Relative Risk Of Recurrence Research Articles

Primary adrenal insufficiency: New genetic causes and their long-term consequences.

Primary adrenal insufficiency (PAI) is a potentially life‐threatening condition that requires urgent diagnosis and treatment. Whilst the most common causes are congenital adrenal hyperplasia (CAH) in childhood and autoimmune adrenal insufficiency in adolescence and adulthood, more than 30 other physical and genetics cause of PAI have been reported. Reaching a specific diagnosis can have implications for management and for monitoring associated features, as well as for counselling families about recurrence risk in siblings and relatives. Here, we describe some recent insights into the genetics of adrenal insufficiency and associated molecular mechanisms. We discuss (a) the role of the nuclear receptors DAX‐1 (NR0B1) and steroidogenic factor‐1 (SF‐1, NR5A1) in human adrenal and reproductive dysfunction; (b) multisystem growth restriction syndromes due to gain‐of‐function in the growth repressors CDKN1C (IMAGE syndrome) and SAMD9 (MIRAGE syndrome), or loss of POLE1; (c) nonclassic forms of STAR and P450scc/CYP11A1 insufficiency that present with a delayed‐onset adrenal phenotype and represent a surprisingly prevalent cause of undiagnosed PAI; and (d) a new sphingolipidosis causing PAI due to defects in sphingosine‐1‐phosphate lyase‐1 (SGPL1). Reaching a specific diagnosis can have life‐long implications for management. In some situations, milder or nonclassic forms of these conditions can first present in adulthood and may have been labelled, “Addison's disease.”

Prognostic Significance of Ki-67 and p53 Immunoexpression in Breast Carcinoma Patients with Positive Axillary Lymph Nodes

Introduction: Breast carcinoma is a heterogenous disorder in which the treatment modality should be based on a risk assessment approach and only patients with higher relative risk of recurrence and distant metastasis should be the appropriate candidates for adjuvant therapy. This is where role of prognostic variables like Ki-67 and p53 immunoexpression as biomarkers of proliferative activity of tumor cells becomes important. Aims and Objectives: The aim of this study was to evaluate the significance of Ki-67 and p53 immunoexpression as prognostic biomarkers in breast carcinoma patients with positive axillary lymph nodes. Material and Methods: A total of 182 breast cancer patients were included in the study, assessed for various clinicopathological characteristics and after receiving the mastectomy/lobectomy specimen, tissue sections about 1cm thick were taken from representative areas, processed in an automated tissue processor (Histokinette) and simultaneously stained for routine hematoxylin and eosin stain along with Ki-67 and p53 immunostains and patients followed up. Results: High Ki-67 and p53 immunoexpression was significantly associated with larger tumor size, higher tumor grade, axillary lymph node metastasis, higher disease stage at presentation, lymphovascular invasion, early recurrence, shortened disease free survival and worse overall survival. Conclusions: Ki-67 and p53 immunoexpression can be used as a surrogate biomarker along with other clinicopathological characteristics in resource constrained facilities for better prediction of prognosis of breast cancer patients with positive axillary lymph nodes.

1439PD - BRCA1 expression level as prognostic factor for recurrence in resected NSCLC with adjuvant chemotherapy: SCAT Trial

BackgroundPost-operative platinum-based chemotherapy is the standard of care for resected NSCLC with nodal involvement. Expression of genes involved in DNA repair may have a prognostic role for the outcome. BRCA1 plays an important role in DNA repair pathways and could have a prognostic impact in this setting. The SCAT trial results found that for low BRCA1 levels subgroup Cis-Gem was superior to Cis-Doc and in high BRCA1 subgroup docetaxel single agent without platinum achieved similar survival to Cis-Doc. Risk of recurrence analysis according BRCA-1 levels has been performed. MethodsFrom Jun/2007 to May/2013 591 patients were screened and 500 were included, 108 in the control arm treated with Cis-Docetaxel and 392 in the experimental arms treated with Cis-Gem, Cis-Doc or docetaxel alone according to terciles of BRCA1 expression level. With a cut-off September 30th 2018 and a median follow-up of 60 months, recurrence patterns were analysed for the whole group according BRCA1 levels in tumor tissue and comparison were made for risk of recurrence, single/multiple recurrence, thoracic/extrathoracic and metastatic sites (liver, bone, brain). ResultsCumulative recurrence was evaluable in 232/456 patients (50.8%), 182/354 patients treated in the experimental arm and in 50/102 patients treated in the control arm (RR 1.04; 0.83-1.30) (p=0.672). The majority of recurrences 159/232 (68.5%) were single site intrathoracic recurrences in 121/232 (52%) while 111/232 were extrathoracic (47.8%). Overall recurrence was 56.5% (113/200 p) for low tercile BRCA1 vs 48.8% (63/129) for intermediate tercile vs 44% (56/127) for high tercile (p=0.025). No differences were seen between tercile groups for single site (p=0.35), multiple site (p=0.26), intrathoracic (p=0.36), or extrathoracic (p=0.38). More frequent distant metastatic sites were: bone (42 patients), brain (38 patients) and liver (11 patients). RIsk reduction was seen for brain metastases in patients with higher tercile BRCA1 (p=0.003). ConclusionsFor NSCLC resected patients with lymph node involvement risk of recurrence remains high with a cumulative rate > 50%. Relative risk of recurrence was lower for tumors with higher BRCA1 levels. Distant metastases were seen in 47.8% of patients. Brain metastases risk was significant lower for patients with low BRCA1 expression. BRCA1 levels acts as a prognostic factor in early stages NSCLC. Clinical trial identificationEudraCT: 2007-000067-15; NCT 00478699. Legal entity responsible for the studySpanish Lung Cancer Group - Grupo Español Cáncer de Pulmón. FundingSanofi Aventis. DisclosureAll authors have declared no conflicts of interest.

Transitional Hypoglycaemia Management in Small for Gestational Age Neonates with Sucrose Enriched Expressed Breastmilk in Resource Poor Setting.

To find out if oral sucrose is as efficacious as intravenous dextrose (IVDx) in treating hypoglycaemia in small for gestational age (SGA) neonates and to compare risk of feed intolerance (FI) and necrotizing enterocolitis (NEC) in oral therapy with IVDx therapy. Eighty SGA haemodynamically stable hypoglycaemic [blood sugar (BS) < 40 mg/dl] neonates of ≥32 to ≤36 week gestational age were randomized to receive oral sugar enriched expressed breastmilk (EBM; Group A) or IV dextrose therapy (Group B; 40 in each group) in similar calculated doses. BS at 6 h after treatment, incidence of recurrence of hypoglycaemia, FI and NEC were compared. Mean BS level at 6 h after treatment in oral supplementation group was 63.53 ± 22.12 mg/dl [3.52 ± 1.22 mmol/l (IQR 49.2-82 mg/dl, 2.7-4.5 mmol/l) vs. 71.28 ± 31.76 mg/dl [3.96 ± 1.76 mmol/l (IQR 48.5-73 mg/dl, 2.69-4 mmol/l) in IVDx group, p = 0.209. Relative risk (RR) of recurrence of hypoglycaemia in oral vs. IV treatment was 1.5 with 95% CI 0.4578-4.9151. Incidence of FI (p = 0.49, RR 1, 95%CI 0.3-3.1) and NEC (p = 0.4, RR 0.2, 95%CI 0.01-4.2) was comparable. In resource poor setting in haemodynamically stable hypoglycaemic SGA neonates, EBM enriched with calculated dose of sucrose given orally maintains euglycaemia (BS 40-125mg/dl, 2.2-6.9 mmol/l) without increased incidence of FI and NEC. This method also prevents lactational failure.

Wilms tumor: 15 years of experience at a children's hospital in Córdoba, Argentina.

The objective of this study was to describe the epidemiology, clinical presentation, treatment and nephrology follow-up of children with Wilms tumor. Data from 46 patients were collected. The clinical presentation occurred at a young age (< 40 months old), with initial symptoms of pain, abdominal mass, and fever. The prevalent histology type was mixed nephroblastoma. All patients received pre-surgery chemotherapy followed by, in most cases, unilateral nephrectomy. Patients with a high histological risk had a 7.2 relative risk of death (75 % confidence interval: 1.5-33.7) compared to the rest, and a 2.5 relative risk of recurrence (75 % confidence interval: 1.0-6.4). Disease-free survival at 5 years was 70 %. Once cancer treatment was completed, 80 % of patients maintained a stage-I kidney function. The most important prognostic factor was histology. These patients required a long-term nephrology follow-up.

Comparative efficacy of IV phenytoin, IV valproate and IV levetiracetam in childhood seizures

Background: Seizures are the most common pediatric neurologic disorder, with 4% to 10% of children suffering at least one seizure in the first 16 years of life objectives to compare efficacy of IV phenytoin, IV valproate, and IV levetiracetam in childhood seizures between 2months to 16 years of age.Methods: This prospective, randomized, study was done on pediatric patients in the age group of 2 months to 16 years who present actively convulsing to the emergency department of pediatrics.Results: At 24 hours seizures were controlled in 44 (88%) patients out of 50 patients in phenytoin group, 39 (78%) out of 50 patients in levetiracetam group and 46 (92%) out of 50 patients in valproate group (p-value 0.115). The relative risk of seizure recurrence for levetiracetam and phenytoin groups when compared to valproate was 2.75 and 1.5, respectively.Conclusions: Present study demonstrates that IV levetiracetam and IV valproate were comparable to IV phenytoin in terms of seizure control in acute setting. All the three are safe and efficacious. Time to regain consciousness was less in valproate group and long-term seizure control too was also better.

Antiviral therapy to reduce hepatocellular carcinoma recurrence in patients with low HBV-DNA levels: A randomized controlled trial.

1510 Background: Despite antiviral treatment has been shown to reduce hepato- cellular carcinoma (HCC) recurrence after curative treatment for hepatitis B virus (HBV)-related HCC in patients with high preoperative HBV-DNA levels, it is still unclear whether antiviral therapy is useful in reducing recurrence in patients with low preoperative HBV-DNA levels. Methods: In this randomized controlled trial, 200 patients who underwent curative resection for HCC with low baseline HBV-DNA levels were ran- domly assigned to receive preemptive antiviral therapy or not. The primary endpoints were recurrence-free survival. This study was censored on March 31, 2015 when all surviving patients had a minimum follow-up of 60 months. The analysis was done on an intention-to-treat basis. Results: The baseline clinical, laboratory, and tumor characteristics of the 2 groups were comparable. The 1-, 3-, and 5-year recurrence-free survival rates for the antiviral group and the control group were 85.9%, 55.2%, and 52.0% and 80.6%, 40.9%, and 32.3%, respectively. The corresponding overall survival rates for the 2 groups were 94.0%, 75.7%, and 64.1% and 90.0%, 62.4%, and 43.7%, respectively. The recurrence-free survival and overall survival for the antiviral group were significantly better than the control group (P 1/4 0.016, P 1/4 0.004, respectively). After adjusting for confounding prognostic factors in a Cox model, the relative risks of recurrence and death for antiviral treatment were 0.601 [95% confidence interval (CI), 0.409– 0.884; P 1/4 0.010] and 0.509 (95% CI, 0.333–0.778; P 1/4 0.002), respectively. Antiviral therapy was an independent protective factor of late tumor recur- rence (hazard ratio [HR] 1/4 0.316, 95% CI 0.157 – 0.637; P 1/4 0.001) but not of early tumor recurrence (HR 1/4 0.782, 95% CI, 0.493–1.240; P 1/4 0.296). Conclusions: In patients with low preoperative HBV-DNA levels, antiviral therapy significantly reduced HCC recurrence after R0 hepatic resection. Clinical trial information: ChiCTR-IPR-15006587.

Correlation between EEG during AED withdrawal and epilepsy recurrence: a meta-analysis.

To assess the risk of epilepsy recurrence after withdrawal from antiepileptic drugs (AEDs), researchers extensively studied recurrence-related risk factors, including electroencephalogram (EEG) during AED withdrawal. The relationship between EEG and epilepsy recurrence is controversial. We used meta-analysis to determine the correlation between EEG during AED withdrawal and epilepsy recurrence. A total of seven studies met the criteria for inclusion. The Newcastle-Ottawa Scale was used to conduct the research quality evaluation. Seven hundred three patients were included in meta-analysis. Patients with abnormal EEGs during withdrawal had a higher recurrence rate than patients with normal EEGs. Abnormal EEGs during withdrawal were a risk factor for recurrence.

Clinicopathological characteristics and risk factors for recurrence of well-differentiated pancreatic neuroendocrine tumors after radical surgery: a case-control study

BackgroundWell-differentiated pancreatic neuroendocrine tumors (PanNETs) usually have a good prognosis; however, there are patients that experience recurrence after curative resection.AimTo explore recurrence-related risk factors by analyzing clinicopathological data of PanNETs after radical surgery.MethodsClinical and pathological data from 47 patients with well-differentiated PanNETs at China-Japan Friendship Hospital from January 2012 to March 2016 were analyzed retrospectively. Univariate and multivariate analyses of the risk factors of PanNETs for postoperative recurrence were conducted.ResultsAmong the 47 patients with well-differentiated PanNETs, there were 38 cases with non-functioning tumors, 9 cases with functional tumors (6 insulinomas, 1 gastrinoma, 1 glucagonoma, and 1 VIPomas). There are 17 cases (36.2%) in the pancreatic head, 17 (36.2%) in the body and tail, 9 (19.1%) in the tail, and 4 (8.5%) in the body. The median tumor size was 3.65 (IQR 2–5.5) cm. Fourteen cases (29.8%) were NET G1, and 33 cases (70.2%) were NET G2. In regard to the clinical stage, 9 (19.1%) cases were IA, 14 (29.8%) cases were IB, 7 (14.9%) cases were IIA, 14 (29.8%) cases were IIB, and 3 cases unknown. There were 17 patients who presented with postoperative recurrence. Univariate analysis showed that AJCC TNM staging, Ki67 index, vascular invasion, margin status, and the regional stage of the tumors are related to the recurrence of patients with PanNETs (p < 0.05). The results of multivariate analysis showed that Ki67 index ≥ 10% is an independent risk factor for the postoperative recurrence of PanNETs (p < 0.05).ConclusionThe Ki67 index ≥ 10% is an independent risk factor for recurrence in well-differentiated PanNETs after radical surgery, and close surveillance for these patients may be needed.

Recurrence Risk of Autism in Siblings and Cousins: AMultinational, Population-Based Study.

Familial recurrence risk is an important population-level measure of the combined genetic and shared familial liability of autism spectrum disorder (ASD). Objectives were to estimate ASD recurrence risk among siblings and cousins by varying degree of relatedness and by sex. This is a population-based cohort study of livebirths from 1998 to 2007 in California, Denmark, Finland, Israel, Sweden and Western Australia followed through 2011 to 2015. Subjects were monitored for an ASD diagnosis in their older siblings or cousins (exposure) and for their ASD diagnosis (outcome). The relative recurrence risk was estimated for different sibling and cousin pairs, for each site separately and combined, and by sex. During follow-up, 29,998 cases of ASD were observed among the 2,551,918 births used to estimate recurrence in ASD and 33,769 cases of childhood autism (CA) were observed among the 6,110,942 births used to estimate CA recurrence. Compared with the risk in unaffected families, there was an 8.4-fold increase in the risk of ASD following an older sibling with ASD and a 17.4-fold increase in the risk of CA following an older sibling with CA. A 2-fold increase in the risk for cousin recurrence was observed for the 2 disorders. There also was a significant difference in sibling ASD recurrence risk by sex. The present estimates of relative recurrence risks for ASD and CA will assist clinicians and families in understanding autism risk in the context of other families in their population. The observed variation by sex underlines the need to deepen the understanding of factors influencing ASD familial risk.

Associations Between Magnetic Resonance Imaging Findings and Clincopathologic Factors in Triple-Negative Breast Cancer

The aim of the study was to evaluate the magnetic resonance imaging findings associated with clinicopathologic factors in patients with triple-negative breast cancer. One hundred one patients with surgically confirmed triple-negative breast cancer who underwent preoperative breast magnetic resonance imaging with diffusion-weighted imaging (DWI) were included in this study. Presence of rim enhancement on contrast-enhanced T1-weighted imaging and hyperintense rim on DWI were visually assessed. Pathologic data about presence of recurrence and presence of lymphovascular invasion (LVI) were reviewed. Statistics for relative risk of recurrence carried out. Of the 101, 13 cases (12.9%) were recurred after a median follow-up of 18.5 months. Rim enhancement was more frequently seen in the LVI-positive group (P = 0.046). Hyperintense rim on DWI and apparent diffusion coefficient values showed no significant relationship with clinical-pathologic factors. Rim enhancement was significantly associated with positive LVI status in patients with triple-negative breast cancer. Our study suggests that rim enhancement may be useful to predict the prognosis.

The rare entity of cystadenocarcinoma (CAC) in parotid gland: A single-center experience

PurposeCystadenocarcinoma (CAC) is an extremely rare disease in parotid gland. This study aimed to identify the clinical characteristics of CAC, and the therapeutic options for its treatment. An attempt was also made to identify postoperative recurrence-related risk factors. Material and methodsA retrospective study was conducted of CAC patients treated between 2008 and 2018. Predictive factors for postoperative recurrence (5-year RFS rate) were preliminarily filtered by Kaplan–Meier analysis and then further confirmed by a Cox regression model. Postoperative recurrence was defined as the primary outcome variable and was measured using both univariate and multivariate analysis. ResultsA total of 27 patients were analyzed, and the total incidence of postoperative recurrence was 33.3% (9/27). In the Cox regression analysis, patients who received a superficial parotidectomy were 0.046 times more likely to develop tumor relapse than those who only underwent enucleation (p = 0.032; 95% CI: 0.003–0.070). The chances of tumor recurrence in patients with the cribriform subtype were 9.701 times that for cases with a papillary pattern (p = 0.016; 95% CI: 1.517–62.030). The risk of postoperative recurrence increased abruptly, with an OR of 6.373 (p = 0.042; 95% CI: 1.070–37.965), when LN metastasis was found in patients. ConclusionPreoperative diagnosis of CAC in parotid gland is extremely important for allowing surgeons to apply appropriate therapeutic strategies (enucleation or superficial parotidectomy). Patients with LN metastasis, cribriform pattern, and Ki-67 positivity should be treated further to avoid tumor relapse.

Benefit of adjuvant chemotherapy in patients with high-risk UICC II colon cancer T4N0M0: A ten-year population-based analysis of 3544 cases.

628 Background: The benefit of adjuvant chemotherapy in UICC stage III colon carcinoma has been demonstrated in numerous studies. For UICC stage II such an advantage was not shown. However, it remains controversial whether adjuvant chemotherapy might be considered in certain high-risk UICC stage II situations. High-risk factors include T4 tumors, associated with an increased risk of recurrence and poorer prognosis due to their more aggressive biological behavior. Methods: The present population-based, multicenter cohort study investigated the influence of adjuvant chemotherapy on survival and recurrence rates in UICC stage II in the high-risk situation T4N0M0. It is based on an anonymized nationwide ADT dataset and includes 208,030 patients diagnosed with colorectal cancer from 2002 to 2011. A total of 3544 patients with a T4 tumor were identified, of whom 34.3% (1215 patients) received adjuvant chemotherapy and 65.7% (2329 patients) none. Results: Median overall survival was markedly prolonged in subjects who received adjuvant chemotherapy from 4.5 years (SD 0.163, 95% CI 4.1-4.8) to 8.1 years (SD 0.474, 95% CI 7.2 -9.0; p &lt; .001). After 5 years, 69.5% of chemotherapy patients were still alive compared to 45.1% of non-chemotherapy patients. After adjusting for factors in a multivariable Cox regression analysis, the significant benefit of adjuvant chemotherapy for overall survival was maintained (HR = 0.642, 95% CI 0.555-0.743, p &lt; .001). The relative cumulative risk of recurrence in the multivariable analysis was HR = 0.696 (95% CI 0.580-0.843, p &lt; .001) for chemotherapy patients. Furthermore, a highly significant improvement in relapse-free survival through chemotherapy was demonstrated (HR = 0.634, 95% CI 0.555-0.725, p &lt; .001). Conclusions: In this representative study, a significant advantage of adjuvant chemotherapy for UICC stage II colon carcinoma patients with a T4 tumor was demonstrated in terms of overall survival, recurrence rate and relapse-free survival. On the basis of these results, adjuvant chemotherapy is recommended for the high-risk situation T4.

Neoadjuvant intra-arterial chemotherapy using an original four-lumen double-balloon catheter for locally advanced uterine cervical cancer

OBJECTIVEWe report a balloon-occluded arterial infusion therapy with an original four-lumen double-balloon catheter (4L-DB) which allows for the efficient injection of an anticancer agent at a high concentration to the target spot for patients with locally advanced uterine cervical cancer.METHODSOne hundred and forty-three patients with locally advanced cervical cancer treated with neoadjuvant intra-arterial chemotherapy (NAIAC) or a primary radical hysterectomy (PRH) were retrospectively assessed. The patients in the NAIAC group received irinotecan 70 mg/m2 intravenously on day 1 and 8 and cisplatin 70 mg/m2 intra-arterially using the 4L-DB on day 2 of a 21-day course, and two courses were performed in principle. The radical hysterectomy was performed within 6 weeks after NAIAC.RESULTSNinety-four patients were treated with NAIAC, and 49 patients undertook a PRH. The response rate of NAIAC on MRI was 92.6%. Fourteen patients (14.6%) had no evidence of cancer cells on pathologic diagnoses. The NAIAC group had a longer disease-free survival than the PRH group (p=0.02); however, the overall survival was not significantly different. The relative risk (RR) for recurrence was higher in patients with lymph node metastasis (RR, 4.31; 95% CI, 2.23-8.43) and lower in those who underwent NAIAC (RR, 0.30; 95% CI, 0.14-0.68).CONCLUSIONOur results with NAIAC using the 4L-DB catheter in locally advanced cervical cancer indicates beneficial effects on primary lesions and improves disease-free survival.

Antiviral Therapy Reduces Hepatocellular Carcinoma Recurrence in Patients With Low HBV-DNA Levels: A Randomized Controlled Trial.

Despite antiviral treatment has been shown to reduce hepatocellular carcinoma (HCC) recurrence after curative treatment for hepatitis B virus (HBV)-related HCC in patients with high preoperative HBV-DNA levels, it is still unclear whether antiviral therapy is useful in reducing recurrence in patients with low preoperative HBV-DNA levels. In this randomized controlled trial, 200 patients who underwent curative resection for HCC with low baseline HBV-DNA levels were randomly assigned to receive preemptive antiviral therapy or not. The primary endpoints were recurrence-free survival. This study was censored on March 31, 2015 when all surviving patients had a minimum follow-up of 60 months. The analysis was done on an intention-to-treat basis. The baseline clinical, laboratory, and tumor characteristics of the 2 groups were comparable. The 1-, 3-, and 5-year recurrence-free survival rates for the antiviral group and the control group were 85.9%, 55.2%, and 52.0% and 80.6%, 40.9%, and 32.3%, respectively. The corresponding overall survival rates for the 2 groups were 94.0%, 75.7%, and 64.1% and 90.0%, 62.4%, and 43.7%, respectively. The recurrence-free survival and overall survival for the antiviral group were significantly better than the control group (P = 0.016, P = 0.004, respectively). After adjusting for confounding prognostic factors in a Cox model, the relative risks of recurrence and death for antiviral treatment were 0.601 [95% confidence interval (CI), 0.409-0.884; P = 0.010] and 0.509 (95% CI, 0.333-0.778; P = 0.002), respectively. Antiviral therapy was an independent protective factor of late tumor recurrence (hazard ratio [HR] = 0.316, 95% CI 0.157-0.637; P = 0.001) but not of early tumor recurrence (HR = 0.782, 95% CI, 0.493-1.240; P = 0.296). In patients with low preoperative HBV-DNA levels, antiviral therapy significantly reduced HCC recurrence after R0 hepatic resection.

Post-Anticoagulation Cessation D-Dimer Testing and VTE Recurrence in Real-World Australian Audit

AimElevated D-dimer post-anticoagulation cessation is a recognised risk factor for recurrent venous thromboembolic events (VTE). In particular, raised D-dimer post cessation has been associated with increased risk of recurrence in unprovoked major VTE. Currently in Australia, D-dimer has not been widely used in practice to stratify the risk of VTE recurrence. This study aims to retrospectively analyse the effect of routine D-dimer testing and it's association with VTE recurrence.MethodsA retrospective evaluation was performed on 1024 patients with a diagnosis of VTE at a tertiary hospital in Australia between January 2013 and December 2016. Data collected included demographics, results and timing of D-dimer testing and serial imaging results.Results1024 patients were reviewed with a total median follow up of 12 months (range 0-59 months). D-dimer was tested in 189 patients (18.5%) within 90 days after cessation of anticoagulation. Of these patients, median age was 58 (18-92) and 55.3% (n=105) were female. 33.3% (n=63) had isolated distal deep vein thrombosis (IDDVT), 66.3% (n=126) had above knee DVT (AKDVT)/pulmonary embolus (PE), 54.5% (n=103) of VTE were provoked.Abnormal post cessation D-dimer (>500) was found in 72 patients (37.9%). Of these, 25 patients were restarted on anticoagulation; one had recurrent VTE whilst on low dose apixaban 2.5mg BD and one had recurrence after cessation of anticoagulation at a later date. Patients with elevated D-dimer post cessation had a higher rate of recurrence with the highest risk in patients with D-dimer >1000 (RR 7.38, p=<0.01) outlined in Table 1.Of the 164 patients with post cessation D-dimer testing who remained off anticoagulation there were a total of 24 (12.6%) episodes of recurrent VTE. Elevated D-dimer post anticoagulation cessation was a significant risk factor for recurrence in both provoked VTE (RR 4.21, p=0.01) and unprovoked VTE cohorts (RR 4.55, p=0.008) outlined in Table 2. When provoked VTE were sub-categorised, raised D-dimer demonstrated the most statistical significance in VTE provoked by travel (RR 13.5 p=0.06).Of the patients with post anticoagulation cessation D-dimer testing 170 patients (89.9%) had repeat imaging to assess for residual thrombus. In the subgroup of patients with no residual thrombus, elevated D-dimer was a significant risk factor for VTE recurrence (RR 6.4, p=<0.01). Patients with normal D-dimer and no residual thrombus had the lowest rate of recurrence 5.4% (n=4) see Table 3.When stratified by type of VTE, elevated D-dimer post anticoagulation cessation was significantly related to risk for recurrence in the overall IDDVT sub-cohort (RR 4.09, p=0.007). This was not significant for the AKDVT/PE sub cohort (RR 3.24, p=0.079). However, for patients with unprovoked AKDVT or PE, having D-dimer tested post anticoagulation, regardless of result, was associated with lower rates of VTE recurrence RR 0.30 (p=0.02) compared to those who had no D-dimer testing as part of follow-up.ConclusionPost treatment D-dimer testing may have a clinical role in stratifying the risk of VTE recurrence along with repeat imaging to detect residual thrombus. Elevated D-dimer post anticoagulation cessation is associated with increased risk of VTE recurrence for both provoked and unprovoked VTE with highest risk in patients with D-dimer >1000. Patients with no residual thrombus and a negative D-dimer post anticoagulation cessation had the lowest rate of recurrence. In the subgroup of patients with provoked VTE and IDDVT a positive D-dimer post cessation was associated with 4.21 and 4.09 relative risk of recurrence respectively, suggesting that the role of D-dimer testing can be extended to these subpopulations. Interestingly, in patients with unprovoked AKDVT or PE, having post-cessation D-dimer testing performed, regardless of result, was associated with a significantly lower rate of VTE recurrence compared to patients without D-dimer testing, which may be related to specialist review and recommencement of anticoagulation in high-risk patients. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Thermal Ablation of Mucosal Defect Margins Reduces Adenoma Recurrence After Colonic Endoscopic Mucosal Resection

Colorectal cancer (CRC) can be prevented by colonoscopy and polypectomy. Endoscopic mucosal resection (EMR) is performed to remove large laterally spreading colonic lesions that have a high risk of progression to CRC. Endoscopically invisible micro-adenomas at the margins of the EMR site might contribute to adenoma recurrence, which occurs in 15% to 30% of patients who undergo surveillance. We aimed to determine the efficacy of adjuvant thermal ablation of the EMR mucosal defect margin in reducing polyp recurrence. We performed a prospective study of 390 patients with large laterally spreading colonic lesions (≥ 20 mm, n= 416) referred for EMR at 4 tertiary centers in Australia. After complete lesion excision by EMR, lesions were randomly assigned to thermal ablation of the post-EMR mucosal defect margin (n= 210) or no additional treatment (controls, n= 206). We performed surveillance colonoscopies with standardized photo documentation and biopsies of the scar after 5 to 6 months. Patient, procedure, and lesion characteristics were similar between the groups. The primary endpoint was detection of lesion recurrence at first surveillance colonoscopy. A significantly lower proportion of patients who received thermal ablation of the post-EMR mucosal defect margin had evidence of recurrence at first surveillance colonoscopy (10/192, 5.2%) than controls (37/176, 21.0%) (P<.001). The relative risk of recurrence in the thermal ablation group was 0.25 compared with the control group (95% confidence interval 0.13-0.48). Rates of adverse events were similar between the groups. In a multicenter randomized trial, thermal ablation of the post-EMR mucosal defect margin significantly reduced polyp recurrence at first surveillance colonoscopy, compared with no additional treatment. Routine implementation of this simple and safe technique could increase the utility of EMR, decrease surveillance burdens, and reduce morbidity and mortality from CRC. ClinicalTrials.gov no: NCT01789749.

Risk of colon cancer recurrence in relation to diabetes.

To describe the association between diabetes and colon cancer recurrence. We conducted a cohort study at two integrated health care delivery systems in the United States. Using tumor registry data, we identified patients aged ≥ 18years when diagnosed with stage I-IIIA adenocarcinomas of the colon during 1995-2014. Pre-existing diabetes was ascertained via diagnosis codes. Medical records were reviewed for eligibility and to abstract recurrence and covariate information. Recurrence was ascertained beginning 90days after the end of colon cancer treatment (i.e., cohort entry). Recurrence of any cancer or a new primary cancer at any site was a secondary outcome. We used multivariable Cox proportional hazards models to estimate hazard ratios (HR) and 95% confidence intervals (CIs) for the associations between diabetes at cohort entry and study outcomes. Among the 1,923 eligible patients, 393 (16.7%) had diabetes at cohort entry. Diabetes was not associated with recurrence (HR 0.87; 95% CI 0.56-1.33) or with any subsequent cancer (HR 1.09; 95% CI 0.85-1.40). When the definition of recurrence included second primary colorectal cancer, risk was non-significantly higher in patients with diabetes than without diabetes. The risk of colon cancer recurrence appears to be similar in patients with and without diabetes at diagnosis. Future studies should evaluate the association between diabetes and colorectal cancer outcomes, especially second primary colon cancers, in larger populations.

Is conservative surgery a better choice for the solid/multicystic ameloblastoma than radical surgery regarding recurrence? A systematic review.

Determine if conservative surgery of primary solid/multicystic ameloblastoma (SMA) is capable of decreasing the recurrence rate as effectively as radical surgery. We searched in MEDLINE, Web of Science, Scopus and Cochrane Library for original studies reporting on the conservative or radical treatment of primary SMA and the related recurrence rate. All selected data were independently assessed. Meta-analysis was performed and the Relative Risk (RR) of recurrence with a confidence interval of 95% was the effect measure. P value for the summary effect of < 0.05 was considered statistically significant. The 2647 records retrieved were reduced to 7 studies to be qualitatively assessed and 4 studies were included in the meta-analysis. RR of 1.88 [0.59, 5.95] of the pooled values pointed that recurrence rate after the conservative surgery is neither comparable nor lower than the radical surgery (P = 0.28). Conservative surgery does not reduce the recurrence rate as efficiently as radical surgery for primary SMA. However, there is not enough evidence to support this statement.

Trauma patients are safe to fly 72 hours after tube thoracostomy removal.

Current recommendations for safe air travel following traumatic pneumothorax are 2 to 3 weeks after radiographic resolution. These recommendations are based on several small observational studies and expert consensus, which cite a theoretical risk of recurrence and hypoxia because of decreased oxygen tension at altitude. We sought to systematically study the timing of chest drain removal after traumatic pneumothorax and risk of recurrence in relation to air travel. A retrospective cohort study of consecutively admitted patients who sustained a traumatic chest injury treated with tube thoracostomy over a 5-year period was undertaken. Adult patients with a postremoval expiratory chest x-ray demonstrating absence of pneumothorax and at least a 24-hour observation period before flight were eligible for study. All patients were transferred to a participating medical center for continued care. In-flight medical monitoring was available for all patients. Baseline patient characteristics, interval period from drain removal to flight, in-flight medical records, and incidence of radiographic or clinical recurrence of pneumothorax at the destination facility were recorded. Seventy-three patients who met the inclusion criteria were studied. All were male with a median age of 24 years (interquartile range [IQR], 22-26 years), injury severity score of 30 (IQR, 24-38), and chest abbreviated injury scale value of 3 (IQR, 2-4). The majority of patients sustained a penetrating injury (74%). The median duration of tube thoracostomy was 4 days (IQR, 3-6 days). The median period between thoracostomy tube removal and flight was 2.5 days (IQR, 1.5-4 days). Twenty-nine patients (40%) remained mechanically ventilated during transport. There were no reported in-flight medical emergencies for the entire cohort. There were no reported postflight radiographic or clinical recurrences during the subsequent 30 days. After a 72-hour period of observation, air travel after tube thoracostomy removal appears safe for both mechanically ventilated and nonventilated patients. Therapeutic, level IV.