Two-year Patient Survival Research Articles

The value of complete remission according to positron emission tomography prior to autologous stem cell transplantation in lymphoma: a population-based study showing improved outcome

BackgroundChimeric antigen-receptor T-cell and bispecific antibody therapies will likely necessitate a reconsideration of the role of autologous stem-cell transplantation (ASCT) in lymphoma. Patients who are likely to profit from ASCT need to be better identified.MethodsHere, we investigated the value of positron emission tomography/computerized tomography (PET/CT) before ASCT. All 521 patients transplanted for lymphoma 1994–2019 at Karolinska (497 conditioned with BEAM) were included.ResultsOutcome improved over three calendar periods 1994–2004, 2005–2014, 2015–2019 (2-year overall survival [OS]: 66, 73, 83%; P = 0.018). Non-relapse mortality (NRM) at 100 days over the three periods were 9.8, 3.9, 2.9%, respectively. The OS improvement between 1994 and 2004 and 2005–2014 was due to lower NRM (P = 0.027), but the large OS advance from 2015 was not accompanied by a significant reduction in NRM (P = 0.6). The fraction of PET/CT as pre-ASCT assessment also increased over time: 1994–2004, 2%; 2005–2014, 24%; 2015–2019, 60% (P < 0.00005). Complete responses (PET/CT-CR) were observed in 77% and metabolically active partial responses (PET/CT-PR) in 23%. PET/CT-CR was a predictor for survival in the entire population (P = 0.0003), also in the subpopulations of aggressive B-cell (P = 0.004) and peripheral T-cell (P = 0.024) lymphomas. Two-year OS and progression-free survival (OS/PFS) for patients in PET/CT-CR were in relapsed/refractory aggressive B-cell lymphoma 87%/75% and peripheral T-cell lymphoma 91%/78%. The corresponding figures in PET/CT-PR were 43%/44 and 33%/33%. Patients with solitary PET/CT-positive lesions showed acceptable outcome with ASCT followed by local irradiation (2-year OS/PFS 80%/60%). CT was less discriminative: 2-year OS/PFS: CT-CR, 76%/66%; CT-PR, 62%/51%. Outcome was inferior after BEAC compared with BEAM conditioning.ConclusionsWe conclude that the improved outcome reflects better, PET/CT-informed, identification of patients who should proceed to ASCT. The excellent survival of patients in PET/CT-CR indicates that ASCT should remain part of standard therapy for lymphoma.

Radical cystectomy and perioperative chemotherapy in octogenarians with bladder cancer.

We aimed to compare the treatment patterns and oncological outcomes, including postoperative morbidity and chemotherapy use, between octogenarians and patients <80 years of age who underwent radical cystectomy for bladder cancer. We conducted a retrospective analysis of 119 patients who underwent radical cystectomy for bladder cancer at our center between January 2013 and April 2019. Comorbidities, clinical and pathological data, 30-day postoperative morbidity, and perioperative chemotherapy use were compared between octogenarians (n=31) and younger patients (n=88). Cancer-specific and overall survival rates were estimated with the Kaplan-Meier method and compared between the groups. No significant differences were found between the age groups in the clinical and pathological findings, including Charlson comorbidity index, modified frailty index, albumin level, renal function, and TNM stage. The median followup for survivors was 19 months (interquartile range [IQR] 11-30). Major complications (Clavien-Dindo grade ≥3) and 30-day postoperative mortality rates did not differ between the age groups (p=0.3 and p=0.18, respectively). Despite no difference in baseline glomerular filtration rates, perioperative chemotherapy utilization rate was lower among octogenarians compared to younger patients (13% vs. 34%, p=0.03). Estimated two-year cancer-specific survival rates for octo-generians and younger patients were 40% and 75%, respectively. Similarly, estimated two-year overall survival rates were 30% and 69%, respectively. Both cancer-specific and overall survival rates were significantly lower in octogenarians (p=0.007 and p=0.001, respectively). Radical cystectomy in octogenarians results in comparable short-term outcomes as in younger patients. However, in the elderly population, perioperative chemotherapy utilization rates are lower and survival is inferior.

Merkel cell carcinoma in Turkey: A multicentric study.

Merkel cell carcinoma (MCC) is a rare but highly aggressive neuroendocrine carcinoma of the skin. In this study, we aimed to evaluate the clinicopathologic characteristics, treatment outcomes, and survival of MCC cases in Turkey. The patients diagnosed with MCC between 1999 and 2018 at twenty different centers in Turkey were included in the study. Patient and tumor characteristics and adjuvant and metastatis treatment outcomes were analyzed retrospectively. The median age of totally 89 patients was 70 (26-93). The most common primary location was lower limbs (n = 29, 32.5%). Immunohistochemically, CK20 positivity was present in 59 patients (66.3%). Only two patients had secondary malignancy. The majority of the patients (n = 76, 85.4%) were diagnosed at the localized stage. Surgery was performed for all patients in the early stage, and adjuvant radiotherapy or/and chemotherapy was applied to 52.6% (n = 40) of nonmetastatic patients. The median follow-up was 29 months. Recurrence developed in 21 (27.6%) of the 76 patients who presented with local or regional disease. Two-year disease-free survival (DFS) was 68.1% and 5-year DFS was 62.0% for localized stage. The 5-year DFS was similar for patients receiving adjuvant treatment (chemotherapy, radiotherapy, or sequential chemoradiotherapy) and without adjuvant therapy (P > 0.05). Two-year overall survival in patients who presented with localized disease was 71.3% and 18.5% in metastatic patients (P < 0.001). In the metastatic stage, platinum/etoposide combination was the most preferred combination regimen. Median progression-free survival (PFS) in first-line chemotherapy was 7 months (95% confidence interval: 3.5-10.5 months; standart error: 1.78). Although MCC is rare in Turkey, the incidence is increasing. Gender, CK20 status, tumor size, lymph node involvement, and adjuvant treatment were not associated with recurrence.

How Are Indeterminate Pulmonary Nodules at Diagnosis Associated with Survival in Patients with High-Grade Osteosarcoma?

How Are Indeterminate Pulmonary Nodules at Diagnosis Associated with Survival in Patients with High-Grade Osteosarcoma?

892MO High-dose chemotherapy with autologous hematopoietic stem cell transplantation in patients with HIV-related lymphoma

The number of prospective matched case-controlled studies to prove the safety and efficacy of autologous stem cell transplantation (ASCT) in HIV-related lymphoma is limited. Between January 2016 and January 2020, twelve patients with HIV-related lymphoma who have undergone ASCT were included in this prospective matched case-control study (study group, n=12). Forty eight non-HIV-infected patients were enrolled to the control group (n=48, 1:4). The median age was 34 (19-66) y.o. The underlying diseases in the study group were Hodgkin lymphoma (HL) n=7 (58,3%) and non-Hodgkin lymphoma (NHL) n=5 (41,7%), complete remission at the moment of ASCT – 66,7%. Conditioning regimen was BEAM with BCNU replacement by Bendamustine 160 mg/m2/day at D-7, D-6. HIV viral load was undetectable; the median number of CD4+ cells was 471,5 (210-715) cells/mcl; all patients were on anti-retroviral therapy (ART). The median follow up time was 16 (1-43) months. The 2-year overall survival (OS) (n=60) was 90%; 91,7% in the study group and 89,9% in the control group, and this was not significantly different between the groups (P= 0,763). Progression-free survival (PFS) at 2 years in the study group was 75%, and was not significantly different to the control group (70,8%; P=0,777). Time to progression (TTP) at 2 years was 14,6% in the study group and 16,7% in the control group (P=0,643). Complete remission at the moment of ASCT improved PFS (P =0,03) and TTP (P =0,044) in the whole group. The median time for recovery of leukocytes, neutrophils, and platelets was D+14,5 (10-25), D+17 (12-30), D+15,5 (11-31), respectively, in the study group and D+14 (10-22), D+15 (10-23), D+15 (8-31) in the control group. Neutrophil recovery was significantly delayed in study group (P=0,04). There was no difference in the rate of organ toxicity according to CTCAE. The transplant-related mortality (TRM) at 2 years was 8,3% in the study group and 6,2% in the control group (P=0,8). Two-year overall survival in patients with HIV-related lymphoma was 91.7%, PFS was 75%, TTP was 14,6% and TRM was 8,3% and did not differ significantly from the control group. Only neutrophil recovery was significantly delayed after ASCT in patients with HIV-related lymphoma. Our data provide further evidence that ASCT is a safe and effective approach for patients with HIV-related lymphoma.

Age-dependent survival in rapidly progressive glomerulonephritis: A nationwide questionnaire survey from children to the elderly.

BackgroundRapidly progressive glomerulonephritis (RPGN) has been known to have a poor prognosis. Although evidence across adult RPGN cases has accumulated over many years, the number of case series in adolescents and young adults has been limited, requiring further studies.MethodsA total of 1,766 cases from 1989 to 2007 were included in this nationwide questionnaire survey, led by Intractable (former name, Progressive) Renal Diseases Research, Research on intractable disease, from the Ministry of Health, Labour and Welfare of Japan. To elucidate age-related differences in 2-year patient and renal survival rates, the cases were divided into the following four groups: children (0–18 years), young adults (19–39 years), the middle-aged (40–64 years), and the elderly (over 65 years).ResultsOf the 1,766 total RPGN cases, antineutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis comprised 1,128 cases (63.9% of all RPGN cases), showing a tendency to increase with age. Two-year patient survival for RPGN was 93.9% among children, 92.6% in young adults, 83.2% in the middle-aged, and 68.8% in the elderly. The younger group (children plus young adults) showed a clearly higher survival rate compared to the older group (middle-aged plus elderly) (p<0.05). ANCA-associated glomerulonephritis also showed similar age-related results with all RPGN cases. The comparison of renal prognosis showed no statistically significant differences both in RPGN and in ANCA-associated GN.ConclusionThe present study described the age-dependent characteristics of the classification of RPGN, especially focusing on a better prognosis of the younger group in patient survival both in RPGN and in ANCA-associated GN.

Postoperative Biochemical Failure in Patients With PI-RADS Category 4 or 5 Prostate Cancers: Risk Stratification According to Zonal Location of an Index Lesion

OBJECTIVE. The objective of our study was to assess postoperative biochemical failure in patients with prostate cancer according to zonal location of an index lesion classified as Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) category 4 or 5. MATERIALS AND METHODS. Consecutive patients (n = 232) with prostate cancer who had PI-RADSv2 category 4 or 5 lesions on MRI and who underwent radical prostatectomy were retrospectively evaluated. We investigated clinical (prostate-specific antigen density), MRI (PI-RADSv2 category of index lesion and zonal location, assessed as peripheral zone [PZ] or transition zone [TZ], of index lesion), and pathologic (tumor volume, tumor grade, and presence of extraprostatic extension) parameters. We analyzed Kaplan-Meier survival curves and the Cox proportional hazards model to assess 2-year biochemical failure-free survival and identify significant parameters associated with postoperative biochemical failure RESULTS. Biochemical failure occurred in 14.2% of patients (33/232). Two-year biochemical failure-free survival of patients with a PI-RADSv2 category 4 or 5 index lesion was 81.3%. For all patients, 2-year biochemical failure-free survival was different according to PI-RADSv2 category (category 4, 86.4%; category 5, 74.5%; p = 0.021) or zonal location (PZ, 75.3%; TZ, 96.8%; p = 0.003). Two-year biochemical failure-free survival in patients with category 4 lesions was similar in patients with PZ lesions (83.1%) and those with TZ lesions (100.0%) (p = 0.072), whereas it was different in patients with category 5 lesions (PZ, 62.0%; TZ, 95.0%; p = 0.002). In multivariate analysis, only zonal location of an index lesion on MRI was associated with biochemical failure (hazard ratio = 0.155; p = 0.012). CONCLUSION. Zonal location of an index lesion on MRI may be a useful imaging bio-marker to predict postoperative biochemical failure.

AORTIC STENOSIS, DIAGNOSIS, TREATMENT TACTICS. WHAT IS IMPORTANT FOR THE THERAPIST TO KNOW?

Aortic stenosis is the most common manifestation of valve heart disease, which requires surgical or endovascular intervention. The prevalence of degenerative aortic stenosis is increasing due to an aging population. The clinical course of aortic stenosis is characterized by a long-existing asymptomatic period. The progressive calcification of the valve cusps leads to the formation of a pressure gradient in the aorta, hemodynamic overload of the left ventricle, the development of myocardial hypertrophy, which contributes to the violation of diastolic function of the left ventricle. After the onset of symptoms of aortic stenosis, the two-year survival in patients who do not undergo surgical correction does not exceed 50 %. The Recommendations of the European Association of Cardiology and the European Association of Cardiothoracic Surgeons for the treatment of patients with valvular heart disease in 2017 discuss aspects of the diagnosis of aortic stenosis and the principles of choosing tactics for managing patients using surgical or catheter treatment methods. Depending on the severity of aortic stenosis, its clinical manifestations, age of patients, and associated pathology, surgical replacement of the aortic valve or its transcatheter implantation may be recommended. The use of drug therapy for aortic stenosis did not show the possibility of improving the prognosis. Drug therapy is used to treat heart failure, hypertension. Important tasks are the control of sinus rhythm and the prevention of thromboembolic complications.

Thigh sarcopenia and hypoalbuminemia predict impaired overall survival after infrainguinal revascularization in patients with critical limb ischemia

Objective This study was performed to determine whether thigh sarcopenia can serve as a clinically relevant predictor of postoperative complications and overall survival after revascularization in patients with critical limb ischemia. Methods Patients who underwent preoperative computed tomography followed by infrainguinal revascularization from 2006 to 2015 were retrospectively analyzed. An axial computed tomography image was obtained at the midpoint of a line extending from the superior border of the patella to the greater trochanter of the femur. The thigh muscle area and bone area were measured. Thigh sarcopenia was defined as thigh muscle area/thigh bone area of &lt;9. Results We included 117 patients with critical limb ischemia who underwent infrainguinal revascularization. The overall survival rates at two years were 86.5% and 55.1% in the thigh sarcopenia (−) and (+) groups, respectively ( p &lt; 0.01). The multivariate analysis showed that thigh sarcopenia (hazard ratio, 2.64; 95% confidence interval, 1.11–6.70; p = 0.03), cerebrovascular disease (hazard ratio, 3.18; 95% confidence interval, 1.31–7.36; p = 0.01), and serum albumin level (1 g/dL per increments) (hazard ratio, 0.41; 95% confidence interval, 0.21–0.81; p = 0.01) were the risk factors for overall survival two years after revascularization. Conclusion Thigh sarcopenia is a risk factor for two-year overall survival in patients with critical limb ischemia after infrainguinal revascularization.

The effect of frailty on outcomes of surgically treated hip fractures in older people.

Hip fractures are associated with mortality, disability, and loss of independence in older adults. While several risk factors associated with poor outcomes following a hip fracture have been identified, the effect of frailty status prior to hip fracture is not well established. To examine the associations of frailty with mortality, change in activities of daily living (ADL) limitations, and transition to permanent residential aged care in older people following a hip fracture. A retrospective cohort study was conducted on people aged 65years and older with a surgically treated hip fracture between 2003 and 2015. Frailty was estimated using a cumulative deficit-based frailty index and categorized into quartiles. Cox multivariable regression, logistic regression, and Fine-Gray multivariable regression models estimated associations of frailty with mortality, ADL limitations, and entry into permanent residential aged care, respectively. Hazard ratios (HR), odds ratios (OR), subdistribution hazard ratios (SHR), and 95% confidence intervals (95%CI) are reported. Out of 4771 individuals with hip fractures, 75.6% were female and the median age was 86 (interquartile range 82-90) years old. The two-year survival of patients following hip fracture was 43.7% (95%CI 40.9-46.7%) in those in the highest quartile of frailty, compared to 54.4% (95%CI 51.8-57.2%) for those in the lowest quartile (HR=1.25, 95%CI 1.11-1.41, p<0.001). No associations between pre-fracture frailty and post-fracture ADL limitations were observed. Additionally, no association of frailty with transition to permanent residential aged care for patients living in the community (n=1361) was observed (SHR=0.98, 95%CI 0.81-1.18, p=1.000). Older patients with the highest level of frailty had an increased risk of mortality after hip fracture. Consideration for appropriate clinical interventions, including fall and frailty prevention measures, may be appropriate for this identified group of vulnerable individuals.

P3545Association between diastolic dysfunction and two-year survival in heart failure patients with mid-range or reduced left ventricular ejection fraction

Abstract Background Extensive studies have demonstrated prognostic impact of echocardiographic defined diastolic dysfunction (DD) in patients with preserved as well as reduced left ventricular ejection fraction (LVEF). Nevertheless, it remains controversial whether evaluation of DD could provide additional prognostic information in heart failure (HF) patients with impaired systolic function. The purpose of present study, therefore, is to investigate the prognostic impact of echocardiography-defined DD on survival in HF patients hospitalized in our centre from 2009 to 2017 with mid-range LVEF (HFmrEF, LVEF 41–49%) and reduced LVEF (HFrEF, LVEF&lt;40%). Methods A total of 2018 patients with echocardiography-evidenced LVEF&lt;50% and hospitalized in our centre between July 2009 to December 2017 were included. Baseline demographic and clinical data were obtained by reviewing the medical records. All patients subsequently completed a median clinical follow-up of 24 (IQR 13–36) months by medical record review or telephone interview. The primary endpoint was all-cause mortality or heart transplantation (HTx). Patients were divided into mild, moderate and severe DD according to recent guidelines. Results The mean age was 69±13 years in the HFmrEF group and 68±13 years in the HFrEF group. All-cause mortality/HTx rate was significantly higher in the HFrEF (all-cause death n=318 and HTx n=11, 30.9%) group than in patients with HFmrEF (all-cause death n=235 and HTx n=2, 24.9%, P=0.003). All-cause mortality/HTx rate increased in proportion to DD severity in HFmrEF patients: 17.1% (54/315) in the mild DD group, 25.4% (115/452) in the moderate DD group, and 37.0% (68/184) in the severe DD group (P&lt;0.001) and in HFrEF patients: 18.9% (43/228) in the mild DD group, 30.3% (146/482) in the moderate DD group, and 39.2% (140/357) in the severe DD group (P&lt;0.001). Multivariable Cox regression analysis showed that Doppler parameter early-diastolic mitral inflow velocity to septal mitral annular velocity ratio (E/E') &gt;14 (HR 1.41, 95% CI 1.06–1.89, P=0.020) and peak tricuspid regurgitation velocity (TRVmax) &gt;2.8m/s (HR 1.75, 95% CI 1.33–2.29, P&lt;0.001) were independent determinants of all-cause mortality/HTx in patients with HFmrEF; while E/E'&gt;14 (HR 1.48, 95% CI 1.08–2.04, P=0.015) remained as an independent determinant of all-cause mortality/HTx in patients with HFrEF after adjustment for clinical and other echocardiographic confounders. Besides DD-related parameters, after adjustment with age and sex, lower tricuspid and mitral annular plane systolic excursions (TAPSE and MAPSE) were also closely related to higher mortality/HTx rate in both HFmrEF and HFrEF patients. Figure 1. Kaplan-Meier curves Conclusion Our results indicate that all-cause mortality/HTx rate increases in proportion to DD severity in both HFmrEF and HFrEF patients.

Prognostic value of the expression of epithelial cell adhesion molecules in head and neck squamous cell carcinoma treated by definitive radiotherapy.

A reliable biomarker can contribute to appropriate treatment selection in the management of head and neck squamous cell carcinoma (HNSCC). Recently, epithelial cell adhesion molecule (EpCAM) was shown to have prognostic features in several malignancies. However, it remains to be elucidated whether EpCAM predicts prognosis of HNSCC after radiotherapy. Therefore, the prognostic potential of EpCAM in HNSCC patients treated by radiotherapy was investigated in this study. All HNSCCs patients examined between January 2013 and December 2015 were analyzed for the expression of EpCAM. One hundred HNSCC patients were identified who were treated by primary radiotherapy. Intense expression of EpCAM was found in 29 HNSCC patients. Two-year overall survival (OS) for patients with intense EpCAM expression was 62.2%, whereas it was 87.9% for those without (P = 0.011). In multivariate analysis, intense EpCAM expression was found to be an independent prognostic factors for OS (P = 0.036). Overall, EpCAM was found to be an independent prognostic factor for HNSCC.

The prognostic impact of cirrhosis on patients receiving maintenance haemodialysis.

Further study is needed on the prognostic impact of cirrhosis on haemodialysis patients. To evaluate cirrhosis' impact according to severity on survival and to provide therapeutic guidelines for haemodialysis cirrhotic patients. Patients with end-stage renal failure treated with haemodialysis were included retrospectively from 01/01/2000 to 31/12/2004 and prospectively from 01/01/2005 to 31/12/2014 in our French Region. Clinical data, presence of cirrhosis and its severity were recorded at the beginning of haemodialysis. The primary endpoint was 2-year survival. Seven thousand three hundred and fifty-four patients (96%) without cirrhosis and 304 patients (4%) with cirrhosis were included. Two-year survival in noncirrhotic patients was higher than in cirrhotic patients (71.7% vs 54.4%, P<0.0001). Patients with decompensated cirrhosis had a worse 2-year outcome (44.1%) as compared to compensated cirrhotic (62.8%, P=0.002) and noncirrhotic patients (71.7%, P<0.0001). Compensated and decompensated cirrhosis were independent predictive factors of 2-year mortality. In sensitivity analysis restricted to cirrhotic patients, 2-year survival of Child-Pugh A patients was higher than in Child-Pugh B and C patients (65.5% vs 27.7% vs 0%, P<0.0001). Development of predictive models based either on severity scores (MELD and Child-Pugh) and extrahepatic comorbidities allowed correct classification of around 70% of patients in terms of mortality and may help to better stratify mortality risk in this population. Cirrhosis is independently associated with mortality in haemodialysis patients. Patients with severe cirrhosis have a poor 2-year outcome. Severity of cirrhosis and presence of extrahepatic comorbidities should be considered when deciding to initiate renal replacement therapy.

Timing of treatment in small-cell lung cancer.

Small-cell lung cancer (SCLC) is an aggressive disease with poor survival and rapid doubling time. Current practice is to treat SCLC as soon as possible but evidence on appropriate timing of treatment from diagnosis(TTD) is lacking. This is a retrospective analysis of SCLC patients from the 2012 to 2015 Kentucky Cancer Registry. Data collected included age at diagnosis, stage, gender, race, insurance and treatment. Factors and survival associated with TTD were identified with logistic regression analyses and Cox proportional hazards models. Among the 2992 SCLC patients, 2371 (79%) of SCLC patients were treated with one or more treatment modalities. Among treated patients, 93% received chemotherapy ± radiation with the mean TTD of 18days. Most patients (80%) have TTD of ≤ 4weeks with 33% treated within 1week, 20% 1-2weeks, and 27% 2-4weeks from diagnosis. Delay in treatment (TTD > 4weeks) was less in stage III and IV disease (odds ratio: 0.33 and 0.27 respectively, p < 0.01) but not significantly associated with age, race, gender, and insurance. One and two-year survival of patients with TTD ≤ 4weeks was significantly worse when compared to > 4weeks (hazard ratio = 1.43, 95% CI 1.2-1.6, p < 0.01; HR = 1.45, 95% CI 1.3-1.6, p < 0.01 respectively). These results show a trend toward better survival with late treatment of SCLC. Therefore, a general urgency to treat SCLC needs to be re-evaluated with consideration of patients needing more optimization before treatment. Further studies are needed to better clarify the appropriate timing of treatment from diagnosis in SCLC and who will benefit from early versus late treatment.

Adult Comorbidity Evaluation-27 as a predictor of postoperative complications, two-year mortality, duration of hospital stay, and readmission within 30 days in patients with squamous cell carcinoma of the head and neck

The Adult Comorbidity Evaluation (ACE)-27 is a validated scoring system for comorbid conditions. We have evaluated the correlation between it and the duration of hospital stay, readmission within 30 days, complications, and two-year survival in patients having primary surgical treatment for squamous cell carcinoma (SCC) of the head and neck. We studied patients with SCC who had selective neck dissection, resection of the tumour, and reconstruction between 2007 and 2013. Patients who had palliative procedures were excluded. We studied the casenotes of 231 patients and recorded the following outcome measures: TNM staging, ACE-27 score, number of days spent in hospital, readmission within 30 days, complications, and mortality at two years.The relation between the ACE-27 score and duration of hospital stay was significant (p=0.000001). The relations between complications and ACE-27 score, and complications and tumour stage, were also significant (p<0.002, and p<0.008, respectively). Two year mortality is significantly related to stage of tumour and ACE-27 score (p=0.001 and p=0.000246 respectively). We conclude that ACE-27 is a validated, relevant, scoring system for patients being operated on for SCC of the head and neck. It is a better prognostic indicator of two-year mortality than TNM stage, and is a good reflection of complications. We therefore suggest that it is used when discussing surgical outcomes, taking consent from newly-diagnosed patients, and when calculating the costs of head and neck oncological surgery.

What Should Be Done for Improving the Outcomes of Salvage from Cardiogenic Shock on ECMO Support?

Purpose Background: Survival rates for patients requiring extracorporeal membrane oxygenation (ECMO) support due to cardiogenic shock remain poor because of difficulties in decision making on optical timing of ECMO removal or conversion to ventricular assist devices (VAD). Methods From 2005 to 2018, 37 patients supported with ECMO due to circulatory deterioration were referred to our institution for implantation of VAD. The outcomes were analyzed using multi-variate analysis to assess the risk factors of VAD implantation, and we adopted a decision-tree to improve the outcomes. Results Six patients were withdrawn from VAD therapy due to stroke and infection. ECMO could be removed in 6 patients (6.1 days of ECMO support), but one of them was estimated to need VAD support due to the IABP-dependent circulatory condition. In total, 26 patients needed VAD support after 5.7 days of ECMO support. Four of them reached to heart transplantation, and VAD was explanted in 2 patients. Six patients remain on VAD. Statistically significant risk factors by multi-variate analysis on 2-year mortality were preoperative renal replacement (p=0.006) and T.Bil (p=0.051, Threshold 4.0 mg/dl). Two-year survival of patients without end-organ dysfunction as mentioned above was excellent (83.3%). However, that of patients with end-organ dysfunction was miserable (23.1%). Based on these findings, we applied to a following decision-tree. Step I: end-organ dysfunction; if yes, additional introduction of more effective circulatory support with left ventricular venting. Step II: aortic valve opening: if no, emergent/urgent VAD implantation. If yes, wait for cardiac functional recovery on ECMO. Step III: cardiac function; if no recovery, VAD implantation, and if recovered, ECMO removal. Since this decision-tree was applied, ECMO support was initiated in four patients with end-organ dysfunction before VAD implantation. After T.Bil decreased from 15.9mg/dl to 4.6 mg/dl and the value of Creatinine from 4.0 mg/dl to 1.5mg/dl, those patients underwent VAD implantation and survived. Conclusion Our experiences of salvage from ECMO suggest that preoperative renal replacement and T.Bil less than 4.0 mg/dl was a strong risk factor for mid-term mortality. For those patients, recovery from end-organ dysfunction before VAD implantation is essential.

Hemodialysis vascular access and subsequent transplantation: a report from the ESPN/ERA-EDTA Registry

BackgroundCurrent guidelines advocate use of arteriovenous fistula (AVF) over central venous catheter (CVC) for children starting hemodialysis (HD). European data on current practice, determinants of access choice and switches, patient survival, and access to transplantation are limited.MethodsWe included incident patients from 18 European countries who started HD from 2000 to 2013 for whom vascular access type was reported to the ESPN/ERA-EDTA Registry. Data were evaluated using descriptive statistics, logistic and Cox regression models, and cumulative incidence competing risk analysis.ResultsThree hundred ninety-three (55.1%) of 713 children started HD with a CVC and were more often females, younger, had more often an unknown diagnosis, glomerulonephritis, or vasculitis, and lower hemoglobin and height-SDS at HD initiation. AVF patients were 91% less likely to switch to a second access, and two-year patient survival was 99.6% (CVC, 97.2%). Children who started with an AVF were less likely to receive a living donor transplant (adjusted HR, 0.30; 95% CI, 0.16–0.54) and more likely to receive a deceased donor transplant (adjusted HR, 1.50; 95% CI, 1.17–1.93), even after excluding patients who died or were transplanted in the first 6 months.ConclusionsCVC remains the most frequent type of vascular access in European children commencing HD. Our results suggest that the choice for CVC is influenced by the time of referral, rapid onset of end-stage renal disease, young age, and an expected short time to transplantation. The role of vascular access type on the pattern between living and deceased donation in subsequent transplantation requires further study.

Incidence and predictors of synchronous liver metastases in patients with gastrointestinal stromal tumors (GISTs)

BackgroundThe liver is the most common metastatic site in patients with gastrointestinal stromal tumors (GISTs). The purpose of this study is to identify the incidence and predictive factors associated with synchronous liver metastases among patients with GISTs. MethodsA retrospective review of the Surveillance Epidemiology and End Results (SEER) database was performed. ResultsOverall, 2757 patients were identified, of which 276 (10%) had synchronous liver metastases. The two-year survival of patients with synchronous liver metastases was 31.9% overall and 37.1% after undergoing surgery with curative intent. Primary tumor size >5 cm (5–10 cm: OR 2.97, 95% CI: 1.03–8.55, p = 0.044, >10 cm: OR 5.59, 95% CI: 1.95–16.07, p = 0.001), presence of nodal metastases (OR 4.09, 95% CI: 2.01–8.33, p < 0.001) and mitotic count >5/50 HPF (OR 1.58, 95% CI: 1.01–2.47, p = 0.044) were associated with the presence of liver metastases. ConclusionsOne out of ten patients with GISTs presents with hepatic metastases. Primary tumor size >5 cm, presence of nodal metastases and mitotic count >5/50 HPF are associated with a higher risk of synchronous hepatic metastases.

Bile Leakage after Liver Transplantation.

Objective To evaluate the risk factors and outcome of bile leak after liver transplantation.MethodsWe undertook a retrospective study of patients who underwent liver transplantation in our institution between January 2010 and January 2014. The characteristics and survival rate of patients with or without bile leak were compared.ResultsBile leak was observed in sixteen patients after liver transplantation (2.7% of the total number of patients transplanted). Total operating time and bile duct reconstruction technique (duct-to-duct anastomosis or Rouxen-Y cholangiojejunostomy) were found to differ significantly between patients with and without bile leak in univariate (p = 0.001 and 0.024, respectively) and multivariate analyses (p = 0.012 and 0.026, respectively). There was no difference in the one-year patient survival rate between the two groups. However, two-year patient survival rate was significantly lower in the bile leak group (p = 0.003). Both one-year and two-year graft survival rates were significantly lower in the bile leak group (p = 0.049 and <0.001, respectively).ConclusionsCholangiojejunostomy and prolonged total operating time are risk factors for bile leak after deceased donor liver transplantation. Bile leak reduces graft and patient survival rates after deceased donor liver transplantation.

Histopathological tumour viability after neoadjuvant chemotherapy influences survival in resected pancreatic cancer: analysis of early outcome data.

Neoadjuvant therapy is increasingly recognized as an effective strategy prior to pancreatoduodenectomy. We investigate the role of neoadjuvant chemotherapy (NAC) followed by surgery and the predictive role of viable residual tumour cells histopathologically on outcomes. The study population comprised of 195 consecutive patients with pancreatic adenocarcinoma who were treated with either NAC or a surgery-first (SF) strategy. Histopathological viable tumour cells were examined in the NAC patients and clinicopathological factors were correlated with overall survival. Forty-two patients (22%) were treated with NAC and 153 patients (78%) underwent SF. NAC was associated with higher estimated blood loss during surgery (928 mL versus 615 mL; P = 0.004), fewer (<15) excised lymph nodes (37% versus 17%; P = 0.015) and lower rates of lymphovascular invasion (65% versus 45%; P = 0.044) when compared with SF. Two-year survival of patients undergoing NAC was 63% and 51% in patients undergoing SF (P = 0.048). The 2-year survival of patients who had >65% residual tumour cells was 45% and 90% in patients who had <65% residual tumour cells (P = 0.022). Favourable responders (<65% viable tumour cells) were observed to have shorter operation time (<420 min) (55% versus 13%; P = 0.038), trend towards negative lymph node status (38% versus 10%; P = 0.067) and greater lymph node harvest in node positive patients (≥4 positive lymph nodes) (77% versus 37%; P = 0.045). The improved survival of patients undergoing NAC indicates effective management of micrometastatic disease and is an effective option requiring further investigation. Histopathological viable tumour cells after NAC was a surrogate marker for survival.