Alex D. Sweeney

Value of Pancreatic Resection for Cancer Metastatic to the Pancreas

BACKGROUND Cancer metastatic to the pancreas from other primary sites is uncommon, and it has been treated with an aggressive surgical approach in fit patients when the primary tumor is controlled and the pancreas is the only site of metastatic disease. The value of pancreatic resection in this setting is unclear. The purpose of this study was to review cases of cancer metastatic to the pancreas. METHODS We reviewed our experience with cancer metastatic to the pancreas and the literature regarding resection of pancreatic metastases. Patient and tumor characteristics were summarized using descriptive statistics. RESULTS A total of 220 patients with pancreatic metastasis were analyzed. Three patients were selected from our own experience, and 217 were selected from a literature review. In the 127 patients whose symptoms were recorded at the time of presentation, the most common presenting symptoms were jaundice (n=32, 25.2%) and abdominal pain (n=25, 19.7%). In the 189 patients for whom the location of the metastasis in the pancreas was revealed, the most common location was the head of the pancreas (n=79, 41.8%). The primary tumor site was most commonly kidney (n=155, 70.5%). Surgical resection was attempted in 177 of 220 patients; 135 patients suffering from renal cell carcinoma (RCC) metastasis also underwent pancreatic resection. In the latter group, a median survival of 70 mo was seen, as well as 78% and 65% 2- and 5 y survival rates, respectively. CONCLUSION Survival after resection of RCC with isolated metastasis to the pancreas is favorable. However, a more detailed analysis considering outcomes without surgery for each primary tumor site is needed before the value of this aggressive surgical approach can be completely assessed in the general occurrence of pancreatic metastasis.

Natural History of Glomus Jugulare: A Review of 16 Tumors Managed with Primary Observation

Objective To characterize clinical disease progression and radiologic growth in a series of observed, previously untreated, glomus jugulare tumors (GJT). Study Design Retrospective review. Setting Tertiary neurotologic referral center. Subjects and Methods All patients with primary GJTs that were observed without intervention for a minimum of 2 years. Primary outcome measures included progression of cranial neuropathy and/or radiologic growth. Results A total of 15 patients (80% female; median age, 69.6 years) with 16 GJTs met inclusion criteria. The most common indications for observation included advanced age (11; 73%) and patient preference (11; 73%). Cranial nerve function remained stable in most subjects over a median clinical follow-up period of 86.4 months. Among the 12 with serial imaging, 5 (42%) GJTs demonstrated radiologic growth, while 7 (58%) remained stable. The median growth rate of the 5 enlarging tumors using the maximum linear dimension was 0.8 mm/y (range, 0.6-1.6 mm/y) or 0.4 cm3/y (0.1-0.9 cm3/y) using volumetric analysis. There were no deaths attributable to tumor progression or treatment. Conclusion In an older subset of patients, we found that a significant number of GJTs do not grow after time of diagnosis and symptoms frequently remain stable for many years. Even with disease progression, most GJTs exhibit indolent growth with slowly progressive cranial neuropathy, affording satisfactory physiologic compensation in most patients. In the absence of brainstem compression or concern for malignancy, observation of GJTs is a viable initial management option for elderly patients.

Impact of Intrascalar Electrode Location, Electrode Type, and Angular Insertion Depth on Residual Hearing in Cochlear Implant Patients: Preliminary Results.

Objective To evaluate the relationship between intrascalar electrode location, electrode type (lateral wall, perimodiolar, and midscala), and angular insertion depth on residual hearing in cochlear implant (CI) recipients. Setting Tertiary academic hospital. Patients Adult CI patients with functional preoperative residual hearing with preoperative and postoperative CT scans. Intervention Audiological assessment after CI. Main Outcome Measures Electrode location, angular insertion depth, residual hearing post-CI, and word scores with CI (consonant-nucleus-consonant [CNC]). Results Forty-five implants in 36 patients (9 bilateral) were studied. Thirty-eight electrode arrays (84.4%) were fully inserted in scala tympani (ST), 6 (13.3%) crossed from ST to scala vestibuli (SV), and 1 (2.2%) was completely in SV. Twenty-two of the 38 (57.9%) with full ST insertion maintained residual hearing at 1 month compared with 0 of the 7 (0%) with non-full ST insertion (p = 0.005). Three surgical approaches were used: cochleostomy (C) 6/44, extended round window (ERW) 8/44, and round window (RW) 30/44. C and ERW were small group to compare with RW approaches. However if we combine C + ERW, then RW has higher chance of full ST insertion (p = 0.014). Looking at the full ST group, neither age, sex, nor electrode type demonstrated statistically significant associations with hearing preservation (p = 0.646, p = 0.4, and p = 0.929, respectively). The median angular insertion depth was 429° (range, 373°–512°) with no significant difference between the hearing and nonhearing preserved groups (p = 0.287). Conclusion Scalar excursion is a strong predictor of losing residual hearing. However, neither age, sex, electrode type, nor angular insertion depth was correlated with hearing preservation in the full ST group. Techniques to decrease the risk of electrode excursion from ST are likely to result in improved residual hearing and CI performance.

Sinonasal adenocarcinoma: a 16-year experience at a single institution.

Adenocarcinoma is a rare tumor of the sinonasal tract. The purpose of this study was to characterize a single institutions experience with this malignancy.

Subtotal Resection for Management of Large Jugular Paragangliomas with Functional Lower Cranial Nerves

Objectives To evaluate tumor control following subtotal resection of advanced jugular paragangliomas in patients with functional lower cranial nerves and to investigate the utility of salvage radiotherapy for residual progressive disease. Study Design Case series with planned chart review. Setting Tertiary academic referral center. Subjects and Methods Patients who presented with advanced jugular paragangliomas and functional lower cranial nerves were analyzed. Primary outcome measures included extent of resection, long-term tumor control, need for additional treatment, and postoperative lower cranial nerve function. Results Twelve patients (mean age, 46.2 years; 7 women, 58.3%) who met inclusion criteria were evaluated between 1999 and 2013. The mean postoperative residual tumor volume was 27.7% (range, 3.5%-75.0%) of the preoperative volume. When the residual tumor volume was less than 20% of the preoperative volume, no tumor growth occurred over an average of 44.6 months of follow-up (P < .01). Four tumors (33.3%) demonstrated serial growth at a mean of 23.5 months following resection, 2 of which were treated with salvage stereotactic radiotherapy providing control through the last recorded follow-up. No patient experienced permanent postoperative lower cranial neuropathy as a result of surgery. Conclusion Subtotal resection of jugular paragangliomas with preservation of the lower cranial nerves is a viable management strategy. If more than 80% of the preoperative tumor volume is resected, the residual tumor seems less likely to grow.

Pediatric Endoscopic Cholesteatoma Surgery

Objectives (1) To describe and review a single center’s pediatric endoscopic cholesteatoma experience, including surgical and audiologic outcomes. (2) To assess the most common locations of residual cholesteatoma following endoscopic removal. Study Design Case series with chart review. Setting Tertiary otologic referral center. Subjects Patients <19 years of age who underwent cholesteatoma removal with either endoscopic or microscopic visualization. Methods In a comparison of patients who underwent total endoscopic ear surgery (TEES), combined endoscopic-microscopic surgery, or microscopic surgery, analyzed outcomes included locations and incidence of recurrent and residual cholesteatoma, complications, and audiometric testing. Results Sixty-six patients (mean age, 10.9 years; range, 4-18 years; 43.4% female) with 76 ears met inclusion criteria. The average overall follow-up was 18.8 months (range, 6.7-48.3). Forty-seven (61.8%) ears underwent microscopic removal of cholesteatoma; 29 (38.1%) ears underwent combined endoscopic-microscopic removal; and 8 (10.5%) ears underwent TEES removal. Significantly more mastoidectomies were completed in microscopic cases as compared with endoscopic cases (P = .049). Though second-look procedures occurred in 15 (51.7%) endoscopic cases and 10 (21.3%) microscopic cases (P = .006), the rate of residual disease was 20.0% and 40.0% in endoscopic and microscopic cases, respectively (P = .38). When controlling for preoperative hearing, only the air-bone gap for TEES demonstrated significant improvement (P = .009). No complications were noted. Conclusion The present report describes our experience with pediatric endoscopic cholesteatoma surgery, demonstrating similar hearing outcomes, rates of recurrence and residual disease, and complication rates as compared with traditional microscopic techniques.

Glomus tympanicum: a review of 115 cases over 4 decades.

Objective To characterize the clinical presentation, surgical management, and outcomes of a large consecutive cohort of patients with glomus tympanicum (GT) tumors managed at a single tertiary referral group over 4 decades. Study Design Retrospective review. Setting Tertiary neurotological referral center. Subjects and Methods All patients underwent surgical treatment of histopathologically confirmed GT between January 1973 and March 2014. Audiometric outcomes were reported according to AAO-HNS guidelines, and tumor stage was described using the Glasscock-Jackson classification system. Results There were 115 patients (90.4% women; mean age, 55.2 years) who met the inclusion criteria; 38 (33.0%) cases of GT were stage I, 51 (44.3%) stage II, 10 (8.7%) stage III, and 16 (13.9%) stage IV. There were 108 (93.9%) patients who underwent gross total removal, while 7 (6.1%) received less than complete resection for advanced disease that was adherent to the petrous carotid artery, facial nerve, stapes footplate, or round window. Two patients who underwent gross total resection experienced transient facial paresis, and 1 had internal carotid injury with stroke. No patients had been diagnosed with recurrent disease at a mean follow-up of 30.4 months. Conclusion Surgery remains the treatment of choice for GT, providing a high rate of tumor control and resolution of aural symptoms with a low risk of complications. The surgical approach and extent of resection should be tailored to the patient. Gross total resection can be performed in over 90% of patients; however, leaving a limited adherent tumor remnant on the facial nerve or carotid artery should be considered with advanced infiltrative disease to prevent unnecessary morbidity.

Contemporary Management of Jugular Paragangliomas

Jugular paragangliomas are generally benign slow-growing tumors that can cause pulsatile tinnitus, hearing loss, and cranial nerves neuropathy. Progressive growth can also lead to intracranial extension. Historically, the treatment of choice for these lesions has been gross total resection. However, over the last 15 years, many groups have adopted less invasive management strategies including stereotactic radiation therapy, subtotal resection, and primary observation in order to reduce treatment-associated morbidity. The focus of this article is to review the modern management of jugular paraganglioma, highlighting the evolving treatment paradigm at the Otology Group of Vanderbilt.

The Utility of a Predictive Model for Cochlear Implant Operating Time.

Objective: This study analyzes multiple factors and their significance in determining the operative timing for cochlear implants at one institution over a 10-year period. Study Design: Retrospective case review. Setting: Tertiary referral center. Patients: All patients including both adult and pediatric undergoing cochlear implantation from 2002 through January 2012. Intervention(s): Cochlear implantation. Main Outcome Measure(s): The overall operative room time and surgical duration for patients undergoing cochlear implantation. Individual factors analyzed for influence on timing included center experience, surgeon experience, location (main OR, childrens OR, outpatient OR), patient age, patient sex, bilaterality, anatomical consideration, complications, and the involvement of residents and fellows. Results: ANOVA analysis of individual factors. Factors associated with increased surgical duration included bilateral implants, abnormal inner ear anatomy, and intraoperative complications. Factors associated with time outside the operation included surgical duration, the surgical suite type, and the availability of a fellow. Total operating room time was significantly reduced in an outpatient setting and in quicker performed procedures. Conclusions: The influence of factors affecting both surgical duration and time in the operating room can be predicted and used to provide more accurate estimates of operating room time.

Wavefront-Guided Photorefractive Keratectomy in Eyes with Prior Radial Keratotomy: A Multicenter Study

PURPOSE To investigate the outcomes of wavefront-guided photorefractive keratectomy (WG PRK) using prophylactic mitomycin C (MMC) in eyes that had previously undergone radial keratotomy (RK). DESIGN Retrospective, observational, consecutive case series. PARTICIPANTS Thirty-two eyes of 27 patients with previous RK that underwent WG PRK with MMC. METHODS The records were reviewed of consecutive RK patients whose eyes underwent WG PRK with MMC in 4 centers with postoperative follow-up of 6 months or longer (range, 6-21 months). Eyes were divided into myopic WG PRK and hyperopic WG PRK groups based on their preoperative spherical equivalent (SE). Preoperative best spectacle-corrected visual acuity (BSCVA) was compared with postoperative uncorrected visual acuity (UCVA) and BSCVA to ascertain efficacy and safety. Change in SE and attempted versus achieved SE were evaluated. Incidences of haze and other complications were recorded. MAIN OUTCOME MEASURES Uncorrected visual acuity, BSCVA, SE, corneal haze, and other complications. RESULTS In the myopic WG PRK group (n = 9), UCVA improved by 3 lines on average (P = 0.015) with UCVA of > or =20/20 in 56% and > or =20/40 in 100% of eyes; 55% were within 0.5 diopter (D), and 100% were within 1 D of attempted refraction. In the hyperopic WG PRK group (n = 23), UCVA improved for 3 lines on average (P<0.001), with UCVA of > or =20/20 in 48% and > or =20/40 in 100% of eyes; 57% were within 0.5 D and 74% were within 1 D of attempted refraction. One eye lost 2 lines of BSCVA as a result of the development of mild to moderate haze, but recovered in 4 months. No eyes lost more than 2 lines of BSCVA. Six eyes (19%; 6/32) experienced the development of haze in the postoperative course, with mild to moderate haze in 1 eye and trace haze in the other 5 eyes. No other complications were noted. CONCLUSIONS Wavefront-guided PRK with MMC in eyes with prior RK improved the UCVA significantly and was safe over the short follow-up of this series. Although haze occurred, no eye suffered persistent visual loss of 2 or more lines. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.