Single-institution Retrospective Series Research Articles

Experience in the Management of Eighty-Two Newborns With Congenital Diaphragmatic Hernia Treated With High-Frequency Oscillatory Ventilation and Delayed Surgery Without the Use of Extracorporeal Membrane Oxygenation

The aim of this study is to analyze neonatal outcome of isolated congenital diaphragmatic hernia and to identify prenatal and postnatal prognosis-related factors. A retrospective single institution series from January 2000 to November 2005 of isolated congenital diaphragmatic hernia neonates was reviewed. Respiratory-care strategy was early high-frequency oscillatory ventilation, nitric oxide in pulmonary hypertension, and delayed surgery after respiratory and hemodynamic stabilization. Survival rate at 1 month was 65.9%. None of the prenatal factors were predictive of neonatal outcome, except an intra-abdominal stomach in left diaphragmatic hernia. Preoperative pulmonary hypertension was more severe in the nonsurvivor group and was predictive of length of ventilation in the survivors. During the first 48 hours of life, the best oxygenation index above 13 and the best PaCO2 above 45 were predictive of poor outcome. When treating isolated congenital diaphragmatic hernia with early high-frequency ventilation and delayed surgery but excluding extracorporeal membrane oxygenation, survival rates compare favorably with other reported series, and the respiratory morbidity is low.

Primary Tumor Resection in Stage IV Breast Cancer: Consistent Benefit, or Consistent Bias?

The recommended primary treatment approach for women with metastatic breast cancer and an intact primary tumor is the use of systemic therapy, with local therapy for the primary tumor reserved for palliation of symptoms. The past 6 years have seen an accelerating pace of publication of studies examining survival outcomes relative to the surgical resection of the intact primary tumor in women with metastatic breast cancer. 1–4 These show that in fact about half the women presenting with de novo metastatic disease undergo resection of the primary tumor and suggest that women so treated survive longer than those treated without resection. In analyses that adjust for tumor burden (number of metastatic sites), types of metastases (visceral, nonvisceral), and the use of systemic therapy, the hazard of death is reduced by 40–50% in women receiving surgical treatment of the primary tumor. Thus, five retrospective studies including the report by Fields et al. 5 in the present issue of the Annals of Surgical Oncology, present us with consistent evidence that either surgical therapy of the primary tumor has a substantial survival benefit in women with metastatic breast cancer, or there is a strong and consistent selection bias driving the use of surgery in women who have more favorable profiles (i.e., younger age, smaller tumor burden, better access to care). It is also possible that surgery is a surrogate indicator of more aggressive therapy overall, including more aggressive systemic therapy, which translates into better survival. All authors acknowledge the problem of selection bias in the interpretation of these data, and all advocate for a randomized trial to settle this question. In this setting, what can we learn from additional single-institution retrospective series addressing this question? Single-institution studies are necessarily smaller than the large data sets that are available from the National Cancer Database (NCDB) 1 and the Surveillance, Epidemiology, and End-Results (SEER) program, 4 but provide richer detail regarding the specifics of local and systemic therapy and the course of the local disease. Such detailed information can garner data on trends and practices to guide the design of a randomized trial. Local therapy questions that require further definition include the timing of surgery, the importance of free surgical margins, and the benefit of axillary clearance and radiotherapy. Additionally, data from single-institution series may generate hypotheses regarding subsets of patients who are more likely to benefit from local therapy. The timing of surgery (early, after response to systemic therapy or later, only if indicated for palliation) has not been examined in any detail, although large databases such as NCDB and SEER capture the first course of treatment most accurately, and therefore women reported as having had surgical therapy would most likely have received this early in their course. This issue is relevant to the hypothesis that local therapy of the primary tumor is beneficial for

EAU Guidelines on Urological Trauma

Purpose: To determine the optimal evaluation and management of genitourinary (renal, ureteral, bladder, urethral and genital) injuries by review of the world's literature on the subject. Methods: A consensus committee convened by the Health Care Office of the European Association of Urology (EAU) to summarize the literature concerning the diagnosis and treatment of genitourinary trauma. Results: Findings of 350 citations are reviewed. Conclusions: The genitourinary trauma literature still relies heavily on expert opinion and single-institution retrospective series. Future prospective trials of the most significant issues, when possible, might improve the quality of evidence that dictates practitioner behavior. This paper represents a 5000 word summary of the full 35,000 word report. Full text of this review is available online at http://www.europeanurology.com.

Review of radiotherapy dose and volume for intracranial ependymoma.

Radiotherapy (RT) is well established in the management of intracranial ependymoma (EP) and post-operative RT is employed for the majority of patients. There are no randomised trials of RT in EP and evidence for dose and volume relies on retrospective single institution series, usually comprising a heterogeneous mix of relatively small numbers of patients recruited over several decades. The literature including RT dose and response data reported since the early 1990s was reviewed. Five-year overall survival (OS) ranges from 40 to 79%. There is some evidence of a dose response relationship from <45 Gy to >50 Gy. In the majority of series outcome is related to WHO grade and extent of resection. There is no evidence of benefit for 'prophylactic' craniospinal RT (CSRT). In all series there is a significant risk of local recurrence, usually within the target volume. Early results of conformal RT have suggested that a margin for CTV of 1 cm around the post-operative tumour bed and any residual GTV is feasible. The main aims of future studies will be to maximise the number of patients achieving complete resection, and RT dose escalation. Hyperfractionated radiotherapy (HFRT) has been employed in some studies and results are awaited. The role of CSRT needs to be evaluated further for patients presenting with leptomeningeal metastases. Multi-institutional and international studies are necessary to improve understanding of the clinical behaviour, biology and management of EP.

Multimodality treatment for patients with hepatocellular carcinoma: a single institution retrospective series

Background: The main therapeutic options for hepatocellular carcinoma (HCC) are hepatic resection, transcatheter arterial embolization (TAE), percutaneous ethanol injection therapy (PEIT) and regional chemotherapy (RC).Methods This study retrospectively examined the results of primary treatment of 600 patients with hepatocellular carcinoma selected according to the treatment guidelines of our facility and the results of various combination therapies for recurrent cases. The selection criteria of therapeutic options included the number and size of tumours and hepatic function. Results The selected primary treatment was hepatic resection for 53.7% of the cases, TAE for 31.5%, PEIT for 8.2% and RC for 6.6%. The treatment for post-resection recurrence was TAE alone for 62.4% of the cases, TAE+RC for 4.0%, PEIT for 15.2%, TAE+PEIT alone for 4.8%, RC for 8.0% and hepatic resection for 5.6%. The treatment for post-TAE recurrence was TAE alone for 83% of the cases, TAE+PEIT for 9%, TAE+RC for 3%, RC alone for 3% and PEIT alone for 2%. For post-PEIT, therapy was PEIT alone for 71.4% of the cases and PEIT+TAE for 28.6%. For post-RC, RC alone was used for 92.5% and RC+PEIT for 7.5%. The cumulative 3 and 5-year survival rates were 84.4% and 70.6% respectively for stage I; 61.5% and 48.6% for stage II; 52.7% and 20.5% for stage III; and 22.8% and 17.1% for stage IVA. The cumulative 5 and 7-year survival rates after the primary treatments were 52.0% and 40.1%, respectively, for hepatic resection; 46.5% and 38.7% for TAE; 49.6% and 33.1% for PEIT; and 16.7% and 8.3% for RC.Conclusions To improve the treatment results for HCC, early detection is essential and various modalities of treatments in combination should be used for recurrence after primary treatment.