The Emotional Impact and Coping Mechanisms Following Adverse Patient Events Among Canadian Vascular Surgeons and Trainees

BACKGROUND

This study's objective is to evaluate the emotional experiences, coping mechanisms, and support resources for Canadian vascular surgeons and trainees following an adverse patient event or near miss.

METHODS

This is a cross-sectional survey study of all Canadian Society for Vascular Surgery (CSVS) members from October to November 2021. We collected data on participant experiences with adverse events, their emotional responses, the coping mechanisms used, and their perceptions on available support resources.

RESULTS

The survey was sent to 233 CSVS members yielding 66 responses. The majority (77%) of respondents had experiences with adverse event causing serious patient harm. The most common negative experience following an adverse event included feelings of negativity towards oneself, general distress, and anxiety about potential for future errors. The most common coping mechanism was seeking advice from a mentor or close colleague. Peers (82%) and senior colleagues (59%) were the most preferred sources of support. Most of the respondents would reach out to a mentor if they had 1, but 30% reported no mentor or close colleague for support.

CONCLUSION

Adverse patient events and near misses have serious negative impact on the lives of Canadian vascular surgeons and trainees. Peers and senior colleagues are the most desired source for support, but this is not universally available. Organized efforts are needed to bring awareness in our vascular surgery community on the ubiquitous nature and detrimental effects of adverse events.

Authorship gender among articles about artificial intelligence in breast imaging

RATIONALE AND OBJECTIVES

The purpose of this study is to investigate the variance of women authors, specifically first and senior authorship among peer-reviewed artificial intelligence-related articles with a specific focus in breast imaging.

MATERIALS AND METHODS

A strategic search was conducted in July 2022 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to capture all existing and publicly available peer-reviewed articles intersecting AI and breast imaging. Primary outcomes were first and senior authors' gender, which were assigned with the aid of an emailed self-declaration survey. Secondary outcomes included country of article, journal impact factor, and year of publication. Comparisons were made using logistic regression models and analysis of variances.

RESULTS

115 studies were included in the analysis. Women authors represented 35.7% (41/115) and 37.4% (43/115) of first and senior authors, respectively. Logistic regression modelling showed a significant increase in women senior authors over time but no changes in women first authors. Impact factor was not associated with female authorship and certain countries had women authorship reach over 50%.

CONCLUSION

This study demonstrates that there is a significant authorship gender gap in artificial intelligence breast imaging research. An increasing temporal trend of senior authors in breast imaging AI-related research is a promising prognosis for more women voices in this field. Further study needs to be done to understand the reasons behind this gap and any potential implications.

Disability, an often-overlooked aspect of equity, diversity, and inclusion among radiology departments in Canada and the United States

PURPOSE

Despite nearly a quarter of Canadians and Americans reported to be living with a disability, persons with disabilities continue to face both physical and cultural barriers with respect to careers in medicine. Equity, diversity, and inclusion (EDI) statements can act as a first step in deconstruction of these cultural barriers. However, when compared to other EDI initiatives focused on gender, race, and ethnicity, persons with disabilities receive little attention.

METHODS

We conducted a cross-sectional analysis of all radiology residency program websites in Canada and the United States (US). Data was collected from each radiology department website including the presence or absence of an EDI statement or page; if present, we determined whether mention was made of persons with disabilities.

RESULTS

We reviewed the websites of 16 Canadian and 181 US radiology residency programs. Seven (44%) Canadian institutions had an EDI statement, with one (14%) mentioning persons with disabilities. In the US, 103 (57%) institutions had an EDI statement, with 42 (41%) mentioning persons with disabilities.

CONCLUSIONS

There were a significant proportion of radiology residency programs without EDI statements on their websites and an even smaller proportion that acknowledged persons with disabilities. An institution's public commitment to EDI, and specifically to patients and providers with disabilities, is central to implementing inclusive change going forward.

Female Authorship Trends Among Articles About Artificial Intelligence in North American Radiology Journals

Purpose: To examine trends in female authorship of peer-reviewed North American radiology articles centred around artificial intelligence (AI). Method: A bibliographic search was conducted for all AI-related articles published in four North American radiology journals. Collected data included the genders of the first and last (senior) authors, year and country. We compared the trends of female authorship using Pearson chi-square, Fisher exact tests and logistic regression models. Results: 453 articles met the inclusion criteria. Among these, 107 (22.3%) had a female first author and 97 (27.3%) had a female senior author. Female first authors were over three times more likely to publish with a female senior author. Among the four journals, the CARJ had the highest proportion of female senior authors at 45.5%. The only significant temporal trend identified was an increase over the years in female senior authors in Radiology. Twenty-four countries contributed to the included articles, with the largest contributors being the United States (n = 290) and Canada (n = 30). Of the countries contributing more than 15 articles, there were none with above 50% female authorship. Conclusions: Female authors are underrepresented in AI-related radiology literature. However, there has been an encouraging recent increase in female authorship in AI-related radiology articles trending towards significance. There is a great opportunity to improve female representation in AI with intentional mentorship and recruitment. We urge more platforms for female voices in radiology as AI becomes increasingly integrated into the radiology community.

An unusual cause of pericardial effusion: A case report of a hepatic abscess following foreign body migration and duodenal perforation

INTRODUCTION AND IMPORTANCE

Although foreign bodies are a rare cause of gastrointestinal tract perforation, they may serve as a nidus for hepatic abscess. Abdominal pain is the most common presenting symptom. We present a case of an ingested pen causing duodenal perforation and hepatic abscess several months after initially presenting with a pericardial effusion.

CASE PRESENTATION

A 59-year-old female living in an intensive tertiary mental health facility was noted to have an incidental pericardial effusion during work-up for hyponatremia. Seven months later, she developed a new fever and was noted to have interval increase in the pericardial effusion size. This prompted further investigation which finally revealed that an ingested pen had perforated through the first part of the duodenum and caused an abscess in the left lobe of the liver. The pericardial effusion was presumed secondary to local inflammation. Upon discovery of the abscess, the patient underwent successful operative management including abscess drainage, foreign body extraction, and duodenal repair.

CLINICAL DISCUSSION

Reports of hepatic abscess from foreign body causing duodenal perforation are rare, with bone fragments and toothpicks the most common foreign bodies implicated. There is one other previously reported case of an ingested pen. Abdominal pain is present in up to 85% of cases, but fever may be the only presenting symptom.

CONCLUSION

Foreign body migration causing a hepatic abscess may present non-specifically with unexplained fever or even pericardial effusion. Psychiatric comorbidities may contribute to delays in diagnosis due to difficulties recalling the episode of ingestion.

Gender-Inclusive Fellowship Naming and Equity, Diversity, and Inclusion in Radiology: An Analysis of Radiology Department Websites in Canada and the United States

Purpose: Transgender and gender non-binary (TGNB) individuals face numerous inequalities in healthcare and there is substantial work to be done in fostering TGNB culturally competent care in radiology. A radiology department's online presence and use of gender-inclusive language are essential in promoting an environment of equity, diversity, and inclusion (EDI). The naming of radiology fellowships and continuing medical education (CME) courses with terminology such as "Women's Imaging" indicates a lack of inclusivity to TGNB patients and providers, which could result in suboptimal patient care. Methods: We conducted a cross-sectional analysis of all institutions in Canada and the United States (US) offering training in Breast Imaging, Women's Imaging, or Breast and Body Imaging. Data was collected from each institution's radiology department website pertaining to fellowship names, EDI involvement, and CME courses. Results: 8 Canadian and 71 US radiology fellowships were identified. 75% of Canadian and 90% of US fellowships had gender-inclusive names. One (12.5%) Canadian and 29 (41%) US institutions had EDI Committees mentioned on their websites. Among institutions publicly displaying CME courses about breast/body or women's imaging, gender-inclusive names were used in only 1 (25%) of the Canadian CME courses, compared to 81% of the US institutions. Conclusions: Most institutions in Canada and the US have gender-inclusive names for their radiology fellowships pertaining to breast and body imaging. However, there is much opportunity to and arguably the responsibility for institutions in both countries to increase the impact and visibility of their EDI efforts through creation of department-specific committees and CME courses.

The COSMIC Bubble Helmet: A Non-Invasive Positive Pressure Ventilation System for COVID-19

Goal: COSMIC Medical, a Vancouver-based open-source volunteer initiative, has designed an accessible, affordable, and aerosol-confining non-invasive positive-pressure ventilator (NIPPV) device, known as the COSMIC Bubble Helmet (CBH). This device is intended for COVID-19 patients with mild-to-moderate acute respiratory distress syndrome. System Design: CBH is composed of thermoplastic polyurethane, which creates a flexible neck seal and transparent hood. This device can be connected to wall oxygen, NIPPVs including Continuous Positive Airway Pressure and Bi-level Positive Airway Pressure, and mechanical ventilators. Discussion: Justification of CBH design components relied on several factors, predominantly the safety and comfort of patients and healthcare providers. Conclusion: CBH has implications within and outside of the pandemic, as an alternative to invasive mechanical ventilation methods. We have experimentally verified that CBH is effective in minimizing aerosolization risks and performs at specified clinical requirements.

Caregiver willingness to vaccinate their children against COVID-19: Cross sectional survey

BACKGROUND

More than 100 COVID-19 vaccine candidates are in development since the SARS-CoV-2 genetic sequence was published in January 2020. The uptake of a COVID-19 vaccine among children will be instrumental in limiting the spread of the disease as herd immunity may require vaccine coverage of up to 80% of the population. Prior history of pandemic vaccine coverage was as low as 40% among children in the United States during the 2009 H1N1 influenza pandemic.

PURPOSE

To investigate predictors associated with global caregivers' intent to vaccinate their children against COVID-19, when the vaccine becomes available.

METHOD

An international cross sectional survey of 1541 caregivers arriving with their children to 16 pediatric Emergency Departments (ED) across six countries from March 26 to May 31, 2020.

RESULTS

65% (n = 1005) of caregivers reported that they intend to vaccinate their child against COVID-19, once a vaccine is available. A univariate and subsequent multivariate analysis found that increased intended uptake was associated with children that were older, children with no chronic illness, when fathers completed the survey, children up-to-date on their vaccination schedule, recent history of vaccination against influenza, and caregivers concerned their child had COVID-19 at the time of survey completion in the ED. The most common reason reported by caregivers intending to vaccinate was to protect their child (62%), and the most common reason reported by caregivers refusing vaccination was the vaccine's novelty (52%).

CONCLUSIONS

The majority of caregivers intend to vaccinate their children against COVID-19, though uptake will likely be associated with specific factors such as child and caregiver demographics and vaccination history. Public health strategies need to address barriers to uptake by providing evidence about an upcoming COVID-19 vaccine's safety and efficacy, highlighting the risks and consequences of infection in children, and educating caregivers on the role of vaccination.

Caregivers' Willingness to Accept Expedited Vaccine Research During the COVID-19 Pandemic: A Cross-sectional Survey

Purpose

This study determined the predictors of caregivers' willingness to accept an accelerated regulatory process for the development of vaccines against coronavirus disease 2019 (COVID-19).

Methods

An international cross-sectional survey was administered to 2557 caregivers of children in 17 pediatric emergency departments (EDs) across 6 countries from March 26, 2020, to June 30, 2020. Caregivers were asked to select 1 of 4 choices with which they most agreed regarding a proposed COVID-19 vaccine–approval process, in addition to questions regarding demographic characteristics, the ED visit, and attitudes about COVID-19. Univariate analyses were conducted using the Mann–Whitney U test for comparing non–normally distributed continuous variables, an independent t test for comparing normally distributed continuous variables, and a χ² or Fisher exact test for categorical variables. Multivariate logistic regression analysis was used for determining independent factors associated with caregivers' willingness to accept abridged development of a COVID-19 vaccine. A P value of <0.05 was considered significant.

Findings

Almost half (1101/2557; 43%) of caregivers reported that they were willing to accept less rigorous testing and postresearch approval of a new COVID-19 vaccine. Independent factors associated with caregivers' willingness to accept expedited COVID-19 vaccine research included having children who were up to date on the vaccination schedule (odds ratio [OR] = 1.72; 95% CI, 1.29–2.31), caregivers' concern about having had COVID-19 themselves at the time of survey completion in the ED (OR = 1.1; 95% CI, 1.05–1.16), and caregivers' intent to have their children vaccinated against COVID-19 if a vaccine were to become available (OR = 1.84; 95% CI, 1.54–2.21). Compared with fathers, mothers completing the survey were less likely to approve of changes in the vaccine-development process (OR = 0.641; 95% CI, 0.529–0.775).

Implications

Less than half of caregivers in this worldwide sample were willing to accept abbreviated COVID-19 vaccine testing. As a part of an effort to increase acceptance and uptake of a new vaccine, especially in order to protect children, public health strategies and individual providers should understand caregivers' attitudes toward the approval of a vaccine and consult them appropriately.

•

Half of caregivers accept an abridged process for rapid COVID-19 vaccine approval.

•

Seeking fast approval associated with caregiver’s gender, intent to vaccinate child.

•

Concern about own COVID-19 infection associated with preferring expedited approval.

Premature termination codon readthrough upregulates progranulin expression and improves lysosomal function in preclinical models of GRN deficiency

Background

Frontotemporal lobar degeneration (FTLD) is a devastating and progressive disorder, and a common cause of early onset dementia. Progranulin (PGRN) haploinsufficiency due to autosomal dominant mutations in the progranulin gene (GRN) is an important cause of FTLD (FTLD-GRN), and nearly a quarter of these genetic cases are due to a nonsense mutation. Premature termination codons (PTC) can be therapeutically targeted by compounds allowing readthrough, and aminoglycoside antibiotics are known to be potent PTC readthrough drugs. Restoring endogenous PGRN through PTC readthrough has not previously been explored as a therapeutic intervention in FTLD.

Methods

We studied whether the aminoglycoside G418 could increase PGRN expression in HEK293 and human induced pluripotent stem cell (hiPSC)-derived neurons bearing the heterozygous S116X, R418X, and R493X pathogenic GRN nonsense mutations. We further tested a novel substituted phthalimide PTC readthrough enhancer in combination with G418 in our cellular models. We next generated a homozygous R493X knock-in hiPSC isogenic line (R493X^−/− KI), assessing whether combination treatment in hiPSC-derived neurons and astrocytes could increase PGRN and ameliorate lysosomal dysfunction relevant to FTLD-GRN. To provide in vivo proof-of-concept of our approach, we measured brain PGRN after intracerebroventricular administration of G418 in mice expressing the V5-tagged GRN nonsense mutation R493X.

Results

The R418X and R493X mutant GRN cell lines responded to PTC readthrough with G418, and treatments increased PGRN levels in R493X^−/− KI hiPSC-derived neurons and astrocytes. Combining G418 with a PTC readthrough enhancer increased PGRN levels over G418 treatment alone in vitro. PGRN deficiency has been shown to impair lysosomal function, and the mature form of the lysosomal protease cathepsin D is overexpressed in R493X^−/− KI neurons. Increasing PGRN through G418-mediated PTC readthrough normalized this abnormal lysosomal phenotype in R493X^−/− KI neuronal cultures. A single intracerebroventricular injection of G418 induced GRN PTC readthrough in 6-week-old AAV-GRN-R493X-V5 mice.

Conclusions

Taken together, our findings suggest that PTC readthrough may be a potential therapeutic strategy for FTLD caused by GRN nonsense mutations.

Multicentre study of the learning curve and surgical performance of cytoreductive surgery with intraperitoneal chemotherapy for pseudomyxoma peritonei

Background

The learning curves for cytoreductive surgery with intraperitoneal chemotherapy for treatment of pseudomyxoma peritonei (PMP) were explored between international centres/surgeons to identify institutional or other factors that might affect performance.

Methods

Data from patients with PMP treated with the combined procedure across 33 international centres between 1993 and 2012 were analysed retrospectively. A risk-adjusted sequential probability ratio test was conducted after defining the target outcome as early oncological failure (disease progression within 2 years of treatment), an acceptable risk for the target outcome (odds ratio) of 2, and type I/II error rates of 5 per cent. The risk prediction model was elaborated and patients were evaluated sequentially for each centre/surgeon. The learning curve was considered to be overcome and proficiency achieved when the odds ratio for early oncological failure became smaller than 2.

Results

Rates of optimal cytoreduction, severe postoperative morbidity and early oncological failure were 84·4, 25·7 and 29·0 per cent respectively. The median annual centre volume was 17 (range 6–66) peritoneal malignancies. Only eight of the 33 centres and six of 47 surgeons achieved proficiency after a median of 100 (range 78–284) and 96 (86–284) procedures respectively. The most important institutional factor affecting surgical performance was centre volume.

Conclusion

The learning curve is extremely long, so centralization and/or networking of centres is necessary to assure quality of services. One centre for every 10–15 million inhabitants would be ideal.

Importance of gender in diffuse malignant peritoneal mesothelioma

BACKGROUND

Combined therapy involving cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy has been shown to improve survival outcomes for patients with diffuse malignant peritoneal mesothelioma (DMPM). The present study aims to investigate gender as a potential prognostic factor on overall survival.

PATIENTS AND METHODS

Over a period of two decades, 294 patients who underwent CRS and perioperative intraperitoneal chemotherapy were selected from a large multi-institutional registry to assess the prognostic significance of gender on overall survival.

RESULTS

Female patients were shown to have a significantly improved survival outcome than male patients (P < 0.001). Staging according to a recently proposed tumor-node-metastasis categorization system was significant in both genders. Older female patients had significantly worse survival than younger female patients (P = 0.019), a finding that was absent in male patients. Female patients with low-stage disease were found to have a very favorable long-term outcome after combined treatment.

CONCLUSIONS

Gender has demonstrated a significant impact on overall survival for patients with DMPM after CRS and perioperative intraperitoneal chemotherapy. An improved understanding of the role of estrogen in the pathogenesis of DMPM may improve the prognostication of patients and determine the role of adjuvant hormonal treatment in the future.

Multi-institutional experience of diffuse intra-abdominal multicystic peritoneal mesothelioma

BACKGROUND

This study was undertaken to measure survival of patients with multicystic peritoneal mesothelioma treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy through a multi-institutional collaboration.

METHODS

A multi-institutional data registry, established by the Peritoneal Surface Oncology Group, was used to identify patients with peritoneal mesothelioma and the subgroup with multicystic tumours, treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Outcomes for this subgroup are reported. The primary endpoint was overall survival. A secondary endpoint was the incidence of treatment-related complications.

RESULTS

Of 405 patients with peritoneal mesothelioma, 26 (6·4 per cent) had multicystic tumours. There were 20 women and six men with a mean(s.d.) age of 42(12) years. The median peritoneal carcinomatosis index (PCI) was 14 (range 6-39). There was no perioperative mortality. Six patients developed grade III or IV complications. After a median follow-up of 54 (range 5-129) months, all 26 patients were still alive.

CONCLUSION

Multicystic peritoneal mesothelioma appears to be a distinct subtype of peritoneal mesothelioma, where long-term survival may be achieved through cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Radioembolization with yttrium microspheres for neuroendocrine tumour liver metastases

Background

90Y microsphere radioembolization is performed by injecting the microspheres through a hepatic artery catheter placed percutaneously via the femoral or brachial artery. This study assessed the efficacy of 90Y microsphere therapy for patients with unresectable neuroendocrine tumour liver metastases (NETLMs). Potential prognostic factors were analysed for their impact on overall survival.

Methods

A prospectively collected database for patients with NETLMs treated by 90Y microspheres in two centres from 2003 to 2008 was examined retrospectively. Serial radiographic evidence was collected during follow-up to assess response.

Results

Fifty-eight patients were included, 51 of whom had evaluable disease at most recent follow-up. Six patients achieved a complete response, 14 a partial response, 14 had stable disease and 17 had disease progression. Overall survival rates at 1, 2 and 3 years were 86, 58 and 47 per cent respectively; median survival was 36 (range 1–61) months. Extent of tumour involvement, radiographic response to treatment, extrahepatic disease and tumour grade were significant prognostic factors for overall survival.

Conclusion

90Y microsphere radioembolization achieved a radiographic response in a significant proportion of patients with NETLMs.

Peritoneal carcinomatosis and liver metastases from colorectal cancer treated with cytoreductive surgery perioperative intraperitoneal chemotherapy and liver resection

BACKGROUND

An aggressive therapy comprising of cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) and liver resection/ablation is generally not offered to patients with both colorectal peritoneal carcinomatosis (CRPC) and liver metastases (LM) as it no longer represents a loco-regional disease. We review the outcomes of patients who underwent an aggressive treatment with a curative intent for both CRPC and LM as a prelude towards determining the suitability of this treatment.

METHODS

Patients with CRPC were treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy in our institution. Patients with LM underwent additional treatment of liver resection/ablation. The characteristics and survival of patients with isolated CRPC and those with both CRPC and LM were compared.

RESULTS

Fifty-five patients underwent complete cytoreductive surgery for treatment of CRPC, amongst which 16 patients had LM. The overall median survival was 36 months. Fourteen of the 16 patients treated for CRPC and LM underwent synchronous treatment. When patients with CRPC alone or CRPC with LM were compared, patients with CRPC and LM had a lower PCI (p=0.03), received less HIPEC infusion (p<0.001), received less of both HIPEC and EPIC infusion (p=0.007), had a shorter procedural duration (p=0.001) and required less blood transfusion (p=0.02). There was no difference in survival between patients who had CRPC alone or CRPC with LM who underwent aggressive treatment (p=0.77).

CONCLUSIONS

A curative procedure may be offered to selected patients with CRPC and LM, especially in those with a low peritoneal cancer index.

Surgical strategies for gastric cancer with synchronous peritoneal carcinomatosis (Br J Surg 2006; 93: 1530–1535)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and publishe in the Journal. Letters must be no more than 250 words in length.

Sex difference in diffuse malignant peritoneal mesothelioma

BACKGROUND

Diffuse malignant peritoneal mesothelioma (DMPM) is rare and in the past has proved an invariably fatal disease. Female patients have been reported to have an improved survival outcome for reasons that are not understood.

METHODS

The survival of 34 men and 28 women who underwent cytoreduction and perioperative intraperitoneal chemotherapy for DMPM was compared. Twenty-five clinicopathological variables were subjected to univariate analysis.

RESULTS

The women had a 5-year survival rate of 63 per cent and median survival was not reached. The men had a 5-year survival rate of 42 per cent, with a median survival of 32 months (P = 0.045). Women had undergone more extensive previous surgery and had less extensive peritoneal involvement at the time of cytoreduction. Tumours in women more frequently showed a small nuclear size (30 microm or less) and the chromatin pattern was more often granular than clear.

CONCLUSION

Women with DMPM had better survival. This observation may be related to the favourable clinical and histopathological features associated with women.

A systematic review on the efficacy of cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for diffuse malignancy peritoneal mesothelioma

BACKGROUND

In the past, diffuse malignant peritoneal mesothelioma (DMPM) was regarded as a preterminal condition. The length of survival was dependent upon the aggressive versus indolent biologic behavior of the neoplasm. The overall median survival was approximately 1 year after systemic chemotherapy. Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has been used as a treatment alternative, but the efficacy of this combined treatment remains to be established.

PATIENTS AND METHODS

Searches for relevant studies published in peer-reviewed medical journals on CRS and PIC for DMPM before May 2006 were carried out on six databases. The reference lists of all retrieved articles were reviewed for further identification of potentially relevant studies. Expert academic surgeons in Washington, DC, USA were asked whether they knew about any important unpublished data. Two investigators independently evaluated each study according to predefined criteria. The quality of each study was assessed. Clinical effectiveness was synthesized through a narrative review with full tabulation of results of all included studies.

RESULTS

Seven prospective observational studies from six tertiary institutions were available, allowing 240 DMPM patients for assessment. The median survival ranged from 34-92 months. The 1-, 3- and 5-year survival varied from 60% to 88%, 43% to 65% and 29% to 59%, respectively. The perioperative morbidity varied from 25% to 40% and mortality ranged from 0% to 8%.

CONCLUSIONS

This systematic review evaluated the current evidence for CRS and PIC for DMPM. Seven observational studies were available for assessment, which demonstrated an improved overall survival, as compared to historical controls, using systemic chemotherapy and palliative surgery.

Cytoreductive surgery and perioperative intraperitoneal chemotherapy for pseudomyxoma peritonei from appendiceal mucinous neoplasms

BACKGROUND

Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has been used to treat pseudomyxoma peritonei. The aim of this prospective study was to evaluate survival outcome and treatment-related prognostic markers in patients who underwent CRS and PIC for pseudomyxoma peritonei from appendiceal mucinous neoplasms.

METHODS

Survival data and 12 clinicopathological and treatment-related prognostic variables for survival were obtained prospectively in 50 consecutive patients (23 men). Univariate analysis was used to determine their prognostic significance for overall survival, determined from the time of CRS.

RESULTS

The mean(s.d.) age was 52(12) years. Eighteen patients had moderate complications, and six patients had severe complications that required operation or intensive care support. Two patients died after surgery. The actuarial 5-year survival rate was 69 per cent. Univariate analysis demonstrated that the extent of previous surgery (P = 0.045) and Ronnett's histopathological classification (P < 0.001) were significantly related to overall survival.

CONCLUSION

CRS combined with PIC was associated with improved survival in patients with less extensive previous surgery and diffuse peritoneal adenomucinosis histopathological type.

Cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis from colorectal carcinoma: non-mucinous tumour associated with an improved survival

AIMS

Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy has been reported as a treatment option for patients with peritoneal carcinomatosis from colorectal carcinoma.

METHODS

Thirty patients with colorectal peritoneal carcinomatosis underwent cytoreductive surgery and perioperative intraperitoneal chemotherapy. All appendiceal cancers were excluded. All patients were followed until January 2006 or death. Univariate analysis was performed to evaluate significant prognostic factors for overall survival, defined from the time of surgery.

RESULTS

There were 13 male patients. The mean age at the time of surgery was 54years. There was no hospital mortality. The mean duration of hospital stay was 27days. The overall median survival was 29months, with 1- and 2-year survival of 72% and 64%, respectively. Twenty-one patients had complete cytoreduction and their 1- and 2-year survival rates were 85% and 71%, respectively. Univariate analysis demonstrated that patients with non-mucinous colorectal adenocarcinoma, Peritoneal Cancer Index (PCI) < or =13, and complete cytoreduction were associated with an improved survival.

CONCLUSIONS

This study reported on 30 patients who underwent cytoreductive surgery and perioperative intraperitoneal chemotherapy for colorectal peritoneal carcinomatosis. Patients with mucinous tumour had relatively more extensive intraperitoneal disease. Non-mucinous colorectal adenocarcinoma, PCI < or =13, and complete cytoreduction were associated with an improved survival.

Comprehensive management of diffuse malignant peritoneal mesothelioma

AIMS

In the past, diffuse malignant peritoneal mesothelioma (DMPM) has been regarded as a terminal condition. The length of the survival was dependent upon the aggressive versus indolent biology of the neoplasm, nevertheless cure was not considered as a reasonable expectation and the overall median survival was approximately one year.

METHODS

A comprehensive literature review and a collection of pertinent data published on DMPM from the Washington Cancer Institute were used to construct this report.

RESULTS

Recent publications from Bethesda MD, New York, Milan Italy, Lyon France and Washington DC have shown a remarkable prolongation in the median survival of this group of patients with approximately half the patients alive at 5 years. These prolonged survivors were treated with an intensive local-regional treatment strategy that included cytoreductive surgery (CRS) with peritonectomy and hyperthermic intraoperative intraperitoneal chemotherapy (HIIC) and some patients with early postoperative intraperitoneal chemotherapy (EPIC). As larger numbers of patients have been treated, clinical features by which to select patients most likely to benefit from this approach have been identified. Also, as the experience in the management of patients receiving these treatments has increased, the morbidity and mortality associated with their management is being reduced.

CONCLUSIONS

A new standard of care involves surgical removal of large disease deposits combined with perioperative intraperitoneal chemotherapy. Knowledgeable management uses selection criteria and incurs low morbidity and mortality.

Management of intrahepatic recurrence after curative treatment of colorectal liver metastases

BACKGROUND

Management of intrahepatic recurrence after complete surgical treatment for colorectal liver metastases is not well defined. The aim of this study was to analyse the survival results of patients who had repeat liver resection for intrahepatic recurrence and to evaluate prognostic indicators for survival.

METHODS

Between 1991 and 2005, 55 patients had repeat liver resection for isolated intrahepatic recurrence. The long-term survival results were assessed. Univariable and multivariable analyses were used to identify prognostic indicators for survival after repeat hepatectomy.

RESULTS

The median survival was 53 (range 2-97) months and the 5-year survival rate was 49 per cent. In univariable analysis, size of largest initial liver metastasis, margin of initial liver surgery, carcinoembryonic antigen (CEA) level before and after initial liver surgery, liver disease-free survival, margin of repeat liver surgery, operation type of repeat surgery and CEA level before and after repeat surgery were significant prognostic factors. In multivariable analysis, largest initial liver metastasis 4 cm or less and CEA level 5 ng/ml or less after repeat liver surgery were independently associated with improved survival.

CONCLUSION

Repeat hepatectomy can achieve an acceptable survival in selected patients with isolated intrahepatic recurrence.

Significance of lymph node metastasis in patients with diffuse malignant peritoneal mesothelioma

BACKGROUND

Diffuse malignant peritoneal mesothelioma (DMPM) is a rare and invariably fatal neoplasm. Some studies have shown that cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) achieved an improved survival, as compared to historical controls. However, the significance of lymph node involvement in this disease has never been well defined.

METHODS

One hundred patients with DMPM underwent CRS and PIC at the Washington Hospital Center. The inclusion criteria for surgery consisted of histological diagnosis of DMPM, age <80 years and good performance status. All data were collected prospectively. Lymph node status, seven clinical variables and eight treatment-related prognostic factors were analyzed for survival.

RESULTS

Seven patients were lymph node positive and they all died of their disease within 2 years after the surgery. The remaining 93 patients had 5- and 7-year survival of 50% and 43%, respectively. Univariate analysis showed that gender (p<0.001), peritoneal cancer index (p=0.009), lymph node status (p<0.001), extra-abdominal invasion (p=0.026), histological type (p<0.001), intraoperative blood loss (p=0.035), completeness of cytoreduction (p<0.001), intraperitoneal chemotherapy regimen (p=0.041), and redo cytoreductive surgery (p=0.022) were significant for survival. Multivariate analysis demonstrated that female gender, lymph node metastasis not detected, epithelial type, and adequate cytoreduction were independently associated with an improved survival.

CONCLUSIONS

CRS and PIC showed an improved survival for DMPM, as compared to historical controls. Lymph node status along with three other prognostic variables was significant in the multivariate analysis.

Synchronous liver resection and cryotherapy for colorectal metastases: survival analysis

INTRODUCTION

The value of synchronous liver resection and cryotherapy ablation remains controversial for colorectal metastases where complete resection is not possible by conventional liver surgery alone.

OBJECTIVE

To review the long-term survival of patients treated using this approach at our institution.

METHODS

A review was undertaken of data held in the prospectively collected liver surgery database of all patients who underwent synchronous liver resection and cryotherapy. Survival analysis was performed and data recorded on the total number of metastases at initial surgery and the number of lesions treated by cryoablation.

RESULTS

Ninety-three patients with colorectal metastases underwent synchronous liver resection and cryotherapy. Data were available on 86 patients with a median follow-up of 18 months (range 1-83). The median number of metastases at initial surgery was four (range 2-11) and the number of lesions treated by cryotherapy ablation was two (range 1-8). Eighty-four per cent had a hepatic artery catheter inserted at surgery and at least one cycle of post-operative hepatic artery chemotherapy. One-, three- and five-year survival was 85%, 43% and 19% respectively, with a median survival of 33 months (95% confidence interval 19.9-42.1). Site of recurrence was recorded and presented.

CONCLUSIONS

Patients with liver metastases that are not amenable to resection alone can achieve worthwhile median survival with synchronous liver resection and cryotherapy ablation.

Surveillance-detected hepatic metastases from colorectal cancer had a survival advantage in seven-year follow-up

PURPOSE

Colorectal cancer is a common cause of cancer-related death. The liver is the most common site of distant metastases and the most amenable to potentially curative surgery. The aim of this study was to determine whether hepatic metastases detected by surveillance following colonic resection were associated with higher resectability rates and to determine whether there was any impact on survival rates.

METHODS

A retrospective study of 211 patients who presented to the liver unit between February 1990 and July 1996 with hepatic metastases following colonic resection for adenocarcinoma was performed. Patients were divided into two groups: Group A (n = 154), hepatic metastases diagnosed by carcinoembryonic antigen or by radiology; and Group B (n = 57), patients with symptomatic presentation.

RESULTS

Potentially curative operations were possible in 51.3 percent (79/154) of Group A patients and 28.1 percent (16/57) of Group B patients (P = 0.0043, chi-squared test). In Groups A and B, 24 percent (37/154) and 43.9 percent (25/57) of patients, respectively, were inoperable. The three-year and five-year survival rates after detection of liver metastases were 26.8 percent (41/153) in Group A and 12.5 percent (7/56) in Group B, and 5.9 percent (9/153) in Group A and 8.9 percent (5/56) in Group B, respectively. Log-rank analysis resulted in P = 0.05, Breslow test in P = 0.01.

CONCLUSION

Our study shows that patients with hepatic metastases from colorectal cancer detected by follow-up were significantly more likely to have a potentially curative operation. Our medium-term survival data show a statistically significant survival benefit in patients with surveillance-detected metastases.

Cytoreduction and intraperitoneal chemotherapy for the management of non-gynecological peritoneal surface malignancy

Peritoneal surface malignancy can arise from pseudomyxoma peritonei, gastrointestinal carcinoma, abdomino-pelvic sarcoma and peritoneal mesothelioma. In the past, only palliative treatments were offered and the results were poor. We have proposed a new concept in managing patients with peritoneal surface malignancy. It involves an aggressive combined treatment modality of cytoreduction and perioperative intraperitoneal chemotherapy. The results are promising for patients with pseudomyxoma peritonei, peritoneal mesothelioma and well-selected patients with invasive peritoneal surface malignancies. The success in such comprehensive treatment depends on tumor biology, patient's co-morbidities, the completeness of cytoreduction, the efficacy of intraperitoneal chemotherapy administration and the surgeon's experience. The importance of patient selection is emphasized. The rationales and the outline of the current management strategies are described. Large phase II studies have demonstrated the marked survival advantage in this aggressive approach to peritoneal surface malignancy.