Surgical Oncology - Articles in Press

Unusual localizations of sentinel lymph nodes in early stage cervical cancer: A review - Corrected Proof

Lobna Ouldamer, Henri Marret, Olivier Acker, Isabelle Barillot, Gilles Body — 2012-05-18

Abstract: Objective: The aim of this study was to systematically determine the frequency of unusual localizations of sentinel lymph node in patients with early stage cervical cancer.Methods: We performed a comprehensive computer literature search of English and French language studies in human subjects on sentinel node procedures in PUBMED database up to December 2010. For each article two reviewers independently performed data extraction using a standard form to determine the route of unusual lymphatic spread of sentinel procedures in cervical cancer.Results: According to our search, 83.7% of detected sentinel lymph nodes in patients with cervical cancer were in expected localizations (i.e., external iliac, obturator, internal iliac or interiliac). The unusual localizations were: 6.6% in the common iliac chain, 4.31% parametrial, 1.26% sacral, 2% in the lower para-aortic area and 0.07% in the inguinal chain.Conclusion: The unusual localizations of sentinel lymph nodes impose to the gynecologic surgeons to be able to perform lymph node dissection in all the territories potentially affected.

Implications of clinical risk score to predict outcomes of liver-confined metastasis of colorectal cancer - Corrected Proof

2012-05-07

Abstract: Objective/background: We investigated the usefulness of a clinical risk scoring system (CRS) for guiding management and defining prognosis for patients with colorectal liver met"astases (CLM).Method: We retrospectively analyzed data about the correlation between outcomes and Fong's CRS from 1989 to 2010 for patients treated for CLM at the Severance Hospital.Results: Of 566 patients, 232 received adjuvant treatment after liver resection. Of these patients, 185 (81%) had a low CRS (0–2) and 47 (19%) had a high CRS (3–5). Stratification into high and low CRS allowed significant distinction between Kaplan–Meier curves for outcome. The 5-year survival rate was 88.5% and 11.5% among patients with a low and high CRS, respectively (P < 0.001). Seventy patients with initially unresectable CLM underwent liver resection after tumor downsizing by induction chemotherapy. Shifting of the CRS from high to low (8 patients; 11.4%) improved disease-free survival and overall survival.Conclusion: High CRS is associated with worse survival after resection in resectable and unresectable disease. The CRS may be used for risk assessment when recommending oncological surgical timing in initially unresectable disease and treatment options for perioperative or adjuvant treatment in resectable disease.

Skeletal metastases – The role of the orthopaedic and spinal surgeon - Corrected Proof

Nicholas Eastley, Martyn Newey, Robert U. Ashford — 2012-05-04

Abstract: Developments in oncological and medical therapies mean that life expectancy of patients with metastatic bone disease (MBD) is often measured in years. Complications of MBD may dramatically and irreversibly affect patient quality of life, making the careful assessment and appropriate management of these patients essential.The roles of orthopaedic and spinal surgeons in MBD generally fall into one of four categories: diagnostic, the prophylactic fixation of metastatic deposits at risk of impending fracture (preventative surgery), the stabilisation or reconstruction of bones affected by pathological fractures (reactive surgery), or the decompression and stabilisation of the vertebral column, spinal cord, and nerve roots.Several key principals should be adhered to whenever operating on skeletal metastases. Discussions should be held early with an appropriate multi-disciplinary team prior to intervention. Detailed pre-assessment is essential to gauge a patient’s suitability for surgery – recovery from elective surgery must be shorter than the anticipated survival. Staging and biopsies provide prognostic information. Primary bone tumours must be ruled out in the case of a solitary bone lesion to avoid inappropriate intervention. Prophylactic surgical fixation of a lesion prior to a pathological fracture reduces morbidity and length of hospital stay. Regardless of a lesion or pathological fracture’s location, all regions of the affected bone must be addressed, to reduce the risk of subsequent fracture. Surgical implants should allow full weight bearing or return to function immediately. Post-operative radiotherapy should be utilised in all cases to minimise disease progression.Spinal surgery should be considered for those with spinal pain due to potentially reversible spinal instability or neurological compromise. The opinion of a spinal surgeon should be sought early, as delays in referral directly correlate to worse functional recovery following intervention. Patients who suffer a slowly progressive deficit, present within hours of complete neurological deficit, or have compression caused by bone alone are those most likely to benefit from surgery. Back pain in the presence of MBD should be regarded as impending spinal cord compression, and investigated urgently to allow intervention prior to the development of neurological compromise.

How does preoperative radiotherapy affect the rate of sphincter-sparing surgery in rectal cancer? - Corrected Proof

Bilal Baker, Habeeb Salameh, Mohammad Al-Salman, Faiez Daoud — 2012-04-26

Abstract: The use of preoperative radiotherapy has resulted in significant downstaging and downsizing of tumor, this in turn facilitated resections permitting sphincter preservation and coloanal anastomosis for patients who would otherwise have not been candidates for this type of surgery as concluded by some small studies. On the other hand, other clinical trials have shown that the effect of radiotherapy on the rate of sphincter preservation is still not clear. Moreover, different modes of radiotherapy have been tested on the rate of sphincter preservation such as pelvic irradiation with or without combination of chemotherapy, short or conventional course radiotherapy, and preoperative or postoperative radiotherapy with different timing intervals of surgery. Unfortunately, these trials didn't clearly answer the question of radiotherapy benefit for the sake of sphincter preserving of rectal cancer patients and the question remained hotly debated.

Dendritic cell therapy in advanced gastric cancer: A promising new hope? - Corrected Proof

2012-04-23

Abstract: Advanced gastric cancer carries a very poor prognosis when the tumor becomes unresectable. Even with the best currently available chemotherapy regimens the survival rate remains dismal. A recent breakthrough in the treatment paradigm has been the approval of trastuzumab, a monoclonal antibody, in HER2-positive metastatic gastric cancer. A large number of trials are underway using dendritic cells (DCs) in a number of human malignancies and do show a ray of hope in management of these patients. This review attempts to summarize tumor immunology and the current data regarding use of DCs in gastric cancer therapy.

Update on totally implantable venous access devices - Corrected Proof

2012-03-19

Abstract: The use of totally implantable venous devices (TIVAD) has changed the care and quality of life for cancer patients, these devices allow chemotherapy administration, and blood sampling without the need for repeated venipuncture. These ports are used mainly when IV access is needed only intermittently over a long period of time.We are presenting a brief overview on TIVADs, with focus on the mid and long-term complications associated with these devices with their management.

Fast-track surgery and technical nuances to reduce complications after radical cystectomy and intestinal urinary diversion with the modified Indiana pouch - Corrected Proof

2012-03-15

Abstract: Objectives: With the purpose to reduce the complications of radical cystectomy and intestinal urinary reconstruction a perioperative protocol based on fast-track surgery principles and technical modifications of the original surgical technique was applied to patient candidates for etherotopic bladder substitution. Our protocol included pre-, intra-, and postoperative interventions. The technical variations of the modified Indiana pouch technique were focused on intestinal anastomosis to restore bowel continuity, uretero-colonic anastomoses, and capacity of the reservoir.Results and limitations: From 2003 to 2010, 68 consecutive patients participated in the study. Two patients died due to surgical complications (2.9%). Overall, 24 of 68 patients experienced complications (35.3%). Surgery was needed under general anaesthesia for seven patients (10.2%) and under local anaesthesia for four (5.9%). Medical complications were encountered in 13 of 68 patients (19.1%). According to Clavien grading, complications were grade 5 in two patients, grade 4 in two patients, grade 3b in five patients, grade 3a in four patients, grade 2 in nine patients, and grade 1b in two patients. A limitation of our series is that patients were recruited at a single urologic centre and were operated by a single surgeon. Findings need validation.Conclusions: Progress in the perioperative management of major surgery and technical refinements can contribute to reduced complications. In addition, the use of objective reporting tools will facilitate comparison of studies.

Management and prognosis of endometrioid borderline tumors of the ovary - Corrected Proof

2012-03-14

Abstract: Background: The Endometrioid Borderline ovarian tumor (EBOT) is the third most common histological subtype of borderline ovarian tumors. Very little is known about the prognosis and management of this entity. This paper consists of a review of the literature and an analysis of clinical series.Study design: A review of the literature on this topic was conducted identifying series reporting consecutive cases of EBOT using 2 search engines (MEDLINE and Pubmed). Personal data on this topic have been included and concern a series of patients treated between 1985 and 2009 for EBOT. These cases included in this series had complete data concerning patient management and follow-up > 12 months.Results: 16 patients were studied: 7 had been treated conservatively and 9 radically. All 16/16 patients had stage I disease at the initial diagnosis but one patient had also developed synchronous endometrioid adenocarcinoma of the uterine corpus. After a median time of 24 months (range, 12–132) post treatment, one (1/16) patient had developed two recurrences. She remains disease-free 42 months after the end of treatment of the last recurrence. These data were compared to the results of 4 series previously reported in the literature. In fact, the present series reports on the first recurrence in EBOT (which was an invasive lesion).Conclusion: Endometrioid borderline ovarian tumors carry a good prognosis. Most EBOT tumors are stage I, therefore surgical staging is not necessary in most of the cases. However, uterine curettage is required in cases of uterine preservation.

Stimulation of neo-angiogenesis by combined use of irradiated and vascularized living bone graft for oncological reconstruction - Corrected Proof

2012-01-12

Abstract: Reconstruction for large bone and osteochondral defects following musculoskeletal tumor excision remains challenging. Mega-prosthesis is clearly a useful reconstructive tool. Because the survival time of tumor patients has been increasing due to better treatment options, the aim of our group is to achieve complete biological reconstruction without using any artificial materials. With this approach, durability would not be a limitation. In the present study, we reviewed the biological reconstructive procedures currently available for large bone defects after tumor excision.Devitalized bone autograft is particularly well suited in the region where allografts are not readily available. However, the complication rate, such as infection and spontaneous bone resorption, was unexpectedly high due to non-viable graft. In an attempt to reduce these complications, we have used irradiated bone autograft in combination with free vascularized viable bone graft. In an experimental study, we demonstrated a neo-vascularization effect of vascularized bone graft with devitalized bone autograft, i.e. to convert dead bone into living bone. Clinically, this technique is best indicated for reconstruction of intercalary bone defect, especially tibial shaft. Some degree of articular change occurs after irradiation and cannot be prevented, even with the combined use of vascularized bone graft. In our experience, secondary procedures such as surface replacement prosthesis are necessary to treat the osteoarthritis in such cases, even if the radiological finding is severe.The rationale for a combined vascularized and irradiated bone autograft is the cumulative advantage provided by the biological properties of the former with the mechanical endurance of the latter.

Sentinel lymph node biopsy in breast cancer: A history and current clinical recommendations - Corrected Proof

Desiree D. D’Angelo-Donovan, Diana Dickson-Witmer, Nicholas J. Petrelli — 2012-01-11

Abstract: The advent of sentinel lymph node biopsy changed the way the surgical community treated breast cancer. It also reduced the post operative morbidity for millions of patients. Now that sentinel lymph node biopsy has become the mainstay of treatment, new clinical questions have arisen and continued research is being done to answer these questions. This report details a brief history of sentinel lymph node biopsy and how it was applied in the treatment a breast cancer. This report also includes a review of the current literature regarding unique clinical scenarios involving sentinel lymph node biopsy in breast cancer including the ACOSOG Z011 trial.

Prediction of normal tissue toxicity as part of the individualized treatment with radiotherapy in oncology patients - Corrected Proof

2012-01-03

Abstract: Normal tissue toxicity caused by radiotherapy conditions the success of the treatment and the quality of life of patients. Radiotherapy is combined with surgery in both the preoperative or postoperative setting for the treatment of most localized solid tumour types. Furthermore, radical radiotherapy is an alternative to surgery in several tumour locations. The possibility of predicting such radiation-induced toxicity would make possible a better treatment schedule for the individual patient. Radiation-induced toxicity is, at least in part, genetically determined. From decades, several predictive tests have been proposed to know the individual sensitivity of patients to the radiotherapy schedules. Among them, initial DNA damage, radiation-induced apoptosis, gene expression profiles, and gene polymorphisms have been proposed. We report here an overview of the main studies regarding to this field. Radiation-induced apoptosis in peripheral blood lymphocytes seem to be the most promising assay tested in prospective clinical trials, although they have to be validated in large clinical studies. Other promising assays, as those related with single nucleotide polymorphisms, need to be validated as well.

18FDG-PET/CT for detection of mediastinal nodal metastasis in non-small cell lung cancer: A meta-analysis - Corrected Proof

Lin Zhao, Zhi-Yi He, Xiao-Ning Zhong, Miao-Ling Cui — 2011-12-26

Abstract: Background: We performed a meta-analysis to evaluate the role of 18F-fluorodeoxyglucos -e positron emission tomography/computed tomography (18FDG-PET/CT) in detecting mediastinal nodal metastasis in patients with non-small cell lung cancer (NSCLC).Methods: Studies about 18FDG-PET/CT for detecting mediastinal nodal metastasis in patient with NSCLC were systematically searched in the MEDLINE, EMBASE, and EBM Review databases from January 1, 2000 to July 26, 2011. A software called “Meta-Disc” was used to obtain pooled estimates of sensitivity, speciﬁcity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR), respectively. We also calculated summary receiver operating characteristic (SROC) curves, and the Q* index.Results: 20 articles fulﬁlled all inclusion criteria (3028 eligible patients). The pooled sensitivity, and speciﬁcity with 95% confidence interval for PET/CT on a per-patient analysis were 0.719 (0.683–0.753), and 0.898 (0.882–0.912). Corresponding values for PET/CT on a per-nodal-station analysis were 0.610 (0.582–0.636), 0.924 (0.918–0.930). The Q* index estimates under SROC were 0.8464 and 0.8067, respectively.Conclusions: 18FDG-PET/CT had more specificity but less sensitivity for mediastinal nodal metastasis in patients with NSCLC.

Rectal cancer surgery: A brief history - Corrected Proof

Avi S. Galler, Nicholas J. Petrelli, Shanthi P. Shakamuri — 2011-10-17

Abstract: In the last 250 years, the treatment of rectal cancer has changed dramatically. Once considered an incurable disease, combined modality therapy has improved mortality from 100% to less than 4% for locally advanced rectal cancer. This dramatic reduction paralleled surgical techniques based on a growing understanding of anatomy and disease pathology. In order to understand modern treatment, it is necessary to recognize the achievements of preceding surgeons.

Vascular encasement as element of risk stratification in abdominal neuroblastoma - Corrected Proof

2011-10-17

Abstract: Background: Vascular encasement of major vessels has been introduced as element of image defined risk factors (IDRF) for stratification of abdominal neuroblastoma. Some subgroups of this tumor entity are still subject of discussion regarding surgical approach and radicality. Aim of this study was to analyse a cohort of related patients.Patients and methods: Children operated on for neuroblastoma with encasement of major abdominal vessels (April 2002–April 2009) were retrospectively evaluated regarding surgical procedures, intra- and postoperative complications, and outcome.Results: There were 18 patients with abdominal NB and encasement of major vessels. Mean age at operation was 43.5 months (2.5–113), mean operation time was 228 minutes (157–428). Complete macroscopic tumor resection was realised in 14 children. Vascular reconstruction was necessary in 5 patients. Tumor progression/relapses requiring further operation occurred in 3 patients. Major postoperative complications were 1 loss of unilateral renal function with subsequent nephrectomy, 1 renal vein thrombosis (operative revision), 1 renal artery embolism (operative revision), and 1 ureteral obstruction (stenting). Mean follow up was 34.8 months (2–78).Conclusions: Vascular encasement as part of IDRF is a valuable tool for stratification of abdominal NB. Surgery of NB with vascular encasement includes divers and complex procedures. Children seem to benefit from complete tumor resection or at least relevant tumor reduction although operations can mean a relevant strain for the patients.

The effects of radiofrequency ablation on the hepatic parenchyma: Histological bases for tumor recurrences - Corrected Proof

G. Gravante, S.L. Ong, M.S. Metcalfe, N. Bhardwaj, D.M. Lloyd, A.R. Dennison — 2011-10-17

Abstract: Background: This review examines histological modifications obtained after liver radiofrequency ablation (RFA).Methods: A literature search has been undertaken for all pre-clinical and clinical studies involving RFA and in which ablation zones have been excised for a complete histological examination.Results: Two main histological areas are present, a central zone of coagulative necrosis and a peripheral rim of congestion and extravasation. Both corresponded to specific microscopic characteristics that evolved over time and that are influenced by the proximity of patent vessels and the liver perfusion status. Viable cells are not present in the central zone but have been described in the ischemic peripheral rim where they survive the ischemia and inflammation process. These correspond in clinical studies to residual viable tumor cells that lead to failure of the procedure.Conclusions: Histological changes following RFA are complex and interactions take place at both a cellular and tissue level. Changes in the peripheral zone must be considered in future studies in order to extend the volume of reliable tumor destruction and increase the effectiveness of the procedure.

Effect of 103Pd radioactive stent on caspase-9, cholangiocarcinoma cell growth and its radiosensitivity - Corrected Proof

2011-10-17

Abstract: Background: To investigate the effect of 103Pd radioactive stent on Caspase-9, cholangiocarcinoma cell growth and its radiosensitivity.Methods: Cholangiocarcinoma was treated with 103Pd radioactive stent at different period. Radiosensitivity of the cells was detected by methyl thiazolyl tetrazolium (MTT) method. Apoptosis of cholangiocarcinoma cells was detected by immunohistochemistry and electron microscope. The activity of Caspase-9 was detected by non-radioimmunoprecipitation, while its protein expression was detected by Western blot.Results: 103Pd radioactive stent had significant inhibitive effect on cholangiocarcinoma cells and it could induce apoptosis. After treatment by 103Pd radioactive stent for 10 days, the activity of Caspase-9 was gradually enhanced, which was markedly decreased in common stent group. Cholangiocarcinoma cells had relatively high sensitivity to 103Pd radiation.Conclusion: 103Pd radioactive stent can activate caspase-9 gene to induce apoptosis of cholangiocarcinoma cell, inhibit its growth and enhance its radiosensitivity.

Corrected Proof

Yuen Cheng Looi — 2011-10-17

Pain associated with cancer, with its various other complications, remains a challenge for many. Any book that can shed more light in this area is thus always welcomed. This 643-page tome aims to “provide a reference for both those who seek the basics and those who seek a scholarly review of the many domains relevant to an in-depth understanding of cancer pain and specialist skills in practice, including syndrome identification and multi-dimensional assessment, the relationships between pain management and cancer medicine and between pain and other quality of life concerns, the many pharmacologic and non-pharmacologic best practices in pain care and the diverse needs of special populations”. These are ambitious aims. Unfortunately, it does not quite deliver.

Recent advances in non-invasive axillary staging for breast cancer - Corrected Proof

O.C. Iwuchukwu, S. Wahed, A. Wozniak, M. Dordea, A. Rich — 2011-10-17

Abstract: Nodal staging in breast cancer is a key predictor of prognosis and directs subsequent adjuvant therapy. This article addresses current modalities of nodal staging in breast cancer but focuses on promising non-invasive alternatives for staging the axilla.

Corrected Proof

M. de Matas — 2011-10-17

This publication is co-authored by a Professor of Neurosurgery and an Associate Professor of Neurology who have specialist interests in both complex spinal surgery and spinal disorders with neurological complications. Both are recognised experts in their fields.

Clinico-pathologic features of primary melanoma and sentinel lymph node predictive for non-sentinel lymph node involvement and overall survival in melanoma patients: A single centre observational cohort study - Corrected Proof

2011-10-17

Abstract: Objective: Completion Lymph Node Dissection (CLND) is the current standard of practice for patients with a positive Sentinel Lymph Node Biopsy (SLNB). Significant morbidity is associated to CLND, so we tried to evaluate which prognostic variables could predict NSLN invasion in SLN-positive patients and their impact on the overall survival (OS).Methods: A retrospective chart review of 603 patients that had undergone SLNB for melanoma between 2000 and 2009 at our department was done. 100 SLN were positive at the histopathological analysis of SLN. Demographic variables, primary melanoma, SLN pathologic features and results of CLND were analysed. Multivariate logistic regression and OS analyses were carried out to test the prognostic relevance of clinico-pathologic variables on CLND results and disease course.Results: Breslow thickness, ulceration and micro/macrometastatic pattern of SLN invasion carried a significantly independent higher likelihood of NSLN involvement; Starz classification did not maintain a statistical significance in multivariate analysis. Only one patient (4.3%) without adverse prognostic factors showed NSLN involvement, which was found in 33.3% of patients with one and 55.9% with two or more adverse parameters (p = 0.0001). OS analyses confirmed the prognostic significance of these factors.Conclusion: Waiting for the results of Multicenter Selective Lymphadenectomy Trial II, our study suggests a clinically useful and easily applicable means of identifying patients with an unfavourable disease course. The presence of one or more adverse factors identifies patients in whom CLND is mandatory to include thereafter in a more strict follow-up program. Moreover, the finding of no adverse prognostic indicators associated to the presence of significant co-morbidities and/or elderly age, could be useful in identifying patients not to treat by CLND.

A case of multiple brain metastases of uterine leiomyosarcoma with a literature review - Corrected Proof

2011-10-17

Abstract: Brain metastasis from uterine leiomyosarcoma is extremely rare, and prognostically alarming despite various treatments. The authors report a case of multiple brain metastases from uterine leiomyosarcoma who took a favorable course after tumor resection and γ-knife treatment. A 50-year-old woman with a history of hysterectomy for uterine leiomyosarcoma two years earlier, presented with a recent onset of headaches and vomiting. Multiple cerebral lesions were found by magnetic resonance imaging (MRI). The Karnofsky performance scale (KPS) was 40 with left hemiparesis and cerebellar ataxia. She was treated by resection of the left occipital and cerebellar tumors, followed by γ-knife irradiation of the residual tumors. KPS was 70 at her discharge from the hospital. MRI failed to show recurrence of the intracranial lesions 6 months after irradiation. She remained at home until she died from massive intra-abdominal bleeding. This is the first case with multiple brain metastases from uterine leiomyosarcoma, who survived with remarkable neurological improvement for 12 months. No comparable survival has been reported in the literature. It is evident that surgical resection and additional γ-knife irradiation contributed to early neurological recovery.

Local recurrence of pancreatic cancer after primary surgical intervention: How to deal with this devastating scenario? - Corrected Proof

2011-10-17

Abstract: The dismal prognosis of pancreatic cancer reflects into the increased recurrence rate, even after R0 pancreaticoduodenectomy. Although, conventional radiation-, chemo- or surgical therapy in much selected cases, seem to work out favorably long term, less invasive and non-toxic methods with more immediate results are always preferred, concerning the already aggravated status of this group of patients.We present hereby a comprehensive review of the literature concerning the treatment of recurrent pancreatic cancer based on the case of a patient who 20 months after a pancreaticoduodenectomy developed portal hypertension and symptomatic first degree esophageal, gastric and mesenteric varices, caused by the nearly complete splenic vein obstruction at the portal vein confluence. The varices were revascularized by a percutaneous transhepatic placement of an endovascular stent into the splenic vein, along with a sequent stereotactic body radiation therapy for the local tumor control.Thanks to the accuracy and safety of the present combined treatment, the patient one year later presents control of the disease and its complications.Our paper is the first in the international literature that tries to review all the treatment modalities available (surgical, adjuvant, neoadjuvant and palliative therapy) and their efficacy, concerning the locally recurrent pancreatic cancer; furthermore, we tried to analyze the application of the above mentioned combined therapeutic approach in similar cases, elucidating simultaneously all the questions that arise. The limited existing data in the international literature and the lack of randomized controlled trials make this effort difficult, but the physician should be aware after all of all the available and innovative treatment modalities, before he chooses one. Finally, we would like to emphasize the fact that not only the local control but also the management of the complications are important for a prolonged median survival and a better quality of life after all.

Management of non metastatic phyllodes tumors of the breast: Review of the literature - Corrected Proof

Parham Khosravi-Shahi — 2011-10-17

Abstract: Phyllodes tumors of the breast are rare tumors, accounting for less than 0.5% of all breast tumors. These tumors are comprised of both stromal and epithelial elements; and traditionally they are graded by the use of a set of histologic features into benign, borderline, and malignant subtypes. Unfortunately, the histologic classification of phyllodes tumors does not reliably predict clinical behavior.The mainstay of treatment of non metastatic phyllodes tumors of the breast is complete surgical resection with wide resection margins. Lumpectomy or partial mastectomy is the preferred surgical therapy. However, despite the complete surgical resection, local failure rate may be high; and 22% of malignant tumors may give rise to haematogenous metastases. The most frequent site of distant metastases is the lungs. Several predictive factors of recurrence and metastases have been described in the literature, such as positive surgical margins, increased stromal cellularity, stromal overgrowth, stromal atypia and increased mitotic activity.Nevertheless, the role of adjuvant therapies (radiotherapy and chemotherapy) is presently undefined and should be tested in multicenter, prospective, randomized trials.

A systematic review of cancer related patient outcomes after anterior resection and abdominoperineal excision for rectal cancer in the total mesorectal excision era - Corrected Proof

P. How, O. Shihab, P. Tekkis, Gina Brown, P. Quirke, R. Heald, B. Moran — 2011-10-17

Abstract: Purpose: It is a widely held view that anterior resection (AR) for rectal cancer is an oncologically superior operation to abdominoperineal excision (APE). However, some centres have demonstrated better outcomes with APE. We conducted a systematic review of high-quality studies within the total mesorectal excision (TME) era comparing outcomes of AR and APE.Methods: A literature search was performed to identify studies within the TME era comparing AR and APE with regard to the following: circumferential resection margin (CRM) status, tumour perforation rates, specimen quality, local recurrence, overall survival (OS; 3 or 5 year), cancer-specific survival (CSS) and disease-free survival (DFS). Additional data regarding patient demographics and tumour characteristics was collected.Results: Twenty four studies fulfilled the eligibility criteria with Newcastle–Ottawa scores of six or greater. Where a significant difference was found, all studies reported lower and more advanced tumours for APE and 4/5 studies observed more frequent use of neoadjuvant and adjuvant therapies in APE patients. Tumour perforation rates and CRM involvement where reported, were significantly greater for APE. 8 out of 10 studies showing significant differences in local recurrence reported higher rates for APE but no differences were observed with distant recurrence. Where differences were noted, AR was reported to have increased DFS, CSS and OS compared to APE.Conclusions: Patients treated with AR have lower rates of tumour perforation and CRM involvement and tend to have better outcomes with regard to disease recurrence and survival. However, tumours treated by APE are lower and more locally advanced.

Resection of perihilar biliary schwannoma - Corrected Proof

2011-10-17

Abstract: Introduction: Schwannomas are usually benign nerve sheath tumors, which typically arise in the head, neck, spinal cord and extremities. Schwannoma of the biliary tract is an extremely rare finding. Patients generally lack symptoms and seek medical attention when tumor growth causes obstructive jaundice. Preoperative diagnosis is difficult and resection is the treatment of choice.Methods: A 54 year-old female with history of back and right labia minor melanoma for which she underwent complete excision and right inguinal lymph node dissection more than 10 years ago, was evaluated for new onset gastroesophageal reflux symptoms and found to have markedly abnormal liver enzymes. Imagining studies revealed intrahepatic ductal dilatation and a 5.2 cm mass in the porta hepatis that was not consistent with cholangiocarcinoma or hepatocellular carcinoma. Multiple percutaneous biopsies of the mass failed to provide a definitive diagnosis. With a high clinical suspicion of metastatic melanoma and no other evident sites of disease, operative intervention was undertaken for diagnosis and definitive treatment.Results: Diagnostic laparoscopy was performed initially, but access to the mass was difficult, given its location. Subsequently, the patient underwent laparotomy, with tumor excision, common bile duct resection and hepato-jejunostomy. Pathologic examination and analysis were consistent with cellular schwannoma. Postoperatively, the patient recovered uneventfully, and liver function studies returned to normal.Conclusion: Schwannomas are uncommon tumors, which very rarely arise from the biliary tract and cause biliary obstruction. Exploration is indicated in order to establish the diagnosis and to render definitive treatment.

Preoperative chemoradiation followed by surgical resection for resectable pancreatic cancer: A review of current results - Corrected Proof

Terence C. Chua, Akshat Saxena — 2011-10-17

Abstract: Background: There has been an interest in the interdisciplinary and multimodality approach that combines chemotherapy and radiation therapy as a preoperative treatment for patients with resectable pancreatic cancer.Methods: Literature search of databases (Medline and PubMed) to identify published studies of preoperative chemoradiation for resectable pancreatic cancer (potentially resectable and borderline resectable) was undertaken. Response to treatment and survival outcomes was examined as endpoints of this review.Results: Seventeen studies; eight phase II studies, and nine observational studies, comprising of 977 patients were reviewed. Gemcitabine-based chemotherapy with radiotherapy was the most common preoperative regimen. Following preoperative treatment, pancreatic surgical resection was performed in 35–100% (median=61%) of patients after a range of 6–32 weeks (median=7 weeks). Rate of pathological response was complete in 5–15% of patients, partial in 33–60% and minimal in 38–42%. The median overall survival ranged from 12 months to 40 months (median=25 months) with a 5-year overall survival rate ranging between 8% and 36% (median=28%). Patients who underwent chemoradiation but did not undergo surgery survived a median period of 7–11 months (median=9 months).Conclusion: Preoperative gemcitabine-based chemoradiation followed by restaging and surgical evaluation for pancreatic resection may identify a sub-population of patients with resectable disease who would benefit the most from surgery. Investigation of this schema of preoperative therapy in a randomized setting of resectable pancreatic cancer is warranted.

Breast cancer in reproductive age. The new plaque or just myth? - Corrected Proof

2011-10-17

Abstract: It is interesting to assess the hitherto knowledge, on breast cancer in reproductive and young females, aged <35. Even if breast cancer is rare in this group, it is, also physically and emotionally devastating. It is characterized by worse prognosis and outcome, in a stage of life, which is delicate for the female patients. This rare subgroup of breast cancer patients is ought to be the center of investigation in future studies. This paper’s mail goal is to elucidate this entity, by presenting several aspects of the disease including risk factors, therapy, natural history and major differences between the groups of breast cancer patients and last but not least, the psychosocial features of this clinical entity, by reviewing the current and past medical literature till April 2011.

Cancer and pregnancy: A comprehensive review - Corrected Proof

E. Voulgaris, G. Pentheroudakis, N. Pavlidis — 2011-10-17

Abstract: Background: Pregnancy complicated by cancer is relatively rare but, as women in western societies tend to delay childbearing to the third and fourth decade of life, this phenomenon is going to be encountered more often in the future.Material and methods: Review of the literature and description of the different diagnostic and therapeutic approaches which are required to diagnose and treat pregnant mothers with cancer.Results: As in non-pregnant patients, every effort should be made to provide the maximal benefit and best prognosis to the pregnant patient. In most cases, in order to avoid any harm to the fetus, different diagnostic approach should be incorporated and treatment should be tailored to each pregnant woman. Cooperation of multidisciplinary teams, incorporating medical and radiation oncologists, surgeons, obstetricians, neonatologists and experienced nursing staff, is required to provide optimal care for the patient. The benefits from use of surgery, chemotherapy and/or radiotherapy as well as the mother’s wishes and beliefs need to be factored into recommendations and treatment planning.Conclusions: With the experience gained, the developments in clinical and radiation oncology and the cooperation of multidisciplinary teams, treatment of cancer during pregnancy with normal fetal outcome is feasible.Highlights: ► Review of the diagnostic and therapeutic dilemmas in cancer during pregnancy. ► Optimal care for the pregnant with minimal harm to the fetus should be the aim. ► Diagnostic approach and treatment needs to be tailored to each woman. ► Strict protocols and multidisciplinary cooperation is mandatory. ► Treatment of gestational cancer with normal fetal outcome is feasible.

Apronectomy combined with laparotomy for morbidly obese endometrial cancer patients - Corrected Proof

2011-10-17

Abstract: Background: The surgical management of morbidly (BMI >40) and super obese (BMI >50) women with endometrial cancer is challenging. The aim of this study was to describe the short and long term outcomes of apronectomy combined with laparotomy for endometrial cancer staging and tumour debulking.Methods: A retrospective case note review of morbidly obese patients undergoing combined apronectomy and laparotomy for suspected endometrial cancer between 2007 and 2009 was performed. Short term (operating time, estimated blood loss, complication rates, duration of hospital stay) and long term outcomes (weight profile over 24-month follow up period) were evaluated.Results: Twenty-one patients were identified with a median age of 58 years and a median BMI of 49 (range 37–64). Apronectomy combined with laparotomy took 192 min on average to complete, with a mean estimated blood loss of 497 ml. There were no intra-operative complications. Postoperative complications included anaemia (14% required a blood transfusion), urinary tract infection (5%) and wound complications (wound infection in 29% and partial wound dehiscence in 5%). The median post-operative stay was 9 days. At twenty-four months, one-third of patients were heavier (mean 5 kg, range 2–8 kg) but almost two-thirds of patients were considerably lighter than they had been pre-operatively (mean 13 kg lighter, range 9–17 kg).Conclusions: Apronectomy combined with laparotomy was safe and well tolerated in this group of patients. Sustained weight loss by two-thirds of the patients over the two-year follow up period may reflect lifestyle changes instigated by individual patients following surgery. Combined apronectomy and laparotomy may provide an alternative to standard surgery for this challenging group of patients.Highlights: ► We combined apronectomy with laparotomy for morbidly obese endometrial cancer patients. ► The short and long term outcomes of 21 patients (median age 58, BMI 49) were retrospectively reviewed. ► On average, surgery lasted 192 min with an EBL of 497 ml; there were no intra-operative complications. ► Wound complications were common (29%) and the median post-operative stay was 9 days. ► At 24 months, two-thirds of the patients weighed less than pre-operatively (mean 13 kg range 9–17 kg).

Sentinel lymph node micrometastasis in human breast cancer: An update - Corrected Proof

Mohamed Salhab, Neill Patani, Kefah Mokbel — 2011-10-17

Abstract: Introduction: The advent of sentinel lymph node biopsy (SLNB) and advances in histopathological and molecular analysis techniques have been associated with an increase in micrometastasis (MM) detection rate. However, the clinical significance of sentinel lymph node micrometastasis (SLN MM) continues to be a subject of much debate. In this article we review the literature concerning SLN MM, with particular emphasis on the prognostic significance of SLN MM. The controversies regarding histopathological assessment, clinical relevance and management implications are also discussed.Methods: Literature review facilitated by Medline and PubMed databases. Cross referencing of the obtained articles was used to identify other relevant studies.Results: Published studies have reported divergent and rather conflicting results regarding the clinical significance and implications of axillary lymph node (ALN) MM in general and SLN MM in particular. Some earlier studies demonstrated no associations, however most recent studies have found SLN MM to be an indicator of poorer prognosis and to be associated with non-SLN involvement.The use of adjuvant chemotherapy and/or hormonal manipulation therapy is associated with an improved survival in patients with SLN MM. Complete ALND may be safely omitted provided that adjuvant systemic therapy recommendations are equal to patients with node-positive disease. However, optimal management of SLN MM is yet to conclude.Furthermore, the identification of MM remains largely dependant on the analytical technique employed and the use of immunohistochemistry (IHC) increases the detection rate of SLN MM. Discrepancies in the histopathological interpretation of TNM classification of SLN tumour burden do exist. Published studies were non-randomized and have significant limitations including a small sample size, limited follow-up period, and lack of standardization and reproducibility of pathological examination of the SLN.Conclusion: Patients with SLN MM have a poorer prognosis than those who are SLN negative. Therapeutic recommendations regarding patients with SLN MM should be taken in the context of multidisciplinary team setting and in selected cases of SLN MM, complete ALND may be safely omitted. A better reproducibility of pathological interpretation of the TNM classification is required so that future therapeutic guidelines can be applied without confusion.Highlights: ► The presence of SLN MM is an indicator of poorer prognosis in breast cancer. ► Use of adjuvant therapy in SLN MM patients is associated with improved survival. ► Complete axillary dissection may be safely omitted in patients with SLN MM. ► The optimal management of SLN MM is yet to conclude.

Primary pancreatic cystic neoplasms of the pancreas revisited. Part IV: Rare cystic neoplasms - Corrected Proof

2011-10-17

Abstract: Primary pancreatic cystic neoplasms are being recognized with increasing frequency due to modern imaging techniques. In addition to the more common cystic neoplasms—serous cystadenoma, primary mucinous cystic neoplasm, and intraductal papillary mucinous neoplasm—there are many other less common neoplasms that appear as cystic lesions. These cystic neoplasms include solid pseudopapillary neoplasm of the pancreas (the most common rare cystic neoplasm), cystic neuroendocrine neoplasm, cystic degeneration of otherwise solid neoplasms, and then the exceedingly rare cystic acinar cell neoplasm, intraductal tubular neoplasm, angiomatous neoplasm, lymphoepithelial cysts (not true neoplasms), and few others of mesenchymal origin. While quite rare, the pancreatic surgeon should at the least consider these unusual neoplasms in the differential diagnosis of potentially benign or malignant cystic lesions of the pancreas. Moreover, each of these unusual neoplasms has their own natural history/tumor biology and may require a different level of operative aggressiveness to obtain the optimal outcome.Highlights: ►Apart from the three common primary pancreatic cystic neoplasms (serous cystic neoplasms, mucinous cystic neoplasms, intraductal papillary mucinous neoplasm), other rare cystic pancreatic neoplasms can be encountered in clinical practice. ►Accurate preoperative identification is not usually possible. ►Surgery is typically required to establish the diagnosis. ►Prognosis depends on the histological type of the neoplasm.

Long term survival in patients with hepatocellular carcinoma directly invading the gastrointestinal tract: Case reports and literature review - Corrected Proof

2011-10-17

Abstract: Hepatocellular carcinoma (HCC) directly invading the gastrointestinal (GI) organs is rare and is associated with poor survival outcome. We report two patients with good long-term outcome following resection of HCC that invaded the stomach and duodenum, respectively. A literature review was conducted to elucidate the course of patients with this pathology. Two cases (57-year-old and 72-year-old males) with enlarged hepatic tumors directly invading the stomach and duodenum underwent hepatectomies with en-bloc resection of the involved organs. Both patients are still alive at 80 and 68 months following the surgery. Our literature review showed that most of the patients with this pathology have manifested, and died of persistent GI bleeding. Patients who were treated surgically had a statistically significant longer survival than those who were treated with non-surgical palliative treatments (P < 0.001). In addition, patients who were treated with surgery with curative intent tend to have a longer survival times than those who were treated with surgery to palliate the bleeding but the difference was not statistically significant (P < 0.174). Removing the tumor completely could significantly prolong the survival of patients with HCC invading the GI tract.

Anterior thigh flap extended hemipelvectomy and spinoiliac arthrodesis - Corrected Proof

2011-10-17

Abstract: We present the technique of anterior thigh flap extended external hemipelvectomy with spinoiliac arthrodesis in treatment of the patient with recurrent low-grade pelvic chondrosarcoma extending to the lower lumbar spine. Extended hemipelvectomy involves skeletal resection beyond the standard hemipelvectomy that is the SI joint by removal of contiguous musculoskeletal structures, such as elements of the sacral and lumbar spine or contralateral pelvic bone, in addition to the affected innominate bone. Spinoiliac arthrodesis reestablishes spinopelvic stability; the anterior thigh musculocutaneous flap provides reliable well-vascularized soft tissue coverage. This technique may serve an important role in the surgical management of patients with low-grade pelvic malignancies.Highlights: ►We present the anterior thigh flap extended external hemipelvectomy and spinoiliac arthrodesis. ►Extended hemipelvectomy involves resection of contiguous structures beyond the SI joint. ►Spinoiliac arthrodesis reestablishes spinopelvic stability. ►The anterior thigh flap provides reliable well-vascularized soft tissue coverage. ►This technique may serve an important role for patients with low-grade pelvic malignancies.

Analysis of prognostic factors in patients with multiple recurrences of papillary thyroid carcinoma - Corrected Proof

Kwang-Min Kim, Joon-Beom Park, Keum-Seok Bae, Seong-Joon Kang — 2011-10-17

Abstract: Purpose: Numerous studies in the past have mentioned various factors that influence the recurrence of papillary thyroid carcinoma, including age, tumor size, advanced stage, extrathyroidal extension, and distant metastasis, and attempts have been made to classify the disease into low-risk and high-risk group based on these clinicopathological factors. However, there has been relatively scarce study on patients with multiple recurrent papillary thyroid carcinoma. This study analyzed the risk factors associated with such cases.Materials and methods: This study investigated various clinicopathological factors of 416 patients who were diagnosed with papillary thyroid carcinoma and received primary surgery at Yonsei University Wonju College of Medicine, Department of Surgery, from January 1983 to December 2006 and were followed up until October 2010. An investigation of factors associated with patients showing multiple recurrences was made.Results: Patients were divided into 3 groups: group 1 (no recurrence, n=380), group 2 (1 recurrence only, n=21), and group 3 (multiple recurrences, n=15). The univariate analysis on risk factors revealed tumor size greater than 2cm, multifocality, clinical apparent lymph node metastasis to be risk factors associated with multiple recurrences of papillary thyroid carcinoma. A multivariate analysis performed on variables selected from univariate analysis demonstrated no significant risk factor. The 10-year disease-specific survival for 3 different patient groups (group 1, 2, and 3) was 100%, 100%, and 83.1%, respectively, and patients in more clinically advanced group demonstrated poorer prognosis (p<0.001). The 10-year overall survival rate for the 3 patient groups was 93.9%, 100%, and 92%, respectively, and clinically advanced groups tended to show poorer overall survival rate as well (p=0.046).Discussion: A more aggressive and extensive surgery, as well as closer follow up, is to be required when operating on patients with tumor size greater than 2cm, multifocality, clinical apparent lymph node metastasis. The use of imaging modalities, such as ultrasonography and PET-CT scan, may be desirable when monitoring such patients.

Prophylactic total gastrectomy for hereditary diffuse gastric cancer. Review of the literature - Corrected Proof

2011-10-17

Abstract: Hereditary diffuse gastric cancer (HDGC) is characterized as an autosomal dominant cancer susceptibility syndrome largely attributable to germline mutations and deletions in the gene encoding E-cadherin, CDH1. Mutation carriers have a more than 70% lifetime risk of developing DGC and an elevated probability of lobular breast cancer. The aim of this review was to evaluate the results of surgical treatment for HDGC with special reference to the extent of its histological spread and to analyze the recent literature in order to provide an update on the current concepts of prophylactic gastrectomy for disease prevention. Nevertheless, it is not clear that our current knowledge of molecular and genetic diagnostics calls for the addition of HDGC to the roster of malignant familial syndromes in which early counseling and preventive surgical intervention should become the standard of care. Endoscopic screening cannot be recommended because the stomach appears normal and biopsies often fail to demonstrate signet ring cell adenocarcinoma. Prophylactic gastrectomy has provided many members of affected families with relief from GC with minimal implications.

Corrected Proof

Devi C.R. Beena, Tieng Swee Tang — 2011-10-17

Ms Altilio and Ms Otis-Green, with other authors, have compiled an extraordinarily informative book, touching on a pertinent aspect under palliative care. They should be commended for this exhaustive effort. Although social work is explained in most books on palliative care, this one brings a refreshing approach to the topic. It provides some new information, like defining the palliative care social worker, genetics and social work, and adds information on existing topics.

Clinical impact of lymph node status in rectal cancer - Corrected Proof

2011-10-17

Abstract: Lymph node status at the time of diagnosis remains one of the principal indicators of prognosis in patients with rectal cancer. Involvement of loco-regional lymph nodes is relevant to surgical and clinical oncologists and continues to impact significantly upon local and systemic management strategies, in both neo-adjuvant and adjuvant settings. In this review, the clinical impact of lymph node status in the surgical management of rectal cancer is considered, with particular reference to the significance of lymphadenectomy and the potential implications for rectal tumours amenable to trans-anal excision. Current standards of care are reviewed and the extent to which the determination of lymph node status influences oncological decisions regarding neo-adjuvant and adjuvant therapies are discussed with areas of controversy highlighted.

The tumor microenvironment - Corrected Proof

Cynthia E. Weber, Paul C. Kuo — 2011-10-17

Abstract: The concept of the tumor microenvironment, developed from Paget’s “seed and soil” theory is made up of the cancer cells, the stromal tissue, and the extracellular matrix. In this mini-review, each of the components of this dynamic network will be examined. We will show that there are a multitude of complex interactions and a host of molecules involved in tumorogenesis and metastasis. We will further illustrate this notion with examples from the tumor microenvironment of breast cancer. Lastly, we conclude with thoughts about how this will influence the surgical field with examples of therapeutic agents already in use that target aspects of this microenvironment.