Single Team Experience Research Articles

A Little Talk on Adamkiewicz's Artery. Some Practical Considerations on the Pre-Operative Identification of This Artery Starting from a Single Team Experience in Pre-Surgical Selective Embolization of Vascularized Spinal Lesions

The major radicular artery eponymically named "Adamkiewicz's artery" (AKA) is an important vessel supplying the spinal cord, especially the lumbar enlargement. This report emphasizes the importance of anatomical knowledge of this artery and highlights the concept of the potential risk of neurological complications during different procedures: spine orthopedic/neurosurgery, aortic repair (vascular surgery) and endovascular selective embolizations performed by interventional neuro/radiologists. Anatomical considerations are made on the spinal cord arterial circulation with a special focus on the AKA. Our review of the literature considered this anatomical element essential to compare the potential risk of spinal cord ischemic damage during orthopedic/neurosurgical spine procedures, aortic vascular surgery repair procedures and endovascular selective arterial embolizations. Evaluation of the endovascular selective arterial spine embolization risk was based on our series of 410 embolization procedures. Spinal cord infarction and transient or permanent paraplegia may result from inadvertent interruption of the AKA. The presence of intersegmental collaterals may decrease the risk of spinal cord ischemia: this is an important element to bear in mind that may help in spine surgery or aortic repair procedures performed by vascular surgeons. Nevertheless, during aortic repair (open surgery or stent-graft procedures) interruption of bilateral segmental arteries at multiple consecutive levels including that of the AKA may occur thereby increasing the ischemic spinal cord risk, annulling the benefit of intersegmental collaterals. Accidental embolizations of the AKA during endovascular spine procedures (i.e. selective arterial embolizations) performed by interventional neuro/radiologists will cause an almost certain spinal cord infarction due to the consequent embolizations of the anterior spinal artery (ASA).

Conservative surgery plus brachytherapy treatment for boys with prostate and/or bladder neck rhabdomyosarcoma: a single team experience

Purpose The aim of this study is to report the results of a conservative surgery + brachytherapy treatment for boys with prostate and/or bladder-neck rhabdomyosarcoma avoiding total cystectomy or prostatectomy and external radiotherapy. Patients From 1991 to 2007, 26 boys were operated for a residual mass after chemotherapy (1 for local relapse). All patients underwent a conservative surgical procedure, with bladder-neck and urethra preservation. Surgery was never microscopically complete. Brachytherapy was systematically performed after tumor resection, as a perioperative procedure, consisting of 2 loops encompassing the prostate and the bladder-neck area. A dose of 60 Gy was delivered with low dose rate. Bladder function was evaluated clinically and with urodynamic study for boys with abnormal continence. Results Median age at operation was 23 months (9 months-11 years). Seventeen boys underwent a partial prostatectomy associated in 5 with a partial cystectomy. The remaining 9 patients underwent a partial cystectomy with no procedure at the level of the prostate. At a median follow-up of 4 years (10 months-14.5 years), 24 of 26 boys are alive. Only 1 patient relapsed locally out of the brachytherapy field and died. A second boy died from metastatic relapse. Only 1 patient with bladder dysfunction after treatment underwent a total cystectomy. Four patients are too young to be evaluated for bladder function (<4 years of age). Seven patients, aged 4 to 6 years, have daytime continence, 1 has diurnal dribbling. Among 11 boys older than 6 years, 9 (82%) are normally continent (3 after temporary dribbling), 2 have diurnal dribbling treated by bladder education. Conclusion Even if very long-term sequelae of brachytherapy cannot be evaluated, this conservative combined treatment may allow normal continence in nearly all patients, even after temporary diurnal incontinence and should be discussed as an alternative to external radiotherapy or radical surgery.

A single team experience of adjuvant radiation therapy in adults with intermediate or high-grade limb soft tissue sarcoma

19509 Background: Limb Soft tissue sarcomas (STS) are currently treated with limb sparing surgery (LSS) followed by radiation therapy (RT). This paper summarizes a one-team experience with homogenous population of adult patients, with intermediate or high grade STS confined to a limb, who were approached by LSS and postoperative RT. Methods: From October 1994 through October 2002, 133 adult patients (75 males, 58 females, age range 18–88 years, median 54) with biopsy-proven intermediate or high-grade limb STS were approached by LSS followed by RT. Their files were retrospectively reviewed for treatment outcome: local control, RT side effects, and time to progression. Tumor site was classified according to its proximal border. STS that involved the arm and the upper axilla was classified as axillary STS. Results: RT related toxicity was manageable, with a low rate of severe effects. At 4-year median follow up, there were 48 recurrences of any type, 23 of isolated local failure, and 35 of systemic spread w/o local failure. DFS and OS were influenced by disease stage II versus I, primary site in the upper limb versus lower limb, MPNST versus other types, induction therapy versus no induction, adequate resection Vs marginal resection or involved margins, and good response to induction therapy versus bad response. DFS and OS were Patient’s age and sex, tumor depth, acute or late toxicity of RT, or the interval of time between the date of definitive surgery and the start of RT did not affect DFS and or OS. Conclusions: The RT protocol is applicable in the era of complicated, expensive and time-consuming 3-D therapy. Our results of LSS + RT in adults with limb HG STS are satisfactory. No significant financial relationships to disclose.

A single-team experience of limb sparing approach in adults with high-grade malignant fibrous histiocytoma

Malignant fibrous histiocytoma (MFH) is the most common subtype of soft-tissue sarcoma (STS). When located in a limb, MFH, is currently treated with limb sparing surgery (LSS) followed by radiation therapy (RT). During 8 years, 42 adult patients with high-grade limb MFH were approached by LSS and RT. Our results reflect a single-team experience and point to several important conclusions. High grade MFH, treated by conservative approach, lead to a 10-year relapse-free survival of 62% and a 10-year overall survival rate of 80%. Recurrences of MFH tend to occur during the first 2 years. Relapse-free survival was affected mainly by location in the lower limb vs. the upper limb, irrespective of the tumor size. Patients who had their diagnostic biopsies in another medical center had a greater tendency to local and systemic relapse. It seems that the most important clues for disease-free survival are the team experience and cooperation. All other factors are tumor-biology dependent, and thus far are beyond our control.

Induction of labor in pregnancies with suspected large-for-gestational-age fetuses and unfavorable cervix

Objectives: To evaluate our single-center, single-team experience with induction of labor in pregnancies with suspected large for gestational age (LGA) fetuses. Study design: A retrospective case-controlled design was used. Non-diabetic patients with a suspected LGA fetus (estimated fetal weight ≥90th percentile) (group 1, n=135) were compared with healthy patients admitted for elective induction of labor for either post-date pregnancy or a subjective perception of decreased fetal movements in the presence of normal fetal heart monitoring and biophysical profile (group 2, n=326), and with healthy women with normal pregnancies and spontaneous onset of labor (group 3, n=574). Results: There were no between-group differences in maternal age, parity, number of prostaglandin E2 (PGE2) tablets used, instrumental delivery rate or Apgar scores. The rate of cesarean section (CS) was significantly higher in the study group (33.3%) than in group 2 (17.8%, P=0.001) and group 3 (10.6%, P=0.004), although this difference disappeared when the multiparous women were analyzed separately (study group: n=58, 10.3% versus group 2: n=169, 7.7% and group 3: n=308, 7.8%, P=0.6). A logistic regression model ( R 2=0.385, P<0.001) was used to control for maternal and gestational age, nulliparity rate, number of PGE2 tablets used, birth weight, and diagnosis (group 1 versus group 2) as predictors of mode of delivery. On stepwise (forward-likelihood) analysis, only nulliparity (odds ratio (OR) 10.0, 95% confidence interval (CI) 2.8–35.6, P<0.001) and maternal age (OR 1.2, 95% CI 1.06–1.36, P=0.002) were independently and significantly associated with increased risk of CS. Conclusions: Induction of labor for suspected LGA fetuses, if performed at all, should be reserved for multiparous women.