Long-term outcomes of patients with papillary thyroid cancer who did not undergo prophylactic central neck dissection.

AIMS: The role of prophylactic central neck dissection (CND) in the management of papillary thyroid carcinoma (PTC) is controversial. This study reports outcomes of an observational approach in PTC patients without clinical evidence of lymph node metastasis. MATERIALS AND METHODS: Patients with PTC who had surgery (without prophylactic CND) between January 2000 and December 2008 were included in this study. Recurrence-free survival (RFS) and disease-specific survival (DSS) were calculated using the Kaplan-Meier method. Cox regression was used in multivariable models. RESULTS: Out of 625 patients, 486 (77.8%) were female, 144 (23%) were aged 55 years or more, 73 (11.7%) had macroscopic extrathyroidal extension, and 79 (12.7%) had pT3 or pT4 disease. Samples were collected from 12 (1.9%) patients with lymph node metastasis in the perithyroidal tissue and 2 (0.3%) patients with lymph node metastasis in the lateral neck lymph tissue for frozen section examination. After a median follow-up of 104 months, the 10-year DSS and RFS rates were 99.7% and 90.2%, respectively. The 10-year lymph node recurrence rate in the central compartment was 2.7%. pT3/4 stage was an independent predictive factor for RFS (P < 0.001, hazard ratio 1.966, 95% confidence interval 1.446-2.673). CONCLUSION: The outcomes of patients with clinically negative lymph nodes in the central compartment were favorable without prophylactic CND.

Is There an Association Between Prophylactic Femur Stabilization and Survival in Patients with Metastatic Bone Disease?

BACKGROUND: The femur is the most common site of metastasis in the appendicular skeleton, and metastatic bone disease negatively influences quality of life. Orthopaedic surgeons are often faced with deciding whether to prophylactically stabilize an impending fracture, and it is unclear if prophylactic fixation increases the likelihood of survival. QUESTIONS/PURPOSES: Is prophylactic femur stabilization in patients with metastatic disease associated with different overall survival than fixation of a complete pathologic fracture? METHODS: We performed a retrospective, comparative study using the national Veterans Administration database. All patient records from September 30, 2010 to October 1, 2015 were queried. Only nonarthroplasty procedures were included. The final study sample included 950 patients (94% males); 362 (38%) received prophylactic stabilization of a femoral lesion, and 588 patients (62%) underwent fixation of a pathologic femur fracture. Mean followup duration was 2 years (range, 0-7 years). We created prophylactic stabilization and pathologic fracture fixation groups for comparison using Common Procedural Terminology and ICD-9 codes. The primary endpoint of the analysis was overall survival. Univariate survival was estimated using the Kaplan-Meier method; between-group differences were compared using the log-rank test. Covariate data were used to create a multivariate Cox proportional hazards model for survival to adjust for confounders in the two groups, including Gagne comorbidity score and cancer type. RESULTS: After adjusting for comorbidities and cancer type, we found that patients treated with prophylactic stabilization had a lower risk of death than did patients treated for pathologic femur fracture (hazard ratio = 0.75, 95% CI, 0.62-0.89; p = 0.002). CONCLUSIONS: In the national Veterans Administration database, we found greater overall survival between patients undergoing prophylactic stabilization of metastatic femoral lesions and those with fixation of complete pathologic fractures. We could not determine the cause of this association, and it is possible, if not likely, that patients treated for fracture had more aggressive disease causing the fracture than did those undergoing prophylactic stabilization. Currently, most orthopaedic surgeons who treat pathological fractures stabilize the fracture prophylactically when reasonable to do so. We may be improving survival in addition to preventing a pathological fracture; further study is needed to determine whether the association is cause-and-effect and whether additional efforts to identify and treat at-risk lesions improves patient outcomes. LEVEL OF EVIDENCE: Level III, therapeutic study.

Curative and Prophylactic Surgery of Young-onset Colorectal Cancer in Inherited Syndromes: A 15-Year Monocentric Retrospective Experience.

BACKGROUND/AIM: Although genoproteomic and clinicopathological knowledge on Lynch syndrome (LS) and familial adenomatous polyposis (FAP) has notably increased during the past two decades and even though surgery represents the mainstay of treatment for both conditions, as of 2019, the surgical choice in terms of timing and procedure still appears controversial in the absence of definitive guidelines. MATERIALS AND METHODS: Data were retrospectively analyzed of patients with colorectal cancer (CRC) surgically treated at our Institution between 1st January 2003 and 31st December 2018. Particular attention was given to patients with LS and FAP ≤45 years of age (young-onset CRC); for this category of patients, the surgical procedures performed were compared in terms of benefits and disadvantages. RESULTS: A total of 1,878 primary CRCs were submitted to major surgery; young-onset malignancies accounted for 3.8% of all CRCs. Thirteen young-onset inherited CRCs were surgically removed from 11 patients with LS and two with FAP. Segmental colectomy and restorative proctocolectomy were the procedures most frequently performed in young patients with LS and FAP, respectively. CONCLUSION: In the light of our retrospective results, we highlight the need for randomized controlled trials comparing the surgical options for LS- and FAP-related CRC developing in young patients. Defining the advantages and risks of each surgical option is of the utmost importance in order to improve prognosis of such patients and establish unanimous recommendations.

Prophylactic Cholecystectomy at Time of Surgery for Small Bowel Neuroendocrine Tumor Does Not Increase Postoperative Morbidity.

BACKGROUND: Prophylactic cholecystectomy at time of surgery for small bowel neuroendocrine tumor (SBNET) has been advocated, as these patients often go on to require somatostatin analogue therapy, which is known to increase risk of cholestasis and associated complications. Little is known regarding patterns of adoption of this practice or its associated morbidity. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2008-2014) was queried to identify patients who underwent SBNET resection. The risk differences of morbidity and mortality associated with performance of concurrent cholecystectomy were determined with multivariable adjustment for confounders. RESULTS: Among 1300 patients who underwent SBNET resection, 144 (11.1%) underwent concurrent cholecystectomy. Median age of patients undergoing cholecystectomy was 62 years [interquartile range (IQR) 52-69 years], and 75 were male. They more commonly had disseminated cancer (36.1 vs. 11.6%, p < 0.001) or SBNET located in duodenum (10.4 vs. 4.9%, p = 0.045) without difference in other baseline characteristics. Operative time was significantly longer in the cholecystectomy group (median 172 vs. 123 min, p < 0.001). Rate of postoperative morbidity was not significantly different between cholecystectomy and no-cholecystectomy groups (11.8 vs. 11.1%, p = 0.79). After adjustment for confounding, the risk difference of morbidity attributable to cholecystectomy was + 0.4% [95% confidence interval (CI) - 4.9 to + 5.6%]. Mortality within 30 days was not significantly different between cholecystectomy and no-cholecystectomy groups (1.4 vs. 0.6%, p = 0.29). CONCLUSIONS: Concurrent cholecystectomy at time of resection of SBNET is not associated with higher morbidity or mortality yet is performed in a minority of patients. Prospective study can identify which patients may derive benefit from this approach.

Prophylactic Preprocedure Platelet Transfusion Is Associated With Increased Risk of Thrombosis and Mortality.

OBJECTIVES: We evaluated thrombosis and mortality rates of hospitalized patients receiving prophylactic platelet transfusion prior to an invasive procedure. METHODS: Patient age and underlying medical condition(s), preprocedure and postprocedure platelet counts, type of procedure, number of platelet products transfused, and any complications were recorded on every prophylactic platelet given prior to an invasive procedure. RESULTS: A total of 376 prophylactic transfusion recipients were identified. Nineteen (5%) thrombotic events were identified and 60 (16%) deaths occurred within 30 days of the preprocedure platelet transfusion. Most deaths were due to infection, sepsis, or organ failure, and none were due to bleeding or thrombosis. CONCLUSIONS: Preprocedure platelet transfusion is associated with an increased risk of thrombosis and 30-day mortality. Whether these findings are due to higher incidences of comorbidities and confounding or to cause and effect is not determinable from these data. This study highlights an association between prophylactic platelet transfusion and thrombosis and poor outcome, including death.