Surgical Oncology

Editorial Board/Aims and Scope

2012-03-01

Is imaging relevant for treatment choice in early stage cervical uterine cancer?

2011-10-26

Abstract: Background: Improvement in the selection of patients with early cervical cancer eligible for different therapeutic options is expected from imaging.Objective: We examined key tumoral features such as tumor diameter cut-off values of 2 cm or 4 cm in largest dimension, distance between tumor and internal os, outer third stromal cervical invasion, parametrial invasion and lymph node invasion.Search strategy: We conducted a literature search to identify all relevant studies based on imaging that evaluated these parameters.Selection criteria: Articles were only considered when data of imaging modalities were compared with histopathological findings of the surgical specimens, considered as the gold standard.Data collection and analysis: We examined series that included more than 30 patients with primary untreated biopsy-confirmed cervical cancer. When numerous articles were obtained for one investigational modality, only series that included more than fifty patients were taken into account.Main results: Data is lacking for the diagnostic value of imaging for assessing tumor diameter cut-off values of 2 cm or 4 cm, and distance between tumor and internal os. There is a high negative predictive value of MRI for complete stromal invasion. Accurate assessment of lymph node status in patients with early cervical cancer is still lacking. PET-CT role is promising, but the diagnostic value of normal-sized hypermetabolic lymph nodes needs further investigation.Conclusion: Based on imaging, accurate selection of patients for treatment choice is still lacking in patients with early cervical cancer.

Do patients with pN0 gastric cancer benefit from prophylactic extended lymphadenectomy?

Dengqun Sun, Renhua Gong, Haorong Wu — 2011-11-09

Abstract: Purpose: To investigate the impact of prophylactic extended lymphadenectomy on survival for patients with node-negative (pN0) advanced gastric cancer according to the extent of lymph node dissection.Methods: This study retrospectively investigated the clinicopathological characteristics and prognostic outcomes of 458 patients who had pN0 advanced gastric cancer between 1995 and 2001. Postoperative survival was compared in patients who underwent different extents of prophylactic lymphadenectomy.Results: The overall 5-year and 10-year survival rates were 62.01% (284/458) and 40.83% (187/458), respectively. The survival rates differed significantly in patients who underwent a different extent of prophylactic lymphadenectomy (≤D1+ versus D2 versus D3 versus ≥D3) (X2 = 8.59, P = 0.035). Survival in patients who received less than D1+ dissection, however, were not significantly better than patients who received D2 dissection (X2 = 0.907, P = 0.341). Survival in patients who received D2 dissection was significantly better than survival in patients who received D3 dissection (X2 = 5.685, P = 0.017). No differences in postoperative survival rates were observed between patients who received D3 dissection and those received more than D3 dissection (X2 = 2.468, P = 0.116). Patients who were older than 60 years and receive more than D2 dissection experienced significantly worse postoperative survival than those who received less than D2 dissection (X2 = 14.885, P = 0.001). The extent of prophylactic lymphadenectomy did not significantly affect local tumor recurrence in patients with node-negative advanced gastric cancer (X2 = 0.458, P = 0.928).Conclusions: D2 prophylactic lymphadenectomy is appropriate for pN0 patients who were less than 60 years old, and less than D2 dissection was suitable for the older cases.

Surgical treatment of locally limited tonsillar cancer

2011-11-21

Abstract: Background: This study aimed to assess the efficacy of primary surgical treatment in the management of locally limited tonsillar carcinoma and the incidence of occult cervical metastasis.Methods: We conducted a retrospective evaluation of the records of all patients treated with primary surgery for pT1 and pT2 tonsillar carcinomas at a tertiary referral center between 1977 and 2005. All cases were assessed for disease-specific survival as well as local control rates, with respect to T and N classification, status of surgical margins, decision on neck management, and adjuvant therapy. Cases were also evaluated for incidence of major complications and incidence of tracheotomies.Results: A total of 209 cases were assessed. Positive surgical margins after completion of surgical treatment and advanced neck disease were shown to be significant negative prognostic factors. The occult metastasis rate was 18.4%.Conclusion: Primary surgical treatment is a very effective modality against locally limited tonsillar carcinoma. Low rates of complications and permanent tracheotomies are to be expected.

Selective organ preservation in muscle-invasive bladder cancer: Review of the literature

Parham Khosravi-Shahi, Luis Cabezón-Gutiérrez — 2011-11-17

Abstract: The standard of care for transitional-cell carcinoma of the bladder with invasion to the muscularis propria is radical cystectomy with bilateral pelvic lymph node dissection. However, currently there is a tendency for organ preservation in selected cases of muscle-invasive bladder cancer. Trimodality treatment, including transurethral resection of the bladder tumor (TURBT), radiation therapy and chemotherapy, has been shown to produce 5-year and 10-year overall survival rates comparable to those of radical cystectomy. The current 5-year overall survival rates range from 50 to 67% with trimodality treatment, and approximately 75% of the surviving patients maintains their bladder. After trimodality treatment complete response is obtained in more than 70% of patients with muscle-invasive bladder cancer. Clinical criteria helpful in determining patients for bladder preservation include such variables as small tumor size (<2cm), early tumor stage (T2–T3 disease), a visibly and microscopically complete TURBT, absence of ureteral obstruction, no evidence of pelvic lymph node metastases, and absence of carcinoma in situ (Tis). The close collaboration of urologists, radiation oncologists and medical oncologists is of paramount importance in succeeding in bladder preservation.

Health-related quality of life in patients with hepatocellular carcinoma after hepatic resection, transcatheter arterial chemoembolization, radiofrequency ablation or no treatment

Adriana Toro, Elia Pulvirenti, Filippo Palermo, Isidoro Di Carlo — 2011-11-21

Abstract: Background: Aim of this work was to compare quality of life (QoL) of patients affected by HCC and submitted to hepatic resection (HR), transarterial chemoembolization (TACE), radiofrequency ablation (RFA), or no treatment (NT).Methods: Patients affected by HCC between 2001 and 2009 were considered for this study. Gender, diabetes, hepatitis status, Child grade, tumor size, and recurrence were analyzed. QoL was assessed before treatment and 3, 6, 12, and 24 months after, using a FACT-Hep questionnaire. P value was considered significant if <0.01 and highly significant if <0.001.Results: Fourteen patients (27.45%) were treated with HR, 15 patients (29.41%) underwent TACE, RFA was performed in 9 patients (17.65%), and 13 patients (25.49%) were not treated.Physical well-being, social/family well-being, emotional well-being, functional well-being and additional concerns 24 months after HR were significantly higher compared to all other treatments.Conclusions: Hepatic resection provides the best QoL at 24 months. RFA provides a worse QoL compared to HR, but a higher QoL compared to TACE or NT.

Peritoneal pseudomyxoma arising from the urachus

2011-10-17

Abstract: Pseudomyxoma peritonei (PMP) arising from urachal tumors is extremely rare. To our knowledge, natural history, tumor biological behaviour, morbidity, treatment, and prognosis of PMP arising from the urachus are determined by the associated PMP. Management of urachal tumors with associated PMP should be based on aggressive locorregional therapy with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, similar to PMP arising from other origins.

Management and prevention of complications of subcutaneous intravenous infusion port

2011-10-17

Abstract: Subcutaneous intravenous infusion port (SIIP) has become an increasingly and widely adopted technique in the management of oncology patients. This route has been used not only for chemotherapy but also for parenteral nutrition provision, blood transfusion, medication administration, blood sample collection, hemodialysis, and so on. This system provides a safe vascular access with low complication rate which helps preventing patients from vascular infection and catheter associated thrombosis. In this study, we reviewed 1247 cases of breast cancer patients that had subcutaneous intravenous infusion port implanted for chemotherapy in our general surgery department from 1990 to 2008. The result indicates that complication decreases as our technique and experience mature. We hereby share our accrued experience and improved technique, hoping to be of help to young surgeons.

Undergraduate training in oncology: An ESO continuing challenge for medical students

2011-10-17

Abstract: During the last six years the European School of Oncology (ESO) opened an undergraduate programme for European medical students, aiming to further improve their oncology knowledge and clinical skills. In this endeavour a 5-day course is organized every summer at the University of Ioannina, Greece, where distinguished European oncologists introduce preselected medical students to cancer medicine. The programme includes teaching of several oncological topic regarding diagnosis and treatment of the most common tumours; interactive case presentations and discussions were also incorporated. An overall of 229 medical students, mostly from European medical schools, have been taking part to this intensive summer course, from 2004 to 2009.This article presents the detailed educational programme, the evaluation results and the outcome of the last six ESO courses; an assessment of the oncological curricula available across European faculties is also presented.

Bioluminescence imaging correlates with tumor progression in an orthotopic mouse model of lung cancer

2011-10-17

Abstract: Background and Objectives: To determine whether bioluminescence imaging of human lung cancer cells growing in an orthotopic murine model provides a sensitive tool for monitoring tumor progression in athymic nude mice.Methods: Human lung cancer (A549) cells were stably transfected with the firefly luciferase gene and inoculated into the right lung of athymic nude mice. Seven days after inoculation tumor growth was evaluated using the Kodak in-vivo Imaging System FX and continued to be monitored on a weekly basis.Results: In duplicate experiments, human lung cancer tumors formed in 90% of animal’s injected orthotopically. The mean intensity of the bioluminescence signal emitted from the lung cancer cells increased logarithmically during the course of study. Mice with positive bioluminescence signaling had confirmed tumors by microscopic histological analysis. Bioluminescence activity had a strong correlation with the tumor volume as determined histologically.Conclusions: Bioluminescence intensity directly correlates with tumor volume and therefore offers a reliable approach for detecting and monitoring the growth of human lung cancer cells in orthotopic murine models.

Re-operation outcome in patients referred to a gynecologic oncology center with presumed ovarian cancer FIGO I-IIIA after sub-standard initial surgery

2011-10-17

Abstract: Background: Surgery is the mainstay of treatment for early ovarian cancer both as therapeutic and comprehensive staging. Only the latter allows appropriate tailoring of systemic treatment. However, the compliance with guidelines for comprehensive staging has been reported to be only moderate and, therefore, re-staging procedures are commonly indicated to avoid undertreatment. The purpose of our study was to evaluate re-operation in a tertiary gynecologic oncology unit after primary operation for presumably ovarian cancer FIGO I-IIIA in general gynecology departments.Material and methods: Forty consecutive patients after primary surgery in the outside institutions for presumed early ovarian cancer with assumed tumor spread limited to the pelvis (FIGO I-IIIA) admitted to our department between 1999 and 2007 were included. In 35 cases re-staging surgery in our unit was indicated. The intra- and post-operative results were compared with initial diagnosis and sites of undetected disease were evaluated. Reasons for re-staging and referral pattern were studied.Results: 40 patients were enrolled of whom 53% came by self-referral. Only 18% were referred by the primary surgeon and the remaining patients were referred by their home gynecologist. Only 5 patients (13%) were classified as having had a comprehensive staging by surgical records and pathology reports and 35 patients underwent comprehensive re-staging laparotomy after which 20 patients (50%) experienced an upstaging including 13 patients with final diagnosis of FIGO stage IIIC. Most frequent sites of primarily undetected tumor were peritoneum (pelvic 34%, diaphragm 13%, paracolic 8%), lymph nodes (para aortic 32%, pelvic 11%), intestines 24%, and residual omental tissue 18%. The indication for post-operative chemotherapy was modified in 53% of patients.Conclusion: Comprehensive staging of presumed early ovarian cancer has been described as major problem especially outside gynecologic oncology units. Re-staging results in our department confirmed this deficiency by showing a considerable proportion of upstaging associated with alterations of recommendations for systemic treatment. However, series like this may even underestimate the problem, because incomplete staging is unfortunately accompanied by non-systematic referral practices not reflecting staging quality.

Genetic abberations in gallbladder cancer

Sanjeev K. Maurya, Mallika Tewari, Raghvendra R. Mishra, Hari S. Shukla — 2011-10-17

Abstract: Gallbladder carcinoma (GBC) is the most common type of biliary tract carcinoma and the third commonest digestive tract malignancy in our region. Studies available in literature do not clearly define the molecular genetic mechanisms involved in the pathogenesis of GBC. Most of these studies are limited to protein expression analysis by immunohistochemistry and western blotting, and only a few have been done on mRNA (messenger RNA) and mutation analysis. This review aims to critically analyze all the available evidence on genetic aberrations in gallbladder carcinoma.

The prognostic significant of percentage drop in serum CEA post curative resection for colon cancer

Won-Suk Lee, Jeong-Heum Baek, Keon Kuk Kim, Yeon Ho Park — 2011-10-17

Abstract: Objective/background: This study aimed to analyze the hypothesis that increased percentage drop in serum CEA post curative resection for colon cancer is associated with improved survival.Methods: Five hundred thirty three patients who underwent colon resection with a curative intent were retrospectively analyzed for their pre- and postoperative CEA levels. The disease-free and overall survival curves were calculated using Kaplan Meier analysis to evaluate cancer related outcomes. For multivariate analysis, the Cox regression model was used.Results: The estimated 5-year overall survival for the preoperative serum CEA > 5 ng/mL group with respect to a postoperative CEA level drop rate of 40%, 50% and 60% were 72.9%, 80.9% and 81.8%, respectively. The estimated 5-year overall survival for the preoperative serum CEA ≤ 5 ng/mL group with respect to each postoperative CEA level drop rate were 86.6%, 97.1% and 97.7%, respectively (P = 0.257, P = 0.092 and P = 0.073, respectively). The prognostic factors for poor survival were the depth of invasion (p = 0.042, hazard ratio: 2.617, 95% CI = 1.021–3.012) and lymph node metastasis (p = 0.008, hazard ratio: 2.249, 95% CI = 1.231–4.111). A 60% drop of the CEA level was an independent prognostic factor for survival (p = 0.001, hazard ratio: 2.954, 95% CI = 1.686–5.176) for patients with a preoperative CEA level > 5 ng/mL.Conclusion: Determining the preoperative CEA level and the early postoperative percent drop of the serum CEA level may be a helpful factor for the prognosis of colon caner patients. However, the percent drop from the pre to postoperative CEA level from the normal range was not associated with survival difference.

Combination cancer immunotherapy “Expanding Paul Ehrlich's Magic Bullet Concept”

Robert L. Elliott — 2011-10-17

The concept of cancer immunotherapy is not new and investigators have tried to stimulate the immune system to fight cancer for over a hundred years. However, success has been limited, inconsistent and very disappointing, thus preventing cancer immunotherapy from becoming a mainstream modality of cancer therapy. In order to improve results of cancer immunotherapy, and catapult it into the mainstream of cancer treatment, an aggressive individual combined approach must be considered and attempted. This communication is admittedly an opinion commentary about a very complex subject and is not a review article. It is important that the reader appreciates this while contemplating the ideas presented.