Short-term preoperative drainage is associated with improved postoperative outcomes compared to that of long-term biliary drainage in pancreatic surgery

Purpose

The treatment of choice for patients presenting with obstructive cholestasis due to periampullary carcinoma is oncologic resection without preoperative biliary drainage (PBD). However, resection without PBD becomes virtually impossible in patients with obstructive cholangitis or severely impaired liver cell function. The appropriate duration of drainage by PBD has not yet been defined for these patients.

Methods

A retrospective analysis was conducted on 170 patients scheduled for pancreatic resection following biliary drainage between January 2012 and June 2018 at the University Hospital Dresden in Germany. All patients were deemed eligible for inclusion, regardless of the underlying disease entity. The primary endpoint analysis was defined as the overall morbidity (according to the Clavien-Dindo classification). Secondary endpoints were the in-hospital mortality and malignancy adjusted overall and recurrence-free survival rates.

Results

A total of 170 patients were included, of which 45 (26.5%) and 125 (73.5%) were assigned to the short-term (< 4 weeks) and long-term (≥ 4 weeks) preoperative drainage groups, respectively.

Surgical complications (Clavien-Dindo classification > 2) occurred in 80 (47.1%) patients, with significantly fewer complications observed in the short-term drainage group (31.1% vs. 52%; p = 0.02). We found that long-term preoperative drainage (unadjusted OR, 3.386; 95% CI, 1.507–7.606; p < 0.01) and periampullary carcinoma (unadjusted OR, 5.519; 95% CI, 1.722–17.685; p-value < 0.01) were independent risk factors for postoperative morbidity, based on the results of a multivariate regression model. The adjusted overall and recurrence-free survival did not differ between the groups (p = 0.12).

Conclusion

PBD in patients scheduled for pancreatic surgery is associated with substantial perioperative morbidity. Our results indicate that patients who have undergone PBD should be operated on within 4 weeks after drainage.

A New Picture of Fire Extent, Variability, and Drought Interaction in Prescribed Fire Landscapes: Insights From Florida Government Records

Florida, United States, government records provide a new resource for studying fire in landscapes managed with prescribed fire. In Florida, most fire area (92%) is prescribed. Current satellite fire products, which underpin most air pollution emission inventories, detect only 25% of burned area, which alters airborne emissions and environmental impacts. Moreover, these satellite products can misdiagnose spatiotemporal variability of fires. Overall fire area in Florida decreases during drought conditions as prescribed fires are avoided, but satellite data do not reflect this pattern. This pattern is consistent with prescribed fire successfully reducing overall fire risk and damages. Human management of prescribed fires and fuels can, therefore, break the conventional link between drought and wildfire and play an important role in mitigating rising fire risk in a changing climate. These results likely apply in other regions of the world with similar fire regimes.

Testicular germ cell tumors in adolescents - results of the protocol MAHO 98 and the identification of good risk patients

BACKGROUND

In adolescents aged 10-15 years germ cell tumors of the testis (TGCT) are rare and information for a risk adapted therapy limited.

AIMS OF THE STUDY

The protocol MAHO 98 for patients (pts) with TGCTs is stratified according to age, stage and histology. Pts ≥ 10 years received after tumororchiectomy 2 courses (crs) PVB and restaging. Residual tumor was resected and therapy continued in regard to inital stage and response. Chemotherapy: PVB: cisplatin (20 mg/m²/day 1-5), vinblastine (3 mg/m²/day 1+2), and bleomycin (15 U/m²/day 1-3). For consolidation 1 crs PVB has been given to stage II patients with CR. In case of PR, 2 crs PEB (vinblastine substituted by etoposide 100 mg/m²/day 1-3) or relapse 3 crs PEI (bleomycin substituted by ifosfamide 1 500 mg/m²/day 1-5) were given.

RESULTS

Between Jan 1998 and Dec 2005, 34 pts (≥ 10 year) were registered, 31 fulfilled the inclusion criteria. Median age: 15;6 years; months (range 13;5-20;2 ). Lugano staging: IA n=14, IB n=2, IC n=3, IIA n=4, IIB n=6, IIC n=1, IIIC n=1. The stage IIIC pt received preoperative chemotherapy, all other pts had tumororchiectomy first. Residual tumor after 2 crs PVB was detected in 4 pts and was resected. Late relapses occurred in 2 pts and were cured by additional therapy. All patients are surviving.

CONCLUSION

Young patients with TGCT stage I and II have an excellent prognosis and further reduction of therapy has to be considered.

Assessing quality of life in long-term survivors after ¹²⁵I brachytherapy for low-grade glioma in childhood

Quality of life (QOL) is important for the survivors of malignancies. We investigated health-related QOL in 51 patients treated with iodine-125 (¹²⁵I) brachytherapy for childhood low-grade gliomas. Instruments included a questionnaire on life situation, German versions of PEDQOL (8-18 years), EORTC QLQ-30 and head and neck module H&N-35 (>18 years), strength and difficulties questionnaire, "Fertigkeitsskala Münster Heidelberg", and an adapted Rankin score. The time lapsed since ¹²⁵I-brachytherapy was 134 months (median, range: 29-293 months). 57% of the patients were over 18 years of age, 34% were 11-17 years old and 8% were younger. 14 had undergone other treatments after ¹²⁵I brachytherapy. Over half of the >18 year olds reported residual problems; 68% were disabled, 38% to a severe degree. Many of the young adults still lived with their parents and 17% were jobless. 43% of the children/adolescents needed rehabilitative treatment, 20% visited special schools and 71% were disabled, 33% severely. The patients and their caregivers rated their QOL as not different from that of the normal population. However, many QOL dimensions correlated to the severity of disability. Comparison of QOL outcomes between different treatment measures would require a prospective study controlling for the most important factors of influence.

Brain metastases in children and adolescents with extracranial germ cell tumor - data of the MAHO/MAKEI-registry

BACKGROUND

We analyzed 15 children and adolescents with extracranial germ cell tumor (GCT) and brain metastases reported to the MAHO/MAKEI registry.

PATIENTS AND METHODS

Between 1982 and 2009, 2 077 patients were prospectively enrolled onto the MAHO/MAKEI studies (overall survival: 0.88+/-0.03). All patients with advanced malignant GCTs received cisplatin-based chemotherapy (overall survival: 0.81+/-0.04 (734/823).

RESULTS

15 patients with brain metastases were reported; in 6 of them at diagnosis and 9 respectively during follow-up (6 weeks-28 months after end of therapy, mean=10 months). Most patients were male (13/15) and adolescent (10/15). 8 patients suffered from mediastinal GCTs. Pure Choriocarcinoma (CC) or CC in combination with other histologies was diagnosed in 12 patients. Clinical symptoms were reported in most patients. In all patients with secondary brain metastases the previously normalised tumor markers AFP and/ or HCG increased again prior to the onset of neurological symptoms. Only 1 of the patients with primary brain metastases survived, whereas 4 of 9 with secondary metastases are in remission after additional treatment.

CONCLUSION

The risk for intracranial metastases increases with age, male gender and mediastinal or testicular primary site and choriocarcinoma histology. Development of neurological symptoms at initial diagnosis or during follow-up should lead to rapid clinical re-evaluation including CNS imaging and assessment of tumor markers. Treatment of brain metastases includes intensified chemotherapy and surgical resection, irradiation has to be considered in special clinical situations.

Note: Design and tests of a 13 kA-6.5 kV thyristor switch for a pulsed inductive vacuum ultraviolet source

In this paper, the design, construction, and test procedure of a closing switch prototype based on thyristors is described. In particular, details are given about the design criteria and about the triggering board architecture, which is a high side biased, self supplied unit using the electrical energy derived from a local snubber network for the gate drive. The structure guarantees a hard firing gate pulse for the required high dI/dt application. Further, the results of the prototype tests are presented and discussed. The stack assembly has a holding voltage of 6.5 kV and is used for switching a series resonant circuit with a ringing frequency of 12 kHz for a pulsed inductive vacuum ultraviolet source. Maximum current amplitudes of 13 kA and pulse energies of more than 600 J were switched during the test procedure.

Thyristor stack for pulsed inductive plasma generation

A thyristor stack for pulsed inductive plasma generation has been developed and tested. The stack design includes a free wheeling diode assembly for current reversal. Triggering of the device is achieved by a high side biased, self supplied gate driver unit using gating energy derived from a local snubber network. The structure guarantees a hard firing gate pulse for the required high dI/dt application. A single fiber optic command is needed to achieve a simultaneous turn on of the thyristors. The stack assembly is used for switching a series resonant circuit with a ringing frequency of 30 kHz. In the prototype pulsed power system described here an inductive discharge has been generated with a pulse duration of 120 micros and a pulse energy of 50 J. A maximum power transfer efficiency of 84% and a peak power of 480 kW inside the discharge were achieved. System tests were performed with a purely inductive load and an inductively generated plasma acting as a load through transformer action at a voltage level of 4.1 kV, a peak current of 5 kA, and a current switching rate of 1 kA/micros.

Quality of Survival in Children and Adolescents After Treatment for Childhood Cancer: The Influence of Reported Late Effects on Health Related Quality of Life

BACKGROUND

Considering the high survival rates of childhood cancer physical and psychosocial long term effects (LF) as well as the estimation of Quality of Life (QoL) are becoming a new focus of clinical research. Thus, disease related as well as age related variables have to be taken into account. This paper evaluates the physical long term effects of childhood cancer survivors. In addition differences of QoL of the survivors in comparison to children and adolescents of the same age are estimated if present and correlated to somatic late effects.

PATIENTS AND METHODS

36 survivors of childhood cancer who are followed at the University Children's Hospital Duesseldorf, with an age range of 8-18 years participate in the evaluation. Together with a clinical examination somatic long term effects and sociodemographic information are documented. QoL is evaluated with a standardized questionnaire (PEDQOL) including the domains physical function, emotion, cognition, autonomy, social function (family, friends and body image). Quality of Life data are compared with data of 319 unselected healthy controls of comparable age groups.

RESULTS

24 of 36 patients show various LF: skeletal deformities, scars, impairment of organ function, infectious complication, hormonal failures. Patients with solid tumors develop more and more frequently severe LF (11/14 pat.) compared to patients with leukaemia and lymphoma (11/22 pat.). Nevertheless health status can be objectively rated as satisfying in comparison to children of the same age. Most patients rate the QoL better than their controls. Patients with severe LF show impairment in the domains body image, emotional and physical functioning and cognition compared to patients without or with minor somatic LF.

CONCLUSION

Our results underline the influence of objective long term effects and subjective QoL on the Quality of Survival. Prospective evaluation will lead to new and important information with respect to the onset of somatic and psychosocial LF and possible coping strategies. These information will establish additional possibilities for initiation of primary and secondary rehabilitation processes.

The Malignant Potential of Teratomas in Infancy and Childhood: The MAKEI Experiences in Non-Testicular Teratoma and Implications for a New Protocol

Since 1982, mature and immature teratomas have been recruited into the MAHO and MAKEI protocols of the German Society for Pediatric Oncology and Hematology (GPOH) for testicular and non-testicular germ cell tumors in order to study the epidemiology and clinical behaviour of teratomas. Patients were registered in the epidemiologic German Childrens Cancer Registry and the GPOH Childrens Tumor Registry for pathological review. Patients with immaturity grade 2 and 3 according to Gonzales-Crussi were eligible for adjuvant chemotherapy. The consecutive protocols MAKEI 83/86/89 have been published previously in detail (Klin Paediatr 1997; 209: 228-234, Med Pediat Oncol 1998; 31: 8-15) and will be compared to the data of MAKEI 96. For this comparison, 274 patients from MAKEI 83/86/89 and 261 patients from MAKEI 96 are evaluable.

RESULTS

1) EFS after complete tumor resection has been estimated to 0.96 +/- 0.01 in both observation periods. 2) Incomplete tumor resection remains the main risk factor for relapse (EFS 0.55 +/- 0.09). 3) The relapse rate declined from 13.9 % in MAKEI 83/86/89 to 9.5 % in MAKEI 96. 4) In MAKEI 83/86/89 four newborns with teratoma died due to perioperative complications and nine children as a result of tumor progression, whereas in MAKEI 96 no newborn died, only one child died from tumor progression, and another child died during long time observation for another reason (meningitis). 5) In accordance to the experience of the MAKEI 83/86/89 studies, no child of the MAKEI 96 study presented with yolk sac tumor at recurrence if adjuvant chemotherapy was administered during first-line treatment because of immaturity. In contrast, more than half of the children with tumor recurrence after watch and wait strategy had yolk sac tumor in addition to teratoma.

Quality of life in children and adolescents with cancer. First results of an evaluation of 49 patients with the PEDQOL questionnaire

BACKGROUND

The assessment of Quality of Life (QoL) in childhood cancer survivors is a new field of research, which is important for a better understanding of how children with cancer feel and how treatment can be optimized. The purpose of our examination in a sample of patients treated in our institution was the evaluation of the questions: How do children with cancer reflect on their QoL in comparison to healthy children of the same age? Are there any significant differences in QoL between children with hematological disorders and children with solid tumors and if that is so, which domains are affected?

PATIENTS AND METHODS

We used for the evaluation a pilotversion of a self-rating QoL questionnaire for children between 8 and 18 years (PEDQOL), who was developed for pediatric oncology. 49 children off treatment of whom 51% had leukemia/lymphoma and 49% had solid tumors compared to 62 healthy school children were examined.

RESULTS

The PEDQOL questionnaire was a good accepted measure among the examined children. The reliability scores of the pilotform for the evaluated domains were also satisfactory (Cronbach's-Alpha > 0.60). In general QoL was scored good by healthy as well as by ill children. In the group of children with leukemia/lymphoma impairment of QoL was more apparent than in children with solid tumors (domains autonomy, emotional functioning, cognition and familial interactions). Survivors of solid tumors reported less impairment of QoL which was mainly seen in physical functioning and body image.

CONCLUSION

In general QoL scored with the PEDQOL pilotquestionnaire was good for most of the childhood cancer survivors. Children with solid tumors show less impairment than children with leukemia/lymphoma. Therefore it could be suggested, that young age at diagnosis and the following longer period of being dependent on familial support, the isolation from peer groups and the longer way to become independent may be reflected by these results. To obtain reliable results how children with cancer express their QoL and what consequences illness, treatment and long term effects of therapy have on the childrens' QoL a multicenter prospective study is needed. This will be realized in the near future in a project on "Long term effects and quality of life in children with leukemia or medulloblastoma", which is supported by the "Kompetenznetz Pädiatrische Onkologie and Hämatologie".

Teratomas in infancy and childhood

BACKGROUND AND PROCEDURE

Outcomes in children with teratomas collected between October 1982 and December 1995 in cooperative protocols of the German Society of Pediatric Oncology and Hematology (GPOH) were analyzed. Teratomas were diagnosed in 329 (42%) of 780 registered patients with germ cell tumors. The annual incidence was 0.24/100,000. Main primary sites were coccygeal (n = 132, 2.2:1 female predominance), ovary (n = 81), testis (n = 40) and brain (n = 15, 2.8:1 male predominance).

RESULTS

Two hundred seventy cases of extracranial non-testicular teratoma were evaluated: In mature teratomas (n = 154) the observed relapse rate was 10%. Incomplete resection was the main risk factor for relapse. After complete resection, the relapse-free survival (RFS, Kaplan-Meier-estimation) was 0.96 +/- 0.01 (n = 126, observation time 18-155 months) in comparison to an RFS of 0.56 +/- 0.09 in incompletely resected teratomas grade 0 (n = 28, observation time 28-94 months) (P < 0.01). Im-mature teratomas were treated by surgery alone in 76 cases and by surgery and adjuvant chemotherapy in 40 cases. The observed relapse risk was 18%. Main risk factors for relapse were incomplete tumor resection (n = 38) as well as immaturity in incompletely resected teratomas. Fifteen of 29 relapsing patients presented with malignant tissue in the recurrent tumor (mainly yolk sac tumor); in contrast, seven of 40 patients with immature teratoma relapsed despite adjuvant chemotherapy without showing malignant components (P = 0.014). Nine of 36 (25%) relapsing patients died of disease. Eleven of the 27 (41%) surviving children suffered from mutilation after repeated surgery.

COMMENTS

It is suggested that an international randomized trial for patients with incompletely resected high risk teratoma be initiated to evaluate the effect of adjuvant chemotherapy on specific end-points: 1) influence on relapse rate in general; 2) reduction of the proportion of malignant relapses; 3) avoidance of mutilating surgery.

[Sonography in tumor after-care of head-neck tumor patients. Value of sonomorphologic criteria and sonographic M/Q quotients]

The ranking of postoperative sonography is examined in respect of imaging of neck lymph node enlargement and neck lymph node metastases or lymphomas, using a prospective study involving 119 patients whose head and neck tumours had already undergone treatment. These patients had been subjected to tumour aftercare for an average period of 26 months. The resulting quotient values (M/Q-Quotient) and the transverse and long axis lengths, respectively, were used as diagnostic criteria for suspicion of malignancy. A cervical lymph node with an M/Q-Quotient greater than two ruled out a metastasis with 94% accuracy. A quotient of less than two confirmed the presence of a metastasis with 92% accuracy. In comparison, evaluation using the transverse axis method ruled out metastasis in 92% of the cases, with a sensitivity of only 83%. The presence of sonomorphological criteria as a highly medullary reflex at the centre of the lymph node or excentric widening of cortex improves diagnostic safety.

[BEP/VIP in children and adolescents with malignant non-testicular germ cell tumors. A comparison of the results of treatment of therapy studies MAKEI 83/86 and 89P/89]

The treatment regimen of the ongoing cooperative study for non testicular germ cell tumors (MAKEI 89 of the German Society of Pediatric Oncology and Hematology), was stratified as in MAKEI 83 and 86 according to histology, localisation and stage. In the 1989 study, vinblastine was replaced by etoposide, resulting in a chemotherapeutic regimen of 3 to 4 courses BEP and 3 to 4 courses VIP in patients with stage I to IV. Total chemotherapy was reduced for 25%. In children under 1 year of age, bleomycin was omitted and bleomycin dose was reduced to 50%. In children up to 2 years because of two toxic deaths due to bleomycin who were registered in MAKEI 89 Pilot phase. Until Jan. 31, 1993, 230 patients were registered in the MAKEI 89 pilot study and the MAKEI 89 study, containing 186 protocol and 44 follow-up patients (patients with intracranial tumors are excluded for the review). 78 of the registered patients had a teratoma, 9 of these 78 patients suffered from a relapse. In 7 of 9 patients a lasting second remission has been achieved. 12 patients offered with germinoma. 1 of 12 patients had a recurrence but is in second remission. 47 patients had malignant non germinomatous germ cell tumors with an event free survival of 91 +/- 0.4%. 2 of the 47 patients relapsed and died. Toxicity was mainly hematologic without evidence of long term effects. Bleomycin induced pulmotoxicity (WHO grade IV) was documented in 1 protocol patient (see above). Nephrotoxicity with a grade III (WHO) decrease of creatinine clearance was found in 25% of the documented patients with a fast return to normal values after the end of therapy in most of the children. For the follow-up MAKEI 93 study, different topics are defined. 1. The value of chemotherapy for immature teratoma has to be discussed. 2. In invasive immature teratoma in children over 1 year of age, the effectiveness of chemotherapy should be proved. 3. Germinomas show high platinum sensitivity, therefore a platinum based chemotherapy has to be examined for this risk group. 4. The value of a wait and see strategy similar to the proved regimen in the French germ cell tumor protocol has to be verified in patients with stage I non germinomatous germ cell tumors. 5. An intensification of chemotherapy in patients with malignant stage III and IV non germinomatous germ cell tumors has to be examined as a new therapeutic approach for this risk group.

[The prognostic significance of serum alpha 1-fetoprotein in children and adolescents with malignant extracranial non-testicular germ cell tumors]

The cooperative therapy study MAKEI 83/86 included an examination of the prognostic value of the AFP in children and adolescents with extracranial non-testicular yolk sac tumors. The serum AFP values of 72 protocol- and follow-up-patients were documented at diagnosis and up to the ninth month of treatment. 32 of these patients had saccrococcygeal tumors, 27 had tumors of the ovary and 13 suffered from extragonadal germ cell-tumors. 4 children showed progressive disease under initial chemotherapy and 1 patient died of therapy, 10 of 72 patients relapsed. The AFP measurements were plotted on semilogarithmic charts. They were compared to the measurements of healthy children up to the age of 1 year. According to the development of the patients' AFP values compared to the reference curves the following classifications could be made: 1. Patients with a normal AFP-decrease id est 50% in less than or equal to 6 days during the 1st month of therapy: 48/72 patients 2. Patients with slow AFP-decrease: 17/72 patients 3. Patients with transient AFP-decrease: 5/72 patients 4. Patients with no AFP-decrease: 2/72 patients According to Kaplan-Meier life table analysis, patients with a normal AFP-decrease had an event-free survival of 89% +/- 4%, whereas all other patients showed an event-free survival of 63% +/- 10% (p less than 0.05). Regarding primary therapy id est tumor resection or preoperative chemotherapy an equal distribution of the patients among those with a normal and slow AFP-decrease was observed.(ABSTRACT TRUNCATED AT 250 WORDS)