Changes in adjuvant therapy utilization in stage I seminoma: are they enough to prevent overtreatment?

OBJECTIVE: To determine if utilization of surveillance or adjuvant chemotherapy has increased compared with that of adjuvant radiotherapy (ART) in clinical stage I seminoma (CSIS) and to estimate the impact of this utilization trend on secondary malignancies. METHODS: The National Cancer Data Base, a web-based data analysis tool was examined for first-course adjuvant therapy management in CSIS from 2000 to 2008. We assessed the utilization in academic vs community practice settings and changes in tumor stage. We also estimated the number of secondary malignancies based on the change in practice. RESULTS: There were 52,672 patients of testicular cancer diagnosed. Of those, 28,974 (55.0%) patients had seminoma with 22,210 (84.2%) patients classified as CSIS. Overall, 14,005 (65.4%), 6430 (30.1%), and 951 (4.4%) patients received ART, surveillance, and adjuvant chemotherapy (AC), respectively. In 2000, most patients received ART (71.7%), followed by surveillance (26.5%), and AC (1.9%). In 2008, the majority of patients still received ART (47.7%) but surveillance (39.6%) and AC (12.6%) totaled a larger proportion. We calculated that this ART utilization rate would lead to an additional 372 solid tumor cases per year, 40 years later, whereas the current surveillance rate would lead to 34 cases of secondary malignancy annually in the United States. CONCLUSION: ART was the leading adjuvant management strategy for CSIS, but its share drastically decreased with a concomitant increase in surveillance and AC, particularly after 2004. These trends were similar in both academic and community settings. The current level of ART, although decreasing, may nevertheless lead to additional cases of solid cancer comparable with testicular cancer deaths.

A Single Surgeon's Experience with Open, Laparoscopic, and Robotic Partial Nephrectomy.

Objective. To report the perioperative outcomes of patients treated with partial nephrectomy by a single surgeon using three surgical modalities-open, laparoscopic, and robotic. Methods. Between August 2006 and February 2012, 106 consecutive patients underwent open partial nephrectomy (OPN) (n = 23), laparoscopic partial nephrectomy (LPN) (n = 48), and robotic partial nephrectomy (RPN) (n = 35) by a single surgeon. Clinical variables, operative parameters, and renal functional outcomes were analyzed. Results. Preoperative patient characteristics were similar except for baseline glomerular filtration rate (GFR), which was highest in the RPN group (P = 0.004). Surgery time was longest in the RPN group (244 minutes) and shortest in the OPN group (163 minutes, P < 0.0001). Patients who had OPN had the highest incidence of 30-day complications (30%), while the RPN approach had the lowest (14%, P = 0.008). Conclusions. When performed by a single surgeon, robotic partial nephrectomy appears to be associated with fewer complications than both open and laparoscopic partial nephrectomy. Kidney function was not affected by surgical approach.

Absence of correlation between symptoms and rhythm in "symptomatic" atrial fibrillation.

BACKGROUND: Symptoms are widely used as a means of assessment and follow-up of patients with atrial fibrillation. This study assessed the correlation between symptoms and cardiac rhythm in patients being evaluated for operative therapy for atrial fibrillation. METHODS: Seven days of preoperative continuous outpatient home electrocardiographic monitoring was performed on 50 patients with symptomatic atrial fibrillation. Cardiac rhythm was continuously monitored automatically, while patients recorded their symptoms electronically. Correlations were then drawn between symptomatic events and actual rhythm, and between atrial fibrillation episodes and symptoms. RESULTS: Fifty patients (37 men) with symptomatic atrial fibrillation were monitored for a combined 356 days (mean, 7.1 days). Patients were average age of 69 years old. Intermittent atrial fibrillation was reported by 36 patients, and 14 believed their atrial fibrillation was continuous. During monitoring, all patients had periods of both atrial fibrillation and normal sinus rhythm. Of the 552 documented episodes of atrial fibrillation, 467 (85%) were asymptomatic, and 85 (15%) episodes were symptomatic. Patients indicated that they experienced atrial fibrillation symptoms 163 times. Of the 163 symptomatic events, 85 (52%) were actual atrial fibrillation, 64 (42%) were sinus rhythm, and 14 (6%) were other rhythms. The ability of an individual patient to accurately identify atrial fibrillation ranged from 0% to 100%. CONCLUSIONS: Patient-reported symptoms of atrial fibrillation had poor correlation with actual rhythm. The lack of correlation between symptoms and rhythm underscores the importance of continuous home monitoring for accurately quantifying preoperative atrial fibrillation burden and for postoperative follow-up.

Intraoperative epicardial electrophysiologic mapping and isolation of autonomic ganglionic plexi.

BACKGROUND: Autonomic ganglionic plexi (GPs) have been implicated as triggers in lone atrial fibrillation (AF). The purpose of this study was to describe the technique and results of epicardial electrophysiologic mapping and the early effects of GP isolation. METHODS: Intraoperative epicardial electrophysiologic mapping was performed on 41 consecutive patients during a stand-alone minimally invasive operation for AF. A map labeling anatomic locations was developed to describe the findings. Intraoperative high-frequency stimulation (800/minute, 12 to 16 mA, pulse duration 9.9 ms) was performed using a standard quadripolar catheter placed directly on the epicardium. Locations where stimulation resulted in ventricular slowing with doubling of the electrocardiographic R-R interval were defined as active GPs. These areas were mapped and described. After dry bipolar radiofrequency isolation, the sites were again stimulated to assess isolation. RESULTS: Forty-one patients (mean age of 60.2 years, 31 males) underwent operation for AF (28 intermittent AF, 13 chronic). Active GPs were identified in all patients (24 bilateral, 17 unilateral). There was a mean of 5.0 GPs on the right and 2.7 on the left. More than 50% of patients had active GPs along the interatrial groove on the right and along the ligament of Marshall. All sites were inactive after radiofrequency isolation. Six-month follow-up is available for 15 patients, with 14 patients free of AF. CONCLUSIONS: Autonomic GPs can be routinely identified during AF surgery utilizing high-frequency stimulation. The GPs are clustered around the interatrial groove and the ligament of Marshall, and the cardiac response to GP stimulation can be eliminated with bipolar radiofrequency isolation. The addition of GP isolation to bilateral pulmonary vein isolation may increase freedom from AF.