Meredith R. Bergey

A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: Part I. Unilateral reconstruction

Background: The purpose of this study was to demonstrate the impact of bilateral free flap breast reconstruction on the abdominal wall. This is the second installation of a two-part series. Presented here are bilateral combinations of three techniques: the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap, deep inferior epigastric perforator (DIEP) flap, and superficial inferior epigastric artery (SIEA) flap. Methods: A blinded prospective cohort study was performed involving 234 patients. Patients were evaluated preoperatively and for 1 year postoperatively. At each encounter, patients underwent objective abdominal strength testing using the Manual Muscle Function Test and Functional Independence Measure and psychometric testing using the Short Form 36 questionnaire. At postoperative visits, patients also completed a questionnaire specific to breast reconstruction. Statistical analysis included the Kruskal-Wallis, Mann-Whitney, Friedman, and Wilcoxon signed rank tests. Results: A total of 234 patients were enrolled. Of these, 157 underwent reconstruction, 82 of which were bilateral. There was a significant decline in upper (p = 0.02) and lower (p = 0.05) abdominal strength from bilateral free TRAM flaps compared with bilateral DIEP flaps. Likewise, there was a significant decline in upper (p = 0.055) and lower (p = 0.04) abdominal strength from bilateral free TRAM flaps compared with bilateral SIEA flaps. For combinations, the most muscle impairment to least was as follows: free TRAM/free TRAM, free TRAM/DIEP, DIEP/DIEP, DIEP/SIEA, and SIEA/SIEA. The free TRAM/SIEA data were not significant. Although psychometric testing showed trends, there was no significant difference among treatment groups. Conclusion: Abdominal wall strength following various combinations of bilateral free flap breast reconstruction techniques closely adheres to theoretical predictions based on the degree of surgical muscle sacrifice.

Degree of Tumor FDG Uptake Correlates with Proliferation Index in Triple Negative Breast Cancer

Purpose2-Deoxy-2-[F-18]fluoro-D-glucose (FDG) uptake may be a useful surrogate marker for proliferation index, but the correlation has not always been clear-cut. Previous research by our group suggests that FDG-positron emission tomography (PET) is sensitive in detecting triple negative breast cancer. We therefore performed a pilot study to test if FDG uptake correlated with proliferation index in women with triple negative cancer.ProceduresTo determine whether proliferation index correlates with metabolic uptake of FDG in women with triple negative breast cancer, we performed a retrospective analysis correlating %Ki67 nuclear stain with tumor maximum standardized uptake values (SUVmax) in a group of 41 women, 22 with triple negative and 19 with non-triple negative breast cancer.ResultsAs expected, [18F]-PET imaging was significantly more sensitive in detecting triple negative breast cancer than non-triple negative breast cancer, 95.5% vs 68.4% (p = 0.036). In general, SUVmax and %Ki67 nuclear stain values rise as histologic grade worsens. Histologic grade of triple negative breast cancer was more often poorly differentiated than non-triple negative cancer (p = 0.001). SUVmax correlated with %Ki67 nuclear staining in our entire cohort (spearman correlation = 0.485, p = 0.002). Moreover, this significant correlation appeared to be driven primarily by a subset of women with triple negative cancer (spearman correlation = 0.497, p = 0.019).ConclusionsDegree of tumor FDG uptake correlated significantly with proliferation index in women with triple negative breast cancer suggesting a potential role of FDG-PET in treatment response monitoring for this group of women. Future studies are necessary to define the role of PET imaging as a non-invasive means to monitor breast cancer treatment response in the neoadjuvant setting.

Improved Survival after Pulmonary Metastasectomy for Soft Tissue Sarcoma

Introduction:Survival after pulmonary metastasectomy for soft tissue sarcoma (STS) has been lower than in osteosarcoma (14–40% versus 40–50%). With improved patient selection criteria and advanced chemotherapy agents, we hypothesized that survival after metastasectomy for STS has improved in recent years. Methods:Retrospective study of 48 patients undergoing pulmonary metastasectomy for STS between 1995 and 2007. Potential predictors of overall survival and disease-free survival (DFS) were examined using the log-rank test or Cox regression. Multivariate analysis was conducted using Cox regression. Results:Overall survival after initial metastasectomy was 67% and 52% at 3 and 5 years, respectively; DFS was 17% and 10% at 3 and 5 years. Univariate analysis indicated that ≤2 pulmonary metastases (p = 0.03), diameter of largest metastasis ≤2 cm (p = 0.09), and the absence of extrapulmonary metastases (p = 0.10) were associated with longer overall survival. Absence of extrapulmonary metastases (p = 0.07) and smaller size of the largest pulmonary metastasis (p = 0.06) were associated with longer DFS. Before 2001, 46.7% of patients received adjuvant chemotherapy versus 72.7% after (p = 0.10). Neither use of chemotherapy nor chemotherapy type was related to overall survival or DFS. Conclusion:Five-year overall survival is substantially higher after pulmonary metastasectomy for STS in our study relative to previously published results (52% versus 14–40%). This improvement does not seem to be the result of greater use of, or newer, chemotherapeutic regimens. Among potential explanations, improved patient selection is the most likely factor.

Longitudinal evaluation of the concordance and prognostic value of lymphovascular invasion in transurethral resection and radical cystectomy specimens.

THIS IS A COMMENT MODERATED PAPER
available at http://www.bjui.org/commentary

Complications following thoracic trauma managed with tube thoracostomy

INTRODUCTION Tube thoracostomy is a common procedure used to treat traumatic chest injuries. Although the mechanism of injury traditionally does not alter chest tube management, complication rates may vary depending on the severity of injury. The purpose of this study was to investigate the incidence of and risk factors associated with chest tube complications (CTCs) following thoracic trauma. METHODS A retrospective chart review of all trauma patients (≥16 years old) admitted to an urban level 1 trauma centre (1/2007-12/2007) was conducted. Patients who required chest tube (CT) therapy for thoracic injuries within 24 h of admission and survived until CT removal were included. CTCs were defined as a recurrent pneumothorax or residual haemothorax requiring CT reinsertion within 24 h after initial tube removal or addition of new CT >24 h after initial placement. Variables including demographic data, mechanism, associated injuries, initial vital signs, chest abbreviated injury score (AIS), injury severity score (ISS), Glasgow coma score (GCS) and length of stay (LOS) and CT-specific variables (e.g. indication, timing of insertion, and duration of therapy) were compared using the chi square test, Mann-Whitney test, and multivariate analysis. RESULTS 154 patients were included with 22.1% (n=34) developing a CTC. On univariate analysis, CTCs were associated with longer ICU and hospital LOS (p=0.02 and p<0.001), increased chest AIS (p=0.01), and the presence of an extrathoracic injury (p=0.047). Results of the multivariate analysis indicated that only increased chest AIS (OR 2.49; p=0.03) was a significantly independent predictor of CTCs. CONCLUSIONS CTCs following chest trauma are common and are associated with increased morbidity. The severity of the thoracic injury, as measured by chest AIS, should be incorporated into the development of CT management guidelines in order to decrease the incidence of CTCs.

Endorectal T2-weighted MRI does not differentiate between favorable and adverse pathologic features in men with prostate cancer who would qualify for active surveillance.

OBJECTIVE With the increased diagnosis of low grade, low volume, potentially non-lethal disease, active surveillance (AS) has become an increasingly popular alternative for select men with low-risk prostate cancer. The absence of precise clinical staging modalities currently makes it difficult to predict which patients are most appropriate for AS. The goal of our study was to evaluate the ability of endorectal MRI (eMRI) to predict adverse pathologic features in patients who would otherwise qualify for an AS program. MATERIALS AND METHODS We retrospectively reviewed our institutions radical prostatectomy (RP) database from 1991 to 2007 and identified 172 patients who would have qualified for AS and underwent preoperative staging eMRI with T2-weighted (T2W) sequences. MRI findings were correlated to final pathology in order to assess the ability of staging eMRI to predict adverse pathologic features in patients suitable for AS. RESULTS The mean age of our cohort was 59.8 ± 6.2 years. The mean PSA at the time of diagnosis was 5.2 ± 2.2 ng/ml. In 51% of patients, no discrete tumor was visualized on eMRI and in 49% of patients a discrete tumor was detected. At the time of RP, Gleason score upgrading, extracapsular extension, and a positive surgical margin occurred in 17%, 6%, and 5% of cases, respectively. Patients with documented tumor on eMRI did not have an increased incidence of adverse pathologic findings with regard to tumor volume (P = 0.31), extra-capsular extension (P = 0.82), Gleason upgrading (P = 0.92), seminal vesicle invasion (P = 0.97), or positive surgical margin rate (P = 0.95) compared with those in whom no tumor was seen. CONCLUSION Discrete tumor identification on eMRI is not predictive of adverse pathologic features in patients who would otherwise qualify for AS. eMRI likely does not provide additional information when prospectively evaluating patients for AS protocols.

Does Race Affect Postoperative Outcomes in Patients With Low-Risk Prostate Cancer Who Undergo Radical Prostatectomy?

OBJECTIVES To assess the magnitude of racial disparities in prostate cancer outcomes following radical prostatectomy for low-risk prostate cancer. METHODS We retrospectively reviewed our database of 2407 patients who under went radical prostatectomy and isolated 2 cohorts of patients with low-risk prostate cancer. Cohort 1 was defined using liberal criteria, and cohort 2 was isolated using more stringent criteria. We then studied pre- and postoperative parameters to discern any racial differences in these 2 groups. Statistical analyses, including log-rank, chi(2), and Fishers exact analyses, were used to ascertain the significance of such differences. RESULTS Preoperatively, no significant differences were found between the white and African-American patients with regard to age at diagnosis, mean prostate-specific antigen, median follow-up, or percentage of involved cores on prostate biopsy. African-American patients in cohort 1 had a greater mean body mass index than did white patients (26.9 vs 27.8, P = .026). The analysis of postoperative data demonstrated no significant difference between white and African-American patients in the risk of biochemical failure, extraprostatic extension, seminal vesicle involvement, positive surgical margins, tumor volume, or risk of disease upgrading. African-American patients in cohort 2 demonstrated greater all-cause mortality compared with their white counterparts (9.4% vs 3.1%, P = .027). CONCLUSIONS In patients with low-risk prostate cancer treated with radical prostatectomy, there exist no significant differences in surrogate measures of disease control, risk of disease upgrading, estimated tumor volume, or recurrence-free survival between whites and African-Americans.

Free flap breast reconstruction in advanced age: Is it safe?

Background: Due to perceived medical and surgical risk, patients of advanced age may not be offered free flap breast reconstruction. The purpose of this study was to determine whether complications are actually higher in patients of advanced age. Methods: A review of 1031 muscle-sparing free transverse rectus abdominis musculocutaneous, deep inferior epigastric perforator, and superficial inferior epigastric artery flaps over 15 years was performed. There were 976 patients younger than 65 years and 55 patients aged 65 and older. Population variables, operative variables, and outcome variables were compared. Statistical analysis included chi-square, Fishers exact, Mann-Whitney, and two-sample t tests. Results: The mean age was 47 years (range, 24 to 79 years). The older group had a higher American Society of Anesthesiologists status (2.1 versus 1.9; p = 0.05), a higher prevalence of hypertension (38 percent versus 18 percent; p < 0.001), a higher average body mass index (30 versus 28; p = 0.039), and lower rates of preoperative (28 percent versus 13 percent; p = 0.016) and postoperative (17 percent versus 2 percent; p = 0.003) chemotherapy. In the older group, more blood transfusions (7 percent versus 2 percent; p = 0.03) were administered and the coupler was used less often (13 percent versus 32 percent; p = 0.009). There was no difference in length of stay (3.5 days), medical complications (4 percent), surgical complications (32 percent), take-backs (1 percent), or revisions (19 percent). Conclusions: Despite higher rates of hypertension, higher American Society of Anesthesiologists status, higher body mass index, and higher rates of blood transfusion, the 65 years and older group had outcomes equal to those of the general population. Thus, free flap breast reconstruction in patients of advanced age is safe, and should be offered when indicated.

Factors associated with mortality and brain injury after falls from the standing position.

BACKGROUND Trauma centers are increasingly tasked with evaluating patients who have sustained low-acuity mechanisms of injury, such as fall from standing (FFS). Previous studies have shown that low-level falls are associated with a high incidence of injury in certain patient groups. The purpose of the current study was to assess risk factors associated with brain injury and death after fall from the standing position only. MATERIALS A retrospective analysis was performed on all patients who presented with FFS as the mechanism of injury from 2000 to 2005. Demographic variables, past medical history, use of warfarin, blood-alcohol level, initial vital signs, injuries, disposition, and mortality outcome were recorded. Data were analyzed to determine risk factors associated with brain injury, need for intensive care unit (ICU) admission, need for emergency operation, and mortality. RESULTS A total of 808 patients were identified. Risk factors associated with brain injury, the need for ICU admission, and death included: Injury Severity Score, age >or=60 years, blood-alcohol level greater than 80 mg/dL, warfarin use, systolic blood pressure <100 mm Hg, and Glasgow Coma Scale <or=12. These risk factors had an additive effect for propensity for brain injury, ICU admission, and death. Increasing Injury Severity Score and use of warfarin had an independent association with mortality. CONCLUSION FFS is a potentially morbid mechanism of injury in those who are using warfarin, those with Glasgow Coma Scale score <or=12, and those who are not inebriated. Age more than 60 years is an additive, but not independent, risk factor for injury.

The presence of lymphovascular invasion in radical cystectomy specimens from patients with urothelial carcinoma portends a poor clinical prognosis.

To assess the prognostic significance of lymphovascular invasion (LVI) on clinical outcomes in patients with transitional cell carcinoma of the bladder treated with radical cystectomy (RC).