Modified Grading System Research Articles

Prevalence, Clinical Characteristics, and Relative Factors of Acquired Punctal Stenosis in Adult Allergic Conjunctivitis Patients

Plain Language SummaryThis study aimed to examine the prevalence of acquired punctal stenosis (APS) among adults with allergic conjunctivitis (AC), describe its characteristics, and identify associated risk factors. We reviewed the medical data of 210 adult patients with AC at Zhongshan Ophthalmic Center. We gathered demographic data and evaluated ocular symptoms. Using slit-lamp microscopy, we assessed and graded the morphology of the lacrimal puncta (lacrimal duct openings) according to a modified grading system. The study results revealed that 69% of the adult patients with AC had APS. Stenotic lacrimal puncta were present in 49.3%, with grade IIa being the most common. The narrowing was most frequently observed in the upper lacrimal puncta compared to the lower ones. Older age and a higher tear meniscus height (TMH) were significantly associated with the presence of APS. Therefore, this study demonstrates that APS is commonly observed in adults with AC, which is associated with the increased age and widened TMH, indicating a possible link between chronic and recurrent AC and the development of APS.

Longitudinal Changes in Ki-67 Indices in Small-Intestinal Neuroendocrine Tumours and Their Impact on Survival

Introduction: The purpose of this study was to evaluate longitudinal changes in Ki-67 indices of SI-NETs and assess the impact of these in overall survival (OS). Methods: We screened 551 patients with SI-NETs diagnosed from 1993, through 2021, identified using the SI-NET databases from five European referral centres. Only patients with well-differentiated tumours and available baseline tumour samples and follow-up re-biopsies were included. For tumour grading, apart from 2017 WHO classification system, we applied a recently proposed SI-NET site-specific modified histopathological grading system with Ki-67 cut-offs of 5 and 10%. Uni- and multivariable regression analyses were used to determine whether there was a difference between OS in SI-NET patients stratified by increment of Ki-67 indices over time and/or progression to a higher grade. Results: We included 45 patients. Median Ki-67 index at SI-NET diagnosis was 2% (range: 0.5–15%). Thirty-three patients had Ki-67 indices <5% (70.2%), 6 had Ki-67: 5–10% (12.8%), and 8 had Ki-67 ≥10% (17%). Mean time to re-biopsy was 48.8 months (SD: ±162.5). At re-biopsy, the median change in Ki-67 index (absolute value; follow-up minus time of diagnosis) was 1% (range: −10 to +38%). An increase in Ki-67 occurred in 20 patients (42.6%); in 14 patients, the change in Ki-67 resulted in progression to higher tumour grade following the modified grading system. Patients with an increment in Ki-67 ≥1% had a median OS of 32.9 months versus 80.5 months in patients without (HR = 5.6, 95% CI: 1.42–22.02; p = 0.014). When applying the novel modified histopathological grading system for SI-NETs, patients with grade progression had a median OS of 32.9 months versus 53.7 months in those without (HR = 4.61, 95% CI: 1.22–13.54; p = 0.022). At multivariable analysis, grade progression was confirmed as an independent predictor for death (HR = 7.2, 95% CI: 1.58–32.82; p = 0.011). Conclusions: Metachronous increment in Ki-67 indices and related grade progression over time following a site-specific modified histopathological grading system with Ki-67 cut-offs of 5 and 10% is observed in approximately 1/3 of SI-NETs subjected to re-biopsy and it is associated with worse survival outcomes.

Analysis of clinical and pathological characteristics of retroperitoneal paraganglioma and associated prognostic factors.

The aim of this study is to explore the long-term prognostic risk factors associated with patients diagnosed with retroperitoneal paraganglioma (RPGL) and examine their clinical and pathological characteristics. Expressions of biomarkers were identified using immunohistochemistry (IHC) and case databases were retrospectively searched. Survival analysis was performed using Kaplan-Meier and Cox risk regression to identify the factors that influence the postoperative progression-free survival of patients with RPGL. A total of 105 patients, most of whom had tumors situated in the paraaortic region, and whose average tumor size was 8.6 cm, were enrolled in this study. The average follow-up duration was 51 months, with a mortality rate of 19% and a recurrence and metastasis rate of 41.9%. Tumors were assessed using the modified Grading system for Adrenal Pheochromocytoma and Paraganglioma (GAPP), and SDHB, S-100, and Ki-67 were stained using IHC in all cases. Out of the total cases examined, negative in SDHB expression were observed in 18.1% of cases, S-100 expression was negative in 36.2% of cases, and endovascular tumor enboluswas present in approximately 25.7% of cases. The results of the univariate analysis indicated that several factors significantly influenced the progression-free survival of patients with PGL as follow: maximum tumor diameter (>5.5 cm), tumor morphological features, tumor grading (modified GAPP score > 6), SDHB negative, S-100 negative, and expression of proliferation index Ki-67 (>3%) (X2 = 4.217-27.420, p < 0.05). The results of the multivariate analysis indicated that negative of S-100 (p = 0.021) and SDHB (p = 0.038), as well as intravascular tumor thrombus (p = 0.047) expression were independent risk factors for progression-free survival in patients. RPGL is characterized by diverse biological features and an elevated susceptibility to both recurrence and metastasis. Both SDHB and S-100 can be employed as traditional IHC indicators to predict the metastatic risk of PGL, whereas the tumor histomorphology-endovascular tumor enbolus assists in determining the metastasis risk of RPGL.

740 Implementation and Retrospective Assessment of a Modified Graft Loss Grading System

Abstract Introduction Success of split-thickness skin grafting (STSG) is a cornerstone of modern burn care and sets the stage for success in acute, rehabilitative and reconstructive care. Shupp et al, proposed a graft loss grading system, which the authors then modified to reflect true clinical practice and changes in management. Purpose of the quality improvement (QI) project was to design, implement and assess this grading system. Methods A modified graft loss grading system was developed and implemented. Burn patients requiring STSG were tracked over a five month period, and initial (first takedown) and subsequent (either outpatient or 7 days after initial assessment) graft loss grades and contributing factors were noted. Assessments were performed an APP and burn surgeon with agreement of an assigned grade. Patient demographic data was recorded. Results 63 patients underwent 66 STSG procedures during the review period (44 males, 19 females). Average age was 33.3 years (range: 1-86). Average % TBSA burn was 10.2% (range 0.2-67%). Obesity was present in 33.3% of patients, cardiac disease (hypertension, coronary artery disease or congestive heart failure) in 21.2%, DM in 21.2% and 24.2% of patients were active smokers. Flame burns represented the etiology in the majority (51.5%) of patients. Overall, 10 patients (16%) on initial assessment and 18 patients (29%) on subsequent assessment had evidence of graft loss. Etiology of graft loss included wound bed viability - the default etiology (10 patients/55%), infection (3 patients/17%) and hematoma/seroma (4 patients/22%). Of the 18 patients, 5 (28%) required re-grafting. Of patients with graft loss, 89% had a comorbidity including DM (28%) and smoking history (28%). Malnutrition was felt to contribute in 3 (17%) of patients. Conclusions A graft loss grading system is a beneficial quality improvement project to characterize the surgical results of burn patients undergoing STSG. This modified grading system better characterizes graft loss outcomes and subsequent changes in management if applicable. Wound bed viability remains a major factor in graft loss, although the majority of these patients had a contributing comorbidity. Applicability of Research to Practice Implementation of a graft loss grading system can be a valuable quality improvement tool that can be employed by burn centers to assessment surgical results.

Predicting difficulty in laparoscopic cholecystectomy preoperatively using modified Randhawa scoring system

Background: Laparoscopic cholecystectomy is a low-risk, minimally invasive operation and currently the standard for treatment of gallstone and gallbladder disease. Preoperative assessment of difficulty is required to prevent problems, ensure readiness, and ensure an effective course of surgery. Methods: In our work, we attempted to use a modified grading system developed by Randhawa et al. to preoperatively predict a difficult laparoscopic cholecystectomy. Age, gender, illness duration, history of prior GB disease, BMI, abdominal scar location (infra or supraumbilical), palpable gallbladder, and sonographic findings (gall bladder wall thickness, pericholecystic collection, and impacted stone) were assessed in patients who had been diagnosed with GB stones and required LC. Depending on the individual surgeon's assessment, a procedure is rated as easy, difficult, or very difficult. Results: On comparison of the test group difficulty level predicted with the gold standard of difficulty level intra op the test group has a sensitivity of 51.9 % and specificity of 100%. The test has a positive predictive value of 100% and Negative predictive value of 91.5%. The test and the gold standard agree on 154 out of 167 having a diagnostic accuracy of 92.21%. The Kappa value of 0.644 indicates very good agreement with a p value of &lt;0.001. Area under the curve indicates 96.1% of the difficulty is predicted by the Total score and significant with p value of &lt;0.001 Conclusions: The current modified Randhawa and Pujahari scoring method is useful and appropriate for forecasting operative outcome in laparoscopic cholecystectomy.

Significant difference in recurrence according to the proportion of high grade patterns in stage IA lung adenocarcinoma.

BackgroundPatients with early lung cancer are the best candidates for surgical resection. However, those patients with high grade patterns (micropapillary or solid) do not have a good prognosis, even if they have been diagnosed with stage I lung adenocarcinoma. A new modified grading system has been introduced and this study aimed to identify the prognostic role of the new grading system in patients with stage IA lung adenocarcinoma.MethodsPatients with pathological stage IA lung adenocarcinoma, according to the eighth TNM classification who underwent curative resection, were reviewed. The pathological data of stage IA adenocarcinoma was reviewed 1 (grade 1: lepidic predominant with no or less than 20% of high grade patterns, grade 2: acinar or papillary predominant with no or less than 20% of high grade patterns, grade 3: any tumor with 20% or more of high grade patterns). Prognostic factors were analyzed for disease‐free interval (DFI) and overall survival (OS) using Cox proportional models.ResultsThe medical records of 429 patients with stage IA lung adenocarcinoma were reviewed. DFI (p < 0.001) and OS (p < 0.001) were significantly lower in patients diagnosed with grade 3 compared with grade 1 and grade 2. Multivariate analysis showed that smoking (p = 0.013), value of SUVmax (p = 0.005), lymphovascular invasion (p = 0.004) and grade 3 (p = 0.008) were significant prognostic factors for DFI.ConclusionsThe proportion of high grade patterns showed a different prognosis, even if curative resection had been performed for stage IA adenocarcinoma. This new grading system is more simple and useful in the prediction of a prognosis in patients with stage IA lung adenocarcinoma.

Sonographic Cardiovascular Assessment of the Aorta: Pilot of a Modified Image Grading System

Objective: Atherosclerosis is a chronic inflammatory disease that can be undetected in middle-aged patients. Abdominal aortic calcifications (AACs) are one form of cardiovascular disease (CVD), and these can go undetected during a routine physician visit. Sonography has the potential to assess CVD progression, quantify plaque in the aorta, and help to quantify risk in asymptomatic patients. Methodology: This pilot study modified a current AAC grading system to create a scoring method for sonographic images among a small cohort of asymptomatic participants. A traditional portable ultrasound unit was used to image participants, and a subset underwent the same imaging with a handheld transducer and tablet. Results: In this cohort, six males and five females, it was possible to adequately visualize and assess plaque, utilizing both types of ultrasound equipment. The abdominal aorta was divided into segments on the sonogram for quality of grading. Ten participants were categorized with a grade II and one participant was given a grade IIIA. Conclusion: Replication of this modified grading system is needed to better understand the clinical utilization of sonography as a risk assessment tool. The risk assessment scoring was not dependent on the type of device used.

A Modified Grading System for Early Right Heart Failure Matches Functional Outcomes and Survival After Left Ventricular Assist Devices.

Early right heart failure (ERHF) remains a common complication after continuous-flow left ventricular assist device (cf-LVAD) and has been associated with increased mortality. The specific criteria used to define ERHF remain somewhat arbitrary. Correlating the degree of ERHF with outcomes after LVAD could inform a more clinically relevant definition. We identified 196 patients who underwent first durable cf-LVAD between 2008 and 2015 at a single center. Postimplant ERHF was graded as absent, mild (requiring inotropic support for 14-20 days), moderate (inotropes for ≥ 21 days), or severe (requiring unplanned RVAD at any time during the index hospitalization). ERHF was associated with clinical outcomes including 1 year survival and New York Heart Association (NYHA) class and 6 minute walk distance (6MWD) at 3 and 6 months. Survival was assessed using the Kaplan-Meier method with log-rank testing and multivariate Cox proportional-hazards modeling. Compared to patients without ERHF, those with mild ERHF had similar 1 year survival (hazard ratio [HR] 0.69, 95% confidence interval [CI]: 0.26-1.80, p = 0.45), while mortality was substantially increased in patients with moderate (HR 2.65, 95% CI: 1.27-5.54, p = 0.009) and severe ERHF (HR 8.16, 95% CI: 3.97-16.76, p < 0.0001). The severity of ERHF was associated with 6MWD at both 3 months (p = 0.001) and 6 months (p = 0.013). The relationship between ERHF and postimplant survival and functional status persisted in multivariate modeling. A simple, modified grading system for ERHF severity is strongly associated with 1 year survival and functional capacity after cf-LVAD. These results argue against using a binary definition for ERHF and suggest the need to modify definition of ERHF severity.

Prenatal grading of fetal congenital heart disease and its influence on decision making during pregnancy and postnatal period: a prospective study

Background Congenital heart defects(CHDs) are an important cause of neonatal mortality and morbidity. With advances in diagnosis and treatment, many defects are now amenable to correction. There is a need for individualized approach to prenatally detected lesions to predict the likely prognosis. Assigning them into risk category helps in prenatal counseling, decision making, referrals and formulation of management plan to improve the outcome. Objective To grade the fetal CHDs according to severity and study its usefulness in decision making. Methods A prospective study at a tertiary care institute between 2016 and 18, including pregnant women with antenatal diagnosis of fetal CHD. Detailed fetal echocardiography was followed by classification of lesions into four risk categories using modified grading system: (A) extremely high risk; (B) high risk (C) moderate risk (D) low risk. Appropriate counseling was provided to facilitate decision making and further management. The grading was reviewed and revised again postpartum/post-mortem for correlation. Results Of the total 137 cases, almost half (45.53%) were Category B, while Category D, C and A had 24.1%, 20.4% and 10.2% of cases respectively. The mean gestation age at diagnosis was 26.5 weeks. Termination of pregnancy was done in 21 cases, mostly in Category B (71.4%) and of the 116 continued pregnancies, there were 16 intrauterine deaths. Prenatal and postnatal findings were available in 109 cases and kappa analysis for agreement between antenatal and postnatal grading showed good agreement (0.82). Conclusion Prenatal grading of congenital heart disease is a reliable, structured and simplified tool that can be used for providing counseling and facilitate decision making.

An Approach to Undiagnosed Bone Tumors

The radiographic appearance of primary bone tumors is important for initial diagnosis and often augments histopathological analysis. The original grading system relied on the radiographic analysis of the margin of the lesions to determine tumor aggression, which often corresponds with malignant potential. The recently developed, modified Lodwick-Madewell grading system also incorporates the appearance of lesion margins on radiographs but also considers the change in margins on serial radiographs and includes a category for clinically suspected, radiographically occult, aggressive lesions. This article reviews the prior and modified grading systems, and the concepts necessary for proper interpretation of the initial appearance of bone tumors which often determines the radiologist's recommendation for biopsy or follow-up imaging.

Should we freeze it? Agreement on fate of borderline blastocysts is poor and does not improve with a modified blastocyst grading system.

What is the inter-observer agreement among embryologists for decision to freeze blastocysts of borderline morphology and can it be improved with a modified grading system? The inter-observer agreement among embryologists deciding whether to freeze blastocysts of marginal morphology was low and was not improved by a modified grading system. While previous research on inter-observer variability on the decision of which embryo to transfer from a cohort of blastocysts is good, the impact of grading variability regarding decision to freeze borderline blastocysts has not been investigated. Agreement for inner cell mass (ICM) and trophectoderm (TE) grade is only fair, factors which contribute to the grade that influences decision to freeze. This was a prospective study involving 18 embryologists working at four different IVF clinics within a single organisation between January 2019 and July 2019. All embryologists currently practicing blastocyst grading at a multi-site organisation were invited to participate. The survey was comprised of blastocyst images in three planes and asked (i) the likelihood of freezing and (ii) whether the blastocyst would be frozen based on visual assessment. Blastocysts varied by quality and were categorised as either top (n= 20), borderline (n= 60) or non-viable/degenerate quality (n= 20). A total of 1800 freeze decisions were assessed. To assess the impact of grading criteria on inter-observer agreement for decision to freeze, the survey was taken once when the embryologists used the Gardner criteria and again 6months after transitioning to a modified Gardner criterion with four grades for ICM and TE. The fourth grade was introduced with the aim to promote higher levels of agreement for the clinical usability decision when the blastocyst was of marginal quality. The inter-observer agreement for decision to freeze was near perfect (kappa 1.0) for top and non-viable/degenerate quality blastocysts, and this was not affected by the blastocysts grading criteria used (top quality; P= 0.330 and non-viable/degenerate quality; P= 0.18). In contrast, the cohort of borderline blastocysts received a mixed freeze rate (average 52.7%) during the first survey, indicative of blastocysts that showed uncertain viability and promoting significant disagreement for decision to freeze among the embryologists (kappa 0.304). After transitioning to a modified Gardner criteria with an additional grading tier, the average freeze rate increased (64.8%; P< 0.0001); however, the inter-observer agreement for decision to freeze was unchanged (kappa 0.301). Therefore, significant disagreement for decision to freeze among embryologists is an ongoing issue not resolved by the two grading criteria assessed here. Blastocyst assessment was performed from time-lapse images in three planes, rather than with a microscope in the laboratory. The inter-observer agreement for decision to freeze may be lower for embryologists working in different clinics with different grading protocols. The decision to freeze a blastocyst with borderline morphology is a common clinical issue that has the potential to arise for any patient during blastocyst culture. Disagreement for decision to freeze these blastocysts, and therefore clinical usability in frozen embryo transfer cycles, affects consistency in patient care due to a potential impact on cumulative live birth rates, as well as financial, emotional and time costs associated with the frozen embryo transfer cycles. We demonstrate significant disagreement for decision to freeze borderline blastocysts among embryologists using the same grading scheme within a large multisite organisation, a phenomenon which was not improved with a modified grading system. Decision-making around borderline embryos is an area requiring further research, especially as studies continue to demonstrate the reduced but modest live birth rates for low quality blastocysts (Grade C). These results provide support for emerging technology for embryo assessment, such as artificial intelligence. None declared. Not applicable.

Clinical study of the puncture success rate during ultrasound-guided percutaneous nephrolithotomy

Objective To evaluate the success rate during ultrasound-guided percutaneous nephrolithotomy (PCNL) and analyze the reasons of puncture failure. Methods A retrospective analysis was performed based on the data of 58 patients who underwent ultrasound-guided PCNL by 4 experienced urologists(10 years' experience of PCNL and more than 80 cases per year)in our center from August 2018 to November 2018. Of all the 58 patients, there were 36 males and 22 females (aged from 22 to 73 years) with the mean age of 51 years. The calculi ranged from 9 mm to 93 mm, with the average of 26.5 mm. The separation of renal collecting system ranged from 5 mm to 30 mm, with the average of 15.1 mm. All of the 58 patients underwent one-stage PCNL and the numbers of punctures, the numbers of percutaneous tubes and the reasons for failure were recorded. Results All percutaneous tubes and surgeries were established and done successfully. Of all the 118 punctures, 74 punctures succeeded by detecting the urine and 68 surgery tracts were established (6 punctures failed because of the dilation). The total puncture success rate was 62.7%(74/118). Of the total 74 successful punctures, 56.8%(42/74)succeeded at the first puncture, 28.4%(21/74)succeeded at the second puncture and 14.9%(11/74)succeeded at least after three punctures. The success puncture rate of the 4 urologists were 59.2%(29/49), 64.1%(25/39), 66.7%(16/24), 66.7%(4/6)respectively, and there were no statistical differences between the puncture success rates of the urologists (P=0.679). Each channel needed 1.7 punctures on average. Fouty-four punctures failed without detecting the urine, including 20 failed punctures because of the puncture tract deviation, 17 punctures without seeing the urine after the core needle being removed, 7 punctures no display on the ultrasound imagine. There were 33 punctures to be tubeless while other 35 indwelling the nephrostomy tubes. Five nephrostomy tubes' position were different with the preoperationally predicted position which means the discrepancy rate was 14.3%(5/35). One patient had complications and classified as Grade II or above on the modified Clavien Grading System of aerothorax. Conclusions The puncture success rate during ultrasound-guided PCNL is not satisfied. The main reasons of puncture failure are the deviation of puncture tract, unclear imaging of puncture tract and other unclear reasons( puncture needle went too deep or superficially or tip of the needle embedded into the stone). Key words: Kidney calculi; Percutaneous nephrolithotomy; Puncture; Success rate

CT imaging improves histopathological grading of retroperitoneal leiomyosarcomas

BackgroundInitial grading of retroperitoneal leiomyosarcoma (LMS) is performed by core biopsy (CB) however, discrepancy between grade of tumour at initial CB and surgical excision is recognised, raising concerns about the accuracy of CB for directing neoadjuvant therapy. The histological grading system used for staging LMS consists of 3 components: tumour differentiation, mitotic index and proportion of necrosis. We postulate that assessment of necrosis by histopathology alone is inadequate, resulting in under-grading of LMS. We propose and assess a combined grading system that incorporates CT scan findings into pre-surgical grading. MethodsRetrospective, blinded review of CT, CB histology and final surgical histology of patients with retroperitoneal LMS was undertaken. A modified grading system, CTH-Grade, was derived by replacing the CB necrosis score with a CT-derived necrosis score. The sensitivity and specificity of CTH-Grade, the standard histopathology scoring, H-grade were compared. Inter-observer variability in assessment of CT necrosis was also assessed. Results53 patients fulfilled criteria for inclusion. CT was more sensitive at detection of necrosis than CB histology alone with sensitivity of 100% vs 53%. The use of CTHGrade resulted in increased detection of high-grade tumours with CTH-grade having sensitivities of 80% and 35% for Grade 2 and 3 tumours respectively vs 53% and 15% with H-Grade. Assessment of reader agreement demonstrated Kappa scores of 0.8. ConclusionHistology from CB under-grades LMS due to undersampling of tumour necrosis. CT is more sensitive in assessing necrosis and its incorporation into a modified CT-histopathology grading system (CTH-Grade) improves accuracy of grading with significant implications for patient management.

Retrograde intrarenal surgery versus mini-percutaneous nephrolithotripsy to treat renal stones 20 mm or larger in diameter using holmium:YAG laser

Objective To evaluate the efficacy and safety of mini-percutaneous nephrolithotripsy (mini-PCNL) and retrograde intrarenal surgery (RIRS) in the treatment of renal stones 20 mm or larger in the longest diameter using holmium:YAG laser. Patients and methods This was a prospective randomized study that included 40 patients who were divided into two groups, with 20 patients each. Group A underwent mini-PCNL using holmium:YAG laser lithotripsy for renal pelvic and calyceal stones. Group B underwent RIRS in which flexible ureteroscopy was used for pelvic and calyceal stones, and semi-rigid ureteroscope was used for only renal pelvic and upper calyceal stones using holmium:YAG laser. In both groups, the procedure outcomes in terms of operative time, blood loss, hospital stay, complications using modified Clavien grading system, the need of auxiliary procedures, and stone-free rates (SFRs) after 3 weeks by using CTUT were evaluated statistically. Results Statistical analysis of the data showed that there was significant difference in the operative time, which was higher in RIRS group compared with mini-PCNL group, whereas the blood loss in terms of mean±SD change in pre-treatment and post-treatment hemoglobin levels and the hospital stay were significantly higher in mini-PCNL group compared with RIRS group. The complications using modified Clavien grading system were higher in mini-PCNL group compared with RIRS group. The SFR was higher in mini-PCNL group. Conclusion In patients with renal stones 20 mm or larger, results showed that mini-PNCL has significantly shorter operative time with higher blood loss and longer hospital stay compared with RIRS. In both groups, the SFR and the need of the auxiliary procedures were comparable.

A modified definition of POPF with cost validation for PPPD

Introduction: Postoperative pancreatic fistula (POPF) is still a major complication after pylorus preserving pancreaticoduodenectomy (PPPD), despite improvements of surgical technique and perioperative management. Therefore, clear definition of POPF after the surgery is important thing to surgeons. Lately, international study group of pancreatic fistula (ISGPF) revised POPF grade system. In this study, we suggested a modified definition of POPF and evaluated the suitability of the grade system for PPPD patients with cost validation comparing to ISFPG grade system. Method: From January 2010 to December 2014, 394 medical records of the patients who underwent PPPD were retrospectively reviewed. The patients were classified according to each POPF definition. (ISGPF and modified) A modified definition was as follow. (POPF was defined as greater peritoneal amylase level than three times of serum amylase level; BL; No additional management except routine management and drain removal within POD #10; Grade A; ISGPF Grade B except radiological intervention, Grade B; radiological intervention, Grade C; hemodynamic instability or reoperation, Grade D; mortality.) After then postoperative day (POD) and admission cost was analyzed according to grading system. Result: In POD analysis, the modified grading system more precisely classified the patients than ISGPF grading system. (ISGPF; BL vs. B: 16.5 day vs. 24.0 day, p<0.001); (Modified; BL vs. A: 14.0 day vs. 21.0 day, p<0.001; A vs. B: 21.0 day vs. 26.0, p=0.002) In admission cost analysis, the modified grading system also more precisely classified the patients than ISGPF grading system. (ISGPF; BL vs. B: 5,960,000 won vs. 7,610,000 won, p=0.003); (Modified; BL vs. A: 5,490,000 won vs. 6,560,000 won, p=0.002; A vs. B: 6,560,000 won vs. 10,630,000 won, p=0.001) Conclusion: The modified POPF grade system was more precise than previous POPF grading system.

Prognostic factors and survival after surgical resection of pancreatic neuroendocrine tumor with validation of established and modified staging systems

BackgroundPancreatic neuroendocrine tumors (PNETs) display wide heterogeneity with highly variable prognosis. This study aimed to identify variables related to survival after surgical resection of PNET. MethodsA total of 143 patients were identified from a prospectively maintained database. Patient characteristics were analyzed and prognostic factors for overall survival and progression-free survival were evaluated. The WHO, ENETS and AJCC scoring systems were applied to the cohort, and their ability to predict patient outcomes were compared. ResultsMultivariate analysis found that female gender, lymph node metastases and increasing WHO 2010 grade to be independently associated with reduced overall survival (P < 0.05). Patients requiring multi-visceral resection or debulking surgery found to be associated with shortest survival. ROC analysis found the ENETS and AJCC scoring systems to be similarly predictive of 5-year overall survival. Modified Ki67 significantly improved its accuracy in predicting 5-year overall survival (AUROC: 0.699 vs 0.605; P < 0.01). ConclusionsMulti-visceral or debulking surgery is associated with poor outcomes. There seems to be no significant difference between enucleation and anatomical segmental resection. Available scoring systems have reasonable accuracy in stratifying disease severity, with no system identified as being superior. Prognostic stratification with modified grading systems needs further validation before applied in clinical practice.

Analysis of the etiology and prognosis of severe complications after percutaneous nephrolithotomy

Objective To analyze the etiology and prognosis of severe complications of percutaneous nephrolithotomy (PCNL). Methods The clinical data of patients with severe complications after PCNL from December 2004 to December 2015 were retrospectively analyzed. Age of the patients ranged from 25 to 69 years old, with an average of 41 years. There were 64 cases with 29 male and 35 female. Fifty-five cases were diagnosed as renal calculi, including 21 cases of left renal calculi, 19 cases of right renal calculi; 15 cases of bilateral renal calculi; 2 cases of the patients were bilateral upper ureteral calculi; 7 patients were renal calculi upper ureteral calculi on the other side. In all cases, the maximum diameter of calculus was 1.8-4.3 cm (mean 2.6 cm) and hydronephrosis depth was 0-5.9 cm (mean 2.3 cm); 15 cases were previously treated with nephrolithotomy. The modified Clavien grading system was used to evaluate surgical complications, and ≥grade Ⅲ complications were considered as serious complications. Results Among the 64 cases, 28 cases were classified as Clavien Ⅲ class. There were 2 cases of bleeding in operation due to renal parenchyma laceration or multiple access, patients were treated with later open surgery. Postoperative bleeding were revealed in 22 cases, 16 of which were hemorrhage from the nephrostomy tubes, 4 of which complained of discontinuity gross hematuria and 2 postoperative bleeding were encountered during the nephrostomy tube remove. All the cases received renal arteriography and were diagnosed with pseudoaneurysm, bleeding were stopped after embolization. 3 cases of pleural injury were treated with closed thoracic drainage, 1 colon injury was treated with open colostomy. There were 32 cases of urinary sepsis considered as Clavien Ⅳ complications, and these patients were transferred to the Intensive Care Unit. Clavien Ⅴ class 4 cases: 1 died of hemorrhagic shock due to pleural injury, 2 cases died of urinary sepsis and multiple organ failure and another case died of pulmonary embolism. Conclusions PCNL has high risk of serious complications, which should be always strictly follow the principles. Adequate preoperative preparation, appropriate surgery access, carefully and gently operate, appropriate antibiotic use and postoperative management are the key measures to reduce the incidence of complications. Key words: Percutaneous nephrolithotomy (PCNL); Severe complications; Etiology; Prognosis

Accuracy of cannulated pedicle screw versus conventional pedicle screw for extra-pedicular screw placement in dysplastic pedicles without cancellous channel in adolescent idiopathic scoliosis: a computerized tomography (CT) analysis.

This study aimed at studying the accuracy and safety of extra-pedicular screw insertion for dysplastic pedicles in AIS comparing cannulated screw system versus conventional screw system. 104 AIS patients with 1524 pedicle screws were evaluated using CT scan. 302 screws were inserted in dysplastic pedicles using fluoroscopic guidance technique. 155 screws were inserted using a cannulated system (Group 1), whereas 147 screws were inserted using standard screws (Group 2).The pedicle perforations were assessed using a classification by Rao et al.; G0: no violation; G1: <2mm perforation; G2: 2-4mm perforation; and G3: >4mm perforation). For anterior perforations, the pedicle perforations were assessed using a modified grading system (Grade 0: no violation, Grade 1: less than 4mm perforation; Grade 2: 4mm to 6mm perforation; and Grade 3: more than 6mm perforation). The perforation rate in Group 1 was4.5%and in Group 2 was15.6%(p=0.001). Most of the perforations were anterior perforations (53.3%). The anterior perforation rate in Group 1 was 1.9% compared to 8.8% in Group 2 (p=0.009). Group 1 has a medial perforation rate of 1.3% compared to Group 2, 6.1% (p=0.031). The rate of critical pedicle perforation in Group 1 was2.6%and in Group 2 was6.8%(p=0.102). InGroup 1, there wereno critical medial perforationbut there wasone G2 lateral perforation, one G2 superior perforation and two G3 anterior perforations. In Group 2, there werethree G2 medial perforations, one G2 lateral perforation, one G2 anterior perforation and five G3 anterior perforations. Usage of cannulated screw system significantly increases the accuracy of pedicle screw insertion in dysplastic pedicles in AIS.

MP68-05 SINGLE SURGEON EXPERIENCE WITH RETAINED ENCRUSTED STENTS: COMBINED ENDOUROLOGICAL APPROACH AND MODIFIED GRADING SYSTEM

You have accessJournal of UrologyStone Disease: Surgical Therapy VI1 Apr 2017MP68-05 SINGLE SURGEON EXPERIENCE WITH RETAINED ENCRUSTED STENTS: COMBINED ENDOUROLOGICAL APPROACH AND MODIFIED GRADING SYSTEM Roberto Lopes, Carlos Watanabe-Silva, Fabricio Beltrame, Alexandre Danilovic, Joaquim Claro, and Fabio Vicentini Roberto LopesRoberto Lopes More articles by this author , Carlos Watanabe-SilvaCarlos Watanabe-Silva More articles by this author , Fabricio BeltrameFabricio Beltrame More articles by this author , Alexandre DanilovicAlexandre Danilovic More articles by this author , Joaquim ClaroJoaquim Claro More articles by this author , and Fabio VicentiniFabio Vicentini More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2321AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The encrusted and retained ureteral stent represents the most challenging complication associated with ureteral stents. The aim of our study is to describe our experience in the management of retained encrusted stents using a combined endourological approach and also to suggest a modified grading system for stent encrustation. METHODS All of the procedures were carried out by the same first surgeon, who is experienced in prone and supine PCNL, retrograde ureteroscopy and retrograde intrarenal surgery. Surgical management was based on the location and the stone burden of cases (considering encrusted stents and associated stones) and of course renal function. Between June 2010 and June 2015, all patients referred with retained and encrusted ureteral stents to our hospital were submitted to a combined endourological approach with a Galdakao-modified Valdivia positioning supine removal of the stents without need of bolster below the patient. RESULTS Fifty patients were evaluated. Two groups were created additionaly to the grading system proposed by Acosta-Miranda et al: calcified and broken stent (stage VI - 9 cases) and isolated ureteral calcification (stage VII - 5 cases). Percutaneous nephrolithotripsy was common for stages III to VI and rare or not performed in stage I, II and VII, as these encrustations were usually minor and not located in the kidney and therefore did not hinder stent extraction (p=0.004). Ureterolithotripsy was commonly used for ureteral stent encrustation, especially in groups with lower stone burden (stages I and II) and stage VII (ureteral only). Length of operation was higher for groups with severe stone burden (stages III and IV - 158.1±64.8 min) when compared to moderate stone burden (stage III - 110.0±64min) and low stone burden (stages I, II, VI and VII - 78.6±29.8 min) - p value 0,0012. Number of procedures, length of stay, blood transfusion, complications and stone analysis were similar between groups. Stone-free was worse in stages III to V, as expected, due to higher stone burden, even though not statistically significant. All stents were successfully removed in all cases (100%) by our combined endourological approach, which was the primary objective of our study. CONCLUSIONS Galdakao-modified Valdivia positioning supine removal of retained and encrusted stents is a safe and feasible technique, with all catheters removed in a single procedure. A modified classification of the encrusted stones might help urologists to advise their patients on expected surgical outcomes. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e919-e920 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Roberto Lopes More articles by this author Carlos Watanabe-Silva More articles by this author Fabricio Beltrame More articles by this author Alexandre Danilovic More articles by this author Joaquim Claro More articles by this author Fabio Vicentini More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

SOCS3 Immunohistochemical Expression Seems to Support the 2005 and 2014 International Society of Urological Pathology (ISUP) Modified Gleason Grading System.

In the 2014, The International Society of Urological Pathology (ISUP) consensus conference update the grading of prostate, last revised in 2005. In this study we evaluate the SOCS3 immunohistochemical protein expression in different Gleason prostatic adenocarcinoma: classical Gleason grade 3, classical Gleason grade 3 upgraded to Gleason grade 4 according to the ISUP modifications and classical and modified Gleason grade 4. The major conclusions were: (i) Cribriform glands should be assigned a Gleason pattern 4, regardless of morphology; (ii) Glomeruloid glands should be assigned a Gleason pattern 4, regardless of morphology; (iii) Grading of mucinous carcinoma of the prostate should be based on its underlying growth pattern rather than all as pattern 4; and (iv) Intraductal carcinoma of the prostate without invasive carcinoma should not assigned Gleason grade and a comment about aggressive carcinoma probably associated should be made. In a recent report we analyzed the methylathion status of cytokine signaling (SOCS) proteins 3 (SOCS3) gene and the consequences of promoter hypermethylation on mRNA and protein expression in a collection of prostate cancer and benign prostate hyperplasia (BPH) and for the first time we demonstrated that a hypermethylation of SOCS3 with a significant reduction of its mRNA and protein expression identifies a subgroup of prostate cancer with a more aggressive behavior. Moreover we demonstrated that the immunohystochemical analysis of SOCS3 protein expression in prostatic cancer biopsies may provide a useful and easier method than SOCS3 methylation analysis to individuate in cancer with intermediate-high grade Gleason score a subgroup of prostate cancer with a more aggressive behavior. A total of 148 radical prostatectomy with diagnosis of prostatic acinar adenocarcinoma were stratified into three different categories on the basis of Gleason grade: (i) Twenty-six prostatic adenocarcinoma with classical and modified Gleason grade 3; (ii) Fifty seven prostatic adenocarcinoma with classical Gleason grade 3 upgraded to Gleason grade 4 by 2005 and 2014 ISUP Consensus Conference; and (iii) Sixty five prostatic adenocarcinoma with classical and modified Gleason grade 4. Immunohistochemical analysis for SOCS3 was performed and SOCS3 staining intensity were evaluated by two pathologists in three different ways on the basis of the intensity of cytoplasmatic staining: positive (intense cytoplasmatic staining in more than 50% of neoplastic cells) (+), negative (absence of cytoplasmatic staining in more than 50% of neoplastic cells) (-), weakly positive (weak cytoplasmatic staining in more than 50% of neoplastic cells (+/-). In the group of prostatic adenocarcinoma Gleason grade 3 we found that SOCS3 positivity (+) were observed in 19 out of 26 cases (73.1%); in 5 out of 26 prostatic adenocarcinoma the neoplastic glands showed weak intensity SOCS3 staining (+/-) (19.2%), while in only two cases we found SOCS-3 negativity (-) (7.7%); in the group of cases with prostatic adenocarcinoma with Gleason grade 4, 16 out 65 cases (24.6%) showed SOCS3 positivity (+); 18 out 65 cases (27.7%) SOCS3 weakly positive (+/-), and in 31 cases (47.7%) SOCS3 negative staining (-) were observed. Interestingly, the group of prostatic adenocarcinoma with histological Gleason 3 pattern upgraded to Gleason 4 pattern according to the 2005 and 2014 ISUP modified grading system, showed SOCS3 positivity (+) in 16 out of 57 cases (28%), in 16 out 57 cases (28%) a weakly positive for SOCS3 (+/-) were observed, while 25 cases (44%) showed negative SOCS3 staining (-). In this study we demonstrated a significant association of SOCS3 positivity (+) with prostatic carcinoma classical Gleason pattern 3 (P < 0.0001), while SOCS3 negative pattern (-) or SOCS3 weakly positive pattern (+/-) were associated to prostatic carcinomas with Gleason pattern 3 upgraded to Gleason pattern 4 (P = 0.0002) and with classical Gleason pattern 4. The significant difference of SOCS3 immunohistochemical expression between classical Gleason grade 3 and Gleason grade 4 upgraded to grade 4 seems to support the definitions and the modifications of Gleason grade 4 of the 2005 and the 2014 International Society of Urological Pathology (ISUP). The hypoexpression of SOCS3 protein in glomeruloid glands could support the hypothesis that from molecular point of view this growth pattern could be different from classical Gleason pattern 3 and biologically more closely to Gleason pattern 4, confirming the conclusions of the 2014 ISUP Conference assigning a Gleason pattern 4 to glomeruloid glands regardless of morphology. Prostate 77: 597-603, 2017. © 2017 Wiley Periodicals, Inc.