Salvage Group Research Articles

Free flap reconstruction of plantar weight-bearing heel defects: Long-term functional and patient-reported outcomes.

Non-healing plantar weight-bearing heel ulcers are a challenging problem to treat. Free tissue transfer (FTT) reconstruction of the heel is an opportunity for limb salvage to preserve gait and ambulation. The aim of this study is to describe surgical and functional outcomes in patients who underwent FTT to treat chronic heel ulcers. A retrospective review of patients who underwent FTT for plantar heel ulcers from 2011 to 2021 was conducted. Patient demographics, comorbidities, perioperative data, postoperative complications, and long-term outcomes were recorded. Primary outcomes included flap success, complications, postoperative ambulation, patient-reported outcome measures and limb salvage, with patients stratified into limb salvage or eventual amputation groups. Forty-four patients underwent 45 heel reconstructions. Average age and BMI were 57.3 years and 30.1kg/m2 , respectively. Thirty-eight patients (86.4%) had calcaneal osteomyelitis, 35 patients (79.5%) had diabetes, and 18 patients (40.9%) had peripheral vascular disease (PVD). Immediate microsurgical success rate was 95.6%. At mean follow-up of 19.6 ± 20.9months, overall limb salvage rate was 73.3% (n=33). Preoperative albumin levels were higher in limb salvage group compared to the amputation group (3.0 vs. 2.4g/dl, p=.018). Prior stroke history and hypoalbuminemia were significantly higher in the amputation group compared to limb salvage group (p=.012 and p=.018, respectively). Risk for eventual amputation was associated with PVD (OR 4.0, p=.053), hypoalbuminemia (OR 4.9, p=.020), and postoperative infection (OR 6.3, p=.013). Of the 12 amputations that occurred, the most common indication for amputation was infection (n=8, 66.7%), which most often occurred at the original wound location (62.5%). At most recent follow-up, 90.7% of patients (n=39) were ambulatory. FTT is an effective alternative to amputation in patients with chronic heel ulcers. Proper patient selection, preoperative optimization, and postoperative care are imperative to the success of this limb salvage procedure.

Technical feasibility of salvage endoscopic submucosal dissection after chemoradiation for locally advanced rectal adenocarcinoma

The standard treatment of locally advanced rectal cancer is chemoradiation (CRT) followed by proctectomy and adjuvant chemotherapy. However, there is an emerging role for nonsurgical management after CRT or total neoadjuvant therapy (TNT) consisting of CRT and neoadjuvant chemotherapy. Endoscopic submucosal dissection (ESD) after CRT or TNT for rectal cancer, termed "salvage ESD," may be a viable nonsurgical option for carefully selected patients. We aimed to evaluate the feasibility and safety of salvage ESD. A retrospective chart review of cases of salvage ESD for locally advanced rectal cancer and standard ESD for rectal tumors without prior CRT from July 2018 to August 2020 at our institution was performed. Clinical factors and imaging, procedural, and pathology results were collected and compared. Twelve salvage ESD cases were compared with 27 standard ESD cases. Before CRT, 83.3% of lesions in the salvage ESD group were initially clinically staged as T3. The en-bloc resection rates were 92.7% and 91.7% (P= 1.00) and R0 resection rates 66.7% and 75.0% (P= .55) for the standard and salvage groups, respectively. In the salvage ESD group, no adverse events were observed, and 75.0% of the adenocarcinomas in the salvage ESD group had morphologically changed to hyperplasia or adenoma after CRT, with no identifiable lesions greater than T1 tumor depth. Salvage ESD for locally advanced rectal cancer is technically feasible with low adverse event rates. There may be a diagnostic role in salvage ESD in assessing pathologic response to CRT and a possible therapeutic role in resection of residual lesions with the potential to avoid surgery.

The use of cell salvage during second-stage reimplantation for the treatment of chronic hip periprosthetic joint infection: a retrospective cohort study

IntroductionGiven the possibility of inadvertent bacterial contamination of salvaged blood, the use of cell salvage is relatively contraindicated in cases of reimplantation for chronic hip periprosthetic joint infection (PJI). However, there are no published data supporting this assertion. The purpose of the current study was to compare the reinfection rate and rate of postoperative allogeneic blood transfusion (ABT) in second-stage reimplantation for PJI with or without intraoperative cell salvage reinfusion.Materials and methodsWe identified 125 patients who underwent two-stage exchange for chronic hip PJI between November 2012 and April 2019. The groups of patients who had (n = 61) and had not (n = 64) received intraoperative cell salvage reinfusion were compared with respect to the curative infection-free rate. Moreover, we compared the need for postoperative ABT and identified independent factors associated with ABT using multiple regression analysis.ResultsThe log-rank survival curve with an endpoint of infection eradication failure was not significantly different between the cell salvage group (98.4%, 95% CI 95.3–99.9%) and the control group (95.3%, 95% CI 90.2–99.9%) at one year (log rank, P = .330). The rates of postoperative ABT in the cell salvage group were significantly lower than those in the control group (11.5% vs 26.6%, P = .041). In multivariable models, patient age, body mass index, preoperative hemoglobin level, and intraoperative cell salvage were independent predictors of ABT exposure (P < .05).ConclusionsThe use of cell salvage during reimplantation in two-stage exchange for chronic hip PJI did not appear to increase the reinfection rate, while it significantly reduced the rate of postoperative allogeneic red blood transfusion. Greater age, lower BMI, lower preoperative hemoglobin, and non-intraoperative cell salvage reinfusion were associated with higher rate of allogeneic red blood transfusion.

Survey of malignant pleural mesothelioma treatment in Japan: Patterns of practice and clinical outcomes in tomotherapy facilities.

We conducted a nationwide survey of tomotherapy for malignant pleural mesothelioma (MPM) in Japan. Fifty-six facilities were surveyed and data on 31 patients treated curatively between 2008 and 2017 were collected from 14 facilities. Twenty patients received hemithorax irradiation after extrapleural pneumonectomy (EPP) (first group). Five patients received irradiation without EPP (second group), while six received salvage radiotherapy for local recurrence (salvage group). Among the seven patients not undergoing EPP, five (four in the second group and one in the salvage group) were treated with lung sparing pleural irradiation (LSPI) and two with irradiation to visible tumors. Two-year overall survival (OS) rates in the first and second groups were 33% and 60%, respectively (median, 13 vs 30 months, P = 0.82). In the first and second groups, 2-year local control (LC) rates were 53 and 67%, respectively (P = 0.54) and 2-year progression-free survival (PFS) rates were 16% and 60%, respectively (P = 0.07). Distant metastases occurred in 15 patients in the first group and three in the second group. In the salvage group, the median OS was 18 months. Recurrence was observed in the irradiated volume in four patients. The contralateral lung dose was higher in LSPI than in hemithorax irradiation plans (mean, 11.0 ± 2.2 vs 6.1 ± 3.1 Gy, P = 0.002). Grade 3 or 5 lung toxicity was observed in two patients receiving EPP and hemithorax irradiation, but not in those undergoing LSPI. In conclusion, outcomes of EPP and hemithorax irradiation were not satisfactory, whereas LSPI appeared promising and encouraging.

Evaluating the technical feasibility of novel salvage endoscopic submucosal dissection after chemoradiotherapy for locally advanced rectal adenocarcinoma.

103 Background: According to the National Comprehensive Cancer Network guideline, locally advanced rectal cancer is treated with chemotherapy with or without radiation, followed by transabdominal resection. However, there has been an emerging role for nonoperative management after chemoradiotherapy, and there is significant morbidity and risks associated with surgical resection. Endoscopic submucosal dissection (ESD) after chemoradiotherapy (CRT) for rectal cancer, which is termed “salvage ESD,” may be a viable option for patients, in terms of evaluating pathological response and providing potential curative resection. We aim to evaluate the feasibility and safety of salvage ESD. Methods: Retrospective chart review of cases of salvage ESD after CRT for locally advanced rectal cancer (salvage group) and standard ESD cases for rectal tumors without prior CRT (standard group) from July 2018 to August 2020 at our institution was performed. Clinical factors, imaging, procedural, and pathology results were collected and compared between the two groups. Results: 12 salvage ESD cases were compared to 27 standard ESD cases. 83.3% of the lesions in the salvage ESD group were initially staged as T3 prior to CRT. 100% of the lesions in the salvage ESD group were scarred down, compared to 33.3% in the standard ESD group (p &lt;0.01). Technical outcomes are shown in the table. The en bloc resection rates were 92.7% and 91.7% (p=1.00) and R0 resection rates were 66.7% and 75.0% (p=0.55) for the standard and salvage groups, respectively. In the salvage ESD group, no adverse events were observed. 66.7% of the adenocarcinomas in the salvage ESD group had morphologically changed to hyperplasia or adenoma after CRT and there were no identifiable lesions greater than T1 staging. Conclusions: Salvage ESD after CRT for locally advanced rectal cancer is technically feasible and with comparable low complication rates. There may be a diagnostic role in salvage ESD in assessing pathological response to CRT, as well as a possibly therapeutic role in resection of residual lesions with the potential to avoid surgery. Further studies are underway comparing the clinical outcomes of salvage ESD with standard surgical resection after CRT for locally advanced rectal cancer.[Table: see text]

Total Knee Arthroplasty: Superiority of Intra-Articular Tranexamic Acid Over Intravenous and Cell Salvage as Blood Sparing Strategy - A Retrospective Study.

PurposeTotal knee arthroplasty is associated with considerable perioperative hemorrhage. The decrease in hemoglobin concentration and the need for allogenic blood transfusion are related to increased morbidity and mortality. Strategies for minimizing perioperative bleeding are used, such as tranexamic acid and cell salvage. The study aimed to compare intravenous, intra-articular tranexamic acid and cell salvage protocols regarding perioperative hemoglobin variation. Secondary outcomes included blood loss; allogenic transfusions; complications and in-hospital stay.Patients and MethodsPatients submitted to unilateral total knee arthroplasty between January and December 2018 were retrospectively evaluated. After excluding 62 patients, 204 were subdivided into 3 groups according to the protocol used. Statistical analysis was performed with SPSS version 26.0. One-way ANOVA and Kruskal–Wallis tests were used. Considered a p-value of <0.05 for statistical significance.ResultsVariation of hemoglobin in the intra-articular tranexamic acid group was significantly lower than that of intravenous (p < 0.001) and cell salvage (p = 0.001) groups. Blood loss, variation of hematocrit, need for blood transfusion and in-hospital stay were also statistically significantly lower in the intra-articular tranexamic acid group. The only related complications were in the intravenous tranexamic acid group. No thromboembolic complications were identified which further solidifies the safety of tranexamic acid administration.ConclusionThis data shows superiority of the intra-articular administration of tranexamic acid over the other techniques in total knee arthroplasty. We propose this protocol as an efficient, low-risk blood-sparing strategy.

Overall and cancer specific survival following radical or adjuvant (chemo)radiotherapy in a retrospective cohort of elderly patients with endometrial cancer

To report the overall survival and cancer specific survival outcomes of elderly women aged ≥70 years who received radical or adjuvant (chemo)radiotherapy for endometrial cancer, we conducted a retrospective review of 93 patients from the West of Scotland Cancer Network (WoSCAN) who received pelvic (+/− para-aortic) radiotherapy over a 5-year period (January 2011 to December 2015, inclusive). Association of treatment type and other variables with overall survival (OS) and cancer specific survival (CSS) were analysed using log rank tests and Cox proportional hazards models. Median age of the study population was 74 years (range 70–90 years); over 50% of patients were aged ≥75 years, and over 25% were ≥80 years. The majority of patients had endometrioid endometrial cancer (75.3%), and 24.7% had a high-risk histological subtype. Stage distribution was as follows: I/II (40.9%); III/IV (41.9%); recurrent disease (17.2%). Radiotherapy was predominantly delivered in the adjuvant setting (61.3%); intent was primary (22.6%) or salvage (16.1%) in the remaining patients. Chemotherapy was administered to almost 50% of the cohort, mainly in conjunction with adjuvant radiotherapy. After median follow up of 96 months, 5-year OS and CSS were 50.5%and CSS 59.3% for the entire series, 57.9% and 62.8% in the adjuvant group, 23.8% and 35.7% in the primary group, and 60.0% and 80.0% in the salvage group, respectively. Age ≥80 years and primary radiotherapy were statistically significant predictors of poorer survival, adjusting for pathology, stage and grade (hazard ratio (HR) 2.06, 95%Confidence Interval (CI) (1.11–3.80), p = 0.021; and HR 2.42 (CI 1.28–4.57), p = 0.006 respectively). In summary, poorer OS was associated with use of (chemo)radiotherapy as primary treatment of endometrial cancer and/or in women aged ≥80 years, suggesting that careful risk/benefit analysis is required in these two groups.

Outcomes of soft-tissue sarcoma in nonagenarians.

Current literature suggests that survival outcomes and local recurrence rates of primary soft-tissue sarcoma diagnosed in the very elderly age range, (over 90 years), are comparable with those in patients diagnosed under the age of 75 years. Our aim is to quantify these outcomes with a view to rationalizing management and follow-up for very elderly patients. Retrospective access to our prospectively maintained oncology database yielded a cohort of 48 patients across 23 years with a median follow-up of 12 months (0 to 78) and mean age at diagnosis of 92 years (90 to 99). Overall, 42 of 48 of 48 patients (87.5%) were managed surgically with either limb salvage or amputation. A lower overall local recurrence rate (LRR) was seen with primary amputations compared with limb salvage (p > 0.050). The LRR was comparable between free (R0), microscopically (R1), and macroscopically positive (R2) resection margins in the limb salvage group. Amputation was also associated with longer survival times (p < 0.050). Overall median survival time was limited to 20 months (0 to 80). Early and aggressive treatment with appropriate oncological surgery confers the lowest LRR and a survival advantage versus conservative treatment in this cohort of patients. With limited survival, follow-up can be rationalized on a patient-by-patient basis using alternative means, such as GP, local oncology, and/or patient-led follow-up. Cite this article: Bone Joint J2022;104-B(1):177-182.

Necrotizing Soft-Tissue Infections: A Retrospective Review of Predictive Factors for Limb Loss.

BackgroundEmergent diagnosis and treatment are important for the survival of patients with necrotizing soft-tissue infections (NSTIs). Death is the most catastrophic outcome, but limb loss is also one of the most important complications that can have a significant impact on the rest of the patient’s life. The purpose of this study was to identify predictive factors for limb loss caused by NSTIs.MethodsThe data of patients at our center who were diagnosed with NSTIs from May 2003 to January 2019 were analyzed retrospectively. The inclusion criteria were patients with a definite diagnosis of NSTI involving the upper or lower limb. A total of 49 patient records were analyzed in terms of demography, laboratory data, microbiological causes, treatment, and final outcome. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scores at initial admission were also collected as laboratory data. Final outcomes were classified into survival with limb salvage and survival with limb loss.ResultsThe limb loss rate was 20.4% (10/49) in our study. On comparison between the limb salvage group and the limb loss group, independent risk factors of limb loss were as follows: presence of hypotension at admission (odds ratio [OR], 8.2; 95% confidence interval [CI], 1.7–38.3; p = 0.008); LRINEC score ≥ 9 (OR, 5.8; 95% CI, 1.3–25.6; p = 0.012), and glucose level > 300 mg/dL (OR, 4.5; 95% CI, 0.9–21.9; p = 0.041). Various microbiological organisms were isolated; the most prevalent specimen was streptococci (32.6%), followed by staphylococci (26.5%). Poor outcomes including limb loss and mortality had no correlation with microbiological organisms.ConclusionsFor patients with NSTIs, the presence of hypotension at admission, a high glucose level (> 300 mg/dL), and a high LRINEC score (> 9) were independent risk factors for limb loss.

Long-term impact of testicular torsion and its salvage on semen parameters and gonadal function

Introduction:Testicular torsion is a urological emergency, and long-term outcomes of testicular torsion on infertility, hormonal function, and salvaged testicular size are unclear.Materials and Methods:We conducted an ambispective, observational study from January 2014 to December 2019. Baseline demographics, time of presentation, clinical features, and management details of all the patients of testicular torsion were recorded from the database. All the patients were followed up in the outpatient clinic for testicular size, hormone levels, semen analysis, and erectile function.Results:Of 85 patients, only 67 could be contacted and included in the final analysis. Group 1(orchiectomy) comprised 44 patients, and Group 2(salvage) had 23 patients. Follow-up duration ranged from 2 to 6 years and mean follow-up was 42 ± 12 months. The median time to presentation was significantly higher in Group 1 (48 hours) as compared to Group 2 (12 hours). The rate of testicular salvage did not vary with age of the patients. Doppler ultrasonography of the scrotum detected 92.5% of all cases of torsion. Antisperm antibody levels were within normal range in all patients. Approximately 47% of patients in the salvage group developed testicular atrophy on follow-up. Serum testosterone level was significantly lower in Group 1 and the subset of patients with testicular atrophy. Rest of the hormonal parameters, semen analysis, and erectile function were comparable between two groups.Conclusion:The time between onset and presentation is an important contributing factor in guiding testicular salvage. Even after salvage, many testes may atrophy on follow-up. Orchiectomy and testicular atrophy in the long term have negative impact on serum testosterone. The patients should be counseled for a long-term follow-up for the risk of testicular atrophy and low testosterone levels.

Salvage Surgery Compared to Surgery After Induction Chemoradiation Therapy for Advanced Lung Cancer

BackgroundSalvage surgery is performed for selected patients with relapses of locally advanced lung cancer after definitive chemoradiation therapy (CRT), and it seems to be effective. To assess the feasibility of salvage surgery after definitive CRT, this study compared clinical outcomes of surgery after definitive CRT with those of surgery after induction CRT. MethodsMedical records of patients who underwent surgery from January 2000 to January 2018 were reviewed. The study compared patients with salvage anatomic pulmonary resection after definitive CRT with patients with surgery after induction CRT in terms of perioperative and long-term outcomes. ResultsA total of 23 patients underwent salvage surgery after definitive CRT for locally advanced lung cancer (salvage group), and 36 underwent surgery after induction CRT for cN2 stage III non-small cell lung cancer (induction CRT group). The surgical procedures in the salvage group were 2 segmentectomies, 13 lobectomies, 1 bilobectomy, and 7 pneumonectomies, and those in the induction CRT group were 34 lobectomies and 2 bilobectomies. There was no 30-day or 90-day mortality in either group. The 5-year overall survival was 44.7% for the salvage group and 58.6% for the induction CRT group. The 5-year progression-free interval was 42.2% for the salvage group and 47.7% for the induction CRT group. ConclusionsSalvage anatomic pulmonary resection after definitive CRT for locally advanced lung cancer is feasible, with acceptable morbidity and prognosis in highly selected patients.

Abstract 6985: Real-World Incidence and Factors That Contributes to the Development of Acute Kidney Injury in Patients Receiving Impella for Hemodynamic Support in a Community Based Health Care System

Introduction: Impella is a peripherally inserted ventricular assist device used for providing hemodynamic support in patients with cardiogenic shock and/or high risk percutaneous coronary interventions (PCI). The aim of the study was to examine the incidence and factors that can impact acute kidney injury (AKI) in a real world, community-based patient population. Methods: A retrospective observational study was conducted on patients with an Impella placed between January 2015- March 2020 at three hospitals within the Geisinger Health Care System. Results: Of the ninety-nine patients identified, 58 patients (58.3%) developed AKI. In those who had Impella placed electively (n=15), 3 patients (20%) developed AKI. In the urgent group (n=35), 9 patients (25.8%) developed AKI. In the emergent group (n=28), 12 patients (42.9%) developed AKI and in the salvage group (n=20), 8 patients (40%) had AKI. The acuity of the procedure did not significantly impact the subsequent development of AKI (p = 0.38). Chronic kidney (CKD) was present in 35 patients (35.4%) in the group and 15 (42.9%) developed AKI. In the 64 patients without CKD, 17 patients (26.6%) had AKI. The difference among the two group was not significant (p = .097). Patients with higher BMI had a lower likelihood of developing AKI compared to the lower BMI patients (p = .001). Patients with a longer duration of Impella implantation had a lower incidence of AKI (p = .001). Conclusions: AKI is a common complication associated with Impella placement, but its development does not appear to be related to the acuity of the procedure. 2. In the current study, the presence of CKD was not a risk factor for developing AKI. 3. Patient with higher BMI and longer duration of Impella had lower likelihood to develop AKI.

Superior Survival Outcome of Blinatumomab Compared to Mitoxantrone-Etoposide-Cytarabine Salvage for Adult Patients with Relapsed or Refractory B-Cell Precursor Acute Lymphoblastic Leukemia: A Propensity Score-Matched Cohort Analysis

Background: Complete remission (CR) rate and long-term overall survival (OS) is very poor in patients with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (R/R BCP-ALL). Previous clinical trials revealed a good remission rate and a safe bridging role to allogeneic-HCT compared to various standard treatments, and several real-world data have been reported.Aim: Here, we analyzed outcome of blinatumomab versus our conventional intensive chemotherapy by propensity score-matched analysis.Methods: From 2009 to 2020, 197 consecutive R/R BCP-ALL were treated with mitoxantrone-etoposide-cytarabine (MEC, n=113) or blinatumomab (n=84), and allogeneic-HCT was planned in patients with CR. For propensity score-matching, the MEC and blinatumomab cohorts were matched in a 1:1 ratio using 5 criteria of age < 35 years old, short CR duration < 12 months, adverse-risk karyotype including Ph-chromosome at relapse, previous allogeneic-HCT, and first-line salvage or not. We compared CR rate, regiment related mortality, and OS with cumulative incidence of relapse (CIR) and non-relapse mortality (NRM).Results: Matched cohort consisted of 52 patients for each salvage group and matched criteria were the same exactly. Median age was 42 years and 34 (65.4%) patients were > 35 years old. There were 22 (42.3%) primary refractoriness, 9 (17.3%) post-chemotherapy relapse and 21 (40.4%) post-HCT relapse. Among 30 relapsed patients, 19 (63.3%) were early relapse with CR duration less than 12 months. There were 25 (48.1%) with poor-risk karyotype at relapse of which 10 were Philadelphia-chromosome. Extramedullary relapse was observed in 14 (26.9%) and 8 (15.4%) were advanced-line salvage. CR rate was significantly higher in blinatumomab (78.8% vs. 53.8%, p=0.012) and more patients proceeded to allo-HCT (80.8% vs. 46.2%, p<0.001). Regimen-related mortality was significantly higher in MEC (40.4% vs. 1.9%, p<0.001). After median follow-up of 32.5 months (range 6.2 to 131.2), 3-year OS of blinatumomab and MEC was 33.2% and 15.4% (p<0.001), and 3-year NRM was 30.3% and 51.9% (p=0.004), respectively. After CR achievement, CIR was not significantly different (46.9% vs. 60.0%). In multivariate analysis, CR duration < 12 months was related with poor OS with high CIR. MEC regimen showed poor OS with high NRM. High NRM was also related with advanced-line salvage.Conclusion: Our matched cohort analysis clearly showed that blinatumomab is superior to MEC salvage regimen. However, we are observing relapse in up to 50% after blinatumomab and following allo-HCT still shows high NRM. Further combinatorial using novel therapeutics are needed for R/R BCP-ALL. [Display omitted] DisclosuresKim: AbbVie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; AIMS Biosciense: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; AML-Hub: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Astellas: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; BL & H: Research Funding; BMS & Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Boryung Pharm Co.: Consultancy; Daiichi Sankyo: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Handok: Consultancy, Honoraria; LG Chem: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Honoraria; Pintherapeutics: Consultancy, Membership on an entity's Board of Directors or advisory committees; Sanofi Genzyme: Honoraria, Speakers Bureau; SL VaxiGen: Consultancy, Honoraria; VigenCell: Consultancy, Honoraria. Lee: Alexion, AstraZeneca Rare Disease: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Review of oncological findings and complications after elective neck dissection during total laryngectomy: a case series

BackgroundThis study aims to report the rate of occult lymph node metastasis during elective neck dissection in clinically and radiologically negative neck (cN0) for patients offered total laryngectomy as either primary or salvage treatment. We also compare the rate of complications and recurrence after elective neck dissection during total laryngectomy.A retrospective review of patients treated in a single teaching hospital in the UK between 2004 and 2020 was performed. We collected the following patient information: age, sex, TNM staging, tumour location and laterality, primary treatment received if recurrent, preoperative imaging, operative details of the elective neck dissection, pathology results, postoperative complications, and recurrence. Inclusion criteria are as follows: squamous cell carcinoma and cN0 neck. Exclusion criteria are as follows: second primary tumour in the head and neck, a total laryngectomy because of a dysfunctional larynx, or a previously performed neck dissection.ResultsOf the 105 included patients, 66 (63%) had primary surgery and 39 (37%) were offered salvage surgery. All cases in the primary group were offered elective neck dissection. Thirty-six patients of the salvage group were offered elective neck dissection. The rate of occult lymph node metastasis was 35% (23/66) and 5.6% (2/36) in the primary and salvage groups, respectively. There was no difference in the overall complication rate in both groups, although the specific incidence of pharyngocutaneous fistula in the salvage group was higher compared with the primary group, 14% vs 7.5%.ConclusionsWe conclude that elective neck dissection is indicated during primary total laryngectomy due to the high rate of occult lymph node metastasis, 35% (23/66) in our series. Conversely, from our data in the salvage setting, the rate of occult lymph node was very low at 5.6% (2/36). The impact on survival is not known. The decision over elective neck dissection may be made more judiciously on an individual basis in the salvage setting.

Postchemotherapy Residual Tumor Resection in Patients with Elevated Tumor Markers.

The oncologic benefit of postchemotherapy (PC) residual tumor resection (RTR) in patients with germ cell tumors and elevated serum tumor markers (STMs) remains unclear. This analysis was performed to better define patients who benefit from surgery in this setting. Of 575 PC-RTR procedures (July 2008-July 2019) 153 were performed in patients with elevated STMs (human chorionic gonadotropin [HCG] >2.0 mIU/ml, alpha-fetoprotein [AFP] >7.0 µg/l), including 55 after first line and 98 after second or later line chemotherapy. Viable cancer in the resected specimen was significantly more common in the salvage group than in the first line group (48.98% vs 16.36%, p=0.0001988) and was a predictor of survival in both groups. A preoperative serum level of AFP ≥30 µg/l was a significant predictor of viable cancer in the first line and salvage groups (55.56% [p=0.0157] and 66.67% [p=0.0017], respectively). The overall relapse-free survival rate (22.7% and 50%, p=0.00032) and overall survival rate (37.8% and 65%, p=0.0059) were significantly worse in the salvage group than in the first line group. A preoperative serum level of AFP ≥30 µg/l and viable cancer/teratoma found in the histological examination of the RTR specimens were significant predictors of relapse after first line chemotherapy. Serum AFP ≥30 µg/l and HCG ≥20 mIU/ml were significant factors affecting survival in the first line group. Patients with AFP serum levels >30 µg/l and HCG ≥20 mIU/ml after first line chemotherapy should receive salvage chemotherapy instead of surgery. After second or later line therapy, the prognosis of patients with elevated markers and surgery is poor regardless of the tumor marker levels. However, 38% of these patients are long-term survivors, which justifies PC-RTR in this setting.

Chronological transition in outcome of second-line treatment in patients with metastatic urothelial cancer after pembrolizumab approval: a multicenter retrospective analysis.

After first-line chemotherapy failure, metastatic urothelial carcinoma (mUC) patients undergo pembrolizumab (PEM) or gemcitabine and docetaxel (GD) therapy. We retrospectively investigated outcomes of second-line GD or PEM for mUC patients. A total of 198 mUC patients from Nagoya City University and affiliated hospitals who received second-line treatment were grouped according to immune check point inhibitor (ICI) availability: Groups A (pre-ICI: n = 104) and B (post-ICI: n = 94). We compared clinical outcomes using Kaplan-Meier curves. Univariate and multivariate Cox regression analyses assessed potential prognostic factors for overall survival (OS). Median OS was significantly longer for Group B [median 13.6months, 95% confidence interval (CI): 7.6-17.6] than A (7.6months, 5.3-8.8). By sub-group analysis, patients received no additional treatment (Naïve, n = 70), or PEM or GD (Salvage, n = 24) in Group B, with median OS of Naïve and A groups similar. Compared to the Salvage group, significant differences in OS were observed (median 7.6months, 95% CI 5.3-8.8; Group A, 7.6months, 4.7-13.8; Naïve, 25.7months, 14.0-31.0; p < 0.01). For the Salvage group, OS for sequential treatment of GD-salvage PEM and PEM-salvage GD patients was similar (p = 0.10). Multivariate analysis showed a low neutrophil-to-lymphocyte ratio (NLR) and high geriatric nutritional risk index (GNRI) as significant prognostic factors affecting long OS [95% CI 1.12-3.45, hazard ratio (HR): 1.97; 95% CI 0.24-0.71, 0.41, respectively]. Second-line GD or PEM therapy for mUC patients showed equivalent survival benefits. GNRI and NLR are prognostic biomarkers for survival outcome.

Patient Satisfaction After the Cleft-Lift Procedure.

IntroductionAlthough Pilonidal disease is rarely life-threatening, it is a painful and potentially embarrassing condition that if left untreated or treated poorly, can disrupt a patient’s ability to enjoy life, function at work, develop relationships, or attend school or the military. There are several different approaches to this problem which include non-surgical measures, minimally invasive surgery, excisional surgery, or flap surgery. This article relates the experience with a surgical practice that offers only the cleft lift procedure and describes the degree of patient satisfaction with the operation.Materials and MethodsSeven hundred and fifty-one patients were treated between 2011 and 2021. Surveys were sent out to these patients by email after at least eight weeks had elapsed from surgery. The study was closed once 500 responses were obtained. Statistical analysis was performed to determine if patients who had undergone previous pilonidal surgery (salvage group) had different opinions than the patients who did not (primary group).ResultsOf the 500 respondents, 494 (98.8%) were “extremely satisfied” or “satisfied” with their procedure; 444 (88.8%) felt that the recovery process was “very easy” or “easy” and only 56 (11.2%) felt that it was “difficult but worth it” or “really hard”. Four hundred and one (80.2%) felt that the activity restrictions were “minimal, I was back to normal activity very quickly”; 438 (89.4%) felt that the scar looked “really good” or answered, “it’s fine, not an issue for me. I’m just glad to be done with this”. Whether the patients had previous failed surgery or not, the vast majority (78.2% and 79.6% respectively) felt that the cleft lift was an appropriate first operation for pilonidal disease; and statistical analysis failed to show any significant differences in opinions between the primary and salvage groups on any of the questions. The few patients who ultimately were dissatisfied with the procedure were unhappy with the cosmetic appearance of the scar and shape of the buttocks. By comparing the demographic characteristics of the respondents to the entire cohort, we found them to be similar groups, suggesting that the respondents were representative of the group as a whole.ConclusionA correctly performed cleft lift operation provides a solution that is very well accepted by patients, specifically in regard to recovery time, appearance, appropriateness, and overall satisfaction.

ADAPT First-Line Strategy for MCA Mainstem Occlusion; Analysis for Optimal Salvage Therapy and its Related Factor

ObjectivesA direct first-pass aspiration technique (ADAPT) is an attractive interventional technique for mechanical thrombectomy (MT), which could achieve recanalization quickly and safely at a small amount of material resources. To clarify its usefulness, our ADAPT first-line strategy for middle cerebral artery (MCA)-mainstem occlusion was retrospectively analyzed. Materials and MethodsWe reviewed 54 consecutive patients who underwent MT for MCA-mainstem occlusion using ADAPT first-line strategy. A salvage procedure was concurrently conducted in cases that failed to achieve successful recanalization by ADAPT attempt alone. Procedural and clinical outcome were assessed in both ADAPT alone and Salvage groups. Further investigation was performed in cases that required salvage procedure to determine the reason, risk factors, and optimal procedure. ResultsForty-one patients (75.9%) were able to achieve successful recanalization with ADAPT technique alone. In salvage group, the procedural time was longer, and rates of successful recanalization were lower than in ADAPT-alone group. No significant difference in the rates of favorable outcomes was observed. Among 13 patients who required salvage therapy, the major reason (eight cases) was intra-procedural “thrombus distal migration”. Failure of recanalization was seen in two cases due to “inaccessibility”. In patients who had “thrombus distal migration”, occlusion in the proximal portion was more frequently observed than in patients who did not (p = 0.032, 63.6% vs. 23.3%). ConclusionsOur ADAPT first-line strategy for MCA-mainstem occlusion demonstrated favorable procedural and clinical outcomes, even in cases that required additional procedures. Further investigation and better understanding are required to refine this promising procedure.

Olaparib as maintenance therapy and salvage therapy in recurrent ovarian cancer: The early experience in Taiwan

ObjectiveThe first Poly (adenosine diphosphate [ADP]-ribose) polymerase inhibitor, olaparib, was approved by Taiwan Food and Drug Administration in June 2018, which was available under a compassionate use program since 2015. This study aims to report the early experience of the effectiveness and adverse effects of olaparib in recurrent ovarian cancer patients in Taiwan. Materials and methodsThis retrospective study enrolled patients with recurrent epithelial ovarian and peritoneal cancer who received olaparib as maintenance therapy or salvage therapy between December, 2015 and October, 2019. We observed response rates in the salvage therapy group, and progression-free interval (PFI) in both groups. ResultsA total of 20 patients (10 in maintenance and 10 in salvage groups) were enrolled. BRCA status was checked in 18 patients by blood or tumor samples, and 83.3% were mutated (n = 15), including pathological/probable pathological variants in BRCA1 (n = 11), BRCA2 (n = 2), or both BRCA1/BRCA2 (n = 2). In the salvage group, there were two partial responses and two stable diseases, adding up to a clinical benefit rate at 40%. In the maintenance group, median PFI was 20.1 months (range, 1.0–33.1). The median PFI of those with chemotherapy-free interval >12 months was not reached, which was significantly better than those ≤12 months, with median PFI 3.1 months (p = 0.022). The most common grade 3/4 adverse effects in patient with olaparib as monotherapy were neutropenia (30.8%) and fatigue (7.7%). Anemia of grade 1/2 was noted in 76.9%. ConclusionThis real-world experience of olaparib for recurrent ovarian cancer in Taiwan showed efficacy and safety similar to the results of previous clinical trial.

Replacement Versus Same-Site Salvage Using Hickman Catheter for Pediatric Stem Cell Transplantation Patients: A Comparative Study

Children undergoing bone marrow transplant need a double-lumen Hickman line. Therefore, changing Port-a-Cath ports to double-lumen Hickman catheter is mandatory. Several methods were described for changing Port-a-Cath ports either through the same-site or a new placement access site. The advantage of one method over the other is still debatable. We conducted this study to compare the safety and effectiveness of replacement versus salvage techniques to change ports to the Hickman lines before bone marrow transplants in pediatric patients. We included 85 pediatric patients who underwent stem cell transplants. Their age ranged from 0.2 to 15 years. According to the Hickman reinsertion technique, we classified the patients into 2 groups; the Replacement group (n = 47) and the Same-site salvage group (n = 38). We compared the data before and after Hickman insertion between both groups. Study outcomes were the catheter duration, its complications, and mortality. The mean age of all patients was 4.7 ± 3.9 years, and 65.9% were males. There was no difference in the baseline data between both groups. During Port-a- Cath first insertion; 16.5% of patients suffered complications, with 10.6% had conversion to cut down, 1.2% had a hematoma, and 4.7% had multiple site insertion. We did not report differences between groups in the complications of the first port insertion. The Hickman duration was longer in the replacement group (4 (Q1-Q2: 2-6) vs. 1 (0.5-3) months, P = 0.005). Increased age (odds ratio [OR]: 1.31, P = 0.001) and male gender (OR: 1.19, P = 0.046) were independent predictors of mortality. Endovascular same-site salvage technique could help preserve vascular access during the tunnel catheter exchange for noninfectious reasons. We recommend the use of the same-site salvage technique in pediatric transplant patients.