Three-year Actuarial Survival Research Articles

Predictors of Outcomes in Patients With Clinically Lymph Node Positive Prostate Cancer After Definitive Radiotherapy.

Studies have suggested that benefits of definitive radiotherapy might be limited to specific patients in clinically lymph node positive (cN1) prostate cancer (PC). However, the beneficial subgroup remains to be elucidated. This study aimed to analyze survival outcomes and prognostic factors after definitive radiotherapy and androgen deprivation therapy (definitive RT+ADT) in these patients and to define subgroups of patients who would benefit from definitive RT+ADT the most. A total of 60 patients with cN1 PC treated with definitive RT+ADT in a single tertiary hospital were accrued. Their clinicopathological variables were analyzed and a new subgroup was identified based on statistically significant variables. At a median follow-up of 31 months, ADT duration ≥24 months (p=0.043, HR=0.26) and positive biopsy core ≥75% (p=0.044, HR=5.29) showed significant relationships with distant metastasis-free survival. Overall survival showed significant relationships with ADT duration ≥24 months (p=0.002, HR=0.06) and number of lymph node (LN) metastases ≥4 (p=0.019, HR=7.17). For prognostic subgroup analysis, patients were divided into three risk groups: low-risk group (LN metastases <4 and ADT ≥24 months), high-risk group (LN metastases ≥4 and ADT <24 months), and intermediate-risk group (all remaining cases). Three-year actuarial overall survival rates for the low-, intermediate-, and high-risk groups were 100%, 93.3%, and 45.7%. ADT duration and number of LN metastases were important prognostic factors in patients with cN1 PC receiving definitive RT+ADT, with low-risk cN1 PC patients showing better outcomes than others.

Biliary Anastomosis Using T-tube Versus No T-tube for Liver Transplantation in Adults: A Review of Literature.

The T-tube-directed biliary anastomosis in orthotopic liver transplantation (OLT) aims to minimize preventable biliary complications, including bile leaks and strictures. Biliary complications in patients with OLT increase the risk of morbidity and mortality. This review paper evaluated the current evidence on the routine use of T-tube reconstruction in OLT cases.A review of prospective, retrospective, observational, cohort studies as well as systematic reviews, meta-analyses, review papers, and opinion papers has been conducted to evaluate the therapeutic potential of T tube-based biliary anastomosis in cases of OLT.Our finding showed a bile leak incidence of 16.6% and 6.6% in T-tube and non-T-tube groups, respectively. The results indicated a lower incidence of anastomotic fistulae in the non-T-tube group (0.6%) compared to the T-tube group (4%). The findings negated statistically significant differences in the three-year actuarial survival rates based on biliary anastomosis with and without T-tube intervention (62.5% vs. 69.8%). The studies revealed a 6-11% and 2-11% incidence of cholangitis in OLT patients with T-tube-based reconstruction and those without a T-tube, respectively, and 26% and 20% incidence of total biliary complications in OLT patients with and without T-tube, respectively. In addition, the findings ruled out the influence of a T-tube on the incidence of perioperative complications, endoscopies, and reoperations in OLT cases.The current evidence correlates the increased incidence of bile leaks, cholangitis, and overall biliary complications with the use of a T-tube during OLT. In addition, T-tube-guided reconstruction has no impact on perioperative complications, overall survival, endoscopies, and reoperations in OLT cases.

Abstract P1-16-02: The impact of locoregional treatment on survival in patients with metastatic breast cancer: A national cancer database analysis

Abstract Purpose and Objectives: Although systemic therapy is the standard treatment for metastatic breast cancer, the value of locoregional treatment (LRT) to the primary tumor and its impact on survival is controversial. This study evaluates survival outcomes in patients with metastatic breast cancer after receiving LRT (surgery and/or radiation therapy) to the primary tumor. Materials and Methods: The National Cancer Database (NCDB) identified 16,128 qualifying cases of stage IV breast cancer (M1, 2004-2013) who received systemic therapy with or without local therapy. Treatment modality was divided into surgery, radiation therapy (RT), surgery with RT (Sx+RT), and no LRT. Median survival and three-year actuarial survival rates (OS) were analyzed for each treatment group. On multivariate analyses, adjusted hazard ratios (HR) with 95% confidence interval were computed using Cox regression modeling to adjust for patient characteristics, year of diagnosis, clinical T and N staging, and facility type. Additionally, survival outcomes for each treatment group were analyzed by metastasis groups (bone, visceral, multiple). Results: A temporal trend of each treatment modality used in years 2004 – 2013 illustrated that the relative use of LRT decreased from 47.2% to 36.2% (p for trend = 0.041). Overall, the median follow-up was 28.3 months and median survival for all patients was 37.2 months. With 9,761 deaths reported, the estimated 3-year survival rate for all patients was 51.3%. The Sx+RT group (n = 2,166) had the highest 3-year survival rate of 69.4%, followed by the surgery group (n = 4,293) with 57.6%, no LRT group (n = 8,955) with 44.3%, and RT group (n = 714) with 41.5% (p &amp;lt; 0.0001). On multivariate analysis, a decreased hazard of death (adjusted HR, 95% CI) was noted in radiation patients compared to no LRT group but without statistical significance (0.91, 0.81-1.0, p = 0.057). Patients receiving surgery (0.68, 0.65-0.71, p &amp;lt; 0.0001) and Sx+RT group (0.46, 0.43-0.49, p &amp;lt; 0.0001) reported statistically significant improved survival compared to the no LRT group. Additionally, later year of diagnosis, low Charlson-Deyo score, high income, private insurance, white race, age 18 - &amp;lt;50, low T and N stage, ductal histology, positive ER/PR/HER2 status, bone only metastasis, and academic facility type were considered favorable factors for OS. When stratified by metastasis type, patients with bone metastasis had the longest 3-year survival rates (74.4% for Sx+RT, 69.4% for surgery, 53.8% for no LRT, 49.3% for RT, p &amp;lt; 0.0001) whereas patients with multiple metastases had the worst outcomes (56.0% for Sx+RT, 43.5% for surgery, 37.9% for no LRT, 34.4% for RT, p = 0.003). Conclusion: Patients with metastatic breast cancer have a large range of survival rates. Locoregional treatment, especially surgery followed by RT, in addition to systemic therapy was associated with improved survival in metastatic breast cancer patients. When survival rates for each treatment modality was stratified by metastasis location, the most favorable survival was observed for the surgery with follow-up radiation group, which is consistent with the overall analysis. Citation Format: Kim KN, Huang D, Qureshi MM, Ko NY, Hirsch AE. The impact of locoregional treatment on survival in patients with metastatic breast cancer: A national cancer database analysis [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-16-02.

Human Papilloma Virus-positive Oropharyngeal Squamous Cell Carcinoma in the Elderly.

Elderly patients with HPV+ oropharyngeal cancer (OPC) represent an understudied cohort of the HPV epidemic. We aimed to investigate the clinical presentation, treatment tolerability and outcomes in patient's ≥65 years old with HPV+ OPC. We identified all patients aged 65 and older treated at our Institution with HPV+ OPC and analyzed patient demographics, disease characteristics, treatment modalities, toxicities, treatment failures, and survival. Charlson comorbidity index was calculated for each patient. 43 patients were identified with a mean age of median age was 70.0 (range 65-86). The mean Charlson comorbidity index score for the cohort was 5.2. In total, 72.1% of patients received what was considered standard-of-care based on stage and pathological features. Nine point three percent of patients required RT-related treatment breaks with the majority being women (75%). Three-year actuarial overall survival was 85.5% (95% CI: 71.4%-100%) and 3-year disease-free survival was 67.3% (95% CI: 49.7-91.0%). This study presented one of the largest series to date evaluating HPV-related OPC in patients ≥65. Elderly individuals with HPV+ OPC have favorable overall survival with high treatment tolerability independent of Charlson co-morbidity score. Elderly patients should be considered for stage-appropriate care with omission of specific therapies based on absolute contraindications and patient preference, but not assumptions regarding tolerability.

Squamous cell carcinoma of the oropharynx: single-institution outcome analysis of patients treated with concurrent chemoradiotherapy.

The object of this study was to analyse our experience with the effects of concurrent chemoradiotherapy for oropharyngeal squamous cell carcinoma, the treatment results of this therapeutic strategy and a salvage treatment for recurrent oropharyngeal squamous cell carcinoma. Seventy-five patients with oropharyngeal squamous cell carcinoma were treated with chemoradiotherapy. The study included twenty-five of these patients who had recurrent oropharyngeal squamous cell carcinoma after chemoradiotherapy Results: The three-year actuarial survival rates for 75 patients by disease stage were as follows: stage II, 100 per cent; stage III, 71.1 per cent; stage IV, 51.7 per cent and overall, 58.2 per cent. The mean time of detection of recurrence was 6.2 months. The total salvage rates of recurrence were 21 per cent. The one and three-year tumour-free actuarial survival rates of those patients who received salvage treatment were 83 and 33 per cent. Surgical salvage was only feasible for early recurrent tumour. Close follow-up surveillance of early recurrence is essential after primary treatment of patients with chemoradiotherapy.

Clinical and laboratory presentations of Janus Kinase II-positive patients in Saudi population

Introduction: Janus Kinase II (JAK-II) mutation has a pivotal role in the pathogenesis of the myeloproliferative neoplasms (MPN) and has been shown to be involved in thrombotic complications of these diseases. However, there are limited data regarding clinic-biological features and cytogenetic abnormalities in the Saudi population. Aim: The main aim of this study was to examine clinical presentations, laboratory findings and prognosis of JAK-II-positive Saudi population referred to KFSHRC for testing for variable indications. Methods: A total of 200 patients was referred to our institute for JAK-II mutation testing by polymerase chain reaction based on clinical/laboratory suspicion; about 102 (51%) proved positive. Of the positive cohort, only 62 patients had completed evaluable medical records. Results: Their mean age was 48.2 (range: 16-81) years and 51.6% were males. About 75% had symptoms such as headache 13 [21%]; pruritus 9 [14.5%], visual 7 [11.3%], erythromelalgia 2 [3.2%], and none specific symptoms like fatigue/weakness abdominal discomfort in 30 (48.2%) while the remaining 25% were diagnosed incidentally from abnormal complete blood cells. Clinic-radiological features included: Splenomegaly (53.6%), hepatomegaly (24%), and skin lesions (8%). Thrombosis of portal, hepatic, splenic and mesenteric veins was seen in 24%, stroke and transient ischemic attack in 14%, deep vein thrombosis and pulmonary embolism in 11.2%, ischemic heart disease in 9.6% and 3.2% had arterial thrombosis. The mean peripheral blood count showed white blood cell 13.3 × 109/l, hemoglobin 147.3 g/l and platelets 714 × 109/l. Of the 35 patients evaluated by bone marrow biopsy, the majority (80%) had hyperculluarity. Cytogenetic abnormalities were found in 7 (20%) of the 35 patients and one patient had both JAK-II and BCR/ABL mutations. All the positive patients except 3 (4.8%) were diagnosed as MPNs, 29 (46.7%) polycythemia vera, 24 (38.7%) essential thrombocythemia, 2 (3.2%) primary myelofibrosis and MPN-not otherwise specified in 1 (1.6%). Treatment modalities including hydroxyurea, anagrelide, and thalidomide were used in 75%, antiplatelets were used in nearly 2/3 (61.3%) and 29% of patients required anticoagulants. Three-year actuarial survival was 87% with death related mainly to progressive fibrosis and cytopenia, thrombotic complications necessitating major surgeries, pneumonia or sepsis.

Complete metabolic response after definitive radiation therapy for cervical cancer: Patterns and factors predicting for recurrence

PurposeThe purpose of this study was to determine the patterns of failure in patients diagnosed with cervical cancer treated with definitive radiotherapy and who subsequently had complete metabolic response (CMR) seen on early post-therapy (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging. Additionally, we sought to determine what factors predict disease recurrence in this patient population. Methods and materialsWe reviewed the records of 155 patients diagnosed with cervical cancer from stages IB1 to IVA who were treated with definitive chemoradiation therapy between 2003 and 2011 and had a FDG-PET at 10–16weeks following completion of therapy. One hundred and twelve (72.0%) had CMR on follow-up FDG-PET and comprised the patients in this study. ResultsThe median age of patients with CMR was 51years and the median tumor size 4.9cm. Median follow up was 15months. Of the 112 patients, 11 (9.8%) had a recurrence and six (5.4%) had isolated local recurrences, and five (4.5%) had distant recurrence. Median time to recurrence was 9months. Three-year actuarial disease-free survival and overall survival rates were 78.9% and 88.0% respectively. On Cox regression multivariate analysis, tumor size was predictive of increased risk of local recurrence in these patients with CMR with p<0.025. Age, stage, histology and nodal positivity were not significant for predicting local, distant or any recurrence. ConclusionPatients treated with concurrent chemoradiation had a CMR which demonstrated good clinical outcomes in terms of local control. There were equal numbers of patients suffering local and distant recurrences. In patients with a CMR, only tumor size was an independent predictor for local recurrence.

Diagnosis and surgical therapy of lung metastases

Operations for pulmonary metastases were carried out on 33 patients from January 1st 1976 to December 31st 1985 at the Surgical Division, University of Cologne. In six cases each, the primary tumors were hypernephromas, colorectal carcinomas and osteocarcinoma. There were five cases of melanoma, three cases of testicular carcinoma, two cases of corpus carcinoma and two cases of soft-tissue sarcoma as well as one case each of parotid, tonsillar and laryngeal carcinoma. The large number of metastases could be determined in 21 cases (64%) by means of preoperative radiodiagnostics with X-rays of the chest in two planes, conventional tomography and computer tomography of the thorax. Computer tomography was the most efficient single investigation. 17 patients received atypical resection and lobectomy was carried out in 16 cases. For all patients, the cumulative survivals revealed a one-year actuarial survival of around 70% and a three-year actuarial survival of about 20%. Patients with several metastases (two to six) had a very much poorer prognosis than patients with solitary pulmonary metastases. There was no connection between the surgical technique selected and the expected survival time in any case. The tumor-free interval between operation on the primary tumor and resection of the pulmonary metastases only had a slight prognostic significance.

Campath-1H induction therapy in African American and Hispanic first renal transplant recipients: 3-year actuarial follow-up.

In a retrospective study of the first 75 primary renal transplant patients given alemtuzumab induction at our center, 20 were African American (27%), 32 were Hispanic (43%), and 23 were non-African American, non-Hispanic (31%). Alemtuzumab was given intraoperatively and 4 days later (0.3 mg/kg), with planned low-dose maintenance mycophenolate mofetil (500 mg twice daily) and tacrolimus (targeted trough levels of 5 to 7 ng/ml) and no corticosteroid therapy after the first week. Median follow-up among ongoing survivors with a functioning graft was 45 months. Three-year actuarial patient and graft survival rates were 95% and 85% in African Americans, 89% and 78% in Hispanics, and 96% and 96% in non-African Americans, non-Hispanics, respectively (not significant). Bioavailability of tacrolimus was significantly lower among African Americans in comparison with the other patient subgroups (P<or=.002). While the incidence of biopsy-proven acute rejection was 20% (4/20) in African Americans, 19% (6/32) in Hispanics, and 13% (3/23) in non-African American, non-Hispanic (not significant), chronic allograft dysfunction occurred more frequently among African Americans (10/20) in comparison with Hispanics (8/32) and non-African American, non-Hispanics (8/23) (P=0.08, log-rank test). In addition, there was a trend at 6 and 12 months posttransplant for the mean serum creatinine to be less favorable among African American patients (P=0.08 and 0.07). No group had increased infection or malignancy. This immunosuppressive protocol appears reasonably safe for 3 years after renal transplantation but suggests higher incidences of biopsy-proven acute rejection, chronic allograft dysfunction, and borderline poorer renal function among African Americans in comparison with the other patient subgroups.

Liver Transplantation in HIV-HCV Coinfected Patients: A Case-Control Study

Liver transplantation (LT) for hepatitis C virus (HCV)-associated cirrhosis in human immunodeficiency virus (HIV)-infected patients was compared with non-HIV patients. Nine patients with HIV-HCV coinfection were compared with patients transplanted before and after each HIV patient (control group). Immunosuppression consisted in tacrolimus with steroids or mycophenolate mofetil. Acute cellular rejection and three-year actuarial patient survival were respectively 44% and 87.5% in HIV group and 22% and 93.7% in the control group (P=NS). Acute hepatitis C virus occurred earlier (2.3 vs. 4.3 months) and was more cholestatic (mean bilirubin: 10.8 vs. 1.6 mg/dL) in the HIV group. Eight (100%) HIV and nine (64.3%) control patients received antiviral treatment with pegylated interferon and ribavirin. One patient (11.1%) of the control group and one patient (20%) of the HIV group presented a sustained virologic response (P=NS). Short- to midterm results of LT in HIV-HCV co-infected patients were excellent and similar to non-HIV patients.

Neoadjuvant chemotherapy followed by concurrent chemo-radiation therapy in locally advanced nasopharyngeal carcinoma

To evaluate the efficacy and outcomes of neoadjuvant cisplatinum and epirubicin chemotherapy followed by concurrent cisplatinum chemotherapy with radiotherapy in patients with locally advanced nasopharyngeal carcinoma. One hundred ten patients (80 male, 30 female) with locally advanced nasopharyngeal carcinoma, staged according to the 1997 International Union Against Cancer/American Joint Committee on Cancer classification system as IIB (n = 9), III (n = 20), IVA (n = 32), and IVB (n = 49), World Health Organization types II (n = 25) and III (n = 85), were included in this protocol between January 1998 and July 2000 at King Faisal Specialist Hospital and Research Centre. Patients underwent two cycles of induction chemotherapy with cisplatinum 100 mg/m(2) and epirubicin 70 mg/m(2) on Days 1 and 21, followed by a radical course of radiotherapy (6,600 cGy in 6.5 weeks, 200 cGy/fraction) starting on Day 42, with three cycles of concurrent cisplatinum 25 mg/m(2) for 4 days on Days 42, 63, and 84. Of 110 patients included in this study, intracranial extension was present in 32 (29%), and nodal stage was N3 in 49 (45%). Complete remission and partial remission were achieved in 87 patients (79%) and 23 patients (21%), respectively. At a median follow-up for surviving patients of 37 months (22-55 months), 49 of 110 patients (44%) had failed treatment: 12 with local, 9 with regional nodes, 4 locoregional, 5 locoregional plus distant areas, and 19 with distant metastases. At the time of writing, 34 patients had died; all deaths were related to the patients' cancer except for 1 patient with treatment-related toxicity. Three-year actuarial overall survival, relapse-free survival, locoregional control, and distant metastasis-free survival rates were 89%, 78%, 88%, and 89% for patients with stage IIB; 71%, 70%, 89%, and 74% for stage III; 68%, 49%, 61%, and 77% for stage IVA; and 70%, 45%, 60%, and 69% for stage IVB, respectively. One patient received only one induction cycle; all others received two cycles; however, 9 of them required 20% reduction in the second cycle dose. Ninety patients (82%) completed two or more concurrent cycles of cisplatinum. Rates of Grade 3 and 4 reactions after induction chemotherapy were as follows: anemia 1% and 0%, leukopenia 8% and 4%, nausea 27% and 0%, vomiting 25% and 0%, and infection 4% and 4%, respectively. Acute Grade 3 and 4 reactions were also observed during chemoradiotherapy: anemia 1% and 0%, leukopenia 31% and 4%, nausea 35% and 0%, vomiting 26% and 2%, infection in 4% and 2%, mucositis in 49% and 0%, and skin reaction in 39% and 0%, respectively. Neoadjuvant chemotherapy followed by concurrent chemoradiotherapy is a safe and effective method of treatment for locally advanced nasopharyngeal carcinoma. Further investigations in prospective studies are required to evaluate this regimen.

Surgical treatment outcomes of localized squamous carcinoma of buccal mucosa.

The purpose of the study was to analyze the outcomes after surgical therapy (peroral wide excision) for early squamous carcinoma of the buccal mucosa. This is a retrospective study of localized squamous carcinoma of the buccal mucosa treated with peroral wide excision at a major tertiary-care hospital. A total of 147 consecutive patients were analyzed. One hundred eight patients (73.5%) had no recurrence, whereas 18 (12.2%) had a local recurrence, 11 (7.5%) had regional metastasis, and 10 (6.8%) had locoregional recurrence over a median follow-up of 46 months. Most patients with local recurrences (15 patients, 83.3%) and regional metastases (eight patients, 72%) could be salvaged with treatment. In contrast, only four patients (40%) with locoregional recurrence could be salvaged. Most of the recurrences in this study group occurred within 2 years of primary treatment (29 [74%] of 39 patients). Three-year actuarial overall survival rate and disease-free survival rates were 91% and 77%, respectively. Peroral wide excision seems to be an adequate procedure for early squamous carcinoma of buccal mucosa. Histologic grade of the tumor emerged as the only prognostic factor of significance for recurrence in this study.

Kidney transplantation from donors aged more than 65 years

BackgroundThere are no agreed criteria to predict the outcome of elderly donor kidneys or to decide between single (SKG) or dual (DKG) kidney graft transplantation. MethodsBetween January 1999 and January 2003, 46 SKG and 14 DKG were performed from elderly donors (mean donor age 71.6 years; range: 66 to 87). Kidney biopsies were scored according to Karpinski. A calculated admission creatinine clearance <50 mL/min and/or a biopsy score of 5 or 6 were used to select kidneys for DKG. Grafts with better function or lower biopsy scores were employed for SKG. ResultsMean cold ischemia time (CIT) was 16.8 hours (range 8.1 to 28.6) in SKG, and 16.3 hours (range 4.6 to 24.3) for the first kidney and 17.4 hours (range 5.1 to 25.9) for the second graft in DKG. Delayed graft function (DGF) occurred in 34.1% SKG and in 28.5% DKG. Acute rejection rates were 9.1% for SKG and 0% for DKG. Three-year actuarial patient survival rates were 97.7% for SKG and 92.9% for DKG; for kidneys, 95.4% and 92.9%. One-year mean serum creatinine levels were 1.8 mg/dL (range 1.1 to 4.0) for SKG and 1.2 mg/dL (range 1.0 to 1.8) for DKG (P = .01). CIT longer than 16 hours was related to increased rates of DGF for both SKG (45.4% vs 22.7%) or DKG (42.9% vs 14.3%) and reduced 3-year graft survival rates (SKG: 90.9% vs 100%; DKG: 85.7% vs 100%). ConclusionsWith stringent selection criteria and short CIT (<16 hours), elderly donor kidneys may show good results, thus meaningfully expanding the donor pool.

Evolving trends in risk profiles and causes of death after heart transplantation: A ten-year multi-institutional study

Background: As therapeutic options evolve for advanced heart failure, the appropriate role for cardiac transplantation will require survival analyses that reflect changing trends in causes of death and patient and institutional risk profiles. Results from multi-institutional studies could be used to monitor progress in individual centers. Methods: Between 1990 and 1999, 7290 patients undergoing cardiac transplantation in 42 institutions entered a formal outcomes study. Changing survival, causes of death, and patient risk profiles were analyzed. Multivariable risk-factor equations were applied to a single institution (300 primary heart transplants) to examine differences in risk-adjusted expected versus observed actuarial outcomes over time. Results: Overall survival in the 42 institutions improved during the decade (P =.02). One- and 3-year cardiac transplant research database survival was as follows: era 1 (1990-1992), 84% and 76%, respectively; era 2 (1993-1995), 85% and 79%, respectively; and era 3 (1996-1999), 85% and 79%, respectively. Causes of death changed over time. Pretransplantation risk profiles increased over time (P =.0001), with increases in reoperations, devices, diabetes, severely ill recipients, pulmonary vascular resistance, sensitization, ischemic times, donor age, and donor inotropic support. Three-year actuarial survival in a single institution was 3% less than risk-adjusted predicted survival in era 1, 1% higher than predicted in era 2, and 7% higher than predicted in era 3. Conclusions: Survival after cardiac transplantation is gradually improving, despite increasing risk profiles. Further improvement requires periodic re-evaluation of risk profiles and causes of death to target areas of surveillance, therapy, and research. By using these methods, progress at individual institutions can be assessed in a time-related, risk-adjusted manner that also reflects changing institutional experience, expertise, or both.J Thorac Cardiovasc Surg 2003;125:881-90

Initial clinical results of stereotactic radiotherapy for the treatment of craniopharyngiomas.

The efficacy and toxicity of stereotactic radiotherapy (SRT) for the treatment of craniopharyngioma has been retrospectively evaluated in 16 patients. The median tumor diameter was 2.8 cm (range 1.5-6.1) and the median tumor volume was 7.7 cc (range 0.7-62.8). SRT was delivered to a single isocenter using a dedicated 6 MV linear accelerator to patients immobilized with a relocatable stereotactic head frame. The three-year actuarial overall survival was 93% and the rate of survival free of any imaging evidence of progressive disease was 75%. The three-year actuarial survival rates free of solid tumor growth or cyst enlargement were 94% and 81% respectively. Our results suggest that SRT is a safe and effective treatment approach for patients with craniopharyngioma. Long-term follow-up is required to determine whether the normal tissue-sparing inherent with SRT results in reduction of the neurocognitive effects of conventional radiotherapy for craniopharyngioma. SRT can be delivered to craniopharyngioma that may be difficult to treat with stereotactic radiosurgery due to proximity of the optic chiasm. Further clinical experience is necessary to determine the clinical utility of beam shaping in the setting of SRT.

Significance of age in the survival of diabetic patients after kidney transplantation.

In recent years acceptance of diabetic patients for renal replacement therapy has increased. Renal transplantation for Type I diabetic patients is widely accepted but the appropriate treatment for Type II diabetic patients is still a matter of dispute. Our study was done to determine whether the age of Type II diabetic patients constituted an additional risk factor. We analyzed the outcome of renal transplantation in 56 diabetic patients, 31 Type I and 25 Type II diabetics (we excluded any who had combined kidney-pancreas transplants). We compared them with 51 non-diabetic patients who were transplanted because of end-stage renal failure due to nephrosclerosis and age-matched to type II diabetic patients. We assessed the one- and three-year patient and graft survival, the quality of renal function, the main complications and causes of mortality. The overall one- and three-year patient survival was 69% and 60% in Type II patients; 73% and 69% in Type I diabetes patients and 88% and 80% in patients with nephrosclerosis. The overall one- and three-year actuarial graft survival was 50% and 38% in patients with Type II disease and 58% and 50% in Type I diabetes, and 76% and 64% in nephrosclerosis. The main cause of graft loss in all groups was death (with functioning kidney) due to infections and cardiovascular complications. Diabetes itself is the most important variable in patients who have poor results after kidney transplantation. Increasing age increases slightly the risk for poor graft and patient survival. Both groups of diabetic patients have poorer results than controls but in this comparison age was an independent factor.

Histologic upgrading of prostate cancer occurs frequently over a short period of time: single hospital experiences of radical prostatectomy.

A total of 163 patients with localized prostate cancer underwent retropubic radical prostatectomy and pelvic lymphadenectomy at a single hospital from 1989 to 1998. We reviewed the patients in terms of their prognostic factors and survival. The patients without advanced diseases were diagnosed as having prostate carcinoma, using either biopsies or transurethral resection of the prostate. The carcinomas were categorized into localized prostate carcinomas (stage A, B or C) as a result of digital rectal examinations, computed tomography scans and bone scans. The patients were informed of the risk of surgery and, if they agreed to sign the consent form, underwent radical prostatectomy under general and epidural anesthesia usually 2 months after a positive biopsy. The surgical specimens were sent for pathology and were graded according to classifications of well-, moderately and poorly differentiated adenocarcinoma. The patients were usually discharged from the hospital 2-3 weeks postoperatively and had regular follow-up treatment. The mean age (+/- SD) was 68.75 (+/- 5.59) years and the mean follow-up period was 47.2 months. There was a significant difference (34.4%) in pathologic grades between biopsy and surgical specimen. In a quarter of the patients (approximately 26.4%) upgrading of the surgical report occurred despite neoadjuvant therapy. Three-year, 5-year and 7-year actuarial survival rates were 91.8%, 79.9% and 71.9%, respectively. Patients with organ-confined prostate cancer underwent radical prostatectomy and survived a fairly good period of time. Histologic upgrading was frequently observed within a short period of time (2 months).

Bilateral skeletonized internal thoracic artery grafts in patients with diabetes mellitus

Objective: Increased risk of deep sternal infections has prohibited routine bilateral internal thoracic artery grafting in diabetic patients. The technique for harvesting the skeletonized internal thoracic artery provides the potential to minimize this risk. The purpose of this study was to compare the outcome of bypass grafting with bilateral skeletonized internal thoracic arteries in diabetic and nondiabetic patients. Methods: From May 1996 to April 1998, 231 consecutive diabetic and 534 nondiabetic patients underwent bilateral skeletonized internal thoracic artery grafting. Mean age was 66 years. Compared with the nondiabetic group, the diabetic group comprised more women (29% vs 18%, P =.001), had a greater prevalence of hypertension (53% vs 44%, P =.019) and congestive heart failure (20% vs 14%, P =.016), but a lower prevalence of preoperative acute myocardial infarction (26% vs 34%, P =.027). Results: Operative mortality of diabetic patients was comparable with that of nondiabetic patients (3% vs 2.6%). The two groups also had similar occurrences of deep sternal infection (2.6% vs 1.7%, respectively, P =.40). Deep sternal infection was significantly more prevalent in obese, diabetic women (3/20 = 15%) than in diabetic patients without this combination of risk factors (3/211 = 1.4%, P <.0001) (odds ratio 11.1, confidence interval 2.1-59.4). Diabetic patients also had a higher incidence of stroke (3.5% vs 0.9%, P =.014). Three-year actuarial survival of diabetic patients was lower (91.3% vs 94.7%, P =.083). Conclusions: Bilateral skeletonized internal thoracic artery grafting is a good surgical revascularization option in diabetic patients. Operative mortality and prevalence of sternal infection are comparable with those of nondiabetic patients. However, the risk of sternal infection in obese diabetic women is high, and for them we advocate the use of a single artery instead of bilateral internal thoracic arteries. (J Thorac Cardiovasc Surg 2001;121:668-74)

Bilateral internal thoracic artery T grafting for coronary artery revascularization. Angiographic assessment and mid-term outcome.

We studied the early outcome of bilateral internal thoracic artery T grafting. Coronary artery bypass grafting was studied retrospectively using bilateral internal thoracic artery T grafting in 51 patients. The T graft was made by anastomosing the free right internal thoracic artery to the in-situ left internal thoracic artery. Average patient age was 63.5 +/- 9.9 years, and the average number of anastomoses per patient was 3.6 +/- 0.9. In 35 patients, the right gastroepiploic artery (21 anastomoses in 20 patients), radial artery (1 anastomosis), free left internal thoracic artery (1 anastomosis) and saphenous vein graft (14 anastomoses in 13 patients) were used as additional bypass conduits. Hospital mortality was 0%. The morbidity of stroke was 1.9% (1 patient) and deep sternal infection 0%. Patency of the in-situ left internal thoracic artery was 49/50 anastomoses (98%) and that of the free right internal thoracic artery 81/84 anastomoses (96.4%). Mid-term coronary angiography in 7 patients demonstrated patent anastomosis of the T graft. Acute myocardial infarction unrelated to graft failure occurred in 2 patients during follow-up. Other patients were evaluated by exercise stress tests every year and none exhibited myocardial ischemia in the areas of T graft coronary revascularization. Three-year actuarial survival rate was 100% and freedom from cardiac events 96%. The bilateral internal thoracic artery T graft provides satisfactory early and mid-term outcomes in properly selected patients.

Allogeneic or autologous bone marrow transplantation (BMT) for non-Hodgkin's lymphoma (NHL): results of a provincial strategy. Ontario BMT Network, Canada.

In 1986, the bone marrow transplant centers in Ontario agreed to a strategy for the treatment of patients with NHL. Suitable patients would undergo autotransplant but be referred for allotransplant if they had persistent marrow involvement or an inadequate marrow/stem cell harvest. Data of all patients were recorded in a database. We reviewed this database to compare these transplant modalities with respect to overall survival, rate of relapse and treatment-related mortality. Between January 1986 and August 1997, 429 patients underwent BMT for NHL - 385 autotransplants and 44 allotransplants. Sixty-eight percent of patients received their transplant for aggressive NHL, while the others had indolent lymphoma. Three-year actuarial survival did not differ between allogeneic and autologous BMT: 71% vs 62%, respectively (P = 0.5330 by log-rank testing). Three-year actuarial rate of relapse was lower after allotransplant than autotransplant: 6% vs 41%, respectively (P = 0.0006 by log-rank testing). Treatment-related mortality was higher after allotransplant than autotransplant: 23% vs 6%, respectively (P = 0.001 by chi2 analysis). For further comparison, autotransplant patients were randomly matched 2:1 with the allotransplant patients for age +/- 5 years, disease status at BMT, disease histology, and year of BMT. In the matched comparison, survival did not differ (relative risk of death after allotransplant: 0.711 (95% CI: 0.309-1.637)). Relapse rate was significantly lower in the allotransplant group (relative risk of relapse for allotransplant: 0.190 (95% CI: 0.043-0.834)) and treatment-related mortality was not significantly different (relative risk for allotransplant: 1.425 (95% CI: 0.527-3.851)). In conclusion, a review of a provincial strategy for treatment of NHL, shows that survival is not different after allogeneic or autologous BMT, but the rate of relapse is lower after allotransplant. These data support continuing the current provincial strategy.