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Spread of tumor to intracranial structures is an infrequent and late manifestation of head and neck cancers. We recently encountered six patients with a distinct clinical syndrome due to involvement of the cavernous sinus, which forms the basis of this report. This syndrome was a source of significant morbidity and mortality, with a mean survival of only 4 months. The diagnosis is often elusive, but is now made more commonly than previously. Whether this reflects increased incidence (due to alterations in the natural history of disease by therapy) or improved diagnosis (due to modern imaging modalities) is unknown. Cavernous sinus involvement may be the first evidence of distant disease in head and neck cancer. Although survival is poor, palliation is worthwhile. Awareness of this syndrome can lead to earlier diagnosis and alteration of treatment.

Knowledge of outcome is essential when analyzing effectiveness of educational programs. Although quantitative data can be analyzed more rigorously than other forms of data, quantitation of behavioral processes is often difficult. To promote our smoking‐cessation program we designed a method that relies on electronic message strips and a dedicated telephone line capable of providing quantitative outcome information. This approach appears quite versatile and shows that the electronic message strip is a surprisingly ineffective method of enlisting subjects into a smoking‐cessation program in our hospital.

About 1% of all cancers are soft tissue sarcomas (STS); about 60% of these occur in the extremities. Post-treatment surveillance programs are designed to identify recurrence, new primary cancers, and complications of therapy early enough to increase survival duration and quality of life. The intensity of surveillance varies among surgeons. We hypothesized that geographic factors would account for much of this variation. The 1,592 members of the Society of Surgical Oncology were surveyed regarding their personal postoperative STS surveillance strategy using standardized clinical vignettes and a questionnaire based on the vignettes. Practice patterns were analyzed by US Census Region, Metropolitan Statistical Area (MSA), and managed care organization (MCO) penetration rate, using repeated measures analysis of variance. The study end-point was surveillance intensity. Mean follow-up intensity for the 12 surveillance modalities on the questionnaire was highly correlated with tumor size, grade, and year post surgery. Controlling for tumor stage, grade, and year post surgery, the practice location of the surgeon infrequently impacted surveillance intensity. MSA was a significant (p0.05) predictor only of office visit frequency. MCO penetration rate significantly predicted only the frequency of urinalysis and tumor-site MRI. US Census Region significantly predicted only the frequency of LFTs. Geographic factors do not generally predict self-reported surveillance practice patterns for patients after curative-intent STS surgery. The overall variation in follow-up intensity appears to reflect factors not evaluated, such as the absence of high-quality evidence supporting any particular strategy and the quality of patients' insurance.

Background The internal thoracic artery (ITA) and inferior epigastric artery (IEA) may be used as conduits for myocardial revascularization. Harvesting the ITAs and IEAs can lead to clinically significant ischemia of the anterior abdominal wall. Methods We created a registry with data from 108 patients receiving myocardial revascularization with 1 or greater ITA and (or) 1 or greater IEA. After revascularization, patients were followed to document their outcomes during hospitalization. We sought to identify risk factors for tissue necrosis in these patients. Results All patients had 1 (84%) or 2 (16%) IEAs harvested. Both ITAs were utilized in 81% of patients; 19% had only the left ITA harvested. All patients in whom 2 IEAs were harvested also had 2 ITAs harvested (17 of 108). Of these 17 patients, 2 (12%) developed abdominal wall necrosis. Only patients who had bilateral ITA and bilateral IEA harvest experienced this complication. Conclusions Bilateral harvest of ITAs and IEAs results in a moderate risk of clinically significant abdominal wall necrosis. The extent of tissue loss may involve skin, muscle, and fascia, but the peritoneum and posterior rectus sheath remained intact in both affected patients in this series. These data may be most valuable to those who contemplate an abdominal operation in a patient who has had one or more of their ITAs or IEAs taken.

Background There is little published evidence regarding intraoperative and postoperative complications in patients with ventriculoperitoneal shunts who undergo cholecystectomy. Methods Nationwide Department of Veterans Affairs databases were searched to identify patients with International Classification of Diseases, 9th revision, Clinical Modification codes for a VP shunt who later had a cholecystectomy during fiscal years 1994 to 2003. Charts on these patients were obtained and reviewed. Results Twenty-three patients were deemed evaluable. Of these, 8 had laparoscopic converted to open cholecystectomies. All conversions were owing to dense adhesions. There were 2 cases of postoperative shunt infection that required shunt removal and replacement. Conclusions The rate of conversion from laparoscopic to open cholecystectomy was 57% in this study, significantly higher than the reported rate of conversion for patients without shunts in Department of Veterans Affairs Medical Centers (5%). Cholecystectomy in adult patients with a preexisting ventriculoperitoneal shunt appears to result in a shunt infection rate similar to that reported after shunt insertion or revision.

Antineoplastic agents may damage germinal epithelium. Testicular circulatory isolation (TCI) is a regional drug exclusion technique designed to minimize this. We evaluated the technical and anaesthetic aspects of TCI in 10 patients who underwent bilateral orchiectomy immediately thereafter. A modified aortic clamp was placed trans-scrotally across the left testicular pedicle without pre-medication or anaesthesia and left in place for 1 h, occluding testicular blood flow. Minimal pain and anxiety were reported during the procedure. There were no complications related to TCI in any patient. This study supports the institution of trials of TCI in young men about to receive fertility-threatening chemotherapy.

Background. Small cell undifferentiated carcinoma of the pancreas is a rare type of pancreatic neoplasm. Methods. The authors report the clinical and pathologic aspects of a patient with this malignant lesion and an extensive serologic and immunohistochemical survey of potential ectopically produced hormones or tumor markers. Results. Neuron-specific enolase (NSE) emerged as a tumor marker. Conclusions. NSE could be valuable in the diagnosis and management of other patients with this rare disease.

From October 1986 to January 1991, 47 patients with esophageal cancer (29 squamous, 18 adenocarcinoma) were treated with simultaneous radiotherapy (3000 or 3600 cGy) and chemotherapy (infusional 5-fluorouracil, cisplatin) delivered during a 5-week period. This treatment was well tolerated; 44 patients (94%) completed a full course of therapy, 40 (85%) had relief from dysphagia, and 21 (45%) noted either weight gain or no net weight loss. One patient (2%) died of complications (tracheoesophageal fistula, perforated ulcer) during chemotherapy and radiotherapy. The remaining 46 patients were referred for operation. Six refused because of excellent relief of their dysphagia, and one was denied operation. Thirty-nine patients went to operation, and 34 (83%) had lesions that were resectable. Eight of the 39 surgically treated patients (21%) had no evidence of residual tumor identified in the resected specimens. One of these complete responders died 7 weeks postoperatively after multiple complications (3% operative mortality rate). Three of the remaining seven have also died since the operation, one of recurrent cancer and two with no known recurrent disease. Actuarial survival in this present series was significantly better than that of our 1980 to 1985 historical control patients (p less than 0.005). There was no difference between patients with squamous carcinoma and those with adenocarcinoma with regard to the prevalence of complete response or long-term survival. Survival of the seven patients who did not undergo operation was comparable with that of the 34 patients in whom esophagectomy was performed. This study suggests that combined preoperative chemotherapy plus radiotherapy for esophageal cancer is well tolerated, provides excellent palliation of symptoms, allows for a high rate of resectability, is equally effective for squamous carcinoma and adenocarcinoma, and provides encouraging early results with regard to long-term survival. The data also call into question the role of esophagectomy, particularly in patients who have a complete response to preoperative therapy.

Several hundred thousand men receive chemotherapy each year; many are sterilized by this treatment. Testicular circulatory isolation (TCI), a regional drug exclusion approach to circumvent chemotherapy-related infertility, lessens doxorubicin-induced testicular injury in the rat. We evaluated the effect of TCI on doxorubicin-induced infertility in this study. Thirty-two eight-week-old male Sprague-Dawley rats were used. Eight rats received TCI for 45 min. Eight received doxorubicin (i.v. bolus) plus sham surgery. Eight received i.v. doxorubicin given immediately after institution of TCI. Eight controls received sham surgery alone. Mating studies began 2 months later. Six of the 8 males receiving TCI alone were fertile. In the doxorubicin-treated, sham-operated group, 0 of 7 animals were fertile. In the doxorubicin-treated group which also received TCI, 2 of 7 males were fertile. In the sham-operated group, all 8 rats were fertile. This is the first evidence that a regional drug exclusion technique can improve fertility in this model.

From the time of its founding in 1913, the American College of Surgeons (ACS) has promoted educational and research collaborations with other medical associations. It is therefore fitting that a program to support international surgical scholars was formalized in 1968 with the launching of the International Guest Scholarship (IGS) program. The first scholars were funded partly by a bequest from former ACS Director Paul R Hawley, MD, FACS (Hon) (1891 to 1965). Major General Hawley, Chief Surgeon of the European Theater of Operations in World War II (Fig. 1) was an accomplished man who had received the Distinguished Service Medal, the Legion of Merit, the Bronze Star, and the Lasker Award from the United States. He was a man of great vision and administrative talents, who became the first director of the Veterans Administration and later the director of Blue Cross Blue Shield before assuming the position of Director of the American College of Surgeons. 1 Dr Hawley realized that funding surgeons from abroad to travel to the Clinical Congress and to American surgical institutions and programs would be beneficial and educational for the selected international scholars as well as the programs and surgeons hosting them. Over the last 40 years this program has grown in scope and vision. We take the 40th anniversary of the founding of the IGS program as an opportunity to review its evolution and evaluate the accomplishments of the ACS international outreach program.

The optimal evaluation of patients with clinically suspected recurrence of rectal carcinoma following initial treatment has yet to be determined. We documented the intensity of the extent-of-disease workup conducted by colorectal surgeons when their patients with rectal carcinoma develop clinical evidence of metastases. A custom-designed questionnaire was mailed to all 1,795 members of the American Society of Colon and Rectal Surgeons. Subjects were asked which laboratory tests and imaging studies they would order for one of their own generally healthy patients with a suspicious abnormality found during surveillance testing. The tests most frequently recommended were computed tomography and serum carcinoembryonic antigen level. Few tests were recommended by >90% of respondents. There is no consensus among experts in this common situation.

Many believe that follow-up testing for rectal carcinoma patients after primary curative-intent therapy should be rather intensive for high-stage lesions and less intensive for low-stage lesions. We recently carried out a survey of the American Society of Colon and Rectal Surgeons (ASCRS) to quantify the strategies they use after primary treatment for their own patients. Considerable variability in surveillance exists. Here we report how initial TNM stage affects follow-up intensity. We devised vignettes succinctly describing otherwise healthy patients with rectal carcinoma (stages I-III). We mailed a questionnaire based on the vignettes to the 1,795 ASCRS members. Responses deemed evaluable were entered into a computer database. The effect of TNM stage on follow-up intensity for patients with stage I, II, or III rectal carcinoma treated with radical surgery was assessed by repeated-measures ANOVA. The surveillance modality most frequently utilized was the office visit. In year 1 following surgery for patients with stage I lesions, 3.8+/-2.7 office visits (mean +/- SD) were recommended, decreasing to 1.5+/-1.0 in year 5. For patients with stage III lesions treated with radical surgery +/- adjuvant therapy, 4.0+/-2.8 office visits were recommended in year 1, decreasing to 1.7+/-1.2 in year 5. Similar results were generated for all commonly used surveillance modalities. The intensity of follow-up after curative-intent treatment for rectal carcinoma varies minimally across TNM stages. This suggests that a controlled trial comparing high-intensity versus low-intensity follow-up testing could be carried out without stratification by TNM stage.

Several hundred thousand men receive chemotherapy each year; many are sterilized by this treatment. Temporary testicular circulatory isolation (TCI), a regional drug delivery approach to circumvent this, decreases doxorubicin-induced testicular injury in the rat and provides partial protection from doxorubicin-related infertility. We evaluated the distribution of doxorubicin and its metabolites (doxorubicinol and doxorubicin aglycone) in rats treated with TCI. In each of 56 male Sprague-Dawley rats, the left spermatic cord and gubernaculum were mechanically clamped for 45 minutes. Immediately after clamp application, these rats received doxorubicin (6 mg/kg, intravenous bolus) and were killed at seven time points after doxorubicin administration, ranging from 30 minutes to 48 hours. Twenty-one control rats were treated identically but did not receive TCI. Doxorubicin and its metabolites were extracted from tissue (left testis, right testis, left kidney, heart, left lung, liver) and serum and analyzed by high-performance liquid chromatography. In the TCI group, the distribution of the parent drug and doxorubicinol in tissue and serum closely approximated levels from doxorubicin-treated controls not receiving TCI in all organs except left testis. No anthracycline was detected at any time point in the left testis of the TCI group. These results indicate that TCI completely protects the testis from doxorubicin exposure in this model and that TCI does not affect distribution of doxorubicin in other organs.

Treatment can transform the metastases of nonseminomatous germ cell carcinoma into histologically mature teratoma. These lesions typically have a benign clinical course. The authors present a case of leiomyosarcoma occurring within such a lesion. It arose 18 years after therapy for metastatic embryonal carcinoma of the testis and appears to have been radiation induced.

Exposure of C6 glial cell cultures to desipramine induced the appearance of opioid receptors and up-regulated sigma receptors. Opioid binding was demonstrated with 3H-etorphine and 3H-dihydromorphine (DHM), but was not observed with the mu, delta and kappa ligands 3H-DAMGE, 3H-DADLE or 3H-(-)ethylketocyclazocine in the presence of specific blockers, respectively. Competition experiments with 3H-DHM and either (-)naloxone or (+)naloxone indicated the presence of authentic opioid receptors. In similar studies with beta-endorphin, its truncated form (1-27) or their N-acetyl derivatives, beta-endorphin proved to have the highest affinity. Opioid receptors in glial cell aggregates were primarily kappa, with few mu and delta sites. Desipramine increased Bmax values for kappa but not mu and delta.

BACKGROUND: A previously published clinical trial of epidural-supplemented versus general anesthesia, Veterans Affairs Cooperative Study No. 345, showed no difference in 30-day mortality and morbidity rates between the two treatments. We hypothesized that long-term postoperative survival would be increased by epidural anesthesia/analgesia supplementation during colon cancer resection. METHODS: We studied long-term survival after resection of colon cancer in a trial of general anesthesia with and without epidural anesthesia and analgesia supplementation for resection of colon cancer in Veterans Affairs Cooperative Study No. 345. Cox and log-normal survival models were used to test the effects of pathological stage, type of anesthesia and other covariates on survival in 177 patients. RESULTS: The presence of distant metastases had the greatest effect on survival. Thus, analyses were performed separately for patients with and without metastases. For those without metastasis, the hazard ratio for the treatment effects changed at 1.46 years. Before 1.46 years, epidural supplementation was associated with improved survival (P = 0.012), while later, the type of anesthesia did not appear to affect survival (P = 0.27). Hypertension was associated with poorer survival (P = 0.029), as was alcoholism in patients who received epidural anesthesia (P = 0.014). Survival of patients with metastases was unaffected by type of anesthesia. There was a significant age by hypertension interaction (P = 0.002). Patients survived longer if they were hypertensive, but had reduced survival if they were older than 66 years and hypertensive. CONCLUSION: Epidural supplementation was associated with enhanced survival among patients without metastases before 1.46 years. Epidural anesthesia had no effect on survival of patients with metastases. Additional studies to confirm or refute these findings are warranted.

Many individuals are concurrently eligible for multiple sources of government-reimbursed health care services (e.g. Department of Veterans Affairs (VA) and Medicare). Unclear is whether combined eligibility translates into increased access to care and/or improved outcomes of care. Alternatively continuity of care may suffer, promoting health inequalities when patients receive health services from multiple unrelated sources of care. The current study examines the impact of dual eligibility for government-reimbursed care on long-term outcomes of care for a population of veterans diagnosed with colorectal cancer and initially treated surgically at Department of Veterans Affairs Medical Centers.

Introduction Limited published information is available concerning the clinical course of spinal cord injured (SCI) patients who later develop rectal cancer and undergo proctectomy. We hypothesized that such patients would have poorer outcomes than comparable neurally-intact patients. Methods We conducted a retrospective study of all SCI veterans receiving care at all Department of Veterans Affairs (DVA) Medical Centers who subsequently underwent proctectomy for rectal cancer during fiscal years 1993–2002. Only patients with SCI due to trauma who met American Spinal Injury Association type A criteria (complete cord injury) were analyzed. The search strategy utilized DVA datasets plus data extracted from medical records. Results There were 33,758 patients with ICD-9-CM diagnosis codes for SCI and 5246 patients with ICD-9-CM procedure codes for proctectomy due to rectal cancer; 72 patients were in both datasets. We received records for 72 patients and excluded 67 after chart review. Incorrect coding (44) and incomplete spinal cord lesions (9) were the most common exclusion criteria. Five patients were considered evaluable. The mean age at diagnosis was 65 (range 49–80). All five had symptomatic cancers and two (40%) had major comorbidities at admission. Postoperative complications occurred in four (80%). The winsorized mean length of stay was 28 days. Conclusions The complication rate and length of stay for SCI patients undergoing proctectomy for rectal cancer were higher than those reported for otherwise comparable neurally-intact patients. SCI should be considered a risk factor for adverse outcomes in operations for rectal cancer as in other major surgery.

Human brain tumors (obtained as surgical specimens) and nude mouse-borne human neuroblastomas and gliomas were analyzed for sigma and opioid receptor content. Sigma binding was assessed using [3H]1,3-di-o-tolylguanidine (DTG), whereas opoid receptor subtypes were measured with tritiated forms of the following: mu, [D-ala2,mePhe4,gly-ol5]enkephalin (DAMGE); kappa, ethylketocyclazocine (EKC) or U69,593; delta, [D-pen2,D-pen5]enkephalin (DPDPE) or [D-ala2,D-leu5]enkephalin (DADLE) with mu suppressor present. Binding parameters were estimated by homologous displacement assays followed by analysis using the LIGAND program. Sigma binding was detected in 15 of 16 tumors examined with very high levels (pmol/mg protein) found in a brain metastasis from an adenocarcinoma of lung and a human neuroblastoma (SK-N-MC) passaged in nude mice. kappa opioid receptor binding was detected in 4 of 4 glioblastoma multiforme specimens and 2 of 2 human astrocytoma cell lines tested but not in the other brain tumors analyzed.

Since the end of the Middle Ages and the demise of the Galenic model of human biology and illness, a reductionist, mechanistic, evidence-based paradigm has prevailed. During the several centuries since this transformation in our worldview, there has been a complete revision in our concepts of how to conceptualize health and manage human disorders. Galileo’s pronouncement, “Measure all that is measurable, and make those things measurable which have hitherto not been measured” has found applications unimaginable by Galileo himself (1). The contents of this book are an extension of this concept, as the authors have quantified their current recommendations about medical care for a well-defined group of patients. We expect that these recommendations will serve as the starting points for the generation of evidence concerning their actual value.

Most patients with rectal cancer are treated with curative-intent surgery; adjuvant chemotherapy and radiation are often used as well. A recent survey of members of the American Society of Colon and Rectal Surgeons (ASCRS) revealed considerable variation in surveillance intensity after primary treatment. We evaluated whether geographic factors may be responsible for the observed variation. Vignettes of hypothetical patients and a questionnaire based on the vignettes were mailed to the 1782 members of ASCRS. Repeated-measures analysis of variance was used to compare practice patterns, as revealed by the responses, according to US Census Regions and Divisions, Metropolitan Statistical Areas (MSA), and state-specific managed care organization (MCO) penetration rates. There was significant variation in surveillance intensity according to the US Census Region and Division in which the surgeon practiced. Non-US respondents employed CT of the abdomen and pelvis, chest radiography, and colonoscopy significantly more often than US respondents. MSA was not a significant source of variation. Surveillance patterns varied significantly by MCO penetration rate for office visits and CT of the abdomen and pelvis but not for other modalities. The US Census Region and Division in which the surgeon practices have a significant effect on surveillance intensity following completion of primary curative-intent therapy for rectal cancer patients. The MSA in which the surgeon practices does not affect surveillance intensity significantly and MCO penetration rate affects follow-up intensity minimally. All significant differences are clinically rather modest, however. These data should be useful in the design of controlled trials on this topic.

Background Approximately 18,000 cerebrospinal fluid shunts, the majority of which are ventriculoperitoneal, are placed each year in the United States. These patients may develop appendicitis and require surgery. Whether the risk of postoperative complications is increased in these patients is unknown. We sought to determine the clinical course of patients with ventriculoperitoneal (VP) shunts who undergo appendectomy for appendicitis. Methods A nationwide search of Department of Veterans Affairs databases was conducted to identify patients with a VP shunt who subsequently developed appendicitis and underwent appendectomy. Patient medical records were analyzed to determine if the presence of a VP shunt affected the surgical approach or the postoperative course of patients who underwent appendectomy. Results Ten patients had ICD-9-CM codes for both appendectomy and a VP shunt. Five met the inclusion criteria for the study and had sufficient data for analysis. Medical records indicated that all of the patients had perforated or gangrenous appendicitis with peritonitis. One patient’s VP shunt was converted to a ventriculoatrial shunt. Another patient’s shunt was removed when culture of his peritoneal fluid grew Gram-positive cocci. There were no instances of postoperative infection, shunt malfunction, or other complication. Conclusion This is the only English language study, to our knowledge, of the clinical course of adults with VP shunts in place at the time of appendectomy for appendicitis. Such patients generally have no complications related to shunt malfunction or infection. In a minority of patients, shunt revision may be required.

6547 Background: The mean lifetime cost of surveillance for a woman diagnosed with breast cancer at age 45 is estimated to be > $35,000. Based on trials comparing low and high intensity surveillanc...

e16538 Background: In the USA, ovarian cancer is the eighth most common cancer in women; about 21,000 new cases are diagnosed each year. Many women experience recurrence after curative-intent treat...

We sought to determine the clinical course of patients with spinal cord injury (SCI) who subsequently developed bronchogenic carcinoma and underwent pulmonary resection.A nationwide retrospective study was conducted of all veterans at Department of Veterans Affairs Medical Centers for fiscal years 1993-2002 who were diagnosed with SCI, subsequently developed non-small cell lung cancer, and were surgically treated with curative intent. Inclusion criteria included American Spinal Injury Association type A injury (complete loss of neural function distal to the injury site) and traumatic etiology. Data were compiled from national Department of Veterans Affairs data sets and supplemented by operative reports, pathology reports, progress notes, and discharge summaries.Seven patients met the inclusion/exclusion criteria and were considered evaluable. Five (71%) had one or more comorbid conditions in addition to their SCIs. All 7 underwent pulmonary lobectomy. Postoperative complications occurred in 4 patients (57%). Two patients died postoperatively on days 29 and 499, yielding a 30-day mortality rate of 14% and an in-hospital mortality rate of 29%.This seems to be the only case study in the English language literature on this topic. Patients with SCI who had resectable lung cancer had a high incidence of comorbid conditions. Those who underwent curative-intent surgery had high morbidity and mortality rates. Available evidence suggests that SCI should be considered a risk factor for adverse outcomes in major surgery of all types, including operations for primary lung cancer.

The follow-up of patients with rectal cancer after potentially curative resection has significant financial and clinical implications for patients and society. The ideal regimen for monitoring patients is unknown. We evaluated the self-reported practice patterns of a large, diverse group of experts. There is little information available describing the actual practice of clinicians who perform potentially curative surgery on rectal cancer patients and follow them after recovery. The 1795 members of the American Society of Colon and Rectal Surgeons were asked, via a detailed questionnaire, how often they request 14 discrete follow-up modalities in their patients treated for cure with TNM stage I, II, or III rectal cancer over the first five post-treatment years. 566/1782 (32%) responded and 347 of the respondents (61%) provided evaluable data. Members of the American Society of Colon and Rectal Surgeons typically follow their own patients postoperatively rather than sending them back to their referral source. Office visit and serum CEA level are the most frequently requested items for each of the first five postoperative years. Endoscopy and imaging tests are also used regularly. Considerable variation exists among these highly experienced, highly credentialed experts. The surveillance strategies reported here rely most heavily on relatively simple and inexpensive tests. Endoscopy is employed frequently; imaging tests are employed less often. The observed variation in the intensity of postoperative monitoring is of concern.

Background: Analysis of geographical variation in utilization of medical resources is often used to identify regions of overutilization or underutilization. Methods: We surveyed the membership of the American Head and Neck Society regarding their recommended frequency of office visits and 13 imaging studies and blood tests for their patients after potentially curative therapy for upper aerodigestive tract cancers. Results: Of the 1322 members surveyed, 610 (46%) responded: 420 responses (32%) were assessable. Responses were compared by US Census Region, Metropolitan Statistical Area, and managed care organization penetration rate. Overseas members (16% of assessable responses) comprised a separate category for the regional analysis. There were statistically significant variations in practice patterns among Census Regions for office visits, complete blood count, computed tomography of the head, sonography, and esophagoscopy. Non-US members recommended significantly more blood tests, imaging studies, and endoscopy than US members for routine cancer surveillance. Only the frequency of office visits differed significantly among Metropolitan Statistical Areas. Surprisingly, the penetration rate of managed care organizations had no significant effect on posttreatment surveillance intensity. Conclusions: This analysis indicates that only a small portion of the wide variation in observed follow-up practice patterns can be explained by geographical determinants.

Purpose : Surgery remains the primary treatment of colorectal cancer. Data are lacking to delineate the optimal surveillance strategy following resection. A large-scale multi-center European study is underway to address this issue (Gruppo Italiano di Lavoro per la Diagnosi Anticipata—GILDA). Methods : Following primary surgery with curative intent, stratification, and randomization at GILDA headquarters, colon cancer patients are then assigned to a more intensive or less intensive surveillance regimen. Rectal cancer patients undergoing curative resection are similarly randomized, with their follow-up regimens placing more emphasis on detection of local recurrence. Target recruitment for the study will be 1500 patients to achieve a statistical power of 80% (assuming an alpha of 0.05 and a hazard-rate reduction of >24%). Results : Since the trial opened in 1998, 985 patients have been randomized from 41 centers as of February 2004. There were 496 patients randomized to the less intensive regimens, and 489 randomized to the more intensive regimens. The mean duration of follow-up is 14 months. 75 relapses (15%) and 32 deaths (7%) had been observed in the two more intensive follow-up arms, while 64 relapses (13%) and 24 deaths (5%) had been observed in the two less intensive arms as of February 2004. Conclusions : This trial should provide the first evidence based on an adequately powered randomized trial to determine the optimal follow-up strategy for colorectal cancer patients. This trial is open to US centers, and recruitment continues.

Clostridium difficile colitis is a relatively common entity, yet large series of patients with fulminant C. difficile colitis are infrequently reported. This study was designed to identify risk factors, clinical characteristics, and outcome of patients who required colectomy for fulminant C. difficile colitis. A population-based study on all patients in 159 hospitals of the Department of Veterans Affairs from 1997 to 2001 was performed. Data were compiled from several national computerized Department of Veterans Affairs data sets. Supplementary information including demographic information, discharge summaries, operative reports, and pathology reports were obtained from local medical records. Patient variables were entered into a computerized database and analyzed using the Pearson chi-squared and Fisher’s exact tests. Statistical significance was designated as P < 0.05. Sixty-seven patients (mean age, 69 (range, 40–86) years; 99 percent males) were identified. All 67 patients had C. difficile verified in the colectomy specimens. Thirty-six of 67 patients (54 percent) developed C. difficile colitis during a hospitalization for an unrelated illness, and 30 of 36 patients (87 percent) after a surgical procedure. Thirty-one of 67 (46 percent) developed C. difficile colitis at home. There was no history of diarrhea in 25 of 67 patients (37 percent). Thirty of 67 patients (45 percent) presented in shock (blood pressure

Limited published information is available concerning the clinical course of spinal cord-injured (SCI) patients who develop prostate carcinoma and subsequently undergo radical surgery. We hypothesized that the choice of surgical treatment and the technical conduct of radical surgery would be influenced by sequelae of SCI and that poorer outcomes would result in this population as compared with neurally intact patients.A nationwide study was conducted of all SCI veterans receiving care at Department of Veterans Affairs Medical Centers who subsequently developed prostate carcinoma and underwent curative-intent radical operations between 1993 and 2002. Only patients with complete SCI due to trauma who met American Spinal Injury Association type A criteria were analyzed. The unpaired t-test was used to analyze data.Of 16,878 patients who underwent radical operations for prostate cancer, 55 had preexisting diagnostic codes for SCI. After record review, 14 met all inclusion criteria. The mean age was 57 years. All were asymptomatic with clinically organ-confined disease diagnosed by an increased prostate-specific antigen level or abnormal digital rectal examination results. Comorbid conditions were present in 9 (69%) of 13 patients. Twelve underwent radical prostatectomy, and two underwent cystoprostatectomy. There were no operative deaths, but 8 (57%) of 14 had complications (P.05). The mean length of stay (16 days) was significantly longer (P.05) than in neurally intact patients.SCI patients tended to be younger than neurally intact patients with prostate cancer, and the rate of cystoprostatectomy was high. The complication rate was significantly higher and the hospital stay was significantly longer than in neurally intact patients.

Genomic epidemiologic data, increasingly supported by clinical outcomes results, strongly suggest that overactivity of angiotensin I-converting enzyme (ACE) may underlie most age-related diseases. Angiotensin II, the main product of ACE, is a pleiotropic hormone, capable of serving as a neurotransmitter, growth factor, angiogenesis factor, vasoconstrictor, pro-thrombotic agent, and cytokine. So it is perhaps not surprising that the ACE D/D genotype is associated with several major psychiatric diseases, most cancers except prostate cancer (where the D/D genotype is actually protective), most cardiovascular diseases, most autoimmune diseases, and even infectious diseases like tuberculosis and HIV. In a preliminary study, angiotensin II blockade appeared to hasten recovery from West Nile virus encephalitis; it may be equally useful in SARS. The ACE gene underwent duplication at the origin of Chordata, just before the "Cambrian Explosion" in the number of species. The ancestral, unduplicated form of ACE is still expressed during the terminal differentiation of human spermatocytes, suggesting a critical role in reproduction. The crystal structure of testicular ACE (tACE) was recently published. Computer modeling suggests that tACE may be activated by both mechanical forces and reducing agents. The duplicated form of ACE (somatic ACE, sACE) is expressed in areas of high fluid flow. sACE may auto-dimerize via a novel protein motif, the "disulfide zipper." The sACE dimer is predicted to have higher catalytic efficiency and redox resistance than tACE.

Soft-tissue sarcoma is an uncommon cancer with the potential for high rates of recurrence after initial therapy. Multiple surveillance strategies have been developed to follow patients after primary treatment. The purpose of this study was to quantify the costs associated with various published post-treatment surveillance strategies. A literature review covering the years 1982-2003 was performed to find all modern published surveillance methods for extremity soft-tissue sarcoma. Only articles describing an explicit 5-year follow-up strategy were included. Total costs of 5-year follow-up were calculated for each strategy using Medicare-allowed charges as a proxy. Thirty-four articles depicting 54 strategies were identified. Total Medicare-allowed charges in year 2003 dollars ranged from 485 dollars for follow-up of low-grade sarcoma to 21,235 dollars for follow-up of high-grade sarcoma, a 42.8-fold cost differential. The average charge for these 54 strategies was 6,401 dollars. Physical examination and chest x-ray were the most commonly used screening modalities. Several guidelines have been proposed for extremity soft-tissue sarcoma patient follow-up, most prominently those of the National Comprehensive Cancer Network. The literature has yet to reflect the consensus these guidelines suggest. This study shows wide disparity in the costs of 54 specific methods of following soft-tissue sarcoma patients. Clinical trials are needed to identify an optimal surveillance strategy, one balancing gains in survival, quality of life, costs, and societal willingness to expend resources. Such trials have not been conducted due to the rarity of extremity soft-tissue sarcomas and the costs associated with conducting long-term trials. Alternatively, prospective evaluation of imaging modalities used in follow-up should be assessed as part of other trials. Computer simulation analysis also holds great promise as an assessment tool for surveillance strategies because patient participation is not required.

Soft-tissue sarcoma is an uncommon cancer with the potential for high rates of recurrence after initial therapy. Multiple surveillance strategies have been developed to follow patients after primary treatment. The purpose of this study was to quantify the costs associated with various published post-treatment surveillance strategies. A literature review covering the years 1982-2003 was performed to find all modern published surveillance methods for extremity soft-tissue sarcoma. Only articles describing an explicit 5-year follow-up strategy were included. Total costs of 5-year follow-up were calculated for each strategy using Medicare-allowed charges as a proxy. Thirty-four articles depicting 54 strategies were identified. Total Medicare-allowed charges in year 2003 dollars ranged from 485 dollars for follow-up of low-grade sarcoma to 21,235 dollars for follow-up of high-grade sarcoma, a 42.8-fold cost differential. The average charge for these 54 strategies was 6,401 dollars. Physical examination and chest x-ray were the most commonly used screening modalities. Several guidelines have been proposed for extremity soft-tissue sarcoma patient follow-up, most prominently those of the National Comprehensive Cancer Network. The literature has yet to reflect the consensus these guidelines suggest. This study shows wide disparity in the costs of 54 specific methods of following soft-tissue sarcoma patients. Clinical trials are needed to identify an optimal surveillance strategy, one balancing gains in survival, quality of life, costs, and societal willingness to expend resources. Such trials have not been conducted due to the rarity of extremity soft-tissue sarcomas and the costs associated with conducting long-term trials. Alternatively, prospective evaluation of imaging modalities used in follow-up should be assessed as part of other trials. Computer simulation analysis also holds great promise as an assessment tool for surveillance strategies because patient participation is not required.

This is a retrospective study aimed to report short-term outcome among patients ageor =70 years surgically treated for colorectal cancer.All patients with the discharge diagnosis of colon and rectal cancer at St. Louis University Hospital from 1992 to 2002 were reviewed. Patients were assessed as to demographics, presenting symptoms, therapy, surgical morbidity and mortality.One hundred eighty-one patients ageor =70 years with colorectal cancer were identified. The mean age was 78 years; 107/181 (59%) were females. Rectal bleeding and change in bowel habits were the most common presenting symptoms. Fifty-four out of 181 (30%) were asymptomatic at diagnosis. The diagnosis was made by colonoscopy in 75% of the patients. One hundred forty-three out of 181 (79%) had colon cancer; 38/181 (21%) had rectal cancer. Fourteen out of 181 (8%) did not undergo surgery. Twenty-two out of 181 (12%) were operated on as a surgical emergency. ASA classification was I-II in 52%, III in 34%, and IV-V in 14%. Nineteen out of 38 (50%) with rectal cancer underwent a sphincter-preserving procedure. Overall, there was a 29% major morbidity from surgery. Thirty-day mortality was 11% (21 deaths). Only the development of a postoperative complication predicted mortality.Elderly patients tolerate surgery well for colon and rectal cancer in the short-term. Many patients are asymptomatic at diagnosis. Surgical emergencies are few and patients have a favorable stage of disease. This data supports aggressive detection of colorectal cancer in asymptomatic elderly patients who may harbor occult colorectal cancer.

A large recent survey disclosed considerable variation in the intensity of follow-up after potentially curative surgery for extremity soft tissue sarcoma among highly credentialed clinicians. The source of the variation is not known. The survey was reanalyzed to investigate whether tumor grade and size account for the variation. The 1,592 members of the Society of Surgical Oncology were surveyed to measure their follow-up practices for 10 years after initial therapy for extremity sarcoma. Repeated-measures analysis of variance was used to measure the relationship among follow-up practice patterns and tumor grade, tumor size, and years after surgery. The 318 respondents who performed surgery and also carried out long-term follow-up for their patients with extremity soft tissue sarcoma were considered evaluable; 94% were general surgeons and 5% were orthopedic surgeons. Office visit, complete blood count, liver function tests, chest X-ray, chest computed tomography, extremity computed tomography, and extremity magnetic resonance imaging were ordered significantly more frequently with increasing tumor grade and size. Tumor grade and size significantly impacted physician practice patterns in post-treatment follow-up, although the degree of variation attributable to these variables was modest. These data permit rational design of a randomized clinical trial of two alternative follow-up plans.

A large recent survey disclosed considerable variation in the intensity of follow-up after potentially curative surgery for extremity soft tissue sarcoma among highly credentialed clinicians. The source of the variation is not known. The survey was reanalyzed to investigate whether tumor grade and size account for the variation. The 1,592 members of the Society of Surgical Oncology were surveyed to measure their follow-up practices for 10 years after initial therapy for extremity sarcoma. Repeated-measures analysis of variance was used to measure the relationship among follow-up practice patterns and tumor grade, tumor size, and years after surgery. The 318 respondents who performed surgery and also carried out long-term follow-up for their patients with extremity soft tissue sarcoma were considered evaluable; 94% were general surgeons and 5% were orthopedic surgeons. Office visit, complete blood count, liver function tests, chest X-ray, chest computed tomography, extremity computed tomography, and extremity magnetic resonance imaging were ordered significantly more frequently with increasing tumor grade and size. Tumor grade and size significantly impacted physician practice patterns in post-treatment follow-up, although the degree of variation attributable to these variables was modest. These data permit rational design of a randomized clinical trial of two alternative follow-up plans.

Background Patients with spinal cord injury (SCI) frequently have pressure ulcers. Surgery is sometimes needed to close them. In rare cases, hemipelvectomy is warranted for extremely severe complications. Methods We conducted a retrospective study using national Department of Veterans Affairs (DVA) computer data sets to identify clinical features of SCI patients who underwent hemipelvectomy for life-threatening septic complications of decubitus ulcers. Results Among the approximately 4 million patients receiving care in the DVA system, more than 40,000 patients were treated on an inpatient basis for SCI during the search period (fiscal years 1989 to 1998). They represent approximately 20% of the total national patient pool. There were 56 patients who supposedly had undergone hemipelvectomy. Chart review eliminated cases that did not meet our inclusion criteria, resulting in 8 evaluable cases. All had complete SCI due to trauma and later developed severe pressure sores with pelvic osteomyelitis or life-threatening soft tissue infection. Conclusions This series is the largest reported to date. The surgery involved significant blood loss (mean 2.6 L). Reoperations and complications were common. The mortality rate was 25%, but the survivors were all markedly improved by the surgery. Some of the complications appeared to be related more to the SCI than to the pelvic sepsis or surgery, suggesting that meticulous perioperative care may be valuable in reducing the complication rate in SCI patients undergoing this radical operation for very severe sequelae of pressure ulcers.

Many advances have been made in the field of colorectal cancer follow-up since the pioneering efforts of Wangensteen and others with second-look operations in the 1950s. The understanding of the biology and natural history of colorectal malignancy has been advanced. Diagnostic methods for detection of recurrent disease have also advanced tremendously with CEA monitoring, immunoscintigraphy. CT, MRI, and PET imaging. As has been discussed in this article, however, no strategy of postoperative follow-up has been shown unequivocally to produce improved survival benefit or cure rate. It is quite possible that benefit will be shown, but well-controlled trials will be required. Cost considerations will likely prove important, because the rate of detection of curable disease will likely.be low. Quality of life issues will also be important in such trials. Better treatment and outcome ol recurrent disease would provide a strong rationale for vigorous postoperative surveillance. New recommendations are currently evolving [54]. Early diagnosis seems likely to enhance the curability of both local and distant relapses and second primary tumors. Furthermore, there may be a survival and quality of life advantage that results from the early institution of chemotherapy, even for those tumors found to be inoperable [55]. In devising a plan for follow-up in patients, it is important to recognize the anatomic and temporal patterns of recurrence as well as their relationships to the initial tumor staging. Although there is little proof that the identification of recurrent disease in follow-up programs increases the likelihood of resectability, cure, or prolonged survival, many physicians have witnessed successful treatment of recurrent colorectal cancer. These anecdotal experiences, the unproven belief that follow-up is beneficial, and traditions imparted during training are among the likely motivating factors for most physicians caring for colorectal cancer patients.

The number of people in the United States with spinal cord injury (SCI) is estimated at about 200,000. The prevalence of gallbladder disease in this population is about three times as high as in neurally intact people, but the results of surgical treatment have received little attention.A retrospective, population-based study of patients with SCI who later received cholecystectomy for benign gallbladder disease was performed. National computer data sets of all patients receiving medical care in all Department of Veterans Affairs (DVA) medical centers for fiscal years 1994 to 1998 were used. Computer-based data were augmented with chart-based resources.During the period of interest, there were 21,849 patients with ICD-9-CM codes for SCI in the DVA computer system, among whom 367 had codes for cholecystectomy. After retrieval and review of data from individual charts, 118 were deemed evaluable. There were 68 who had successful laparoscopic cholecystectomy and 14 who required conversion to open cholecystectomy after laparoscopic efforts failed (conversion rate 14 of 82=17%). There were 36 who received planned open cholecystectomy. Patients under the age of 60 years were more likely to have a laparoscopic approach (P0.05). Emergency cholecystectomies were more likely to be performed via the open route (P0.01). The morbidity rate was 8 of 68 (12%) for successful laparoscopic cholecystectomy, 4 of 14 (29%) for failed laparoscopic surgery completed by conventional open technique, and 11 of 36 (31%) for planned open surgery. The mortality rate in the traditional surgery group was 1 of 36 (3%). There were no deaths in the other groups.We believe this series is the largest so far reported. The mortality rate of cholecystectomy in SCI patients is comparable to that in neurally intact individuals, but the morbidity rate is high. Contractures, stomas, heterotopic ossification, and other sequelae of SCI do not generally cause technical difficulties with surgery. If complications of cholecystectomy are indeed SCI-related, attention to perioperative SCI care could improve outcomes of cholecystectomy. Future research should continue to explore this important research topic.

The objective was to analyze the impact of clinical beliefs on surgical decision making in the posttreatment follow-up of patients with upper aerodigestive tract cancer. Clinical beliefs, defined as perceived benefits and risks of surveillance, were examined. All 824 members of the Society of Head and Neck Surgeons (SHNS) and 522 members of the American Society for Head and Neck Surgery, who were not SHNS members, were surveyed using TNM stage-specific clinical vignettes to measure surgical decision making in the posttreatment follow-up of patients with upper aerodigestive tract cancer. Controlling for physician demographic and practice characteristics, the relationship between clinical beliefs and diagnostic test ordering practices of surgeons was examined using Poisson and negative binomial regression analysis. Age 50 and over and South Central U.S. practice location were significant predictors of the frequency of surveillance testing in at least three TNM stage I models as was the clinical belief that no survival benefit results from the follow-up of patients with TNM stage I cancers. Less than 15% of the variability in follow-up intensity was explained by the TNM stage I models. Predictive ability was substantially improved for the TNM stage II-IV models by including lower TNM stage practice patterns as an independent variable. Most models predicted at least 50% of the variation in follow-up testing. The two clinical beliefs with the greatest impact on surgical decision making in the posttreatment follow-up of patients with upper aerodigestive tract cancer are that surveillance: i) permits palliative treatment and improves quality of life and ii) provides no survival benefit for patients with TNM stage I cancers. Knowledge of lower TNM stage practice patterns can be used to further improve predictive ability for higher stage models.

The objective was to analyze the impact of clinical beliefs on surgical decision making in the posttreatment follow-up of patients with upper aerodigestive tract cancer. Clinical beliefs, defined as perceived benefits and risks of surveillance, were examined. All 824 members of the Society of Head and Neck Surgeons (SHNS) and 522 members of the American Society for Head and Neck Surgery, who were not SHNS members, were surveyed using TNM stage-specific clinical vignettes to measure surgical decision making in the posttreatment follow-up of patients with upper aerodigestive tract cancer. Controlling for physician demographic and practice characteristics, the relationship between clinical beliefs and diagnostic test ordering practices of surgeons was examined using Poisson and negative binomial regression analysis. Age 50 and over and South Central U.S. practice location were significant predictors of the frequency of surveillance testing in at least three TNM stage I models as was the clinical belief that no survival benefit results from the follow-up of patients with TNM stage I cancers. Less than 15% of the variability in follow-up intensity was explained by the TNM stage I models. Predictive ability was substantially improved for the TNM stage II-IV models by including lower TNM stage practice patterns as an independent variable. Most models predicted at least 50% of the variation in follow-up testing. The two clinical beliefs with the greatest impact on surgical decision making in the posttreatment follow-up of patients with upper aerodigestive tract cancer are that surveillance: i) permits palliative treatment and improves quality of life and ii) provides no survival benefit for patients with TNM stage I cancers. Knowledge of lower TNM stage practice patterns can be used to further improve predictive ability for higher stage models.

The optimal extent-of-disease evaluation for patients with clinically suspected melanoma recurrence is not known. The available modalities are numerous and many are expensive. We documented the extent of work-up carried out by plastic surgeons when their patients with melanoma develop clinical recurrence. A custom-designed questionnaire was mailed to a random sample (n=3,032) of the 4,320 members of the American Society of Plastic and Reconstructive Surgeons (ASPRS). Subjects were asked which specific laboratory tests and imaging studies they would order for a patient with initial T2N0M0 disease treated with curative intent who later presented with either regional nodal metastases or pulmonary metastases. We measured the variability in practice patterns among surgeons and estimated the effects of physician age, U.S. census region, health maintenance organization (HMO) penetration rates, and type of recurrence (regional versus systemic) on work-up intensity. Of the 1,142 questionnaires completed (38%), 395 (35%) were evaluable. Non-evaluability was usually due to lack of melanoma patient follow-up in surgeons' practices. Lesion biopsy, chest X-ray, complete blood count, liver function tests, and computed tomography were frequently used, but there was no consensus for most modalities. More tests, particularly computed tomography, were utilized for evaluating systemic recurrence than for regional recurrence (p

The optimal extent-of-disease evaluation for patients with clinically suspected melanoma recurrence is not known. The available modalities are numerous and many are expensive. We documented the extent of work-up carried out by plastic surgeons when their patients with melanoma develop clinical recurrence. A custom-designed questionnaire was mailed to a random sample (n=3,032) of the 4,320 members of the American Society of Plastic and Reconstructive Surgeons (ASPRS). Subjects were asked which specific laboratory tests and imaging studies they would order for a patient with initial T2N0M0 disease treated with curative intent who later presented with either regional nodal metastases or pulmonary metastases. We measured the variability in practice patterns among surgeons and estimated the effects of physician age, U.S. census region, health maintenance organization (HMO) penetration rates, and type of recurrence (regional versus systemic) on work-up intensity. Of the 1,142 questionnaires completed (38%), 395 (35%) were evaluable. Non-evaluability was usually due to lack of melanoma patient follow-up in surgeons' practices. Lesion biopsy, chest X-ray, complete blood count, liver function tests, and computed tomography were frequently used, but there was no consensus for most modalities. More tests, particularly computed tomography, were utilized for evaluating systemic recurrence than for regional recurrence (p0.05). The intensity of work-up differed significantly (p0.05) by surgeon age for three diagnostic tests but not by U.S. census region or HMO penetration rate. This is the first empirical data on this subject from a large sample of an international society of highly credentialed experts. The lack of consensus for most tests in current practice is presumably due to multiple factors, including the lack of evidence supporting any particular strategy.

Wound healing consists of re-epithelialization, contraction and formation of granulation and scar tissue. TGF-b is involved in these events, but its exact roles are not well understood. Here we demonstrate that topical application of a synthetic TGF-b antagonist accelerates re-epithelialization in pig burn wounds (100% re-epithelialization in antagonist-treated wounds vs. approximately 70% re-epithelialization in control wounds on postburn day 26) and reduces wound contraction and scarring in standard pig skin burn, pig skin excision and rabbit skin excision wounds. These results support the distinct roles of TGF-b in the complex process of wound healing and demonstrate the feasibility of manipulating wound healing by TGF-b antagonist.

The purpose of this study was to define risk factors that predict 30-day morbidity and mortality after gastrectomy for cancer in Veterans Affairs (VA) Medical Centers.The VA National Surgical Quality Improvement Program prospectively collected data on 708 patients undergoing gastrectomy for cancer in 123 participating VA medical centers from 1991 to 1998. Independent variables included 68 preoperative patient characteristics and 12 intraoperative variables; the dependent variables were 21 defined adverse outcomes and death. Predictive models for 30-day morbidity and mortality were constructed by using stepwise logistic regression analysis.The 30-day morbidity rate was 33.3% (236 of 708). The overall 30-day mortality rate was 7.6% (54 of 708). Significant positive predictors of morbidity (P.05) included current pneumonia, American Society of Anesthesiologists class IV (threat to life), partially dependent functional status, dyspnea on minimal exertion, preoperative transfusion, extended operative time, and increasing age. Significant positive predictors of mortality (P.05) included do not resuscitate status, prior stroke, intraoperative transfusion, preoperative weight loss, preoperative transfusion, and elevated preoperative alkaline phosphatase level.Risk factors predicting morbidity and mortality rates at VA hospitals after gastrectomy for gastric cancer are reported by using a prospectively collected, multi-institutional database. Assigning relative weights to factors associated with adverse outcomes may help improve patient care.

Introduction In patients with spinal cord injury (SCI), abdominal diseases such as renal carcinoma are often diagnosed and treated late in their course. Methods A population-based retrospective review of SCI patients receiving care for renal cell carcinoma (RCC) in all Department of Veterans Affairs (DVA) medical centers was conducted for fiscal years 1988 to 1998. Results Of 96 patients identified, 57 were evaluable and 27 met study criteria. The mean patient age was 59 (range, 41-79 years). The mean time between SCI and treatment for RCC was 25 years (range, 1-51 years). All patients were men; 22/27 (81%) had 1 or more comorbid conditions. RCC was an incidental finding on surveillance imaging studies in 81% (22/27) of the patients. All 27 patients were treated surgically, 74% (20/27) by radical nephrectomy and 26% (7/27) by partial nephrectomy. All tumors were renal cell adenocarcinomas. Pathological staging by the tumor, nodes, and metastasis system was possible in 25; 92% (23/25) of tumors were stage I and 8% (2/25) were stage II. Postoperative morbidity occurred in 56% (15/27), and death occurred in 7% (2/27). Conclusion In SCI patients in the DVA system, diagnosis of RCC is usually the result of an incidental finding on surveillance imaging. Tumors are diagnosed at early stages and partial nephrectomy is often feasible. Many of the postoperative complications are related to the SCI, and may be preventable.