Evolving Trends in Autologous Breast Reconstruction: Is the Deep Inferior Epigastric Artery Perforator Flap Taking Over?

BACKGROUND: Enthusiasm for the deep inferior epigastric artery perforator (DIEP) flap for autologous breast reconstruction has grown in recent years. However, this flap is not performed at all centers or by all plastic surgeons for breast reconstruction, and it is unclear whether practice patterns have measurably changed. This study aimed to (1) evaluate changing trends in breast flap use in the United States in recent years and (2) identify how these trends have affected charges and costs associated with autologous breast reconstruction. METHODS: Patients undergoing autologous breast reconstruction [latissimus dorsi (LD), pedicled transverse rectus abdominus myocutaneous (pTRAM), free TRAM (fTRAM), and DIEP] were identified using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database (2009-2011). A total of 19,182 hospital discharges were reviewed. Patient demographics, hospital teaching center status, payer status, length of stay, total charges, and total costs per discharge were reviewed. Statistical analysis was performed using linear regression, t test, and analysis of variance models. RESULTS: Between 2009 and 2011, the total number of discharges did not change significantly. Patient age distribution was similar for all flap groups. For individual flaps, there was a significant increase in DIEP flaps (P = 0.03), with a decreasing trend for other abdominal-based flaps. The patients receiving DIEP flap breast reconstruction were covered by private insurance at a higher rate than all other flap procedures (P = 0.03), whereas other potential cost determinants did not differ significantly between the groups. The mean charge per flap was $40,704 for LD, $51,933 for pTRAM, $69,909 for fTRAM, and $82,320 for DIEP. The mean cost per flap was $12,017 for LD, $15,538 for pTRAM, $20,756 for fTRAM, and $23,616 for DIEP. CONCLUSIONS: Between 2009 and 2011, the total amount of autologous breast reconstruction discharges was relatively stable, but the number of DIEP flaps increased significantly. Review of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample data shows that, compared with LD, pTRAM, and fTRAM flaps, the DIEP flap is associated with higher charges and costs.

A comprehensive analysis of parotid and salivary gland cancer: worse outcomes for male gender.

BACKGROUND: To determine the effects of patient demographics, socioeconomic status (SES) and clinical variables on outcomes for patients with salivary and parotid gland tumors. METHODS: Florida cancer registry and inpatient hospital data were queried for cancer of the salivary glands diagnosed between 1998-2002. RESULTS: A total of 1573 patients were identified. Women were diagnosed at a younger age (median age (years): women 60.8 versus men 64.3, P=0.003). Men were more often diagnosed with high grade tumors (65.1% versus 41.9% for women, P<0.001) and advanced disease stage (>stage III: 60.2 versus 49.4%, P<0.001), but underwent surgical extirpation and received radiation at equal rates compared with women. Overall 5-year survival rates was superior in women (67.4% versus 55.6%, P=0.001). By multivariate analysis, adjusted for patient comorbidities, age over 65 (HR 3.43 P=0.008), advanced disease stage (HR 8.05 P<0.001), and high tumor grade (HR 2.33, P<0.001) were independent predictors of worse prognosis. Improved outcomes were observed for female gender (HR 0.68, P=0.011). Tumors located in the parotid gland (HR 0.631 P=0.003) and receiving both surgical extirpation and radiation were predictors of improved survival. CONCLUSION: Salivary gland tumors carry a worse prognosis than tumors of the parotid. Male patients have worse outcomes.

Improved survival with lymph node sampling in Wilms tumor.

OBJECTIVE: We sought to determine the impact of number of lymph nodes examined on survival for Wilms tumor (WT). METHODS: Data from the Surveillance, Epidemiology, and End Results and Florida Cancer Data System were queried for patients < 20 years of age with WT. RESULTS: Of 1805 WT patients, 1340 had lymph node (LN) data available following surgery. The mean age for the cohort was 3.3 ± 2.8 y. Most patients were White (78%), and non-Hispanic (78%). A total of 297 patients (22%) had 0 LN sampled, while 697 (52%) had 1-5 LN, 210 (16%) had 6-10 LN, and 136 (10%) had >10 LN. Overall 5-y survival was 91%. By univariate analysis, 5-y survival was significantly lower for patients with 0 LN sampled (87% versus 91% 1-5 LN; 93% 6-10 LN; 95% >10 LN, P = 0.005). Multivariate analysis confirmed a survival advantage for patients having 1-5 LN (HR 0.600, P = 0.016), 6-10 LN (HR 0.521, P = 0.048), and >10 LN (HR 0.403, P = 0.039) compared with patients with 0 LN examined. CONCLUSION: Failure to biopsy lymph nodes for WT patients not only increases the risk of local recurrence due to understaging and inadequate adjuvant therapy, but is also an independent prognostic indicator of lower survival.

Rhabdomyosarcoma in children: a SEER population based study.

OBJECTIVE: To examine incidence and outcomes for pediatric rhabdomyosarcoma (RMS). METHODS: The SEER registry was examined for patients with RMS < 20 y old. RESULTS: Overall, 1544 patients were identified for an incidence of 0.4414/100,000 per year. Males outnumbered females 3:2. Tumors were classified as embryonal (67%), alveolar (32%), and pleomorphic (1%). Alveolar and pleomorphic RMS were more common in adolescents, whereas embryonal type was more common in younger children (P = 0.0001). Pleomorphic (47%) and alveolar (39%) RMS commonly presented with distant disease, in contrast to embryonal (25%). Most patients had surgical resection (81%) and radiotherapy (63%). Overall, 5- and 10-y survival was 60% and 57%, respectively. Univariate analysis identified higher survival for age < 10 y, local stage, favorable site, embryonal type, <5 cm tumor size, and surgical resection. Multivariate analysis identified non-embryonal type (HR 1.451), non-favorable site (HR 1.570), no surgery (HR 1.726), age ≥ 10 y (HR 1.734), 1973-1978 diagnosis year (HR 1.730), and distant disease (HR 3.456) as independent predictors of mortality. CONCLUSIONS: Embryonal histology, the most common type of pediatric RMS, presents in young children and has better prognosis than alveolar or pleomorphic types. Patients with embryonal tumors, favorable tumor location, age < 10 y, localized disease, and surgical resection have improved survival.

Obesity and weight loss at presentation of lung cancer are associated with opposite effects on survival.

BACKGROUND: Lung cancer is the second most common neoplasm and the leading cause of cancer deaths in the United States. In cancer, weight loss and obesity are associated with reduced survival. However, the effect of obesity or weight loss at presentation on lung cancer survival has not been well studied. MATERIALS AND METHODS: Using an extensive cancer dataset, we identified 76,086 patients diagnosed with lung cancer during the period of 1998-2002, of which 14,751 patients presented with obesity and/or weight loss. We examined the relationship between survival and weight loss or obesity at diagnosis using univariate and multivariate analysis. RESULTS: Median survival time (MST) for all lung cancer patients was 8.7 mo. Patients presenting with weight loss (15.8%) had shorter MST versus those who did not (6.4 versus 9.2 mo, P < 0.001) and patients with weight loss had significantly shortened MST for all stages and histologic subtypes. In contrast, obese patients at presentation (5.4%) had longer MST relative to non-obese patients (13.0 versus 8.6 mo, P < 0.001), which was significant across all stages and histologic subtypes. Multivariate analysis revealed that the absence of weight loss was an independent, positive predictor of improved survival (HR = 0.087, P < 0.001), while the absence of obesity was an independent predictor of worsened survival in lung cancer (HR = 1.16, P < 0.001). CONCLUSIONS: Our results demonstrate an inverse relationship between survival and weight loss at presentation and a potentially protective effect of obesity in lung cancer survival, which could be due to greater physiologic reserves, thereby prolonging life by slowing the progress of cancer cachexia.

Evidence-based medicine and its role in plastic surgery.

In an era in which evidence-based medicine (EBM) has become an intricate aspect of the practice and advancement of the field of medicine, plastic surgery must aim to sustain its role as a pioneer division. It is critical that plastic surgeons understand the significance of EBM and, more importantly, its application to everyday practice. We aimed to review a comprehensive systemic approach to gather high-quality data that help support clinical decision making and assist in determining best available treatment. In addition, we provide evidence supporting the role of EBM in the field of plastic surgery.

Pediatric facial trauma: a review of guidelines for assessment, evaluation, and management in the emergency department.

Approximately 22 million children in the United States sustain traumatic injuries every year, the etiologies of which vary with age as well as social and environmental factors. If not managed properly, these injuries can have a significant impact on future growth and development. Evaluation of facial injuries presents a unique diagnostic challenge in this population, as differences from adult anatomy and physiology can result in vastly different injury profiles. The increased ratio of the cranial mass relative to the body leaves younger patients more vulnerable to craniofacial trauma. It is essential that the treating physician be aware of these variations to properly assess and treat this susceptible and fragile patient population and ensure optimal outcomes. This article reviews the proper emergency department assessment and treatment of facial fractures in the pediatric population as well as any associated injuries, with particular emphasis on initial patient stabilization, radiological evaluation, and therapeutic options.

Does chemoradiotherapy improve outcomes for surgically resected adenocarcinoma of the stomach or esophagus?

BACKGROUND: To use a population-based registry to evaluate the effect of chemotherapy or radiation on survival for patients undergoing curative-intent surgery for adenocarcinoma of the esophagus or stomach. METHODS: A linked data set between the Florida Cancer Data System and the Florida Agency for Health Care Administration from 1998 to 2003 was queried. RESULTS: Overall, 3,378 patients underwent surgical extirpation with curative intent, 636 patients had esophageal adenocarcinoma (EAC), and 2,742 patients had gastric adenocarcinoma (GAC). Outcomes were adjusted for patient comorbidities and hospital teaching status. Overall, no benefit was observed for adjuvant therapies for EAC patients. A small improvement in survival was observed with adjuvant therapies for GAC. For localized EAC or GAC there was no additional survival benefit associated with adjuvant therapies. For patients with regional EAC, chemotherapy (20.0 vs. 13.0 months, P < .001) and radiation (18.6 vs. 13.5 months, P = .007) were associated with a statistically significant survival benefit. In multivariate analysis, independent predictors of improved survival for regional EAC include chemotherapy (hazard ratio [HR] .535, P < .001) and radiotherapy (HR .656, P = .01). For GAC, patients with regional disease showed an improved median survival with chemotherapy (21.1 vs. 11.2 months, P < .001) and radiotherapy (22.6 vs. 12.3 months, P < .001). In multivariate analysis, independent predictors of improved survival for regional GAC include chemotherapy (HR .629, P < .001) and radiation (HR .603, P < .001). CONCLUSIONS: Patients with regional adenocarcinoma of the esophagus or stomach, but not those with localized disease, derive a statistically significant survival benefit from the addition of chemotherapy and radiation to surgical resection.

Pediatric solid tumors and second malignancies: characteristics and survival outcomes.

BACKGROUND: To examine the incidence, characteristics, and outcomes for second malignancies following the diagnosis of a primary solid tumor in pediatric patients. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried from 1973 to 2005, excluding recurrences, in patients <20 y. RESULTS: A total of 31,685 cases of pediatric solid malignancies were identified. Overall, 177 patients were diagnosed with a unique second malignancy before the age 20 (0.56%) The mean follow-up was for 8.5 y (2 mo-30.8 y). Mean age at diagnosis of the primary tumor was 7.7 y. The most common primary malignancies were CNS tumors (22.5%), followed by soft tissue sarcoma (15.8%), retinoblastoma (14.1%), and bone tumors (13%). Hematologic malignancies (35.5%) were the most common second malignancies noted in the cohort, followed by bone tumors (18%) and soft tissue sarcomas (15%). Hematologic malignancies had a shorter latency (3.1 y) compared with solid second tumors (11.6 y). The overall 10-y survival for the entire cohort was 41.5%. For most tumor categories, development of a secondary malignancy was associated with lower 5- and 10-y survival than expected. CONCLUSIONS: CNS tumors, retinoblastoma, and soft tissue sarcomas in children are the most common solid primary tumors, with an increased risk of a second malignancy. Leukemia is the most common second malignancy seen in pediatric solid tumors. Second malignancies are associated with significantly reduced survival rates compared with the general childhood cancer population.

Primary solid tumors of the colon and rectum in the pediatric patient: a review of 270 cases.

OBJECTIVE: To study the outcomes of solid tumors of the colon and rectum in pediatric patients. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database (1973-2005) was queried for patients less than 20 y of age. RESULTS: Overall, 270 patients with malignant tumors of the lower gastrointestinal tract were identified. The annual incidence was 1.04 cases per million in 2005. Overall, equal distribution between boys (50.7%) and girls (49.3%) was observed. The majority of tumors arose in adolescents (68.1% were older than 15 y). Tumors were more commonly seen in white (77.8%) and non-Hispanic (78.9%) patients. Tumors were identified in the right colon (45.9%), transverse colon (9.3%), left colon (20.4%), rectum (15.2%), and anal canal (1.1%). The most common histology of these tumors was adenocarcinoma (35.6%), followed by carcinoid (34.1%). Disease specific 5- and 10-y-survival for the entire cohort was 61.0% and 57.9%, respectively. Multivariate analysis of the cohort identified tumor stage (HR 8.39, P < 0.001 for distant disease), tumor type (signet ring HR 2.12, P = 0.025, and carcinoid HR = 0.14, P = 0.001), and surgical resection (no surgery HR 2.98, P = 0.010) as independent predictors of worse outcome. CONCLUSION: In the pediatric population, solid tumors of the colon and rectum occur more frequently in the right side of the colon in teenagers. Surgical resection significantly improves survival for most pediatric tumors of the lower gastrointestinal tract.

Incidence and outcomes of extremity soft-tissue sarcomas in children.

BACKGROUND: We studied the outcomes of pediatric extremity tumors on a population scale. METHODS: The Surveillance, Epidemiology, and End Results database (1973-2006) was queried for all patients under 20 y of age. RESULTS: Overall, 1175 patients were identified. The median age at diagnosis was 12 y, but most patients were ≥10 y of age (72%, n = 842). Most tumors were non-rhabdomyosarcoma soft tissue sarcomas (NRSTS) (79%, n = 879). The most common tissue of origin was muscle (43%, n = 474). Most rhabdomyosarcoma (RMS) (n = 220) were alveolar type (n = 140). Most patients presented with local disease (64%, n = 699), and underwent surgical intervention (88%, n = 1027), but did not have radiotherapy (62%, n = 710). RMS was more likely to present in younger children (P < 0.001) and with distant disease (P < 0.001). Older patients were more likely to receive radiotherapy than infants (P < 0.001). Overall 5-y survival was 79%. RMS had significantly worse 5-y survival (56% versus 85% for NRSTS, P < 0.001). Surgical intervention was associated with higher 5-y survival (84% versus 48%, P < 0.001). Radiotherapy was associated with worse 5-y survival (74% versus 83%, P = 0.002). Multivariate analysis identified RMS (HR 2.20, P < 0.001), nerve and muscle (not synovial sarcoma) tissue of origin (HR 2.26, P = 0.002, and HR 1.59, P = 0.036), regional or distant disease (HR 1.65, P = 0.011, and HR 5.96, P < 0.001, respectively), and lack of surgical intervention (HR 2.20, P < 0.001) as independent predictors of poor outcome. CONCLUSIONS: Extremity sarcomas are most common in older children. RMS is more common in younger children, but is associated with lower survival, and is an independent prognostic indicator of mortality.

Pediatric non-Wilms renal tumors: subtypes, survival, and prognostic indicators.

BACKGROUND: To determine the outcomes and predictors of survival for pediatric non-Wilms renal tumors (NWRT). METHODS: The SEER database (1973-2005) was queried for all patients < 20 y of age. RESULTS: Overall, 349 cases of NWRT were identified. The major histologic groups included renal cell carcinoma (RCC) (44%), clear cell sarcoma of the kidney (CCSK) (17%), and malignant rhabdoid tumor (MRT) (12%). A bimodal age distribution was observed, with tumors commonly presenting in patients ≤4 y of age and ≥15 y of age. More than 50% of RCC presented at ≥15 y of age, whereas ≥80% of CCSK or MRT patients were ≤4 y of age. Most RCC (57%) and CCSK (53%) were locally staged while most MRT presented with distant disease (51%, P < 0.001). Overall 10-y survival was 63% with improved survival observed in patients with CCSK (79%) and RCC (70%) versus MRT (29%, P < 0.001). By univariate analysis, surgical resection was associated with improved overall 10-y survival (68% versus 30%, P < 0.001), while no benefit was observed for radiotherapy (60% versus 63%, P = 0.8). By multivariate analysis, worse overall survival was observed for patients ≥ 10 y old (HR 4.01, P = 0.013) and those with advanced disease (HR = 12.78, P < 0.001). Patients with MRT (HR = 11.61, P < 0.001) and CCSK (HR = 3.68, P = 0.038) had significantly worse prognosis compared with those with RCC. Surgical resection improved overall survival (HR = 0.36, P = 0.001). CONCLUSION: For pediatric NWRT, younger patients and those with RCC have improved survival, while a diagnosis of MRT portends a worse prognosis. Surgical extirpation significantly improves survival for all patients.

Do all patients with carcinoma of the esophagus benefit from treatment at teaching facilities?

BACKGROUND: We sought to determine whether patients with esophageal carcinoma benefit from regionalization of care. METHODS: The Florida Cancer Data System (FCDS) and the Agency for Health Care Administration data sets (1998-2002) were merged and queried. RESULTS: A total of 5,041 patients (87.6% Caucasian vs. 11.1% African American (AA)) demonstrated a median survival time of 9.8 months overall and 23.4 months following surgical resection (P < 0.001). Adenocarcinoma arose predominantly in Caucasian patients (98.1%). Patients with adenocarcinoma (n = 2,248) derived a treatment benefit at a TF (HR = 1.35, P = 0.003), including an improved 90-day mortality following surgery (2.1% vs. 4.0%, P < 0.001). Squamous cell carcinoma (SCC) arose predominantly in AA patients (91.6%). No overall survival benefit at TF was observed (HR = 1.01, P = 0.915), however a trend for reduced 90-day surgical mortality was observed at TF (1.9% vs. 5.2%, P = 0.062). Multivariate analysis for adenocarcinoma demonstrates that poverty, lack of chemotherapy or surgery, and failure to provide treatment at a TF are independent predictors of worse survival. For SCC patients, AA race was a significant predictor of poorer survival while TF and poverty level were not. CONCLUSIONS: These data suggest no benefit from potential regionalized care for patients with squamous histology, which disproportionately affects AA.

Does Children's Oncology Group hospital membership improve survival for patients with neuroblastoma or Wilms tumor?

PURPOSE: To determine prognostic significance of hospital surgical volume and Children's Oncology Group (COG) membership on neuroblastoma (NBL) and Wilms tumor (WT) survival. METHODS: The Florida Cancer Data System was queried from 1981 to 2004. RESULTS: Of 869 NBL patients, 463 were treated at COG/HVC, 246 at COG/LVC, and 160 at non-COG/LVC. COG hospitals treated a larger proportion of patients <1 year of age (P = 0.002) and relatively more patients with adrenal and mediastinal tumors (P = 0.005). COG centers more frequently administered chemotherapy (72% vs. 51%, P < 0.001). Five- and 10-year survival rates were higher at COG/HVC (70.6%, 67.7%) and COG/LVC (75.8%, 72.6%) than non-COG/LVC (59.5%, 54.4%, P < 0.05). Of 790 WT patients, 395 were treated at COG/HVC, 210 at COG/LVC, and 185 at non-COG/LVC. COG hospitals treated younger patients and lower staged tumors (P < 0.05). COG centers more frequently administered chemotherapy (88% vs. 59%, P < 0.001). Five- and 10-year survival rates were higher at COG/HVC (91.3%, 89.9%) and COG/LVC (96.7%, 94.7%) than non-COG/LVC (82.4%, 81.7%, P < 0.05). Multivariate analysis demonstrated WT patients treated at non-COG hospitals, but not NBL patients, had worse survival (HR 3.107, P = 0.01). CONCLUSION: Children treated at COG hospitals had higher overall use of chemotherapy. This translated into a significantly improved survival benefit for WT.

A comprehensive evaluation of outcomes for inflammatory breast cancer.

OBJECTIVE: Inflammatory breast cancer (IBC) remains the breast malignancy with the worst prognosis. We sought to determine the effects of race, socioeconomic status and treatment on outcomes for women with IBC. Study design The Florida cancer registry, inpatient and ambulatory data were queried for patients diagnosed from 1998 to 2002. RESULTS: A total of 935 patients with IBC were identified (1.5% of all breast cancers). Overall, 83.1% were Caucasian, 13.9% African American (AA), and 15.7% Hispanic. The mean age of diagnosis was 57 years old. AA patients presented at a younger age, with higher tumor grade, and were less likely to undergo surgical therapy than their Caucasian counterparts. Median survival time (MST) for the entire cohort was 32 months, while MST for AA patients was 20 months. Patients who received chemotherapy before surgery, surgery without chemotherapy, and surgery before chemotherapy demonstrated an independent, significantly improved outcome in comparison to patients who underwent chemotherapy without surgical extirpation. The administration of radiation therapy did not demonstrate an improvement in survival. By multivariate analysis, AA race (HR = 2.19) and failure to provide surgery (HR = 2.3) were independent predictors of worse prognosis. No effect of poverty or ethnicity on outcome was observed. CONCLUSIONS: IBC carries a poor prognosis for all patients with significantly worse outcomes for AA women. Multimodality therapy provided the best survival rates.

Impact of teaching facility status and high-volume centers on outcomes for lung cancer resection: an examination of 13,469 surgical patients.

BACKGROUND: Studies suggest that institutional case volume and teaching status significantly affect patient survival. We sought to compare outcomes of surgical resection for lung cancer at teaching facilities (TF) and at high-volume centers (HVC). METHODS: Patients undergoing lung cancer resection with curative intent were examined using a linked dataset from 1998 to 2002 between the Florida Cancer Data System and the Florida Agency for Health Care Administration. RESULTS: A total of 13,469 patients were analyzed and outcomes adjusted for comorbidities. Median survival time (MST) was superior for patients treated at TF versus nonteaching facilities (NTF) (47.1 versus 40.5 months, P < 0.001). Mortality rates at NTF were higher at 30 days (2.6% versus 1.1%, P < 0.001), 90 days (6.8% versus 3.8%, P < 0.001), and at 5 years (63.9% versus 59.2%, P = 0.005). Similarly, MST was superior in the cohort treated at HVC versus low-volume center (LVC) (45.1 versus 39.8 months, P < 0.001). Mortality was observed to be higher in LVC than HVC at 30 days (2.7% versus 1.6%, P < 0.001), 90 days (7.5% versus 4.0%, P < 0.001), and at 5 years (63.5% versus 59.3%, P = 0.002). Significant preoperative, independent predictors of survival include age, sex, smoking status, and the existence of certain comorbidities. Treatment at a TF or HVC were independent predictors of better outcome. Race, use of chemotherapy or radiation did not affect outcomes. CONCLUSION: Surgical treatment for lung cancer at TF or HVC results in significantly better short- and long-term patient outcomes.

Impact of hospital volume on surgical outcome for head and neck cancer.

The objective of this study was to define the prognostic significance of surgical center case volume on outcome for head and neck cancer (HNC). Florida cancer registry and inpatient hospital data were queried for HNC diagnosed from 1998 to 2002. Of the 11,160 operative cases of HNC identified, 35.3% were treated at low-volume centers (LVCs), 32.7% in intermediate-volume centers (IVC), and 32.1% at high-volume centers (HVC). A larger proportion of high-grade tumors (27.9%) and lesions over 30 mm (39.7%) were resected at HVC (p < 0.001). Median survival was 61 months for HVC, 52 months for IVC, and 47 months for LVC (p < 0.001). Univariate analysis demonstrated significantly improved survival at HVC for low-, medium-, and high-grade tumors, small tumors (<30 mm), and for cancers of the parotid, larynx, and pharynx. On multivariate analysis, corrected for patient comorbidities, treatment at a HVC was a significant independent predictor of improved survival (HR = 1.25, p = 0.001). We conclude that HNC patients treated at HVC have significantly better long-term survival and cure rates. Where possible, patients with large (>30 mm), high-grade or parotid, larynx, and pharynx tumors should be evaluated and offered care at a high-volume center.

Pediatric intestinal foregut and small bowel solid tumors: a review of 105 cases.

BACKGROUND: The outcomes of pediatric intestinal foregut and small bowel solid tumors have never been studied on a population scale. MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results database (1973-2005) was queried for all patients under 20 y of age. RESULTS: A total of 105 cases of pediatric intestinal foregut and small bowel solid tumors were identified. Tumors occurred in the esophagus (8.6%), stomach (61%), and small bowel (30.5%). The most common histologies include sarcoma (43.8%), which consisted mostly of gastrointestinal stromal tumors (GIST), carcinoma (41.0%), which consisted mostly of adenocarcinomas, and neuroendocrine tumors (NET) (10.5%). Most tumors were poorly differentiated and presented with advanced disease. The overall median survival time was 207 mo. Gastric solid tumors had significantly worse 5- and 10-y survival compared with their small bowel counterparts, though this difference disappeared in those who received surgical resection. Patients with carcinoma had significantly worse survival compared with those with sarcoma or NET, regardless of site and surgical intervention. Univariate analysis identified race, differentiation, stage, and surgery as significant predictors of survival. Multivariate analysis revealed that African American race, advanced stage of disease, carcinoma histology, and failure to undergo surgical extirpation were all independent predictors of worse outcome. In patients with carcinoma, failure to undergo radiotherapy was also a predictor of worse outcome. CONCLUSION: Surgery is associated with a significantly improved survival for pediatric patients with solid tumors of the intestinal foregut and small bowel. Radiotherapy appears to be an important adjuvant therapy for patients with carcinoma.

A population-based analysis of 1037 malignant ovarian tumors in the pediatric population.

BACKGROUND: Concerns of malignant potential have impacted the utilization of ovarian salvage for treatment of ovarian masses in children. METHODS: The Surveillance, Epidemiology, and End Results (SEER) registry was analyzed for all females < or =19 y diagnosed with an ovarian tumor between 1973 and 2005. RESULTS: Overall, 1037 pediatric patients with ovarian tumors were identified. Approximately 61.7% of tumors occurred in patients 15 to 19 y old. The age-adjusted incidence of all malignant pediatric ovarian tumors in those < or =9 y was 0.102 versus 1.072 per 100,000 in those aged 10 to 19 y. The majority of cases (57.4%) present at an early localized stage. The predominant pathology was germ cell tumors in all age groups (77.4%). Overall 5- and 10-y survival rates are 91.7% and 91.4%, respectively. By multivariate analysis, advanced disease stage (HR 3.17, P<0.001), lack of surgery (HR 4.49, P =0.039), and poorly differentiated tumors (HR 3.40, P=0.011) were associated with worse outcomes. CONCLUSIONS: Malignant ovarian tumors are rare, particularly in patients under 5 y of age. Furthermore, the most common histologies are of low metastatic potential and carry high cure rates. Thus, the surgeon should implement ovarian-sparing strategies on the affected ovary unless a malignancy is clearly suspected and conserve the contralateral ovary in all children.

Pediatric FAST and elevated liver transaminases: An effective screening tool in blunt abdominal trauma.

BACKGROUND: The current standard for the evaluation of children with blunt abdominal trauma (BAT) consists of physical examination, screening lab values, and computed tomography (CT) scan. We sought to determine if the focused assessment with sonography for trauma (FAST) combined with elevated liver transaminases (AST/ALT) could be used as a screening tool for intra-abdominal injury (IAI) in pediatric patients with BAT. METHODS: Registry data at a level 1 trauma center was retrospectively reviewed from 1991-2007. Data collected on BAT patients under the age of 16 y included demographics, injury mechanism, ISS, GCS, imaging studies, serum ALT and AST levels, and disposition. AST and ALT were considered positive if either one was >100 IU/L. RESULTS: Overall, 3171 cases were identified. A total of 1008 (31.8%) patients received CT scan, 1148 (36.2%) had FAST, and 497 (15.7%) patients received both. Of the 497 patients, 400 (87.1%) also had AST and ALT measured. FAST was 50% sensitive, 91% specific, with a positive predictive value (PPV) of 68%, negative predictive value (NPV) of 83%, and accuracy of 80%. Combining FAST with elevated AST or ALT resulted in a statistically significant increase in all measures (sensitivity 88%, specificity 98%, PPV 94%, NPV 96%, accuracy 96%). CONCLUSIONS: FAST combined with AST or ALT > 100 IU/L is an effective screening tool for IAI in children following BAT. Pediatric patients with a negative FAST and liver transaminases < 100 IU/L should be observed rather than subjected to the radiation risk of CT.