Jo Ann Brooks

Outcome of Patients With Residual Germ Cell or Non-Germ Cell Malignancy After Resection of Primary Mediastinal Nonseminomatous Germ Cell Cancer

PURPOSE To identify prognostic variables and outcomes in patients with primary mediastinal nonseminomatous germ cell tumor (PMNSGCT) with postchemotherapy resection of persistent cancer. PATIENTS AND METHODS Forty-seven consecutive patients with residual cancer after resection of PMNSGCT were retrospectively reviewed. Univariate comparisons were performed. RESULTS At diagnosis, 43 patients had elevated serum tumor markers (STMs), and 20 had extramediastinal disease. At resection, 21 patients had elevated STMs. After resection, 26 patients had germ cell tumors (GCT), 12 had malignant transformation of teratoma with elements of non-GCT, and nine had both GCT and non-GCT. Sixteen of 47 patients continuously have no evidence of disease (NED). This includes eight of 26 patients with GCT histology and two of 12 patients with non-GCT histology. Of 27 patients with mediastinal-only disease at presentation, 14 have continuously NED. Of 20 patients with extramediastinal disease at presentation, two have continuously NED. Seven of 21 patients with elevated STMs at time of resection have continuously NED. Sixteen patients received adjuvant chemotherapy, and seven have continuously NED. Overall, 16 of 47 patients have continuously NED, an additional four patients have NED with further therapy (currently NED), two patients are alive with disease, 23 patients died of disease, and two patients died postoperatively. CONCLUSION The presence of elevated STMs at resection does not appear to alter outcome if residual disease is completely resected. In this poor-risk patient population, surgical resection of persistent cancer, even in the presence of elevated STMs, can still achieve long-term survival.

Postoperative Nosocomial Pneumonia: Nurse-sensitive Interventions

Nosocomial pneumonia (NP) is well documented as the second most common nosocomial infection. It is now more common in surgical patients than surgical-site or wound infection. Healthcare implications of NP include not only increased patient morbidity and mortality, but also increased use of healthcare resources. The advanced practice nurse plays an integral role in the prevention and minimization of NP across healthcare settings. This article focuses on postoperative NP after abdominal, cardiac, or thoracic surgery in the non-mechanically ventilated patient and discusses the diagnostic assessment, risk factors, and potential nurse-sensitive interventions to prevent or minimize this complication. Ideas for potential nursing research related to these risk factors are described.

A retrospective analysis to identify variables predictive of achieving a pCR after neoadjuvant chemoradiation therapy for locally advanced esophageal cancer

4061 Background: Patients achieving a complete pathological response (pCR) after neoadjuvant chemoradiation therapy (CRTx) for locally advanced esophageal cancer have a superior prognosis as compared to those who do not achieve a pCR. A retrospective, institutional review was conducted to identify variables potentially predictive of achieving a pCR. METHODS From 1992 through 2002, 86 patients with esophageal cancer were identified who met criteria for review including pretreatment transesophageal ultrasound (EUS) stage ≥ II and platinum-based CRTx followed by transthoracic esophagectomy including complete staging with celiac and mediastinal lymph node dissections. The cohort was mainly male (88.2%, n=75) with a mean age of 57.8 yrs and adenocarcinoma as the predominant histology (89.4%, n=76). Fifty-five (65.8%) patients demonstrated EUS stages III or IVa prior to CRTx. RESULTS Twenty-five (29.4%) patients demonstrated a pCR after CRTx. Although none of the 10 variables analyzed were significantly predictive of a pCR, trends emerged in patients demonstrating a pCR including lower body mass index (BMI mean 27.6 vs non-pCR 30.1; p=0.12) and squamous cell as compared to adenocarcinoma histology (55.6%, n=5 vs 26.7%, n=20; p=0.11). Pretreatment EUS T stages 1 and 2, EUS N stage 0 and overall EUS stages IIa and IIb all demonstrated a higher percentage of patients achieving a pCR (T 1 or 2 47.0%, n=8 vs T 3 or 4 25.4%, n=17, p=0.14; N0 40.0%, n=8 vs N1 26.6%, n=17, p=0.27; stages IIa or IIb 41.3%, n=12 vs III, IVa or IVb 23.6%, n=13, p=0.13). Age (p=0.35), amount of weight loss (p=0.81) and gender (p=0.99) were not predictive of achieving a pCR. Multivariate analysis with variable entry set at p<0.15 demonstrated squamous cell histology to be most predictive of pCR (p=0.04). CONCLUSIONS A lower BMI, squamous cell histology, and earlier EUS T, N and overall EUS stage increased the likelihood of patients achieving a pCR after CRTx in this retrospective study. Continued study is indicated to avoid the costs and potential for additional risks of CRTx in patients who predictably will not achieve a pCR. [Table: see text].

Short- and Long-Term Outcomes After Large Pulmonary Resection for Germ Cell Tumors After Bleomycin-Combination Chemotherapy

BACKGROUND Treatment of nonseminomatous germ cell tumors frequently requires bleomycin-combination chemotherapy followed by resection of residual disease. Bleomycin administration however raises concerns with respect to postoperative respiratory complications, particularly for patients undergoing large pulmonary resections. We undertook an institutional review to determine the outcome of large pulmonary resections after bleomycin-combination chemotherapy. METHODS Between 1981 and 2001, 530 patients presented to our institution for resection of residual intrathoracic disease for either metastatic testicular or primary mediastinal nonseminomatous germ cell tumors. We subsequently reviewed 32 of these patients who required pneumonectomy (n = 19; RIGHT = 9, LEFT = 10) or bilobectomy (n = 13) after bleomycin-combination chemotherapy. RESULTS There were four operative deaths (13%). All postoperative deaths occurred in patients undergoing right-sided resections (pneumonectomy, n = 2; bilobectomy, n = 2) as a consequence of pulmonary complications. Operative survivors had a pulmonary morbidity of 18%. Fourteen of 20 long-term survivors were found to have a satisfactory performance status at follow-up. CONCLUSIONS Otherwise young and healthy male nonseminomatous germ cell tumors patients requiring large pulmonary resections after bleomycin-combination chemotherapy appear to be at higher than anticipated risk for pulmonary-related morbidity and mortality. However long-term survivors report an acceptable functional status.