Abstract Objective A change has recently been made to the Federation of Gynecology and Obstetrics (FIGO) staging system for cervical cancer to account for size within stage IIA cancers. This study ...was designed to investigate the impact of size within stage I-IIIB cervical carcinoma, and to validate these changes. Methods The Surveillance, Epidemiology, and End Results Program database was used to extract data on patients from 1988 to 2008. Patients were included who had information recorded regarding stage, size, and type of treatment received. They were then stratified by stage and size, and analyzed for cause-specific survival (CSS) using Kaplan Meier estimates, as well as hazard ratios using Cox proportional hazards regression modeling. Results A total of 18,649 cases were evaluated. All stages evaluated demonstrated improved CSS on Kaplan Meier estimates for smaller tumor sizes (largest p = 0.0003). Hazard ratios were significantly worse for larger tumor sizes on both univariate and multivariate modeling. Specifically, stage IIA cancers demonstrated a hazard ratio of 2.0 on univariate, and 1.69 on multivariate analysis (C.I. 1.46–2.75, p < 0.0001 and C.I. 1.20–2.38, p = 0.0025, respectively). Further size subdivisions of 2 and 4 cm for stage I, 4 cm for stage IIB, and 4 and 6 cm for stage IIIB also maintained prognostic significance. On multivariate analysis within each stage, size was the only variable to maintain independent significance in all stages evaluated. Conclusions Size is independently prognostic within each stage in cervical cancer, validating the recent changes to the FIGO staging system.
Epistaxis is a routine complaint in Emergency Medicine and presents most commonly in adults and children and its incidence increases with age. It is rare in infants and neonates. We discuss a case of ...epistaxis in a four-month-old male who presented to a critical access hospital. What initially appeared to be routine brisk epistaxis was later discovered to be a large, complex, epiglottic hemangioma. The patient was stabilized using topical tranexamic acid, nasal packing with ketamine sedation, and sent to a tertiary care center for definitive management. He required advanced airway management in the OR for definitive airway management for airway-obstructing hemangioma excision.
Mucoepidermoid carcinoma (MEC) is a rare malignancy of the head and neck; however, it accounts for a majority of the tumors of the salivary glands. This study used a national population-based ...registry to describe the pre-treatment and treatment-related prognostic factors that influence survival in patients with MEC of the major salivary glands. To our knowledge, this is the largest population-based study examining predictors of both overall and cause-specific survival of MEC of the major salivary glands.
To identify prognostic factors influencing overall survival (OS) and cause-specific survival (CSS) of patients with MEC of the major salivary glands.
We used the Surveillance, Epidemiology and End-Results Database of the National Cancer Institute to investigate a variety of factors that could influence survival of patients diagnosed with mucoepidermoid carcinoma of the major salivary glands. A total of 2210 patients diagnosed with MEC of the major salivary glands during the years of 1975-2016 were studied. The primary endpoints were OS and CSS. Cox regression analysis was used to perform univariate and multivariate analyses of clinical variables such as age at diagnosis, diagnosis year, sex, race, tumor size, stage, grade, treatment with or without surgical excision, and adjuvant radiotherapy treatment.
A total of 2210 patients diagnosed with MEC of the major salivary glands met inclusion criteria. In this study, 95% of patients underwent surgical excision and 41% received adjuvant radiation therapy. Median OS time for Grade I, II, and III/IV was 401 mo (± 48.25, 95%CI), 340 mo (± 33.68, 95%CI) and 55 mo (± 11.05, 95%CI), respectively. Univariate analysis revealed that lack of surgical excision was associated with decreased OS hazard ratio (HR) 4.26,
< 0.0001 and that patients with localized disease had improved OS compared to both regional and distant disease (HR 3.07 and 6.96, respectively,
< 0.0001). Additionally, univariate analysis demonstrated that male sex, age over 50 at diagnosis, Grade III tumors, and increasing tumor size were associated with worsened OS (
< 0.0006). Univariate analysis of CSS similarly revealed that lack of surgical excision and Grade III carcinoma conferred decreased CSS (HR 4.37 and 5.44, respectively,
< 0.0001). Multivariate analysis confirmed that increasing age, in 10-year age bands, advanced tumor stage, increasing tumor size, Grade III carcinoma, male sex, and lack of surgical excision were associated with a statistically significant decrease in OS and CSS (
< 0.04). Of note, multivariate analysis revealed that the use of adjuvant radiation therapy was not associated with improved OS or CSS.
Multivariate analysis demonstrated increasing age, advanced tumor stage, increasing tumor size, Grade III carcinoma, male sex, and lack of surgical excision were associated with decreased OS and CSS (
< 0.04).
We present a unique case of a patient simultaneously diagnosed with solitary fibrous tumor (SFT) and unrelated adenocarcinoma of the lung, both proven with separate pathology. It was subsequently ...found that the SFT had metastasized to the brain by additional pathology, and not the predicted adenocarcinoma. SFTs are a rare mesenchymal neoplasm that accounts for less than 2% of all reported soft tissue tumors. SFTs most commonly arise in the thoracic cavity, but are frequently found in various locations throughout the body, and rarely metastasize to the brain. This case highlights that rare neoplasms, such as SFT, should not be ruled out as a potential cause of metastasis. Due to the rarity of this clinical situation, we also provide a review and discussion of previously reported SFT cases and the use of postoperative radiation therapy. The optimal treatment for individual patients remains unclear in this unique situation. Surgical resection followed by adjuvant Gamma Knife radiation therapy to the surgical bed appears to be a safe option for local treatment of SFT in select patients. Further studies are needed of this rare clinical situation in order to better understand and optimize future treatments for patients with SFT and metastasis to the brain.
Epithelioid sarcoma is a rare high-grade malignancy identified by Enzinger in 1970. It accounts for 1% of all reported soft tissue sarcomas and presents most commonly in distal upper extremities in ...young adults with a male predominance. At this time, there are only 5 previously reported cases of primary epithelioid sarcoma of the orbit. We present a primary orbital epithelioid sarcoma case of a patient who underwent orbital exenteration followed by external beam radiation treatment. Because the literature is limited, this is to our knowledge the largest descriptive analysis of cases of orbital epithelioid sarcoma. We also provide a detailed review of all the previously reported primary orbital epithelioid sarcoma cases, as well as a discussion on the use of postoperative radiation therapy for patients with epithelioid sarcoma. Surgical resection followed by adjuvant radiation therapy appears to be a safe option for local treatment of this rare malignancy, but further future studies are needed of this rare clinical situation in order to better understand and optimize treatment for patients with orbital epithelioid sarcoma.
Stereotactic radiosurgery (SRS) is well established in the treatment of brain metastases, however it's exact role remains unclear. A single metastasis at presentation raises additional challenges, ...however there is minimal outcome data within this subgroup. We sought to evaluate the outcomes of treatment in patients with a single brain metastasis, as well as factors impacting local control.
All patients treated with SRS for a single brain metastasis were evaluated. Data was collected regarding patient demographics, treatment characteristics, and treatment outcomes. Univariate analyses were performed to evaluate the impact of treatment and patient variables on these outcomes. Emphasis was placed on analyses of factors impacting LC.
Between 1998 and 2011, a total of 141 patients underwent SRS for a single brain metastasis; in addition 31 had surgical resection, 15 received whole brain radiotherapy (WBRT), and 2 underwent both. There was no statistical impact on local control (LC) or distant intracranial control (DIC) with the addition of WBRT or surgery (LC 74%, 100%, and 58%, and DIC 37%, 67%, and 49% for SRS alone, SRS + WBRT, and SRS + surgery, respectively, smallest p = 0.17). Local control was decreased with larger tumors, doses <20Gy, and tight overtreatment ratios (i.e. conformity) (largest p = 0.02), although the independence of these factors could not be established. Long term freedom from requiring future whole brain radiotherapy was 73%.
SRS alone for patients with single brain metastases demonstrates acceptable intracranial outcomes. Further evaluation into factors impacting LC are warranted.
Epidemiologic information, including animal characteristics (e.g., observable risk factors or clinical signs) predisposing to animal disease, is frequently used for design of targeted surveillance ...systems, but this information is infrequently used for population inference. In this study, we report the evaluation of use of epidemiologic information for population inference in targeted surveillance in three animal disease scenarios. We adapted sampling theory using Monte Carlo methods to determine target population sample size to detect disease with 95% confidence, using information from the epidemiologic parameters risk ratio and fraction of the population with the characteristic. These parameters and their uncertainties were derived from a reference population. The next step was to use a second (sampled) population to evaluate effects of sampling the targeted population. The focus of the study was on estimation of prevalence. Our results showed that if one is less certain of the epidemiologic parameters, a rational decision is to model the input parameter distributions reflecting this uncertainty, thereby increasing the sample size above the minimum needed for the detection of the disease with a known confidence. Targeted surveillance is appropriate for prevalence estimation when one has representative and justifiable estimates of key epidemiologic parameters.
Objective
The objective was to evaluate if the release of randomized trials evaluating the impact of adjuvant radiotherapy after prostatectomy in high risk patients had any impact on national ...practice patterns in patients with at least two high risk features.
Methods
The SEER database was used to extract data for patients with a diagnosis of prostate adenocarcinoma from the years 2004–2010, and who underwent prostatectomy with pathologic features of both extracapsular extension (ECE) and positive margins. Adjuvant radiotherapy (ART) utilization was calculated on a yearly basis, and odds ratios were calculated for the likelihood of ART use by year compared to 2004.
Results
Between 2004 and 2010, 5,231 patients were identified who underwent prostatectomy with both ECE and positive margins, of which only 19 % received ART. ART utilization was 21, 20, 22, 20, 18, 18, and 15 % for the years 2004–2010, respectively. Odds ratios demonstrated that the likelihood of ART to be used compared to 2004 demonstrated a statistical decrease from 0.97 (95 % C.I. 0.76–1.25,
p
= 0.85) in 2005 to 0.67 (95 % C.I. 0.51–0.90,
p
< 0.01) in 2010. At the end of the study time period, patients with higher risk disease were more likely to receive ART, with differences noted in clinical T stage, pretreatment PSA, Gleason score, Gleason patterns, and D’Amico risk classification (largest
p
= 0.02).
Conclusion
The release of randomized controlled trials demonstrating clinical and survival benefits with ART use in high risk patients has failed to increase the utilization of ART, instead demonstrating decreased utilization. In light of recently published guidelines, future changes will be of interest.
The essential role of the medial temporal lobe (MTL) in long-term memory for individual events is well established, yet important questions remain regarding the mnemonic functions of the component ...structures that constitute the region. Within the hippocampus, recent functional neuroimaging findings suggest that formation of new memories depends on the dentate gyrus and the CA
field, whereas the contribution of the subiculum may be limited to retrieval. During encoding, it has been further hypothesized that structures within MTL cortex contribute to encoding in a content-sensitive manner, whereas hippocampal structures may contribute to encoding in a more domain-general manner. In the current experiment, high-resolution fMRI techniques were utilized to assess novelty and subsequent memory effects in MTL subregions for two classes of stimuli—faces and scenes. During scanning, participants performed an incidental encoding (target detection) task with novel and repeated faces and scenes. Subsequent recognition memory was indexed for the novel stimuli encountered during scanning. Analyses revealed voxels sensitive to both novel faces and novel scenes in all MTL regions. However, similar percentages of voxels were sensitive to novel faces and scenes in perirhinal cortex, entorhinal cortex, and a combined region comprising the dentate gyrus, CA
, and CA
, whereas parahippocampal cortex, CA
, and subiculum demonstrated greater sensitivity to novel scene stimuli. Paralleling these findings, subsequent memory effects in perirhinal cortex were observed for both faces and scenes, with the magnitude of encoding activation being related to later memory strength, as indexed by a graded response tracking recognition confidence, whereas subsequent memory effects were scene-selective in parahippocampal cortex. Within the hippocampus, encoding activation in the subiculum correlated with subsequent memory for both stimulus classes, with the magnitude of encoding activation varying in a graded manner with later memory strength. Collectively, these findings suggest a gradient of content sensitivity from posterior (parahippocampal) to anterior (perirhinal) MTL cortex, with MTL cortical regions differentially contributing to successful encoding based on event content. In contrast to recent suggestions, the present data further indicate that the subiculum may contribute to successful encoding irrespective of event content.
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