Introduction The impact of esophageal tumor length on pT1 esophageal adenocarcinoma has not been well evaluated. Methods Case histories of all patients (n = 133) undergoing esophageal resection from ...1979 to 2007 with pT1 adenocarcinoma of the esophagus were reviewed. Univariate and multivariate analyses of esophageal tumor length and other standard prognostic factors were performed. Results Patients with early-stage pT1 esophageal adenocarcinoma with tumors less than 3 cm demonstrate decreased long-term survival (3 years: >3 cm = 46% vs 93%; P < .001) and higher risk of lymph node involvement (lymph node positive: >3 cm = 47% vs 10%; P < .001). Multivariable analysis shows that esophageal tumor length (>3 cm) is an independent risk factor for survival in patients with pT1 early-stage esophageal cancer (hazard ratio: 4.8, 95% confidence intervals: 1.4–16.5; P < .001) even when controlled for submucosal involvement, lymph node involvement, and lymphatic/vascular invasion status. In combination with submucosal involvement, esophageal tumor length (>3 cm) identifies a high-risk population of pT1 esophageal adenocarcinoma (3 years: group 1 0 risk factors = 100%, group 2 1 risk factor = 87%, and group 3 2 risk factors = 33%; P < .001). Conclusions This study demonstrates that esophageal tumor length (>3 cm) is a risk factor for long-term survival and lymph node involvement in early-stage pT1 esophageal adenocarcinoma. Esophageal tumor length (>3 cm) in combination with submucosal involvement may help to identify a high-risk group of patients with pT1 esophageal adenocarcinoma.
The current American Joint Committee on Cancer (AJCC) esophageal cancer staging for nodal status is difficult to interpret and is based solely on lymph node location relative to the primary tumor's ...esophageal location. Recent reports suggest that the number of lymph nodes involved is also an important factor. We reviewed our esophageal experience to propose an improved nodal staging system.
In all, 1,027 patients with resected esophageal cancer from 1970 to 2005 were reviewed. Lymph nodes stations were assigned according to AJCC criteria. Overall survival was assessed by Kaplan-Meier analysis. The impact of location, number of involved lymph nodes, and use of preoperative chemotherapy or radiation therapy, or both, was assessed.
Nonregional nodal involvement (n = 17) was associated with decreased survival compared with regional (n = 441) or celiac nodal (n = 73) involvement (3-year: 0% versus 24% and 23%; p < 0.001). The number of involved lymph nodes was strongly associated with survival (3-year: 0 nodes = 63%, 1 to 3 nodes = 31%, more than 3 nodes = 13%; p < 0.001), and multivariable Cox proportional-hazards analysis suggested that the location and number of involved lymph nodes were independent predictors of survival (p < 0.001). We propose a modified nodal staging system that designates celiac nodes as regional and includes number of involved nodes: pN0, no nodes (3 years = 63%, n = 496); pN1-regional, 1 to 3 nodes (3 years = 32%, n = 292); pN2-regional, more than 3 nodes (3 years = 14%, n = 222); pN3-nonregional node (3 years = 0%, n = 17 p < 0.0001). This modified nodal staging system better predicts survival than the current AJCC nodal staging system in which survival for pN1 (3 years = 24%) and pM1a (3 years = 23%) do not differ (p = 0.67). The use of induction before surgical resection did not alter the predictive effect of the new nodal staging system.
Modification of the AJCC nodal classification system to incorporate the number of involved lymph nodes with regional and nonregional node location simplifies and better predicts long-term survival than does the current AJCC nodal system.
Our aim was to validate the effect of histopathologic tumor viability (HTV) on extended survival outcomes and assess the prognostic ability of the current staging system in patients receiving ...preoperative chemoradiotherapy (CRT).
The American Joint Committee on Cancer, 7th Edition, esophageal carcinoma staging system is derived from patients treated with surgery alone and does not account for the treatment effect of CRT. The extent of HTV after CRT is based on response to neoadjuvant therapy and has been shown to correlate with patient outcome.
Medical records of 1278 patients who underwent esophagectomy (1990-2011) were reviewed; 784 patients underwent preoperative CRT. Histologic tumor viability was assessed in 602 patients and classified as 0% to 10%, 11% to 50%, and more than 50%. Survival was estimated using the Kaplan-Meier method at potential median follow-up of 67 months. Univariate and multivariate analyses identified variables associated with survival.
Multivariate analysis identified HTV of greater than 50% (P < 0.001, HR 2.5), positive pathologic nodal status (P < 0.001, HR 1.6), and positive clinical nodal status (P = 0.002, HR 1.5) but not pathologic T status (P = 0.816, HR 1.2) to be independently associated with survival. Actuarial 5- and 10-year survival was 52% and 43% (HTV of 0%-10%), 45% and 33% (HTV of 11%-50%), and 16% for both (HTV of >50%). The best 5-year survival 56% was achieved in N0 patients with HTV of 0% to 10% (P = 0.056, HR 1.0), contrary to 6% observed in node-positive patients with HTV of greater than 50% (P < 0.001, HR 3.1). Patients with HTV of greater than 50% demonstrated distant recurrence more frequently than those with HTV of less than 50% (51% vs 33%, P = 0.010, OR: 2.2) CONCLUSIONS:: After preoperative chemoradiation, long-term outcomes of esophageal carcinoma are best predicted utilizing histologic tumor viability; HTV may be a practical early endpoint predicting efficacy of therapy.
Background Cervical recurrence occurs in up to 30% of patients after surgical treatment for papillary thyroid cancer. This study sought to determine an appropriate algorithm for followup evaluation. ...Study Design Patients undergoing total thyroidectomy for papillary thyroid cancer were identified. Clinicopathologic data were recorded, as were the results of all followup evaluations including radioiodine scan, cervical ultrasonography, and serum thyroglobulin levels. The disease recurrence-free survival probability was estimated, and risk factors for recurrence were determined. Results Thyroidectomy with or without neck dissection was performed in 162 patients. We excluded 36 patients (followup less than 6 months in 26, extracervical disease at diagnosis in 4, unknown tumor size in 6) from the analysis. Of the remaining 126 patients, 109 (86.5%) had no evidence of disease, with serum thyroglobulin < 1 ng/mL at last followup; 4 (3.2%) had no evidence of disease (negative imaging), with serum thyroglobulin > 1 ng/mL, and 13 (10.3%) had recurrent disease. Cervical recurrence occurred in nine patients, all detected by routine ultrasonography. Pulmonary metastases occurred in four patients; three were diagnosed by chest CT and one by radioiodine scan. Thyroid stimulating hormone-suppressed thyroglobulin levels were available in 11 of the 13 patients and were elevated in 9. Patients with high T stage (extrathyroidal extension), or high N stage had an increased risk of recurrence. Conclusions A followup strategy emphasizing routine cervical ultrasonography and unstimulated thyroglobulin is effective in identifying patients with recurrent papillary thyroid cancer, and may minimize the indiscriminate use of therapeutic radioiodine for radiographically occult disease. Surgery remains the optimal treatment of cervical recurrence, which is the dominant pattern of treatment failure.
Purpose of Review
Plastic surgery reconstruction involving the spinal region may be necessary to fill dead space, buttress a durotomy repair to help prevent or treat a cerebrospinal fluid (CSF) leak, ...resurface the skin, and/or transfer vascularized bone to augment stabilization after vertebrectomy or sacrectomy. Reconstruction can be employed in the prophylactic setting—in patients at high-risk for wound healing complications – or in the therapeutic setting, to treat wound healing complications after they have occurred. In general, the goals of soft tissue reconstruction include coverage of vitals structures and spinal hardware, obliteration of dead space, and a layered water-tight closure; goals of bony reconstruction include providing a stable vertebral construct by increasing the rapidity and durability of the osseous union.
Recent Findings
Paraspinous muscle advancement flaps remain the workhorse for midline posterior trunks wounds. Multiple studies including a systematic review and meta-analysis have established that immediate spinal reconstruction decreases wound complications and increases hardware retention. This approach has been shown to be cost-effective and safe in those considered to be at high-risk for wound healing complications. Regarding osseous reconstruction, transferring vascularized bone is associated with a higher union rate and a shortened time to union in patients requiring vertebrectomy or sacrectomy for primary bony tumors.
Summary
Plastic surgery reconstruction remains an important adjunctive maneuver to optimize healing in high-risk spinal surgery patients. A multidisciplinary approach between the spinal surgery team and plastic surgery team is key for surgical planning and patient optimization. It is important to consider the utility of prophylactic spinal reconstruction in patients who are deemed high-risk for wound healing complications (previous spine surgery, previous radiation, obese, diabetes, malnutrition) in order to prevent complications before they occur. Once a postoperative wound healing complication has occurred following spinal surgery, spinal reconstruction can also be pursued with the goal of protecting spinal hardware and preventing impending exposure.
Surgical Prevention of Lymphedema Sputova, Klara; Kim, Laura Minhui; Francis, Ashleigh M.
Current surgery reports (Philadelphia, PA),
08/2023, Letnik:
11, Številka:
8
Journal Article
Purpose of Review
Secondary lymphedema is a feared complication of cancer treatment that can lead to poor quality of life and life-threatening infections. True incidence of lymphedema is difficult to ...determine, but as the number of cancer survivors increases, lymphedema is becoming a significant health concern. Lymphedema is a progressive and debilitating disease that has no cure. While nonoperative and operative approaches to lymphedema management are available, they can only limit or slow the disease progression. However, with the recent advent of lymphedema microsurgery, the focus has shifted to the surgical prevention of lymphedema via immediate lymphatic reconstruction (ILR).
Recent Findings
Recent studies including a meta-analysis have shown that ILR may be effective in preventing the development of both upper and lower extremity lymphedema if the lymphatic system is prophylactically repaired at the time of lymphadenectomy. In the upper extremity, the rate of lymphedema after ILR has been reported as low as 4% at 4-year follow up as compared to 30% in the control group. In the lower extremity, similar results in lower lymphedema incidence after ILR are noted, although fewer studies exist with smaller sample sizes.
Summary
Immediate lymphatic reconstruction is a safe and well-tolerated procedure with very promising outcomes in decreasing the incidence of lymphedema in cancer survivors. More research is needed to continue to evaluate the technical details of ILR and how it can be used most effectively to prevent lymphedema, as well as explore additional surgical techniques.
Commonwealth Fusion Systems (CFS) is pursuing the high-field approach to fusion energy, enabled by magnets composed of 4 mm 2G REBCO wire. Most of these magnets will operate in the high field (20 T) ...and low temperature (∼20 K) regime and therefore require characterization of the critical current at those parameters. The industry standard is to use (77 K, self-field) data for rapid characterization of critical current. However, Ic (77 K, SF) is a poor predictor of performance at high (>6 T) field, low temperature applications, and so more predictive correlations are extremely desirable. This study examines critical current correlations between high temperature (44-77 K) with low field (0-5 T) and low temperatures (20 K) with high field (6-20 T) from multiple manufacturers. Employing these correlations will allow for the use of cheaper and simpler critical current test systems that can still accurately predict high field, low temperature performance. Moreover, they will provide higher confidence in the predicted performance of magnets. This paper presents the predictive ability of these correlations and the associated error analysis.
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