Significant Risk Factor For Recurrence Research Articles

Co-expression of PKM2 and TRIM35 predicts survival and recurrence in hepatocellular carcinoma.

The identification of prognostic markers for hepatocellular carcinoma (HCC) is needed for clinical practice. Tripartite motif-containing 35 (TRIM35) is a tumor suppressor of HCC. TRIM35 inhibits phosphorylation of pyruvate kinase isoform M2 (PKM2), which is involved in aerobic glycolysis of cancer cells. We found that expression of PKM2 was significantly increased in HCC tissues. This overexpression of PKM2 was correlated with a high TNM stage and level of vascular invasion. Patients with HCC who were positive for PKM2 expression and negative for TRIM35 expression had shorter overall survival and time to recurrence than patients who were negative for PKM2 and positive for TRIM35. Furthermore, PKM2/TRIM35 combination was an independent and significant risk factor for recurrence and survival. In conclusion, PKM2 (+) and TRIM35 (-) contribute to the aggressiveness and poor prognosis of HCC. PKM2/TRIM35 expression could be a biomarker for the prognosis of HCC and target for cancer therapy.

Tumor-associated macrophages are a useful biomarker to predict recurrence after surgical resection of nonfunctional pancreatic neuroendocrine tumors.

Patients with nonfunctional pancreatic neuroendocrine tumors (NF-PNETs) have poorer survival than those with functional PNETs. Our objective was to identify risk factors for recurrence after resection to better define surveillance parameters to improve long-term outcomes. A retrospective analysis was performed for NF-PNET patients who underwent resection at the University of Michigan from 1995 to 2012. Immunohistochemical staining of tissues from patients with and without disease recurrence was performed for Ki-67 and the macrophage marker CD68, as tumor-associated macrophages are important for PNET development and progression. Clinicopathological factors and patient outcomes were measured. Ninety-seven NF-PNET patients underwent surgical resection. There was a recurrence rate of 14.4% (14/97). The median time to recurrence was 0.61 years, with 10 (71%) patients recurring within the first 2 years. Six of 7 patients (86%) monitored at 6-month surveillance intervals were diagnosed with recurrence on their first computed tomographic scan or during the intervening intervals. By Cox proportional hazards analysis, the most significant independent risk factors for recurrence were higher grade, stage, and intraoperative blood loss. High CD68 score and Ki-67 index correlated with recurrence risk, and Ki-67 index inversely correlated with time to recurrence. In patients who otherwise had few risk factors, a high CD68 score was a significant prognostic factor for recurrence. In patients with NF-PNETs, risk factors associated with recurrence were high EBL, grade, stage, CD68 score, and Ki-67 index. The CD68 score was an important prognostic factor in patients who otherwise had few clinicopathological risk factors; therefore, the CD68 score should be considered when planning surveillance strategies. We recommend that NF-PNET patients at high risk of recurrence undergo initial surveillance every 3 months for 2 years after surgery.

Factors affecting hernia recurrence after Strattice mesh repair: A retrospective study

Aim The aim of the present study was to explore the factors that affect hernia recurrence after Strattice mesh repair. Patients and Methods The present study is a retrospective study of the medical records of 42 patients who underwent Strattice mesh hernia repair at Ruby Memorial Hospital, West Virginia University. Strattice mesh was employed in a variety of ventral hernia procedures, including primary ventral hernia repair, recurrent ventral incisional hernia repair, component separation (abdominal wall reconstruction), parastomal hernia repair and infected inguinal hernia repair. The main collected variables were body mass index, intraoperative hernia defect size, diabetes, wound events and steroid use. Results For 42 patients, the overall recurrence rate was 21.43 per cent. The mean body mass index (BMI) was 36.4. BMI and sex were significant risk factors for recurrence (P = 0.036, P = 0.002), respectively. The mean defect size was 97 cm2. The hernia defect size was not significantly associated with the hernia recurrence rate (P = 0.166). Of the 10 diabetics, five developed recurrence. However, diabetes was not significantly associated with the hernia recurrence rate (P = 0.726). A total of four patients (9.52 per cent) were using steroids; one developed recurrence, which was not significantly associated with the hernia recurrence rate (P = 0.20). Wound infection also was not significantly associated with recurrence (P = 0.323). Conclusions Only sex and an increase in the BMI were significantly associated with the risk of hernia recurrence. In order to decrease the modifiable risk of hernia recurrence, surgeons should counsel obese patients regarding preoperative weight loss.

Patient-Related Risk Factors for Recurrence After Inguinal Hernia Repair

Several factors influence the risk of recurrence after inguinal hernia surgery; however, a systematic review and meta-analysis of patient-related risk factors for recurrence after inguinal hernia surgery has not been performed earlier. MEDLINE, Embase, and Cochrane databases were searched in June 2013 for studies evaluating patient-related risk factors for recurrence after inguinal hernia operation. Observational studies evaluating nontechnical patient-related risk factors for recurrence after inguinal hernia surgery were included. Outcome variables were grouped under patient demographics, hernia characteristics, connective tissue composition and degradation, habits and social relations, and conditions related to inguinal hernia recurrence. From a total of 5061 records screened, we included 40 observational studies enrolling 720 651 inguinal hernia procedures in 714 917 patients in the systematic review. Of the 40 studies, 14 studies were included in 8 meta-analyses evaluating sex, hernia type, hernia size, re-recurrence, bilaterality, mode of admission, age, and smoking as risk factors for recurrence after inguinal hernia surgery in a total of 378 824 procedures in 375 620 patients. We found that female sex, direct inguinal hernias at the primary procedure, operation for a recurrent inguinal hernia, and smoking were significant risk factors for recurrence after inguinal hernia surgery. This knowledge of patient-related risk factors for recurrence after inguinal hernia surgery could be implemented in clinical practice.

Reduced expression of transcriptional intermediary factor 1 gamma promotes metastasis and indicates poor prognosis of hepatocellular carcinoma.

Transcriptional intermediary factor 1 gamma (TIF1γ) may play either a potential tumor-suppressor or -promoter role in cancer. Here we report on a critical role of TIF1γ in the progression of hepatocellular carcinoma (HCC). Reduced expression of TIF1γ was detected in HCC, especially in advanced HCC tissues, compared to adjacent noncancerous tissues. HCC patients with low TIF1γ expression had shorter overall survival times and higher recurrence rates than those with high TIF1γ expression. Reduced TIF1γ expression was an independent and significant risk factor for recurrence and survival after curative resection. In HCC cells, TIF1γ played a dual role: It promoted tumor growth in early-stage HCC, but not in advanced-stage HCC, whereas it inhibited invasion and metastasis in both early- and advanced-stage HCC. Mechanistically, we confirmed that TIF1γ inhibited transforming growth factor-β/ Drosophila mothers against decapentaplegic protein (TGF-β/Smad) signaling through monoubiquitination of Smad4 and suppressed the formation of Smad2/3/4 complex in HCC cells. TGF-β-inducing cytostasis and metastasis were both inhibited by TIF1γ in HCC. We further proved that TIF1γ suppressed cyotstasis-related TGF-β/Smad downstream c-myc down-regulation, as well as p21/cip1 and p15/ink4b up-regulation in early-stage HCC. Meanwhile, TGF-β inducible epithelial-mesenchymal transition and TGF-β/Smad downstream metastatic cascades, including phosphatase and tensin homolog deleted on chromosome ten down-regulation, chemokine (CXC motif) receptor 4 and matrix metalloproteinase 1 induction, and epidermal growth factor receptor- and protein kinase B-signaling transactivation, were inhibited by TIF1γ. In addition, we found that the down-regulation of TIF1γ in HCC was caused by hypermethylation of CpG islands in the TIF1γ promoter, and demonstrated that the combination of TIF1γ and phosphorylated Smad2 was a more powerful predictor of poor prognosis. TIF1γ regulates tumor growth and metastasis through inhibition of TGF-β/Smad signaling and may serve as a novel prognostic biomarker in HCC.

Sutured repair of primary small umbilical and epigastric hernias: concomitant rectus diastasis is a significant risk factor for recurrence.

Umbilical and epigastric hernias are common in the adult population and prompt repair is advised. We aimed to evaluate the impact of concomitant rectus diastasis on the outcome of patients who underwent primary sutured fascia closure of a hernia without mesh. We performed a retrospective analysis of 231 consecutive adult patients who had undergone elective suture-based repair of small (<2 cm) and primary umbilical or epigastric hernias with respect to complications, recurrence, and chronic pain. Patients with rectus diastasis suffered from a significantly increased rate of hernia recurrence (29/93 vs. 9/108; p < 0.001). The use of absorbable sutures also had a negative influence on the recurrence rate (26/90 vs. 12/111; p = 0.001). Obesity (body mass index > 35 kg/m(2)) was associated with more complications (p = 0.02). Wound infections following hernia repair also were associated with a higher rate of recurrence (p = 0.08) and chronic pain (p = 0.02). The mean follow-up via a structured questionnaire was 31 months (range 3-59) and data were available for 201 of 231 patients (87 %). We strongly recommend preoperatively checking for rectus diastasis and using nonabsorbable sutures as an alternative to mesh repair only when repairing small umbilical or epigastric hernias (<2 cm) and there is no concomitant rectus diastasis. Patients with coexistent rectus diastasis definitely benefit from mesh-based repair of the midline to decrease the recurrence rate.

Anatomic Versus Nonanatomic Hepatectomy for a Solitary Hepatocellular Carcinoma

BackgroundIt remains controversial whether anatomical resection (AR) improves the prognosis for hepatocellular carcinoma (HCC) or not. To our knowledge, there have been a few well-matched studies about this issue. The aim of the present study was to compare the recurrence-free survival of AR versus nonanatomical resection (NAR) for a solitary HCC using propensity score matching. MethodsThe present study included 236 patients who had a solitary HCC without macroscopic vessel thrombosis. Those patients were divided into AR (n = 139) and NAR (n = 97) groups. A propensity score matching was performed to minimize the effect of potential confounders. ResultsSixty-four patients from each group were matched. Preoperative confounding factors were balanced between the two groups. The median recurrence-free survival times in the AR and NAR groups were 33.8 and 30.8 months, respectively (P = 0.520). There were no significant differences in the intrahepatic recurrence pattern (P = 0.097). Operative procedure was not a significant risk factor for recurrence in both uni- and multivariate analyses. ConclusionsThis case-matching study using a propensity score shows that there is no superiority of AR to NAR relevant to the recurrence-free survival in patients with a single HCC.

P06.01 * PROGESTERONE RECEPTOR EXPRESSION PREDICTS RECURRENCE OF CRANIAL BUT NOT SPINAL MENINGIOMAS

OBJECTIVE: The expression of estrogen receptors (ER) and progesterone receptors (PR) has been studied since 30 years in intracranial meningiomas, whereas only few studies concern spinal meningiomas. The aim of the study is to define whether the ER and PR expression may be associated to recurrence of spinal meningiomas as well as demonstrated for intracranial ones. MATERIALS AND METHODS: The only six patients with spinal meningiomas who experienced recurrence after complete resection (group I) from a surgical series of 140 patients operated on between 1986 and 2010 were reviewed. The investigated factors included tumor size, type of arachnoidal interface, Simpson grade of resection (I versus II), ER and PR expression, proliferation index Ki67/ MiB1. The same factors have also been investigated in 50 consecutive spinal meningiomas with no recurrence (group II), in 50 consecutive intracranial meningiomas which recurred (group III) and in 50 consecutive intracranial meningiomas with no recurrence (group IV). The data were statistically analyzed with the Kaplan-Meier method. RESULTS: The statistical analysis showed that the higher Ki67/MiB1 (p < 0.0001) was the most significant risk factor for recurrence of both spinal and intracranial meningiomas, whereas the invasion of the spinal-arachnoidal interface showed tendency to significance. As expected, the larger tumor size and the Simpson grade II resection were risk factors for recurrence of intracranial but not for spinal meningiomas. The PR expression was positive in all spinal meningiomas (both recurrent and not recurrent); on the other hand, in the groups of intracranial meningiomas the PR expression was negative in 81.5% of cases which recurred and positive in all (100%) cases with no recurrence. The ER expression was not correlated to the recurrence. CONCLUSION: The Ki67/MiB1 is clearly correlated to recurrence of spinal meningiomas; on the other hand the PR expression seems to be not significant, differently from intracranial meningiomas.

Extracapsular dissection of benign parotid tumors.

Iro andZenk1 are tobecommendedon their concise and thoroughdiscussionof the role of extracapsular dissection (ED) in the surgical management of benign parotid tumors. This discussion, aswell as a reviewof the literature, supports their hypothesis that “ED isa safeand effectivesurgical technique in the management of benign parotidneoplasms.”The true challenge is howbest to incorporate this information and surgical technique into the global management of parotid tumors. Several points require consideration: the correct definitionof theavailable andhistorical techniques for addressing parotid neoplasms, close analysis of the comparisons to date, a thorough understanding of the technique as well as evaluation of the relevant complication rates, and specific pitfalls associated with ED. Finally, as noted by all authors publishing on this procedure, significant expertise is required to successfully integrate ED into practice. Enucleation andnodulectomy should remainprocedures of historical note andnot be consideredwith currentmanagement techniques. ThedefinitionofED is very specificwith the goal of complete removal of the tumor with a 2to 3-mm cuff of normal parotid tissue, if possible, andno formal identificationof thenervebefore tumor removal. Superficial parotidectomy impliesdissectionof all facial nervebranches and the removal of theentire superficial lobe; partial parotidectomy (PP) implies the dissection of only nerve branches that is required to safely remove the tumor with a cuff of normal parotid tissue surrounding it. Historically, the pendulum swung drastically away from enucleation procedures because of the high recurrence rates toward the thorough superficial parotidectomy, which advocated wide margins around tumors, yet requiredextensive facialnervedissection. Inanappropriate fashion, thependulumhas returned centrallywithdemonstration that effective control ofbenignparotid tumors canbeachieved byPP, addressingonlybranchesof the facial nerve systemthat are in anatomical proximity to the tumor and leaving amuch smaller cuff of parotid tissue around the tumor.2 Extracapsular dissection represents the continuation of this principle by advocating theremovalof the tumorwithnervedissectiononly when required. The end points for surgical management of parotid tumors are straightforward: complete tumor removal in a fashion to prevent recurrence and limitation of any facial muscular dysfunction related to nerve dissection. Minor complications include Frey syndrome, periauricular numbness, and contour deformity. The significant surgical experiences with ED indicate the nearly equitable success of this procedure compared with superficial parotidectomy regarding recurrence and final facial nerve function. Extracapsular dissection demonstrates less transient nerve dysfunction in many series, which is understandable compared with the extensive facial nerve dissection that occurs with superficial parotidectomy.3 Directly comparing ED with appropriate PP procedures would be more informative and appropriate. Tumor recurrence rates and facial nerve functionwithED must also take into account that most ED series involved significant selectionbias,with smaller,mobile, and favorably selected tumors chosen to undergo ED and tumors that did not meet these criteria preoperatively or intraoperatively removed with superficial parotidectomy. These criteria clearly indicate that for ED to be successful, appropriate technique must be joined with excellent surgical decision making. The importance of capsular exposure in themanagement ofbenignparotid tumorscontinues tobeapointofdebate.Limited tumor exposure is commonwith all parotid surgeries and is not a significant risk factor for recurrence,4whereas formal disruption and spillage of the tumor presents a risk for recurrence. The risk of potential disruption or spillage could increase with greater direct exposure of the tumor capsule– parotid interfaceduringED.For this reason,EDtechniquesused in experienced centers attempt to leave a small cuff of parotid tissue on the tumor, allowing ED to limit the welldescribed pathologic features of incomplete capsule, tumor pseudopodia, and tumor satellites. The lower ratesofFrey syndromereportedwithEDareunderstandable, butmust be placed in the context of overall patient satisfaction and quality of life. The presence of gustatorysweatingonstarch iodineevaluationorbysolicitedpatient historymustbegradedby its effecton thepatient's life if avoidanceof this limitedcomplication is tobecomeapotentialdriver for a change in surgical technique that has afforded excellent results. Similarly, issues related to contour and cosmetic appearancemust beplaced in context. Again, themajor studies comparedEDand superficial parotidectomywhich, bydefinition, involves a greater resection of benign parotid tissue. Resultant contourdeformitieswouldbegreatly lessenedwithanappropriate PP combined with simple regional tissue mobilization techniques. Clinical experiencedemonstrates successful subjective results equivalent to those noted by Iro and Zenk1 in their experience. Potential pitfalls specifically related to ED exist. The success of ED is intricately related to technological support including appropriate preoperative imaging and facial nerve monitoring, which can be variable throughout practice centers. The authors1 note that revision parotidectomy after ED would be an easier procedure with fewer potential complications compared with other interventions. After ED, identification of the main trunk of the facial nerve system as well as previouslyuninvolvednervebrancheswouldbemorestraightforward.Yet, the facial nervebranches thatwere in closeproxRelated article page 768 Clinical Review& Education Clinical Challenges in Otolaryngology

Ten-Year Experience With Liver Transplantation for Hepatocellular Carcinoma in a Federal University Hospital in the Northeast of Brazil

Hepatocellular carcinoma (HCC) is the most frequent and important primary liver tumor, with annual worldwide incidence of over 1 million cases, accounting for at least 500,000 deaths per year. The majority of cases of HCC occur in the setting of liver cirrhosis. In this retrospective, descriptive, and analytical study, between May 2002 and April 2012, 664 liver transplantations (LT) were conducted at a Federal University Hospital in the Northeast of Brazil, among which 140 LT were performed in patients with HCC. The tumor was more frequent in men with an average age of 56 years and infected with hepatitis C virus, many with a history of alcohol abuse. Alpha-fetoprotein was not useful in the diagnosis, and imaging methods have failed to diagnose the nodules in 19 patients (13.6%). Transarterial chemoembolization was the most-used bridging therapy to inhibit tumor growth for patients with HCC eligible for transplantation. The implementation of the Model for End Stage Liver Disease score in 2006 brought benefits to these patients. The rate of HCC recurrence after LT was 8.57% and occurred more often in the first 2 years after transplantation, with the liver graft being the most common site. Significant risk factors for recurrence were a long time on the LT waiting list, number of liver nodules over 3.5, and the presence of vascular invasion. In conclusion, LT for HCC leads to excellent long-term survival, with relatively few patients dying from tumor recurrence.

Long-term outcomes after fertility-sparing laparoscopic radical trachelectomy in young women with early-stage cervical cancer: an Asan Gynecologic Cancer Group (AGCG) study.

To evaluate the long-term outcomes and risk factors for recurrence after fertility-sparing laparoscopic radical trachelectomy (LRT) in young women with early-stage cervical cancer. Eighty-eight consecutive patients from four tertiary cancer centers in Korea who had attempted fertility-sparing LRT for early-stage cervical cancer were included in this study. Seventy-nine patients completed LRT. The mean age and tumor size were 31 years (range, 20-40 years) and 1.8 cm (range, 0.4-7 cm), respectively. Twenty-nine patients had a tumor size greater than 2 cm, 22 had deep stromal invasion greater than 50%, and twelve had lymphovascular space invasion. After a median follow-up time of 44 months (range, 3-105 months), nine patients had recurrence and one had died of disease. A tumor size greater than 2 cm (P = 0.039) and a depth of stromal invasion greater than 50% (P = 0.016) were significant risk factors for recurrence. This is the largest series on fertility-sparing LRT in young women with early cervical cancer. LRT is a feasible and safe fertility-sparing alternative to radical hysterectomy in these women. A tumor size greater than 2 cm and a depth of stromal invasion greater than 50% were risk factors for recurrence.

Prognostic significance of histologic differentiation, carcinoembryonic antigen value, and lymphovascular invasion in stage I non–small cell lung cancer

For stage I non-small cell lung cancer (NSCLC), the only 2 prognostic factors incorporated into the seventh edition of the TNM staging system were tumor size and visceral pleural invasion. However, with this staging system, the prognostic precision of survival has proved elusive, suggesting the need to include additional prognostic factors. To improve prognostic applications and treatment decisions, we investigated clinicopathologic factors affecting progression-free survival in patients with surgically resected stage I NSCLC. From January 2004 to December 2011, we retrospectively reviewed the clinicopathologic characteristics of 758 consecutive patients with surgically resected stage I NSCLC at the National Taiwan University Hospital. The 5-year progression-free survival rate was 82.3% and 64.0% for those with stage IA (n=481) and stage IB (n=277), respectively. Multivariate analysis revealed poor or moderate histologic differentiation and elevated preoperative serum carcinoembryonic antigen were statistically significant risk factors for recurrence in patients with stage IA. Poor or moderate histologic differentiation, elevated preoperative serum carcinoembryonic antigen, lymphovascular invasion, and tumor size>2 cm were statistically significant risk factors for recurrence in patients with stage I NSCLC. The 5-year progression-free survival rate was 93.0%, 73.8%, and 40.6% for stage I patients with no, 1 or 2, and >2 risk factors, respectively (P<.001). In addition to tumor size, we identified 3 other independent risk factors for recurrence in patients with stage I NSCLC. These 3 risk factors warrant consideration as additional predictors in the next version of the TNM staging system.

γ-Glutamyltranspeptidase is a prognostic marker of survival and recurrence in radiofrequency-ablation treatment of hepatocellular carcinoma.

Serum γ-glutamyltranspeptidase (GGT) level, which is often elevated in hepatocellular carcinoma (HCC), has now been found to be an oxidative stress marker which correlates with inflammation in the extracellular hepatic microenvironment. The aim of this study was to investigate the prognostic significance of GGT serum levels in patients undergoing radiofrequency ablation (RFA) therapy for the treatment of HCC. This retrospective study included 254 patients with small liver cancer (tumor of ≤5 cm in diameter and nodule of ≤3 cm) who had been treated with RFA. Baseline serum GGT was examined before therapy, and overall survival (OS) and recurrence-free survival were evaluated by the Kaplan-Meier method. Univariate and multivariate analyses were used to analyze the significance of GGT and other serum markers as prognostic factors. After a median follow-up of 27 months, 51 patients had died and 123 had hepatic recurrence. After treatment with RFA, HCC patients with elevated GGT had a shorter OS versus those with normal GGT level (p = 0.001); they also had higher recurrence (p = 0.001). On multivariate analysis, albumin (p = 0.003), GGT (p = 0.035), and tumor size (p = 0.027) were independent risk factors for survival, and GGT (p = 0.010) and tumor size (p = 0.026) were significant risk factors for recurrence. Serum GGT is a convenient prognostic biomarker related to OS and recurrence in HCC patients undergoing RFA treatment.

Chondrosarcoma of the hyoid bone: Case report and review of current management options

We describe a 53-year-old man who presented with a painless neck mass and underwent a resection that identified the tumor as a low-grade chondrosarcoma of the hyoid bone. We reviewed the literature for diagnosis and management options of this exceptionally rare diagnosis. We conducted a search of the published medical literature before September 2012 in MEDLINE and PubMed using the terms "chondrosarcoma" and "hyoid." The search led to 19 case reports. We then searched for recent advances in diagnosis and treatment. Chondrosarcomas of the hyoid bone present as slow-growing, painless masses of the neck. CT and MRI are useful for imaging, but definitive diagnosis is made by biopsy. The preferred treatment is complete surgical removal, whereas radiation is used as adjuvant therapy. Positive surgical margin is a significant risk factor for recurrence. Long-term follow-up is recommended because of recurrences many years later.

Recurrence of Clostridium difficile infection among veterans with spinal cord injury and disorder

Recurrent Clostridium difficile (CDI) infection is a growing concern; however, there are little data on impact of recurrent CDI on those with spinal cord injury and disorder (SCI/D). Therefore, the objective of this study was to identify risk factors associated with recurrence of CDI among Veterans with SCI/D. This was a retrospective cohort study with data from outpatient, inpatient, and extended care settings at 83 Department of Veterans Affairs facilities from 2002 to 2009. Of 1,464 cases of CDI analyzed, 315 cases (21.5%) had a first recurrence of CDI. Multivariable regression demonstrated that risk factors significantly associated with increased recurrence were concomitant fluoroquinolone use (odds ratio [OR], 1.39; 95% confidence interval [CI]: 1.08-1.80), whereas concomitant tetracycline use (OR, 0.35; 95% CI: 0.14-0.90), and cerebrovascular accident (OR, 0.46; 95% CI: 0.25-0.85) were associated with decreased recurrence. A subanalysis in those with health care facility-onset CDI showed that increased length of stay postinitial CDI was a significant risk factor for recurrence as was concomitant use of fluoroquinolones and that tetracycline remained protective for recurrence. Concomitant fluoroquinolone use was a risk factor for the recurrence of CDI. In contrast, tetracyclines and cerebrovascular accident were protective. Length of stay greater than 90 days from the initial CDI episode was also a risk factor for recurrence among those with health care facility-onset CDI. Future studies should focus on effective strategies to prevent these risk factors among the SCI/D population.

Surgical treatment of aortic valve endocarditis: a 26-year experience.

ObjectiveWe have retrospectively analyzed the results of the operations made for aortic valve endocarditis in a single center in 26 years.MethodsFrom June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years.ResultsTwo hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up.ConclusionSurgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low.

Analysis of risk factors for recurrence after curative resection of well‐differentiated pancreatic neuroendocrine tumors based on the new grading classification

It is difficult to predict the malignant potential of pancreatic neuroendocrine tumors (PNETs) precisely. This study investigated the validity of a new grading system adopted by the World Health Organization 2010 classification to determine risk factors for recurrence of PNETs. Data of 70 patients with PNETs who underwent curative resection were retrospectively examined by uni- and multivariate analyses. Histopathological findings were re-reviewed by experienced pathologists. NET G1 was defined as mitotic count <2 per 10 high power fields (HPF) and/or ≤2% Ki67 index, and NET G2 as 2-20 mitosis per 10 HPF and/or 3-20% Ki67 index. There were 58 patients with NET G1 and 12 with NET G2. Incidence of recurrence was 11.4%. Univariate analysis demonstrated significant risk factors for recurrence including NET G2 of histological grade (P = 0.0089), male gender (P = 0.0333), tumor size ≥ 20 mm (P = 0.0117), lymph node metastasis (P = 0.0004), liver metastasis (P < 0.0001), lymphatic invasion (P = 0.046), and neural invasion (P = 0.0002). By multivariate analysis, histological grade (hazard ratio; 59.76, P = 0.0022) and neural invasion (hazard ratio; 147.49, P = 0.0016) were significantly associated with recurrence of PNETs. This study confirmed the prognostic relevance of the new grading classification and that evaluation of perineural invasion and histological grade should be considered as prognostic predictors in well-differentiated PNETs (NET G1 and G2).

Recurrence of ovarian endometrioma after laparoscopic excision: Risk factors and prevention

The aim of this study was to assess the cut-off age of the risk factors for postoperative recurrence of ovarian endometriomas and to evaluate the end-points of follow-up after laparoscopic excision of ovarian endometriomas. We retrospectively reviewed 167 patients who underwent laparoscopic excision of ovarian endometriomas at our hospital between 2000 and 2009, and followed up the patients until 2010. Following surgery, patients chose to receive gonadotrophin-releasing hormone agonist, oral contraceptive pills (OCP), dienogest, or no medication and underwent regular ultrasonographic examinations. Potential risk factors for recurrence, including age at surgery, were assessed in the patients receiving no medication. Postoperative recurrence, defined as re-appearance of an ovarian endometrioma > 2 cm in size, was assessed for each treatment group. Age at surgery was the only significant risk factor for recurrence, at a cut-off of 32 years, obtained through receiver-operator curve analysis. In patients not receiving medication, the recurrence rate gradually increased up to 50% over 5 years; there was no recurrence 5 years after surgery. Although no recurrence was seen in patients during continuous treatment with OCP or dienogest, the disease recurred in 55.5% of patients after discontinuing OCP. Although adjuvant therapy for all patients may represent overtreatment, the findings of the present study suggest that, in the interest of fertility preservation, continuous postoperative hormonal treatment should be administered, at least to patients younger than 32 years. In patients who decline hormonal treatment, we recommend that they undergo follow-up for recurrence until 5 years after surgery.

Focal Segmental Glomerulosclerosis in Children

Focal segmental glomerulosclerosis (FSGS), the second leading cause of end stage renal disease in children, appears to be increasing. Moreover, posttransplantation FSGS recurrence is a major problem, and there is concern that children receiving kidneys from living donors (LD) have increased recurrence risk. Data from the United Network for Organ Sharing from 1988 to 2008 were analyzed for number of de novo transplant recipients with a primary diagnosis of FSGS in children 1 to 20 years of age. Poisson regression was used for trend analysis. Univariate and multivariable logistic regression analyses were performed to examine the association of gender, race, human leukocyte antigen matching, age, and donor type with recurrence. Trend analysis of kidney transplantations for FSGS in children (n=2157) showed an increase in cases of 5.8% per year or 209% over 20 years (P<0.0001). Recurrence was reported in 327 (15%) cases overall, with a preponderance for white recipients (P<0.001) in younger age subgroups (P<0.01). Donor type was significant (P=0.02), with recurrence reported in 17% versus 14% of recipients of kidneys from LDs versus deceased donors. Using multivariate analysis, recipients' young age (P=0.02) and white race (P<0.001) were identified as significant risk factors for recurrence, whereas receiving a LD kidney became insignificant. FSGS as a cause of pediatric end-stage renal disease leading to transplantation is on the rise. FSGS recurrence is highest in young, white children, whereas receiving a LD kidney is not independently associated with increased risk of recurrence.

Could the types of paraclinoid aneurysm be used as a criterion in choosing endovascular treatment? Neuro-radiologists’ view

The type of paraclinoid aneurysm has been used to decide management methods. Our aim was to assess the relation of the types of paraclinoid aneurysms and outcomes after endovascular treatment and the efficiency of present endovascular techniques. A retrospective analysis was performed on patients with saccular paraclinoid aneurysms that had more than 6months of angiographic follow-up or recurrence within this period after endovascular treatment from January 2009 to December 2010. Paraclinoid aneurysms were classified into two types and then further into four subtypes by a modified classification method. A classification-based microcatheter shaping method was used in the procedure. The significant risk factors of angiographic results were determined through correlation analysis and logistic regression analysis by SPSS 17.0. There were 64 aneurysms in 56 patients; 28 aneurysms belonged to Type I, while 36 were Type II. A total of 12 aneurysms were managed with coil embolization, and 52 with stent-assisted coiling technique. Our classification-based microcatheter shaping method was successful in all cases. Coil protrusion happened in two cases without severe complications. Recurrence were found in 13 (20.3%) aneurysms followed up at 12.42 ± 3.78 (mean±SD) months after treatment. The correlation between aneurysm types and immediate angiographic result or follow-up angiographic results did not reach statistical significance. Aneurysm types were not the risk factor of recurrence. The types of paraclinoid aneurysm had not been significant correlated with outcomes of endovascular treatment. Fundus size was the significant risk factor of recurrence after endovascular treatment. A classification-based microcatheter shaping method may be used in endovascular treatment paraclinoid aneurysms. The present endovascular techniques are safe and effective.