Surgical Oncology

Editorial Board/Aims and Scope

2010-06-01

Cervical lymph node dissection in papillary thyroid cancer: Current trends, persisting controversies, and unclarified uncertainties

George H. Sakorafas, Dimitrios Sampanis, Michael Safioleas — 2010-06-01

Abstract: Cervical lymph node metastases are very common in patients with papillary thyroid cancer (PTC). Despite that PTC has an excellent prognosis, lymphatic spread is associated with increased risk of loco-regional recurrence, which significantly impairs quality-of-life and can alter prognosis of the patient. Therefore, the identification of lymph node metastases preoperatively is very important for the surgeon to plan the optimal surgical therapy for the individual patient. In most western countries, cervical lymph node dissection (CLND) is performed in the presence of cervical lymphadenopathy (therapeutic CLND). In contrast, in eastern countries (mainly in Japan, where the use of postoperative radioiodine adjuvant therapy is restricted by law), most surgeons perform prophylactic CLND (i.e., CLND in the absence of cervical lymphadenopathy). CLND is performed on a compartment-oriented basis. Currently, given the very high incidence of cervical lymph node metastases in PTC, there is a clear trend –even in western countries– in favor of central (level IV) node dissection, even in patients without clinically or ultrasonographically evident node disease. This surgical strategy will prevent disease recurrence, which may require an additional and more morbid surgery. Experience is therefore required from the part of the operating surgeon, who should be able to perform safely CLND at the time of initial surgery (thyroidectomy), to minimize surgical morbidity.

A new concept of endoscopic lung cancer resection: Single-direction thoracoscopic lobectomy

2010-06-01

Abstract: Although video-assisted thoracoscopic surgery was introduced in the early 1990s, its use in the treatment of lung cancer has been limited. We examined the effectiveness of a simplified surgical method for thoracoscopic lobectomy in patients with lung cancer from May 2006 to October 2007. This novel single-direction thoracoscopic lobectomy was characterized by incisions convenient for the placement of instruments and the lobectomy proceeded progressively in a single direction from superficial to deep structures. The procedure was completed successfully in 26 of 28 patients, with no perioperative deaths. The average operation time was 135min (range, 100–200min), average blood loss was 125mL (range 10–500mL) and average number of lymph nodes dissected was 11.8 (range, 6–23). The average postoperative hospital stay was 7.4 days (range, 5–10 days). Single-direction thoracoscopic lobectomy is a simple, safe, and effective procedure for lobe resection with clear procedural steps. It overcomes the difficulty in manipulation of incomplete lung fissures and potentially extends the indications of thoracoscopic lobectomy.

Principles and Practice of Surgical Oncology: A Multidisciplinary Approach to Difficult Problems (Hardcover)

Riccardo A. Audisio — 2010-06-01

Drs. Howard and Allan Silberman have to be congratulated for putting together 56 chapters (over 1000 pages) of updated science, summarising the state of the art in Surgical Oncology. The contributors list is outstanding and every individual chapter is commented by a senior authority of world-wide profile, providing an expert counterpoint and critical assessment. The Authors obviously believe that alternative views are necessary to highlight and emphasise problems in order to appreciate controversial issues.

Evolution of cancer survival analysis

Shunzo Maetani, John W. Gamel — 2010-06-01

Survival analysis is a useful tool for evaluating survival differences between groups, the effect of prognostic factors on survival, and the efficacy of cancer treatments. It is important to note that no survival analysis is done without an assumption (survival model). Even the Kaplan-Meier curve assumes that censored subjects will follow the same survival pattern after withdrawal as non-censored subjects. Depending on the model used, survival analysis may yield different results, and hence may have various impacts on the outcome of future patients. Oncologists, therefore, should have a sufficient knowledge of survival model.

Concepts in cancer survival analysis: Research questions, data, and models

Ewout W. Steyerberg, Thomas A. Gerds — 2010-06-01

The Editorial in this journal addresses the important point of analysis of cancer survival. Some issues may merit some further comments. First there is the issue of what can be estimated from the data as available. Different models have been proposed, with the Cox proportional hazard models being most popular in medicine. This model allows for the estimation of relative risk between groups, expressed in the ratio of hazards. Indeed, parametric models can also be used. The hazard ratio (HR) as estimated from e.g., a Weibull model will usually not differ much from the HR estimated from a standard Cox model . But cure models bring about problems in their estimation, and more importantly, in their definition of ‘cure’. Cure status is often not properly defined in the sense that a medical doctor would be able to tell the difference between a cured and a non-cured patient at a specific time point during follow-up.

Survival analysis in clinical trials: Old tools or new techniques

Xavier Paoletti, Bernard Asselain — 2010-06-01

Almost 40 years have passed since the publication by D.R. Cox in 1972 of the most widely used method of life table analysis . The same year R. Peto and J. Peto published the logrank test statistic . These approaches are now recognized as the two major cornerstones of survival data analyses. In the meantime, numerous statisticians have developed or updated tools for survival analysis. In the journal, Maetani and Gamel question the importance and the applicability of these classical approaches and wonder just how useful some new techniques can be in clinical research. In particular, are they still relevant when a fraction of the population is cured, which is hopefully more and more frequent with the advance of surgery and systemic treatments.

Commentary on paper, ‘cancer survival analysis’

Richard Sposto — 2010-06-01

In their paper “Evolution of cancer survival analysis”, Drs. Maetani and Gamel highlight some of the differences between the most ubiquitous and well accepted methods for analyzing survival data – the Kaplan Meier (or product-limit) estimator, the logrank test, Cox regression analysis – and methods based on what can be referred to as cure models, of which the Boag model is probably the earliest example. Boag’s simple but useful idea was that after treatment – which at the time comprised surgery and radiation over a short period of time – cancer patients either were cured of the cancer, or were not cured and would die from the cancer at varying times, so that a statistical model could be used to predict the chance that a patient was cured as well as to describe the life expectancy of those who were not. Other similar models , models with extensions to add the ability to study the influence of covariables on cure rate and time to failure , and models that relax some of the required strong assumptions have also since been developed.

Summary comments

D.R. Cox — 2010-06-01

The paper by Paoletti and Asselain and the accompanying commentaries make many interesting points about the analysis of survival data. Dominating issues of statistical analysis are those of data definition and quality and of clear formulation of objectives. The start point for measuring survival should be clearly and appropriately defined and the end point likewise; more than one definition may be needed. Parallel study of health-related quality of life may be critical. Possible objectives may include one or more of

Drugs of anaesthesia and cancer

Letterio B. Santamaria, Daniela Schifilliti, Domenico La Torre, Vincenzo Fodale — 2010-06-01

Abstract: Anaesthesia represents one of the most important medical advances in history, and, nowadays, can widely be considered safe, thanks to the discovery of new drugs and the adoption of modern technologies. Nevertheless, anaesthetic practices still represent cause for concern regarding the consequences they produce. Various anaesthetics are frequently used without knowing their effects on specific diseases: despite having been reported that invasion or metastasis of cancer cells easily occurs during surgical procedures, numerous anaesthetics are used for cancer resection even if their effect on the behaviour of cancer cells is unclear.Guidelines for a proper use of anaesthetics in cancer surgery are not available, therefore, the aim of the present review is to survey available up-to-date information on the effects of the most used drugs in anaesthesia (volatile and intravenous anaesthetics, nitrous oxide, opioids, local anaesthetics and neuromuscular blocking drugs) in correlation to cancer. This kind of knowledge could be a basic valuable support to improve anaesthesia performance and patient safety.

Immunoreactivity and prognostic value of tumor-associated glycoprotein 72 in primary gallbladder carcinoma

Miao Ouyang, Wei Wu, Yiyou Zou, Jun Zhou, Zhiming Wang, Xiaoping Wan — 2010-06-01

Abstract: Aim: The purpose of this study was to investigate the expression of tumor-associated glycoprotein 72 (TAG-72) in primary gallbladder carcinoma (PGC) with an attempt to determine the potential usefulness of it in diagnostic and prognostic applications.Methods: Tissue samples from 118 patients with PGC, 30 patients with chronic cholecystitis, and 20 normal gallbladders were stained with anti-TAG-72 antibodies for immunohistochemical analysis. Then, the clinical outcome of the patients after a maximum follow-up of 5 years was determined in 110 out of 118 patients.Results: Clinicopathological characteristics of the carcinomas and clinical outcome of the patients were associated with the TAG-72 expression. TAG-72 was expressed more frequently in cancerous tissues of larger size, with lymph nodes metastasis, and with poor differentiation. Especially, a statistical association was found with more advanced UICC stages of the disease (55.77%, 65.38%, 92.86%, 93.75% and 100% in stages IA, IB, IIA, IIB, and III, respectively, p=0.02). Using a proportional hazard model, the survival rate of the patients with PGC expressing TAG-72 was significantly lower than the patients without TAG-72 expression (p<0.01), and including information of TAG-72 staining patterns within cancerous tissues along with clinical cancer staging may improve the accuracy of predicting patients' prognosis.Conclusion: These data suggest that TAG-72 expression is associated with clinicopathological parameters of aggressiveness in PGC. The detection of it combined with cancerous staging may increase the ability of investigators to predict the prognosis of patients with PGC.

Potential advantage of preoperative three-dimensional mapping of sentinel nodes in breast cancer by a hybrid single photon emission CT (SPECT)/CT system

2010-06-01

Abstract: Objective: This study aims to assess the role of three-dimensional single-photon emission computed tomography (3D-SPECT/CT) in sentinel node (SN) identification, and to analyze the impact of such information on estimating metastases to SNs.Background: Nodal status is a key factor for breast cancer. SN biopsy has been established as the alternative to routine axillary dissection these days. We investigated both the anatomical location of SNs demonstrated by our 3D-SPECT/CT system and the correlation to SN positivity.Methods: Two hundred and twenty-three clinically node-negative patients underwent SN biopsy. All of the axillary structures, including SNs, were visualized by a SPECT/CT combined system after subcutaneous injection of 99mTc-phytate. By plotting the visualized SNs, the most frequent SN location ‘Pedestal area (PA)’ was designated.Results: SPECT/CT detected 99mTc uptake in 217 cases (97.3%). 3D-SPECT/CT images visualized the accurate location of SNs in each case. In patients whose SNs were histopathologically negative (SN−), 228 (98.3%) SNs were found in the PA, and 4 (1.7%) were in other zones. In those with histopathologically positive SNs (SN+), 65 (78.3%) SNs were in the PA and 18 (21.7%) were outside it. The difference in SN distribution (i.e., in or out of the PA) between SN+ and SN− patients was statistically significant (p<0.001, chi-square test).Conclusions: SN biopsy navigated by 3D-SPECT/CT can clarify the preoperative anatomical localization of SNs in patients with breast cancer. Atypical distribution of SNs out of the PA may suggest SN positivity, reflecting failure of the lymphatic drainage systems.

Pelvic reconstruction with a combined hemipelvic prostheses after resection of primary malignant tumor

Zheng Guo, Jing Li, Guo-Xian Pei, Xiang-Dong Li, Zhen Wang — 2010-06-01

Abstract: Background: Hemipelvic resections for primary malignant bone tumor require reconstruction to restore weight bearing along anatomic axes. However, reconstruction of the pelvic arch remains a major surgical challenge because of the high rate of associated complications. We designed a combined hemipelvic prosthetic system to reconstruct the pelvis and purpose of this investigation was to assess the oncology and functional outcome and complication rate following this procedures.Methods: we retrospectively reviewed 18 patients who had primary malignant pelvic tumor resections and reconstructions with the combined hemipelvic prosthesis using pedicle screw-rod constructs augmented with antibiotic cement in combination with a special designed acetabular reinforcement shell and hip prosthesis between 2001 and 2007. Patients were examined clinically and radiographically and were assessed functionally with Musculoskeletal Tumor Society score.Results: Five (27.8%) patients had type II periacetabular pelvic resection and 5 (27.8%) had types I and II (periacetabular and ilium) pelvic resections. Six (33.3%) patients had types II and III (periacetabular and pubis) pelvic resections, 1 (5.6%) had types I and II and III resections and 1 (5.6%) had a types I and II and IV (periacetabular and ilium and sacrum) resections. Patient survival status, function, and complications were evaluated at a mean following up of 41 months (range, 7–73 months). Ten patients (55.6%) had no evidence of disease, five patients (27.7%) had died from their disease, and three patients (16.7%) were alive with disease. The overall survival rate was 72.2% at 5 years. Local recurrence occurred in four patients (22.2%). Six of 17 patients (35.3%) showed lung metastatic progression. The average MSTS 93 score was 65.5% and 71.7% at three months after surgery and at the last followup. Six (33.3%) patients had surgery-related complications including dislocation in 2, wound dehiscence in 2, deep-vein thrombosis in 1, screw loosening in 1 and sciatic nerve palsy in 1. There was no infection occurred in this series.Conclusions: Pelvic reconstruction using combined hemipelvic prosthetic system after a limb-salvage resection is an acceptable method because of its lower complication and satisfactory functional outcome and its feasibility of reconstruction for any type of periacetabular tumor resection without elaborate preoperative customize.Level of evidence: Level IV, therapeutic study.

Prognostic effect of different cut-off values (20mm, 30mm and 40mm) for clinical tumor size in FIGO stage IB cervical cancer

2010-06-01

Abstract: Objective: The aim of this study is to evaluate whether applying cut-off values of 20mm, 30mm and 40mm for tumor size have prognostic value in terms of survival or not.Material and methods: Medical records of 193 patients with FIGO stage IB cervical cancer (IB1: 173, IB2: 20) undergoing radical hysterectomy were evaluated. Tumor size was defined as the greatest tumor diameter determined by rectovaginal examination under general anesthesia. The influence of cut-off values (20mm, 30mm, and 40mm) on surgical-pathologic risk factors and survival rates was evaluated.Results: Tumor size was ≤20mm in 71, ≤30mm in 125 and ≤40mm in 174 patients. Only 40mm was associated with the presence of metastasis in at least one of pelvic or para-aortic lymph nodes. Depth of stromal invasion was affected by 20mm and 30mm. For parametrial and surgical margin involvement, only 30mm had a statistically significant effect. Probability of receiving adjuvant radiotherapy was similar with all of the cut-off values. Neither cut-off value had a statistically significant effect in terms of survival rates. It was observed that lymph node metastasis and age affected 5-year disease-free survival (DFS) and 5-year overall survival (OS) rates. OS, but not DFS, was affected by lymphovascular space invasion. Stage, cell type, grade, parametrial invasion, presence of tumor at surgical margin and depth of stromal invasion did not affect recurrence or survival rates. Age and pelvic lymph node involvement were independent prognostic factors.Discussion: The present study did not find a single cut-off value for tumor size that can predict all surgical-pathologic risk factors. Recurrence and survival were not affected by any of these values.

Corrigendum to “Nipple sparing mastectomy: Where are we now?” [Surgical Oncology 2008 17 261–266]

Alice P. Chung, Virgilio Sacchini — 2010-06-01

The author regrets that in the above published paper an error occurred in Table 4. The table stated that Caruso et al. (reference 26 in your paper) reported partial necrosis in 2% of patients who had radiation therapy; however this should be 12%. The corrected Table appears below.