Surgical Oncology

Editorial Board/Aims and Scope

2009-12-01

Laparoscopic radical hysterectomy with lymphadenectomy in patients with early cervical cancer: Our instruments and technique

2009-12-01

Abstract: The purpose of this study is to describe the technique of total laparoscopic radical hysterectomy (type III procedure) with lymphadenectomy as performed at the Advanced Gynecological Endoscopy Center of the Malzoni Medical Center, Avellino, Italy.Seventy-seven patients underwent total laparoscopic radical hysterectomy (type II, III) with lymphadenectomy between January 2000 and March 2008. FIGO stage included five patients Ia1 with LVSI (lymph-vascular involvement), 24 patients Ia2, and 48 patients Ib1. 60 patients underwent a class III procedure and 17 patients a class II procedure according to the Piver classification.Histological types included squamous cell carcinoma in 65 patients, adenocarcinomas in 10 patients, and adenosquamous carcinoma in two. Para-aortic lymphadenectomy was performed up to the level of the inferior mesenteric artery in eight cases with positive pelvic lymph nodes at frozen section evaluation.Total laparoscopic radical hysterectomy can be considered a safe and effective therapeutic procedure for the management of early stage cervical cancer with a low morbidity; moreover, the laparoscopic route may offer an alternative option for patients undergoing radical hysterectomy, although multicenter studies and long-term follow-up are required to evaluate the oncologic outcomes of this procedure.

Surgical management of hepatocellular carcinoma: Is the jury still out?

G. Morris-Stiff, D. Gomez, N. de Liguori Carino, K.R. Prasad — 2009-12-01

Abstract: Introduction: Hepatocellular carcinoma (HCC) is currently the fifth most common neoplasm worldwide. The only therapies which are capable of providing cure are hepatic resection and liver transplantation. Results from either resection or transplantation show 5-year survival rates of up to 70% in selected patients. Patient assessment is key to selecting candidates for surgery be it resection or transplantation.Methods: A search was performed of the English Medline database for the period 1997–2006 using the MeSH headings: hepatocellular carcinoma, liver resection, and liver transplantation, with the main analysis concentrated on survival data for all patients undergoing resection or transplantation.Results: There is a large variation in the mortality and recurrence rate following resection/transplantation due to differences in definition in different series. The median perioperative (30 day/in-hospital) mortality rate following resection was a median of 4.7%. The median 1, 3 and 5 year overall survival rates were 80.1%, 55% and 37.1%, respectively. The disease-free survivals at identical time intervals were 64%, 38% and 27%. The median 30 day mortality following liver transplant was 4.7% and the median 3-month mortality was 13.3%. The median overall 1, 3, and 5-year survival rates were 80.9%, 70.2% and 62%, respectively, whilst the disease-free survivals at identical time intervals were 79%, 62.5% and 54.5%. Several risk factors for overall and/or disease-free survival following resection and transplantation were found in those papers where a multivariate analysis was included.Discussion: A possible algorithm would be to perform resection for patients with preserved liver function and offer transplantation to those of Child–Pugh status B or C who fit within Milan criteria. If recurrence occurred after resection or underlying liver disease progresses, salvage transplants may be performed.Conclusion: The current evidence base for resection and transplantation in the treatment of HCC is inadequate to provide a definite answer as to which is optimal therapy and a randomised controlled trial to compare the outcomes of resection and transplantation is now required.

Laparoscopic assisted distal gastrectomy for early gastric cancer: Is it an alternative to the open approach?

Danny Yakoub, Thanos Athanasiou, Paris Tekkis, George B. Hanna — 2009-12-01

Abstract: Objective: This study aims to compare short term outcomes and oncological value of laparoscopy assisted (LADG) and open distal gastrectomy (ODG) in the treatment of early gastric cancer.Methods: Meta-analysis of 12 studies, including three randomized controlled trials, published between 2000 and 2007, comparing laparoscopy assisted and open distal gastrectomy in 951 patients with early gastric cancer, was done. Outcomes of interest were operative data, lymph node clearance, postoperative recovery complications.Results: Overall morbidity rate was significantly less with LADG (10.5% versus 20.1%, P=0.003, OR 0.52, CI 0.34–0.8). A mean of 4.61 less number of lymph nodes dissected than ODG (CI −5.96, −3.26 P<0.001) when all studies are included. There was no difference between the two groups in number of lymph nodes dissected when less than D2 lymphadenectomy was done (2.44 nodes less in LADG group, CI −5.52, 0.63; P=0.12). LADG patients had less operative blood loss (mean of 151ml, P<0.001), less time to walking, oral intake and flatus. LADG patients had less length of hospital stay (5.7days, P<0.001), postoperative fever and pain. ODG group showed significantly less operative time. There was no significant difference between the two groups in the incidence of anastomotic complications and wound infection.Conclusion: LADG is a safe technical alternative to ODG for early gastric cancer with a lower overall complication rate and enhanced postoperative recovery. Endorsing LADG as a better alternative to ODG requires data on long term survival, quality of life and cost effectiveness.

Localized resection for colon cancer

R.A. Cahill, J. Leroy, J. Marescaux — 2009-12-01

Abstract: Localized resection of early stage colon cancer is increasingly technically feasible by truly minimally invasive means. Such techniques as endoscopic submucosal dissection (ESD) and Natural Orifice Transluminal Endoscopic Surgery (N.O.T.E.S.) now raise the prospect of focused intraluminal and transmural resection of small primary tumors without abdominal wall transgression. The potential clinical benefit that patients may accrue from targeted dissection as definitive treatment in place of radical operation is not yet definitively proven but may be considerable at least in the short-term. However, oncological propriety and outcomes must be maintained. In particular methods by which regional nodal staging can be assured if standard operation is avoided need still to be established. Sentinel node mapping is one such putative means of doing so that deserves serious consideration from this perspective as it performs a similar function for breast cancer and melanoma and because there is already considerable evidence to suggest the technique in colonic neoplasia may be at its most accurate in germinal disease. In addition, it may already be employed by laparoscopy while solely transluminal means of its deployment are advancing. While the confluence of operative technologies and techniques now coming on-stream has the potential to precipitate a dramatic shift in the paradigm for the management of early stage colonic neoplasia, considerable confirmatory study is required to ensure that oncology propriety and treatment efficacy is maintained so that patient benefit may be maximized.

Endoprosthetic proximal femur replacement: Metastatic versus primary tumors

2009-12-01

Abstract: Few studies have examined the impact of underlying diagnosis on the functional and oncologic outcomes following endoprosthetic proximal femur replacement (PFR). We performed a retrospective review of 61 consecutive cemented bipolar PFR in 59 patients for treatment neoplastic lesions with a minimum follow-up of 24months. Twenty-two patients had primary bone tumors and 39 had metastatic disease. Average follow-up for the 30 surviving patients was 55.4months and the mean postoperative survival for the 29 patients who died was 12.2months. Patients with primary tumors demonstrated significantly better functional outcomes than those with metastatic disease, with mean Musculoskeletal Tumor Society functional scores of 80.2 and 66.8%, respectively (p=0.0002). Age correlated inversely with functional scores (r=−0.48; p=0.0002), while femoral resection length did not. Preoperative pathologic fracture did not appear to adversely impact final functional outcomes. The Kaplan–Meier 5-year implant survival estimate was 92.5%, with aseptic loosening as the endpoint. Both functional results and survival are increased for primary tumors versus metastatic disease following PFR. However, PFR results in excellent local disease control, reliable pain relief and good functional results in both groups, with prosthesis survival exceeding that of the patient in many cases.

Successful publishing: How to get your paper accepted

2009-12-01

Abstract: Medical science is rapidly evolving and an incredible number of publications are being published. Are they all worth reading? Authors are deemed responsible for what they put down in writing; whether they are first or corresponding author, it really makes no difference. Editors of peer-reviewed international journals have agreed to share their views with the readership, in order to optimise the quality of contributions as well as to assist junior colleagues in their editorial efforts. Starting from an historical perspective, ethical issues in publishing are discussed and technical suggestions on how to get the final draft accepted for publication are outlined. Contributing towards medical science is a great pleasure to be experienced and shared.

Loss of Bcl-2 expression in colon cancer: A prognostic factor for recurrence in stage II colon cancer

2009-12-01

Abstract: Aims: To evaluate the prognostic value of immunohistochemical expression of Bcl-2 in colon cancers.Patients and methods: Two hundred and twenty-six resected and paraffin-embedded colon carcinomas were analysed by immunostaining using monoclonal antibodies for Bcl-2. We evaluated whether the Bcl-2 staining patterns, semi-quantitatively assessed, could be correlated with the pTNM stage, size and tumour circumference, differentiation, appearance, vascular invasion, perineural invasion, colloid component, margins, involvement of adjacent structures, stromal appearance, flow cytometry and the S-phase.Results: Eighty patients (36%) were considered Bcl-2 positive. The extent of Bcl-2 expression by tumour cells decreased significantly with respect to increasing tumour size (P=0.042), the extension of parietal invasion pT (P=0.007), the invasive nature of the tumour (P=0.024), and extent of the circumference (P=0.024). In a multivariate analysis, Bcl-2 expression does not appear as an independent prognosis factor in the overall population as in the 166 patients with optimal resection. Of the 59 stage II patients, using univariate analysis, Bcl-2 appears to be predictive of relapse-free survival (P=0.025) but not of overall survival (P=0.09).Conclusion: The loss of Bcl-2 expression appears to be correlated with increase in number of relapses in the stage II colon cancers and could be a potential useful additional histo-prognostic marker in therapy decision making. Bcl-2 immunodetection seems to be associated with slower local tumour growth.

Gene expression profiling: Decoding breast cancer

Femke de Snoo, Richard Bender, Annuska Glas, Emiel Rutgers — 2009-12-01

Abstract: Gene expression assays that are used in daily clinical practice for treating early breast cancer patients have been introduced in the clinic only recently. This review discusses the development of these arrays, summarizes the validation of those that are commercially available and indicates how the information provided by these assays can help in the care of patients. The review also provides an extensive overview of commercially available assays focusing on MammaPrint, the first and only assay for breast cancer management that has been cleared by the FDA.

Impact of total retrieved lymph nodes on staging and survival of patients with gastric cancer invading the subserosa

2009-12-01

Abstract: Purpose: To investigate the impact of total retrieved lymph nodes (tLNs) on staging and survival in patients with pT2b gastric cancer according to the nodal status.Methods: Clinicopathological characteristics and prognostic outcomes of 392 patients with pT2b gastric cancer between 1980 and 2005 were retrospectively investigated based on the nodal status.Results: The number of metastatic lymph nodes (mLNs) was highly correlated with the number of tLNs (P<0.001). The overall 5-year and 10-year survival rates were 39.0% (153/392) and 17.9% (70/392), respectively. The survival rates in patients with pN0 cancers did not differ significantly from that in patients with pN1 cancer when the tLNs were 25 or less. However, the survival rate in patients with N0 cancers was significantly greater than that in patients with pN1 cancers when the tLNs were more than 25 (64.3% vs. 36.9%, χ2=4.339, P=0.037). Moreover, both 5- and 10-year survival rates differed significantly among patients with pN1, pN2 and pN3 gastric cancer regardless of tLNs. Multivariate analysis revealed that age, tumor focus number, tumor location, and mLN, but not tLNs, were independent prognostic predictors in patients with pT2b gastric cancer.Conclusions: To improve the accuracy of staging, no less than 15 tLNs should be pathologically examined in patients with pN1–3, and 25 tLNs for the patients with N0. More tLNs may not be associated with a better prognosis in pT2b disease because the extent of lymph node dissection is pre-defined for the operation.

Color atlas of cutaneous excisions and repairs

Philip T.H. Brackley — 2009-12-01

Plastic Surgery, more than any other surgical specialty, is visual. As a plastic surgical trainee, much of the work load involves excision of various skin cancers and resurfacing the defect created using the foundation principles of the reconstructive ladder. Creating the “hole” is relatively straight forward. It is the “filling of the hole” that surgeons can literally fall short, either by compromising excision margins to ensure the surrounding tissue will come together or by utilizing poorly designed local flaps that either do not reach their destination end point or are aesthetically suboptimal.

Controversies in the Treatment of Prostate Cancer

L. Denis — 2009-12-01

This compact 130 page book, published in the solid Karger style tradition represents a number of presentations from the 10th International Symposium on Special Aspects of Radiotherapy hold in Berlin, September 2–8, 2006. With the scientific publication pace in this millennium any book is a bit outdated by the time it is published. However the editors and authors, a fine blend of urologists and radiation oncologists, were clearly instructed to focus their contribution on compact no-nonsense facts presented for clinical practice. This rather difficult task has been executed in an exemplary way.

Surgical recall

Lynda Wyld — 2009-12-01

This book has been written by Lorne H Blackbourne, a surgeon in Texas, USA. The book is aimed at students and junior residents in surgery. I enjoyed reading this book as the style of writing is informal and practically orientated. The book contains a wealth of useful information and is small enough to be carried as a pocket guide. There are however some criticisms to be levelled at the book.

The Cambridge Illustrated History of Surgery

Riccardo A. Audisio, Matilde M. Audisio — 2009-12-01

History is a means of illustrating our progression through the past, thus enabling us to better understand the present. Whilst considering the history of our progress through the past centuries (as well as the diversity of this progress across different cultures) we are able to better appraise our present performance.

Erratum to “Book Review: Clinical Progress in Renal Cancer. Informa Healthcare, Tim Eisen, Tim Christmas (Eds.). (2007). 209 pp., ISBN: 10-284284-604X” [Surg. Oncol. 17 (2008) 59]

Tim Porter — 2009-12-01

The ISBN of the book “CLINICAL PROGRESS IN RENAL CANCER” should appear as follows: 184184604X.