Prognostic factors effective on survival of patients with glioblastoma: Anadolu Medical Center experience.

AIM: The aim of this study is to offer survival following radiation therapy using intensity-modulated radiotherapy or volumetric arc therapy with temozolomide in patients with glioblastoma. MATERIALS AND METHODS: Ninety-two previously treated patients with high-grade glioma (World Health Organization [WHO] grade IV) were studied in Anadolu Medical Center, Department of Radiation Oncology, between January 2006 and July 2015. The diagnosis was established by pathology in all cases. The median age was 59 years (range, 19-86 years). The median tumor diameter was 45 mm, and the rate of the multicentric tumors was 16.3%. The location of the tumor was temporal in 33.7%, parietal in 14.1%, frontal in 23.9%, occipital in 9.8%, and others in 18.5%. The gross total and subtotal resection were performed in 60.9% of the patients, partial resection in 26.1%, and only stereotactic biopsy in 13.0% of the patients. RESULTS: The median overall survival (OS) was 33.01 ± 4.76 months (95% confidence interval 25.64-40.38 months). 1, 2, and 5 years OS was 74.3%, 44.3%, and 31.8%, respectively. The median progression-free survival (PFS) was 27.36 ± 3.87 months (95% confidence interval 19.82-34.89 months). 1, 2, and 5 years PFS was 62.7%, 32.6%, and 27.2%, respectively. On univariate analysis, gender, extent of surgery, tumor size, Karnofsky performance status, and tumor suppressor gene (P53) were significant predictors of OS and PFS. On multivariate analysis, gender (PFS: P = 0.006, OS: P = 0.003), extent of surgery (PFS: P = 0.004, OS: P = 0.012), P53 (PFS: P = 0.003, OS: P = 0.021), and size of tumor (PFS: P = 0.005, OS: 0.012) remained significantly associated with PFS and OS. There is no statistically significant in OS and PFS between female and male (OS: log-rank: 0.79 P = 0.375, PFS: log-rank: 0.54 P = 0.465). PSF and OS were not significantly significant with total/near total resection compared with partial resection (PSF: P = 0.46 log-rank = 0.54, OS: P = 0.340 log-rank = 0.91). Patients with P53 <50% value and patients with P53 >50% value were compared and results were not found statistically significant (PSF: P = 0.917 log-rank = 0.01, OS: P = 0.892 log-rank = 0.02). For patients with tumor size <0 mm, small tumor size did not improve the PSF and OS (PSF: P = 0.291 log-rank = 1.11, OS: P = 0.288 log-rank = 1.13). CONCLUSION: Ninety-two previously treated patients with high-grade glioma (WHO Grade IV) were evaluated with multivariate analysis. Gender, extent of surgery, P53, and tumor size were found as prognostic factors affecting on survival.

The effect of external beam irradiation timing on skin graft survival.

BACKGROUND: The purpose of this study was to evaluate skin graft integrity after external beam irradiation in a rat model. METHODS: Forty-eight male Wistar rats were randomly assigned to 8 groups (A, B, C, D, A(c), B(c), C(c) and D(c)). A rectangular full-thickness skin graft was raised and reapplied to its original bed on the dorsum of each rat. Groups A(c), B(c), C(c) and D(c) were the control groups and were not given postoperative irradiation. After grafting, 25 Gy unfractioned cobalt(60) irradiation was administered to groups A, B, C and D on postoperative days 10, 20, 30 and 40, respectively. Histological samples were obtained 8 weeks after grafting. Dermal and epidermal thickness were measured by the KS-400 image analysis program. RESULTS: The difference in the epidermal and/or dermal thickness between the irradiated groups was not found to be significant. Furthermore, when histological features and the image analysis of the irradiated groups were compared with each other, there were no significant differences between the groups. CONCLUSIONS: Although we are aware that experimental results may not directly translate to the clinical setting, the present study indicates that external radiotherapy can be performed to skin-grafted areas as early as 10 days postoperatively.

Is adjuvant therapy necessary for peritoneal cytology-positive surgical-pathologic Stage I endometrial cancer? Preliminary results.

OBJECTIVE: To compare the clinical and laboratory findings between adjuvant therapy performed and not performed on peritoneal cytology-positive patients with cytology-negative cases of surgical-pathologic Stage I endometrial cancer. METHODS: Twelve peritoneal cytology-positive and 12 negative surgical-pathologic Stage I endometrial cancer cases were used in the study. Adjuvant radiotherapy was performed for six cytology-positive patients (group I); no adjuvant therapy was performed for six cytology-positive (group II) and 12 cytology-negative patients (control group). Pelvic examination, vaginal cytology, serum CA125 levels and routine blood tests were checked at two-month intervals for two years and at six-month intervals for the third year. Abdominopelvic computerized tomography was planned annually. RESULTS: There was no statistically significant difference among the three groups and no recurrence in any group. CONCLUSION: We do not recommend adjuvant therapy for cytology-positive patients if the tumor is confined to the uterus.

Does off-pump coronary artery bypass surgery reduce mortality in high risk patients?

BACKGROUND: The aim of this retrospective study was to compare outcome in two groups of patients who were classified according to their risk groups and underwent coronary revascularization with or without cardiopulmonary bypass. MATERIAL AND METHODS: Between January 1996 and July 2000, 480 cases that underwent coronary artery bypass surgery (CABG) were included in a retrospective nonrandomized manner for study. Group 1 included 210 patients who were revascularized using off-pump techniques. Octopus 2 and 3 (Medtronic, Inc., Minneapolis, MN) were used for tissue stabilization. Group 2 included 270 cases who underwent CABG using CPB. Emergency cases, combined operations, reoperations, and patients in cardiogenic shock were excluded. Demographic variables were comparable between two the groups. Using the Allegheny Clinic Risk Scoring Scale [Magovern 1996], patients in both groups were scored as low, moderate, and high risk. In Group 1, 37 % of patients consisted of high risk patients while Group 2 had 14% (p < 0.05). Student's t-test and chi-square test were used for statistical analysis and alfa < 0.05 was considered significant. RESULTS: Mortality was 1.4% in Group 1 and 1.5% in Group 2 (p = ns). Mean anastomosis per patient was 2.6 +/- 0.6 in Group 1 and 3.2 +/- 0.5 in Group 2 (p < 0.05). Patients in Group 1 needed less blood transfusions and less inotropic support postoperatively (p < 0.05). There were also fewer minor neurological events (p < 0.05) and pulmonary complications (Type 2) in Group 1. Atrial fibrillation rate, infection, and major neurological deficit (Type 1) were similar in both groups. Mortality was less among Group 1 high risk patients (3.9 %) in comparison to Group 2 high risk patients (7.9 %), but this did not reach statistical significance. CONCLUSIONS: In low or moderate risk patients, CABG can be performed safely with or without CPB. In high risk patients with several comorbidities, off-pump CABG seems to be a safe and efficient method that can improve outcome.

Analyses of 98 seminoma cases: a review article.

98 Patients with seminoma were treated at Clinic of Radiation Oncology of Gülhane Military Medicine Academy between the years 1974-1995. All cases were undergone orchiectomy. The median age of the patients whom were staged respectively 76%, 17%, 7% according to AJCC system, stage I, stage II and stage III was 28 (20-58). While 87 patients were undergone only radiotherapy, 11 patients with advanced stage had taken chemotherapy with radiotherapy. In 52 months of median follow up duration, 5 year disease free survival rates were 98.6%, 93.3%, 25% and 94.5% for stage I, stage II, stage III and all stages respectively. As a result, we can propose that the seminoma is a disease with good results in oncology. In our view detailed staging and new treatment approaches in advanced disease will achieve better results in the future.

Split-course radiotherapy with or without concurrent or sequential chemotherapy in non-small cell lung cancer.

In our department we designed a three-armed study to compare the effects of sequential and concurrent chemoradiotherapy in locally advanced non-small cell lung cancer. Each treatment arm consisted of 15 patients with histologically confirmed stage III non-small cell lung cancer. In group 1, the main treatment approach was split-course radiotherapy alone. In group 2, 6 mg/m2 of cisplatin was applied daily and concurrently with split-course radiotherapy. In group 3, two cycles of etoposide, ifosfamide, and cisplatin chemotherapy, which ended three weeks before split-course radiotherapy, was applied. Overall response rates were 40%, 66%, and 53% in groups 1, 2, and 3, respectively. Median survival was 10, 11, and 10 months for groups 1, 2, and 3 respectively. Results are discussed in the light of the literature.

The use of the 5-HT3-receptor antagonist ondansetron for the treatment of postcardiotomy delirium.

OBJECTIVE: To evaluate the effect of the 5-HT3-receptor antagonist ondansetron in patients with postcardiotomy delirium. DESIGN: Prospective study. SETTING: University hospital. PARTICIPANTS: Thirty-five patients who had undergone coronary artery bypass graft surgery. INTERVENTIONS: Thirty-five patients, 23 men and 12 women, who developed delirium in the intensive care unit after coronary artery bypass graft surgery were included. Mean patient age was 51.3 years (range, 36 to 79 years). A mental status scoring scale was developed, and patients were scored 0 to 4 according to their delirium status after confirming that there were no correctable metabolic abnormalities as an underlying cause for delirium. Normal behavior was scored as 0, and severe verbal and physical agitation was scored as 4. Patients received a single dose of ondansetron, 8 mg, intravenously and were reevaluated 10 minutes later. MEASUREMENTS AND MAIN RESULTS: Before the treatment, 7 patients had a score of 2 (20%); 10 patients (28.6%), 3; and 18 patients (51.4%), 4. After the treatment, 28 patients (80%) dropped their score to 0; 6 patients (17.1%) dropped to a score of 1, and 1 patient (2.9%) remained at a score of 4. The mean score dropped from 3.20 + 1.01 to 0.29 + 0.75 after treatment. Wilcoxon signed ranks test was used for statistical evaluation, and the fall in delirium score after ondansetron treatment was found to be statistically significant (p < 0.001). CONCLUSIONS: The use of ondansetron was effective and safe and without important side effects. This positive effect of the 5-HT3-receptor antagonist ondansetron led to speculation that impaired serotonin metabolism may play a role in postcardiotomy delirium.

Off-pump coronary artery bypass grafting with use of the octopus 2 stabilization system.

BACKGROUND: The treatment of coronary artery disease has evolved rapidly over the last two decades. The gold standard of surgical revascularization, the on-pump coronary artery bypass graft, has been challenged by the development of percutaneous transluminal coronary angioplasty. Our experience with the alternative of the off-pump ("beating heart") coronary artery bypass (OPCAB) technique during a period of 18 months suggests that OPCAB avoids the complications of cardiopulmonary bypass and offers patients the benefit of long-term graft patency that greatly exceeds that of current endovascular technologies. METHODS: The early results of 126 OPCAB procedures performed through a medial sternotomy incision during a period of 18 months were evaluated. There were 80 male and 46 female patients, with a mean age of 69 +/- 4.3 years. Emergency cases and reoperations were not included. A total of 268 anastomoses were performed, with a mean number of 2.12 anastomoses per patient. Conduits used, with their percentage of use, were: left internal thoracic artery (LITA) (100%), right internal thoracic artery (11.1%), greater saphenous vein (84%), and radial artery (31%). In 72% of the cases, off-pump surgery was chosen because of patient risk factors such as atherosclerotic aortic disease, previous cerebrovascular accident or carotid artery disease, renal dysfunction, malignancy or poor left ventricular function. RESULTS: There was no operative mortality. One-month postoperative mortality was three patients (2.3%). Two died because of mesenteric ischemia, and the other death was due to cardiac failure. Seventy-one patients had a control angiogram before discharge. The patency of LITA anastomosis was 100% while overall patency rate was 95%. In 43 patients for whom an angiogram could not be performed, a Thallum 201 stress test was performed three months postoperatively. Thirty-eight patients had a normal test while five patients showed signs of ischemia. These patients had a control angiogram: in four patients anastomoses were patent, but in one patient there was a severe narrowing of a venous anastomosis to the distal right coronary artery (RCA) which was corrected with angioplasty. In the whole series eight patients (6.3%) refused to have any control examination. CONCLUSIONS: Our early results suggest that off-pump CABG with Octopus 2 (Medtronic, Inc., Minneapolis, MN) can be a good alternative in high risk patients who need multiple vessel revascularization.

Comparison of granulocyte-colony, stimulating factor and granulocyte macrophage-colony stimulating factor in the treatment of chemotherapy extravasation ulcers.

The results of perilesional granulocyte macrophage-colony stimulating factor and granulocyte-colony stimulating factor application in a patient with chemotherapy extravasation ulcers are reported. A 64-year-old patient with recurrent ovarian carcinoma was admitted to our department in February 1999. In June 1998, six cycles of chemotherapy were applied to the patient after surgery. At the first cycle, two ulcers appeared on both lower arms related to doxorubicin extravasation despite all interventions. When the patient was admitted to in our department, we observed an ulcer on the distal part of the right lower arm with a dimension of 1.5x2 cm and another on the proximal portion of the left lower arm with a dimension of 2.5x3 cm. Of those ulcers, the bigger and deeper one on the left was treated with weekly 400 mcg granulocyte macrophage-colony stimulating factor subcutaneously for three weeks. The lesion completely disappeared in the fourth week. The other ulcer that was left for control on the right arm was treated with weekly 48 M.U. granulocyte-colony stimulating factor for four weeks. This ulcer did not reduce in size. As a result granulocyte-colony stimulating factor did not affect the healing of chemotherapy extravasation ulcers, as did granulocyte macrophage-stimulating factor.

The use of a stentless porcine bioprosthesis to repair an ascending aortic aneurysm in combination with aortic valve regurgitation.

Over the years, many surgical methods have evolved for the treatment of ascending aortic aneurysm in combination with aortic valve regurgitation; however, precise guidelines for optimal surgical techniques for varying presentations have not been defined. We describe the use of a stentless porcine bioprosthesis (Medtronic Freestyle) in a patient with an ascending aortic aneurysm and aortic regurgitation. We used the complete root replacement method, and anastomosed a Dacron graft (Hemashield) between the bioprosthetic valve and the native aorta to replace the distal part of the aneurysm.

Fifteen cases of male breast carcinoma treated between 1980 and 1995.

Male breast carcinoma is a rare malignity. In Turkey, as in other countries, there are insufficient studies on male breast cancer. In the Radiation Oncology Department, Gülhane Military Medical Academy, we treated 15 cases of male breast cancer versus 1393 female breast cancer. Two of the cases had stage I, nine had stage II, and the remaining four had stage III disease. Median age was 52. All patients had definitive external beam radiation therapy with daily 200 cGy fractionation, following surgery. Median follow-up was 227 months. Five year survival rate was found to be 60% for all stages. Our evaluations of the pathologic findings, management, and treatment outcome were compared with literature.

A no-touch technique for calcified ascending aorta during coronary artery surgery.

Despite improvements in cardiovascular surgery techniques over the years, the incidence of neurologic complications has not declined, and stroke remains a possible (and devastating) sequela to coronary artery surgery. In this report, we describe a moderate hypothermic fibrillatory arrest technique that avoids cross-clamping or otherwise touching the aorta; use of the internal thoracic arteries and the right gastroepiploic artery provides optimum revascularization and minimizes the risk of cerebrovascular accident. Over a 1-year period, we used the technique in 21 patients who had heavy calcifications of the ascending aorta. No hemodynamic problems, lower-limb ischemia, or neurologic complications were seen. Only 1 patient underwent reoperation (for bleeding), and another--whose revascularization was incomplete--had a high postoperative level of myocardial creatine kinase MB isoenzyme and a new Q wave, but no hemodynamic deterioration. This technique seems reasonable, because it appears to provide good myocardial protection and to reduce neurologic complications, without comprising myocardial revascularization.