Prolonged overall survival following metastasectomy in stage IV melanoma.

BACKGROUND/OBJECTIVES: Current literature supports mixed conclusions regarding the outcomes of metastasectomy in Stage IV melanoma. The objective of this national study was to determine the associations of non-primary site surgery with overall survival (OS) in Stage IV melanoma. METHODS: The National Cancer Database (NCDB) was queried for all Stage IV melanoma cases diagnosed from 2004 to 2015. Cases missing treatment/staging data or undergoing palliative treatment were excluded (remaining n = 14 034). Patients were separated into 'metastasectomy' (n = 4214, 30.0%) and 'non-metastasectomy' (n = 9820, 70.0%) cohorts. Survival outcomes were analysed using Kaplan-Meier and Cox proportional hazards regressions. RESULTS: On univariate analysis, patients with Stage IV melanoma undergoing metastasectomy (median survival: 15.67 month) had greater overall survival compared with those not receiving non-primary surgery (median survival: 7.13 month; 5-year OS 13.2% vs. 5.6%, P < 0.001). M1a patients that underwent non-primary metastasectomy (median survival: 46.36 month) showed greater survival than those that did not (median survival: 15.31 month; P < 0.001). Metastasectomy was undertaken more frequently for cutaneous (M1a) metastasis compared with non-M1a metastasis (34.6% vs. 28.4%, P < 0.001). Of those receiving metastasectomy, 20.3% also received primary site resection, 33.6% radiation, 26.5% chemotherapy and 31.5% immunotherapy. Controlling for covariates on Cox proportional hazard analysis, all metastasectomy patients demonstrated longer survival [Hazard Ratio = 0.519, P < 0.001; CI 95% (0.495-0.545)] as well as when analysing solely M1a metastasectomy patients [Hazard Ratio = 0.546, P < 0.001; CI 95% (0.456-0.653)], lung (M1b) metastasectomy patients [Hazard Ratio = 0.389, P < 0.001; CI 95% (0.328-0.462)] and visceral (M1c) metastasectomy patients [Hazard Ratio = 0.474, P < 0.001; CI 95% (0.434-0.517)]. CONCLUSION: Metastasectomy for Stage IV melanoma is independently associated with improved OS in metastatic cases involving the skin, lung and visceral organs.

Non-linear Poincaré analysis of respiratory efforts in sleep apnea.

OBJECTIVES: Obstructive sleep apnea (OSA) is a risk factor for hypertension, has effects on cardiovascular system and increases the sympathetic activity. The aim of the study was to evaluate the effectiveness of the non-linear Poincaré plot analysis to predict OSA based on polysomnography (PSG). METHODS: The database of this study was collected by the sleep laboratory at the Philipps University in Marburg, Germany. It includes 24 PSG of men and women between 27-63 years old with obstructive and mixed sleep apnea. The start and end of apnea events in PSGs were marked. The Poincaré plots of pre-apneic phase including 4-1 minutes before apnea were evaluated. Wilcoxon test was used for statistical analysis. RESULTS: Poincaré analysis showed that the dynamics of chest and respiratory efforts changed two minutes before the apnea and SD1/SD2 ratios of these parameters significantly increased in the pre-apneic phase (p≤0.01). The SD1/SD2 ratio of nasal airflow did not show significant difference even in episodes close to apnea. CONCLUSIONS: Our results suggest that Poincaré plot parameters of PSG have the potential to be considered predictors of apnea with the ability to show the dynamic of changes, which could lead to pre-diagnosis or prediction of apnea about 2-3 minutes before its occurrence (Tab. 2, Fig. 4, Ref. 23).

Renal Excretion of Contrast on CT Myelography: A Specific Marker of CSF Leak.

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate the sensitivity and specificity of renal/ureteric opacification on postmyelographic CT as a sign of CSF leak. MATERIALS AND METHODS: We performed a retrospective review of postmyelographic CT scans from 49 consecutive patients seen between January 2008 and August 2018 with imaging and/or clinical findings related to intracranial hypotension. Each scan was evaluated by both a neuroradiology fellow and a board-certified neuroradiologist for the presence of contrast in the renal excretory system. A similar assessment was also performed on 90 consecutive control subjects who underwent CT myelography for alternative indications. RESULTS: Among the 49 patients with suspected CSF leak, 21 (43%) had an overt CSF leak on postmyelographic CT (group 1) and 28 (57%) did not (group 2). Overall, renal contrast was identified in 7/49 patients (14.3%): 5 (24%) patients in group 1, and 2 (7%) patients in group 2. Renal contrast was not seen in any of the 90 controls on postmyelographic CT. CONCLUSIONS: Renal contrast was exclusively seen in patients with a clinically or radiographically suspected CSF leak. Given its 100% specificity, identification of this finding should prompt a second look for subtle myelographic contrast extravasation or an underlying CSF-venous fistula. Our results suggest that this sign may be considered an additional diagnostic criterion for CSF leak in the absence of an identifiable leak.