Multi-institutional Retrospective Review Research Articles

Is the endometrial evaluation routinely required in patients with adult granulosa cell tumors of the ovary?

ObjectiveGranulosa cell tumors (GCTs) are the most common estrogen-secreting ovarian tumors; perhaps due to the persistent hyperestrogenism, a wide spectrum of associated endometrial pathologies ranging from endometrial hyperplasia to carcinoma has been documented in patients with GCTs. The aim of this study is to evaluate the incidence of endometrial pathologies in a large series of GCT patients treated in MITO centers. MethodsA retrospective multi-institutional review of patients with granulosa cell tumors of the ovary treated or referred to MITO centers was conducted. Descriptive statistics were used to characterize the patient population and to assess the association of GCT and endometrial abnormalities at the time of diagnosis; multivariate regression analysis was also performed to identify independent predictors of endometrial abnormalities. ResultsA total of 150 patients with primary adult GCT was identified. During the preoperative assessment, endometrial pathology was found in 35.9% of symptomatic patients and in 90.9% of asymptomatic women with endometrial thickening at transvaginal ultrasound. At the time of surgery, hyperplasia was documented in 29.2% of patients, whereas endometrial cancer occurred in 7.5% of patients. Almost all of the patients (97.6%) with endometrial hyperplasia were older than 40years. All patients with endometrial cancer were older than 40years and postmenopausal. ConclusionsEndometrial carcinoma/atypical hyperplasia were commonly observed in GCT patients >40years; based on these data, endometrial sampling should be performed in symptomatic women at least 40years of age. In asymptomatic women <40years, endometrial sampling is of low yield.

Outcome of patients with positive heparin–platelet factor-4 antibodies: A retrospective multi-institutional observational study

Studies show increased mortality with positive heparin–platelet factor-4 (H–PF4) antibodies, especially in hemodialysis patients. We aimed to compare mortality and thrombosis in hospitalized patients with positive, equivocal and negative H–PF4 antibody results. Information was collected on these patients using a multi-institutional retrospective electronic medical record review. Patients tested for H–PF4 antibodies by commercial ELISA during the years 2006 to 2010 were identified. We compared 30-day, 90-day and 1-year mortality in patients with negative, equivocal and positive H–PF4 test and evaluated the relationship between H–PF4 status and rate of thrombosis. Four hundred and seventeen patients had ELISA testing for H–PF4 antibodies. Forty-four patients had equivocal (optical density value 0.4–0.9) and 21 had positive (value 1) H–PF4 antibody test. There were no statistically significant differences in mortality between patients with negative, equivocal and positive results at all three time points (p = 0.22, 0.27 and 0.38, respectively) even after excluding patients with thrombosis (p = 0.22, 0.24 and 0.31, respectively). Age and Charlson score were associated with increased 30-day, 90-day and 1 year mortality. Odds ratio of having thrombosis was 23.1 for positive vs. equivocal results (p < 0.001); however, there was no statistically significant difference between equivocal vs. negative results (p = 0.22). Our results revealed no association between H–PF4 status and mortality, as well as no difference in 1-year survival between the positive and negative groups.

Cochlear Implantation for Single‐Sided Deafness: Early Outcomes for 12 Patients

Objectives: (1) Summarize hearing status in the nonimplant ear. (2) Report audiometric and subjective outcomes. Methods: Multi-institutional retrospective chart review. We report outcomes of cochlear implantation in 12 patients with single-sided deafness. Hearing status in the nonimplant ear included: 6 patients with American Academy of Otolaryngology—Head and Neck Surgery Class A, 4 with Class B, and 2 with Class C (1 with WRS 90%). Five of 12 (42%) patients had normal hearing in the nonimplanted ear. There were 6 male and 6 female patients. Average age was 51.5 years (range, 9-75 years). Average preoperative word recognition score in the nonimplanted ear was 82% (range, 52%-100%). Average preoperative pure tone average was 30.4 dB (range, 2-60 dB). Results: Average post-implantation follow-up was 8 months (range, 1-36 months). Etiologies of deafness included 5 idiopathic sudden-sensorineural, 3 Ménière’s Disease, 2 idiopathic progressive, 1 labyrinthitis, and 1 iatrogenic. Audiometric results for the implant-only condition demonstrated mean consonant-nucleus-consonant score of 67% (range, 10%-88%) and mean AzBio score of 83% (range, 73%-97%). Objective testing in noise also showed substantial improvement compared to the preoperative condition. All are daily users. Conclusions: Although cochlear implantation for asymmetric hearing loss and single-sided deafness is not Food and Drug Administration approved in the United States, our patients report a high level of satisfaction. Early audiometric data indicate that these patients score similarly to standard implant users in the CI only condition. In addition, they show substantial improvement in noise since preoperative testing. More data are needed to determine future candidacy for this intervention.

Utility of bone marrow aspiration and biopsy in initial staging of Ewing sarcoma.

The current standard of care for initial staging of pediatric Ewing sarcoma (EWS) patients is to obtain a bilateral bone marrow aspiration and biopsy (BMAB). The incidence of bone marrow (BM) disease in patients deemed non-metastatic by conventional and metabolic imaging and the concordance of BM positivity with other clinical characteristics are not well established. This study is a multi-institutional retrospective review of newly diagnosed EWS patients less than 40 years of age with initial staging that included imaging and BMAB. A total of 116 patients were eligible with 85 patients considered non-metastatic and 31 considered metastatic by imaging. None of the 85 patients with non-metastatic disease were BMAB positive (0%; 95% CI: 0-4.2%); 13 of the 31 patients with metastases were BMAB positive (41.9%; 95% CI: 24.5-60.9%). Primary tumor size was significantly higher in patients with metastases (P = 0.017). Bone metastasis by imaging had high correlation with BMAB positivity (P = 0.0002). In addition, the number of bony metastatic sites was significantly higher in patients with a positive BMAB as compared to those with a negative BMAB (median 3.5 and 0.0, respectively; P < 0.001). BMAB may not be required for initial staging of pediatric and young adult EWS patients deemed non-metastatic by imaging. In patients with metastatic disease, there is a high correlation of BM involvement with multiple bone metastases.

Palonostron with aprepitant plus dexamethasone to prevent chemotherapy-induced nausea and vomiting (CINV) during gemcitabine/cisplatin (GC) in urothelial cancer (UC) patients: A multi-institutional retrospective study in Japan.

362 Background: GC combination chemotherapy of is a standard regimen for advanced UC. Although this is a highly emetogenic chemotherapy, there has been no study concerning antiemetic prophylaxis for CINV during GC. The aims of this study were to evaluate CINV during GC and to compare the antiemetic efficacy of the triple combination of palonosetron, aprepitant and dexamethasone with that of our old regimen using first-generation 5-HT3 receptor antagonists and dexamethasone. Methods: We conducted a retrospective multi-institutional review of the medical records of 122 patients who received GC for advanced urothelial cancer between February 2005 and January 2012. Uncontrolled CINV events were identified through records of nausea and vomiting, additional infusion, rescue medications, and/or records of food intake. Nausea, vomiting, and anorexia were classified using the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. Results: A total of 75 and 47 patients were treated with first-generation 5-HT3 receptor antagonists (ondansetron or granisetron) plus dexamethasone (group 1) and palonosetron with dexamethasone plus aprepitant (group 2), respectively. There was no significant difference in age, sex, or the dose of cisplatin between the 2 groups. Patients in group 2 had significantly higher CR (defined as no emetic episodes and no rescue medication use) rates than those in group 1 during the overall phase in the first cycle (85.7% versus 65.3%, p=0.012) and all cycles (78.7% versus 50.7%, p=0.0019) of GC. Patients in group 2 were more likely to achieve more favorable CINV control, e.g., a lower grade of nausea, vomiting, or anorexia, lower incidence of rescue therapy required, and shorter time to become CINV-free, than patients in group 1. Conclusions: This study shows that palonosetron in combination with aprepitant and dexamethasone is more effective to prevent chemotherapy-induced nausea and vomiting in UC patients treated with GC than first-generation 5-HT3 receptor antagonists plus dexamethasone.

Adverse Events of Stapling in Thoracic Surgery: Relations between an Incidence of Adverse Events and a Stapling Volume

The use of staplers for thoracic surgery has been widely accepted and regarded as a safe procedure. However, sometimes adverse events (AEs) of stapling are experienced. The aim of the present study was to retrospectively analyze AEs of stapling in thoracic surgery. A retrospective multi-institutional review was conducted by the 27 institutions of the Central Japan Lung Cancer Surgery Study Group. Between January 2009 and December 2010, 4495 patients underwent thoracic surgery using mechanical stapling. Stapling of various tissues was performed 16403 times. Total number of AEs related to stapling was 126 (0.77%). One hundred and nine events occurred intraoperative and 17 events occurred postoperative. The AE rates ranged from 0% to 1.8%. No relationship was seen between the incidence of AE and a stapling volume of thoracic surgery. We have investigated intraoperative and postoperative AEs of stapling. Generally, stapling in thoracic surgery was safe. An AE rate of stapling in thoracic surgery is not influenced by the numbers of stapling in institutions.

Adverse Events of Lung Tissue Stapling in Thoracic Surgery

The use of staplers for thoracic surgery has been regarded as a safe procedure though sometimes adverse events (AEs) of stapling are experienced. The aim of this study is to analyze AEs of lung tissue stapling. A retrospective multi-institutional review was conducted by 27 institutions of the Central Japan Lung Cancer Surgery Study Group. During the research period, lung tissue stapling was performed 10908 times. Total number of AEs related to stapling was 81 (0.74%). Seventy events occurred intraoperatively and 11 events occurred postoperatively. Intraoperative stapling AEs were air leakage (n = 26), laceration of the adjacent lung tissue (n = 23), stapling failure (n = 14), oozing (n = 4), and others (n = 3). The postoperative AEs were prolonged air leakage (n = 9), bleeding from the chest wall (n = 1), and postoperative bleeding (n = 1). Only one case died of acute exacerbation of interstitial pneumonia which was induced after completion lobectomy to cure postoperative bleeding. No relationship was seen between the incidence of AE and cartridge colors or compression types of staplers except the length of cartridges. Lung tissue stapling in thoracic surgery was safe. The most frequent cause of AEs was stapler-tissue thickness mismatch. The appropriate selection of the cartridge color may decrease the AE incidence of the lung tissue stapling.

Complications of Bronchial Stapling in Thoracic Surgery

The use of staplers for thoracic surgery has been widely accepted and regarded as a safe procedure. However, complications of stapling are occasionally experienced. The aim of this retrospective study was to analyze complications of bronchial stapling. A retrospective multi-institutional review was conducted by the Central Japan Lung Cancer Surgery Study Group, comprising 29 institutions. All instances of bronchial stapling in thoracic surgery were reviewed during the research period. Bronchial stapling was performed 2,030 times, using 36 kinds of staplers. The total number of complications related to stapling was 36 (1.8 %); 31 events occurred intraoperatively and five events occurred postoperatively. The intraoperative complications were air leakage (N = 20) and stapling failure (N = 11), which were caused by stapler-tissue thickness mismatch (N = 17), stapler defect (N = 3), tissue fragility (N = 2), and unknown reasons (N = 9). In all 31 cases, intraoperative complications were recovered intraoperatively with additional suturing, and no further complications were observed postoperatively. The postoperative complications were bronchopleural fistula (BPF) (N = 4) and bleeding from the chest wall (intercostal artery) (N = 1). The rate of BPF was 0.2 % (4 of 2,030). Two of four BPFs induced critical conditions. Postoperative bleeding was caused by the use of Duet TRS(TM). Both total complications and BPF occurred more frequently in the main bronchus than in the lobar or segmental bronchus. No relationship was seen between the incidence of complications and cartridge colors in lobar bronchial stapling. The compression types of staplers were associated with the incidence of complication. Intraoperative and postoperative complications of bronchial stapling were studied. Generally, bronchial stapling in recent thoracic surgery was safe, but rare postoperative complications may induce critical conditions. Knowledge of potential complications and causes of bronchial stapling may decrease the incidence of stapling complications.

Treatment for Perforated Gastric Ulcer: a Multi-institutional Retrospective Review

BackgroundThe optimal treatment for patients with perforated gastric ulcer (PGU) remains controversial. This study therefore investigated the treatment status for this disease in clinical practice. MethodsWe retrospectively reviewed 183 patients with PGU from 1998 to 2007 across 15 institutions, and analyzed patient characteristics and short- and long-term outcomes according to treatments received. ResultsOf the 183 patients, 57 who were treated conservatively had less abdominal tenderness, lower levels of serum C-reactive protein, and shorter time to presentation than the 126 patients who underwent emergency surgery. There was no significant difference in baseline characteristics between the 41 successful patients and 16 failed patients in the conservative treatment group; however, the latter had a longer average hospital stay. Eighty-three of the emergency surgery patients who underwent gastrectomy had longer surgical times, greater blood loss, and shorter time to resumption of diet than the 57 patients undergoing stomach-preserving surgery; however, there was no significant difference in postoperative complications and hospital stay between these groups. Of 91 patients who received stomach-preserving treatment, only three had treatment failure in the long-term follow-up period. ConclusionStrictly selected patients should be initially considered for conservative treatment. The short-term outcomes of stomach-preserving surgery are comparable to gastrectomy; however, further evaluation of the long-term outcomes of stomach-preserving treatment is required.

Prognosis for Sixth Nerve Palsy Arising from Paranasal Sinus Disease

The abducens nerve, cranial nerve VI (CNVI), is the medial-most nerve in the cavernous sinus. Its close proximity to the sphenoid sinus makes it susceptible to injury, invasion, or compression from a sphenoid pathology leading to horizontal gaze diplopia. A wide range of literature describes myriad causes for CNVI palsy, but there is a lack of references that point to paranasal sinus pathology as an etiology, as well as the prognosis and timeline for resolution. Here, we describe a series of patients that presented with CNVI palsy, their management, and prognosis for recovery. This study was designed to evaluate and understand prognostic factors predicting disease course and likelihood of resolution in patients with abducens nerve palsy. A multi-institutional retrospective review was performed of all patients presenting with CNVI palsy between 2009 and 2012. The demographic data, radiological features, treatment regimens, and disease courses were analyzed. Fifteen patients at four institutions were identified. Seven patients had neoplasms originating from the paranasal sinuses, three suffered from allergic fungal sinusitis, three patients had invasive fungal sinusitis, one patient had fibrous skull base dysplasia, and one had chronic bacterial sinusitis. The average follow-up time from presentation was 9 months (range, 1-16 months). Thirteen patients underwent surgery, three received chemotherapy, and four had radiation therapy. CNVI palsy resolved in 50% of the cases, with an average time to resolution of 6 weeks (range, 2-12 weeks). Paranasal sinus pathology is a rare cause of CNVI palsy. A number of factors may help to predict prognosis in these patients. Masses compressing, but not destroying or invading, the cavernous sinus had optimal posttreatment outcomes with full resolution occurring as early as 2 weeks. Destructive lesions that invaded CNVI and its vasculature, i.e., invasive fungus, were negative indicators for recovery. Knowledge of factors that affect recovery can help clinicians predict disease course and prognosis for resolution of the defect.

Long-term follow-up is crucial after treatment for granulosa cell tumours of the ovary

Objective:The aim of this study is to evaluate the long-term outcome of granulosa cell tumour (GCT) of the ovary in a large series of patients treated in MITO centres (Multicentre Italian Trials in Ovarian Cancer) and to define prognostic parameters for relapse and survival.Methods:A retrospective multi-institutional review of patients with GCTs of the ovary treated or referred to MITO centres was conducted. Surgical outcome, intraoperative and pathological findings and follow-up data were analysed. Kaplan–Meier and Cox proportional hazards analyses were used to determine the predictors for survival and recurrence.Results:A total of 97 patients with primary GCT of the ovary were identified. The median follow-up period was 88 months (range 6–498). Of these, 33 patients had at least one episode of disease recurrence, with a median time to recurrence of 53 months (range 9–332). Also, 47% of recurrences occurred after 5 years from initial diagnosis. At multivariate analysis, age and stage were independent poor prognostic indicators for survival; surgical treatment outside MITO centres and incomplete surgical staging retained significant predictive value for recurrence in both univariate and multivariate analyses.Conclusions:This study confirms the generally favourable prognosis of GCTs of the ovary, with 5-year overall survival approaching 97%. Nevertheless, prognosis after 20 years was significantly poorer, with 20-year survival rate of 66.8% and a global mortality of 30–35. These findings support the need for lifelong follow-up even in early-stage GCT.

Adverse events of pulmonary vascular stapling in thoracic surgery

The use of staplers for thoracic surgery has been widely accepted and regarded as a safe procedure. However, adverse events (AEs) of stapling are occasionally experienced. The aim of this retrospective study was to analyse the AEs of stapling in pulmonary vascular surgery. A retrospective multi-institutional review was conducted by the 29 institutions of the Central Japan Lung Cancer Surgery Study Group. All staplings of the pulmonary artery (PA) and vein in thoracic surgery were reviewed during the research period. Stapling of the PA and vein was performed 3393 times. The total number of AEs related to stapling was nine (0.27%). Eight events occurred intraoperatively and one occurred immediately after the operation. Intraoperative AE occurred more frequently than postoperative AE. AE in the PA occurred more frequently than in the pulmonary vein. The intraoperative AEs were oozing (n=3), stapling failure (n=2), laceration of the peripheral vasculature at compression (n=2) and technical injury of the vasculature at insertion (n=1). The causes of AEs were reported to be tissue fragility (n=3), stapler rocking during stapling (n=2), stapler-tissue thickness mismatch (n=2) and technical failure (n=1). The only postoperative AE was staple line rupture of the PV stump. No relationship was seen between the incidence of AE and cartridge colours, compression types of staplers or numbers of staple lines. Generally, stapling of the pulmonary vasculatures in recent thoracic surgery has been safe. Furthermore, the knowledge of the possible risks of pulmonary vascular stapling may help to decrease the AEs of stapling.

The effect of the new 2010 World Health Organization criteria for semen analyses on male infertility

To quantify the effect of the new 2010 World Health Organization (WHO) semen analysis reference values on reclassifying previous semen analysis parameters and definition of patients with male factor infertility. A multi-institutional retrospective chart review. University and private male infertility clinics. Men referred for infertility evaluation. Comparison of semen analysis values based on 2010 versus 1999 reference criteria. Quantification of the change based on individual sperm parameters and as a whole. A total of 184 men had at least two semen analyses; 13 (7%), 17 (9.2%), 34 (18.4%), and 29 (15.7%) patients changed classification to being at or above the reference values by the 2010 criteria for semen volume, sperm concentration, motility, and morphology, respectively. A total of 501 men had one semen analysis on file; 40 (7.9%), 31 (6.2%), 50 (9.9%), and 74 (19.3%) would change classification for volume, concentration, motility, and morphology, respectively. Overall, 103 patients (15.1%) who had one or more parameter below the reference value on the original analysis were converted to having all parameters at or above the 2010 reference values. The 2010 reference values result in some infertile men being reclassified as fertile if status is based on semen analysis alone. This may lead to fewer men being referred for proper infertility evaluation or treatment.

Lateralized petrous internal carotid artery: imaging features and distinction from the aberrant internal carotid artery

This study aimed to describe the lateralized petrous internal carotid artery (ICA), a rare variant of the intratemporal course of the ICA, and distinguish it from aberrant ICA. A retrospective multi-institutional review of all patients diagnosed over a 10-year period with lateralized ICA was completed. Medical records were reviewed for demographic data as well as clinical information in all patients. Computerized tomography (CT) studies were reviewed in all patients. Magnetic resonance studies in this patient group were reviewed when available. In order to obtain normative data for the ICA, the intratemporal course of the ICA was evaluated on 50 consecutive high-resolution sinus CT scans. Sixteen cases of lateralized ICA were identified on CT scans in 12 patients. In each of these, the ICA entered the skull base in a position more lateral to the cochlea than normal and protruded into the anterior mesotympanum with dehiscent or thinned overlying bone. Magnetic resonance angiography was available in 5 of 12 patients and catheter angiography in 1 of 12. Lateralized petrous ICA can be identified on CT by its more posterolateral entrance to the skull base and protrusion into the anterior mesotympanum. It can be distinguished from the aberrant ICA which enters the posterior hypotympanum through an enlarged inferior tympanic canaliculus, then courses across the inferior cochlear promontory to connect with the normal horizontal petrous ICA. Lateralized ICA is best considered an incidental petrous ICA variant. Awareness of this entity is important in the presurgical evaluation of the temporal bone to avoid vascular injury and confusion with the congenital diagnosis of aberrant ICA.

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

What's known on the subject? and What does the study add? Upper urinary tract urothelial carcinomas (UUT-UCs) are rare tumours. Because of the aggressive pattern of UC, radical nephroureterectomy (RNU) with bladder cuff removal remains the 'gold-standard' treatment. However, conservative strategies, such as segmental ureterectomy (SU) or endourological management, have also been developed in patients with imperative indications. Some teams are now advocating the use of conservative management more commonly in cases of elective indications of UUT-UCs. Due to the paucity of cases of UUT-UC, only limited data are available on the oncological outcomes afforded by conservative management. We retrospectively investigated the oncological outcomes after SU and RNU in a large multi-institutional database. Overall, 52 patients were treated with SU and 416 with RNU. There was no statistical difference between the RNU and SU groups for the 5-year probability of cancer-specific survival, recurrence-free survival and metastasis-free survival. The type of surgery was not a significant prognostic factor in univariate analysis. The results were the same in a subgroup analysis of only unifocal tumours of the distal ureter with a diameter of <2 cm and of low stage (≤T2). Our results suggest that oncological outcomes after conservative treatment with SU are comparable to RNU for the management of UUT-UC in select cases. To compare recurrence-free survival (RFS), metastasis-free survival (MFS) and cancer-specific survival (CSS) after segmental ureterectomy (SU) vs radical nephroureterectomy (RNU) for urothelial carcinoma (UC) of the upper urinary tract (UUT-UC) located in the ureter. We performed a multi-institutional retrospective review of patients with UUT-UC who had undergone RNU or SU between 1995 and 2010. Type of surgery, Tumour-Node-Metastasis status, tumour grade, lymphovascular invasion and positive surgical margin were tested as prognostic factors for survival. In all, 52 patients were treated with SU and 416 with RNU. The median (range) follow-up was 26 (10-48) months. The 5-year probability of CSS, RFS and MFS for SU and RNU were 87.9% and 86.3%, respectively (P = 0.99); 37% and 47.9%, respectively (P = 0.48); 81.9% and 85.4%, respectively (P = 0.51). In univariable analysis, type of surgery (SU vs RNU) failed to affect CSS, RFS and MFS (P = 0.94, 0.42 and 0.53, respectively). In multivariable analyses, pT stage and pN stage achieved independent predictor status for CSS (P = 0.005 and 0.007, respectively); the positive surgical margin and pT stage were independent prognostic factors of RFS and MFS (P = 0.001, 0.04, 0.009 and 0.001, respectively). The main limitation of the study is its retrospective design, which is due to the rarity of the disease. Short-term oncological outcomes after conservative treatment with SU are comparable to RNU for the management of UUT-UC in select cases and should be considered an option. In every other case, RNU still represents the 'gold standard' for the treatment of UUT-UC.

Multi-institutional review of sequential intravesical gemcitabine and mitomycin C chemotherapy for non-muscle-invasive bladder cancer.

294 Background: Combination chemotherapy is the standard of care for neoadjuvant, adjuvant, and metastatic bladder cancer due to increased efficacy when compared to monotherapy. We report our experience with sequential intravesical combination chemotherapy using gemcitabine and mitomycin C (MMC) for non-muscle invasive bladder cancer (NMIBC). Methods: We performed a multi-institutional retrospective review of 47 consecutive patients who received 6 weekly treatments with sequential gemcitabine (1g) and mitomycin C (40mg) chemotherapy for NMIBC. Thirty patients received treatment at University of Iowa, 14 at UCSF and 3 at University of Minnesota. Results: A total 47 patients (median age 70, range 32-85; 36 males, 11 females) previously failing a median of 2 intravesical treatments were reviewed. The complete response (CR), 1-year recurrence-free survival (1-RFS) and 2-year recurrence-free survival (2-RFS) for all patients was 68%, 48% and 38%, respectively. In all, 14 of 47 patients (30%) remain free of recurrence with a median time to followup of 26 months (range 6-80 months). The median time to recurrence for all patients who recurred was 4 months (range 1-33 months). Ten patients required cystectomy. Conclusions: Sequential intravesical combination chemotherapy using gemcitabine and MMC appears to be a useful treatment for patients with a history of NMIC which has failed BCG or other intravesical therapy, in addition to patients with intermediate and high-risk disease.

Endoscopic transnasal intraorbital surgery: our experience with 16 cases

The objective of the study is to present our multicentric experience on intraorbital lesions managed by means of an endonasal endoscopic approach. The study design used was multi-institutional retrospective review. We collected data on 16 intraorbital medially-located lesions, all managed by means of an endonasal route, treated in four different skull base centers. We retrospectively reviewed the technical details, complications, histology, and general outcome. The endoscopic endonasal approach was effective in removing completely intraorbital extra-intraconal tumors in 8 cases, in performing biopsies for histological diagnosis in 6 intraorbital intraconal tumors, and in draining 1 extraconal abscess. No major complications were observed; in particular, there was no optic nerve damage. Minor, temporary complications (diplopia) were seen in 3 cases; only 2 patients experienced a permanent diplopia related to medial rectus muscle impairment, in 1 case associated with enophthalmos. Our preliminary multi-centric clinical experience suggests that medially located intraorbital lesions, and in particular the infero-medial ones, can be successfully and safely managed by such an approach. The well-known advantages of the endoscopic techniques, namely the lack of external scars, less bleeding, shorter hospital stay, and fewer complications, are confirmed.

Robotic lobectomy for non–small cell lung cancer (NSCLC): Long-term oncologic results

We evaluated a large series of patients undergoing robotic lobectomy for the treatment of early-stage non-small cell lung cancer (NSCLC) to assess long-term oncologic efficacy. A multi-institutional retrospective review of patients undergoing robotic lobectomy for NSCLC was performed. Robotic lobectomy was performed in a manner consistent with the Cancer and Leukemia Group B (CALGB) consensus video-assisted thoracic surgery (VATS) lobectomy technique using a robotic surgical system. Perioperative outcomes and long-term follow-up were recorded prospectively, and survival was calculated from the date of surgery to last follow-up. From November 2002 through May 2010, a total of 325 consecutive patients underwent robotic lobectomy for early-stage NSCLC at 3 institutions. The median age of patients was 66 years (range, 30-87 years), and 37% (120) were female. The majority were in clinical stage I (IA, 247; IB, 63). Conversion rate to thoracotomy was 8% (27/325). Overall morbidity rate was 25.2% (82/325), and major complication rate was 3.7% (12/325). There was 1 in-hospital death (0.3%), and the median length of stay was 5 days (range, 2-28 days). Pathologic stage distribution was 54% (176) IA, 22% (72) IB, 13% (41) IIA, 5% (15) IIB, and 6% (21) IIIA. With a median follow-up of 27 months, overall 5-year survival was 80% (95% confidence intervals [CI]=73-88), and by pathologic stage, 91% (CI=83-99) for stage IA, 88% (CI=77-98) for stage IB, and 49% (CI=24-74) for all patients with stage II disease. Overall 3-year survival for patients with stage IIIA disease was 43% (CI=16-69). Robotic lobectomy for early-stage NSCLC can be performed with low morbidity and mortality. Long-term stage-specific survival is acceptable and consistent with prior results for VATS and thoracotomy.

How does the new 2010 world health organization (WHO) criteria for semen analyses affect those presenting to infertility clinic?

Semen analysis is one of the first steps in evaluating male infertility. Since 1980 the World Health Organization (WHO) has published 5 editions of guidelines for semen analysis. The most recent edition published in 2010 for the first time provides reference values for semen parameters based on values from fertile men above the 5th percentile. The objective of the study was to quantify the effect of the new criteria on reclassifying previous semen analysis parameters and definition of patients with male factor infertility. This was a multi-institutional retrospective review of males referred to infertility clinics and had a semen analysis obtained for their work up. The semen analyses of patients who were classified as infertile by timeline and previous semen analysis criteria were reexamined to determine how many would change classifications to be in the normal fertile range based on the 2010 WHO lower reference limits. Average semen volume, sperm concentration, motility, and morphology were recorded. 184 men had at least 2 semen analyses on file. Of these, 13 (7%), 17 (9.2%), 34 (18.4%), and 29 (15.7%) patients would change classification to being at or above the reference value by the 2010 criteria for semen volume, sperm concentration, sperm motility, and sperm morphology respectively. 203 men had one semen analysis on file. Of these 23 (11.3%), 14 (6.8%), 20 (9.8%), and 45 (22.1%) would change classification for semen volume, sperm concentration, motility, and morphology respectively. Overall, 43 (11.1%) patients who had one or more abnormal parameter on the original analysis would be converted to having all parameters within normal. The new 2010 WHO reference ranges for semen analysis would result in some patients being reclassified as fertile if based upon semen analysis alone. These lower reference limits may lead to some men not being defined as male factor infertility and not referred for proper evaluation or treatment.

Patterns of spread and recurrence of sex cord-stromal tumors of the ovary

Objective. Sex cord-stromal tumors are an uncommon type of ovarian neoplasm and limited data are available in the literature to guide clinical management. Recent published series suggested a lack of lymph node involvement and recommended abandonment of the lymph node dissection as part of the primary surgical staging of these tumors. To confirm these findings, we evaluated pathologic findings in women undergoing surgical management of sex cord-stromal tumors in the Seattle metropolitan area. Methods. A retrospective multi-institutional review of all patients treated with sex cord-stromal tumors at University of Washington Medical Center and Swedish Medical Center in Seattle was conducted. Information was collected on the pathology, evaluation, and treatment of these patients. Results. A total of 87 patients were available for analysis, the majority of whom had adult granulosa cell tumors (82%) and Sertoli–Leydig cell tumors (13%). Of these patients, 68% had complete or partial surgical staging procedures, and 47 patients had some nodal tissue examined as part of the initial or restaging procedure. All nodes examined were negative. Tumor size was significantly associated with risk of recurrent disease, with a 20% increase in the hazard of recurrence for each increase of tumor size of 1 cm (HR, 1.20; 95% CI, 1.11–1.07). Conclusions. This study confirms the finding that lymph node metastasis are rare in sex-cord stromal tumors. These findings support the hypothesis that routine lymphadenectomy provides limited additional information in the management of these patients and can be omitted from the primary surgical staging procedure or secondary restaging procedures.