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Teratoma , Neoplasias Testiculares , Humanos , Masculino , Teratoma/cirurgia , Neoplasias Testiculares/cirurgiaRESUMO
MicroRNAs (miRNAs) are emerging as highly sensitive and specific markers for testicular germ cell tumors (GCTs) across the spectrum of disease. However, their utility in specific clinical scenarios requires further study. Here, we review the current evidence for miRNAs as tumor markers for the evaluation of treatment response in patients undergoing chemotherapy for the treatment of advanced testicular GCT.
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Biomarcadores Tumorais , MicroRNAs , Neoplasias Embrionárias de Células Germinativas , Teratoma , Neoplasias Testiculares , Humanos , Neoplasias Testiculares/tratamento farmacológico , Neoplasias Testiculares/genética , Neoplasias Testiculares/patologia , Masculino , MicroRNAs/genética , Neoplasias Embrionárias de Células Germinativas/tratamento farmacológico , Neoplasias Embrionárias de Células Germinativas/genética , Neoplasias Embrionárias de Células Germinativas/patologia , Teratoma/tratamento farmacológico , Teratoma/genética , Teratoma/patologia , Biomarcadores Tumorais/genética , Biomarcadores Tumorais/análiseRESUMO
OBJECTIVE: To review the presentation and long-term oncologic outcomes of patients with regressed ("burnt out") primary testicular germ cell tumors (GCT). Certain testicular GCT can present with complete regression of the primary tumor. It is not well established if this is associated with more aggressive disease or worse oncologic outcomes. METHODS: We queried our prospectively maintained testicular cancer clinical database at a tertiary cancer center and identified patients without prior chemotherapy who had regressed primary GCT at radical orchiectomy from 1990 to 2023. All specimens were reviewed by a genitourinary pathologist at diagnosis. Long-term clinical outcomes were reported by Kaplan-Meier method. RESULTS: Fifty-six patients met inclusion criteria; at diagnosis, 17 had no evidence of extra-testicular disease and 39 had advanced (clinical stage [CS] II+) GCT. All CSx (no viable disease or germ cell neoplasia in situ at orchiectomy, and no evidence of advanced disease) and CS0 patients were managed with surveillance and had 5-year recurrence-free survival (RFS) of 88% (95% CI: 39%, 98%). All patients with CS II+ disease underwent primary treatment with surgery (n = 5) or first-line chemotherapy (n = 34). Two- and 5-year RFS for patients with CSII+ disease was 94% (95% CI: 78%, 98%) and 90% (95% CI: 72%, 97%), respectively. CONCLUSION: Patients with regressed primary testicular GCT often present with advanced disease, possibly due to lack of early clinical signs from the primary tumor. Our analysis shows excellent long-term oncologic outcomes similar to those reported in the literature for patients with viable primary testicular GCT.
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Currently, evaluation for hematuria is driven by the AUA/SUFU guidelines, and urine markers are not recommended for routine evaluation. Bladder cancer is a disease characterized by a high recurrence rate that is impacted by stage and grade. The use of urine markers within the guidelines is recommended for very specific indications such as atypical cystoscopic findings or atypical cytologic findings. Routine use is also not recommended for patients undergoing surveillance. Many protein, DNA and RNA, and molecular biomarkers have been examined as an adjunct to cystoscopy and cytology in the diagnosis and surveillance of bladder cancer, and several FDA-approved tumor markers are now available. The role of biomarkers remains an important area of further study to enhance the diagnosis and surveillance of bladder cancer. Beyond this, tumor markers may also play an important role in risk stratification and prediction of treatment response, allowing for personalized care for patients with bladder cancer. This article reviews the urine biomarkers currently available in the diagnosis and surveillance of bladder cancer.
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Carcinoma de Células de Transição , Neoplasias da Bexiga Urinária , Humanos , Neoplasias da Bexiga Urinária/diagnóstico , Neoplasias da Bexiga Urinária/terapia , Carcinoma de Células de Transição/diagnóstico , Cistoscopia , Biomarcadores Tumorais/análiseRESUMO
BACKGROUND: Management and palliation of pathologic fracture (PFx) secondary to metastatic prostate (mCaP) and renal cancer (mRCa) is hospital resource intensive. Using a national all-payer database, we assessed the burden of PFx secondary to mCaP and mRCa nationwide. Admission rates, mortality, surgical fixation rates, and risk factors for high-cost admissions for pathologic fractures were assessed METHODS: National Inpatient Sample was queried from 2013 to 2015 for mCaP and mRCa admissions. Hospitalization costs of PFx was assessed over time by cancer type. Hospitalization outcomes were stratified by cancer type. Multivariable logistic regression models were constructed to examine predictors of high-cost admission for PFx (>75th percentile). RESULTS: From 2013 to 2015, there were 21,466 and 6,334 admissions for mCaP and mRCa with bone metastasis, respectively. Proportion of admissions for PFx was greater in mRCa than mCaP (15.9% vs. 7.2%, P < 0.01). PFx secondary to mRCa was associated with longer length of stay, hospitalization cost, and greater rate of surgical fixation. Costs of admission for PFx increased by $4,005 dollars from 2013 to 2015 for mRCa (Pâ¯=â¯0.03), but did not increase for mCaP (Pâ¯=â¯0.5). On multivariable analysis, mRCa was associated with greater odds of PFx (OR:2.12, P < 0.01), and high-cost hospitalization for mRCa associated PFx (OR:1.37, Pâ¯=â¯0.02). CONCLUSIONS: PFx secondary to mRCa represents a significant health care burden. mRCa was associated with greater odds of PFx compared to mCaP, as well as greater inpatient morbidity and cost. Formalized guidelines on screening and management of bone lesions in mRCa may be needed to mitigate this under-recognized health care burden.
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Neoplasias Ósseas , Carcinoma de Células Renais , Fraturas Espontâneas , Neoplasias Renais , Neoplasias Ósseas/secundário , Carcinoma de Células Renais/complicações , Carcinoma de Células Renais/patologia , Fraturas Espontâneas/complicações , Hospitalização , Humanos , Neoplasias Renais/complicações , Neoplasias Renais/patologia , Tempo de Internação , Masculino , Neoplasias da Próstata/complicações , Neoplasias da Próstata/patologia , Melhoria de QualidadeRESUMO
INTRODUCTION: Cowden syndrome patients are at an increased risk of developing differentiated thyroid carcinoma (DTC). There are limited studies of thyroid cancer biology within this population. We aimed to describe the frequency and progression of DTC in this population. METHOD: We reviewed all patients with clinically or genetically confirmed Cowden syndrome treated at our institution between 1979 and 2017. Presentation, operative details, pathology, and adjuvant treatment for all thyroid diseases were analyzed. RESULTS: Forty-seven patients were identified. Thirty-seven received a clinical diagnosis while 10 tested positive on genetic testing for the PTEN gene. Average follow-up time was 10 years. Twenty-three patients underwent a total thyroidectomy. Nine patients were diagnosed with thyroid cancer, with a mean age of 28.5 years, 4 cases of the follicular variant of papillary thyroid cancer (PTC), 4 of PTC, and 1 of cystic PTC. One patient required an interval lateral neck dissection but no patients developed distant metastasis. Fourteen patients underwent thyroidectomy, 12 due to follicular adenoma, Hürthle cell adenoma, or multinodular goiter, 1 due to Graves' disease, and 1 who elected to undergo a prophylactic thyroidectomy. No mortality was associated with thyroid cancer in these patients. CONCLUSION: Patients with Cowden syndrome are at a significantly increased risk of developing DTC and have a younger age of onset. In this study, 20% of the patients with Cowden syndrome were diagnosed with DTC, but distant metastasis and overall mortality were absent. Clinical features were similar to those of sporadic DTC, proving that, apart from screening, Cowden syndrome-related DTC can be treated in similar fashion.
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STUDY DESIGN: Single-center retrospective review of pediatric patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis (AIS). OBJECTIVE: To determine what clinical and operative factors influence inflation-adjusted hospital costs of posterior spine fusion surgery for AIS. With rising healthcare costs and the advent of bundled payments, it is essential understand the predictors of costs for surgical procedures. We sought to determine the components of hospital costs for AIS posterior spine fusion surgery using standardized, inflation-adjusted, line-item costs for services and procedures. METHODS: The study population comprised 148 AIS patients who underwent spinal fusion surgery at a large tertiary care center between 2009 and 2016. Data on medical characteristics, curve type, curve magnitude, number of screws and the number of levels was collected through manual chart review of X-rays and medical records. Hospital costs from admission until discharge were retrieved from an institutional database that contained line-item details of all procedures and services billed during the hospital episode. Bottom-up microcosting valuation techniques were used to generate standardized inflation-adjusted estimates of costs and standard deviations in 2016 dollars. RESULTS: Mean cost of AIS surgery was $48,058 ± 9379. Physician fees averaged 15% of the total cost ($7045 ± 1732). Implant costs and surgical/anesthesia/surgeon's fees accounted for over 70% of the hospital costs. Mean number of screws was 16 ± 4.5, mean number of levels fused was 11.2 ± 2.2, and the mean implant density (screws per level fused) was 1.45 ± 0.35. On multivariate analysis, the number of screws per level fused, number of levels fused, curve magnitude and length of stay were all significantly associated with hospital costs (p < 0.01). CONCLUSIONS: Bundled payments for AIS surgery should include adjustments for number of levels fused and curve size. Areas for cost savings include further reduction in implant costs, shortening length of stay, and reducing intraoperative costs. LEVEL OF EVIDENCE: III.
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Custos e Análise de Custo/métodos , Planos de Pagamento por Serviço Prestado/economia , Custos de Cuidados de Saúde , Hospitalização/economia , Escoliose/economia , Escoliose/cirurgia , Fusão Vertebral/economia , Fusão Vertebral/métodos , Adolescente , Parafusos Ósseos/economia , Redução de Custos , Feminino , Humanos , Inflação , Tempo de Internação/economia , Masculino , Estudos RetrospectivosRESUMO
STUDY DESIGN: Retrospective review of prospective registries. OBJECTIVES: We hypothesized that patients with congenitally fused ribs who underwent thoracostomy upon implantation of rib-based distraction devices would achieve improved spine growth compared with those who did not undergo thoracostomy. SUMMARY OF BACKGROUND DATA: Patients with fused ribs may develop thoracic insufficiency syndrome. Treatment for severe early-onset spinal deformity with rib fusions often includes the placement of rib-based expansion devices with surgical division of the fused ribs (thoracostomy). The effect of thoracostomy on spinal growth has not been fully examined. METHODS: Two multicenter registries of primarily prospectively collected data were searched. Patients with fused ribs and implantation of a rib-based device were identified. A total of 151 patients with rib fusions treated with rib-based constructs and minimum two-year follow-up were included. Among those, 103 patients were treated with expansion thoracostomy at the time of implantation, whereas 48 patients received device implantation alone. We evaluated change in T1-T12 and T1-S1 height, coronal Cobb angle, kyphosis, and number of surgeries. Preoperative deformity was similar between the two groups. Only 19% of patient underwent final fusion, with similar numbers fused in each group. RESULTS: At latest follow-up, the expansion thoracostomy group had a greater total improvement in T1-S1 height (7.2 cm vs. 4.8 cm, p = .004). There was no difference between the two groups for change in spinal height at each lengthening procedure. Interestingly, thoracostomy patients also underwent more total surgeries (11.5 vs. 9.6, p = .031) and more lengthening procedures (8.3 vs. 6.6, p = .017) than the comparison group despite similar length of follow-up. CONCLUSIONS: Patients who underwent expansion thoracostomy at the time of rib expansion device implantation achieved greater improvement in T1-S1 height than those who underwent implantation of rib expansion device alone. Further work is needed to evaluate whether expansion thoracostomy impacts pulmonary function.
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Costelas , Escoliose , Toracostomia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Fixadores Internos , Masculino , Estudos Retrospectivos , Costelas/anormalidades , Costelas/cirurgia , Escoliose/patologia , Escoliose/cirurgia , Parede Torácica/anormalidades , Parede Torácica/cirurgia , Toracostomia/instrumentação , Toracostomia/métodos , Resultado do TratamentoRESUMO
STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To compare the use of spine-based versus rib-based implants for the treatment of early-onset scoliosis (EOS) in the setting of rib fusions. SUMMARY OF BACKGROUND DATA: Treatment for severe early-onset spinal deformity with rib fusions includes growing spine devices with proximal rib or spine anchors. The results of treatment, however, have not been compared between spine-based versus rib-based proximal anchors. METHODS: 169 patients with rib fusions treated with rib-based or spine-based constructs and minimum two-year follow-up were included. Sixteen patients were treated with proximal spine-based anchors and 153 with proximal rib-based devices (VEPTRs). Overall, 104 of the patients with rib-based fixation underwent thoracoplasty at the index surgery. We evaluated change in T1-T12 and T1-S1 height, coronal Cobb angle, kyphosis, and number of lengthening/revision surgeries. RESULTS: Kyphosis increased a mean of 7° in the rib-based group and decreased a mean of 20 degrees in the spine-based group (p = .002). Major Cobb angle decreased in both groups (p < .0001); however, the spine-based group had greater Cobb angle improvement (24 vs. 11 degrees, p = .04). From implant and lengthening of distraction devices, there was a mean 3.3-cm (22%) increase in T1-T12 height and a mean of 8.0 lengthenings in the rib-based group compared with a 5.7-cm increase and 6.3 lengthening surgeries in the spine-based group. Patients with rib-based constructs had a mean of 11 total procedures, whereas spine-based patients had a mean of 8. CONCLUSIONS: Patients underwent a mean of eight lengthening surgeries before final fusion or cessation of lengthening with a modest 2.3-cm increase in T1-T12 height. Compared with proximal rib anchors, proximal spine anchors controlled kyphosis and improved Cobb angle correction for early-onset scoliosis with rib fusions.
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Costelas/cirurgia , Escoliose/cirurgia , Fusão Vertebral/instrumentação , Coluna Vertebral/cirurgia , Âncoras de Sutura , Doenças Torácicas/cirurgia , Fatores Etários , Idade de Início , Pré-Escolar , Feminino , Humanos , Masculino , Estudos Prospectivos , Desenho de Prótese , Estudos Retrospectivos , Escoliose/complicações , Fusão Vertebral/métodos , Coluna Vertebral/anormalidades , Doenças Torácicas/complicações , Vértebras Torácicas/cirurgia , Toracoplastia/instrumentação , Toracoplastia/métodos , Resultado do TratamentoRESUMO
PURPOSE: Placement of pedicle screws can be performed using freehand/fluoroscopic technique or intraoperative computed tomography (CT)-guided navigation. We sought to compare screw malposition and return to operating room (OR) for pedicle screw malposition for screws placed with and without CT-guided navigation. METHODS: This study was a single-center retrospective comparative study. All patients younger than 18 years with minimum two-year follow-up who underwent pedicle screw instrumentation between 2009 and 2015 were included. Institutional review board approval was obtained and patient charts were reviewed for patient demographics and surgical outcomes. If available, incidental CTs following the index surgery were reviewed to assess screw position. RESULTS: A total of 217 patients underwent spinal instrumentation. Overall, 112 patients had pedicle screws placed using fluoroscopic guidance, whereas 105 patients had screws placed using low-dose intraoperative CT-guided navigation (O-arm; Medtronics). Of the total cohort, 107 (49.3%) patients had adolescent idiopathic scoliosis, and the remainder had neuromuscular, tumor, congenital, or other diagnoses. Patients in each group had a similar number of levels fused (fluoroscopic = 10.9 vs. CT navigation = 9.8, p = .06). There was no difference in total estimated blood loss (1,127 vs. 1,179 mL, p = .63) or in blood loss per level fused (133.7 vs. 146.6 mL, p = .47). Patients with screws placed using fluoroscopic guidance had a shorter total operative time (441 vs. 468 minutes, p = .04); however, there was no difference when controlling for number of levels fused (58.3 vs. 61.5 minutes/level, p = .63). Postoperative CTs were available in 51 patients representing 526 imaged screws, which showed a significantly higher rate of severely malpositioned (>4 mm) screws in the fluoroscopic group than the CT navigation group (3.3% vs. 1.0%, p = .027). There was a 3.6% rate of return to OR for pedicle screw malposition in the freehand/fluoroscopic group compared with 0% in the CT-guided navigation group (p = .048). Including patients with less than two-year follow-up (169 fluoroscopy, 220 CT guidance) also found higher rates of screw malposition (13.5% vs. 7.1%, p = .004), severe screw malposition (3.0% vs. 0.50%, p = .04), and return to OR due to screw malposition (2.4% vs. 0%, p = .02) in patients with screws placed using fluoroscopic guidance. CONCLUSION: Patients with pedicle screws placed with CT-guided navigation had a lower rate of severely malpositioned screws and unplanned returns to the OR. There was no significant difference in blood loss or operative time when controlling for number of levels fused. SIGNIFICANCE: In the era of health care "never-events," return to OR for screw malposition could certainly be deemed unacceptable. Use of intraoperative CT-guided navigation thus far eliminated return to OR for screw malposition in a complex cohort of pediatric spinal deformity patients, without measurable increase in operative time or blood loss.
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Fluoroscopia , Reoperação/estatística & dados numéricos , Fusão Vertebral , Cirurgia Assistida por Computador , Tomografia Computadorizada por Raios X , Adolescente , Criança , Feminino , Fluoroscopia/métodos , Fluoroscopia/estatística & dados numéricos , Humanos , Masculino , Parafusos Pediculares/efeitos adversos , Complicações Pós-Operatórias , Fusão Vertebral/efeitos adversos , Fusão Vertebral/instrumentação , Fusão Vertebral/métodos , Fusão Vertebral/estatística & dados numéricos , Coluna Vertebral/cirurgia , Cirurgia Assistida por Computador/métodos , Cirurgia Assistida por Computador/estatística & dados numéricos , Tomografia Computadorizada por Raios X/métodos , Tomografia Computadorizada por Raios X/estatística & dados numéricosRESUMO
BACKGROUND: Early-onset scoliosis (EOS) is a potentially life-threatening condition that requires early intervention to prevent severe deformity and pulmonary compromise. Observational studies have demonstrated that children receiving multiple procedures requiring general anesthesia are at a higher risk for adverse neurocognitive outcomes. We sought to characterize anesthetic exposure in EOS patients and to determine risk factors for increased exposure. We hypothesized that patients treated for EOS were at risk of receiving large amounts of cumulative anesthesia in childhood because of the need for early intervention to preserve pulmonary function. We sought to determine which factors impacted the amount of anesthesia patients received over the course of treatment. METHODS: Records of all EOS patients treated at a tertiary referral center from 2000 to 2014 were reviewed. Patients with a minimum two-year follow-up, under age 10 at diagnosis, were included. Anesthesia was recorded in three categories: 1) orthopedic surgeries; 2) nonorthopedic surgeries; and 3) imaging/associated procedures. Diagnoses included congenital, idiopathic, neuromuscular, and syndromic scoliosis. Treatment groups were: observation, bracing, Mehta casting, growing spine, or fusion. RESULTS: Mean cumulative anesthesia time was 1606 minutes. Patients with neuromuscular (mean 2132 minutes, p = .006) or congenital scoliosis (1875 minutes, p < .001) received more anesthesia than those with idiopathic scoliosis (754 minutes). Patients treated by fusion (2036 minutes, p < .001) or growing spine (2855 minutes, p < .001) received more anesthesia than those treated by bracing. CONCLUSIONS: Disease severity, non-idiopathic diagnoses, and longer length of follow-up were associated with increased anesthesia. Patients who presented at earlier ages, and those treated by Mehta casting, were more likely to exceed three hours of anesthesia prior to age 3. LEVEL OF EVIDENCE: III.