RESUMO
OBJECTIVES: Plavix (clopidogrel) is a potent antiplatelet agent used to prevent thrombosis in a variety of clinical settings. The perioperative management of thoracic surgery patients who are on clopidogrel at the time of surgery is not well defined. We conducted this review to examine the perioperative management and outcomes of patients undergoing general thoracic surgical procedures. METHODS: From January 2005 to January 2010, 165 patients on clopidogrel underwent 182 operative procedures. Three management strategies were identified: Group I: clopidogrel continued through surgery (n = 17), Group II: clopidogrel discontinued with a bridging agent (n = 44) and Group III clopidogrel discontinued without a bridging agent (n = 121). Propensity score matched cohorts (17 clopidogrel continued; 34 clopidogrel discontinued) were constructed based on age, clopidogrel indication, American Society of Anesthesiology status, and procedure and used to compare the impact of clopidogrel management on postoperative bleeding and cardiovascular morbidity. RESULTS: Unmatched analysis revealed a significantly higher rate of transfusion in the group of patients who continued on clopidogrel throughout the perioperative period, compared with patients who had clopidogrel discontinued. Although there were more cardiovascular events in Groups II and III, there were no significant differences between groups in postoperative mortality, myocardial infarction, stroke, or reoperation for bleeding. In propensity matched patients only the rate of postoperative transfusions was significantly higher in patients continued on clopidogrel compared with patients whose clopidogrel was discontinued (35.3 vs. 2.9%), p < 0.004. CONCLUSIONS: In selected patients, some thoracic surgical procedures can be performed safely on clopidogrel but are associated with higher rates of postoperative transfusion.
Assuntos
Substituição de Medicamentos , Inibidores da Agregação Plaquetária/administração & dosagem , Procedimentos Cirúrgicos Torácicos , Ticlopidina/análogos & derivados , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/terapia , Clopidogrel , Esquema de Medicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/efeitos adversos , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/terapia , Pontuação de Propensão , Reoperação , Estudos Retrospectivos , Fatores de Risco , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Ticlopidina/administração & dosagem , Ticlopidina/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: The optimal management of stage II endometrial cancer remains uncertain. We examined the role of radical hysterectomy and adjuvant radiotherapy for stage II endometrial cancer. STUDY DESIGN: The Surveillance, Epidemiology, and End Results database was used to identify 1577 women with stage II endometrioid type endometrial adenocarcinoma who underwent surgical staging. RESULTS: The cohort included 1198 women who underwent simple hysterectomy (76%) and 379 who underwent radical hysterectomy (24%). Radical hysterectomy had no effect on survival (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.61-1.23). Patients who did not receive radiation were 48% (HR, 1.48; 95% CI, 1.14-1.93) more likely to die than those who underwent adjuvant radiotherapy. The survival benefit from radiation was most pronounced in women who underwent radical hysterectomy. CONCLUSION: Adjuvant radiation improves survival. Although the routine performance of radical hysterectomy does not appear to be justified, patients with high-risk stage II tumors appear to benefit from combination therapy with radical hysterectomy and radiotherapy.
Assuntos
Neoplasias do Endométrio/radioterapia , Neoplasias do Endométrio/cirurgia , Histerectomia , Neoplasias Uterinas/radioterapia , Neoplasias Uterinas/cirurgia , Adulto , Idoso , Neoplasias do Endométrio/patologia , Feminino , Humanos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Radioterapia Adjuvante , Neoplasias Uterinas/patologiaRESUMO
BACKGROUND: Tracheostomies are typically provided to wean patients off the ventilator. However, in many circumstances tracheostomies are placed in patients who are at the end of their life with little hope of meaningful recovery. Palliative care teams decrease utilization of aggressive medical interventions in patients who are at the end of life. OBJECTIVE: The study objective was to determine the impact of a palliative care team on tracheostomy utilization in a community hospital setting. METHODS: The study was a four-year retrospective analysis of adult patients undergoing elective tracheostomy two years before and after the establishment of a palliative care program. The study in an ethnically diverse community hospital included patients older than 18 years old, with patients undergoing a tracheostomy due to trauma excluded. Before and after comparisons were made of demographics, in-hospital mortality, length of stay, and discharge status of patients undergoing tracheostomy. RESULTS: Seven hundred ninety patients undergoing tracheostomy were identified (n = 406, n = 384 before and after September 10, 2010, respectively). Patients were ethnically diverse (Caucasian 43%, Asian 23%, African American 11%, Hispanic 7%). The number of hospital admissions slightly increased during these two time periods (n = 58,926; n = 60,662, respectively). There were no statistical differences in age (73 versus 72, p = 0.827); gender (n = 218 [54%] versus n = 217 [57%] male, p = 0.426); or race (n = 187 [46%] versus n = 150 [39%] Caucasian, p = 0.073) in the two time periods. Patients who underwent tracheostomy after a palliative care service was established had less incidence of comorbid disease (Charlson Comorbidity Index score [CCIS]: 2 versus 3, p = 0.025); lower inpatient mortality (n = 107 [28%] versus n = 148 [37%], p = 0.009]); greater discharge to home or rehabilitation (n = 262 [68%] versus n = 249 [62%], p = 0.01); and lower rates of palliative weaning from mechanical ventilation (n = 61[16%] versus n = 113 [28%], p < 0.001). CONCLUSIONS: In an ethnically diverse community hospital, the institution of a palliative care program appears to have improved patient selection for tracheostomy with lower rates of inpatient mortality, improved rates of home discharge, and lower rates of palliative weaning from mechanical ventilation.
Assuntos
Cuidados Paliativos/métodos , Preferência do Paciente/estatística & dados numéricos , Respiração Artificial/tendências , Assistência Terminal/tendências , Traqueostomia/tendências , Desmame do Respirador/tendências , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar/tendências , Hospitais Comunitários/estatística & dados numéricos , Humanos , Revisão da Utilização de Seguros , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , New York , Cuidados Paliativos/tendências , Alta do Paciente/tendências , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Distribuição por Sexo , Assistência Terminal/métodos , Desmame do Respirador/métodosRESUMO
Fetal adenocarcinoma is a rare lung malignancy associated with improved outcomes compared to more common adenocarcinoma variants. We describe a case of a 31-year-old woman who presented with right-sided chest pain, and was subsequently diagnosed with an intermediate-grade stage IV fetal adenocarcinoma with chest wall invasion. She was treated with surgical resection and adjuvant radiation.
Assuntos
Adenocarcinoma/diagnóstico , Neoplasias Pulmonares/diagnóstico , Neoplasias Embrionárias de Células Germinativas/diagnóstico , Pneumonectomia/métodos , Adenocarcinoma/cirurgia , Adenocarcinoma de Pulmão , Adulto , Biópsia , Diagnóstico Diferencial , Feminino , Humanos , Neoplasias Pulmonares/cirurgia , Imageamento por Ressonância Magnética , Neoplasias Embrionárias de Células Germinativas/cirurgia , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: In clinical stage IIIA non-small cell lung cancer, the role of surgical resection, particularly pneumonectomy, after induction therapy remains controversial. Our objective was to determine factors predictive of survival after postinduction surgical resection. METHODS: We retrospectively reviewed a prospectively collected database of 136 patients who underwent surgical resection after induction chemotherapy (n = 119) or chemoradiation (n = 17) from June 1990 to January 2010. RESULTS: One hundred five lobectomies or bilobectomies and 31 pneumonectomies were performed. There was 1 perioperative death (pneumonectomy). Seventy-one patients had downstaging to N0 or N1 nodal status (52%). There were 2 complete pathologic responses. Median follow-up was 42 months (range, 0.69-136 months). Overall 5-year survival for entire cohort was 33% (36% lobectomy, 22% pneumonectomy, P = .001). Patients with pathologic downstaging to pN0 or pN1 had improved 5-year survival (45% vs 20%, P = .003). For patients with pN0 or pN1 disease, survival after lobectomy was better than after pneumonectomy (48% vs 27%, P = .011). In patients with residual N2 disease, there was no statistically significant survival difference between lobectomy and pneumonectomy (5-year survival, 21% vs 19%; P = .136). Multivariate analysis showed as independent predictors of survival age (hazard ratio, 1.05; P = .002), extent of resection (hazard ratio, 2.01; P = .026), and presence of residual pN2 (hazard ratio, 1.60; P = .047). CONCLUSIONS: After induction therapy for patients with clinical stage IIIA disease, both pneumonectomy and lobectomy can be safely performed. Although survival after lobectomy is better, long-term survival can be accomplished after pneumonectomy for appropriately selected patients. Nodal downstaging is important determinant of survival, particularly after lobectomy.
Assuntos
Carcinoma Pulmonar de Células não Pequenas/terapia , Neoplasias Pulmonares/terapia , Pneumonectomia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Carcinoma Pulmonar de Células não Pequenas/patologia , Quimioterapia Adjuvante , Distribuição de Qui-Quadrado , Intervalo Livre de Doença , Feminino , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Linfonodos/patologia , Masculino , Mediastinoscopia , Pessoa de Meia-Idade , Terapia Neoadjuvante , Estadiamento de Neoplasias , Pneumonectomia/efeitos adversos , Pneumonectomia/mortalidade , Modelos de Riscos Proporcionais , Radioterapia Adjuvante , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
Adjuvant radiotherapy after complete resection of localized, invasive thymic epithelial tumors is considered by many to be the standard of care, despite little supporting literature. We hypothesized that individual studies may lack statistical power to demonstrate a reduction in recurrence with this approach, but meta-analysis of published data may allow for more adequate statistical evaluation. Analysis of data from 592 patients with completely resected stage II or III thymic epithelial tumors, however, revealed no statistically significant reduction in recurrence after adjuvant radiotherapy (odds ratio 1.05; 95% confidence interval: 0.63 to 1.75; p = 0.840). Additionally, the majority of publications suggest that the most common sites of recurrence are the lung, pleura, and diaphragm, even when incompletely resected patients are included.
Assuntos
Neoplasias do Timo/radioterapia , Carcinoma/patologia , Carcinoma/radioterapia , Carcinoma/cirurgia , Ensaios Clínicos como Assunto , Terapia Combinada , Humanos , Invasividade Neoplásica , Estadiamento de Neoplasias , Radioterapia Adjuvante/métodos , Prevenção Secundária , Neoplasias do Timo/patologia , Neoplasias do Timo/cirurgiaRESUMO
BACKGROUND: Black women with endometrial cancer have been more likely to die than white patients. The authors examined factors associated with the poor outcome for black women with uterine corpus tumors and analyzed whether these characteristics have changed over time based on year of diagnosis. METHODS: The authors examined women with uterine neoplasms recorded from 1988-2004 in the Surveillance, Epidemiology and End Results (SEER) Database. The authors developed Cox proportional hazards models to examine the effect of race on survival and stratified women by year of diagnosis into 3 groups: 1988-1993, 1994-1998, 1999-2004. RESULTS: A total of 80,915 patients including 5564 (7%) black women were identified. Black patients were significantly younger, had more advanced stage tumors, and had more aggressive, nonendometrioid histologic variants (P<.001). Black women were 60% more likely to die from their tumors than white women when matched for other prognostic variables (hazards ratio, 1.60; 95% confidence interval, 1.51-1.69). For each of the 3 time periods, survival was worse for blacks even when stratified by stage and histology. Over time, the incidence of serous and clear-cell tumors increased, and the use of radiation decreased for both races. Staging lymphadenectomy was performed more commonly in both blacks (45%) and whites (48%) who had been treated more recently. CONCLUSIONS: Black women with uterine corpus tumors were more likely to die from their disease. This survival difference has persisted over time. The clinical characteristics of blacks and whites have remained relatively constant. The proportion of women who undergo surgical staging has increased with time and was well matched between races.
Assuntos
Negro ou Afro-Americano , Disparidades nos Níveis de Saúde , Neoplasias Uterinas/etnologia , População Branca , Adulto , Idoso , Feminino , Disparidades em Assistência à Saúde/tendências , Humanos , Pessoa de Meia-Idade , Prognóstico , Taxa de Sobrevida/tendências , Resultado do Tratamento , Neoplasias Uterinas/mortalidade , Neoplasias Uterinas/terapiaRESUMO
BACKGROUND: The current international staging system for lung cancer designates intralobar satellites as T4 disease. In this study, we sought to determine the impact of multifocal, intralobar non-small cell lung cancer (NSCLC) on patient survival and its potential relevance to stage designation. METHODS: We conducted a retrospective review of our thoracic surgical cancer registry from 1990 to 2005. Included were 53 patients with a resected lung cancer containing intralobar satellites detected preoperatively (n = 8) or in the resected specimen (n = 45). Patients with multicentric bronchioloalveolar cancer were excluded. All patients had an anatomic resection with mediastinal lymph node dissection. Median follow-up for the entire group was 31 months. Survival was calculated by the Kaplan-Meier method. A Cox proportional hazards regression model was performed to examine simultaneously the effects on overall survival of age, gender, nodal disease, number of satellite lesions, lymphatic invasion, and T status. RESULTS: The median age of the 53 patients with multifocal, intralobar (T4) disease was 68 years and 31 were women. Ten patients had more than one satellite lesion. Overall 5-year survival was 47.6% (95% confidence interval [CI], 27.36% to 65.30%) for all patients with resected intralobar satellites. Patients without nodal metastases had a 5-year survival of 58.4% (95% CI, 28.76% to 79.30%). The Cox regression identified female gender (adjusted hazard ratio [HR], 0.31; 95% CI, 0.10 to 0.96; p < 0.04) as a significant prognostic variable but only a trend towards significance for nodal status (adjusted HR, 2.3; 95% CI, .83 to 6.26; p < 0.11). CONCLUSIONS: Patients with intralobar multifocal NSCLC detected in the resected specimen have a more favorable prognosis after surgical resection than might be predicted by their stage T4 designation. Five-year survival rates, especially in T4N0 patients, more closely approximate those with stages IB or II NSCLC.
Assuntos
Carcinoma Pulmonar de Células não Pequenas/patologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/cirurgia , Idoso , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Metástase Linfática , Masculino , Estadiamento de Neoplasias , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Sistema de Registros , Estudos Retrospectivos , Fatores SexuaisRESUMO
BACKGROUND: To determine the eventual outcome of abnormalities detected on surveillance computed tomography (CT) in patients with previously resected nonsmall-cell lung cancer (NSCLC), and to assess the accuracy of CT when used by the thoracic surgeon, and to determine the characteristics of abnormalities on CT that correlate with the development of recurrent NSCLC. METHODS: A cohort of patients who had abnormal postoperative CT scans of the chest and upper abdomen in 2002 were followed up into 2005. Abnormalities consisted of pulmonary nodules, pleural effusions, or adenopathy. Data collected included recurrence patterns, the availability of previous scans for comparison, the interval between initial resection and the abnormal CT, nodule size, growth, and multiplicity, as well as progression of pleural effusions or adenopathy. RESULTS: In all, 105 scans in 92 patients were read as abnormal in 2002 by the radiologist. After further investigation or follow-up, or both, for a mean of 3.2 years, 78% of patients who had recurrent NSCLC had their site of first recurrence inside the chest. The negative predictive value of CT when used by the thoracic surgeon was 99%; however, the positive predictive value was only 53%. Abnormalities that correlated with the diagnosis of recurrent cancer included pulmonary nodules that either grew or were larger than 1 cm and pleural effusions that developed after the first postoperative year. CONCLUSIONS: Intrathoracic recurrent NSCLC was rarely missed by the surgeon utilizing surveillance CT, but a significant number of negative investigations were generated by its use. Characteristics of abnormal surveillance CT findings exist that correlate with the presence of malignancy.
Assuntos
Carcinoma Pulmonar de Células não Pequenas/diagnóstico por imagem , Neoplasias Pulmonares/diagnóstico por imagem , Recidiva Local de Neoplasia/diagnóstico por imagem , Segunda Neoplasia Primária/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Calcinose/diagnóstico por imagem , Carcinoma Pulmonar de Células não Pequenas/secundário , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Estudos de Coortes , Diagnóstico Diferencial , Intervalo Livre de Doença , Seguimentos , Cirurgia Geral , Humanos , Neoplasias Pulmonares/cirurgia , Doenças Linfáticas/diagnóstico por imagem , Metástase Linfática/diagnóstico por imagem , Médicos/psicologia , Derrame Pleural/diagnóstico por imagem , Derrame Pleural Maligno/diagnóstico por imagem , Radiologia , Estudos RetrospectivosRESUMO
OBJECTIVE: With the widespread use of computed tomography and the emergence of screening programs, non-small cell lung cancer is increasingly detected in sizes 1 cm or less. We sought to examine the long-term survival and recurrence patterns after resection of these tumors. METHODS: We conducted a retrospective review over a 15-year period to identify patients with surgically resected non-small cell lung cancer measuring 1 cm or less. Medical records were reviewed, and survival data were analyzed by the Kaplan-Meier method. RESULTS: There were 83 patients (26 men, 57 women) with a median age of 67 years (range 43-88 years). Median tumor size was 0.90 cm. Lobectomy was performed in 71 patients, bilobectomy in 1, pneumonectomy in 1, segmentectomy in 5, and wedge resection in 5. Postoperative stage was IA in 67 patients, IB in 4, IIA in 1, IIB in 4, IIIA in 2, and IIIB in 5. Median follow-up was 31 months. There was 1 operative death (1.2%). In 5 (31.3%) of the 16 patients with non-IA disease, recurrent cancer developed after resection. No recurrences were observed in the 67 patients with stage IA disease. The 5- and 10-year overall survivals for the entire cohort were 86% and 72%, respectively, and the disease-specific survival was 91% at both time points. For patients with stage IA disease, 5- and 10-year survivals were 94% and 75%, respectively, and the disease-specific survival was 100% at both time points. CONCLUSION: Eighty-one percent of patients with resected non-small cell lung cancer measuring 1 cm or less had stage IA disease. After surgical resection, recurrence is rare and long-term survival is excellent.
Assuntos
Carcinoma Pulmonar de Células não Pequenas/mortalidade , Carcinoma Pulmonar de Células não Pequenas/patologia , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Recidiva Local de Neoplasia/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Feminino , Humanos , Neoplasias Pulmonares/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de TempoRESUMO
BACKGROUND: The purposes of this study were to determine the frequency of downstaging of T or N after neoadjuvant chemotherapy and radical resection in patients with carcinoma of the esophagus, and to evaluate the effect of tumor downstaging on survival. METHODS: A cohort of patients who underwent neoadjuvant chemotherapy followed by radical surgical resection for carcinoma of the esophagus was identified from a large, prospectively maintained, single-institution database of esophageal cancer patients. Patients were included if they had an accurate pretreatment clinical stage determined by the authors. Data collected included demographic data, the type of staging regimen, the chemotherapy agents used, clinical and pathologic data and stages, and survival data. Downstaging of T or N was determined by comparing the pretreatment, clinical stage to the postresection, pathologic stage. Downstaging was then evaluated in the context of survival. RESULTS: Seventy-seven patients were identified who had an accurate clinical stage assigned and underwent neoadjuvant chemotherapy followed by radical resection. Patients were clinically staged before treatment using computed tomography, positron emission tomography, and endoscopic ultrasonography. Thirty-seven patients (48%) experienced downstaging of T or N, and this group of patients had a 5-year overall actuarial survival of 63%, compared with 23% for those who were not downstaged (p = 0.002). Three patients had a complete pathologic response to neoadjuvant chemotherapy (3.9%). CONCLUSIONS: Patients who experience downstaging of T or N after neoadjuvant chemotherapy and radical surgical resection for esophageal carcinoma have a significantly higher survival rate compared with those who do not experience downstaging. This enhanced survival is comparable to survival rates reported in complete pathologic responders after neoadjuvant chemoradiation.