Did the COVID-19 Pandemic Cause a Delay in the Diagnosis of Acute Appendicitis?

BACKGROUND: Appendectomy for acute appendicitis remains one of the most common surgical procedures. This study aims to assess the clinical presentation and delays in diagnosing acute appendicitis during the COVID-19 pandemic. METHODS: We evaluated data of all adult patients who underwent an appendectomy at our hospital between June 1, 2019 and June 1, 2020. Demographic data, admission type to the emergency room, radiological findings, pathological findings, and hospitalization time were noted. Patients were divided into four groups of 3-month periods, pre (Groups 5, 4, 3, 2) and during the pandemic (Group 1). Hospitalization time and perforation status of each group were compared. The hospital admission type and their effect on perforation were also evaluated. RESULTS: Two hundred and fourteen patients were included; 135 patients were male, and 57 were female. The median age was 39 years. In Group 1 (pandemic period), 28.8% of patients were referred to us from pandemic hospitals. The median hospitalization time was 7.3 h before pandemics (Group 2-5), 5 h in the pandemic period (Group 1). Perforation rates were 27.8% in Group 1, 23.3% in Group 2, 16.3% in Group 3, 14.0% in Group 4, and 18.6% in Group 5 (0 = 0.58). There was no difference in the patients in Group 1 in the rate of perforated appendicitis in patients who were referred from other pandemic hospitals (29.4) and those admitted via our own emergency room (16.6%) (p = 0.27) during the pandemic period. CONCLUSION: We did not observe any clear increase in the diagnosis of perforated appendicitis during the pandemic period, even in patients who were transferred from other hospitals.

Preoperative neutrophil-to-lymphocyte ratio as a predictive factor for survival in nonmetastatic colorectal cancer.

BACKGROUND: The pretreatment ratio of neutrophils to lymphocytes (NLR) has been suggested as an indicator of poor outcome in various cancers. This study aimed to determine whether the preoperative NLR may be a predictor of survival in patients who underwent curative resection for colorectal cancer (CRC). MATERIALS AND METHODS: The records of 219 CRC patients underwent curative resection between 2008 and 2014 were retrospectively evaluated. NLR was calculated by preoperative complete blood counts. The effects of age, gender, anatomic location, histologic grade, lymphovascular invasion, pathological T, pathological N, and tumor-node-metastasis stages and NLR on disease-free survival (DFS) and overall survival (OS) were analyzed using univariate and multivariate analyses. The optimal cutoff value for NLR was determined using receiver operating characteristic curve analysis. RESULTS: The best cutoff value of NLR was 2.8. Multivariate analysis showed that NLR was not a predictor of DFS. However, NLR was found as an independent prognostic factor for OS (Hazard ratio, 5.4; 95% confidence interval, 2.3-12.5; P = 0.0001). CONCLUSION: A preoperative NLR of more than 2.8 might be an independent predictor for OS in patients with CRC. This simple and routinely available laboratory parameter may be used as a useful marker for identifying patients with a worse prognosis.

Serum antithyroglobulin antibody levels are not a good predictive factor on detection of disease activity in patients with papillary thyroid carcinoma.

OBJECTIVE: Thyroglobulin antibodies (TgAb) are detected in thyroid cancer patients up to 25%. We investigated the prognostic value of TgAb positivity in patients with papillary thyroid carcinoma (PTC) after initial therapy. PATIENTS AND METHODS: A database of 109 consecutive patients who underwent total thyroidectomy and therapeutic lateral neck dissection followed by remnant ablation for PTC between January 1989 and December 2014 was reviewed We recorded the patients' all serum Tg and TgAb levels over time to establish changing trends. Patients were classified as either positive or negative according to serum TgAb levels. The recurrence or persistence rates in both groups were compared. RESULTS: Of the 109 patients enrolled 14 patients had TgAb positivity. Thirty-two (29.3%) showed disease recurrence or persistent disease during 101 months of follow-up. Twenty-seven of 95 patients (28.4%) with negative TgAb had persistent or recurrent disease, whereas 5 of 14 patients (35.7%) with positive TgAb had persistence or recurrence (P = 0.57). No significant difference in disease-free survival (115.3 ± 10.8 vs. 224.1 ± 16.6 months, P = 0.78) and overall survival (P = 0.59) was observed between TgAb positive and TgAb negative patients. CONCLUSIONS: TgAb status is not useful as a prognostic and predictive factor for clinical outcomes in patients with PTC in our experience.

The prognostic factors for clinical N1b patients in thyroid papillary carcinoma.

BACKGROUND: The aim of this study is to determine the prognostic factors which affect both disease-free survival (DFS) and overall survival (OS) in thyroid papillary carcinoma with clinical lateral lymph node metastasis. METHODS: One hundred and three papillary thyroid carcinomas diagnosed in adult patients received therapeutic lateral neck dissection between December 1989 and June 2010 were analyzed retrospectively. All of the patients were classified as American Thyroid Association (ATA) intermediate risk category. Age, gender, tumor stage and size, multicentricity and bilaterality, vascular invasion and extrathyroidal invasion, ipsilateral/contralateral lymph node involvement, lymph node ratio, extranodal tumor extension, and development of recurrence were the factors which might affect disease-free and OS. Univariate and multivariate analyses were performed. ROC analysis was used to find the cutoff value for lymph node ratio. RESULTS: One hundred and three patients were followed median 101 months. Locoregional or systemic recurrence developed in 20 patients (19.4%) while 7 patients (6.8%) had persistent disease. In multivariate analysis, lymph node ratio (P = 0.003, relative risk [RR] 5.4, 95% confident interval [CI] 1.7-16.5) and contralateral lymph node involvement (P = 0.02, RR 4.9, 95% CI 1.3-18.5) were the independent factors affecting DFS where contralateral lymph node involvement (P = 0.009, RR 44.4, 95% CI 2.5-765.2) was the only factor which affected OS. CONCLUSIONS: Lymph node ratio and contralateral metastasis affect DFS while contralateral metastases only affect OS in patients with N1b thyroid papillary carcinoma.

How to manage pseudoangiomatous stromal hyperplasia: our clinical experience

Background/aim: Pseudoangiomatous stromal hyperplasia (PASH) is a rare and benign mesenchymal proliferative breast lesion. Our aim is to review the clinical and radiological features of PASH and define a standard approach for its diagnosis and management. Materials and methods: Clinical records of 35 consecutive patients with PASH were retrospectively reviewed between 2009 and 2015. Patients with clinically or radiologically detected mass and patients who underwent biopsy for other indications and were diagnosed incidentally were included in the study. Results: There were 34 female patients and one male patient with gynecomastia. Twenty-three patients had palpable masses, and 16 of them were diagnosed as PASH with a median size of 3.1 cm. PASH did not show any specific features in radiological imaging. Core needle biopsy was performed for 3 patients before surgical excision; however, the lesions had not been diagnosed as PASH. In pathological examination, lesions associated with PASH showed nonproliferative changes in 14 patients, proliferative changes without atypia in 17, one phyllodes tumor, one in situ tumor, and one invasive cancer. Conclusion: Imaging findings of PASH are nonspecific. It is difficult to give a true prognostic diagnosis through pathological evaluation of big masses with core needle biopsy. We recommend surgical excision, especially for big lesions with suspicious features.

Sentinel lymph node status affects long-term survival in patients with intermediate-thickness melanoma.

OBJECTIVE: The aim of this study was to examine the role of sentinel lymph node biopsy (SLNB) on long-term disease outcome in patients with intermediate-thickness primary cutaneous melanomas. MATERIALS AND METHODS: Forty patients with intermediate-thickness melanomas, defined as 1.0-4.0 mm, underwent SLNB between 1998 and 2011. The disease-free survival (DFS), overall survival (OS) and prognostic factors were analyzed. RESULTS: Median age was 53 years (range: 24-74 years). Median Breslow thickness was 2.8 mm (range: 1.0-4.0 mm) and 27.5% were ulcerated melanomas. Median follow-up time was 70 months (range: 23-168 months). The number of patients with sentinel lymph node (SLN)-positive was 9 (22.5%) and completion lymph node dissection was performed in all of these patients. Ten patients (25%) developed distant and locoregional recurrence; 4 in the SLN-positive group (4/9; 45%) and 6 in the SLN-negative group (6/31; 19%), P < 0.042. In the SLN-negative group, one patient developed regional node recurrence; false-negative rate was 10%. SLN positivity and ulceration were independent prognostic factors for DFS in multivariate analysis (hazard ratio [HR] of 4.6, and 10.5, respectively; P < 0.011). For OS SLN positivity, ulceration and Breslow thickness were found to be the significant prognostic factors (HR of 5.4, 8.5 and 5.0, respectively; P < 0.024). Ten-year DFS and OS for SLN-negative and SLN-positive patients were 71%, 47% (P < 0.003), and 80%, 55% (P < 0.005), respectively. CONCLUSION: This study shows that survival rates are worse in the SLN-positive patients according to the long-term follow-up data. Ulceration and Breslow thickness also have significant effects on long-term survival in patients with intermediate-thickness primary cutaneous melanomas.

Adjuvant chemoradiation versus chemotherapy for stage III gastric cancer after surgery with curative intent.

OBJECTIVE: Gastric cancer is often diagnosed at an advanced stage and surgery alone cannot guarantee satisfactory results. Both chemoradiotherapy (CRT) and chemotherapy (CT) are used in postoperative therapy. However, it is controversial whether CRT or CT is better after D2 lymphadenectomy. In this study we investigated the efficacy of adjuvant CRT versus CT in stage III gastric cancer patients treated with R0 gastrectomy and D2 lymph node dissection. PATIENTS AND METHODS: Data from 92 patients diagnosed with gastric adenocarcinoma and treated with surgery followed by adjuvant treatment were retrospectively analyzed. Patients were classified into two groups depending on type of adjuvant treatment such as CT (Arm A) and CRT (Arm B). RESULTS: Twenty-one patients in Arm A and 71 patients in Arm B were included. Median age at diagnosis was 60 years. The median follow-up time was 30 months. No difference in local recurrence (14.3 vs 15.7%, P = 0.89), peritoneal recurrence (29.4 vs 23.5%, P = 0.62), and distant metastases rates (57.1 vs 45.1%, P = 0.42) were observed between the arms. Disease-free survival (DFS) rates did not differ between Arms A and B (26 and 22 months, P = 0.80) respectively. Median overall survival (OS) in Arm A was 29 months and it was 32 months for Arm B. There was no difference in 5-year OS and DFS between Arms A and B (23.8 vs 34.4%, P = 0.74; and 24.1 vs 32.9%, P = 0.80). CONCLUSIONS: Adjuvant CRT does not appear to improve clinical outcomes compared to adjuvant CT in this study and prospective studies are required to confirm these results.

The Effect of Helicobacter pylori on Gastric Cancer Treated with Adjuvant Chemotherapy After Curative Resection.

Helicobacter pylori has been associated with diverse pathologies of varying severity. We investigated the H. pylori infection status and its association with the pathologic features and clinical outcomes in stage III gastric cancer patients treated with adjuvant therapy after curative resection. Between 2004 and 2009, the records of 76 consecutive patients were retrospectively reviewed. H. pylori infection was confirmed by examination of pathological specimen. The relationship between H. pylori and the clinicopathological features was analyzed by Fisher exact test, Student's t test, and Kaplan-Meier method. Of the 76 patients, 16 patients (21.1 %) were confirmed for H. pylori infection. The median age was 59 years. Twenty-three patients received chemotherapy and remainder received chemoradiotherapy. H. pylori status did not correlate with the clinicopathologic features. It was greater in non-neoplastic tissue than the tumor tissue (21.1 vs 7.9 %). Median follow-up was 21 months. During this period, 88.2 % patients had experienced tumor recurrence, and 85.5 % patients had died. Recurrence was observed in 87.5 % patients and in 88.3 % patients in H. pylori-positive and H. pylori-negative patients, respectively (P = 0.92). Disease-free survival was 28.4 ± 7.9 months and overall survival was 31.5 ± 7.4 months in H. pylori-positive patients compared with 28.3 ± 3.7 and 33.2 ± 3.4 months, respectively, in H. pylori-negative patients. H. pylori infection status did not have effect on the overall or disease-free survival (p = 0.85 and P = 0.86), respectively. H. pylori status might not be useful as a prognostic and predictive factor for clinical outcomes.

Clinical experience in appendiceal neuroendocrine neoplasms.

AIM OF THE STUDY: To analyse the incidence of appendiceal neuroendocrine neoplasms in appendectomy specimens and establish the epidemiological and histopathological features, treatment, and clinical course. MATERIAL AND METHODS: Between 2004 and 2013, 975 patients who underwent appendectomy in Ankara Oncology Education and Research Hospital were retrospectively analysed. RESULTS: Neuroendocrine neoplasm was detected in the nine of 975 (0.9%) patients. Neuroendocrine neoplasms were diagnosed in eight patients by appendectomy, which was performed because of the prediagnosis of acute appendicitis, and in one patient by the suspicious mass detection during surgical procedures that were done in the appendix for a different reason. Eight of the patients' tumours were in the tip of the appendix, and one of the patients' tumours was at the base of appendix. Tumour size in 77.8% of patients was equal or less than 1 cm, in 22.2% patients it was 1-2 cm. There was tumour invasion in the muscularis propria layer in four patients, in the serosa layer in three patients, and in the deep mesoappendix in two patients. Patients were followed for a median of 78 months. In the follow-up of patients who were operated because of colon cancer, metachronous colon tumour evolved. This patient died due to progressive disease. Other patients are still disease-free. CONCLUSIONS: The diagnosis of neuroendocrine neoplasm is often incidentally done after appendectomy. Tumour size is important in determining the extent of disease and in the selection of the surgical method during operation.

Incidental extraspinal findings on magnetic resonance imaging of intervertebral discs.

INTRODUCTION: We aimed to evaluate pathological extraspinal findings and congenital anomalies/anatomical variations that were incidentally detected on the magnetic resonance imaging (MRI) scans of intervertebral discs, to find the frequencies of these incidental findings, and to emphasise the clinical importance of them. MATERIAL AND METHODS: A retrospective study including 1031 consecutive patients (730 females and 301 males, with a median age of 46 years) was conducted by evaluating a total of 1106 MRI examinations of intervertebral discs. Examinations were performed with a 1.5 T MRI unit. Incidental findings were classified as pathological findings and congenital anomalies/anatomical variations. RESULTS: The percentages of incidental extraspinal pathological findings and congenital anomalies/anatomical variations were 16.6% (95% confidence interval (CI): 14.4-18.8) and 3.7% (95% CI: 2.6-4.3), respectively. The percentage of incidental extraspinal pathological findings on cervical spinal MRI was 25.7% (95% CI: 20.1-31.7), thyroid nodules being the most common incidental findings. On thoracic spinal MRI (n = 19), inferior pole thyroid nodules were demonstrated as incidental extraspinal pathological findings, with a percentage of 10.5% (95% CI: 9.6-11.5). On lumbar spinal MRI, incidental pathological findings were detected with a percentage of 14.2% (95% CI: 11.9-16.6), while the percentage of congenital anomalies/anatomical variations was 4.8% (95% CI: 3.4-6.3). Eventually, 6.5% (95% CI: 2.6-9.4) of all cases with incidental extraspinal pathological findings underwent surgery. CONCLUSIONS: On MRI examination of intervertebral discs, paying attention to incidentally detected pathological extraspinal findings and congenital anomalies/anatomical variations is very important due to the fact that they can alter the treatment of the patient or affect the patient's life.

Importance of the development time of isolated bone metastasis in breast cancer.

BACKGROUND AND AIMS: To investigate whether isolated bone metastases at the time of diagnosis is a different entity than bone metastases after breast cancer surgery. PATIENTS AND METHODS: One hundred thirty-nine patients were examined between June 2004 and January 2007. These patients were classified into synchronous (group I) and metachronous groups (group II) depending on time to development of bone metastases. Patients and tumor characteristics, treatment, clinical progression, and survival were compared for each group. RESULTS: There were 44 patients in group I and 95 patients in group II. The median follow-up time was 36 months. The two groups showed similar results when patients, tumor characteristics, and clinical progression were compared. In the groups, the median time to progression was 14 vs 13 months (p = 0.70), and median overall survival was 47 vs 46 months (p = 0.96), respectively. CONCLUSION: Development time of bone metastasis has no effect on clinical progression, time to progression, and overall survival in breast cancer.

Inflamed vermiform appendix within the sac of incarcerated left inguinal hernia.

A 54-year-old male complained of a continuous pain together with an irreducible swelling of the left inguinal region 8 hours prior to admission to the surgical emergency department. His physical examination revealed a very painful, erythematous, irreducible swelling in the left inguinal region without abdominal peritoneal irritation. Routine blood tests disclosed mild leukocytosis. Abdominal plain X-ray film was not specific, and ultrasonography revealed a 10 cm in length inactive, edematous intestinal section within the inguinal hernia. With the diagnosis of strangulated inguinal hernia, he underwent surgical exploration through a transverse inguinal incision. By opening the hernia sac, 6-8 cc inflammatory fluid drained out, and an inflamed vermiform appendix adhered to the inner surface of the sac was seen. Appendicectomy and primary hernia repair were performed at the same time through the inguinal incision. The postoperative course was uneventful, and the histological examination of the specimen revealed an inflamed appendix.

Predictors of malignancy in patients with a thyroid nodule that contains Hürthle cells.

OBJECTIVE: Fine needle aspiration cytology of a thyroid nodule with Hürthle cells can be present in both benign and malignant diseases of the thyroid. The aim of this study was to identify the factors that predict malignancy in patients who underwent thyroidectomy with a preoperative fine needle aspiration cytology that contains a predominance of Hürthle cells. STUDY DESIGN: Retrospective data collection. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Medical records of 70 consecutive patients were reviewed between March 2005 and August 2010. Predictive factors, as well as age, gender, preoperative serum thyroid-stimulating hormone level, the microscopic findings of fine needle aspiration, ultrasonographic appearance, and size and number of nodules in the pathology report, were correlated with final histopathologic diagnosis of benign or malignant disease. RESULTS: Patients' final pathology showed that 21 patients (30%) had malignant disease, of whom 15 patients (71.4%) had papillary carcinoma and 6 patients (28.6%) had Hürthle cell carcinoma. Forty-nine (70%) patients had benign disease (hyperplastic/adenomatoid nodule in 24 patients, Hashimoto thyroiditis in 18 patients, Hürthle cell adenoma in 5 patients, and follicular adenoma in 2 patients). The rate of malignancy was higher in male patients (42.9% vs 28.6%), with nodules measuring ≥2 cm (36.7% vs 25.0%), the presence of a solitary nodule (34.3% vs 27.7%), and the presence of metaplasia in fine needle aspiration (36.4% vs 27.1%), although none was found to be significant (P > .05). CONCLUSION: Thyroid nodules that are reported in cytology as Hürthle cell lesions require surgery to differentiate benign from malignant disease.

Clinical significance of residual occult malignancy in thyroid carcinoma.

PURPOSE: Total or near-total thyroidectomy is advocated in reducing the recurrence rate and improving survival in differentiated thyroid carcinoma. However, this potential benefit could be seen in all patient groups or only in the patients who have multifocal disease. We analyzed the clinical significance of occult multifocal disease in patients with completion thyroidectomy. PATIENTS AND METHODS: Ninety-seven patients in whom the completion thyroidectomy was performed within 6 months were included. The patients were grouped according to whether they have malignancy in the remnant thyroid tissue. The groups were examined and compared according to patients and tumor characteristics. The effect of the presence of residual tumor in remnant thyroid tissue on clinical course, disease-free survival, and overall survival were evaluated as well. RESULTS: After completion thyroidectomy, 20 (20.6%) of the 97 patients revealed additional cancer focus in the residual tissue. Median follow-up period was 104 months (range, 84-205 months). Only tumor multifocality in the resected lobe after first surgery was predictive of the presence of malignancy in the thyroid remnant (P = .002; relative risk, 4.9; 95% confidence interval, 1.7-14.5). Detection of malignancy in the remnant thyroid tissue did not affect the disease-free survival (P = .39). There were no deaths in patients who underwent reoperative thyroid surgery. CONCLUSIONS: Only tumor multifocality in the original thyroid lobe was predictive of finding additional cancer in the contralateral lobe. However, clinical significance of occult multifocal disease was not shown.

Prognostic role of serum cancer antigen 15-3 in breast cancer patients with isolated bone metastases.

OBJECTIVE: To investigate the association between cancer antigen (CA) 15-3 and clinicopathological parameters in patients who had breast cancer with isolated bone metastases at the time of diagnosis and to analyse the effect on clinical outcomes. METHODS: Between June 2004 and January 2007, the data of 129 consecutive patients were examined. RESULTS: Elevated CA 15-3 levels were associated with poor disease-free survival (p = 0.001) and overall survival (p = 0.006). In multivariate analysis, serum CA 15-3 level (p = 0.003) was found to be an independent factor in overall survival. CONCLUSION: Elevated CA 15-3 level is a useful parameter for predicting clinical outcomes.

The value of resection of primary tumor in gastric cancer patients with liver metastasis.

PURPOSE: Surgery for gastric cancer with synchronous liver metastasis is applied for palliation. The aim was to determine whether surgical removal of the primary tumor provides a better survival and disease progression METHODS: Sixty-two patients are classified according to the primary tumor were removed or not. Patients and tumor characteristics, removal of the primary tumor are examined as the factors that were affecting overall survival and metastatic progression-free survival. RESULTS: The mean follow-up time was 243±23 days. The mean survival of the resection and nonresection groups were 422±50 and 170±16 days (p = 0.0001), respectively. After adjustment for other covariates, resection was associated with a trend toward improvement in overall survival (p = 0.003; relative risk RR: 0.34; 95% confidence interval (CI): 0.17-0.66) and improvement in metastatic progression-free survival (p = 0.07, RR = 0.51; 95% CI: 0.25-1.07). CONCLUSIONS: Excision of the primary tumor has an effect on metastatic progression-free survival and overall survival.

The role of surgery in breast cancer patients with isolated bone metastases at the time of diagnosis.

BACKGROUND: Surgery for the primary tumor in breast cancer patients with synchronous isolated bone metastasis is applied for palliation. The aim was to determine whether surgical removal of the primary tumor provides a better survival and disease progression. METHODS: Forty-four patients were diagnosed between the dates June 2004 and January 2007 and these patients are classified according to the removal of the primary tumor or not. Patients and tumor characteristics, removal of the primary tumor, and response to systemic therapy are examined as the factors that were affecting overall survival and time to progression of the disease. RESULTS: The median follow-up time was 37.5 months. Mean time to progression and overall survival was longer for the patients who received surgery than the patients who did not (20.4 vs. 18.4 months and 57.6 vs. 44.5 months, respectively), but these were not significant (P = 0.58, P = 0.39). In multivariate analysis, response to systemic treatment [(P = 0.03), hazard ratio = 0.44, 95% confidence interval = 0.20-0.93] was independent factor associated with overall survival. CONCLUSION: The response to systemic therapy is the major factor on survival in the breast cancer patients with isolated bone metastasis. Excision of the primary tumor has no effect on time to progression and overall survival.

Permanent hypocalcemia in patients operated for thyroid carcinoma.

AIM AND OBJECTIVE: The incidence and risk factors for permanent hypocalcemia in thyroid carcinoma were investigated. MATERIALS AND METHODS: The records of 417 patients were reviewed retrospectively at tertiary oncology referral center. Total or subtotal thyroidectomy patients constituted group I (n = 225), reoperative thyroid surgery patients constituted group II (n = 106), and therapeutic neck dissection cases constituted group III (n = 86). Age, gender, thyroid functions, pathologically verified tumor type, differentiation, localization and size, multicentricity, thyroid capsule invasion, extrathyroidal soft tissue invasion, coexistence of lymphocytic thyroiditis, metastatic lymph nodes dissected, incidental parathyroidectomy, and the type of surgery were investigated. RE SULTS: Permanent hypocalcemia was seen in 32 (7.7%) patients. The incidence of permanent hypocalcemia for each group was 1.7%, 10.3% and 19.7%, respectively. Related risk factors were hyperthyroidism for group I [adjusted relative risk (RR) = 21.1, 95% confidence interval (CI) = 2.6-165, p = 0.01] incidental parathyroidectomy for group II (RR = 7.8, 95% CI = 1.9-31.0, p = 0.004), and extrathyroidal soft tissue invasion (RR = 3.1, 95% CI = 1.1-9.5, p = 0.03) for group III. CONCLUSION: Permanent hypocalcemia rate was increased with reoperative thyroid surgery and neck dissection added to total thyroidectomy. Hyperthyroidism, incidental parathyroidectomy and extrathyroidal extension were related risk factors.