Presence Of Disseminated Disease Research Articles

Institutional performance and validation of severity of illness score for children with acute hematogenous osteomyelitis.

A scoring system has recently been published that uses parameters within the first 4-5 days of hospitalization to determine the severity of illness (SOI) in children with acute hematogenous osteomyelitis (AHO). To our knowledge, no additional studies to date have examined the validity of the SOI score outside of the institution of origin. This study evaluates the performance of the SOI score in a retrospective cohort of cases at our institution. Patients admitted to our institution over the past 5 years with AHO who met inclusion and exclusion criteria were analyzed. Parameters including C reactive protein over the first 96 h of hospitalization, febrile days on antibiotics, ICU admission, and presence of disseminated disease were used to calculate the SOI score for each patient. Pearson and Spearman correlations were used when appropriate. SOI score comparison between groups was achieved with the Kruskal-Wallis and Wilcoxon two-sample tests. Seventy-four patients were analyzed. Significantly higher SOI scores were noted for patients with bacteremia, ICU admission, fever for two or more days on presentation, multiple surgeries, and any complication. Markers of disease severity that significantly correlated with SOI score were total length of stay, LOS, duration of antibiotic course, number of surgical procedures, and case mix index. The SOI score functioned well as higher scores were associated with sicker patients. The SOI score is helpful for determining which patients will require longer hospitalizations and more intense treatment in a setting other than the institution of origin.

Clinical, Microbiological Profile and Treatment Outcomes of Infants with BCG Adenitis: A Retrospective Study.

Bacille Calmette-Guérin (BCG) adenitis is an uncommon complication following BCG vaccination. In rare cases, infants can develop other complications. Controversy exists regarding the diagnosis and management of these cases. Not much information is available in literature regarding their microbiological and immunological characteristics. Electronic medical records of children presenting to the Pediatric Infectious Diseases clinic in a tertiary care hospital from January 2011-December 2020 with a diagnosis of BCG adenitis were retrospectively reviewed. Their clinical, microbiological, treatment and follow-up data were noted and analyzed. During the study period, 40 infants presented with a probable diagnosis of BCG adenitis with or without disseminated BCG. Median age at symptom onset was 4(2.5-5.9) months. Nine infants had disseminated disease at presentation. Fifteen infants were suspected to have underlying immune deficiency of whom 12 had proven defects in immune function. On multivariable logistic regression analysis, presence of disseminated disease was the only factor predictive of underlying immunodeficiency. Isoniazid monoresistance was seen in seven cases (32%) of the 22 samples sent for TB cultures. Though BCG adenitis runs a benign course, it could rarely be the first manifestation of an underlying immune defect. There is sizable isoniazid monoresistance, hence sending tissue samples for microbiologic evaluation is necessary to guide anti-tubercular therapy.

Next-generation sequencing of cerebrospinal fluid for clinical molecular diagnostics in pediatric, adolescent and young adult brain tumor patients.

Safe sampling of central nervous system tumor tissue for diagnostic purposes may be difficult if not impossible, especially in pediatric patients, and an unmet need exists to develop less invasive diagnostic tests. We report our clinical experience with minimally invasive molecular diagnostics using a clinically validated assay for sequencing of cerebrospinal fluid (CSF) cell-free DNA (cfDNA). All CSF samples were collected as part of clinical care, and results reported to both clinicians and patients/families. We analyzed 64 CSF samples from 45 pediatric, adolescent and young adult (AYA) patients (pediatric = 25; AYA = 20) with primary and recurrent brain tumors across 12 histopathological subtypes including high-grade glioma (n = 10), medulloblastoma (n = 10), pineoblastoma (n = 5), low-grade glioma (n = 4), diffuse leptomeningeal glioneuronal tumor (DLGNT) (n = 4), retinoblastoma (n = 4), ependymoma (n = 3), and other (n = 5). Somatic alterations were detected in 30/64 samples (46.9%) and in at least one sample per unique patient in 21/45 patients (46.6%). CSF cfDNA positivity was strongly associated with the presence of disseminated disease at the time of collection (81.5% of samples from patients with disseminated disease were positive). No association was seen between CSF cfDNA positivity and the timing of CSF collection during the patient's disease course. We identified three general categories where CSF cfDNA testing provided additional relevant diagnostic, prognostic, and/or therapeutic information, impacting clinical assessment and decision making: (1) diagnosis and/or identification of actionable alterations; (2) monitor response to therapy; and (3) tracking tumor evolution. Our findings support broader implementation of clinical CSF cfDNA testing in this population to improve care.

Effectiveness of Acyclovir Prophylaxis Against Varicella Zoster Virus Infection after Hematopoietic Stem Cell Transplantation: A Systematic Review and Meta-Analysis

Background: Varicella zoster virus (VZV) infection is a common complication after hematopoietic stem cell transplantation (HCT) and occurs in 16%-41% of transplant recipients, with a relatively high incidence. Although localized dermatomal rashes are a typical symptom of VZV infection, dissemination to internal organs and secondary bacterial infections are occasionally fatal. Furthermore, patient quality of life is impaired by postherpetic neuralgia. To reduce the incidence of VZV infection after HCT, the efficacy of long-term acyclovir prophylaxis has been evaluated. Several studies concluded that VZV infection was suppressed during prophylaxis, but increased after acyclovir discontinuation, i.e., rebound effect exists. We conducted a meta-analysis to evaluate the efficacy of acyclovir prophylaxis against VZV infection after HCT and whether rebound effect really exists or not.Methods: Medline, Embase plus Embase classics, and Cochrane Central Register of Controlled Trials were used for systematic review of studies from 1980 to June 23, 2017, without language restrictions. The literature search strategies used Medical Subject Headings and free text words related to “acyclovir,” “hematopoietic stem cell transplantation,” and “varicella zoster virus.” Exclusion criteria were animal or in vitro studies, case control studies, and case reports. Intervention of this research was defined as acyclovir prophylaxis after HCT.We used the Cochrane Collaboration's Risk of Bias tool and Newcastle-Ottawa Quality Assessment Scale (NOS ) to evaluate the study quality. The primary outcome was to evaluate the incidence of VZV infection within the first year after acyclovir discontinuation compared with that in patients without acyclovir prophylaxis. The secondary outcome was the risk of VZV infection/reactivation during acyclovir prophylaxis after HCT. Subgroup analyses were conducted according to acyclovir dose (>400 or ≤400 mg), duration of acyclovir treatment (>6 or ≤6 months), and presence of disseminated disease. We conducted a sensitivity analysis for studies with a NOS score of ≥7 points. The analysis was conducted using Review Manager Version 5.3. We performed a meta-analysis using fixed effect models with risk ratio (RR) and a 95% confidence interval (CI). Heterogeneity was assessed using the chi-squared test and I-squared statistic. Publication bias was assessed with funnel plots.Results: Of 1,803 studies from the search database, seven studies with a total of 2,226 patients were eligible. Patients were divided into the acyclovir prophylaxis (n = 1,204) and no prophylaxis groups (n = 1,022). We compared the incidence of VZV infection between the two groups, within 1 year after discontinuing acyclovir prophylaxis in the acyclovir prophylaxis group and without any acyclovir after HCT in the no prophylaxis group . Results showed that acyclovir prophylaxis significantly reduced the incidence of VZV infection (RR: 0.37, 95% CI: 0.30-0.46, heterogeneity I2 = 35%, χ2 = 9.27). The risk of VZV infection/reactivation during acyclovir prophylaxis was reduced (RR: 0.17, 95% CI: 0.12-0.24, heterogeneity I2 = 0%, χ2 = 0.41). Among four studies that reported disseminated disease, acyclovir prophylaxis reduced the RR of disseminated disease (RR: 0.31, 95% CI: 0.19-0.58, heterogeneity I2 = 0%, χ2 = 1.02). The analysis of four studies reporting acyclovir prophylaxis for >6 months indicated that longer prophylaxis reduced the RR of VZV infection (RR: 0.34, 95% CI: 0.27-0.43, heterogeneity I2 = 48%, χ2 = 5.80). Patients receiving low-dose acyclovir showed significant reduction in the incidence of VZV infection (RR: 0.31, high 95% CI: 0.18-0.54). Results of the sensitivity analysis for studies with NOS score of ≥7 points showed significant reduction in the incidence of VZV infection with acyclovir prophylaxis (RR: 0.43, 95% CI: 0.30-0.62, heterogeneity I2 = 39%, χ2 = 8.24).Conclusions: This study showed that long-term acyclovir prophylaxis significantly reduced the incidence of VZV infection even after its discontinuation compared with no treatment and indicated that rebound effect did not exist. Long-term acyclovir prophylaxis for VZV infection after HCT is effective during and after therapy. This study also showed that low dose was sufficient for VZV prophylaxis. Based on our results, we recommend long-term prophylaxis for >6 months. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

EPCT-21. NEXT-GENERATION SEQUENCING OF CEREBROSPINAL FLUID FOR CLINICAL MOLECULAR DIAGNOSTICS IN ADOLESCENT AND YOUNG ADULT (AYA) BRAIN TUMOR PATIENTS

PurposePediatric central nervous system tumors remain a leading cause of cancer-related death in children and adolescents. Safe sampling of tumor tissue for diagnostic purposes may be challenging. Subclinical detection of disease prior to clinical or imaging progression may provide opportunity for earlier intervention and ultimately improve overall survival. Additionally, our understanding of molecular evolution in response to therapy remains limited, given the rarity of serial sampling of tumor tissue. MethodsWe report our experience with minimally invasive molecular diagnostics using a validated next generation sequencing assay for sequencing of cerebrospinal fluid (CSF) cell-free DNA (cfDNA) obtained at the time of surgery, by intraventricular catheter or lumbar puncture. All CSF samples were collected as part of clinical care, and results reported to both clinicians and patients/families. ResultsWe analyzed 64 CSF samples from 45 pediatric and adolescent and young adult (AYA) patients (pediatric=25; AYA=20) with primary and recurrent brain tumors across 12 histopathological subtypes including high-grade glioma (n=10), medulloblastoma (n=10), pineoblastoma (n=5), low grade glioma (n=4), diffuse leptomeningeal glioneuronal tumor (DLGNT) (n=4), metastatic retinoblastoma (n=4), ependymoma (n=3), and other (n=5). Somatic alterations were detected in 28/64 samples (44.4%) and in at least one sample per unique patient in 22/45 patients (48.8%). CSF cfDNA positivity was strongly associated with the presence of disseminated disease at the time of collection (86.3%). No association was seen between CSF cfDNA positivity and the timing of CSF collection during the patient’s disease course. ConclusionWe identified four general categories where CSF cfDNA testing provided additional relevant diagnostic, prognostic, and/or therapeutic information, impacting clinical assessment and decision making: 1) diagnosis; 2) identification of actionable alterations; 3) track response to therapy; and 4) monitoring tumor evolution. Our findings support broader implementation of clinical CSF cfDNA testing in this population that may improve care.

MP50-15 ASSOCIATION BETWEEN WEIGHT GAIN AND SARCOPENIC OBESITY IN PATIENTS WITH PROSTATE CANCER TREATED WITH ANDROGEN DEPRIVATION THERAPY

2012. Half the patients had localized disease and were referred for curative intended radiation, whereas the remaining patients had disseminated disease. ADT was given as LHRH agonists, LHRH antagonists, or orchiectomy. We collected blood samples, questionnaire, performed DXA scan and bone scintigraphy prior to initiating ADT and during the following two years of ADT. The study was approved by the local ethical committee. None of the patients had received prior androgen deprivation nor osteoporosis treatment. RESULTS: A total of 105 individuals were included. The mean age of the participants was 70 (range 53-91, SD 6.3) years. The median PSA level was 30.5 (range 1-5714) mg/L. The median Gleason score was 7 (range 5-10, SD 1.1). A total of 50 patients had localized prostate cancer; the remaining 55 patients had disseminated disease. The prevalence of osteoporosis was 10% and the prevalence of osteopenia was 58% prior to initiating ADT, and after two years of ADT it rose to 22% and 57%, respectively. In multivariate analysis smoking and presence of disseminated disease were significantly associated with an increased risk of osteoporosis, whereas a high body mass index was significantly associated with a decreased risk of osteoporosis. CONCLUSIONS: Osteoporosis was present among patients with prostate cancer and evolved rapidly during two years of ADT. Further awareness regarding osteoporosis and bone health in prostate cancer patients is needed and we recommend that patients with prostate cancer are DXA scanned prior to and during ADT.

Patients with multiple endocrine neoplasia type 1 (MEN1) have late progression and long survival despite the presence of disseminated disease: the experience of a referral centre in Greece

Patients with multiple endocrine neoplasia type 1 (MEN1) have late progression and long survival despite the presence of disseminated disease: the experience of a referral centre in Greece

Spontaneous regression of metastatic cancer: learning from neuroblastoma

Several interesting biological questions arise when thinking about the heterogeneous presentation of neuroblastoma, especially with regard to the molecular differences between very low- and high-risk disease. Why do some metastatic tumours spontaneously differentiate or regress entirely? Does the presence of disseminated disease always indicate metastases, or might some cases be better considered as multifocal disease?

MRI of the carcinomatous meningitis: Rare form of prostate cancer dissemination

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Cardiac metastasis from renal cell carcinoma without inferior vena involvement: a review of the literature based on a case report. Two different patterns of spread?

We report the case of a 59-year-old man with advanced renal cell carcinoma (RCC), without inferior vena cava (IVC) involvement, treated with radical nephrectomy, palliative radiotherapy for bone metastasis, and medical therapy for bone and lung metastases. The patient died of cardiac arrest after evidence of massive malignant pericardial effusion. At autopsy, massive myocardial and pericardial neoplastic invasion was found. Heart involvement via the IVC is a well-known phenomenon during RCC progression, while in the absence of IVC involvement, clinically evident cardiac involvement is exceptional, with few cases reported in the worldwide literature. Analysis of prior reports and of the present case provides evidence on how the cardiac metastasis may have two distinct origins and clinical features. The first is hematogenous, via the IVC, even in the absence of renal vein involvement; it is generally circumscribed and has a good prognosis after surgery. The second is through the intrathoracic lymphatic system, in the presence of disseminated disease, especially pulmonary metastasis, and this type has a very poor prognosis.

Prognostic Value of ERBB2 Amplification and Protein Expression in Small Cell Lung Cancer

Our objective was to evaluate ERBB2 oncogene amplification using fluorescence in situ hybridization (FISH) and protein overexpression using immunohistochemical techniques, and to explore their possible prognostic value in a series of patients with small cell carcinoma. Included in the study were 99 patients with small cell tumors, classified in 2 broad groups: patients with limited locally advanced disease and patients with disseminated disease. Material for study was obtained in 97% of the cases (96/99) by means of endoscopic biopsy and by tomography-guided needle biopsy in the remaining 3% (3/99). Survival was analyzed using the Kaplan-Meier method. The 92 men (92.9%) and 7 women (7.1%) in the study had a mean (SD) age of 62.9 (10.4) years (range, 36-81 years); 39.4% (n=39) and 60.6% (n=60) of the subjects had limited and disseminated disease, respectively. ERBB2 protein overexpression was observed in 26.3% of the patients (n=26), 15.4% (n=4) of whom had limited disease and 84.6% (n=22) of whom had disseminated disease (P=.005). Although mean survival was slightly longer for patients who were negative for ERBB2 protein overexpression, the difference was not statistically significant. FISH identified gene amplification in 6.3% (1 in 16) of the studied cases (ratio, 2.3). The protein product of the ERBB2 oncogene is overexpressed in 33.3% of small cell lung carcinomas and is associated with the presence of disseminated disease. Further studies are necessary to evaluate the possible benefits of specific treatment.

CD8+ T cell-mediated control of distant tumours following local photodynamic therapy is independent of CD4+ T cells and dependent on natural killer cells

Cancer survival rates decrease in the presence of disseminated disease. However, there are few therapies that are effective at eliminating the primary tumour while providing control of distant stage disease. Photodynamic therapy (PDT) is an FDA-approved modality that rapidly eliminates local tumours, resulting in cure of early disease and palliation of advanced disease. Numerous pre-clinical studies have shown that local PDT treatment of tumours enhances anti-tumour immunity. We hypothesised that enhancement of a systemic anti-tumour immune response might control the growth of tumours present outside the treatment field. To test this hypothesis we delivered PDT to subcutaneous (s.c.) tumours of mice bearing both s.c. and lung tumours and monitored the growth of the untreated lung tumours. Our results demonstrate that PDT of murine tumours provided durable inhibition of the growth of untreated lung tumours. The inhibition of the growth of tumours outside the treatment field was tumour-specific and dependent on the presence of CD8+ T cells. This inhibition was accompanied by an increase in splenic anti-tumour cytolytic activity and by an increase in CD8+ T cell infiltration into untreated tumours. Local PDT treatment led to enhanced anti-tumour immune memory that was evident 40 days after tumour treatment and was independent of CD4+ T cells. CD8+ T cell control of the growth of lung tumours present outside the treatment field following PDT was dependent upon the presence of natural killer (NK) cells. These results suggest that local PDT treatment of tumours lead to induction of an anti-tumour immune response capable of controlling the growth of tumours outside the treatment field and indicate that this modality has potential in the treatment of distant stage disease.

Clinically Aggressive Solid Pseudopapillary Tumors of the Pancreas

Solid pseudopapillary tumors (SPTs) are unusual neoplasms of the pancreas of uncertain histogenesis that occur mostly, but not exclusively, in young women. The pathologic features and immunophenotype of SPT are unique and well characterized. Despite its low malignant potential, proximately 15% of patients with SPT develop metastatic disease, mostly involving the liver or peritoneum. Even in the presence of disseminated disease, the clinical course is usually protracted, and the overall 5-year survival is reportedly 97%. We have encountered 2 cases of SPT possessing unusual pathologic features and exhibiting an aggressive clinical course. At the time of presentation, 1 patient had liver metastasis, and the other had a lymph node metastasis and developed liver metastases within 3 months. Both died of disease at 6 and 16 months, respectively, following the initial diagnosis. Review of other cases of SPT treated at Memorial Sloan-Kettering Cancer Center (New York, NY) revealed that 5 of 34 cases (15%) with conventional histologic features developed liver metastases. In contrast to the 2 cases reported here, all 5 patients survived for a mean of 106 months (39-193 months), and only 2 died of disease 5 and 10 years, respectively, following the initial resection. The pathologic features of the two rapidly fatal cases, which might have been indicative of their aggressive behavior, included a diffuse growth pattern, extensive tumor necrosis, significant nuclear atypia, an unusually high mitotic rate (35-70/50 high power fields), and in one a component of sarcomatoid carcinoma. However, regions displaying the typical histologic features of SPT were also evident. Abnormal beta-catenin distribution and markedly increased MIB1 expression were detected by immunohistochemistry in both cases. The immunohistochemical staining patterns were otherwise similar to those of conventional SPTs. Although precise pathologic criteria suggesting a high risk for aggressive behavior are uncertain, recognition of some of the unusual pathologic features displayed in these 2 cases may be useful in the prediction of potentially more aggressive SPTs. The possibility that these tumors represent high-grade malignant transformation of a conventional low-grade SPT is proposed.

Combining gene expression profiles and clinical parameters for risk stratification in medulloblastomas.

Stratification of risk in patients with medulloblastoma remains a challenge. As clinical parameters have been proven insufficient for accurately defining disease risk, molecular markers have become the focus of interest. Outcome predictions on the basis of microarray gene expression profiles have been the most accurate to date. We ask in a multivariate model whether clinical parameters enhance survival predictions of gene expression profiles. In a cohort of 55 young patients (whose medulloblastoma samples have been analyzed previously for gene expression profile), associations between clinical and gene expression variables and survival were assessed using Cox proportional hazards models. Available clinical variables included age, stage (ie, the presence of disseminated disease at diagnosis), sex, histologic subtype, treatment, and status. Univariate analysis demonstrated expression profiles to be the only significant clinical prognostic factor (P=.03). In multivariate analysis, gene expression profiles predicted outcome independent of other criteria. Clinical criteria did not significantly contribute additional information for outcome predictions, although an exploratory analysis noted a trend for decreased survival of patients with metastases at diagnosis but favorable gene expression profile. Gene expression profiling predicts medulloblastoma outcome independent of clinical variables. These results need to be validated in a larger prospective study.

Unusual presentation of choriocarcinoma

BackgroundChoriocarcinoma is an aggressive neoplasm arising in the body of the uterus. The disease normally spreads to lung and brain.Case ReportA case of malignant trophoblastic disease with brain metastasis, raised intra cranial pressure and small bowel metastasis presenting with acute abdomen is reported.ConclusionsMalignant transformation in a hydatidiform mole is rare event. Involvement of gastrointestinal tract is rarer even in presence of disseminated disease. Surgery is the treatment of choice for gastrointestinal complications.

FOREQUARTER AMPUTATION FOR HIGH-GRADE MALIGNANT TUMOURS OF THE SHOULDER GIRDLE

We reviewed 20 patients after forequarter amputation performed for high-grade malignant tumours of the shoulder girdle (Enneking grades IIB to III). The operations were classified as palliative or curative according to the resection margins and the presence of disseminated disease at the time of the surgery. There were five palliative and 15 curative procedures. Two patients died from unrelated causes, septicaemia and suicide. Eight died in the first two years, four of whom had had a palliative operation. Four died between two and five years after surgery, one after a palliative operation. Five patients are alive, at a mean of 89.4 months after surgery, four of whom are free from disease. The median survival after a palliative amputation was 20.6 months. Our overall five-year survival (palliative and curative cases) was 21.2%, for curative cases it was 30.2%. None of the patients use an artificial prosthesis. Despite the disfigurement which results from this operation, it still has a useful role to play in the management of high-grade malignant tumours of the upper limb.

Forequarter amputation for high-grade malignant tumours of the shoulder girdle.

We reviewed 20 patients after forequarter amputation performed for high-grade malignant tumours of the shoulder girdle (Enneking grades IIB to III). The operations were classified as palliative or curative according to the resection margins and the presence of disseminated disease at the time of the surgery. There were five palliative and 15 curative procedures. Two patients died from unrelated causes, septicaemia and suicide. Eight died in the first two years, four of whom had had a palliative operation. Four died between two and five years after surgery, one after a palliative operation. Five patients are alive, at a mean of 89.4 months after surgery, four of whom are free from disease. The median survival after a palliative amputation was 20.6 months. Our overall five-year survival (palliative and curative cases) was 21.2%, for curative cases it was 30.2%. None of the patients use an artificial prosthesis. Despite the disfigurement which results from this operation, it still has a useful role to play in the management of high-grade malignant tumours of the upper limb.

Metastatic adenocarcinoma in a thyroid colloid nodule: A rare presentation of colon cancer

Colorectal cancer can remain asymptomatic for years. Frequently symptoms develop insidiously and may often remain unnoticed for long periods, even in the presence of disseminated disease. We herein report an unusual case of a patient with carcinoma of the sigmoid colon and multiple liver metastases. The diagnosis was established only after the patient was operated on for a large colloid nodule, a single microscopic metastatic focus being noticed in the histologic sections. The differential diagnosis compared with the columnar type of papillary carcinoma is discussed.

Factors Affecting the Yield of Acid-fast Sputum Smears in Patients With HIV and Tuberculosis

To evaluate the sensitivity of acid-fast sputum smears in the diagnosis of pulmonary Mycobacterium tuberculosis (MTB). Retrospective chart and radiographic film review. Department of Veterans Affairs Medical Center in New York City. All patients with positive sputum cultures for MTB during 1989 to 1991, including 100 with HIV, and 76 without HIV infection. The likelihood of a positive acid-fast sputum smear, related to chest radiograph findings, CD4 cell counts, drug sensitivity, and the presence of disseminated disease. Overall, 60 percent of patients with HIV had positive acid-fast smears, compared with 57 percent of non-HIV-infected patients. A relative absence of cavitary infiltrates did not substantially reduce the frequency of acid-fast smears in patients with and without HIV. Patients with HIV and CD4 count < 50, 50 to 200, and > 200 had positive acid-fast smear rates of 58 percent, 60 percent, and 56 percent, respectively; HIV-infected patients with drug-resistant organisms had 65 percent positive smears. Smear positivity was 96 percent in patients with HIV infection and disseminated MTB, CONCLUSIONS: Positive acid-fast sputum smears in culture-proven MTB occur with similar frequency in patients with and without HIV. The absence of cavitary disease did not significantly reduce the frequency of positive acid-fast smears. For patients with HIV, the likelihood of a positive smear was also independent of CD4 cell counts and drug resistance. Patients with HIV and disseminated MTB had positive sputum smears in nearly all cases.

Cost and Survival Analysis of Metastatic Cerebral Tumors Treated by Resection and Radiation

The surgical treatment of metastatic brain tumors remains controversial, primarily because of the limited prognosis of patients with metastatic cancer. The cost effectiveness of even standard therapies is of increasing concern to third-party payers. We reviewed the records of patients who had a single metastatic brain tumor resected at the Medical Center Hospital of Vermont (a referral center in a rural state) since cost data recording began. The 32 patients ranged in age from 35 to 77 years, with a 2.2:1 female-to-male ratio. Thirty-four percent of tumors originated in the lung, 15.6% were renal, 12.5% were breast, 12.5% were gynecological, 9.4% were gastrointestinal, and 9.4% were ultimately of unknown origin. Thirty-one tumors were completely resected; 30 patients were irradiated, most after surgery (mean dose, 3,908 +/- 1,250 cGy). Karnofsky scores improved from 80 +/- 11 to 88 +/- 16 postoperatively (P = 0.0038, one-tailed paired t-test). Patients were hospitalized an average of 8.22 +/- 6.26 days postoperatively, with total operative and postoperative charges of $19,190 +/- 5,684, noninclusive of radiotherapy. The expected median survival of all patients was 26 months (Kaplan-Meier estimate). The presence of disseminated disease was not significantly correlated with survival (P = 0.237). The number of postoperative days was more for patients with disseminated disease (P = 0.0274), but not for patients with infratentorial tumors (P = 0.6991). Age higher than the median was not correlated with an increased number of postoperative days (P = 0.1366) nor was a preoperative Karnofsky score of 70 or less (P = 0.1382).(ABSTRACT TRUNCATED AT 250 WORDS)