HR =0.53, P=0.025, 95% CI: 0.31–0.92) and metastasis (HR =0.44, P=0.000, 95% CI: 0.28–0.68).ConclusionsRadical surgery offers the only chance to cure pulmonary artery sarcoma. Palliative and aggressive surgery can relieve the symptoms and extend the life expectance. Patients can benefit from adjuvant and/or neo-adjuvant chemotherapy, especially those who have metastasis or undergo incomplete resection.

Pulmonary resection is associated with long-term survival and should remain a therapeutic option in oligometastatic lung cancer

ObjectivesComprehensive local consolidative therapy led to improved overall survival in oligometastatic non–small cell lung cancer in a recent phase II trial, yet the role of pulmonary resection in ongoing oligometastatic trials is a matter of controversy. We sought to examine outcomes after pulmonary resection with radiotherapy used as a benchmark comparator. MethodsPatients treated at a single institution (2000-2017) with cT1-3N0-2M1 non–small cell lung cancer, 3 or less synchronous metastases, and performance status 0 to 1, and who received comprehensive local consolidative therapy were analyzed according to local consolidative therapy modality for the primary lesion. Progression was analyzed with death as a competing risk. ResultsOf 88 patients meeting inclusion criteria, 63 (71.6%) received radiotherapy for local consolidative therapy modality for the primary lesion and 25 (28.4%) underwent surgery (lobectomy 20/25 [80.0%], pneumonectomy 3/25 [12.0%], sublobar 2/25 [8.0%]). Time from diagnosis to local consolidative therapy modality for the primary lesion was similar. Surgical patients were younger and had lower intrathoracic disease burden. Ninety-day post-treatment mortality was low (surgery 0/25 [0.0%], radiotherapy 1/63 [1.6%]). Median postoperative survival time was 55.2 months (95% confidence interval, 20.1 to not reached), with 1- and 5-year overall survivals of 95.7% and 48.0%, respectively. After radiotherapy, median postoperative survival time was 23.4 months (confidence interval, 17.2-35.9); 1- and 5-year overall survivals were 74.3% and 24.2%, respectively. No differences were observed between modalities in site of first failure, cumulative incidence of locoregional failure (P = .635), or systemic progression (P = .747). ConclusionsPulmonary resection is feasible and associated with long-term survival in selected patients with synchronous oligometastatic non–small cell lung cancer. Surgery should remain a local consolidative therapeutic option for patients with operable oligometastatic non–small cell lung cancer enrolled in ongoing and future randomized clinical trials.

Cut it out! Thoracic surgeon's approach to pulmonary mucormycosis and the role of surgical resection in survival.

Mucormycosis portends a poor prognosis with mortality rates ranging from 50% to 70% in pulmonary mucormycosis (PM) and up to 95% in disseminated disease. However, detailed outcomes data have been lacking. It remains unknown how to identify patients who would benefit from surgical resection. We present our experience with patients undergoing surgical resection for PM, including an analysis of factors affecting postoperative survival. We also describe a thoracic surgeon's approach through illustrative cases. We conducted a single-centre retrospective study of all adult patients with PM who received antifungal therapy and underwent surgical resection or who received antifungal therapy alone at Stanford between January 2004 and June 2018. Twelve patients received antifungal therapy and underwent surgical resection and 13 patients received antifungal therapy alone. From infection onset to death (or right-censoring if still alive), patients who underwent surgical resection had a median survival of 406days (mean, 561.3; range, 22-2510), and patients who received antifungal therapy alone had a median survival of 28days (mean, 66.7; range, 8-447). In patients who underwent surgical resection, median postoperative survival time was 154days (range, 11-2495), in-hospital mortality was 16.7%, and 1-year mortality was 50.0%. Age, primary disease, ASA status, extrapulmonary dissemination, laterality, multilobar involvement, number of lesions, largest lesion size, platelet count, surgical approach, type of resection or extent of resection were not significantly associated with postoperative survival. Surgical resection significantly increases survival and should be strongly considered for selected patients with PM.

Prognostic Differences in Patients with Solitary and Multiple Spinal Metastases

ObjectivesTo investigate the association between the number of metastases to the spine and survival in patients with metastatic spinal cord compression (MSCC), as well as the prognosis difference between patients with solitary spinal metastasis (SSM) and multiple spinal metastases (MSM).MethodsThree institutional databases were searched to identify all patients who had undergone spinal surgery for metastatic spinal tumors between March 2002 and June 2010. As well as age and gender, preoperative medical conditions were collected from medical records, including primary tumor, preoperative Frankel score, other bone metastases, preoperative Karnofsky performance status (KPS), number of involved vertebrae, pathological fracture metastasis site, serum albumin, sphincter dysfunction and the time of developing motor deficits before surgery. Survival data were obtained from medical records or via telephone follow‐ups. Univariate and multivariate predictors of overall survival for each group were assessed using the Cox proportional hazards model.ResultsThe median postoperative survival time was 6.0 ± 0.6 months (95% confidence interval [CI] 4.8–7.2) in patients with SSM and 7.0 ± 1.0 months (95% CI 5.1–8.9) in patients with MSM (P = 0.238). The difference in survival was not significant between groups. Furthermore, univariate analysis showed that the number of spinal metastases had no significant association with survival (P = 0.075). Primary tumor (P = 0.004) and preoperative KPS (P < 0.001) were independent prognostic factors in the whole cohort; primary tumor (P = 0.020), time of developing motor deficit (P = 0.041) and preoperative KPS (P = 0.038) were independent prognostic factors in patients with SSM; while preoperative KPS (P = 0.001) and serum album level (P < 0.001) were independent prognostic factors in patients with MSM.ConclusionThe number of spinal metastases has not proven to be useful in predicting the prognosis for patients with MSCC. Consequently, more aggressive operations should be considered for patients with multiple spinal metastases.

Diagnostic value of combined serum CA19-9 with CT scanning in patients with pancreatic cancer

Objective To evaluate the diagnostic value of combined serum tumor marker CA19-9 with CT scanning in the patients with pancreatic cancer. Methods A total of 89 patients with suspected pancreatic cancer diagnosed by CT scanning were selected at our hospital from May 2012 to December 2016.The detected results of serum CA19-9 were recorded, and the specificity, sensitivity, positive and negative predictive value of serum CA19-9 in the diagnosis of pancreatic cancer were statistically calculated and analyzed.The correlations between the pre- and post-operative serum levels of CA19-9 and the survival time in pancreatic cancer patients undergoing operation were analyzed. Results The specificity, sensitivity, positive predictive value and negative predictive value of serum CA19-9 combined with CT scanning in the diagnosis of pancreatic cancer were 97.2%, 86.4%, 100.0%, 94.0% respectively.With the increase of preoperative serum levels of CA19-9, the resection rate and median postoperative survival time gradually decreased.Patients with normal serum levels of CA19-9 after operation had longer postoperative survival time than patients with high postoperative serum levels of CA19-9. Conclusions As one of the tumor markers of pancreatic cancer, serum CA19-9 detection has a high diagnostic sensitivity.Combined with CT scanning, serum CA19-9 detection can significantly improve the diagnostic accuracy of pancreatic cancer.Serum CA19-9 can also be used as a mean of efficacy evaluation after radical resection of pancreatic cancer. Key words: Pancreatic neoplasms; Antigens, neoplasm

Effect of combined treatment including surgery and postoperative adjuvant therapy on spinal metastases of Tomita type 7

Objectives: Identify the efficacy of multidisciplinary treatment including palliative spinal surgery on patients with Tomita type 7 spinal metastases.Patients and methods: A retrospective analysis of surgery treated spinal metastatic patients from January 2013 to December 2016 in Tianjin Medical University Cancer Institute and Hospital were performed. Surgical procedures and intraoperative parameters and postoperative adjuvent treatments were studied. Patients’ demographic characteristics and medical conditions including paralysis statues, quality of life and pain levels and postoperative survival time were identified.Results: 50 patients were identified with mean age at the time of surgery of 57.68 years old (range 27–78 years). The mean Tokuhashi score was 8.48 and the spinal instability neoplastic score (SINS) averaged at 10.52 points. 48 patients (96%) encountered epidural spinal cord compression. Kaplan-Meier method determined median postoperative survival time was 12.00 months (95% CI: 7.05–16.95 months). The mean score of visual analogue scale (VAS) decreased from 7.66 preoperatively to 1.96 postoperatively. The Frankel scale was improved by at least one grade in 47 patients. Patient’s quality of life showed significant improvements.Conclusion: Multidisciplinary treatment including palliative spinal surgery was associated with alleviating pain, improving neurologic function and quality of life in patients with Tomita type 7 spinal metastases.

Effects of the extent of regional lymph node dissection on the prognosis of patients with T4 gallbladder carcinoma: a multi-center retrospective analysis

Objective To investigate the effects of the extent of regional lymph node dissection on the prognosis of patients with T4 gallbladder carcinoma. Methods The retrospective cohort study was conducted. The clinicopathological data of 64 patients with T4 gallbladder carcinoma who underwent radical cholecystectomy in the 4 medical centers between January 2013 and December 2016 were collected, including 31 in the Eastern Hepatobiliary Surgery Hospital of Naval Medical University, 16 in the First Affiliated Hospital of Xi′an Jiaotong University, 11 in the Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine and 6 in the Affiliated Hospital of North Sichuan Medical College. There were 27 males and 37 females, aged from 35 to 77 years, with a median age of 59 years. Sixty-four patients underwent radical cholecystectomy and regional lymph node dissection. According to the extent of intraoperative lymph node dissection, 25 patients (13 in the Eastern Hepatobiliary Surgery Hospital of Naval Medical University, 6 in the First Affiliated Hospital of Xi′an Jiaotong University, 4 in the Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine and 2 in the Affiliated Hospital of North Sichuan Medical College) whose extent of lymph node dissection involved lymph nodes next to cystic duct, hepatoduodenal ligament, back of head of pancreas, next to common hepatic artery and celiac trunk were allocated into the extended dissection group, 39 patients (18 in the Eastern Hepatobiliary Surgery Hospital of Naval Medical University, 10 in the First Affiliated Hospital of Xi′an Jiaotong University, 7 in the Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine and 4 in the Affiliated Hospital of North Sichuan Medical College) whose extent of lymph node dissection involved lymph nodes next to cystic duct and hepatoduodenal ligament were allocated into the control group. Observation indicators: (1) postoperative complications; (2) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative overall survival up to January 2018. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was evaluated with the independent-sample t test. Count data were represented as absolute number or percentage, and comparison between groups was analyzed using the chi-square test and Fisher exact probability. The survival curve was drawn using the Kaplan-Meier method, and the comparison of survival rates was done by the Log-rank test. Results (1) Postoperative complications: 64 patients with T4 gallbladder carcinoma underwent successful radical cholecystectomy and regional lymph node dissection, without intraoperative death. Twelve patients had different degrees of postoperative complications. Four of 7 patients undergoing extended radical cholecystectomy had postoperative complications. Twenty-five patients in the extended dissection group were cured by conservative treatment, including 4 with intraperitoneal infection and 2 with pancreatic leakage, with a complication incidence of 24.0%(6/25). Thirty-nine patients in the control group were cured by conservative treatment, including 5 with intraperitoneal infection and 1 with gastric retention, with a complication incidence of 15.4%(6/39). There was no statistically significant difference in the complication incidence between the two groups (χ2=0.284, P>0.05). (2) Follow-up and survival situations: 64 patients were followed up for 1-60 months. The postoperative overall median survival time was 11 months. The postoperative median survival time, 1-, 3- and 5-year cumulative survival rates were respectively 18 months, 80%, 16%, 9% in the extended dissection group and 8 months, 21%, 4%, 0 in the control group, with a statistically significant difference in the prognosis between the two groups (χ2=14.744, P<0.05). Conclusions On the premise of practiced surgical skill, extended regional lymph node dissection cannot increase incidence of surgical complication in patients with T4 gallbladder carcinoma after radical resection. Actively extending lymph node dissection up to near common hepatic artery, peri-celiac trunk and back of head of pancreas can improve long-term survival and prognosis. Key words: Biliary tract neoplasms; Gallbladder carcinoma, stage T4; Radical resection; Regional lymph node dissection; Multi-center; Retrospective research

Hypothermic Perfusion Hepatectomy for Unresectable Liver Cancer: A Single-Center Experience

Introduction: Despite technical advancements in liver surgery, resection of liver tumors that involve the hepatic veins adjacent to the vena cava or hepatic hilum remains technically challenging. We present our surgical techniques and the long-term outcome of 5 patients with conventionally unresectable tumors. Method: Between September 1999 and March 2016, we encountered 5 patients with conventionally unresectable tumors that were successfully treated by “ex-situ liver resection” and “in-situ & ante -situm hypothermic liver perfusion” under total vascular exclusion and venovenous bypass. Result: These approaches allowed complete tumor removal with vascular reconstruction under a bloodless operation field, while minimizing hepatic ischemic injury and preserving liver function. No perioperative mortalities occurred and postoperative complications were minimal. The postoperative survival periods were limited due to the advanced malignancies in our patients, but the survival benefit was encouraging. The median postoperative survival time was 29.1 months, with the longest survival period being nearly 10 years. Furthermore, these approaches improved the quality of life and provided our patients with an opportunity for additional treatment. Conclusion: Hypothermic perfusion hepatectomy is a realistic option for achieving surgical cure or significantly improved survival and quality of life in patients with tumors deemed unresectable using conventional normothermic hepatectomy. These approaches can overcome the limitations of the liver’s restricted normothermic ischemia tolerance or inaccessible tumor locations.

Clinical Results of Minimally Invasive Spine Stabilization for the Management of Metastatic Spinal Tumors Based on the Epidural Spinal Cord Compression Scale.

Purpose Minimally invasive spine stabilization (MISt) using percutaneous pedicle screws plays a significant role in palliative surgery for metastatic spinal tumors. However, few studies have investigated surgical outcomes based on the epidural spinal cord compression scale (ESCCS). The purpose of this study was to examine outcomes of metastatic spinal tumors as evaluated by ESCCS in patients treated by MISt. Methods The subjects were 56 patients who underwent MISt for metastatic spinal tumors, including 34 patients with ESCCS 2 or milder (group A) and 22 patients with ESCCS 3 (group B). We analyzed baseline characteristics, perioperative factors and clinical results such as postoperative survival time, neurological outcomes, Barthel Index for activities of daily living (ADL), visual analogue scale (VAS), and the rate of discharge to home. Results The baseline age (P=0.07), tumor diagnosis (P=0.23), spinal level of compression (P=0.35), American Spinal Injury Association classification (P=0.49), revised Tokuhashi score (P=0.92), spinal instability neoplastic score (P=0.28), VAS (P=0.35), Barthel Index (P=0.07), American Society of Anesthesiologists physical status classification (P=0.76), and type of surgery (P=0.40) did not differ significantly between the two groups. The median postoperative survival time did not differ significantly between the groups (12.0 versus 15.0 months, P=0.60). Neurological improvement by at least 1 grade or maintenance of grade E was favorable in group A. Patients in group A had less posterior decompression (P=0.006), a higher rate of chemotherapy (P=0.009), a higher postoperative Barthel Index (P=0.04), and a higher rate of discharge to home (P=0.01) and no patients died in the hospital (P=0.004). Conclusions No significant difference was noted in the postoperative survival time between the 2 groups. Patients in the ESCCS 2 or milder group had favorable neurological improvement, higher rates of chemotherapy, better postoperative ADL, and the higher rate of discharge to home.

The establishment of a decision tree model for the individualized treatment of spinal metastases based on RPA

Objective To evaluate the prognostic factors of spinal metastases by recursive partitioning analysis (RPA) and establish a decision tree model that can guide clinicians to select individualized treatment. Methods Between January 2011 and December 2015, three institutional databases were searched to identify 169 patients with metastatic spinal tumors underwent surgery. The ratio of male and female was 1.48∶1 (102 males and 67 females). The average age was 59.2±11.1 years. One-hundred eighteen cases of patients were randomly selected as training samples and the remaining 51 cases were verified samples. Preoperative factors were collected and analyzed by RPA methods, including primary tumor, KPS score, Frankel grade, gender, age, visceral metastasis, bone metastasis, spinal metastasis, blood glucose, blood pressure, surgery site, symptoms, surgery interval, serum albumin level and other risk factors. Pearson's Chi-square test was performed to judge the segmentation point of the decision tree model. The decision tree model is built using the Chi-square automatic interaction detector (CHIAD) algorithm and sensitivity and specificity was automatically calculated. Results The median postoperative survival time was 12.6±1.2 months [95%CI(10.1, 15.0)]. 70% were randomly selected as the experimental group (118 cases), and 30% were the verification group (51 cases). The sensitivity was 96.9%. The specificity was 89.8%. The Kappa coefficient was 0.874 in the experimental group. The sensitivity was 95.4%. The specificity was 90.8%. The Kappa coefficient was 0.810 in the test group. The prognostic factors (weight from high to low) based on RPA were Frankel grade (F=8.132, P=0.005), the primary tumor and the KPS score (Equal, F=9.871, P=0.000 and F=11.945, P=0.003), serum albumin and movement time (Equal, F=7.566, P=0.018 and F=9.966, P=0.008). The decision tree model consists of 7 types. Survival time was 51 months, 18 months, 13 months, 8 months, 4 months, 5 months, 9 months in the class I~VII, respectively. According to the difference of RPA survival time, the operation was classified as 3 grade. Total spinal resection was regarded as grade 1, including class I and class II, with an average survival time of over 18 months. Limited operation was regarded as grade 2, including class III, V and VII with survival time in 6-18 months. The conservative treatment was regarded as grade 3, including class Ⅳ and Ⅵ with the survival time was less than 6 months. Conclusion The decision tree model based on RPA for predicting the survival time of spinal metastases can not only identify the prognostic factors, but also classify and grade various prognostic factors; the decision tree model is simple and can guide clinicians to choose the best surgical plan by predicting the survival time. Key words: Methods; Decision trees; Multicenter study; Individualized medicine