Frailty Cost: Economic Impact of Frailty in the Elective Surgical Patient.

BACKGROUND: Frailty in the surgical patient has been associated with increased morbidity, mortality, and failure to rescue. However, there is little understanding of the economic impact of frailty. STUDY DESIGN: A prospective database of elective surgery patients at an academic medical center was used to create a modified version of the Risk Analysis Index (RAI), a validated frailty index. This included 10,257 patients undergoing elective operations from 2016 to 2017. Patients were classified as not frail (RAI = 0), somewhat frail (RAI = 1 to 10), or significantly frail (RAI > 10). Cost, revenue, and income data were procured from the finance department. Univariate and multivariate analyses were performed. RESULTS: Frail patients were more likely to be older (65 years vs 50 years; p < 0.001) and inpatient (19% vs 36%; p < 0.001). General surgical, gynecologic, urologic, and cardiothoracic services operated on a higher percentage of significantly frail patients compared with orthopaedic, neurosurgical, and vascular (p < 0.001). On univariate analysis, frail patients were more likely to die (0% vs 0.4%; p < 0.001) and have increased length of stay (0.8 vs 2.1 days; p < 0.001), higher total cost ($6,934 vs $13,319), and lower net hospital income ($5,447 vs $3,129) (p < 0.001). On multivariate analysis, frailty was independently associated with increased direct cost (odds ratio [OR] 2.2; p < 0.001), indirect cost (OR 1.9; p < 0.001), total cost (OR 2.2; p < 0.001), and net income (OR 0.8; p < 0.001). Stratified by service line and inpatient vs outpatient status, frailty continued to be associated with increased direct cost, indirect cost, total cost, and decreased hospital income. CONCLUSIONS: Although a significant number of data exist on the impact of frailty in the surgical patient, the economic impacts have only limited description in the literature. Here we demonstrate that frailty, independent of age, has a detrimental financial impact on cost and hospital income in elective surgery.

Project IMPACT Pilot Report: Feasibility of Implementing a Hospital-to-Home Transition Bundle.

BACKGROUND AND OBJECTIVES: To improve hospital to home transitions, a 4-element pediatric patient-centered transition bundle was developed, including: a transition readiness checklist; predischarge teach-back education; timely and complete written handoff to the primary care provider; and a postdischarge phone call. The objective of this study was to demonstrate the feasibility of bundle implementation and report initial outcomes at 4 pilot sites. Outcome measures included postdischarge caregiver ability to teach-back key home management information and 30-day reuse rates. METHODS: A multisite, observational time series using multiple planned sequential interventions to implement bundle components with non-technology-supported and technology-supported patients. Data were collected via electronic health record reviews and during postdischarge phone calls. Statistical process control charts were used to assess outcomes. RESULTS: Four pilot sites implemented the bundle between January 2014 and May 2015 for 2601 patients, of whom 1394 had postdischarge telephone encounters. Improvement was noted in the implementation of all bundle elements with the transitions readiness checklist posing the greatest feasibility challenge. Phone contact connection rates were 69%. Caregiver ability to teach-back essential home management information postdischarge improved from 18% to 82%. No improvement was noted in reuse rates, which differed dramatically between technology-supported and non-technology-supported patients. CONCLUSIONS: A pediatric care transition bundle was successfully tested and implemented, as demonstrated by improvement in all process measures, as well as caregiver home management skills. Important considerations for successful implementation and evaluation of the discharge bundle include the role of local context, electronic health record integration, and subgroup analysis for technology-supported patients.

Incidence of complications in bronchoscopy. Multicentre prospective study of 20,986 bronchoscopies.

AIM: To evaluate the frequency of complications in bronchoscopy from data compiled between 1/2/2002 to 1/2/2003. MATERIALS AND METHODS: Nineteen Italian centres of thoracic endoscopy participated in the study, for a total of 20,986 bronchoscopies (FBS), including 10,658 explorative bronchoscopies (EB) (50.79%), 5,520 bronchial biopsies (BB) (26.30%), 1,660 transbronchial biopsies (TBB) (7.91%), 1,127 broncho-alveolar lavages (BAL) (5.37%), 930 transbronchial needle-aspirates (TBNA) (4.43%), 1.091 therapeutic bronchoscopies (TB), comprising ND-YAG Laser, argon-plasma, electrocautery knife, stent insertion (5.20%). 82.4% of the procedures involved the use of a flexible bronchoscope, 16.3% were carried out using a rigid bronchoscope and 1.3% using the mixed technique. RESULTS: The total number of complications recorded was 227 (1.08% of the cases examined), including 20 (0.09%) during local anesthesia and pre-medication, 195 (0.92%) during the endoscopic procedures and 12 (0.05%) in the two hours following FBS. The total number of deaths was 4 (0.02%), due to cardiac arrest, pulmonary edema, delayed respiratory failure and shock in pre-medication, respectively. 68.28% of the complications were treated medically, 25.99% by means of endoscopy and 5.72% with surgery. The healing percentage was 98.2%. CONCLUSIONS: This study has shown that bronchoscopy is a safe method with low incidence of mortality and complications. The preparation, experience and continuous training of the operators of the medical and nursing team seem to play a fundamental role in reducing the incidence of complications at least in certain procedures such as BB and TBB.

Bacterial contamination of cystic fibrosis clinics.

BACKGROUND: Respiratory pathogens from CF patients can contaminate inpatient settings, which may be associated with increased risk of patient-to-patient transmission. Few data are available that assess the rate of bacterial contamination of outpatient settings. We determined the frequency of contamination of CF clinics and the effectiveness of alcohol-based disinfectants in reducing hand carriage of bacterial pathogens. METHODS: We conducted a point prevalence survey and before-after trial in outpatient clinics at 7 CF centers. The study examined CF patients with positive respiratory cultures for Pseudomonas, Staphylococcus, Stenotrophomonas or Burkholderia species. Hand carriage and environmental contamination with respiratory pathogens were assessed during clinic visits (Part I) and the effectiveness of hand hygiene performed by CF patients (Part II) was determined using molecular typing of recovered isolates. RESULTS: In Part I (n=97), the contamination rate was 13.6%. Pseudomonas and S. aureus, including methicillin-resistant strains, were cultured from patients' hands (7%), the exam room air (8%), and less commonly, environmental surfaces (1%). In Part II (n=100), the hand carriage rate of pathogens was 13.5% and 4 participants without initial detection of pathogens had hand contamination when recultured at the end of the clinic visit. CONCLUSIONS: Respiratory pathogens from CF patients can contaminate their hands and the clinic environment, but the actual risk of patient-to-patient transmission in the outpatient setting remains difficult to quantify. These findings support several recommendations CF infection control recommendations including hand hygiene for staff and patients, contact precautions for certain pathogens, and disinfecting equipment and surfaces touched by patients and staff.

Correlation of recurrence rates and times with posttreatment human papillomavirus status in patients treated with loop electrosurgical excision procedure conization for cervical squamous intraepithelial lesions.

The aim of the present study was to assess recurrence rates and times in patients with squamous intraepithelial lesion (SIL) of the uterine cervix treated with loop electrosurgical excision procedure (LEEP) conization, in order to define categories of patients who have a different risk of recurrence and who need a different surveillance protocol. This study was carried out on 119 consecutive patients who underwent LEEP. All patients were followed up with cervical smear and colposcopy after 3, 6, and 12 months in the first-year posttreatment, and every 6-12 months afterwards. Human papillomavirus (HPV) testing was performed at the time of LEEP and repeated 3-6 months later. The histologic examination of LEEP specimens revealed stage IA1 squamous cell cervical cancer in 4 (3.4%) cases, high-grade SIL in 75 (63%) cases, and low-grade SIL in 40 (33.6%) cases. The four patients with stage IA1 cervical cancer were not included in the further analyses. Disease recurred in none of the 50 patients with negative posttreatment HPV testing, in 4 (9.3%) of the 43 patients with positive posttreatment HPV testing and negative surgical margins, and in 8 (36.4%) of 22 patients with positive posttreatment HPV testing and positive margins. The combined evaluation of surgical margin status and posttreatment HPV testing could allow to subdivide patients treated with LEEP into categories at different risk of recurrence, requiring new tailored surveillance procedures.

HPV testing and Pap test: role for a combined approach in a non-screened population.

The aim of the present study was to test the polymerase chain reaction (PCR) as a tool to identify human papillomavirus (HPV) in routine cytological samples scraped from the uterine cervix. Moreover, attention has been focused on the correlation between HPV types and early intraepithelial lesions. The study involved 586 women who had undergone conventional Pap test. Analysis of HPV infection was performed by PCR and HPV typing by dot blot. In a group of 78 cases histologically diagnosed as high-grade squamous intraepithelial lesions (HSILs), the cytological diagnosis was correct in 92.3% and the HPV test was positive in 89.8% of cases; combined positivity at Pap and/or HPV tests raised this figure to 99.0%. In a group of 67 cases histologically diagnosed as low-grade squamous intraepithelial lesions (LSILs), the cytological diagnosis was correct in 73.1% and the PCR-based HPV test was positive in 64.2%; combined positivity at Pap and/or HPV tests raised this figure to 91.0%. This study confirms the limitations of screening programs based on Pap test only. Our results suggest, in fact, that adding the HPV test to primary screening could increase the yield of preinvasive cervical lesions.

Tracheobronchial aspiration of foreign bodies: current indications for emergency plain chest radiography.

PURPOSE: The purpose of this study was to determine the role of plain chest radiography in the evaluation of patients with suspected foreign-body aspiration. MATERIALS AND METHODS: During a 5-year period, 31 patients (18 men and 13 women; age range 6 months to 85 years) were referred to our observation for clinical suspicion of foreign-body aspiration. Clinically, the patients presented with cough in 27/31 cases (87.1%), decreased breath sounds in 22/31 (71%), choking in 18/31 (58.1%), fever in 7/31 (22.6%) and cyanosis in 5/31 (16.1%). Suspected foreign-body aspiration had occurred 2-72 h before hospitalisation. Within 2 h of hospitalisation, all patients underwent plain chest radiography performed in the upright position (two projections) in 10/31 (32.3%) patients and in the supine decubitus position in the remaining 21 (67.7%) patients. Plain chest radiography was subsequently integrated with multislice computed tomography (MSCT) of the chest in 3/31 (9.7%) patients and with bronchoscopy in 27/31 (87.1%) patients. RESULTS: Plain chest radiography showed the presence of a foreign body in the tracheobronchial tree in 7/31 (22.6%) patients, who subsequently underwent successful bronchoscopy in all cases. Foreign bodies included tooth fragment (three cases), nail (two cases), metallic spiral of a ball-point pen (one case) and an earring (one case). In the remaining 24/31 patients, plain chest radiography was positive in 14 cases, showing atelectasis (seven cases), pneumonia (six cases), pulmonary hyperinflation (one case) and pneumomediastinum (one case). Such findings had been caused by an aspirated foreign body, which was subsequently removed by means of bronchoscopy in all 14 patients. Moreover, three of the remaining ten patients with negative plain chest radiograph were submitted to MSCT of the chest, which required in 1 case tracheobronchial aspiration of a foreign body that was subsequently removed by means of bronchoscopy. Overall, plain chest radiography showed the presence of foreign-body aspiration and/or pleuroparenchymal lesions in 21/31 patients (67.7%); bronchoscopy was positive in 23/27 patients (85.2%), localising the foreign body in the right main bronchus in 16/27 patients (59.3%), left main bronchus in 7/27 patients (25.9%), intermediate bronchus in 2/27 patients (7.4%) and right lower lobe bronchus in 2/27 patients (7.4%). No late complications were observed within 6 months of hospital discharge. CONCLUSIONS: Plain chest radiography remains the initial imaging modality for patients with clinically suspected tracheobronchial aspiration of a foreign body. Nevertheless, in the case of negative chest radiography and a clinical suspicion of foreign-body aspiration, MSCT-possibly integrated with virtual bronchoscopy-should be considered in order to avoid unnecessary bronchoscopy.

Association of bacterial infection and red blood cell transfusion after coronary artery bypass surgery.

BACKGROUND: Previous studies have shown an association between red blood cell transfusions (RBC) and bacterial infections following coronary artery bypass graft (CABG) surgery. We sought to assess whether there is an independent effect of RBC on the incidence of bacterial infections. METHODS: This was a prospective cohort study of 533 CABG patients over a 7-month period. Subjects were followed from time of CABG until 30 days postoperatively. Data were collected on patient and treatment characteristics, surgical management, and transfusion incidence. RESULTS: Seventy-five (14.1%) of 533 patients developed a bacterial infection. After controlling for patient and disease characteristics, invasive treatments, surgical time, and the transfusion of other substances, the adjusted rates of bacterial infection were 4.8% for no RBC transfusion, 15.2% with one to two units, 22.1% with three to five units, and 29.0% with greater than or equal to six units, (p(trend) < 0.001). Diabetes was the only patient or disease factor significantly associated with bacterial infection (p < 0.001). CONCLUSIONS: RBC transfusions were independently associated with a higher incidence of post-CABG bacterial infections. The risk of infection increased in proportion to the number of units of RBC transfused.

The frequency and cost of patient-initiated device removal in the ICU.

OBJECTIVE: To determine the frequency and pattern with which patients in the intensive care unit (ICU) remove medical devices on their own, and the costs associated with this problem. DESIGN: Prospective observational study. SETTING: Two 10-bed sections of a multidisciplinary ICU in a tertiary care teaching hospital. PATIENTS: Adults admitted to the ICU for longer than 24 hours during October 1998. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Medical records were reviewed prospectively for the occurrence of patient-initiated device removal and the responses to those events by health care providers. Associated costs were estimated using hospital databases and Medicare physician reimbursement schedules. Annual cost estimates were calculated using 1997 admission statistics for 1211 adults in an ICU for more than 24 hours. Thirty-six patients were studied for 199 patient-days. Ten patients (28%) removed 42 devices: 88% of these events involved gastrointestinal tubes and vascular catheters. Significant agitation was documented within 2 hours before 74% of the events. Estimated cost associated with device removal was $7606, or $181/event. The estimated annual cost in this 42-bed ICU was more than $250,000. CONCLUSIONS: Patients commonly remove medical devices on their own, and this represents significant consumption of health care resources.

Prevalence, age distribution and aetiology of bronchiectasis: a retrospective study on 144 symptomatic patients.

The incidence of bronchiectasis (BCT) has probably decreased in developed countries in recent years, but reliable statistical data on its occurrence are still lacking. The aim of the present study was to retrospectively evaluate the prevalence, age distribution and aetiology of BCT, diagnosed in a selected series of symptomatic patients of a Western country by using bronchography. The authors analysed the main known predisposing and associated conditions (PACs), and the occurrence and age distribution of BCT in 144 consecutive patients who underwent bronchological examination (fibreoptic bronchoscopy and bronchography) in the years 1987-1994 because of recurrent purulent bronchitis and/or haemoptysis. The overall prevalence of BCT was 34% (49/144); its age distribution was: 17.2% (0-10 yrs), 43.7% (11-20 yrs), 38% (21-30 yrs), 37.5% (31-40 yrs), 33.3% (41-50 yrs), 40% (51-60 yrs), and 20% (61-70 yrs). Thirty-one PACs were found in 29/144 patients of the whole study group. The prevalence of BCT was significantly higher in the subgroup of 29 patients with PACs than in the subgroup of 115 patients without PACs (75.9% versus 23.5%; p < 0000001). The aetiology of BCT was mainly unexplained, as it was only possible to detect 24 PACs in 22/49 patients with BCT (44.9%): congenital, genetic and immune disorders (eight), localized airways obstructive diseases (five), pulmonary infections (three), bronchial asthma (two), pulmonary lobar fibrosis (two), ulcerative colitis (two), dermatomiositis (one), and toxin inhalation (one). The authors conclude that bronchiectasis still occurs in a large percentage of symptomatic patients of a developed country in the post-antimicrobial era, especially in the second to sixth decades, as well as in the presence of predisposing and associated conditions; its aetiology remains unknown in more than half of cases.

Endobronchial metastasis from stomach carcinoma.

We describe the case of a 57-yr-old female with endobronchial metastasis from stomach carcinoma. Respiratory symptoms began 3 months before the diagnosis of the gastric cancer. Chest computed tomography revealed a reticular lymphangitic carcinomatosis pattern with hilar and mediastinal lymphadenopathy. Fibreoptic bronchoscopy showed a spread submucosal infiltration which narrowed the apical segment of the left lower lobar bronchus. The biopsy specimen at that level was histologically identical to the gastric primitive cancer. To the authors' knowledge, stomach carcinoma has rarely been reported to give rise to airway metastases.

Frequency, severity, and treatment of agitation in young versus elderly patients in the ICU.

STUDY OBJECTIVE: To study the frequency, duration, severity, and treatment of agitation in patients in the intensive care unit (ICU) to determine if the elderly represent a distinct population. DESIGN: Prospective cohort study SETTING: Tertiary care, 10-bed, multidisciplinary ICU. PATIENTS: All patients older than 18 years of age admitted for longer than 24 hours during a 4-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred thirty patients were studied for 916 patient-days; 63 (48%) were elderly (> 65 yrs). Nurses and physicians described agitated behavior in 92 patients (70.8%) during 534 (58.3%) patient-days, and it was severe or dangerous in 60 patients (46.1%) during 273 (30%) patient-days. There were no age-related differences in frequency, severity, and duration of agitation. Opiates, benzodiazepines, and haloperidol were administered during 72%, 62%, and 29% of agitated patient-days, respectively. Haloperidol was administered more often to elderly patients (p=0.015); otherwise no between-group differences were noted. Daily dosing requirements were less in the elderly for intermittent intravenous lorazepam, haloperidol, and morphine but not for midazolam (p=0.15). When these dosages were corrected for body mass, no statistical differences between young and old were found. CONCLUSION: In the ICU, the elderly are not a distinct population for agitation.

Assessing sedation during intensive care unit mechanical ventilation with the Bispectral Index and the Sedation-Agitation Scale.

OBJECTIVE: To describe the level of sedation for a cohort of mechanically ventilated adult intensive care unit (ICU) patients using validated subjective and objective tools. DESIGN: Prospective convenience sample. SETTING: Multidisciplinary 34-bed ICU at Maine Medical Center, a 599-bed nonuniversity, academic medical center. PATIENTS: Sixty-three adult ICU patients were monitored during 64 episodes of ventilatory support. MEASUREMENTS AND MAIN RESULTS: Patients were prospectively evaluated by one trained investigator using the revised Sedation-Agitation Scale (SAS) and were simultaneously monitored for 1 to 5 hrs using the Bispectral Index (BIS), a numeric scale from 0 to 100 derived from the electroencephalogram. BIS values were assigned to baseline, stimulated, and average conditions for each patient by a separate investigator blinded to SAS scores. Ventilator settings, medications, and the lung injury severity (LIS) score were also recorded. Sedation levels varied from very deep sedation (SAS score = 1, BIS score = 43) to mild agitation (SAS score = 5, BIS score = 100). Heavily sedated patients (SAS score = 1-2, n = 20) had higher FIO2 (0.52 vs. 0.42, p = .008), oxygenation index (9.4 vs. 5.4, p = .03), and LIS scores (1.3 vs. 0.7, p = .004) and lower baseline (66 vs. 78, p = .01), average (66 vs. 81, p < .001), and stimulated (89 vs. 96, p = .016) BIS scores compared with more awake patients. Patients with intermittent neuromuscular blockade use (n = 4) had higher FIO2 (0.65 vs. 0.44, p = .006), minute ventilation (14.6 vs. 9.9 L/min, p = .005), positive end-expiratory pressure (7.5 vs. 4.8 cm H2O, p = .05), oxygenation index (15.7 vs. 6.0, p < .001), and LIS scores (3.3 vs. 1.0, p = .036) and were more sedated, with higher suppression ratios (3.5 vs. 0.6, p = .05) and lower SAS scores (1.5 vs. 4, p = .035). The average BIS values correlated well with SAS (r2 = .21, p < .001). CONCLUSIONS: SAS and BIS work well to describe the depth of sedation for ventilated ICU patients. Deeper sedation and intermittent neuromuscular blockade were used for patients with greater ventilatory requirements and more severe lung disease. The correlation between subjective and objective scales varied in medical, surgical, and trauma patients. Further research with SAS and BIS may facilitate the development of quantitative sedation guidelines for the ICU.

Community-acquired pneumonia in adults: a multicentric observational AIPO study.

The aim of this study was to obtain reliable data about the current aetiology (i.e. the frequency of the individual pathogens) of community-acquired pneumonia (CAP) while surveying the diagnostic and therapeutic behaviour of Italian chest physicians, compared with existing guidelines, and to test the usefulness of the current severity "criteria" or score as a predictor of disease outcome and guide for appropriate hospitalization. A prospective multicentre observational trial was carried out between October 1994 and February 1996 by the Italian Association of Hospital Pneumologists (AIPO) study group on respiratory infections. A total of 613 consecutive patients suffering from CAP were enrolled in 25 centres throughout Italy. Clinical, radiological and microbiological data were collected and patients were followed-up until complete resolution or death. Aetiological tests were not carried out in 204 patients. In the remaining 409 cases, the aetiology was defined by serological and quantitative microbiological tests in 184 (44.9%) patients. A total of 194 strains of pathogen were detected. The most frequently detected micro-organism was Streptococcus pneumoniae (18.5% of pathogen strains) but, unlike in other series of patients, high percentages of intracellular pathogens (32.5%, all with serological confirmation, mostly due to Chlamydia pneumoniae (13.4%) and of Gram-negative enterobacteria and Pseudomonas aeruginosa (12.5%) were also found. Antibiotic treatment differed from that recommended in American Thoracic Society guidelines, with a greater use of third-generation cephalosporins. Overall, a higher rate of hospitalization and a lower death rate than in other comparable studies was observed.

Antibiotic optimization. An evaluation of patient safety and economic outcomes.

BACKGROUND: Although numerous reports have described interventions designed to influence antibiotic utilization, to our knowledge none have been evaluated in a randomized study. METHODS: Adult inpatients receiving 1 or more of 10 designated parenteral antibiotics for 3 or more days during a 3-month period were randomized to an intervention (n = 141) and a control (n = 111) group using an unblocked, computer-generated random number table. Obstetric patients and those seen in infectious disease consultation were excluded. The intervention group received antibiotic-related suggestions from a team consisting of an infectious disease fellow and a clinical pharmacist. Both groups were evaluated for clinical and microbiological outcomes as well as antibiotic utilization via prospective chart reviews and analysis of the hospital's administrative database. RESULTS: Sixty-two (49%) of the intervention group patients received a total of 74 suggestions. Sixty-three (84%) of these suggestions were implemented; the majority involved changes in antibiotic choice, dosing regimen, or route of administration. Per patient antibiotic charges were nearly $400 less in the intervention group vs controls (P = .05). Almost all the savings were related to lower intravenous antibiotic charges. Clinical and microbiological response, antibiotic-associated toxic effects, in-hospital mortality, and readmission rates were similar for both groups. Multiple linear regression analysis identified randomization to the intervention group and female sex as the sole predictors of lower antibiotic charges. There was a trend toward a shorter length of stay for the intervention group (20 vs 24.7 days, P = .11). CONCLUSIONS: This is the first randomized study to evaluate whether antibiotic choices can be influenced in a cost-effective fashion without sacrificing patient safety. We demonstrate that 50% of patients initially treated with expensive parenteral antibiotics can have their regimens refined after 3 days of therapy and that these modifications result in good clinical outcomes with a substantial reduction in antibiotic expense.

Serum levels of soluble receptors for tumor necrosis factor (p55 and p75 sTNFr) in endometrial cancer.

The pretreatment serum levels of the soluble receptors for tumor necrosis factor (p55 and p75 sTNFr) were retrospectively measured in 38 patients with endometrial cancer and 55 patients with benign uterine diseases as controls. Serum p55 and p75 sTNFr levels were significantly higher in patients with endometrial cancer (median = 2.4 ng/ml, range = 1.4-6.8 ng/ml, and median = 7.1 ng/ml, range = 2.5-19.5 ng/ml, respectively) than in controls (median = 1.7 ng/ml, range = 0.5-4.0 ng/ml, p < 0.0001, and median = 5.2 ng/ml, range = 2.6-21.9 ng/ml, p = 0.03, respectively). In the former, serum p55 and p75 sTNFr values correlated with the extent of disease (stage III-IV versus I-II: p = 0.04 and p = 0.03, respectively). Among the 23 patients with stage I endometrial cancer who underwent initial surgery, the preoperative serum levels of both receptors correlated with the histologic grade and myometrial invasion but not with the clinical outcome. In conclusion, a stage-dependent release of the soluble receptors for TNF into the bloodstream occurs in patients with endometrial cancer.

The influence of some prognostic factors on the clinical outcome of patients with squamous cell carcinoma of the vulva.

The present paper examined the influence of patient age, surgical T stage, tumor size, tumor differentiation and lymphnodal status on the clinical outcome of 29 patients with primary vulvar squamous cell carcinoma treated with radical surgery. Eighteen patients underwent radical vulvectomy with bilateral inguinal-femoral lymphadenectomy alone; 10 patients had additional bilateral pelvic lymphadenectomy; another patient had additional bilateral pelvic lymphadenectomy and anterior pelvic exenteration for a carcinoma of the clitoris involving the urethra. Nine patients developed relapsing disease; the site of recurrence was local in 4 patients, inguinal in 2, both local and inguinal in one patient, pelvic in one, both pelvic and distant in one. Eight recurrences occurred within 24 months from surgery; another patient developed an inguinal recurrence 45 months after operation. The actuarial 5-year disease-free survival rates were as follows: 64% for patients younger than 70 years and 63% for patients 70 years of age or older (p = not significant); 79% for patients with surgical T1-T2 stage disease and 30% for those with surgical T3 stage disease (p = 0.01); 88% for patients with tumor size less than 3 cm and 31% for those with tumor size greater than 3 cm (p less than 0.001); 66% for patients with well or moderately differentiated tumor and 51% for those with poorly differentiated tumor (p = not significant); 82% for patients with negative groin lymph nodes and 39% for those with positive groin lymph nodes (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)