A pre-operative nomogram for decision making in oncological surgical emergencies.

BACKGROUND: The purpose of the study was to propose a clinical decision-making tool for predicting mortality in patients undergoing emergency abdominal surgery with a palliative intent in the oncology setting. METHODS: Identification of all emergency surgical procedures performed in a Department of Oncologic Surgery in a Comprehensive Cancer Center between January 2008 and January 2013. Multivariate logistic and Cox regression models were used to identify factors predicitve of mortality at 3 months and survival probabilities. Models were internally validated using bootstrapping and calibration. RESULTS: The mortality rates were 30% at 1 month, 46.7% at 3 months and 83.3% at the end of the study. One model based on the albumin level and the P-POSSUM score (AUC: 0.725) adequately predicted mortality at 3 months. A survival nomogram predicted mortality with a concordance index (CI) of 0.718, using the following factors: WHO performance status (P = 0.02), albumin level (P < 0.01) and P-POSSUM score (P < 0.01). The origin or the extent of the carcinoma did not own sufficient pronostic impact to be selected in this model. CONCLUSIONS: Pre-operative mortality risk scores can be developed in a palliative context. Physicians counselling and surgical decision making should be based on the use of these tools.

Spontaneous regression of primary abdominal wall desmoid tumors: more common than previously thought.

PURPOSE: The relevance of the initial observational approach for desmoid tumors (DTs) remains unclear. We investigated a new conservative management treatment for primary abdominal wall DTs. METHODS: Data were collected from 147 patients between 1993 and 2012. The initial therapeutic approaches were categorized as front-line surgery [surgery group (SG), n = 41, 28 %] and initial observation or medical treatment [nonsurgery group (NSG), n = 106, 72 %]. The cumulative incidence of the last strategy modification was estimated using competing risk methods with variable censoring times. RESULTS: Of the 147 patients, 143 were female (97 %). In the SG, 27 patients (66 %) required full-thickness abdominal wall mesh repair. In the NSG, 102 patients (96 %) underwent initial observation and four received medical treatment. In the NSG, the 1- and 3-year incidences of changing to medical treatment (no further changes during the follow-up) were 19 % [95 % confidence interval (CI) 11-28] and 25 % (95 % CI 17-35), respectively, and the 1- and 3-year incidences of a final switch to surgery were 14 % (95 % CI 8-22) and 16 % (95 % CI 9-24), respectively. An initial tumor size of >7 cm was associated with a higher strategy modification risk (p = 0.004). Of the 102 patients initially observed, 29 experienced spontaneous regression over a median follow-up period of 32 months. All second-intent resections were macroscopically completed, with R0 resections achieved in 82 % of patients. CONCLUSIONS: This study supports an initial nonsurgical approach to abdominal wall DTs ≤7 cm, followed by surgery based on tumor growth in select cases.

Conservative en bloc surgery for aggressive angiomyxoma achieves good local control: analysis of 14 patients from a single institution.

BACKGROUND: The purpose of this study was to assess the value of conservative surgery in aggressive angiomyxoma (AA) in our institutional series. METHOD: This was a retrospective review of patients with AA treated at our institution between 1999 and 2010. RESULTS: Fourteen consecutive patients were analyzed: 8 primary tumors and 6 recurrences. Female/male ratio was 13:1; median female age was 36 years. Median size of primary lesions was 12 cm (range, 7-17 cm). Median size of recurrences was 20.5 cm (range, 3-44 cm). Twelve patients were operated on. Two asymptomatic patients whose surgery would have been mutilating were placed under wait and see. Four patients had concomitant visceral resections because of massive infiltration. No tumor rupture was recorded on pathological examination. Margins were R0 (n = 2), R1 (n = 10), and R2 (n = 0). Seven patients (50%) received radiotherapy. Median postoperative follow-up was 69 months, and no patient was lost at follow-up. All patients operated on (primaries and recurrences) had no evidence of recurrence. CONCLUSION: Conservative and planned en bloc surgery achieves good local control with low morbidity. Radiotherapy could enhance local control in advanced disease. Wait and see is an exploratory option for asymptomatic, stable, and nonprogressing AA in which surgery would be mutilating.