Gausihi Sivarajah

Background: While surgery remains the mainstay of treatment for limb sarcoma, extreme old age is a relative contraindication to oncological surgery. Methods: Patients >80 years referred with primary extremity soft-tissue sarcoma (ESTS) between 2007 and 2016 were retrospectively reviewed. Prognostic variables, including ASA status and Clinical Frailty Scores, were collected. Endpoints were perioperative morbidity, locoregional (LRR) and distant recurrence (DR), disease-specific survival (DSS) adjusted using competing risk modelling, and overall survival (OS). Results: A total of 141 primary tumours were identified, with 116 undergoing resections. Main motives for nonoperative management were severe frailty or significant comorbidity (56.0%). The operative group had a median age of 84 (range 80-96) years and median follow-up of 16 months (range 0-95). 45.7% of patients received radiotherapy. Median hospital stay was 7 (range 0-40) days, with frailty (p = 0.25) and ASA (p = 0.28) not associated with prolonged admission. 12.9% developed significant complications, with one perioperative mortality. 24.1% had LRR, occurring at a median of 14.5 months. All patients with reported DR (28.4%), except one, died of their disease. Frailty did not confer a significant difference in adjusted LRFS (p = 0.95) and DMFS (p = 0.84). One- and 5-year adjusted DSS and OS was 87.0% versus 74.9% and 62.3% versus 27.4%, respectively. Frailty (CFS ≥4) was associated with worse OS (hazard ratio [HR] 2.49; 95% confidence interval [CI] 1.51-4.12; p < 0.001), however not with adjusted DSS (p = 0.16). Nonoperative management conferred a 1- and 5-year adjusted DSS was 58.3% and 44.4%, respectively. Conclusions: Extremity surgery for sarcoma is well tolerated in the frail very elderly population with low morbidity and comparable oncological outcomes.

Objective: To determine whether patients from regional areas undergoing surgery for kidney cancer present with more advanced disease as a result of geographic isolation. Patients and Methods: Retrospective analysis of 221 patients undergoing surgery for renal cell carcinoma ( RCC ) from J anuary 2004 to J une 2012, from both a metropolitan centre and a large inner regional hospital. Data was collected on age, gender, presentation (incidental or symptomatic), clinical stage and pathological features. The A ustralian S tandard G eographical C lassification‐ R emoteness A rea ( ASGC‐RA ) is a system developed to allow quantitative comparisons between metropolitan and rural A ustralia. A score was assigned to each patient based on their location of residence at the time of surgery: metropolitan, RA 1; inner regional, RA 2; outer regional, RA 3. Statistical significance was specified as P < 0.05 on P earson's chi‐square tests. Results: Patients in each ASGC‐RA group did not differ significantly in age, sex or mode of presentation. Pathological T stage on presentation increased with increasing ASGC‐RA and thus distance from tertiary centres ( P = 0.004). The proportion of patients with ≥ T 3 disease rose from 30% of RA 1 to 73% of RA 3 patients ( P = 0.016) treated at our tertiary centre. Similarly, our regional centre had a larger proportion of patients presenting with ≥ T 3 disease from RA 3 (31% vs 5%, P = 0.003). When the 221 patients with RCC were analysed as a group, clinical T stage was significantly associated with ASGC‐RA ( P < 0.001), symptomatic presentation ( P < 0.001), N stage ( P < 0.001), M stage ( P < 0.001) and F uhrman grade ( P < 0.001). Conclusions: Our data quantifies the detrimental effect of physical distance on the health outcomes of regional A ustralians with kidney cancer. Australia's unique geography and rural culture may preclude any attempts to centralise cancer care to specialised metropolitan units, as has occurred in other countries.

The Cook-Swartz implantable Doppler probe (Cook Medical^®, Cook Ireland Ltd., Limerick, Ireland) has evolved as a useful option for postoperative free flap monitoring. For placement, the probe either is left unattached around the venous pedicle or is secured. In our experience with over 300 applications, we typically secure the cuff with two small microclips, or use fibrin glue. These techniques require redundant silicone cuff for apposition; however, we have encountered some vessels that are of sufficiently large diameter as to not provide enough cuff to employ these methods. The first technique comprises the application of two interrupted sutures through the cuff ends to mimic the technique of microclips. The sutures can be tightened to the desired tension and can be used in cases where the cuff ends are not in direct apposition. A second technique is to excise a segment of silicone cuff and either clip or suture the excised segment to the cuff ends, effectively elongating the cuff diameter. All four techniques (nonattachment, microclip fixation, suture fixation, silicone cuff elongation) have been used effectively, and none have resulted in any complications. Of note, the technique of nonattachment was associated with an increased rate of false-positive results, as migration away from the vessel was postulated to have occurred. There are a range of techniques for attachment of the implantable Doppler probe, and each contributes to the range of options for cuff attachment in difficult cases, with each technique worthwhile in particular settings.