Punam P. Parikh

A review of 218 pediatric cases of hepatocellular carcinoma

PURPOSE This study evaluates the incidence trends and clinical outcomes of children with hepatocellular carcinoma (HCC) and assesses factors predictive of patient survival. METHODS The Surveillance, Epidemiology, and End Results registry was queried from 1973 to 2009 for all patients between ages 0 and 19 with primary HCC. Demographics, tumor histology, surgical intervention, and patient survival were collected. RESULTS Overall, 218 patients were identified. The annual age-adjusted incidence was 0.05 cases per 100,000 in 2009. Fibrolamellar subtype tumors were exclusive to children >5years old and exhibited greater survival compared to non-fibrolamellar subtype (57% vs. 28%, respectively, p=0.002). Tumor extirpation for patients with resectable disease significantly improved overall survival at 5years compared to no surgery (60% vs. 0%, respectively, p<0.0001). Overall 5-, 10- and 20-year survival for the entire cohort was 24%, 23%, and 8%, respectively. Independent prognostic factors of lower mortality according to multivariate analysis were surgical resection (hazard ratio (HR)=0.18), non-Hispanic ethnicity (HR=0.52), and local disease at presentation (HR=0.46). CONCLUSION Over the past four decades, the incidence of HCC has remained relatively stable. Children of Hispanic ethnicity have high mortality rates. However, HCC resection for curative intent significantly improves outcomes.

Predictors of survival and incidence of hepatoblastoma in the paediatric population

OBJECTIVES This study evaluates current trends in incidence, clinical outcomes and factors predictive of survival in children with hepatoblastoma (HB). METHODS The Surveillance, Epidemiology and End Results (SEER) database was queried for the period 1973-2009 for all patients aged <20 years with HB. RESULTS A total of 606 patients were identified. The age-adjusted incidence was 0.13 patients per 100 000 in 2009. An annual percentage change of 2.18% (95% confidence interval (CI) 1.10-3.27; P < 0.05) was seen over the study period. Overall survival rates at 5, 10 and 20 years were 63%, 61% and 59%, respectively. Ten-year survival rates significantly improved in patients with resectable disease who underwent operative treatment in comparison with those with non-resectable HB (86% versus 39%; P < 0.0001). Multivariate analysis showed surgical treatment (hazard ratio (HR) = 0.23, 95% CI 0.17-0.31; P < 0.0001), Hispanic ethnicity (HR = 0.61, 95% CI 0.43-0.89; P = 0.01), local disease at presentation (HR = 0.43, 95% CI 0.29-0.63; P < 0.0001) and age < 5 years (HR = 0.63, 95% CI 0.41-0.95; P < 0.03) to be independent prognostic factors of survival. CONCLUSIONS The incidence of paediatric HB has increased over time. Hepatoblastoma is almost exclusively seen in children aged < 5 years. When HB presents after the age of 5 years, the prognosis is most unfavourable. Tumour extirpation markedly improves survival in paediatric patients with local disease.

Considerations for Initial Dosing of Botulinum Toxin in Treatment of Adductor Spasmodic Dysphonia

Objectives To assess the effect on voice improvement and duration of breathiness based on initial dose of onabotulinum toxin A (BTX-A) in the management of adductor spasmodic dysphonia (SD) and to compare voice outcomes for initial bilaterally injected doses of 1.25 units (group A) vs 2.5 units (group B) of BTX-A. Study Design Case series with chart review of patients with adductor SD treated at a tertiary care facility from 1990 to 2011. Setting Academic subspecialty laryngology practice. Methods Demographic data (age and sex), voice rating, duration of voice improvement, and breathiness were evaluated and compared between groups A and B using the Student t test and χ2 analysis. Results Of 478 patients identified, 305 (223 in group A, 82 in group B) patients met inclusion criteria. The average age was 56.2 years in group A and 57.4 years in group B (P = .5). The female to male ratio was 2.91 for group A vs 3.56 for group B (P = .61). Good voice outcomes (grade 3 or 4) were reported by 91% of group A patients vs 94% of group B (P = .75). The average duration of voice improvement was 99.7 days for group A and 108.3 days for group B (P = .54). The average duration of breathiness was 10.88 days for group A vs 15.42 days for group B (P = .02). Conclusion Patients injected with 1.25 units bilaterally had a statistically significant shorter duration of breathiness without a statistically significant difference in clinical effectiveness or voice outcome. It is therefore recommended that a relatively low initial BTX-A dose be used with subsequent titration to achieve improved voice outcomes.

Are burn patients really at risk for thrombotic events

There continues to be debate about the routine use of deep vein thrombosis (DVT) prophylaxis in burn patients. The concern is that routine prophylaxis may lead to adverse events. The debate hinges on the incidence of DVT and its relation to the risk–benefit ratio. This study seeks to estimate the true rate of DVT in burn patients, and to evaluate possible risk factors to its development. The Nationwide Inpatient Sample was queried for all patients with age ≥18 years with ICD-9 codes for burn injuries. Demographic data, comorbidities, burn data, length of stay, total charges, procedures, presence of central venous catheter, and mortality were recorded. Patients were classified based on the presence of DVT. Student’s t-test, &khgr;2 test, and logistic regression were performed. 36,638 burn patients were identified. DVT rate was 0.8%. Patients with DVT were older, had longer hospitalizations, more procedures, and higher charges. On logistic regression, black race, TBSA ≥20%, history of previous venous thrombotic events, blood transfusion, and mechanical ventilation were the significant factors associated with DVT. Patients with DVT were almost twice as likely to die during the admission (P = .011). This is the largest series to date examining the risk factors for DVT in burn patients. DVT developed in approximately 0.8% of burn patients. Black race, TBSA ≥20%, blood transfusions, and mechanical ventilation were associated with approximately 2-fold odds of developing DVT. Identification of these additional risk factors may allow targeted patient prophylaxis. Additionally, patients with DVT incurred higher total charges and longer hospitalization.

Simple acute appendicitis versus non-perforated gangrenous appendicitis: is there a difference in the rate of post-operative infectious complications?

BACKGROUND According to the 2002 Surgical Infection Society Guidelines on Antimicrobial Therapy for Intra-abdominal Infections, antimicrobial therapy is not recommended beyond 24 hours for the treatment of postoperative acute or gangrenous appendicitis without perforation. However, clinicians commonly consider gangrenous appendicitis to pose a greater risk of post-operative infectious complications, such as surgical site infections and intra-abdominal abscesses. This study examines the relative risk of post-operative infection between patients with simple and gangrenous appendicitis. METHODS A retrospective review of patients with either non-perforated gangrenous or simple appendicitis from 2010 to 2012 was performed at a large urban teaching hospital. RESULTS The rate of post-operative intra-abdominal abscess formation, which was diagnosed on patient readmission to the hospital, was significantly greater in patients with non-perforated gangrenous appendicitis in comparison to those with simple non-perforated appendicitis. Also, patients with non-perforated gangrenous appendicitis received extended courses of post-operative antibiotics, despite SIS recommendations. CONCLUSIONS The role of peri-operative antibiotics for non-perforated gangrenous appendicitis merits further study.

Risk of concomitant malignancy in hyperfunctioning adrenal incidentalomas

BACKGROUND Adrenal masses are common incidental findings on radiologic imaging. The association between malignancy and hormonal hyperactivity found in incidentally discovered adrenal tumors, however, remains unclear. METHODS A retrospective analysis of prospectively collected data from patients who underwent adrenalectomy for incidentally discovered adrenal tumors at a single institution. Outcomes and operative data were compared by univariate analysis. Area under the curve was used to analyze the effect of tumor size in predicting malignancy. RESULTS There were 49 patients who initially presented with adrenal incidentalomas that underwent adrenalectomy. Most patients were Caucasian women with an average age of 51 ± 14 years. Of this group, 24 patients underwent resection for hyperfunctioning adrenal glands. There were no significant differences in malignancy rates between hyperfunctional and nonfunctional tumors (4.1% vs. 12.0%, P = 0.32). On final histopathology, there were four patients with adrenal malignancies: two adrenocortical carcinomas and two metastatic from renal carcinoma. Only one patient with a hyperfunctioning adrenal tumor had underlying malignancy. Overall, invasion of adjacent structures (P < 0.001), presence of lymphadenopathy (P = 0.02), metastasis (P = 0.03), irregular tumor margins (P = 0.01), heterogeneity (P = 0.05), and tumor size >6 cm (P = 0.04) on radiologic imaging were strongly associated with malignancy in adrenal incidentalomas. CONCLUSIONS The risk of concomitant malignancy and hormonal hyperactivity in adrenal incidentalomas is very low. Tumor size (>6 cm) and radiographic features remain the most important predictors of adrenal malignancy, regardless of tumor function.

Sex variability of fine-needle aspiration reliability in the diagnosis of malignancy in thyroid nodules ≥4 cm

BACKGROUND The effect of sex on fine-needle aspiration (FNA) diagnosis of thyroid cancer remains unknown. This study determines the reliability of FNA when evaluating thyroid nodules ≥4 cm in women and men. METHODS Prospectively collected data of 1,068 patients who underwent FNA and thyroidectomy at a tertiary medical center were retrospectively reviewed. Data were stratified by sex and thyroid nodule size ≥4 cm. RESULTS The FNA false-negative rate for thyroid malignancy in women and men was 17% and 0%, respectively. FNA was less predictive of malignancy in women (odd ratio = 31.7; 95% confidence interval, 19.2 to 52.5; P < .0001) compared with men (odds ratio = 51.7; 95% confidence interval, 11.8 to 225.1; P < .0001) with thyroid nodules ≥4 cm. CONCLUSIONS For the diagnosis of malignancy in large thyroid nodules, FNA may be less reliable in women compared with men. This study advocates using a more aggressive approach that includes surgical resection for definitive diagnosis in women with thyroid nodules ≥4 cm.

A schwannoma of the greater petrosal nerve located within the petrous apex and treated with stereotactic radiotherapy

A 26 year-old female experienced progressive left sided pulsatile tinnitus and conductive hearing loss for two years, which following an extensive clinical workup, was diagnosed as a left greater petrosal nerve schwannoma located within the petrous apex of the temporal bone. Between neurosurgical management and radiation therapy, multiple therapeutic options were presented to the patient, who ultimately chose stereotactic radiotherapy as an alternative to surgical resection due to the potential morbidity associated with surgery. The patient received three fractions of 600 cGy without subsequent worsening of her symptoms, new onset neurologic symptoms or radiation induced side effects reported at a 3, 6 and 12 month clinic visits. A follow-up MRI at 6 and 12 months post radiation administration demonstrated no further tumor growth.

Surgeon-performed ultrasound predictors of malignancy in patients with Hürthle cell neoplasms of the thyroid

BACKGROUND Fine-needle aspiration cannot reliably determine malignancy in patients with Hürthle cell neoplasms (HCNs) of the thyroid. Thyroid nodule size and characteristics determined by surgeon-performed ultrasound (SUS) may be useful for predicting malignancy in HCN preoperatively. This study examined whether tumor size and features by SUS can reliably predict malignancy in patients with HCN. MATERIALS AND METHODS We performed a retrospective review of 84 patients with HCN by fine-needle aspiration, who underwent SUS and thyroidectomy from 2002 to 2010. All patients underwent thyroid lobectomy with isthmusectomy unless there was a history of radiation exposure, familial thyroid cancer, obstructive symptoms, bilateral nodules, and/or patient preference, in which case total thyroidectomy was performed. Tumor size and malignant features by SUS were correlated with final histopathology using multivariate regression analysis. RESULTS On final histopathology, 29 patients had malignant thyroid nodules and 55 patients had benign ones. There were no statistically significant differences in terms of age, race, ethnicity, or gender between HCN patients who revealed malignant or benign nodules on final pathology. Tumor size ≥ 4 cm measured by SUS did not predict malignancy in HCN. Hypoechogenicity and hyperechogenicity were significantly associated with malignancy, whereas isoechogenicity was predictive of benignity (P = 0.044). No other ultrasonographic features were predictive for thyroid carcinoma by multivariate analysis. CONCLUSIONS Tumor size and features determined by SUS do not reliably predict malignancy in patients with HCN. Such patients at risk for malignancy should initially undergo thyroid lobectomy for definitive diagnosis.

Infant with bilateral pulmonary sequestrations with portal venous drainage excised by video-assisted thoracic surgery

INTRODUCTION Bilateral pulmonary sequestrations are rare congenital anomalies. Despite its benign nature, the potential complications of pulmonary sequestration (PS) are significant, including recurrent pulmonary infections, hemoptysis, congestive heart failure, and malignant potential. Therefore, the main treatment is surgical excision, even for patients with asymptomatic PS. CASE We present an infant in whom an intralobar PS of the right lung and an extralobar PS of the left lung were diagnosed on prenatal screening ultrasonography. Both were found to have venous drainage into the portal vein. Surgical excision was performed via video-assisted thoracic surgery (VATS) at 14 months of age. CONCLUSION PS may present with unique vascular connections, including venous drainage into the portal vein. VATS resection for pulmonary sequestration is feasible and effective as an alternative to bilateral thoracotomies, in the setting of extensive preoperative planning and performance by an experienced thoracoscopic surgeon.