Utility of Amplatzer Vascular Plug with Preoperative Common Hepatic Artery Embolization for Distal Pancreatectomy with En Bloc Celiac Axis Resection

DOE Office of Scientific and Technical Information (OSTI.GOV)

Toguchi, Masafumi, E-mail: e024163@yahoo.co.jp; Tsurusaki, Masakatsu; Numoto, Isao

PurposeTo evaluate the feasibility and safety of the Amplatzer vascular plug (AVP) for preoperative common hepatic embolization (CHA) before distal pancreatectomy with en bloc celiac axis resection (DP-CAR) to redistribute blood flow to the stomach and liver via the superior mesenteric artery (SMA).Materials and MethodsFour patients (3 males, 1 female; median age 69 years) with locally advanced pancreatic body cancer underwent preoperative CHA embolization with AVP. After embolization, SMA arteriography was performed to confirm the alteration of blood flow from the SMA to the proper hepatic artery.ResultsIn three of four patients, technical successes were achieved with sufficient margin from the originmore » of gastroduodenal artery. In one patient, the margin was less than 5 mm, although surgery was successfully performed without any problem. Eventually, all patients underwent the DP-CAR without arterial reconstruction or liver ischemia.ConclusionsAVP application is feasible and safe as an embolic procedure for preoperative CHA embolization of DP-CAR.« less

Intrahepatic, peri-hilar and distal cholangiocarcinoma: Three different locations of the same tumor or three different tumors?

PubMed

Ercolani, G; Dazzi, A; Giovinazzo, F; Ruzzenente, A; Bassi, C; Guglielmi, A; Scarpa, A; D'Errico, A; Pinna, A D

2015-09-01

Few papers deal with pathologic characteristics and outcome of the 3 different cholangiocarcinomas based on location (intrahepatic, peri-hilar, distal). There is little evidence regarding similarity and differences. From two tertiary referral Italian Centers (in Bologna and Verona), 479 patients with cholangiocarcinoma were evaluated between 1980 and 2011. Several pathologic characteristics and their impact on survival were analyzed among resected patients for cholangiocarcinomas depending on the site of origin. Tumour location was intrahepatic in 172 cases (36%), peri-hilar in 243 (51) and distal in 64(13%). Curative resection was performed in 339 (70%) patients. Intrahepatic cholangiocarcinoma showed higher probability to achieve R0 resection (81%), but was more frequently associated with presence of microvascular invasion (71%). Distal cholangiocarcinoma presented less R0 resections (58%), higher lymphnode involvement (60%) and lower microvascular invasion (49%). Hilar cholangiocarcinoma had intermediate characteristics (R0: 65% of cases). Median follow up was 30.2 ± 38 months; the 5 years overall survival was 31% in the resected population. Overall survival curves were similar among the three groups. At univariate analysis surgical margins, lymphnode status, perineural invasion, T category, TNM stage, microvascular invasion, tumour grading had significant impact on survival. At multivariate analysis, only microvascular invasion was significantly related to long term results (HR = 1,7; 95% CI = 1,0-2,5)". Micro-vascular invasion has the strongest impact on survival in all three types of cholangiocarcinoma. In case of comparable pathologic characteristics and stage, the three tumors show similar outcome; depending on location, it shows a different tendency to invade bordering structures which affect the outcome. Copyright © 2015 Elsevier Ltd. All rights reserved.

[Efficacy analysis of proximally extended resection for locally advanced rectal cancer after neoadjuvant chemoradiotherapy].

PubMed

Qin, Qiyuan; Kuang, Yingyi; Ma, Tenghui; Wu, Yali; Wang, Huaiming; Pi, Yanna; Wang, Hui; Wang, Lei

2017-11-25

To evaluate the short-term outcomes and perioperative safety of proximally extended resection for locally advanced rectal cancer after neoadjuvant chemoradiotherapy. From colorectal cancer database in The Sixth Affiliated Hospital of Sun Yat-sen University, a cohort of patients who underwent neoadjuvant chemoradiotherapy(1.8-2.0 Gy per day, 25-28 fractions, concurrent fluorouracil-based chemotherapy) followed by curative sphincter-preserving surgery for locally advanced rectal cancer between May 2016 and June 2017 were retrospectively identified. Exclusion criteria were synchronous colon cancer, intraoperatively confirmed distal metastasis, multiple visceral resection, and emergency operation. Thirty-one patients underwent proximal extended resection and two were excluded for incomplete extended resection, then 29 patients were enrolled as the extended group. Using propensity scores matching with 1/1 ration, 29 locally advanced rectal cancer patients who underwent conventional resection after neoadjuvant chemoradiotherapy at the same time were matched as the conventional group. Clinical data of two groups were analyzed, and the baseline characteristics and short-term outcomes were compared using the t test, χ 2 test, or Mann-Whitney U test. Two groups were well balanced with respect to the baseline characteristics after propensity score matching. As compared with conventional group, patients in extended group had longer surgical specimen [(18.8±5.1) cm vs.(11.6±3.4) cm, t=6.314, P=0.000] and longer proximal resection margin [(14.8±5.5) cm vs.(8.2±3.0) cm, t=5.725, P=0.000], but also had longer total operating time [(322.4±100.7) min vs.(254.6±70.3) min, t=2.975, P=0.004] and more intraoperative blood loss [100(225) ml vs. 100(50) ml, Z=-2.403, P=0.016]. No significant differences were observed in the length of distal resection margin, ratio of positive resection margin, number of retrieved lymph node, time of analgesic use, time of draining tube use, time to first flatus, time to first oral diet, and postoperative hospital stay. During the perioperative period of 30 days, the morbidity of complication in extended group and conventional group was 17.2%(5/29) and 34.5% (10/29), respectively (P=0.134). Proximally extended resection is a radical and safe surgical alternative for locally advanced rectal cancer after neoadjuvant chemoradiotherapy, which can potentially reduce the risk of anastomosis complication.

[Robotic rectal resection in rectal cancer: short term results in a monocentric prospective study].

PubMed

Bianchi, P; Petz, W; Spinoglio, G; Belotti, D; Bertani, E; Zampino, M G; Crosta, C; Lazzari, R; Andreoni, B

2011-12-01

The aim of this study was to evaluate technical feasibility, oncological safety and short-term clinical results of robotic rectal resection for cancer. From January 2008 to July 2010, 46 patients (27 males and 19 females, median age 69 years, median BMI 24.6 kg/m2) with histologically-proven adenocarcinoma of medium and distal rectum were enrolled in a prospective database. Preoperative assessment was performed with colonoscopy with biopsies, thoraco-abdominal CT scan, pelvic MRI and endorectal-ultrasound (ERUS). In the case of locally advanced non metastatic disease (T3/4 or N1/2), patients received preoperative radiotherapy (45 Grays in 5 weeks) and chemotherapy (oral Capecitabine). The robotic system was a four-arms Da Vinci® (Intuitive Surgical, Sunnyvale, CA, USA); arms position is not modified during the entire surgical procedure. Twenty-five patients received a preoperative radio-chemotherapy. Surgical procedure was an abdomino-perineal amputation in nine patients and an anterior resection in the remaining 37, with temporary ileostomy in 16 cases and a laparoscopic mobilization of splenic flexure in 25. Median operative time was 251 minutes, median time of first bowel movements 1.7 days and median hospital stay 6.7 days. Major complications requiring reoperation verified in 2 patients, while overall complication rate is 15.2%. Median number of harvested lymph nodes per patient was 18; median distance of the tumour from distal resection margin was 2 cm; distance of the tumour from circumferential margin was superior to 1 mm in all of the patients. At a median follow up of 11 months, all patients are alive and disease-free. Robotic rectal resection is a feasible technique which can provide good oncological and short-term clinical results.

Robotic versus laparoscopic proctectomy for rectal cancer: a meta-analysis.

PubMed

Memon, Sameer; Heriot, Alexander G; Murphy, Declan G; Bressel, Mathias; Lynch, A Craig

2012-07-01

Robot-assisted laparoscopic surgery is being performed more frequently for the minimally invasive management of rectal cancer. The objective of this meta-analysis was to compare the clinical and oncologic safety and efficacy of robot-assisted versus conventional laparoscopic surgery. A search of the Medline and Embase databases was performed for studies that compared clinical or oncologic outcomes of conventional laparoscopic proctectomy with robot-assisted laparoscopic proctectomy for rectal cancer. The methodological quality of the selected studies was critically assessed to identify studies suitable for inclusion. Meta-analysis was performed by a random effects model and analyzed by Review Manager. Clinical outcomes evaluated were conversion rates, operation times, length of hospital stay, and complications. Oncologic outcomes evaluated were circumferential margin status, number of lymph nodes collected, and distal resection margin lengths. Eight comparative studies were assessed for quality, and seven studies were included in the meta-analysis. Two studies were matched case-control studies, and five were unmatched. A total of 353 robot-assisted laparoscopic surgery proctectomy cases and 401 conventional laparoscopic surgery proctectomy cases were analyzed. Robotic surgery was associated with a significantly lower conversion rate (P=0.03; 95% confidence interval 1-12). There was no difference in complications, circumferential margin involvement, distal resection margin, lymph node yield, or hospital stay (P=NS). Robot-assisted surgery decreased the conversion rate compared to conventional laparoscopic surgery. Other clinical outcomes and oncologic outcomes were equivalent. The benefits of robotic rectal cancer surgery may differ between population groups.

Type of Resection (Whipple vs. Distal) Does Not Affect the National Failure to Provide Post-resection Adjuvant Chemotherapy in Localized Pancreatic Cancer.

PubMed

Bergquist, John R; Ivanics, Tommy; Shubert, Christopher R; Habermann, Elizabeth B; Smoot, Rory L; Kendrick, Michael L; Nagorney, David M; Farnell, Michael B; Truty, Mark J

2017-06-01

Adjuvant chemotherapy improves survival after curative intent resection for localized pancreatic adenocarcinoma (PDAC). Given the differences in perioperative morbidity, we hypothesized that patients undergoing distal partial pancreatectomy (DPP) would receive adjuvant therapy more often those undergoing pancreatoduodenectomy (PD). The National Cancer Data Base (2004-2012) identified patients with localized PDAC undergoing DPP and PD, excluding neoadjuvant cases, and factors associated with receipt of adjuvant therapy were identified. Overall survival (OS) was analyzed using multivariable Cox proportional hazards regression. Overall, 13,501 patients were included (DPP, n = 1933; PD, n = 11,568). Prognostic characteristics were similar, except DPP patients had fewer N1 lesions, less often positive margins, more minimally invasive resections, and shorter hospital stay. The proportion of patients not receiving adjuvant chemotherapy was equivalent (DPP 33.7%, PD 32.0%; p = 0.148). The type of procedure was not independently associated with adjuvant chemotherapy (hazard ratio 0.96, 95% confidence interval 0.90-1.02; p = 0.150), and patients receiving adjuvant chemotherapy had improved unadjusted and adjusted OS compared with surgery alone. The type of resection did not predict adjusted mortality (p = 0.870). Receipt of adjuvant chemotherapy did not vary by type of resection but improved survival independent of procedure performed. Factors other than type of resection appear to be driving the nationwide rates of post-resection adjuvant chemotherapy in localized PDAC.

Total mesorectal excision for the treatment of rectal cancer

PubMed Central

Zedan, Ali; Salah, Tareq

2015-01-01

Introduction In the surgical treatment of rectal cancer, a clear circumferential resection margin and distal resection margin should be obtained. The aim of this study was to determine the morbidity, mortality, survival outcome, and local failure after total mesorectal excision (TME) in the surgical treatment of rectal cancer. Methods This retrospective study was conducted on 101 patients treated for rectal cancer using low anterior resection (LAR), abdominoperinial resection (APR), or Hartmaan’s technique. In all operative procedures, total mesorectal excisions (TMEs) were done. The patients were treated from November 2000 to April 2011 in the South Egypt Cancer Institute (SECI) of Assuit University (Egypt). Neo-adjuvant therapy was given to those patients with serosalin filtration, lymph node involvement, and sexual and urinary function impairment. Data were analyzed using IBM-SPSS version 21, and survival rates were estimated using the Kaplan-Meier method. Results One hundred one patients were evaluable (61 males, 40 females). Regarding the operative procedure used, it was: (APR), LAR, Hartmaan’s technique in 15.8%, 71.3%, and 12.9% of patients, respectively. Operation-related mortality during the 30 days after surgery was 3%. The operations resulted in morbidity in 25% of the patients, anastomotic site leak in 5.9% of the patients, urinary dysfynction in 9.9% of the patients, and erectile dysfunction in 15.8% of the male patients. Regarding safety margin, the median distances were distal/radial margin, 23/12 mm, distal limit 7 cm. Median lymph nodes harvest 19 nodes. Primary tumor locations were anteriorly 23.8%, laterally 13.9%, posteriorly 38.6%, and circumferential 23.8%. Protective stoma 16.8%. Primary Tumor TNM classification (T1, T2, T3, and T4; 3, 28.7, 55.4, and 12.9%, respectively). Nodes Metastases (N0, N1, and N2; 57.4, 31.7, and 10.9%, respectively). TNM staging (I, II, III, and IV; 15.8, 29.7, 46.5, and 7.9%, respectively). Chemotherapy was administered to 67.3% of the patients. Radiotherapy (short course neoadjuvant, long course neoadjuvant, and adjuvant postoperative used in 33.7, 20.8, and 19.8% of patients, respectively). Survival 5-years CSS was 73% and 5-years RFS 71%. Mean operative time was 213 minutes. The average amount of intraoperative blood loss was 344 mL. Conclusion Total mesorectal excision (TME) represents the gold-standard technique in rectal cancer surgery. It is safe with neoadjuvent chemoradiotherapy and provides both maximal oncological efficiency (local control and long-term survival and maintenance of a good quality of life). PMID:26816592

Total mesorectal excision for the treatment of rectal cancer.

PubMed

Zedan, Ali; Salah, Tareq

2015-12-01

In the surgical treatment of rectal cancer, a clear circumferential resection margin and distal resection margin should be obtained. The aim of this study was to determine the morbidity, mortality, survival outcome, and local failure after total mesorectal excision (TME) in the surgical treatment of rectal cancer. This retrospective study was conducted on 101 patients treated for rectal cancer using low anterior resection (LAR), abdominoperinial resection (APR), or Hartmaan's technique. In all operative procedures, total mesorectal excisions (TMEs) were done. The patients were treated from November 2000 to April 2011 in the South Egypt Cancer Institute (SECI) of Assuit University (Egypt). Neo-adjuvant therapy was given to those patients with serosalin filtration, lymph node involvement, and sexual and urinary function impairment. Data were analyzed using IBM-SPSS version 21, and survival rates were estimated using the Kaplan-Meier method. One hundred one patients were evaluable (61 males, 40 females). Regarding the operative procedure used, it was: (APR), LAR, Hartmaan's technique in 15.8%, 71.3%, and 12.9% of patients, respectively. Operation-related mortality during the 30 days after surgery was 3%. The operations resulted in morbidity in 25% of the patients, anastomotic site leak in 5.9% of the patients, urinary dysfynction in 9.9% of the patients, and erectile dysfunction in 15.8% of the male patients. Regarding safety margin, the median distances were distal/radial margin, 23/12 mm, distal limit 7 cm. Median lymph nodes harvest 19 nodes. Primary tumor locations were anteriorly 23.8%, laterally 13.9%, posteriorly 38.6%, and circumferential 23.8%. Protective stoma 16.8%. Primary Tumor TNM classification (T1, T2, T3, and T4; 3, 28.7, 55.4, and 12.9%, respectively). Nodes Metastases (N0, N1, and N2; 57.4, 31.7, and 10.9%, respectively). TNM staging (I, II, III, and IV; 15.8, 29.7, 46.5, and 7.9%, respectively). Chemotherapy was administered to 67.3% of the patients. Radiotherapy (short course neoadjuvant, long course neoadjuvant, and adjuvant postoperative used in 33.7, 20.8, and 19.8% of patients, respectively). Survival 5-years CSS was 73% and 5-years RFS 71%. Mean operative time was 213 minutes. The average amount of intraoperative blood loss was 344 mL. Total mesorectal excision (TME) represents the gold-standard technique in rectal cancer surgery. It is safe with neoadjuvent chemoradiotherapy and provides both maximal oncological efficiency (local control and long-term survival and maintenance of a good quality of life).

Single-Incision Laparoscopic Anterior Resection Using a Curved Stapler.

PubMed

Watanabe, Jun; Ota, Mitsuyoshi; Suwa, Yusuke; Ishibe, Atsushi; Masui, Hidenobu; Nagahori, Kaoru

2016-11-01

Single-incision laparoscopic colectomy is technically limited because of such factors as instrument crowding, in-line viewing, and insufficient countertraction. In particular, it is technically difficult to cut the distal rectum from the umbilicus using an articulating linear stapler in single-incision laparoscopic anterior resection. After treating the mesorectum, the 5-mm trocar is replaced with a 12-mm trocar. The cartridge of the curved stapler is mounted while the shaft of the stapler is inserted into the 12-mm port extracorporeally. The curved stapler is inserted through the umbilical incision with the cartridge. A multichannel port is then mounted, and the abdominal cavity is reinsufflated. The curved stapler can then be operated intracorporeally. This procedure facilitates the vertical dissection of the rectum from the umbilicus. A total of 27 consecutive patients were analyzed in this study. All the procedures were safely performed without any complications. The median distance from the peritoneal reflection to the transection point of the distal bowel in single-incision laparoscopic anterior resection was 5.0 cm (range, -2.0 to 15.0). One stapler firing was required to achieve distal bowel division in 26 patients (96.3 %), whereas 2 firings were required in 1 patient (3.7 %). The median distal margin was 7.0 cm (range, 3.0-13.0). The time from the insertion of the stapler to transection was 180 seconds (range, 100-420). There were no cases of anastomotic leakage. In single-incision laparoscopic anterior resection, it is feasible to perform rectal transection from the umbilicus by using a curved stapler. This technique may allow for the omission of 1 trocar from the operation.

Pancreas-sparing duodenectomy for an obstructive adenocarcinoma of the duodenum

PubMed Central

Lam, D; Croome, KP; Hernandez-Alejandro, R

2012-01-01

A duodenal adenocarcinoma arising from the junction of the second and third portion of the duodenum, which was resected by pancreas-sparing duodenectomy, is reported. The completely obstructing tumour was circumferential and measured 6.5cm x 3.5cm x 1.0 cm. There was no evidence of pancreas invasion, nor any lymph node metastasis. Pancreas-sparing duodenectomy was performed, with dissection of the pancreaticoduodenal lymph nodes. The proximal duodenum was transected just distal to the ampula of Vater and jejunum was transected just distal to the ligament of Treitz. A hand-sewn side-to-side anastomosis for the duodenojejunostomy was performed. There were no postoperative complications. Pathology reported a duodenal adenocarcinoma resected with negative margins. Pancreaticoduodenectomy is the treatment of choice for a duodenal adenocarcinoma, however, pancreas-sparing duodenectomy may be a safe alternative for duodenal tumours not involving the 2nd portion, especially in elderly patients with multiple medical comorbidities. PMID:24960771

Pancreas-sparing duodenectomy for an obstructive adenocarcinoma of the duodenum.

PubMed

Lam, D; Croome, Kp; Hernandez-Alejandro, R

2012-08-01

A duodenal adenocarcinoma arising from the junction of the second and third portion of the duodenum, which was resected by pancreas-sparing duodenectomy, is reported. The completely obstructing tumour was circumferential and measured 6.5cm x 3.5cm x 1.0 cm. There was no evidence of pancreas invasion, nor any lymph node metastasis. Pancreas-sparing duodenectomy was performed, with dissection of the pancreaticoduodenal lymph nodes. The proximal duodenum was transected just distal to the ampula of Vater and jejunum was transected just distal to the ligament of Treitz. A hand-sewn side-to-side anastomosis for the duodenojejunostomy was performed. There were no postoperative complications. Pathology reported a duodenal adenocarcinoma resected with negative margins. Pancreaticoduodenectomy is the treatment of choice for a duodenal adenocarcinoma, however, pancreas-sparing duodenectomy may be a safe alternative for duodenal tumours not involving the 2(nd) portion, especially in elderly patients with multiple medical comorbidities. © JSCR.

Surgical strategy for bile duct cancer: Advances and current limitations

PubMed Central

Akamatsu, Nobuhisa; Sugawara, Yasuhiko; Hashimoto, Daijo

2011-01-01

The aim of this review is to describe recent advances and topics in the surgical management of bile duct cancer. Radical resection with a microscopically negative margin (R0) is the only way to cure cholangiocarcinoma and is associated with marked survival advantages compared to margin-positive resections. Complete resection of the tumor is the surgeon’s ultimate aim, and several advances in the surgical treatment for bile duct cancer have been made within the last two decades. Multidetector row computed tomography has emerged as an indispensable diagnostic modality for the precise preoperative evaluation of bile duct cancer, in terms of both longitudinal and vertical tumor invasion. Many meticulous operative procedures have been established, especially extended hepatectomy for hilar cholangiocarcinoma, to achieve a negative resection margin, which is the only prognostic factor under the control of the surgeon. A complete caudate lobectomy and resection of the inferior part of Couinaud’s segment IV coupled with right or left hemihepatectomy has become the standard surgical procedure for hilar cholangiocarcinoma, and pylorus-preserving pancreaticoduodenectomy is the first choice for distal bile duct cancer. Limited resection for middle bile duct cancer is indicated for only strictly selected cases. Preoperative treatments including biliary drainage and portal vein embolization are also indicated for only selected patients, especially jaundiced patients anticipating major hepatectomy. Liver transplantation seems ideal for complete resection of bile duct cancer, but the high recurrence rate and decreased patient survival after liver transplant preclude it from being considered standard treatment. Adjuvant chemotherapy and radiotherapy have a potentially crucial role in prolonging survival and controlling local recurrence, but no definite regimen has been established to date. Further evidence is needed to fully define the role of liver transplantation and adjuvant chemo-radiotherapy. PMID:21603318

[NOTES ASSISTED ENDOLUMENAL RECTAL RESECTION AND SPECIMEN EXTRACTION WITHOUT RECTAL STUMP OPENING - OUR EXPERIENCE WITH THIS NOVEL TECHNIQUE IN A PORCINE MODEL].

PubMed

Kvasha, Anton; Rosenthal, Eyal; Khalifa, Muhammad; Waksman, Igor

2017-05-01

Laparoscopic surgery has long been used for colon and rectal resection, and the laparoscopic-assisted approach has prevailed in surgical practice. While this technique includes the fashioning of an intra-corporeal anastomosis, it still requires an abdominal incision for specimen extraction. Elimination of the abdominal incision and its potential complications has been the motivation for the development of natural orifice specimen extraction (NOSE) techniques. Many of these techniques make use of an open rectal stump, which poses as a potential for intra-abdominal contamination. Our group has recently described a novel, NOTES assisted, clean, endoluminal rectal resection utilizing transabdominal and transanal approaches. In this paper we report the combined experience of two study groups: an open approach to the abdominal cavity and a laparoscopic approach to the peritoneal cavity. Ten female pigs were used for this research; 5 in a group using an open approach and 5 using a laparoscopic approach for the abdominal part of the procedure. During the procedure, the rectum was mobilized. An end-to-end circular stapler was used to create a recto-rectal intussusception and pull-through (IPT). The specimen was resected and extracted by making a full thickness incision through 2 bowel walls. The stapler was applied, and a recto-rectal anastomosis created. This was allowed to retract into the abdomen. Peritoneal fluid was sampled for bacteria, the pigs were sacrificed immediately after the experiment and necropsy was performed. All 10 pigs underwent an endoluminal rectal resection utilizing the trans-anal IPT technique. The proximal and distal resection margins remained approximated over the shaft of the anvil after bowel resection in all 10 subjects. A 2- to 4-mm resection margin, distal to the ligatures was accomplished consistently in all 10 subjects. No aerobic or anaerobic bacterial growth was observed in any of the peritoneal fluid samples. Our research demonstrated the feasibility of the described technique in both open and laparoscopic approaches to a clean endoluminal bowel resection and trans-anal specimen extraction without rectal stump opening. The fact that no bacterial growth was found in any of the peritoneal samples supports the initial classification of this novel technique as clean, as opposed to clean contaminated, which classifies all other techniques in use to date.

An extremely rare case of distal common bile duct adenocarcinoma in a 65-year-old male patient.

PubMed

Florescu, Lucian Mihai; Gheonea, Ioana Andreea; Ene, Dragoş; Florescu, Dan Nicolae; Braia, Natalia; Pirici, Daniel; Şandru, Vasile; Forţofoiu, Mircea Cătălin; Ciurea, Tudorel

2018-01-01

Cholangiocarcinoma is an extremely rare and highly aggressive primary malignancy of the biliary tract. The current report illustrates a rare case of distal common bile duct adenocarcinoma encountered in a 65-year-old male patient who was thoroughly investigated after presenting with a two weeks history of pain in the right hypochondrium, jaundice and unintentional weight loss (6 kg in two weeks). The medical team opted for a pancreaticoduodenectomy (Whipple procedure) managing to obtain negative resection margins of the tumor with a favorable immediate postoperative evolution. However, the surgical team was forced to reintervene twice due to complications caused mainly by the patient's disregard.

Ductal drainage or resection for chronic pancreatitis.

PubMed

Taylor, R H; Bagley, F H; Braasch, J W; Warren, K W

1981-01-01

We report a 10 year review comparing the results of pain relief after three procedures for chronic pancreatitis: Whipple pancreatoduodenectomy, modified Puestow side-to-side longitudinal pancreaticojejunostomy and distal pancreatic resection. Results of follow-up review at 6 months, 2 years and 5 years were tabulated. Five year follow-up data were available on more than 80 percent of patients. The proportion of good results for pain relief decreased with the passage of time regardless of the procedure performed. Although equally good results are obtained after either pancreatoduodenectomy or pancreaticojejunosotomy, we conclude that in the presence of a dilated duct, the procedure of choice is pancreaticojejunostomy. If the duct is not dilated, we then favor pancreatoduodenectomy, after which the pain relief is significantly better (p = 0.05) than after distal resection. Our data show that, for all factors evaluated, the poorest pain relief was obtained after distal resection. Therefore that procedure has limited value when used specifically for relief of pain in chronic pancreatitis, except in the uncommon circumstance when the disease is confined to the distal part of the gland. Our study also shows that patients who have more radical distal resection have no better pain relief than those who have 50 percent distal resection.

Solo-Surgeon Single-Port Laparoscopic Anterior Resection for Sigmoid Colon Cancer: Comparative Study.

PubMed

Choi, Byung Jo; Jeong, Won Jun; Kim, Say-June; Lee, Sang Chul

2018-03-01

To report our experience with solo-surgeon, single-port laparoscopic anterior resection (solo SPAR) for sigmoid colon cancer. Data from sigmoid colon cancer patients who underwent anterior resections (ARs) using the single-port, solo surgery technique (n = 31) or the conventional single-port laparoscopic technique (n = 45), between January 2011 and July 2016, were retrospectively analyzed. In the solo surgeries, making the transumbilical incision into the peritoneal cavity was facilitated through the use of a self-retaining retractor system. After establishing a single port through the umbilicus, an adjustable mechanical camera holder replaced the human scope assistant. Patient and tumor characteristics and operative, pathologic, and postoperative outcomes were compared. The operative times and estimated blood losses were similar for the patients in both treatment groups. In addition, most of the postoperative variables were comparable between the two groups, including postoperative complications and hospital stays. In the solo SPAR group, comparable lymph nodes were attained, and sufficient proximal and distal cut margins were obtained. The difference in the proximal cut margin significantly favored the solo SPAR, compared with the conventional AR group (P = .000). This study shows that solo SPAR, using a passive camera system, is safe and feasible for use in sigmoid colon cancer surgery, if performed by an experienced laparoscopic surgeon. In addition to reducing the need for a surgical assistant, the oncologic requirements, including adequate margins and sufficient lymph node harvesting, could be fulfilled. Further evaluations, including prospective randomized studies, are warranted.

Early pancreatic dysfunction after resection in trauma: An 18-year report from a Level I trauma center.

PubMed

Mansfield, Nicole; Inaba, Kenji; Berg, Regan; Beale, Elizabeth; Benjamin, Elizabeth; Lam, Lydia; Matsushima, Kazuhide; Demetriades, Demetrios

2017-03-01

Early pancreatic dysfunction after resection in trauma has not been well characterized. The objective of this study was to examine the incidence and clinical impact of new-onset endocrine and exocrine dysfunction after pancreatic resection for trauma. All patients sustaining a pancreatic injury from 1996 to 2013 were identified. Patients with preinjury diabetes were excluded. Survivors were divided into three groups according to the extent of anatomic resection-distal, proximal, or total pancreatectomy. Clinical demographics and outcome data were abstracted. Blood glucose levels, hemoglobin A1c, and insulin requirements were used to assess endocrine pancreatic function. Reported steatorrhea, diarrhea, or supplemental pancreatic enzyme requirements were used to assess exocrine pancreatic function. During the study period, 331 pancreatic injuries were identified, of which 109 (33%) required resection and 84 survived to hospital discharge. Four were excluded. Of 80 cases analyzed, 73 (91%) underwent distal pancreatectomy, 7 (9%) proximal pancreatectomy, and none a total pancreatectomy. The distal resection group was predominantly male (88%), median age 24 years, and mean BMI 27 (kg/m). Thirty-eight (52%) required insulin postoperatively, with the greatest proportion (47%) requiring insulin for ≤1 day; no patients were discharged on insulin. The proximal resection group was predominantly male (86%), median age 31 years, and mean BMI 32 (kg/m). Six of seven required insulin postoperatively and two of seven were insulin dependent at time of hospital discharge. For both distal and proximal resections, none had evidence of exocrine dysfunction or received pancreatic enzyme supplementation at discharge. Exocrine dysfunction after distal or proximal pancreatectomy for trauma is rare. The incidence of early onset endocrine dysfunction after traumatic distal pancreatectomy is also rare; however, it can be seen after proximal resection. Therapeutic study, level IV.

Transoral bisected resection for T1-2 oral tongue squamous cell carcinoma to secure adequate deep margin.

PubMed

Choi, Nayeon; Cho, Jae-Keun; Lee, Eun Kyu; Won, Sung Jun; Kim, Bo Young; Baek, Chung-Hwan

2017-10-01

To investigate the clinical usefulness of transoral bisected resection (TBR) asa new method to secure adequate deep resection margin in T1-2 oral tongue squamous cell carcinomas (SCC). Among 75 patients with cT1-2N0 oral tongue SCCs, 45 (60%) received transoral en-bloc resection (TER) while 30 (40%) received patients underwent TBR. Primary tumor resection was performed with 1.5-cm surgical resection margin for both groups. Mucosal and deep resection margins, adjuvant treatments including re-resection of the tongue and cheomoradiotherapy, local and regional recurrence free survival, and overall survival were compared between the two groups. Mean deep resection margin in the TBR group was 9.9mm (95% CI: 8.4-11.4mm), which was significantly (P<0.001) wider than that of the TER group (mean: 5.4mm, 95% CI: 4.5-6.3mm). However, mucosal resection margins were not significantly (P=0.153) different between the two groups. Re-resection of tongue was performed for 6 (13.3%) of 17 (37.8%) patients with inadequate deep resection margin in the TER group and none (0%) in 4 (13.3%) patients with inadequate deep resection margin in the TBR group. Adjuvant radiation due to inadequate deep resection margin was performed for 6.7% of patients in both groups. The TBR group had better local recurrence free survival than the TER group. However, regional recurrence free survival and overall survival were not significantly different between the two groups. TBR could provide adequate deep resection margin for early stage tongue cancers with better local tumor control than TER. It can decrease the necessity of adjuvant treatment for re-resection of the tongue. Copyright © 2017 Elsevier Ltd. All rights reserved.

Concordance of gross surgical and final fixed margins in vulvar intraepithelial neoplasia 3 and vulvar cancer.

PubMed

DeSimone, Christopher P; Crisp, Meredith P; Ueland, Frederick R; DePriest, Paul D; van Nagell, John R; Lele, Subodh M; Modesitt, Susan C

2006-08-01

To prospectively evaluate the concordance of initial surgical vulvar margins and final fixed margins and to determine the amount of microscopic pathology of grossly negative margins in women with vulvar intraepithelial neoplasia (VIN) 3 or vulvar carcinoma. Women with VIN 3 or vulvar carcinoma undergoing surgical excision were identified. Prior to excision, acetic acid was used to highlight the lesions, and 2 sutures were placed, 1 at the edge of gross disease and another 1 cm distal from the first. After specimen removal and fixation, the distance between sutures and microscopic involvement of VIN was determined. Twenty-seven women were enrolled; however, only 19 had final fixed specimens that could be accurately measured. The median fixed distance of the vulvar margin was 0.85 cm (mean, 0.83; SD, 0.19) as compared to the gross, 1-cm margin (p = 0.001). Three subjects (16%) had microscopic involvement by VIN 3 in the grossly negative epithelium between the 2 sutures, but none had a positive peripheral margin. The gross surgical margin after vulvar resection is reduced by 15% when measured in its final fixed state, and a grossly negative 1-cm margin will seldom harbor significant disease.

Effect of luminal contents on postresectional longitudinal and mucosal growth in the ileum of suckling rats.

PubMed

Ford, W D; de Vries, J E; Ross, J S; Malt, R A

1985-11-01

Effects of luminal contents on adaptive growth of the ileum in the neonatal small bowel of rats were examined after resection of the proximal small bowel and after removal of the ileum from the enteric stream. Four weeks after resection of the proximal 60% of the small bowel in 10-day-old rats, the distal 40% of the small bowel elongated by 281%. This distal segment also elongated by 265% after intestinal transection (p greater than 0.05), but by only 191% when it was bypassed (bypass versus resection or transection, p less than 0.001). After resection the distal villi were 81% taller, but after transection they were only 19% taller (p less than 0.001 versus resection); after bypass they did not grow (p less than 0.001 versus resection or transection). The distal crypts were 404% deeper after resection, 331% deeper after transection (p less than 0.05), and 291% deeper after bypass (p less than 0.001 versus resection, p greater than 0.05 versus transection). The DNA content was 517% greater after resection, 364% greater after transection (p less than 0.001), and 73% greater after bypass (p less than 0.001 versus transection or resection). Maximal elongation of the small bowel occurs in the presence of luminal nutrition. Increasing luminal nutrition is associated with increasing mucosal hyperplasia.

The feasibility and advantages of billroth-I reconstruction in distal gastric cancers following resection.

PubMed

Ganesh, M S; Reddy, K G; Venkata Subbareddy, D S

2012-01-01

Gastric carcinomas are common malignancies in southern India and distal stomach remains the commonest site in low socio economic groups. Surgery still remains an important modality of treatment to achieve local control and also relieve obstructive symptoms. In this study we investigated the feasibility of performing a gastrectomy and billroth-1 type of anastomosis in a rural cancer center setting, with parameters like adequacy of margins, ease of anastomosis and its functional results were analysed. Eight patients presenting to a rurally based cancer center underwent a distal gastrectomy and billroth-1 type of anastomosis for continuity restoration. All the patients had adequate proximal and distal marg. The surgical time varied between-hrs. The anastomosis was constructed without any tension on bowel ends in all patients. The average time to start oral feeds varied between- None of the patients showed symptoms of bile reflux nor dumping. The average hospital stay varied between. Billroth-1 anastomosis is a physiologically more natural way of restoring continuity following a gastrectomy and it is a procedure which would be technically more simpler and decrease per and post operative complications and allow speedier post operative recovery following surgery on distal gastric cancers.

Laparoscopic common hepatic artery ligation and staging followed by distal pancreatectomy with en bloc resection of celiac artery for advanced pancreatic cancer.

PubMed

Raut, V; Takaori, K; Kawaguchi, Y; Mizumoto, M; Kawaguchi, M; Koizumi, M; Kodama, S; Kida, A; Uemoto, S

2011-11-01

Adeno-carcinomas of pancreatic body are usually asymptomatic and progress to advanced stage with involvement of major arteries. Resection of advanced cancer along with en bloc resection of a common hepatic artery and celiac trunk enables a "curative" resections and only possible treatment. However, the celiac axis resection always has a risk of compromising blood supply to liver, resulting in the hepatic insufficiency. We evaluated practicability of a two-stage procedure for the advanced pancreases body cancer, laparoscopic clamping of a common hepatic artery followed by open distal pancreatectomy with en bloc celiac arterial resection to prevent the hepatic insufficiency. Seventy-five-year-old woman diagnosed with a 50-mm pancreatic body mass, invading splenic artery, common hepatic artery, splenic vein, and portal vein at the confluence. STAGE-1: At laparoscopy, after confirming absence of the peritoneal, superficial liver metastases and negative peritoneal cytology; we approached the common hepatic artery through the lesser sac and ligated. STAGE-2: Her liver function tests were normal after 2 weeks, and CT angiography showed complete blockage of the common hepatic artery with sufficient collateral circulation to the liver through inferior pancreatico-duodenal artery and gastro-duodenal artery. We performed an open distal pancreatectomy with en bloc resection of celiac artery. Histopathology examination confirmed R0 resection. The celiac axis resection with distal pancreatectomy improves the chance of R0 resection and potentially, survival of the patient. Preoperative laparoscopic ligation of the common hepatic artery is a safe, effective, and in-expensive technique to prevent postoperative hepatic insufficiency and improves the safety of en bloc celiac artery resection with a distal pancreatectomy. Also these patients have high risk of peritoneal dissemination. Diagnostic laparoscopy is useful to detect occult metastasis, which are missed by per-operative CT scan. © 2011 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Blackwell Publishing Asia Pty Ltd.

One-millimeter cancer-free margin is curative for colorectal liver metastases: a propensity score case-match approach.

PubMed

Hamady, Zaed Z R; Lodge, J Peter A; Welsh, Fenella K; Toogood, Giles J; White, Alan; John, Timothy; Rees, Myrddin

2014-03-01

To investigate the influence of clear surgical resection margin width on disease recurrence rate after intentionally curative resection of colorectal liver metastases. There is consensus that a histological positive resection margin is a predictor of disease recurrence after resection of colorectal liver metastases. The dispute, however, over the width of cancer-free resection margin required is ongoing. Analysis of observational prospectively collected data for 2715 patients who underwent primary resection of colorectal liver metastases from 2 major hepatobiliary units in the United Kingdom. Histological cancer-free resection margin was classified as positive (if cancer cells present at less than 1 mm from the resection margin) or negative (if the distance between the cancer and the margin is 1 mm or more). The negative margin was further classified according to the distance from the tumor in millimeters. Predictors of disease-free survival were analyzed in univariate and multivariate analyses. A case-match analysis by a propensity score method was undertaken to reduce bias. A 1-mm cancer-free resection margin was sufficient to achieve 33% 5-year overall disease-free survival. Extra margin width did not add disease-free survival advantage (P > 0.05). After the propensity case-match analysis, there is no statistical difference in disease-free survival between patients with negative narrow and wider margin clearance [hazard ratio (HR) 1.0; 95% (confidence interval) CI: 0.9-1.2; P = 0.579 at 5-mm cutoff and HR 1.1; 95% CI: 0.96-1.3; P = 0.149 at 10-mm cutoff]. Patients with extrahepatic disease and positive lymph node primary tumor did not have disease-free survival advantage despite surgical margin clearance (9 months for <1-mm vs 12 months for ≥1-mm margin clearance; P = 0.062). One-mm cancer-free resection margin achieved in patients with colorectal liver metastases should now be considered the standard of care.

Significance of post-resection tissue shrinkage on surgical margins of oral squamous cell carcinoma.

PubMed

El-Fol, Hossam Abdelkader; Noman, Samer Abduljabar; Beheiri, Mohamed Galal; Khalil, Abdalla M; Kamel, Mahmoud Mohamed

2015-05-01

Resecting oral squamous cell carcinoma (SCC) with an appropriate margin of uninvolved tissue is critical in preventing local recurrence and in making decisions regarding postoperative radiation therapy. This task can be difficult due to the discrepancy between margins measured intraoperatively and those measured microscopically by the pathologist after specimen processing. A total of 61 patients underwent resective surgery with curative intent for primary oral SCC were included in this study. All patients underwent resection of the tumor with a measured 1-cm margin. Specimens were then submitted for processing and reviewing, and histopathologic margins were measured. The closest histopathologic margin was compared with the in situ margin (1 cm) to determine the percentage discrepancy. The mean discrepancy between the in situ margins and the histopathological margins of all close and positive margins were 47.6% for the buccal mucosa (with a P value corresponding to 0.05 equaling 2.1), which is statistically significant, 4.8% for the floor of mouth, 9.5% for the mandibular alveolus, 4.8% for the retromolar trigon, and 33.3% for the tongue. There is a significant difference among resection margins based on tumor anatomical location. Margins shrinkage after resection and processing should be considered at the time of the initial resection. Tumors located in the buccal mucosa show significantly greater discrepancies than tumors at other sites. These findings suggest that it is critical to consider the oral site when outlining margins to ensure adequacy of resection. Buccal SCC is an aggressive disease, and should be considered as an aggressive subsite within the oral cavity, requiring a radical and aggressive resective approach. Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Optic nerve gliomas: role of Ki-67 staining of tumour and margins in predicting long-term outcome.

PubMed

Yeung, Sonia N; White, Valerie A; Nimmo, Michael; Rootman, Jack

2011-08-01

Although optic nerve gliomas (ONGs) are generally slow-growing with a good prognosis, factors for identifying cases that may pursue a more aggressive course are not well established. The authors investigated cell proliferation markers for prognostic significance in a series of resected ONGs. Twelve cases of resected ONG were identified out of a total of 38 examined at the authors' institution between 1981 and 2008. Clinical data were reviewed. Ki-67 and p53 immunohistochemical staining was performed on the tumour mass and the proximal resection margin. All of the tumours were low-grade pilocytic astrocytomas. Six patients were suspected to have histologically positive proximal resection margins. Ki-67 labelling indices (LI) ranged from 0.3% to 5.9% (mean 2.4%) for the tumour mass and from 0 to 2.1% (mean 0.9%) for the proximal resection margins. One patient had evidence of progression 25 months after subtotal surgical resection. The Ki-67 LI of the proximal resection margin in this case was similar to the main tumour value. The other six patients with histologically negative proximal resection margins all had lower relative proliferation indices at the resection margin when compared with the tumour mass and are currently stable with no evidence of progression. Routine histological examination of resection margins may be difficult to interpret in the setting of reactive gliosis. A resection margin with a Ki-67 LI similar to the tumour bulk value may have an adjunctive role in identifying cases with the potential for growth thereby facilitating the decision-making process for future management and surveillance.

Single-Docking Full Robotic Surgery for Rectal Cancer: A Single-Center Experience.

PubMed

Alfieri, Sergio; Di Miceli, Dario; Menghi, Roberta; Cina, Caterina; Fiorillo, Claudio; Prioli, Francesca; Rosa, Fausto; Doglietto, Giovanni B; Quero, Giuseppe

2018-06-01

Robotic surgery has gradually gained importance in the treatment of rectal cancer. However, recent studies have not shown any advantages when compared with laparoscopy. The objective of this study is to report a single surgeon's experience in robotic rectal surgery focusing on short-term and long-term outcomes. Sixty consecutive robotic rectal resections for adenocarcinoma, over a 4-year period, were retrospectively reviewed. Patients' characteristics and perioperative outcomes were analyzed. Oncological outcomes and surgical resection quality as well as overall and disease-free survival were also assessed. Thirty patients out of 60 (50%) underwent neoadjuvant therapy. Anterior rectal resection was performed in 52 cases (86.7%), and abdominoperineal resection was done in 8 cases (13.3%). Mean operative time was 283 (±68.6) minutes. The conversion rate was 5% (3 patients). Postoperative complications occurred in 10 cases (16.7%), and reoperation was required in 1 case (1.7%). Mean hospital stay was 9 days, while 30-day mortality was 1.7% (1 patients). The histopathological analysis reported a negative circumferential radial margin and distal margins in 100% of cases with a complete or near complete total mesorectal excision in 98.3% of patients. Mean follow-up was 32.8 months with a recurrence rate of 3.4% (2 patients). Overall survival and disease-free survival were 94% and 87%, respectively. Robotic surgery for rectal cancer proves to be safe and feasible when performed by highly skilled surgeons. It offers acceptable perioperative outcomes with a conversion rate notably lower than with the laparoscopic approach. Adequate pathological results and long-term oncological outcomes were also obtained.

Modified toe pulp fillet flap coverage: Better wound healing and satisfactory length preservation.

PubMed

Baek, Sang Oon; Suh, Hyo Wan; Lee, Jun Yong

2018-01-01

Amputation is commonly performed for toe necrosis secondary to peripheral vascular diseases, such as diabetes mellitus. When amputating a necrotic toe, preservation of the bony structure is important for preventing the collapse of adjacent digits into the amputated space. However, in the popular terminal Syme's amputation technique, partial amputation of the distal phalanx could cause increased tension on the wound margin. Herein, we introduce a new way to resect sufficient bony structure while maintaining the normal length, based on a morphological analysis of the toes. Unlike the pulp of the finger in the distal phalanx, the toe has abundant teardrop-shaped pulp tissue. The ratio of the vertical length to the longitudinal length in the distal phalanx was compared between the toes and fingers. Amputation was performed at the proximal interphalangeal joint level. Then, a mobilizable pulp flap was rotated 90° cephalad to replace the distal soft tissue defect. This modified toe fillet flap was performed in 5 patients. The toe pulp was found to have a vertically oriented morphology compared to that of the fingers, enabling length preservation through cephalad rotation. All defects were successfully covered without marginal ischemia. While conventional toe fillet flap coverage focuses on the principle of length preservation as the first priority, our modified method takes both wound healing and length into account. The fattiest part of the pulp is advanced to the toe tip, providing a cushioning effect and enough length to substitute for phalangeal bone loss. Our modified method led to satisfactory functional and aesthetic outcomes.

Outcome of Laparoscopic Versus Open Resection for Transverse Colon Cancer.

PubMed

Zeng, Wei-Gen; Liu, Meng-Jia; Zhou, Zhi-Xiang; Hou, Hui-Rong; Liang, Jian-Wei; Wang, Zheng; Zhang, Xing-Mao; Hu, Jun-Jie

2015-10-01

Laparoscopic resection for transverse colon cancer remains controversial. The aim of this study is to investigate the short- and long-term outcomes of laparoscopic surgery for transverse colon cancer. A total of 278 patients with transverse colon cancer from a single institution were included. All patients underwent curative surgery, 156 patients underwent laparoscopic resection (LR), and 122 patients underwent open resection (OR). The short- and long-term results were compared between two groups. Baseline demographic and clinical characteristics were comparable between two groups. Conversions were required in eight (5.1 %) patients. LR group was associated with significantly longer median operating time (180 vs. 140 min; P < 0.001). Median estimated blood loss was significantly less in LR group (90 vs. 100 ml; P = 0.001). Time to first flatus and oral intake was significantly earlier in LR group. Perioperative mortality and morbidity rate were not significantly different between two groups. Tumor size, number of lymph nodes harvested, length of proximal, and distal resection margin were comparable between two groups. Postoperative hospital stay was significantly shorter in LR group (9 vs. 10d; P < 0.001). Five-year disease-free survival and overall survival rate were similar between two groups. Laparoscopic resection for transverse colon cancer is associated with better short-term outcomes and equivalent long-term oncologic outcomes.

Ankle arthrodesis with bone graft after distal tibia resection for bone tumors.

PubMed

Campanacci, Domenico Andrea; Scoccianti, Guido; Beltrami, Giovanni; Mugnaini, Marco; Capanna, Rodolfo

2008-10-01

Treatment of distal tibial tumors is challenging due to the scarce soft tissue coverage of this area. Ankle arthrodesis has proven to be an effective treatment in primary and post-traumatic joint arthritis, but few papers have addressed the feasibility and techniques of ankle arthrodesis in tumor surgery after long bone resections. Resection of the distal tibia and reconstruction by ankle fusion using non-vascularized structural bone grafts was performed in 8 patients affected by malignant (5 patients) or aggressive benign (3 patients) tumors. Resection length of the tibia ranged from 5 to 21 cm. Bone defects were reconstructed with cortical structural autografts (from contralateral tibia) or allografts or both, plus autologous bone chips. Fixation was accomplished by antegrade nailing (6 cases) or plating (2~cases). All the arthrodesis successfully healed. At followup ranging from 23 to 113 months (average 53.5), all patients were alive. One local recurrence was observed with concomitant deep infection (a below-knee amputation was performed). Mean functional MSTS score of the seven available patients was 80.4% (range, 53 to 93). Resection of the distal tibia and arthrodesis of the ankle with non-vascularized structural bone grafts, combined with autologous bone chips, can be an effective procedure in bone tumor surgery with durable and satisfactory functional results. In shorter resections, autologous cortical structural grafts can be used; in longer resections, allograft structural bone grafts are needed.

Transanal total mesorectal excision: a systematic review of the experimental and clinical evidence.

PubMed

Araujo, S E; Crawshaw, B; Mendes, C R; Delaney, C P

2015-02-01

Achieving a clear distal or circumferential resection margins with laparoscopic total mesorectal excision (TME) may be laborious, especially in obese males and when operating on advanced distal rectal tumors with a poor response to neoadjuvant treatment. Transanal (TaTME) is a new natural orifice translumenal endoscopic surgery modality in which the rectum is mobilized transanally using endoscopic techniques with or without laparoscopic assistance. We conducted a comprehensive systematic review of publications on this new technique in PubMed and Embase databases from January, 2008, to July, 2014. Experimental and clinical studies written in English were included. Experimental research with TaTME was done on pigs with and without survival models and on human cadavers. In these studies, laparoscopic or transgastric assistance was frequently used resulting in an easier upper rectal dissection and in a longer rectal specimen. To date, 150 patients in 16 clinical studies have undergone TaTME. In all but 15 cases, transabdominal assistance was used. A rigid transanal endoscopic operations/transanal endoscopic microsurgery (TEO/TEM) platform was used in 37 patients. Rectal adenocarcinoma was the indication in all except for nine cases of benign diseases. Operative times ranged from 90 to 460 min. TME quality was deemed intact, satisfactory, or complete. Involvement in circumferential resection margins was detected in 16 (11.8 %) patients. The mean lymph node harvest was equal or greater than 12 in all studies. Regarding morbidity, pneumoretroperitoneum, damage to the urethra, and air embolism were reported intraoperatively. Mean hospital stay varied from 4 to 14 days. Postoperative complications occurred in 34 (22.7 %) patients. TaTME with TEM is feasible in selected cases. Oncologic safety parameters seem to be adequate although the evidence relies on small retrospective series conducted by highly trained surgeons. Further studies are expected.

Circumferential resection margin positivity after preoperative chemoradiotherapy based on magnetic resonance imaging for locally advanced rectal cancer: implication of boost radiotherapy to the involved mesorectal fascia.

PubMed

Kim, Kyung Hwan; Park, Min Jung; Lim, Joon Seok; Kim, Nam Kyu; Min, Byung Soh; Ahn, Joong Bae; Kim, Tae Il; Kim, Ho Geun; Koom, Woong Sub

2016-04-01

To identify patients who are at a higher risk of pathologic circumferential resection margin involvement using preoperative magnetic resonance imaging. Between October 2008 and November 2012, 165 patients with locally advanced rectal cancer (cT4 or cT3 with <2 mm distance from tumour to mesorectal fascia) who received preoperative chemoradiotherapy were analysed. The morphologic patterns on post-chemoradiotherapy magnetic resonance imaging were categorized into five patterns from Pattern A (most-likely negative pathologic circumferential resection margin) to Pattern E (most-likely positive pathologic circumferential resection margin). In addition, the location of mesorectal fascia involvement was classified as lateral, posterior and anterior. The diagnostic accuracy of the morphologic criteria was calculated using receiver operating characteristic curve analysis. Pathologic circumferential resection margin involvement was identified in 17 patients (10.3%). The diagnostic accuracy of predicting pathologic circumferential resection margin involvement was 0.73 using the five-scale magnetic resonance imaging pattern. The sensitivity, specificity, positive predictive value and negative predictive value for predicting pathologic circumferential resection margin involvement were 76.5, 65.5, 20.3 and 96.0%, respectively, when cut-off was set between Patterns C and D. On multivariate logistic regression, the magnetic resonance imaging patterns D and E (P= 0.005) and posterior or lateral mesorectal fascia involvement (P= 0.017) were independently associated with increased probability of pathologic circumferential resection margin involvement. The rate of pathologic circumferential resection margin involvement was 30.0% when the patient had Pattern D or E with posterior or lateral mesorectal fascia involvement. Patients who are at a higher risk of pathologic circumferential resection margin involvement can be identified using preoperative magnetic resonance imaging although the predictability is moderate. © The Author 2016. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Imaging and Clinicopathologic Features of Esophageal Gastrointestinal Stromal Tumors

PubMed Central

Winant, Abbey J.; Gollub, Marc J.; Shia, Jinru; Antonescu, Christina; Bains, Manjit S.; Levine, Marc S.

2016-01-01

OBJECTIVE The purpose of this article is to describe the imaging and clinicopathologic characteristics of esophageal gastrointestinal stromal tumors (GISTs) and to emphasize the features that differentiate esophageal GISTs from esophageal leiomyomas. MATERIALS AND METHODS A pathology database search identified all surgically resected or biopsied esophageal GISTs, esophageal leiomyomas, and esophageal leiomyosarcomas from 1994 to 2012. Esophageal GISTs were included only if imaging studies (including CT, fluoroscopic, or 18F-FDG PET/CT scans) and clinical data were available. RESULTS Nineteen esophageal mesenchymal tumors were identified, including eight esophageal GISTs (42%), 10 esophageal leiomyomas (53%), and one esophageal leiomyosarcoma (5%). Four patients (50%) with esophageal GIST had symptoms, including dysphagia in three (38%), cough in one (13%), and chest pain in one (13%). One esophageal GIST appeared on barium study as a smooth submucosal mass. All esophageal GISTs appeared on CT as well-marginated predominantly distal lesions, isoattenuating to muscle, that moderately enhanced after IV contrast agent administration. Compared with esophageal leiomyomas, esophageal GISTs tended to be more distal, larger, and more heterogeneous and showed greater IV enhancement on CT. All esophageal GISTs showed marked avidity (mean maximum standardized uptake value, 16) on PET scans. All esophageal GISTs were positive for c-KIT (a cell-surface transmembrane tyrosine kinase also known as CD117) and CD34. On histopathology, six esophageal GISTs (75%) were of the spindle pattern and two (25%) were of a mixed spindle and epithelioid pattern. Five esophageal GISTs had exon 11 mutations (with imatinib sensitivity). Clinical outcome correlated with treatment strategy (resection plus adjuvant therapy or resection alone) rather than risk stratification. CONCLUSION Esophageal GISTs are unusual but clinically important mesenchymal neoplasms. Although esophageal GISTs and esophageal leiomyomas had overlapping imaging features, esophageal GISTs tended to be more distal, larger, more heterogeneous, and more enhancing on CT and were markedly FDG avid on PET. Given their malignant potential, esophageal GISTs should be included in the differential diagnosis of intramural esophageal neoplasms. PMID:25055264

Simultaneous laparoscopy-assisted low anterior resection and distal gastrectomy for synchronous carcinoma of rectum and stomach

PubMed Central

Zhu, Qian-Lin; Zheng, Min-Hua; Feng, Bo; Lu, Ai-Guo; Wang, Min-Liang; Li, Jian-Wen; Hu, Wei-Guo; Zang, Lu; Mao, Zhi-Hai; Dong, Feng; Ma, Jun-Jun; Zong, Ya-Ping

2008-01-01

Laparoscopic resection of rectal cancer or gastric cancer has been advocated for the benefits of a reduced morbidity, a shorter treatment time, and similar outcomes. However, simultaneous laparoscopy-assisted low anterior resection and distal gastrectomy for synchronous carcinoma of rectum and stomach are rarely documented in literature. Endoscopic examination revealed a synchronous carcinoma of rectum and stomach in a 55-year-old male patient with rectal bleeding and epigastric discomfort. He underwent a simultaneous laparoscopy-assisted low anterior resection and distal gastrectomy with regional lymph nodes dissected. The operation time was 270 min and the estimated blood loss was 120 mL. The patient required parenteral analgesia for less than 24 h. Flatus was passed on postoperative day 3, and a solid diet was resumed on postoperative day 7. He was discharged on postoperative day 13. With the advances in laparoscopic technology and experience, simultaneous resection is an attractive alternative to a synchronous gastrointestinal cancer. PMID:18528944

Resection margin and recurrence-free survival after liver resection of colorectal metastases.

PubMed

Muratore, Andrea; Ribero, Dario; Zimmitti, Giuseppe; Mellano, Alfredo; Langella, Serena; Capussotti, Lorenzo

2010-05-01

Optimal margin width is uncertain because of conflicting results from recent studies using overall survival as the end-point. After recurrence, re-resection and aggressive chemotherapy heavily affect survival time; the potential confounding effect of such factors has not been investigated. Use of recurrence-free survival (RFS) may overcome this limitation. The aim of this study is to evaluate the impact of width of resection margin on RFS and site of recurrence after hepatic resection for colorectal metastases (CRM). From a prospectively maintained institutional database (1/1999-12/2007) we identified 314 patients undergone hepatectomy for CRM (1/1999-12/2007) with detailed pathologic analysis of the surgical margin and complete follow-up imaging studies documenting disease status and site of recurrence, which was categorized as: resection margin (M(arg)), other intra-hepatic ((other)IH), lung (L) or other extra-hepatic ((other)EH). Recurrence-free estimation was the survival end-point. Median follow-up was 56.5 months. Two hundred and fifteen patients (68.8%) recurred at 288 sites after a mean of 15.5 months. A positive resection margin was associated with an increased risk of M(arg) recurrence (P < 0.001). The presence of >or=2 metastases was the only factor increasing the risk of positive margins (P < 0.05). The width of the negative resection margin (>or=1 cm versus >1 cm) was not a prognostic factor of worse RFS (30.2% versus 37.3%, P = 0.6). Node status of the primary tumour, and size and number of CRM were independent predictors of RFS. Tumour biology and not the width of the negative resection margin affect RFS.

Long-term consequences from bladder perforation and/or violation in the presence of transitional cell carcinoma: results of a small series and a review of the literature.

PubMed

Mydlo, J H; Weinstein, R; Shah, S; Solliday, M; Macchia, R J

1999-04-01

Perforation of the bladder during transurethral resection is a worrisome complication for most urologists. Little is known about the consequences of seeding of tumor cells into the peritoneum or retroperitoneum. We reviewed several hospital patient databases as well as the literature to determine the outcome of such situations. We performed a local multi-institutional case and MEDLINE review using key words, such as bladder neoplasm, neoplasm seeding, perforation, rupture, transurethral resection, peritonitis and tumor. We also contacted several urologists and oncologists at major cancer centers in the United States and Europe regarding the incidence and followup of perforated/violated bladder cancer cases. There were 16 bladder violations in the presence of transitional cell carcinoma, including 2 partial cystectomies that had negative margins and no subsequent metastatic recurrences, a bladder tumor that was detected during suprapubic prostatectomy and perforations during transurethral resection (extraperitoneal in 4 cases and intraperitoneal in 9). Two patients died of sepsis and existing metastatic disease, respectively. The only recurrence among the remaining 11 patients developed after intraperitoneal bladder perforation during transurethral resection for Ta grade 2 tumor. Several anecdotal reports discussed local and distal tumor recurrences, suggesting that even superficial transitional cell carcinoma can behave aggressively if grown in an environment outside the bladder. However, these reports are rare. Any benefit of prophylactic chemotherapy was not proved. While perforation of the bladder during transurethral resection for cancer and the possibility of tumor implantation are matters of concern, our review demonstrates that few patients return with an extravesical tumor recurrence either locally or distally compared to those with a nonruptured bladder after resection. Although our patient sample is small and there are a limited number of reports in the literature, the risk of recurrence still exists and the urologist should be aware of its possibility. Since recurrences are usually rapid, they may easily manifest to the urologist at followup. However, one should also consider chest x-rays and/or computerized tomography to rule out recurrences that are not clinically obvious.

Clinicopathologic study on metachronous double cholangiocarcinomas of perihilar and subsequent distal bile duct origin.

PubMed

Shinohara, Kentaro; Shimoyama, Yoshie; Ebata, Tomoki; Yokoyama, Yukihiro; Mizuno, Takashi; Nakaguro, Masato; Nagino, Masato

2017-07-01

Despite an increasing number of long-term survivors after the resection of perihilar cholangiocarcinoma, metachronous carcinoma in the remnant distal bile duct has not been well documented because of its rarity. The aim of this study was to clarify the feasibility of operative resection and the pathologic features for metachronous double cholangiocarcinomas. Between 2003 and 2013, 6 patients underwent resections for both a primary perihilar cholangiocarcinoma and a metachronous distal cholangiocarcinoma. Their medical records were retrospectively reviewed. At a median of 42 months (range, 19-138 months) after the hepatectomy, a metachronous distal cholangiocarcinoma was detected by follow-up computed tomography and, interestingly, no symptoms were observed. Despite severe adhesions, a pancreatoduodenectomy was undertaken in all patients; there were no serious complications, and the procedure resulted in an R0 resection. Although 2 patients died of the disease after the second operation, the remaining 4 patients are now alive with (n = 1) or without recurrence. A pathologic survey showed that 4 patients had changes of biliary intraepithelial neoplasia-2/3 around their primary and metachronous lesions. The primary and metachronous cholangiocarcinomas showed histologic similarity in 4 of the 6 patients and immunohistochemical concordance in 3 of the 6 patients. Pancreatoduodenectomy for metachronous distal cholangiocarcinoma can lead to a favorable prognosis. Careful observation after the resection of perihilar cholangiocarcinoma is mandatory to detect this potentially curable disease. Pathologically, some of the multicentric cholangiocarcinomas present histologic and immunohistochemical similarities. Copyright © 2017 Elsevier Inc. All rights reserved.

Evaluation of endorectal ultrasound (ERUS) and MRI for prediction of circumferential resection margin (CRM) for rectal cancer.

PubMed

Tsai, Catherine; Hague, Cameron; Xiong, Wei; Raval, Manoj; Karimuddin, Ahmer; Brown, Carl; Phang, P Terry

2017-05-01

ERUS and MRI are used for preoperative imaging of rectal cancer. Here, we compare ERUS and MRI for accuracy of CRM prediction at mid- and distal rectal locations. In retrospective review, 20 rectal cancer patients having TME surgery had both ERUS and MRI preoperatively: 8 mid rectum and 12 in distal rectum. Predicted CRM by ERUS and MRI were compared to TME pathology. Overall, predicted CRM was 6.5 ± 3.6 mm by ERUS, 7.7 ± 5.0 mm by MRI, and 6.0 ± 4.6 mm by pathology. Overall, correlation coefficients to pathology were 0.77 (p = 0.0004) for ERUS and 0.64 (p = 0.008) for MRI. In distal rectum, correlation coefficients were 0.71 (p = 0.02) for ERUS and -0.10 (p = 0.79) for MRI. In mid rectum, correlation coefficients were 0.92 (p = 0.01) for ERUS and 0.44 (p = 0.38) for MRI. While MRI is used routinely for preoperative rectal cancer imaging, ERUS can provide additional assessment of CRM for mid or distal rectal lesions. Further investigation is needed to support these preliminary ERUS CRM findings in mid and distal rectum. Copyright © 2017 Elsevier Inc. All rights reserved.

Risk Factors Associated With Circumferential Resection Margin Positivity in Rectal Cancer: A Binational Registry Study.

PubMed

Warrier, Satish K; Kong, Joseph Cherng; Guerra, Glen R; Chittleborough, Timothy J; Naik, Arun; Ramsay, Robert G; Lynch, A Craig; Heriot, Alexander G

2018-04-01

Rectal cancer outcomes have improved with the adoption of a multidisciplinary model of care. However, there is a spectrum of quality when viewed from a national perspective, as highlighted by the Consortium for Optimizing the Treatment of Rectal Cancer data on rectal cancer care in the United States. The aim of this study was to assess and identify predictors of circumferential resection margin involvement for rectal cancer across Australasia. A retrospective study from a prospectively maintained binational colorectal cancer database was interrogated. This study is based on a binational colorectal cancer audit database. Clinical information on all consecutive resected rectal cancer cases recorded in the registry from 2007 to 2016 was retrieved, collated, and analyzed. The primary outcome measure was positive circumferential resection margin, measured as a resection margin ≤1 mm. A total of 3367 patients were included, with 261 (7.5%) having a positive circumferential resection margin. After adjusting for hospital and surgeon volume, hierarchical logistic regression analysis identified a 6-variable model encompassing the independent predictors, including urgent operation, abdominoperineal resection, open technique, low rectal cancer, T3 to T4, and N1 to N2. The accuracy of the model was 92.3%, with an receiver operating characteristic of 0.783 (p < 0.0001). The quantitative risk associated with circumferential resection margin positivity ranged from <1% (no risk factors) to 43% (6 risk factors). This study was limited by the lack of recorded long-term outcomes associated with circumferential resection margin positivity. The rate of circumferential resection margin involvement in patients undergoing rectal cancer resection in Australasia is low and is influenced by a number of factors. Risk stratification of outcome is important with the increasing demand for publicly accessible quality data. See Video Abstract at http://links.lww.com/DCR/A512.

Totally laparoscopic radical BII gastrectomy for the treatment of gastric cancer: a comparison with open surgery.

PubMed

Lee, Wei-Jei; Wang, Weu; Chen, Tai-Chi; Chen, Jung-Chieh; Ser, Kong-Han

2008-08-01

Laparoscopically assisted distal gastrectomy has been used for distal part early gastric cancer resection. However, use of totally laparoscopic gastric cancer resection remains limited because of technical problems, especially when standard D2 nodal dissection was applied. We had reported the first totally laparoscopic Billroth II (BII) subtotal gastrectomy with lymphadenectomy for early gastric cancer in the year 1998. The aim of this study is to determine whether this procedure is superior to conventional open technique. The clinical course of 34 consecutive patients who underwent totally laparoscopic BII gastrectomy using an upper to lower, right to left, and clockwise quadrant-to-quadrant technique was compared with 34 sex-matched and age-matched patients who underwent open gastrectomy. Main outcome measures included operative time, blood loss, length of stay, morbidity and mortality, adequacy of lymphadenectomy, and long-term outcome. In the laparoscopic group, all the operations were completed by laparoscopic technique, but 1 patient required secondary laparotomy for total gastrectomy owing to inadequate resection margin. There was no operation mortality in this study. The postoperative complication rates were similar in these 2 groups. The mean operative time for laparoscopic group was 283+/-122 minutes (range: 186 to 480 min), significantly longer than the 195+/-26 minutes in the conventional group (P<0.001). Laparoscopic group was associated with less intraoperative blood loss (74 vs. 190 mL; P<0.01), early flatus passage (2.9 vs. 4.9 d; P<0.01), less usage of analgesics (3.5 vs. 5.8 doses; P<0.05), and a shorter postoperative hospital stay (8.5 vs. 12.1 d; P<0.01). There was no significant difference between laparoscopic and conventional open radical gastrectomy with regard to ratio of free margin, number of harvested lymph nodes, and survival. Although totally laparoscopic BII gastrectomy using the upper to lower technique required a longer surgical time and was technically more demanding than conventional open surgery, it resulted in shorter recovery time, less analgesic use, and less severe physical discomfort without compromising the operative curability and oncologic outcomes.

Circumferential resection margin (CRM) positivity after MRI assessment and adjuvant treatment in 189 patients undergoing rectal cancer resection.

PubMed

Simpson, G S; Eardley, N; McNicol, F; Healey, P; Hughes, M; Rooney, P S

2014-05-01

The management of rectal cancer relies on accurate MRI staging. Multi-modal treatments can downstage rectal cancer prior to surgery and may have an effect on MRI accuracy. We aim to correlate the findings of MRI staging of rectal cancer with histological analysis, the effect of neoadjuvant therapy on this and the implications of circumferential resection margin (CRM) positivity following neoadjuvant therapy. An analysis of histological data and radiological staging of all cases of rectal cancer in a single centre between 2006 and 2011 were conducted. Two hundred forty-one patients had histologically proved rectal cancer during the study period. One hundred eighty-two patients underwent resection. Median age was 66.6 years, and male to female ratio was 13:5. R1 resection rate was 11.1%. MRI assessments of the circumferential resection margin in patients without neoadjuvant radiotherapy were 93.6 and 88.1% in patients who underwent neoadjuvant radiotherapy. Eighteen patients had predicted positive margins following chemoradiotherapy, of which 38.9% had an involved CRM on histological analysis. MRI assessment of the circumferential resection margin in rectal cancer is associated with high accuracy. Neoadjuvant chemoradiotherapy has a detrimental effect on this accuracy, although accuracy remains high. In the presence of persistently predicted positive margins, complete resection remains achievable but may necessitate a more radical approach to resection.

Exogenous glucagon-like peptide-2 improves outcomes of intestinal adaptation in a distal-intestinal resection neonatal piglet model of short bowel syndrome.

PubMed

Suri, Megha; Turner, Justine M; Sigalet, David L; Wizzard, Pamela R; Nation, Patrick N; Ball, Ron O; Pencharz, Paul B; Brubaker, Patricia L; Wales, Paul W

2014-10-01

Endogenous glucagon-like peptide-2 (GLP-2) levels and intestinal adaptation are reduced in distal-intestinal resection animal models of short bowel syndrome (SBS) that lack remnant ileum. We hypothesized that exogenous GLP-2 would improve intestinal adaptation in a distal-intestinal resection neonatal piglet model of SBS. In all, 35 piglets were randomized to 2 treatment and 3 surgical groups: control (sham), 75% mid-intestinal resection (JI), and 75% distal-intestinal resection (JC). Parenteral nutrition (PN) commenced on day 1 and was weaned as enteral nutrition (EN) advanced. IV GLP-2 (11 nmol/kg/d) or saline was initiated on day 2. Piglets were maintained for 14 d. Clinical, functional, morphological, and histological outcomes were obtained. JC-GLP-2 piglets had fewer days on PN (10.0 ± 0.6 vs. 13.8 ± 0.2), more days on EN (4.0 ± 0.6 vs. 0.2 ± 0.2), a higher percentage of EN at termination (92 ± 5 vs. 52 ± 10%), fewer days of diarrhea (8.0 ± 0.7 vs. 12.3 ± 0.4), increased intestinal length (19 ± 4 vs. -5 ± 3%), and deeper jejunal crypts (248 ± 21 vs. 172 ± 12 μm), compared with saline piglets. GLP-2 therapy improves clinical, morphological, and histological outcomes of intestinal adaptation in a distal-intestinal resection model of SBS. Since this anatomical subtype represents the majority of clinical cases of neonatal SBS, these results support a potential role for GLP-2 therapy in pediatric SBS.

Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic adenocarcinoma following neoadjuvant therapy.

PubMed

Baumgartner, Joel M; Krasinskas, Alyssa; Daouadi, Mustapha; Zureikat, Amer; Marsh, Wallis; Lee, Kenneth; Bartlett, David; Moser, A James; Zeh, Herbert J

2012-06-01

Celiac trunk encasement by adenocarcinoma of the pancreatic body is generally regarded as a contraindication for surgical resection. Recent studies have suggested that a subset of stage III patients will succumb to their disease in the absence of distant metastases. We hypothesized that patients with stage III tumors invading the celiac trunk, who are free of distant disease following neoadjuvant therapy, may derive prolonged survival benefit from aggressive surgical resection. We performed a retrospective review of distal pancreatectomies with en bloc celiac axis resection for pancreatic adenocarcinoma. Eleven patients underwent a distal pancreatectomy with en bloc celiac axis resection after completing neoadjuvant chemoradiation therapy. Median operative time was 8 h, 14 min, and median estimated blood loss was 700 ml. Median length of stay was 9 days. Five patients (45%) had postoperative complications; three were Clavien grade I. Four patients (35%) had pancreatic leaks; two were ISGPF grade B, and two were grade A. There were two 90-day perioperative deaths. Ten patients had R0 resections (91%). After a median follow-up of 41 weeks, six patients recurred. Four of the five patients with SMAD4 loss recurred, and two of the five patients with intact SMAD4 recurred. Median disease-free and overall survival were 21 weeks and 26 months, respectively. Resection of pancreatic body adenocarcinoma with celiac axis resection is technically feasible with acceptable perioperative morbidity and mortality.

Limb saving surgery for Ewing's sarcoma of the distal tibia: a case report.

PubMed

Mizoshiri, Naoki; Shirai, Toshiharu; Terauchi, Ryu; Tsuchida, Shinji; Mori, Yuki; Katsuyama, Yusei; Hayashi, Daichi; Oka, Yoshinobu; Kubo, Toshikazu

2018-05-02

Ewing's sarcoma is a primary malignant tumor of bone occurring mostly in childhood. Few effective reconstruction techniques are available after wide resection of Ewing's sarcoma at the distal end of the tibia. Reconstruction after wide resection is especially difficult in children, as it is necessary to consider the growth and activity of the lower limbs. A 12-year-old Japanese boy had presented with right lower leg pain at age 8 years. Imaging examination showed a bone tumor accompanied by a large extra-skeletal mass in the distal part of his tibia. The tumor was histologically diagnosed as Ewing's sarcoma. The patient received chemotherapy, followed by wide resection. Reconstruction consisted of a bone transport method involving external fixation of Taylor Spatial Frame. To prevent infection after surgery, the external fixation pin was coated with iodine. One year after surgery, the patient showed poor consolidation of bone, so iliac bone transplantation was performed on the extended bones and docking site of the distal tibia. After 20 months, tibia formation was good. Three years after surgery, there was no evidence of tumor recurrence or metastases; bone fusion was good, and he was able to run. The bone transport method is an effective surgical method of reconstruction after wide resection of a bone tumor at the distal end of the tibia, if a pin can be inserted into the distal bone fragment. Coating external fixation pins with iodine may prevent postoperative infection.

Probe-based confocal laser endomicroscopy in the margin delineation of early gastric cancer for endoscopic submucosal dissection.

PubMed

Park, Jun Chul; Park, Yehyun; Kim, Hyun Ki; Jo, Jeong-Hyeon; Park, Chan Hyuk; Kim, Eun Hye; Jung, Da Hyun; Chung, Hyunsoo; Shin, Sung Kwan; Lee, Sang Kil; Lee, Yong Chan

2017-05-01

We evaluated probe-based confocal laser endomicroscopy (pCLE) in the margin delineation of early gastric cancer (EGC) for endoscopic submucosal dissection in comparison with white-light imaging with chromoendoscopy (CE). We conducted a prospective, randomized controlled study from November 2013 to October 2014 in a tertiary referral hospital. A total of 101 patients scheduled for endoscopic submucosal dissection due to differentiated EGC were randomized into pCLE and CE groups (pCLE 51, CE 50). Markings were made by electrocautery at the proximal and distal tumor margins, as determined by either pCLE or CE. The distance from the marking to the tumor margin was measured in the resected specimen histopathologically and was compared between the two groups by a linear mixed model. Among 104 lesions, 80 lesions with 149 markings (pCLE 68, CE 81) were analyzed after excluding undifferentiated EGCs (n = 8) and unidentifiable markings (n = 13). Although the complete resection rate showed no difference between the groups (94.6% vs 93.2%, P = 1.000), the median distance from the marking to the margin was shorter in the pCLE group (1.3 vs 1.8 mm, P = 0.525) and the proportion of the distance <1 mm was higher (43.9% vs 27.6%, P = 0.023) in the pCLE group. Finally, subgroup analysis with superficial flat lesions (18 lesions, 31 marking dots) showed a significantly decreased distance in the pCLE group (0.5 vs 3.1 mm, P = 0.007). Among EGCs with superficial flat morphology, in which the accurate evaluation of lateral extent is difficult with CE, pCLE would be useful for more precise margin delineation. © 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

Metastasis Infiltration: An Investigation of the Postoperative Brain-Tumor Interface

DOE Office of Scientific and Technical Information (OSTI.GOV)

Raore, Bethwel; Schniederjan, Matthew; Prabhu, Roshan

Purpose: This study aims to evaluate brain infiltration of metastatic tumor cells past the main tumor resection margin to assess the biological basis for the use of stereotactic radiosurgery treatment of the tumor resection cavity and visualized resection edge or clinical target volume. Methods and Materials: Resection margin tissue was obtained after gross total resection of a small group of metastatic lesions from a variety of primary sources. The tissue at the border of the tumor and brain tissue was carefully oriented and processed to evaluate the presence of tumor cells within brain tissue and their distance from the resectionmore » margin. Results: Microscopic assessment of the radially oriented tissue samples showed no tumor cells infiltrating the surrounding brain tissue. Among the positive findings were reactive astrocytosis observed on the brain tissue immediately adjacent to the tumor resection bed margin. Conclusions: The lack of evidence of metastatic tumor cell infiltration into surrounding brain suggests the need to target only a narrow depth of the resection cavity margin to minimize normal tissue injury and prevent treatment size-dependent stereotactic radiosurgery complications.« less

Recurrent GCT of Distal Femur Treated with Resection Arthrodesis with Non-Vascularized Bilateral Fibular Graft and A Custom-Made Interlock Nail.

PubMed

Sanesh, Tuteja; Sachin, Kale; Prasad, Chaudhari; B, Dhar Sanjay

2016-01-01

Giant Cell Tumors commonly occur around the knee joint in the age group of 20-30 years. They are treated with intra-lesional curettage or local resection and limb reconstruction. Management of large bone defects after resection is a challenge and is of ten complicated with non-union of grafts, infection and delayed weight bearing. A 37-year-old male presented with an aggressive recurrent giant cell tumor of the distal femur. He was and was diagnosed with a GCT of the left distal femur 2 years ago for which he was treated with an intralesional curettage and Poly methylmetacrylate implantation. A resection arthrodesis using a bilateral non-vascularised intramedullary fibular graft and a custom made intramedullary nail was performed. The follow-up radiographs showed union at graft-host junction and hypertrophy of the grafted fibula at 2 years post surgery. Non-vascularised fibular graft is an effective alternative for resection arthrodesis with the advantages of a simpler and shorter surgical procedure and without the needs for a microsurgical setup.

Recurrent GCT of Distal Femur Treated with Resection Arthrodesis with Non-Vascularized Bilateral Fibular Graft and A Custom-Made Interlock Nail

PubMed Central

Sanesh, Tuteja; Sachin, Kale; Prasad, Chaudhari; Sanjay, B Dhar

2016-01-01

Introduction: Giant Cell Tumors commonly occur around the knee joint in the age group of 20-30 years. They are treated with intra-lesional curettage or local resection and limb reconstruction. Management of large bone defects after resection is a challenge and is of ten complicated with non-union of grafts, infection and delayed weight bearing. Case Presentation: A 37-year-old male presented with an aggressive recurrent giant cell tumor of the distal femur. He was and was diagnosed with a GCT of the left distal femur 2 years ago for which he was treated with an intralesional curettage and Poly methylmetacrylate implantation. A resection arthrodesis using a bilateral non-vascularised intramedullary fibular graft and a custom made intramedullary nail was performed. The follow-up radiographs showed union at graft-host junction and hypertrophy of the grafted fibula at 2 years post surgery. Conclusion: Non-vascularised fibular graft is an effective alternative for resection arthrodesis with the advantages of a simpler and shorter surgical procedure and without the needs for a microsurgical setup. PMID:28116258

The effect of distal clavicle excision on in situ graft forces in coracoclavicular ligament reconstruction.

PubMed

Kowalsky, Marc S; Kremenic, Ian J; Orishimo, Karl F; McHugh, Malachy P; Nicholas, Stephen J; Lee, Steven J

2010-11-01

Recently, some have suggested that the acromioclavicular articulation confers stability to the construct after coracoclavicular ligament reconstruction for acromioclavicular joint separation. Therefore, it has been suggested that distal clavicle excision should not be performed in this context to protect the graft during healing. Sectioning the acromioclavicular ligaments would significantly increase in situ forces of a coracoclavicular ligament graft, whereas performing a distal clavicle resection would not further increase in situ graft forces. Controlled laboratory study. A simulated coracoclavicular reconstruction was performed on 5 cadaveric shoulders. Static loads of 80 N and 210 N were applied directly to the clavicle in 5 directions: anterior, anterosuperior, superior, posterosuperior, and posterior. The in situ graft force was measured using a force transducer under 3 testing conditions: (1) intact acromioclavicular ligaments, (2) sectioned acromioclavicular ligaments, and (3) distal clavicle excision. For both magnitudes of load, in all directions, in situ graft force with intact acromioclavicular ligaments was significantly less than that with sectioned acromioclavicular ligaments (P < .001). Distal clavicle excision did not further increase the in situ graft forces with load applied to the clavicle in an anterior, anterosuperior, or superior direction. However, in situ graft forces were increased with distal clavicle excision when the clavicle was loaded with 210 N in the posterosuperior direction (60.4 ± 6.3 N vs 52.5 ± 7.1 N; P = .048) and tended to be increased with posterior loading of the clavicle (71.8 ± 6.2 N vs 53.1 ± 8.8 N; P = .125). Intact acromioclavicular ligaments protect the coracoclavicular reconstruction by decreasing the in situ graft force. The slight increase in the in situ graft force only in the posterosuperior and posterior direction after distal clavicle excision suggests only a marginal protective role of the acromioclavicular articulation. Further, the peak graft forces observed represent only a small fraction of the ultimate failure strength of the graft. Distal clavicle excision can perhaps be safely performed in the context of coracoclavicular ligament reconstruction without subjecting the graft to detrimental in situ force. Although the acromioclavicular articulation serves only a marginal role in protecting the coracoclavicular ligament graft, reconstruction of the acromioclavicular ligaments may serve an important role in decreasing in situ graft force during healing.

Zollinger-Ellison syndrome: classical considerations and current controversies.

PubMed

Epelboym, Irene; Mazeh, Haggi

2014-01-01

Zollinger-Ellison syndrome (ZES) is an endocrinopathy characterized by gastrin-secreting tumors, responsible for causing the formation of multiple, refractory, and recurrent peptic ulcers in the distal duodenum and proximal jejunum. Two main variants have been described, sporadic and those found in association with parathyroid and pituitary tumors, a genetic disorder known as multiple endocrine neoplasia-1 (MEN-1). Biochemical serum evaluation for elevated gastrin, followed by radiological or nuclear localization of the primary lesion, is mandated for establishing diagnosis. The mainstays of treatment include management of hypersecretory state with medical suppression of gastric acid production and surgical resection of primary tumor for the prevention of malignant transformation and metastatic complications. Medical therapy with proton pump inhibitors has virtually eliminated the need for acid-reducing surgical procedures. Surgical approach to sporadic and MEN-1-associated ZES varies based on our understanding of the natural history of the condition and the probability of cure; however, resection to a negative microscopic margin is indicated in both cases. Postoperative surveillance involves measurement of gastrin level, followed by imaging if elevation is detected. Re-excision of recurrent or resection of metastatic disease is a subject of controversy; however, at the present time aggressive cytoreductive approach is favored.

The impact of operative approach on outcome of surgery for gastro-oesophageal tumours.

PubMed

Suttie, Stuart A; Li, Alan Gk; Quinn, Martha; Park, Kenneth Gm

2007-08-20

The choice of operation for tumours at or around the gastro-oesophageal junction remains controversial with little evidence to support one technique over another. This study examines the prevalence of margin involvement and nodal disease and their impact on outcome following three surgical approaches (Ivor Lewis, transhiatal and left thoraco-laparotomy) for these tumours. A retrospective analysis was conducted of patients undergoing surgery for distal oesophageal and gastro-oesophageal junction tumours by a single surgeon over ten years. Comparisons were undertaken in terms of tumour clearance, nodal yield, postoperative morbidity, mortality, and median survival. All patients were followed up until death or the end of the data collection (mean follow up 33.2 months). A total of 104 patients were operated on of which 102 underwent resection (98%). Median age was 64.1 yrs (range 32.1-79.4) with 77 males and 25 females. Procedures included 29 Ivor Lewis, 31 transhiatal and 42 left-thoraco-laparotomies. Postoperative mortality was 2.9% and median survival 23 months. Margin involvement was 24.1% (two distal, one proximal and 17 circumferential margins). Operative approach had no significant effect on nodal clearance, margin involvement, postoperative mortality or morbidity and survival. Lymph node positive disease had a significantly worse median survival of 15.8 months compared to 39.7 months for node negative (p = 0.007), irrespective of approach. Surgical approach had no effect on postoperative mortality, circumferential tumour, nodal clearance or survival. This suggests that the choice of operative approach for tumours at the gastro-oesophageal junction may be based on the individual patient and tumour location rather than surgical dogma.

Success of dental implants in vascularised fibular osteoseptocutaneous flaps used as onlay grafts after marginal mandibulectomy.

PubMed

Chang, Y-M; Pan, Y-H; Shen, Y-F; Chen, J-K; ALDeek, N F; Wei, F-C

2016-12-01

We have evaluated the survival of dental implants placed in vascularised fibular flap onlay grafts placed over marginal mandibulectomies and the effects on marginal bone loss of different types of soft tissue around implants under functional loading. From 2001-2009 we studied a total of 11 patients (1 woman and10 men), three of whom had had ameloblastoma and eight who had had squamous cell carcinomas resected. A total of 38 dental implants were placed either at the time of transfer of the vascularised fibular ostoseptocutaneous flaps (nine patients with 30 implants) or secondarily (two patients with eight implants). Four patients were given palatal mucosal grafts to replace intraoral skin flaps around the dental implants (n=13), and the other seven had the skin flaps around the dental implants thinned (n=25) at the second stage of implantation of the osteointegrated teeth. All vascularised fibular osteoseptocutaneous flaps were successfully transferred, and all implants survived a mean (range) of 73 (33-113) months after occlusal functional loading. The mean (SD) marginal bone loss was 0.5 (0.3) mm on both mesial and distal sides in patients who had palatal mucosal grafts, but 1.8 (1.6) mm, and 1.7 (1.5) mm, respectively, on the mesial and distal sides in the patients who had had thinning of their skin flaps. This difference is significant (p=0.008) with less resorption of bone in the group who had palatal mucosal grafts. Palatal mucosa around the implants helps to reduce resorption of bone after functional loading of implants. Copyright © 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

[Case-control study on transverse carpal ligament resection for the prevention of delayed carpal tunnel syndrome after distal radius fracture].

PubMed

Wang, Yan-jie; Wang, Shi-gang; Miao, Shu-juan; Su, Xia

2011-06-01

To investigate the effects of open reduction by palm side for the distal radius fracture and T shape plate internal fixation with simultaneous anterior transverse carpal ligament resection for the prevention of delayed carpal tunnel syndrome after operation. From March 2000 to March 2007, 32 patients (8 males and 24 females, ranging in age from 46 to 66 years) with distal radius fracture were treated with open reduction by palm side and T shape plate internal fixation with simultaneous anterior transverse carpal ligament resection; while 30 patients (7 males and 23 females,ranging in age from 45 to 65 years) only with open reduction by palm side and T shape plate internal fixation. The incidences of delayed carpal tunnel syndrome between the two groups were compared. Among 32 patients treated with open reduction by palm side and T shape plate internal fixation with anterior transverse carpal ligament resection, 3 patients had delayed carpal tunnel syndrome; while in 30 patients treated with open reduction by palm side and T shape plate internal fixation, 10 patients had delayed carpal tunnel syndrome. There was significant statistically difference (P < 0.05%). Simultaneous anterior transverse carpal ligament resection can effectively prevent the delayed carpal tunnel syndrome occurrence for the distal radius fracture with open reduction by palm side.

Margin Status Remains an Important Determinant of Survival after Surgical Resection of Colorectal Liver Metastases in the Era of Modern Chemotherapy

PubMed Central

Andreou, Andreas; Aloia, Thomas A.; Brouquet, Antoine; Dickson, Paxton V.; Zimmitti, Giuseppe; Maru, Dipen M.; Kopetz, Scott; Loyer, Evelyne M.; Curley, Steven A.; Abdalla, Eddie K.; Vauthey, Jean-Nicolas

2013-01-01

Objective To determine the impact of surgical margin status on overall survival (OS) of patients undergoing hepatectomy for colorectal liver metastases (CLM) after modern preoperative chemotherapy. Summary Background Data In the era of effective chemotherapy for CLM, the association between surgical margin status and survival has become controversial. Methods Clinicopathologic data and outcomes for 378 patients treated with modern preoperative chemotherapy and hepatectomy were analyzed. The effect of positive margins on OS was analyzed in relation to pathologic and computed tomography-based morphologic response to chemotherapy. Results Fifty-two of 378 resections (14%) were R1 resections (tumor-free margin < 1 mm). The 5-year OS rates for patients with R0 resection (margin ≥ 1 mm) and R1 resection were 55% and 26%, respectively (P=0.017). Multivariate analysis identified R1 resection (P=0.03) and minor pathologic response to chemotherapy (P=0.002) as the 2 factors independently associated with worse survival. The survival benefit associated with negative margins (R0 vs. R1 resection) was greater in patients with suboptimal morphologic response (5-year OS rate: 62% vs. 11%, P=0.007) than in patients with optimal response (3-year OS rate: 92% vs. 88%, P=0.917) and greater in patients with minor pathologic response (5-year OS rate: 46% vs. 0%, P=0.002) than in patients with major response (5-year OS rate: 63% vs. 67%, P=0.587). Conclusions In the era of modern chemotherapy, negative margins remain an important determinant of survival and should be the primary goal of surgical therapy. The impact of positive margins is most pronounced in patients with suboptimal response to systemic therapy. PMID:23426338

Margin status remains an important determinant of survival after surgical resection of colorectal liver metastases in the era of modern chemotherapy.

PubMed

Andreou, Andreas; Aloia, Thomas A; Brouquet, Antoine; Dickson, Paxton V; Zimmitti, Giuseppe; Maru, Dipen M; Kopetz, Scott; Loyer, Evelyne M; Curley, Steven A; Abdalla, Eddie K; Vauthey, Jean-Nicolas

2013-06-01

To determine the impact of surgical margin status on overall survival (OS) of patients undergoing hepatectomy for colorectal liver metastases after modern preoperative chemotherapy. In the era of effective chemotherapy for colorectal liver metastases, the association between surgical margin status and survival has become controversial. Clinicopathologic data and outcomes for 378 patients treated with modern preoperative chemotherapy and hepatectomy were analyzed. The effect of positive margins on OS was analyzed in relation to pathologic and computed tomography-based morphologic response to chemotherapy. Fifty-two of 378 resections (14%) were R1 resections (tumor-free margin <1 mm). The 5-year OS rates for patients with R0 resection (margin ≥1 mm) and R1 resection were 55% and 26%, respectively (P = 0.017). Multivariate analysis identified R1 resection (P = 0.03) and a minor pathologic response to chemotherapy (P = 0.002) as the 2 factors independently associated with worse survival. The survival benefit associated with negative margins (R0 vs R1 resection) was greater in patients with suboptimal morphologic response (5-year OS rate: 62% vs 11%; P = 0.007) than in patients with optimal response (3-year OS rate: 92% vs 88%; P = 0.917) and greater in patients with a minor pathologic response (5-year OS rate: 46% vs 0%; P = 0.002) than in patients with a major response (5-year OS rate: 63% vs 67%; P = 0.587). In the era of modern chemotherapy, negative margins remain an important determinant of survival and should be the primary goal of surgical therapy. The impact of positive margins is most pronounced in patients with suboptimal response to systemic therapy.

Robot-assisted laparoscopic resection of clinical T4b tumours of distal sigmoid and rectum: initial results.

PubMed

Crolla, Rogier M P H; Tersteeg, Janneke J C; van der Schelling, George P; Wijsman, Jan H; Schreinemakers, Jennifer M J

2018-05-16

Radical resection by multivisceral resection of colorectal T4 tumours is important to reduce local recurrence and improve survival. Oncological safety of laparoscopic resection of T4 tumours is controversial. However, robot-assisted resections might have advantages, such as 3D view and greater range of motion of instruments. The aim of this study is to evaluate the initial results of robot-assisted resection of T4 rectal and distal sigmoid tumours. This is a cohort study of a prospectively kept database of all robot-assisted rectal and sigmoid resections between 2012 and 2017. Patients who underwent a multivisceral resection for tumours appearing as T4 cancer during surgery were included. Rectal and sigmoid resections are routinely performed with the DaVinci robot, unless an indication for intra-operative radiotherapy exists. 28 patients with suspected T4 rectal or sigmoid cancer were included. Most patients (78%) were treated with neoadjuvant chemoradiotherapy (n = 19), short course radiotherapy with long waiting interval (n = 2) or chemotherapy (n = 1). En bloc resection was performed with the complete or part of the invaded organ (prostate, vesicles, bladder, abdominal wall, presacral fascia, vagina, uterus, adnex). In 3 patients (11%), the procedure was converted to laparotomy. Twenty-four R0-resections were performed (86%) and four R1-resections (14%). Median length of surgery was 274 min (IQR 222-354). Median length of stay was 6 days (IQR 5-11). Twelve patients (43%) had postoperative complications: eight (29%) minor complications and four (14%) major complications. There was no postoperative mortality. Robot-assisted laparoscopy seems to be a feasible option for the resection of clinical T4 cancer of the distal sigmoid and rectum in selected cases. Radical resections can be achieved in the majority of cases. Therefore, T4 tumours should not be regarded as a strict contraindication for robot-assisted surgery.

The White test: a new dye test for intraoperative detection of bile leakage during major liver resection.

PubMed

Nadalin, Silvio; Li, Jun; Lang, Hauke; Sotiropoulos, Georgios C; Schaffer, Randolph; Radtke, Arnold; Saner, Fuat; Broelsch, Christoph E; Malagó, Massimo

2008-04-01

To describe a new intraoperative bile leakage test in patients undergoing a major liver resection aimed to combine the advantages of each of the other standard bile leakage tests (accurate visualization of leaks, reproducibility, and ease of use) without their disadvantages. At the end of the major hepatic resection, 10 to 30 mL of sterile fat emulsion, 5%, is injected via an olive-tip cannula through the cystic duct while manually occluding the distal common bile duct. As the biliary tree fills with fat emulsion solution, leakage of the white fluid is visualized on the raw surface of the liver resection margin. The detected leakages are closed by means of single stitches. Afterwards, the residual fat emulsion on the resection surface is washed off with saline and the White test is repeated to detect and/or exclude additional bile leakages. At the end, residual fat emulsion is washed out from the biliary tract by a low-pressure infusion of saline solution. Intraoperatively, additional potential bile leakages (not seen using a conventional saline bile leakage test) were identified in 74% of our patients. Postoperative bile leakages (within 30 days) occurred in only 5.1% of patients when the White test was used. No adverse effects related to this technique were observed. The White test has clear advantages in comparison with other bile leakage tests: it precisely detects bile leakages, regardless of size; it does not stain the resection surface, allowing it to be washed off and repeated ad infinitum; and it is safe, quick, and inexpensive.

[Dynamic radioulnar convergence after Darrach operation, soft tissue stabilizing operations of the distal ulna and ulnar head prosthesis implantation--an experimental biomechanical study].

PubMed

Sauerbier, M; Hahn, M E; Fujita, M; Neale, P G; Germann, G; An, K N; Berger, R A

2002-08-01

The most common method of treating the arthrotic distal radioulnar joint (DRUJ) is resection of the entire ulnar head (Darrach procedure). Complications related to instability of the distal forearm resulting from loss of the ulnar head are usually manifested by pain and weak grip strength and have remained the drawbacks of this procedure. In an attempt to mechanically stabilize the distal forearm, an endoprosthesis was developed to replace the ulnar head after Darrach resection. The purpose of this study was to: 1) evaluate the dynamic effects of the Darrach procedure on radioulnar convergence; and 2) evaluate the mechanical efficacy of two soft tissue stabilizing techniques (Pronator quadratus advancement flap and ECU/FCU tenodesis) for the unstable distal ulnar stump and 3) the stability after the implantation of an ulnar head endoprosthesis following a Darrach resection on radioulnar convergence. With a dynamic PC-controled forearm simulator the rotation of 7 fresh-frozen cadaver upper extremities was actively and passively performed while loading relevant muscles. Resultant total forearm torque and the 3-dimensional kinematics of the ulna, radius and third metacarpal were recorded simultaneously. The implantation of the ulnar head endoprosthesis effectively restored the stability of the DRUJ. There were significantly better results after the implantation of the prosthesis compared with the Darrach and the soft tissue stabilization procedures. This study provides laboratory validity to the option of implanting an ulnar head endoprosthesis as an attempt to stabilize the distal forearm after Darrach resection in lieu of performing soft tissue stabilization techniques.

The impact of caudate lobe resection on margin status and outcomes in patients with hilar cholangiocarcinoma: a multi-institutional analysis from the US Extrahepatic Biliary Malignancy Consortium.

PubMed

Bhutiani, Neal; Scoggins, Charles R; McMasters, Kelly M; Ethun, Cecilia G; Poultsides, George A; Pawlik, Timothy M; Weber, Sharon M; Schmidt, Carl R; Fields, Ryan C; Idrees, Kamran; Hatzaras, Ioannis; Shen, Perry; Maithel, Shishir K; Martin, Robert C G

2018-04-01

The objective of this study was to determine the impact of caudate resection on margin status and outcomes during resection of extrahepatic hilar cholangiocarcinoma. A database of 1,092 patients treated for biliary malignancies at institutions of the Extrahepatic Biliary Malignancy Consortium was queried for individuals undergoing curative-intent resection for extrahepatic hilar cholangiocarcinoma. Patients who did versus did not undergo concomitant caudate resection were compared with regard to demographic, baseline, and tumor characteristics as well as perioperative outcomes. A total of 241 patients underwent resection for a hilar cholangiocarcinoma, of whom 85 underwent caudate resection. Patients undergoing caudate resection were less likely to have a final positive margin (P = .01). Kaplan-Meier curve of overall survival for patients undergoing caudate resection indicated no improvement over patients not undergoing caudate resection (P = .16). On multivariable analysis, caudate resection was not associated with improved overall survival or recurrence-free survival, although lymph node positivity was associated with worse overall survival and recurrence-free survival, and adjuvant chemoradiotherapy was associated with improved overall survival and recurrence-free survival. Caudate resection is associated with a greater likelihood of margin-negative resection in patients with extrahepatic hilar cholangiocarcinoma. Precise preoperative imaging is critical to assess the extent of biliary involvement, so that all degrees of hepatic resections are possible at the time of the initial operation. Copyright © 2017 Elsevier Inc. All rights reserved.

Comparison of standard laparoscopic distal pancreatectomy with minimally invasive distal pancreatectomy using the da Vinci S system.

PubMed

Ito, Masahiro; Asano, Yukio; Shimizu, Tomohiro; Uyama, Ichiro; Horiguchi, Akihiko

2014-01-01

Minimally invasive procedures for pancreatic pathologies are increasingly being used, including distal pancreatectomy. This study aimed to assess the indications for and outcomes of the da Vinci distal pancreatectomy procedure. We reviewed the medical records of patients who underwent pancreatic head resection from April 2009 to September 2013. Four patients (mean age, 52.7 years) underwent da Vinci distal pancreatectomy and 10 (mean age, 68.0 +/- 12.1 years) underwent laparoscopic distal pancreatectomy. The mean surgical duration was 292 +/- 153 min and 306 +/- 29 min, the mean blood loss was 153 +/- 71 mL and 61.7 +/- 72 mL, and the mean postoperative length of stay was 24 +/- 11 days and 14 +/- 3 days in the da Vinci distal pancreatectomy and laparoscopic distal pancreatectomy groups, respectively. One patient who underwent da Vinci distal pancreatectomy developed a pancreatic fistula, while 2 patients in the laparoscopic distal pancreatectomy group developed splenic ischemia and gastric torsion, respectively. Laparoscopic and robotic pancreatic resection were both safe and feasible in selected patients with distal pancreatic pathologies. Further studies are necessary to clarify the role of robotic surgery in the advanced laparoscopic era.

Post-resection mucosal margin shrinkage in oral cancer: quantification and significance.

PubMed

Mistry, Rajesh C; Qureshi, Sajid S; Kumaran, C

2005-08-01

The importance of tumor free margins in outcome of cancer surgery is well known. Often the pathological margins are reported to be significantly smaller than the in situ margins. This discrepancy is due to margin shrinkage the quantum of which has not been studied in patients with oral cancers. To quantify the shrinkage of mucosal margin following excision for carcinoma of the oral tongue and buccal mucosa. Mucosal margins were measured prior to resection and half an hour after excision in 27 patients with carcinoma of the tongue and buccal mucosa. The mean margin shrinkage was assessed and the variables affecting the quantum of shrinkage analyzed. The mean shrinkage from the in situ to the post resection margin status was 22.7% (P < 0.0001). The mean shrinkage of the tongue margins was 23.5%, compared to 21.2% for buccal mucosa margins. The mean shrinkage in T1/T2 tumors (25.6%) was significantly more than in T3/T4 (9.2%, P < 0.011). There is significant shrinkage of mucosal margins after surgery. Hence this should be considered and appropriate margins should be taken at initial resection to prevent the agony of post-operative positive surgical margins. Copyright 2005 Wiley-Liss, Inc.

Surgical quality of wedge resection affects overall survival in patients with early stage non-small cell lung cancer.

PubMed

Ajmani, Gaurav S; Wang, Chi-Hsiung; Kim, Ki Wan; Howington, John A; Krantz, Seth B

2018-07-01

Very few studies have examined the quality of wedge resection in patients with non-small cell lung cancer. Using the National Cancer Database, we evaluated whether the quality of wedge resection affects overall survival in patients with early disease and how these outcomes compare with those of patients who receive stereotactic radiation. We identified 14,328 patients with cT1 to T2, N0, M0 disease treated with wedge resection (n = 10,032) or stereotactic radiation (n = 4296) from 2005 to 2013 and developed a subsample of propensity-matched wedge and radiation patients. Wedge quality was grouped as high (negative margins, >5 nodes), average (negative margins, ≤5 nodes), and poor (positive margins). Overall survival was compared between patients who received wedge resection of different quality and those who received radiation, adjusting for demographic and clinical variables. Among patients who underwent wedge resection, 94.6% had negative margins, 44.3% had 0 nodes examined, 17.1% had >5 examined, and 3.0% were nodally upstaged; 16.7% received a high-quality wedge, which was associated with a lower risk of death compared with average-quality resection (adjusted hazard ratio [aHR], 0.74; 95% confidence interval [CI], 0.67-0.82). Compared with stereotactic radiation, wedge patients with negative margins had significantly reduced hazard of death (>5 nodes: aHR, 0.50; 95% CI, 0.43-0.58; ≤5 nodes: aHR, 0.65; 95% CI, 0.60-0.70). There was no significant survival difference between margin-positive wedge and radiation. Lymph nodes examined and margins obtained are important quality metrics in wedge resection. A high-quality wedge appears to confer a significant survival advantage over lower-quality wedge and stereotactic radiation. A margin-positive wedge appears to offer no benefit compared with radiation. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

DNA Resection at Chromosome Breaks Promotes Genome Stability by Constraining Non-Allelic Homologous Recombination

PubMed Central

Koshland, Douglas

2012-01-01

DNA double-strand breaks impact genome stability by triggering many of the large-scale genome rearrangements associated with evolution and cancer. One of the first steps in repairing this damage is 5′→3′ resection beginning at the break site. Recently, tools have become available to study the consequences of not extensively resecting double-strand breaks. Here we examine the role of Sgs1- and Exo1-dependent resection on genome stability using a non-selective assay that we previously developed using diploid yeast. We find that Saccharomyces cerevisiae lacking Sgs1 and Exo1 retains a very efficient repair process that is highly mutagenic to genome structure. Specifically, 51% of cells lacking Sgs1 and Exo1 repair a double-strand break using repetitive sequences 12–48 kb distal from the initial break site, thereby generating a genome rearrangement. These Sgs1- and Exo1-independent rearrangements depend partially upon a Rad51-mediated homologous recombination pathway. Furthermore, without resection a robust cell cycle arrest is not activated, allowing a cell with a single double-strand break to divide before repair, potentially yielding multiple progeny each with a different rearrangement. This profusion of rearranged genomes suggests that cells tolerate any dangers associated with extensive resection to inhibit mutagenic pathways such as break-distal recombination. The activation of break-distal recipient repeats and amplification of broken chromosomes when resection is limited raise the possibility that genome regions that are difficult to resect may be hotspots for rearrangements. These results may also explain why mutations in resection machinery are associated with cancer. PMID:22479212

Combined robotic transanal total mesorectal excision (R-taTME) and single-site plus one-port (R-SSPO) technique for ultra-low rectal surgery-initial experience with a new operation approach.

PubMed

Kuo, Li-Jen; Ngu, James Chi-Yong; Tong, Yiu-Shun; Chen, Chia-Che

2017-02-01

Robot-assisted rectal surgery is gaining popularity, and robotic single-site surgery is also being explored clinically. We report our initial experience with robotic transanal total mesorectal excision (R-taTME) and radical proctectomy using the robotic single-site plus one-port (R-SSPO) technique for low rectal surgery. Between July 2015 and March 2016, 15 consecutive patients with ultra-low rectal lesions underwent R-taTME followed by radical proctectomy using the R-SSPO technique by a single surgeon. The clinical and pathological results were retrospectively analyzed. The median operative time was 473 (range, 335-569) min, and the estimated blood loss was 33 (range, 30-50) mL. The median number of lymph nodes harvested was 12 (range, 8-18). The median distal resection margin was 1.4 (range, 0.4-3.5) cm, and all patients had clear circumferential resection margins. We encountered a left ureteric transection intraoperatively in one patient, and another patient required reoperation for postoperative adhesive intestinal obstruction. There was no 30-day mortality. R-taTME followed by radical proctectomy using the R-SSPO technique for patients with low rectal lesions is technically feasible and safe without compromising oncologic outcomes. However, there were considerable limitations and a steep learning curve using current robotic technology.

Prognostic significance of positive circumferential resection margin in esophageal cancer: a systematic review and meta-analysis.

PubMed

Wu, Jie; Chen, Qi-Xun; Teng, Li-song; Krasna, Mark J

2014-02-01

To assess the prognostic significance of positive circumferential resection margin on overall survival in patients with esophageal cancer, a systematic review and meta-analysis was performed. Studies were identified from PubMed, EMBASE, and Web of Science. Survival data were extracted from eligible studies to compare overall survival in patients with a positive circumferential resection margin with patients having a negative circumferential resection margin according to the Royal College of Pathologists (RCP) criteria and the College of American Pathologists (CAP) criteria. Survival data were pooled with hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs). A random-effects model meta-analysis on overall survival was performed. The pooled HRs for survival were 1.510 (95% CI, 1.329-1.717; p<0.001) and 2.053 (95% CI, 1.597-2.638; p<0.001) according to the RCP and CAP criteria, respectively. Positive circumferential resection margin was associated with worse survival in patients with T3 stage disease according to the RCP (HR, 1.381; 95% CI, 1.028-1.584; p=0.001) and CAP (HR, 2.457; 95% CI, 1.902-3.175; p<0.001) criteria, respectively. Positive circumferential resection margin was associated with worse survival in patients receiving neoadjuvant therapy according to the RCP (HR, 1.676; 95% CI, 1.023-2.744; p=0.040) and CAP (HR, 1.847; 95% CI, 1.226-2.78; p=0.003) criteria, respectively. Positive circumferential resection margin is associated with poor prognosis in patients with esophageal cancer, particularly in patients with T3 stage disease and patients receiving neoadjuvant therapy. Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Lymph node metastasis after endoscopic submucosal dissection of a differentiated gastric cancer confined to the mucosa with an ulcer smaller than 30 mm.

PubMed

Fujii, Hiroyuki; Ishii, Eiji; Tochitani, Shinako; Nakaji, So; Hirata, Nobuto; Kusanagi, Hiroshi; Narita, Makoto

2015-01-01

In the expanded indications for endoscopic resection, Japanese guidelines for gastric cancer include differentiated cancers confined to the mucosa with an ulcer <30 mm. We describe a patient with lymph node metastasis after curative endoscopic submucosal dissection (ESD) for a tumor of this indication. The patient was a 70-year-old man with chronic hepatitis C. He underwent ESD for early gastric cancer in May 2010. Pathology revealed a moderately differentiated adenocarcinoma, 22 × 17 mm in size, that was confined to the mucosa with an ulcer. The horizontal and vertical margins were negative for the tumor. We diagnosed thiscase as curative resection of expanded indication and followed this patient with endoscopy, abdominal ultrasonography (AUS) or enhanced computed tomography (CT) approximately every 6 months. After 17 months, lymph node metastasis was detected with AUS and CT and diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsy in August 2011. Distal gastrectomy with D2 dissection was carried out in December 2011. Although it is low, the possibility of recurrence should be borne in mind after endoscopic treatment of early gastric cancer, despite its inclusion in the expanded indications for endoscopic resection. © 2014 The Authors. Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society.

The Hand-Assisted Laparoscopic Approach to Resection of Pancreatic Mucinous Cystic Neoplasms: An Underused Technique?

PubMed

Postlewait, Lauren M; Ethun, Cecilia G; McInnis, Mia R; Merchant, Nipun; Parikh, Alexander; Idrees, Kamran; Isom, Chelsea A; Hawkins, William; Fields, Ryan C; Strand, Matthew; Weber, Sharon M; Cho, Clifford S; Salem, Ahmed; Martin, Robert C G; Scoggins, Charles; Bentrem, David; Kim, Hong J; Carr, Jacquelyn; Ahmad, Syed; Abbott, Daniel; Wilson, Gregory C; Kooby, David A; Maithel, Shishir K

2018-01-01

Pancreatic mucinous cystic neoplasms (MCNs) are rare tumors typically of the distal pancreas that harbor malignant potential. Although resection is recommended, data are limited on optimal operative approaches to distal pancreatectomy for MCN. MCN resections (2000-2014; eight institutions) were included. Outcomes of minimally invasive and open MCN resections were compared. A total of 289 patients underwent distal pancreatectomy for MCN: 136(47%) minimally invasive and 153(53%) open. Minimally invasive procedures were associated with smaller MCN size (3.9 vs 6.8 cm; P = 0.001), lower operative blood loss (192 vs 392 mL; P = 0.001), and shorter hospital stay(5 vs 7 days; P = 0.001) compared with open. Despite higher American Society of Anesthesiologists class, hand-assisted (n = 46) had similar advantages as laparoscopic/robotic (n = 76). When comparing hand-assisted to open, although MCN size was slightly smaller (4.1 vs 6.8 cm; P = 0.001), specimen length, operative time, and nodal yield were identical. Similar to laparoscopic/robotic, hand-assisted had lower operative blood loss (161 vs 392 mL; P = 0.001) and shorter hospital stay (5 vs 7 days; P = 0.03) compared with open, without increased complications. Hand-assisted laparoscopic technique is a useful approach for MCN resection because specimen length, lymph node yield, operative time, and complication profiles are similar to open procedures, but it still offers the advantages of a minimally invasive approach. Hand-assisted laparoscopy should be considered as an alternative to open technique or as a successive step before converting from total laparoscopic to open distal pancreatectomy for MCN.

Stapler versus scalpel resection followed by hand-sewn closure of the pancreatic remnant for distal pancreatectomy.

PubMed

Probst, Pascal; Hüttner, Felix J; Klaiber, Ulla; Knebel, Phillip; Ulrich, Alexis; Büchler, Markus W; Diener, Markus K

2015-11-06

Resections of the pancreatic body and tail reaching to the left of the superior mesenteric vein are defined as distal pancreatectomy. Most distal pancreatectomies are elective treatments for chronic pancreatitis, benign or malignant diseases, and they have high morbidity rates of up to 40%. Pancreatic fistula formation is the main source of postoperative morbidity, associated with numerous further complications. Researchers have proposed several surgical resection and closure techniques of the pancreatic remnant in an attempt to reduce these complications. The two most common techniques are scalpel resection followed by hand-sewn closure of the pancreatic remnant and stapler resection and closure. To compare the rates of pancreatic fistula in people undergoing distal pancreatectomy using scalpel resection followed by hand-sewn closure of the pancreatic remnant versus stapler resection and closure. We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Biosis and Science Citation Index from database inception to October 2015. We included randomised controlled trials (RCTs) comparing stapler versus scalpel resection followed by hand-sewn closure of the pancreatic remnant for distal pancreatectomy (irrespective of language or publication status). Two authors independently assessed trials for inclusion and extracted the data. Taking into consideration the clinical heterogeneity between the trials (e.g. different endpoint definitions), we analysed data using a random-effects model with Review Manager (RevMan), calculating risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). In two eligible trials, a total of 381 participants underwent distal pancreatic resection and were randomised to closure of the pancreatic remnant either with stapler (n = 191) or scalpel resection followed by hand-sewn closure (n = 190). One was a single centre pilot RCT and the other was a multicentre blinded RCT. The single centre pilot RCT evaluated 69 participants in five intervention arms (stapler, hand-sewn, fibrin glue, mesh and pancreaticojejunostomy), although we only assessed the stapler and hand-sewn closure groups (14 and 15 participants, respectively). The multicentre RCT had two interventional arms: stapler (n = 177) and hand-sewn closure (n = 175). The rate of postoperative pancreatic fistula was the main outcome, and it occurred in 79 of 190 participants in the hand-sewn group compared to 65 of 191 participants in the stapler group. Neither the individual trials nor the meta-analysis showed a significant difference between resection techniques (RR 0.90; 95% CI 0.55 to 1.45; P = 0.66). In the same way, postoperative mortality and operation time did not differ significantly. The single centre RCT had an unclear risk of bias in the randomisation, allocation and both blinding domains. However, the much larger multicentre RCT had a low risk of bias in all domains. Due to the small number of events and the wide confidence intervals that cannot exclude clinically important benefit or harm with stapler versus hand-sewn closure, there is a serious possibility of imprecision, making the overall quality of evidence moderate. The quality of evidence is moderate and mainly based on the high weight of the results of one multicentre RCT. Unfortunately, there are no other completed RCTs on this topic except for one relevant ongoing trial. Neither stapler nor scalpel resection followed by hand-sewn closure of the pancreatic remnant for distal pancreatectomy showed any benefit compared to the other method in terms of postoperative pancreatic fistula, overall postoperative mortality or operation time. Currently, the choice of closure is left up to the preference of the individual surgeon and the anatomical characteristics of the patient. Another (non-European) multicentre trial (e.g. with an equality or non-inferiority design) would help to corroborate the findings of this meta-analysis. Future trials assessing novel methods of stump closure should compare them either with stapler or hand-sewn closure as a control group to ensure comparability of results.

The assessment of mucosal surgical margins in head and neck cancer surgery with narrow band imaging.

PubMed

Šifrer, Robert; Urbančič, Jure; Strojan, Primož; Aničin, Aleksandar; Žargi, Miha

2017-07-01

The diagnostic gain of narrow band imaging in the definition of surgical margins in the treatment of head and neck cancer was evaluated. A prospective study, blinded to the pathologist, with historical comparison. The study group included 45 patients subjected to the intraoperative definition of margins by narrow band imaging. The control group included 55 patients who had undergone standard definition of margins. All patients underwent resection of the tumor and frozen section analysis of superficial margins. The rate of initial R 0 resection and the ratio of histologically negative margins for both groups were statistically compared. The rate of initial R 0 resection in the study group and in the control group was 88.9% and 70.9% (P = .047), and the ratio of histologically negative margins was 95.9% and 88.4% (P = .017), respectively. Narrow band imaging reveals a microscopic extension of the tumor that could be effectively used to better define superficial margins and to achieve a higher rate of initial R 0 resections. 4 Laryngoscope, 127:1577-1582, 2017. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Impact of centralization of pancreatoduodenectomy on reported radical resections rates in a nationwide pathology database.

PubMed

Onete, Veronica G; Besselink, Marc G; Salsbach, Chanielle M; Van Eijck, Casper H; Busch, Olivier R; Gouma, Dirk J; de Hingh, Ignace H; Sieders, Egbert; Dejong, Cornelis H; Offerhaus, Johan G; Molenaar, I Quintus

2015-08-01

Centralization of a pancreatoduodenectomy (PD) leads to a lower post-operative mortality, but is unclear whether it also leads to improved radical (R0) or overall resection rates. Between 2004 and 2009, pathology reports of 1736 PDs for pancreatic and peri-ampullary neoplasms from a nationwide pathology database were analysed. Pre-malignant lesions were excluded. High-volume hospitals were defined as performing ≥ 20 PDs annually. The relationship between R0 resections, PD-volume trends, quality of pathology reports and hospital volume was analysed. During the study period, the number of hospitals performing PDs decreased from 39 to 23. High-volume hospitals reported more R0 resections in the pancreatic head and distal bile duct tumours than low-volume hospitals (60% versus 54%, P = 0.035) although they operated on more advanced (T3/T4) tumours (72% versus 58%, P < 0.001). The number of PDs increased from 258 in 2004 to 394 in 2009 which was partly explained by increased overall resection rates of pancreatic head and distal bile duct tumours (11.2% in 2004 versus 17.5% in 2009, P < 0.001). The overall reported R0 resection rate of pancreatic head and distal bile duct tumours increased (6% in 2004 versus 11% in 2009, P < 0.001). Pathology reports of low-volume hospitals lacked more data including tumour stage (25% versus 15%, P < 0.001). Centralization of PD was associated with both higher resection rates and more reported R0 resections. The impact of this finding on overall survival should be further assessed. © 2015 International Hepato-Pancreato-Biliary Association.

Is intralesional resection suitable for central grade 1 chondrosarcoma: A systematic review and updated meta-analysis.

PubMed

Chen, X; Yu, L J; Peng, H M; Jiang, C; Ye, C H; Zhu, S B; Qian, W W

2017-09-01

The surgical choice for grade 1 chondrosarcoma has been debated for decades. Intralesional resection can minimize the damage caused by surgery and offer better functional outcome. However, controversy remains about whether it will result in higher rates of local recurrence and metastasis, fewer complications, and better functional outcome compared with resection with wide margin. This systematic review and updated meta-analysis therefore compared intralesional resection and resection with wide margin in terms of local recurrence, metastasis, complications, and functional outcome. Medline, Embase, and the Cochrane Library were comprehensively searched in December 2016 to identify studies comparing intralesional resection and resection with wide margin for central grade 1 chondrosarcoma. Data of interest were extracted and analyzed using Review Manager 5.3. Ten studies involving 394 patients were included, with 214 patients who had intralesional resection and 180 patients who had resection with wide margin for grade 1 chondrosarcoma. Intralesional resection was associated with lower complication rates (P < 0.0001) and better Musculoskeletal Tumor Society score (MSTS). There were no significant differences in terms of overall local recurrence (P = 0.27), local recurrence based on adjuvant therapies (P = 0.22), local recurrence in studies that included lesions of the hand, foot, pelvis, and axial skeleton (P = 0.55), and metastasis (P = 0.74) between groups. Intralesional resection provides lower complications and better functional outcome with no significant increase in the risk of recurrence and metastasis. We think it is a suitable treatment for central grade 1 chondrosarcoma. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

Factors affecting surgical margin recurrence after hepatectomy for colorectal liver metastases.

PubMed

Akyuz, Muhammet; Aucejo, Federico; Quintini, Cristiano; Miller, Charles; Fung, John; Berber, Eren

2016-06-01

Hepatic recurrence after resection of colorectal liver metastasis (CLM) occurs in 50% of patients during follow-up, with 2.8% to 13.9% presenting with surgical margin recurrence (SMR). The aim of this study is to analyze factors that related to SMR in patients with CLM undergoing hepatectomy. Demographics, clinical and survival data of patients who underwent hepatectomy were identified from a prospectively maintained, institutional review board (IRB)-approved database between 2000 and 2012. Statistical analysis was performed using univariate Kaplan Meier and Cox proportional hazard model. There were 85 female and 121 male patients who underwent liver resection for CLM. An R0 resection was performed in 157 (76%) patients and R1 resection in 49. SMR was detected in 32 patients (15.5%) followed up for a median of 29 months (range, 3-121 months). A half of these patients had undergone R1 (n=16) and another half R0 resection (n=16). Tumor size, preoperative carcinoembryonic antigen (CEA) level and margin status were associated with SMR on univariate analysis. On multivariate analysis, a positive surgical margin was the only independent predictor of SMR. The receipt of adjuvant chemotherapy did not affect margin recurrence. SMR was an independent risk factor associated with worse disease-free (DFS) and overall survival (OS). This study shows that SMR, which can be detected in up to 15.5% of patients after liver resection for CLM, adversely affects DFS and OS. The fact that a positive surgical margin was the only predictive factor for SMR in these patients underscores the importance of achieving negative margins during hepatectomy.

Dermatofibrosarcoma protuberans of the vulva: margins assessment and reconstructive options - a report of two cases.

PubMed

Bertolli, Eduardo; Bretchbuhl, Eduard Renè; Camarço, William Ricardo; Campagnari, Mariane; Molina, André Sapata; Baiocchi, Glauco; Macedo, Mariana Petaccia; Pinto, Clovis Antonio; Cunha, Isabela Werneck; Neto, João Pedreira

2014-12-29

Dermatofibrosarcoma Protuberans (DFSP) of the vulva is rare and oncologic surgery with free margins may lead to severe functional damage, requiring multidisciplinary approach regarding resection, margin assessment and reconstruction.Case Report: Two cases of DFSP in vulva were treated in a single institution. A 28-year-old patient with an incisional biopsy in the vulvar region revealing DFSP underwent a partial vulvectomy with clitoris preservation. Pathological studies revealed free margins and reconstructive surgery was performed. This patient is disease free in a 40 months follow up. The other, a 57-year-old patient was also referred after an incomplete resection of a DFSP in the vulvar region. A 1-cm margim resection followed by Complete Circumferential and Peripheral Deep Margin Assessment (CCPDMA) was performed. Although the upper lateral margin was positive, it was possible to perform another wide local excision with preservation of the clitoris and primary closure. DFSP of the vulva requires an accurate evaluation of margins, resections following oncological principles and reconstruction. Although being a very challenging lesion that usually implies difficult surgical management, if treated in a multidisciplinary environment, with surgical oncologists, experienced dermatopathologists and reconstructive surgeons can achieve good results. Even in difficult cases that presents with large lesions and compromising challenging areas, a complete oncologic resection can be performed minimizing functional damage for the patient.

High-definition endoscopy with digital chromoendoscopy for histologic prediction of distal colorectal polyps.

PubMed

Rath, Timo; Tontini, Gian E; Nägel, Andreas; Vieth, Michael; Zopf, Steffen; Günther, Claudia; Hoffman, Arthur; Neurath, Markus F; Neumann, Helmut

2015-10-22

Distal diminutive colorectal polyps are common and accurate endoscopic prediction of hyperplastic or adenomatous polyp histology could reduce procedural time, costs and potential risks associated with the resection. Within this study we assessed whether digital chromoendoscopy can accurately predict the histology of distal diminutive colorectal polyps according to the ASGE PIVI statement. In this prospective cohort study, 224 consecutive patients undergoing screening or surveillance colonoscopy were included. Real time histology of 121 diminutive distal colorectal polyps was evaluated using high-definition endoscopy with digital chromoendoscopy and the accuracy of predicting histology with digital chromoendoscopy was assessed. The overall accuracy of digital chromoendoscopy for prediction of adenomatous polyp histology was 90.1 %. Sensitivity, specificity, positive and negative predictive values were 93.3, 88.7, 88.7, and 93.2 %, respectively. In high-confidence predictions, the accuracy increased to 96.3 % while sensitivity, specificity, positive and negative predictive values were calculated as 98.1, 94.4, 94.5, and 98.1 %, respectively. Surveillance intervals with digital chromoendoscopy were correctly predicted with >90 % accuracy. High-definition endoscopy in combination with digital chromoendoscopy allowed real-time in vivo prediction of distal colorectal polyp histology and is accurate enough to leave distal colorectal polyps in place without resection or to resect and discard them without pathologic assessment. This approach has the potential to reduce costs and risks associated with the redundant removal of diminutive colorectal polyps. ClinicalTrials NCT02217449.

[Closure of pancreas stump after distal and segmental resection : Suture, stapler, coverage or anastomosis?

PubMed

Michalski, C W; Tramelli, P; Büchler, M W; Hackert, T

2017-01-01

Postoperative pancreatic fistulas represent the most frequent complication after distal and segmental pancreatectomy and occur with a frequency of up to 50 %. There are many technical variations of pancreatic stump treatment for reduction of fistula rates after distal resection. Most of these techniques have only been analyzed in retrospective studies and the evidence for or against a specific technique is low. Several retrospective trials have been conducted with good results to compare suturing with stapled closure of the remnant and to assess the effect of a vascularized falciform ligament patch in reducing postoperative pancreatic fistula; however, in a recently published randomized trial, which analyzed closure of the remnant with a pancreaticojejunostomy compared to standard closure, these results could not be confirmed. Because stapler resection and closure is the most commonly used technique in laparoscopic distal pancreatectomy, there are a large number of studies which assessed various novel methods of improving stapling. Extended stapler compression time and mesh augmentation of the stapler line can be valid methods to reduce fistula rates. Central pancreatectomy is a relatively rarely used procedure where the right-sided pancreatic remnant is closed in the same fashion as during distal pancreatectomy and the left-sided remnant is connected to the intestines with a pancreaticojejunostomy or pancreaticogastrostomy. In conclusion, postoperative pancreatic fistula rates are still a relevant clinical problem after distal pancreatectomy and further studies on potentially improved novel techniques are required.

Retroperitoneal margin involvement by adenocarcinoma of the caecum and ascending colon: what does it mean?

PubMed

Scott, N; Jamali, A; Verbeke, C; Ambrose, N S; Botterill, I D; Jayne, D G

2008-03-01

Circumferential margin involvement (CRM) is a powerful predictor of local recurrence, distant metastasis and patient survival in rectal cancer. In this study, we aimed to determine the frequency of retroperitoneal margin involvement in right colon cancer and describe its relationship to tumour stage and outcome of surgical treatment. Two hundred and twenty-eight consecutive resections for adenocarcinoma of the ascending colon and caecum were identified between 1998 and 2006. Tumour involvement of the posterior retroperitoneal surgical resection margin (RSRM) was recorded and correlated with tumour stage, grade and clinical outcome. RSRM positive patients were compared with CRM positive rectal tumours resected in the same surgical unit. Nineteen of 228 right hemicolectomies (8.4%) showed tumour involvement of the RSRM (defined as < or = 1 mm). Approximately half of the RSRM positive patients underwent palliative resections because of synchronous distant metastases. Out of nine 'potentially curative' resections where the RSRM was involved, five patients subsequently developed metastatic recurrence and two isolated local recurrence. RSRM positivity was associated with advanced tumour stage and more extensive extramural spread than CRM positive rectal cancers. Retroperitoneal surgical resection margin involvement by caecal and ascending colon carcinoma is a marker of advanced tumour stage and associated with a high incidence of synchronous and metachronous distant metastasis. More aggressive surgery to obtain a clear margin or postoperative radiotherapy to the tumour bed is likely to benefit only a minority of patients.

MRI Evaluation of Resection Margins in Bone Tumour Surgery

PubMed Central

Traore, Sidi Yaya; Lecouvet, Frédéric; Galant, Christine

2014-01-01

In 12 patients operated on for bone sarcoma resection, a postoperative magnetic resonance imaging of the resection specimens was obtained in order to assess the surgical margins. Margins were classified according to MRI in R0, R1, and R2 by three independent observers: a radiologist and two orthopaedic surgeons. Final margin evaluation (R0, R1, and R2) was assessed by a confirmed pathologist. Agreement for margin evaluation between the pathologist and the radiologist was perfect (κ = 1). Agreement between the pathologist and an experienced orthopaedic surgeon was very good while it was fair between the pathologist and a junior orthopaedic surgeon. MRI should be considered as a tool to give quick information about the adequacy of margins and to help the pathologist to focus on doubtful areas and to spare time in specimen analysis. But it may not replace the pathological evaluation that gives additional information about tumor necrosis. This study shows that MRI extemporaneous analysis of a resection specimen may be efficient in bone tumor oncologic surgery, if made by an experienced radiologist with perfect agreement with the pathologist. PMID:24976785

Limited distal clavicle excision of acromioclavicular joint osteoarthritis.

PubMed

Gokkus, K; Saylik, M; Atmaca, H; Sagtas, E; Aydin, A T

2016-05-01

Resection of the distal aspect of clavicle has a well-documented treatment modality in case of acromioclavicular joint osteoarthritis resistant to conservative treatment. Limited (mean ∼0.5cm distal end of clavicle resection) distal clavicle excision of A-C joint arthritis in cases resistant to conservative treatment may reduce the pain and improve the shoulder function. In this study, we retrospectively evaluated the results of limited distal clavicle excision of acromioclavicular joint osteoarthritis resistant to conservative treatment. All patients were evaluated by using the Visual Analogue Scale (VAS) and UCLA shoulder rating scale (University of California Los Angeles), either before surgery or final follow-up period for pain and functional results, respectively. A total of 110 patients (48 male, 62 female) with AC joint arthritis, treated between the years of 2008-2012, were retrospectively analyzed. A total of 30 patients (12 male, 18 female) who failed to show improvement with conservative treatment underwent limited surgical open excision of distal clavicle. The mean age of the study population was 52.5±1.2 years. The mean follow-up period was 27±1.3 months. The mean preoperative VAS score was 83.6±5.58 (range, 70-90) while mean VAS was 26.6±9.3 (range, 10-50) at the final follow-up. There was a statistically significant difference between pre- and postoperative VAS scores in patients who had treated by surgical approach (P<0.001). The mean UCLA score of the patients increased postoperatively from 11.5 (range, 9-14) to 29.2 (range, 27-32) at the final follow-up. There was a statistically significant difference between the two time periods with respect to UCLA scores (P<0.001). In patients with AC osteoarthritis resistant to conservative therapy, the hypothesized limited clavicle excision (mean ∼0.5cm distal end of clavicle resection with preserving coracoclavicular ligaments and inferior capsule) reduced the pain and improved the shoulder function. Our midterm follow-up (mean 27 months) results showed that limited distal clavicle excision of patients with AC joint osteoarthritis resistant to conservative treatment (0.5cm distal end of clavicle resection with preserving inferior capsule, and coracoclavicular ligaments) reduced the pain and improved the shoulder function. IV (Retrospective study). Copyright © 2016 Elsevier Masson SAS. All rights reserved.

A-Frame free Vascularized Fibular Graft and Femoral Lengthening for Osteosarcoma Pediatric Patients.

PubMed

Cashin, Megan; Coombs, Christopher; Torode, Ian

2018-02-01

Pediatric limb reconstruction after resection of a malignant tumor presents specific challenges. Multiple surgical techniques have been used to treat these patients. This paper describes a staged surgical technique for the reconstruction of large distal femoral defects due to tumor resection in skeletally immature patients. Three pediatric patients with osteosarcoma of the distal femur underwent staged reconstruction. Neoadjuvant chemotherapy was followed by en bloc tumor resection and immediate reconstruction of the distal femoral defect with a vascularized free fibular autograft utilizing a unique A-frame construct combined with intramedullary nail fixation. The second stage was a planned gradual lengthening of the healed construct, over a custom-made magnetically driven expandable intramedullary nail. All patients achieved bony union and satisfactory length with minimal complications. The patients all returned to full, unlimited physical activities. The early results confirm that the described technique is a safe and reliable procedure for the reconstruction of large femoral defects in pediatric patients with osteosarcoma. Level IV-therapeutic.

Augmented reality in a tumor resection model.

PubMed

Chauvet, Pauline; Collins, Toby; Debize, Clement; Novais-Gameiro, Lorraine; Pereira, Bruno; Bartoli, Adrien; Canis, Michel; Bourdel, Nicolas

2018-03-01

Augmented Reality (AR) guidance is a technology that allows a surgeon to see sub-surface structures, by overlaying pre-operative imaging data on a live laparoscopic video. Our objectives were to evaluate a state-of-the-art AR guidance system in a tumor surgical resection model, comparing the accuracy of the resection with and without the system. Our system has three phases. Phase 1: using the MRI images, the kidney's and pseudotumor's surfaces are segmented to construct a 3D model. Phase 2: the intra-operative 3D model of the kidney is computed. Phase 3: the pre-operative and intra-operative models are registered, and the laparoscopic view is augmented with the pre-operative data. We performed a prospective experimental study on ex vivo porcine kidneys. Alginate was injected into the parenchyma to create pseudotumors measuring 4-10 mm. The kidneys were then analyzed by MRI. Next, the kidneys were placed into pelvictrainers, and the pseudotumors were laparoscopically resected. The AR guidance system allows the surgeon to see tumors and margins using classical laparoscopic instruments, and a classical screen. The resection margins were measured microscopically to evaluate the accuracy of resection. Ninety tumors were segmented: 28 were used to optimize the AR software, and 62 were used to randomly compare surgical resection: 29 tumors were resected using AR and 33 without AR. The analysis of our pathological results showed 4 failures (tumor with positive margins) (13.8%) in the AR group, and 10 (30.3%) in the Non-AR group. There was no complete miss in the AR group, while there were 4 complete misses in the non-AR group. In total, 14 (42.4%) tumors were completely missed or had a positive margin in the non-AR group. Our AR system enhances the accuracy of surgical resection, particularly for small tumors. Crucial information such as resection margins and vascularization could also be displayed.

[A cutaneous horn of the free margin of the eyelid: an anatomical and clinical observation].

PubMed

D'Hermies, F; Gerolami-Favreul, I; Meyer, A; Morel, X; Halhal, M; Sam, H; Elmaleh, C; Renard, G; Behar-Cohen, F

2003-05-01

A cutaneous horn was observed close to the free margin of the inferior right eyelid in a 26-year-old-male patient. A minimal resection was primarily performed. Histopathologic study disclosed a precancerous keratosis. As the tumor had not been entirely excised, a complementary resection was performed secondarily to obtain the entire resection of the tumor.

Factors affecting surgical margin recurrence after hepatectomy for colorectal liver metastases

PubMed Central

Akyuz, Muhammet; Aucejo, Federico; Quintini, Cristiano; Miller, Charles; Fung, John

2016-01-01

Background Hepatic recurrence after resection of colorectal liver metastasis (CLM) occurs in 50% of patients during follow-up, with 2.8% to 13.9% presenting with surgical margin recurrence (SMR). The aim of this study is to analyze factors that related to SMR in patients with CLM undergoing hepatectomy. Methods Demographics, clinical and survival data of patients who underwent hepatectomy were identified from a prospectively maintained, institutional review board (IRB)-approved database between 2000 and 2012. Statistical analysis was performed using univariate Kaplan Meier and Cox proportional hazard model. Results There were 85 female and 121 male patients who underwent liver resection for CLM. An R0 resection was performed in 157 (76%) patients and R1 resection in 49. SMR was detected in 32 patients (15.5%) followed up for a median of 29 months (range, 3–121 months). A half of these patients had undergone R1 (n=16) and another half R0 resection (n=16). Tumor size, preoperative carcinoembryonic antigen (CEA) level and margin status were associated with SMR on univariate analysis. On multivariate analysis, a positive surgical margin was the only independent predictor of SMR. The receipt of adjuvant chemotherapy did not affect margin recurrence. SMR was an independent risk factor associated with worse disease-free (DFS) and overall survival (OS). Conclusions This study shows that SMR, which can be detected in up to 15.5% of patients after liver resection for CLM, adversely affects DFS and OS. The fact that a positive surgical margin was the only predictive factor for SMR in these patients underscores the importance of achieving negative margins during hepatectomy. PMID:27294032

Surgical margin-negative endoscopic mucosal resection with simple three-clipping technique: a randomized prospective study (with video).

PubMed

Mori, Hirohito; Kobara, Hideki; Nishiyama, Noriko; Fujihara, Shintaro; Kobayashi, Nobuya; Ayaki, Maki; Masaki, Tsutomu

2016-11-01

Although endoscopic mucosal resection is an established colorectal polyp treatment, local recurrence occurs in 13 % of cases due to inadequate snaring. We evaluated whether pre-clipping to the muscularis propria resulted in resected specimens with negative surgical margins without thermal denaturation. Of 245 polyps from 114 patients with colorectal polyps under 20 mm, we included 188 polyps from 81 patients. We randomly allocated polyps to the conventional injection group (CG) (97 polyps) or the pre-clipping injection group (PG) (91 polyps). The PG received three-point pre-clipping to ensure ample gripping to the muscle layer on the oral and both sides of the tumor with 4 mL local injection. Endoscopic ultrasonography was performed to measure the resulting bulge. Outcomes included the number of instances of thermal denaturation of the horizontal/vertical margin (HMX/VMX) or positive horizontal/vertical margins (HM+/VM+), the shortest distance from tumor margins to resected edges, and the maximum bulge distances from tumor surface to the muscularis propria. The numbers of HMX and HM+ in the CG and PG were 27 and 6, and 9 and 2 (P = 0.001), and VMX and VM+ were 8 and 5, and 0 and 0 (P = 0.057). The shortest distance from tumor margin to resected edge [median (range), mm] in polyps in the CG and PG was 0.6 (0-2.7) and 4.7 (2.1-8.9) (P = 0.018). The maximum bulge distances were 4.6 (3.0-8.0) and 11.0 (6.8-17.0) (P = 0.005). Pre-clipping enabled surgical margin-negative resection without thermal denaturation.

Stereotactic Radiosurgery of the Postoperative Resection Cavity for Brain Metastases: Prospective Evaluation of Target Margin on Tumor Control

DOE Office of Scientific and Technical Information (OSTI.GOV)

Choi, Clara Y.H.; Chang, Steven D.; Gibbs, Iris C.

2012-10-01

Purpose: Given the neurocognitive toxicity associated with whole-brain irradiation (WBRT), approaches to defer or avoid WBRT after surgical resection of brain metastases are desirable. Our initial experience with stereotactic radiosurgery (SRS) targeting the resection cavity showed promising results. We examined the outcomes of postoperative resection cavity SRS to determine the effect of adding a 2-mm margin around the resection cavity on local failure (LF) and toxicity. Patients and Methods: We retrospectively evaluated 120 cavities in 112 patients treated from 1998-2009. Factors associated with LF and distant brain failure (DF) were analyzed using competing risks analysis, with death as a competingmore » risk. The overall survival (OS) rate was calculated by the Kaplan-Meier product-limit method; variables associated with OS were evaluated using the Cox proportional hazards and log rank tests. Results: The 12-month cumulative incidence rates of LF and DF, with death as a competing risk, were 9.5% and 54%, respectively. On univariate analysis, expansion of the cavity with a 2-mm margin was associated with decreased LF; the 12-month cumulative incidence rates of LF with and without margin were 3% and 16%, respectively (P=.042). The 12-month toxicity rates with and without margin were 3% and 8%, respectively (P=.27). On multivariate analysis, melanoma histology (P=.038) and number of brain metastases (P=.0097) were associated with higher DF. The median OS time was 17 months (range, 2-114 months), with a 12-month OS rate of 62%. Overall, WBRT was avoided in 72% of the patients. Conclusion: Adjuvant SRS targeting the resection cavity of brain metastases results in excellent local control and allows WBRT to be avoided in a majority of patients. A 2-mm margin around the resection cavity improved local control without increasing toxicity compared with our prior technique with no margin.« less

Identification of predisposing factors for osteonecrosis of the jaw after marginal mandibulectomy in the surgical management of oral squamous cell carcinoma.

PubMed

Ito, Ran; Huang, Jung-Ju; Hsieh, Wei-Chuan; Kao, Huang-Kai; Lao, William Wei-Kai; Fang, Ku-Hao; Huang, Yenlin; Chang, Yu-Liang; Cheng, Ming-Huei; Chang, Kai-Ping

2018-03-01

The aim of this study is to evaluate osteonecrosis of the jaw (ONJ) with the extent of marginal mandibulectomy. Between January 2006 and December 2012, 3087 patients undergoing ablative resection were consecutively enrolled. Among them, 345 cases undergoing marginal mandibulectomy were retrospectively reviewed. The occurrence of ONJ was 5.51% and associated with body mass index, overall stage, diabetes, concomitant mandibulotomy, and radiotherapy (P = 0.023, 0.033, 0.009, 0.016, and 0.006, respectively). As for bone parameters based on radiological measurements after marginal mandibulectomy, resected bone height, remaining bone height to original bone height ratio, and resected bone height to original bone height ratio were associated with ONJ. In multivariate logistic analyses, concomitant mandibulotomy, radiotherapy, diabetes, resected bone height of >14.5 mm, resected bone height to original bone height ratio of >49.5%, and remaining bone height to original bone height ratio of <53.5% indicated higher risks for ONJ (adjusted HR: 4.345, 4.152, 4.079, 3.402, 3.541, and 3.211; P = 0.018, 0.013, 0.009, 0.021, 0.018, and 0.043, respectively). This study demonstrated the predisposing factors and parameters associated with ONJ with marginal mandibulectomy; more caution is necessitated in performing marginal mandibulectomy in patients with multiple risks to prevent ONJ. © 2017 Wiley Periodicals, Inc.

Therapeutic dormancy to delay postsurgical glioma recurrence: the past, present and promise of focal hypothermia.

PubMed

Wion, Didier

2017-07-01

Surgery precedes both radiotherapy and chemotherapy as the first-line therapy for glioma. However, despite multimodal treatment, most glioma patients die from local recurrence in the resection margin. Glioma surgery is inherently lesional, and the response of brain tissue to surgery includes hemostasis, angiogenesis, reactive gliosis and inflammation. Unfortunately, these processes are also associated with tumorigenic side-effects. An increasing amount of evidence indicates that the response to a surgery-related brain injury is hijacked by residual glioma cells and participates in the local regeneration of tumor tissues at the resection margin. Inducing therapeutic hypothermia in the brain has long been used to treat the secondary damage, such as neuroinflammation and edema, that are caused by accidental traumatic brain injuries. There is compelling evidence to suggest that inducing therapeutic hypothermia at the resection margin would delay the local recurrence of glioma by (i) limiting cell proliferation, (ii) disrupting the pathological connection between inflammation and glioma recurrence, and (iii) limiting the consequences of the functional heterogeneity and complexity inherent to the tumor ecosystem. While the global whole-body cooling methods that are currently used to treat stroke in clinical practice may not adequately treat the resection margin, the future lies in implantable focal microcooling devices similar to those under development for the treatment of epilepsy. Preclinical and clinical strategies to evaluate focal hypothermia must be implemented to prevent glioma recurrence in the resection margin. Placing the resection margin in a state of hibernation may potentially provide such a long-awaited therapeutic breakthrough.

Distal radius reconstruction with vascularized proximal fibular autograft after en-bloc resection of recurrent giant cell tumor.

PubMed

Yang, Yun-Fa; Wang, Jian-Wei; Huang, Pin; Xu, Zhong-He

2016-08-17

Giant cell tumors (GCTs) located in the distal radius are likely to recur, and the treatment of such recurrent tumors is very difficult. Here, we report our clinical experience in distal radius reconstruction with vascularized proximal fibular autografts after en-bloc excision of the entire distal radius in 17 patients with recurrent GCT (RGCT) of the distal radius. All 17 patients with RGCT in distal radius underwent plain radiography and/or magnetic resonance imaging (MRI) of the distal radius as the initial evaluation after hospitalization. Then the distal radius were replaced by vascularized proximal fibular autografts after en-bloc RGCT resection. We assessed all patients by using clinical examinations, plain radiography of the wrist and chest, and Mayo wrist scores in the follow-ups. After an average follow-up of 4.3 years (range: 1.5-10.0 years), no lung metastasis or local recurrence was detected in any of the 17 patients. In total, 14 patients had excellent or good functional wrist scores, 16 were pain free or had occasional pain, and 15 patients returned to work. The mean range of motion of the wrist was 101° (flexion-extension), and the mean grip strength was 77.2 % of the contralateral normal hand. En-bloc excision of the entire distal radius and distal radius reconstruction with a vascularized proximal fibular autograft can effectively achieve local tumor control and preserve wrist function in patients with RGCT of the distal radius.

Pancreatic resection for renal cell carcinoma metastasis: An exceptionally rare coexistence.

PubMed

Boussios, Stergios; Zerdes, Ioannis; Batsi, Ourania; Papakostas, Vasilios P; Seraj, Esmeralda; Pentheroudakis, George; Glantzounis, George K

2016-01-01

Pancreatic metastases are uncommon and only found in a minority of patients with widespread metastatic disease at autopsy. The most common primary cancer site resulting in pancreatic metastases is the kidney, followed by colorectal cancer, melanoma, breast cancer, lung carcinoma and sarcoma. Herein, we report a 63-year-old male patient who presented -3.5 years after radical nephrectomy performed for renal cell carcinoma (RCC)-with a well-defined lobular, round mass at the body of the pancreas demonstrated by abdominal Magnetic Resonance Imaging (MRI). The patient underwent distal pancreatectomy combined with splenectomy and cholecystectomy. Histopathological examination revealed clusters of epithelial clear cells, immunohistochemically positive for RCC marker, and negative for CD10 and CA19-9. A final diagnosis of clear RCC metastasizing to pancreas was obtained in view of the past history of RCC, microscopy and the immunoprofile. This was the second metachronous disease recurrence after a previous metastatic involvement of the liver, developed 19 months from the initial diagnosis. The patient has remained well at a 6 month follow up post-resection. Solitary pancreatic metastases may be misdiagnosed as primary pancreatic cancer. However, imaging including computed tomography (CT) and MRI, may discriminate between them. Surgical procedures could differentiate solitary metastasis from neuroendocrine neoplasms. The optimal resection strategy involves adequate resection margins and maximal tissue preservation of the pancreas. Recently, an increasing number of surgical resections have been performed in selected patients with limited metastatic disease to the pancreas. In addition, a rigid follow-up scheme, including endoscopic ultrasound (EUS) and CT is essential give patients a chance for a prolonged life. Copyright © 2016 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Interventional fluorescence spectroscopy: preliminary results to detect tumor margins during glioma resection with two fluorescence spectra of PpIX

NASA Astrophysics Data System (ADS)

Alston, L. M.; Guyotat, J.; Mahieu-Williame, L.; Hebert, M.; Kantapareddy, P.; Meyronet, D.; Rousseau, D.; Montcel, B.

2017-07-01

We show the feasibility of using an intraoperative spectroscopic device to identify tumors margins during glioma resection. The collected fluorescence spectra is fitted with two reference spectra of PpIX and the contribution of each spectrum enables to overcome the sensitivity of current techniques by seeing tumor margins and low grade gliomas.

Comparison of surgical performance and short-term clinical outcomes between laparoscopic and robotic surgery in distal gastric cancer.

PubMed

Eom, B W; Yoon, H M; Ryu, K W; Lee, J H; Cho, S J; Lee, J Y; Kim, C G; Choi, I J; Lee, J S; Kook, M C; Rhee, J Y; Park, S R; Kim, Y W

2012-01-01

The authors aimed to compare the surgical performance and the short-term clinical outcomes of robotic assisted laparoscopic distal gastrectomy (RADG) with laparoscopy-assisted distal gastrectomy (LADG) in distal gastric cancer patients. From April 2009 to August 2010, 62 patients underwent LADG and 30 patients underwent RADG for preoperative stage I distal gastric cancer by one surgeon at the National Cancer Center, Korea. Surgical performance was measured using lymph node (LN) dissection time and number of retrieved LNs, which were viewed as surrogates of technical ease and oncologic quality. In clinicopathologic characteristics, mean age, depth of invasion and stage were significantly different between the LADG and RADG group. Mean dissection time at each LN station was greater in the RADG group, but no significant intergroup difference was found for numbers of retrieved LNs. Furthermore, proximal resection margins were smaller, and hospital costs were higher in the RADG group. In terms of the RADG learning curve, mean LN dissection time was smaller in the late RADG group (n = 15) than in the early RADG group (n = 15) for 4sb/4d, 5, 7-12a stations, but numbers of retrieved LNs per station were similar. With the exception of operating time and cost, the numbers of retrieved LNs and the short-term clinical outcomes of RADG were found to be comparable to those of LADG, despite the surgeon's familiarity with LADG and lack of RADG experience. Further studies are needed to evaluate objectively ergonomic comfort and to quantify the patient benefits conferred by robotic surgery. Copyright © 2011 Elsevier Ltd. All rights reserved.

Can Navigation-assisted Surgery Help Achieve Negative Margins in Resection of Pelvic and Sacral Tumors?

PubMed

Abraham, John A; Kenneally, Barry; Amer, Kamil; Geller, David S

2018-03-01

Navigation-assisted resection has been proposed as a useful adjunct to resection of malignant tumors in difficult anatomic sites such as the pelvis and sacrum where it is difficult to achieve tumor-free margins. Most of these studies are case reports or small case series, but these reports have been extremely promising. Very few reports, however, have documented benefits of navigation-assisted resection in series of pelvic and sacral primary tumors. Because this technology may add time and expense to the surgical procedure, it is important to determine whether navigation provides any such benefits or simply adds cost and time to an already complex procedure. (1) What proportion of pelvic and sacral bone sarcoma resections utilizing a computer-assisted resection technique achieves negative margins? (2) What are the oncologic outcomes associated with computer-assisted resection of pelvic and sacral bone sarcomas? (3) What complications are associated with navigation-assisted resection? Between 2009 and 2015 we performed 24 navigation-assisted resections of primary tumors of the pelvis or sacrum. Of those, four were lost to followup after the 2-year postoperative visit. In one patient, however, there was a failure of navigation as a result of inadequate imaging, so nonnavigated resection was performed; the remaining 23 were accounted for and were studied here at a mean of 27 months after surgery (range, 12-52 months). During this period, we performed navigation-assisted resections in all patients presenting with a pelvis or sacral tumor; there was no selection process. No patients were treated for primary tumors in these locations without navigation during this time with the exception of the single patient in whom the navigation system failed. We retrospectively evaluated the records of these 23 patients and evaluated the margin status of these resections. We calculated the proportion of patients with local recurrence, development of metastases, and overall survival at an average 27-month followup (range, 12-52 months). We queried a longitudinally maintained surgical database for any complications and noted which, if any, could have been directly related to the use of the navigation-assisted technique. In our series, 21 of 23 patients had a negative margin resection. In all patients the bone margin was negative, but two with sacral resections had positive soft tissue margins. Six of 23 patients experienced local recurrence within the study period. Three patients died during the study period. Seventeen patients demonstrated no evidence of disease at last recorded followup. We noted three intraoperative complications: one dural tear, one iliac vein laceration, and one bladder injury. Eight patients out of 23 had wound complications resulting in operative débridement. Two patients in the series developed transient postoperative femoral nerve palsy, which we believe were caused by stretch of the femoral nerve secondary to the placement of the reference array in the pubic ramus. Navigation-assisted resection of pelvic and sacral tumors resulted in a high likelihood of negative margin resection in this series, and we observed relatively few complications related specifically to the navigation. We have no comparison group without navigation, and future studies should indeed compare navigated with nonnavigated resection approaches in these anatomic locations. We did identify a potential navigation-related complication of femoral nerve palsy in this series and suggest careful placement and observation of the reference array during the operative procedure to lessen the likelihood of this previously unreported complication. We suggest it is worthwhile to consider the use of navigation-assisted surgery in resection of tumors of the pelvis and sacrum, but further study will be needed to determine its precise impact, if any, on local recurrence and other oncologic outcomes. Level IV, therapeutic study.

Combined modified en bloc corpectomy with replacement of the aorta in curative interdisciplinary treatment of a large osteosarcoma infiltrating the aorta.

PubMed

Pilger, Amrei; Tsilimparis, Nikolaos; Bockhorn, Maximilian; Trepel, Martin; Dreimann, Marc

2016-05-01

We report a case of a large three-level spinal osteosarcoma infiltrating the adjacent aorta. This is the first case in which a combined modified three-level en bloc corpectomy with resection and replacement of the adjacent aorta was successful as a part of interdisciplinary curative treatment. Case report. The surgical procedure was performed as a two-step treatment. A heart lung machine (HLM) was not used, in order to avoid cerebral and spinal ischemia and to decrease the risk of hematogenous tumor metastases. Instead, a bypass from the left subclavian artery the distal descending aorta was used. We modified the en bloc corpectomy procedure, leaving a dorsal segment of the vertebral bodies to enable rapid surgery. The procedure was successful and the en bloc resection of the vertebral body with aortal resection could be achieved. Except for pallhypesthesia in the left dermatomes Th7-Th10, the patient does not have any postoperative neurologic deficits. Combined corpectomy with aortic replacement should be considered as a reasonable option in the curative treatment of osteosarcoma with consideration of the immense surgical risks. The use of an HLM is not necessary, especially considering the inherent risk of hematogenous tumor metastases. Modified corpectomy leaving a dorsal vertebral body segment was considered a reasonable variation since tumor-free margins could still be expected.

Recent technological developments: in situ histopathological interrogation of surgical tissues and resection margins

PubMed Central

Upile, Tahwinder; Fisher, Cyril; Jerjes, Waseem; El Maaytah, Mohammed; Singh, Sandeep; Sudhoff, Holger; Searle, Adam; Archer, Daniel; Michaels, Leslie; Hopper, Colin; Rhys-Evans, Peter; Howard, David; Wright, Anthony

2007-01-01

Objectives The tumour margin is an important surgical concept significantly affecting patient morbidity and mortality. We aimed in this prospective study to apply the microendoscope on tissue margins from patients undergoing surgery for oral cancer in vivo and ex vivo and compare it to the gold standard "paraffin wax", inter-observer agreement was measured; also to present the surgical pathologist with a practical guide to the every day use of the microendoscope both in the clinical and surgical fields. Materials and methods Forty patients undergoing resection of oral squamous cell carcinoma were recruited. The surgical margin was first marked by the operator followed by microendoscopic assessment. Biopsies were taken from areas suggestive of close or positive margins after microendoscopic examination. These histological samples were later scrutinized formally and the resection margins revisited accordingly when necessary. Results Using the microendoscope we report our experience in the determination of surgical margins at operation and later comparison with frozen section and paraffin section margins "gold standard". We were able to obtain a sensitivity of 95% and a specificity of 90%. Inter-observer Kappa scores comparing the microendoscope with formal histological analysis of normal and abnormal mucosa were 0.85. Conclusion The advantage of this technique is that a large area of mucosa can be sampled and any histomorphological changes can be visualized in real time allowing the operator to make important informed decisions with regards the intra-operative resection margin at the time of the surgery. PMID:17331229

Autofluorescence of normal and neoplastic human brain tissue: an aid for intraoperative delineation of tumor resection margins

NASA Astrophysics Data System (ADS)

Bottiroli, Giovanni F.; Croce, Anna C.; Locatelli, Donata; Nano, Rosanna; Giombelli, Ermanno; Messina, Alberto; Benericetti, Eugenio

1998-01-01

Light-induced autofluorescence measurements were made on normal and tumor brain tissues to assess their spectroscopic properties and to verify the potential of this parameter for an intraoperative delineation of tumor resection margins. Spectrofluorometric analysis was performed both at the microscope on tissue sections from surgical resection, and on patients affected by glioblastoma, during surgical operation. Significant differences in autofluorescence emission properties were found between normal and tumor tissues in both ex vivo and in vivo measurements, indicating that the lesion can be distinguished from the informal surrounding tissues by the signal amplitude and the spectral shape. The non-invasiveness of the technique opens interesting prospects for improving the efficacy of neurosurgical operation, by allowing an intraoperative delimitation of tumor resection margins.

The Prognostic Value of Signet-Ring Cell Histology in Resected Gastric Adenocarcinoma.

PubMed

Postlewait, Lauren M; Squires, Malcolm H; Kooby, David A; Poultsides, George A; Weber, Sharon M; Bloomston, Mark; Fields, Ryan C; Pawlik, Timothy M; Votanopoulos, Konstantinos I; Schmidt, Carl R; Ejaz, Aslam; Acher, Alexandra W; Worhunsky, David J; Saunders, Neil; Swords, Douglas; Jin, Linda X; Cho, Clifford S; Winslow, Emily R; Cardona, Kenneth; Staley, Charles A; Maithel, Shishir K

2015-12-01

Conflicting data exist on the prognostic implication of signet-ring cell (SRC) histology in gastric adenocarcinoma (GAC). All patients who underwent curative-intent resection of GAC from the seven institutions of the U.S. Gastric Cancer Collaborative between 2000 and 2012 were included. Primary end points were recurrence-free survival (RFS) and overall survival (OS). Stage-specific analyses were performed. A total of 768 patients met the inclusion criteria. SRC was present in 40.6 % of patients and was associated with female sex (52.9 vs. 38.6 %; p < 0.001), younger age (61 vs. 67 years; p < 0.001), poor differentiation (94.8 vs. 50.3 %; p < 0.001), perineural invasion (PNI) (41.4 vs. 23 %; p < 0.001), microscopically positive resection margins (R1, 24.7 vs. 8.6 %; p < 0.001), distal location (82.2 vs. 70.1 %; p < 0.001), receipt of adjuvant therapy (63 vs. 51.2 %; p = 0.002), and more advanced stage (stage 3: 55.2 vs. 36.5 %; p < 0.001). SRC was associated with earlier recurrence (56.7 months vs. median not reached; p = 0.009) and decreased OS (33.7 vs. 46.6 months; p = 0.011). When accounting for other adverse pathologic features, PNI (hazard ratio [HR] 1.57; p = 0.016) and higher stage (HR 2.64; p < 0.001) were associated with decreased RFS, but SRC was not. Although PNI (HR 1.52; p = 0.007), higher stage (HR 2.11; p < 0.001), greater size (HR 1.05; p = 0.016), and adjuvant therapy (HR 0.50; p < 0.001) were associated with OS, SRC was not. Similarly, when accounting for adverse pathologic factors on multivariate analysis, stage-specific analyses showed no association between SRC and RFS or OS. SRC histology is associated with adverse pathologic features including poor differentiation, higher stage, and microscopically positive resection margins but is not independently associated with reduced RFS or OS. Identification of signet-ring histology during preoperative evaluation should not, in isolation, dictate treatment strategy.

Immunohistologic analysis of spontaneous recurrent laryngeal nerve reinnervation in a rat model.

PubMed

Rosko, Andrew J; Kupfer, Robbi A; Oh, Sang S; Haring, Catherine T; Feldman, Eva L; Hogikyan, Norman D

2018-03-01

After recurrent laryngeal nerve injury (RLN), spontaneous reinnervation of the larynx occurs with input from multiple sources. The purpose of this study was to determine the timing and efficiency of reinnervation across a resected RLN segment in a rat model of RLN injury. Animal study. Twelve male 60-day-old Sprague Dawley rats underwent resection of a 5-mm segment of the right RLN. Rats were sacrificed at 1, 2, 4, and 12 weeks after nerve injury to harvest the larynx and trachea for immunohistologic analysis. The distal RLN segment was stained with neurofilament, and axons were counted and compared to the nonoperated side. Thyroarytenoid (TA) muscles were stained with alpha-bungarotoxin, synaptophysin, and neurofilament to identify intact neuromuscular junctions (NMJ). The number of intact NMJs from the denervated side was compared to the nonoperated side. Nerve fibers regenerated across the resected RLN gap into the distal recurrent laryngeal nerve to innervate the TA muscle. The number of nerve fibers in the distal nerve segment increased over time and reached the normal number by 12 weeks postdenervation. Axons formed intact neuromuscular junctions in the TA, with 48.8% ± 16.7% of the normal number of intact NMJs at 4 weeks and 88.3% ± 30.1% of the normal number by 12 weeks. Following resection of an RLN segment in a rat model, nerve fibers spontaneously regenerate through the distal segment of the transected nerve and form intact NMJs in order to reinnervate the TA muscle. NA. Laryngoscope, 128:E117-E122, 2018. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.

Computer-aided resection and endoprosthesis design for the management of malignant bone tumors around the knee: outcomes of 12 cases.

PubMed

Ding, Huan-wen; Yu, Guang-wen; Tu, Qiang; Liu, Bao; Shen, Jian-jian; Wang, Hong; Wang, Ying-jun

2013-11-22

To report the outcomes of computer-aided resection and endoprosthesis design for the management of malignant bone tumors around the knee. Computed tomography (CT) and magnetic resonance imaging (MRI) data were input into computer software to produce three-dimensional (3D) models of the tumor extent. Imaging data was then used to create a template for surgical resection, and development of an individualized combined allogeneic bone/endoprosthesis. Surgical simulations were performed prior to the actual surgery. This study included 9 males and 3 females with a mean age of 25.3 years (range, 13 to 40 years). There were 9 tumors in the distal femur and 3 in the proximal tibia. There were no surgical complications. In all cases pathologically confirmed clear surgical margins were obtained. Postoperative radiographs showed the range of tumor resection was in accordance with the preoperative design, and the morphological reconstruction of the bone defect was satisfactory with complete bilateral symmetry. The mean follow-up time was 26.5 months. Two patients died of their disease and the remaining are alive and well without evidence of recurrence. All patients are able to ambulate freely without restrictions. At the last follow-up, the average International Society of Limb Salvage score was 25.8 (range, 18 to 27), and was excellent in 8 cases and good in 4 cases. Computer-aided design and modeling for the surgical management of bone tumors and subsequent limb reconstruction provides accurate tumor removal with the salvage of a maximal amount of unaffected bone and precise endoprosthesis reconstruction.

Chronic Osteomyelitis of the Distal Femur Treated with Resection and Delayed Endoprosthetic Reconstruction: A Report of Three Cases.

PubMed

Ryan, Sean; Eward, William; Brigman, Brian; Zura, Robert

2017-01-01

Chronic osteomyelitis involving the distal femur often results in amputation or arthrodesis. This article presents three cases of chronic osteomyelitis treated with a staged approach culminating in endoprosthetic reconstruction. Stage one involved resection of infected bone and placement of an intramedullary nail spanning the bony defect between proximal femur and tibia, with antibiotic cement packed around the nail. Patients were then placed on long-term IV +/- oral antibiotics to clear the infection. A "cooldown" period was then used between stages where patients were off antibiotics and inflammatory markers were monitored for signs of remaining infection. Stage two then involved reconstruction of the distal femur and knee with an endoprosthesis. In the appropriate patient, this treatment strategy offers another option in this challenging population.

Changes in ice-margin processes and sediment routing during ice-sheet advance across a marginal moraine

USGS Publications Warehouse

Knight, P.G.; Jennings, C.E.; Waller, R.I.; Robinson, Z.P.

2007-01-01

Advance of part of the margin of the Greenland ice sheet across a proglacial moraine ridge between 1968 and 2002 caused progressive changes in moraine morphology, basal ice formation, debris release, ice-marginal sediment storage, and sediment transfer to the distal proglacial zone. When the ice margin is behind the moraine, most of the sediment released from the glacier is stored close to the ice margin. As the margin advances across the moraine the potential for ice-proximal sediment storage decreases and distal sediment flux is augmented by reactivation of moraine sediment. For six stages of advance associated with distinctive glacial and sedimentary processes we describe the ice margin, the debris-rich basal ice, debris release from the glacier, sediment routing into the proglacial zone, and geomorphic processes on the moraine. The overtopping of a moraine ridge is a significant glaciological, geomorphological and sedimentological threshold in glacier advance, likely to cause a distinctive pulse in distal sediment accumulation rates that should be taken into account when glacial sediments are interpreted to reconstruct glacier fluctuations. ?? 2007 Swedish Society for Anthropology and Geography.

Management of pancreatic trauma.

PubMed Central

Jones, R C

1978-01-01

Since 1950, 300 patients sustaining pancreatic injuries have been managed. Three-fourths of the injuries were due to penetrating trauma with a 20% mortality and one-fourth due to blunt trauma resulting in an 18% mortality. The pancreatic injury was responsible for death in only 3% of patients. Early onset of shock resulted in 38% mortality whereas only 4% of normotensive patients died. No patient died of an isolated pancreatic injury. Sepsis was the second most common cause of death following hemorrhage. Preoperative serum amylase was elevated more frequently following blunt trauma than penetrating trauma, but did not correlate with injury. There has been a tendency toward more frequent use of distal pancreatectomy for simple penetrating injuries without obvious ductal violation which increases operative time, blood loss and possible intra-abdominal abscess since resection usually requires splenectomy. Patients considered for an 80% distal resection are better managed with a Roux-en-Y limb to the distal pancreas since three patients developed diabetes following an 80% or greater resection. A conservative approach consisting of Penrose and sump drainage is adequate for most injuries. PMID:646495

[Resection margins in conservative breast cancer surgery].

PubMed

Medina Fernández, Francisco Javier; Ayllón Terán, María Dolores; Lombardo Galera, María Sagrario; Rioja Torres, Pilar; Bascuñana Estudillo, Guillermo; Rufián Peña, Sebastián

2013-01-01

Conservative breast cancer surgery is facing a new problem: the potential tumour involvement of resection margins. This eventuality has been closely and negatively associated with disease-free survival. Various factors may influence the likelihood of margins being affected, mostly related to the characteristics of the tumour, patient or surgical technique. In the last decade, many studies have attempted to find predictive factors for margin involvement. However, it is currently the new techniques used in the study of margins and tumour localisation that are significantly reducing reoperations in conservative breast cancer surgery. Copyright © 2012 AEC. Published by Elsevier Espana. All rights reserved.

Optical assessment of tumor resection margins in the breast

PubMed Central

Brown, J. Quincy; Bydlon, Torre M.; Richards, Lisa M.; Yu, Bing; Kennedy, Stephanie A.; Geradts, Joseph; Wilke, Lee G.; Junker, Marlee; Gallagher, Jennifer; Barry, William; Ramanujam, Nimmi

2011-01-01

Breast conserving surgery, in which the breast tumor and surrounding normal tissue are removed, is the primary mode of treatment for invasive and in situ carcinomas of the breast, conditions that affect nearly 200,000 women annually. Of these nearly 200,000 patients who undergo this surgical procedure, between 20–70% of them may undergo additional surgeries to remove tumor that was left behind in the first surgery, due to the lack of intra-operative tools which can detect whether the boundaries of the excised specimens are free from residual cancer. Optical techniques have many attractive attributes which may make them useful tools for intra-operative assessment of breast tumor resection margins. In this manuscript, we discuss clinical design criteria for intra-operative breast tumor margin assessment, and review optical techniques appied to this problem. In addition, we report on the development and clinical testing of quantitative diffuse reflectance imaging (Q-DRI) as a potential solution to this clinical need. Q-DRI is a spectral imaging tool which has been applied to 56 resection margins in 48 patients at Duke University Medical Center. Clear sources of contrast between cancerous and cancer-free resection margins were identified with the device, and resulted in an overall accuracy of 75% in detecting positive margins. PMID:21544237

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ben-David, Merav A.; Griffith, Kent A.; Abu-Isa, Eyad

Purpose: The role of radiation therapy (RT) in extrahepatic cholangiocarcinoma (EHCC) is not clear and only limited reports exist on the use of this modality. We have reviewed our institutional experience to determine the pattern of failure in patients after potentially curative resection and the expected outcomes after adjuvant RT and in unresectable patients. Methods and Materials: After institutional review board approval, 81 patients diagnosed with EHCC (gallbladder 28, distal bile duct 24, hilar 29) between June 1986 and December 2004 were identified and their records reviewed. Twenty-eight patients (35%) underwent potentially curative resection with R0/R1 margins. Fifty-two patients (64%)more » were unresectable or underwent resection with macroscopic residual disease (R2). All patients received three-dimensional planned megavoltage RT. The dose for each patient was converted to the equivalent total dose in a 2 Gy/fraction, using the linear-quadratic formalism and {alpha}/{beta} ratio of 10. The median dose delivered was 58.4 Gy (range, 23-88.2 Gy). 54% received concomitant chemotherapy. Results: With a median follow-up time of 1.2 years (range, 0.1-9.8 years) 75 patients (93%) have died. Median overall survival (OS) and progression-free survival (PFS) were 14.7 (95% CI, 13.1-16.3) and 11 (95% CI, 7.6-13.2) months, respectively. There was no difference among the three disease sites in OS (p = 0.70) or PFS (p = 0.80). Complete resection (R0) was the only predictive factor significantly associated with increase in both OS and PFS (p = 0.002), and there was no difference in outcomes between R1 and R2 resections. The first site of failure was predominantly locoregional (68.8% of all failures). Conclusion: Local failure is a major problem in EHCC, suggesting the need for more intense radiation schedules and better radiosensitizing strategies. Because R1 resection appears to convey no benefit, it appears that surgery should be contemplated only when an R0 resection is likely. Borderline-resectable patients might be better served by neoadjuvant therapy.« less

The use of CT derived solid modelling of the pelvis in planning cancer resections.

PubMed

Bruns, J; Habermann, C R; Rüther, W; Delling, D

2010-06-01

Resection of malignant tumors of the pelvis is demanding. To avoid disabling hemipelvectomies, years ago internal hemipelvectomy combined with partial pelvic replacements had become a surgical procedure. To achieve adequate reconstructions custom-made replacements were recommended. In early stages of the surgical procedure using megaprostheses, individual pelvic models were manufactured. Since little is known about the accuracy of such models we analysed the charts of 24 patients (25 models) for whom an individual model of the osseous pelvis had been manufactured. Two patients refused surgery. In 23 patients partial resection of the bony pelvis was performed followed by a partial pelvic replacement (13x), hip transposition procedure (5x), ilio-sacral resection (4x), or revision surgery. In all patients who received a partial pelvic replacement, the fit of the replacement was optimal. No major unplanned resection was necessary. The same was observed in patients who received a hip transposition procedure or an ilio-sacral resection. Oncologically, in most of the patients we achieved wide resection margins (14x). In 5 patients the margins were marginal (4x) or intralesional (1x). In two cases the aim was a palliative resection because of a metastatic disease (1x) or benign entity (1x). Pelvic models are helpful tools to planning the manufacture of partial pelvic replacements and ensuring optimal osseous resection of the involved bone. Further attempts have to be made to evaluate the aim of navigational techniques regarding the accuracy of the osseous and soft-tissue resection.

Hepatic Resection for Colorectal Liver Metastases: A Cost-Effectiveness Analysis

PubMed Central

Beard, Stephen M.; Holmes, Michael; Price, Charles; Majeed, Ali W.

2000-01-01

Objective To analyze the cost-effectiveness of resection for liver metastases compared with standard nonsurgical cytotoxic treatment. Summary Background Data The efficacy of hepatic resection for metastases from colorectal cancer has been debated, despite reported 5-year survival rates of 20% to 40%. Resection is confined to specialized centers and is not widely available, perhaps because of lack of appropriate expertise, resources, or awareness of its efficacy. The cost-effectiveness of resection is important from the perspective of managed care in the United States and for the commissioning of health services in the United Kingdom. Methods A simple decision-based model was developed to evaluate the marginal costs and health benefits of hepatic resection. Estimates of resectability for liver metastases were taken from UK-reported case series data. The results of 100 hepatic resections conducted in Sheffield from 1997 to 1999 were used for the cost calculation of liver resection. Survival data from published series of resections were compiled to estimate the incremental cost per life-year gained (LYG) because of the short period of follow-up in the Sheffield series. Results Hepatic resection for colorectal liver metastases provides an estimated marginal benefit of 1.6 life-years (undiscounted) at a marginal cost of £6,742. If 17% of patients have only palliative resections, the overall cost per LYG is approximately £5,236 (£5,985 with discounted benefits). If potential benefits are extended to include 20-year survival rates, these figures fall to approximately £1,821 (£2,793 with discounted benefits). Further univariate sensitivity analysis of key model parameters showed the cost per LYG to be consistently less than £15,000. Conclusion In this model, hepatic resection appears highly cost-effective compared with nonsurgical treatments for colorectal-related liver metastases. PMID:11088071

[Organ-limited prostate cancer with positive resection margins. Importance of adjuvant radiation therapy].

PubMed

Porres, D; Pfister, D; Brehmer, B; Heidenreich, A

2012-09-01

For pT3 prostate cancer with positive resection margins, the importance of postoperative radiation therapy is confirmed by a high level of evidence. However, for the pT2,R1 situation prospective, randomized studies concerning this question are lacking. Despite better local tumor control in the pT2 stage the PSA recurrence rate lies between 25% and 40% and positive margins are an independent factor for recurrence. Retrospective studies suggest a positive effect of adjuvant or salvage radiation for the oncological outcome in the pT2,R1 situation. On the other hand the side effects profile, with a potentially negative influence of postoperative continence and various delayed toxicities, is not insignificant despite modern radiation techniques and in the era of ultrasensitive PSA analysis should be considered in the risk-benefit assessment. As long as the optimal initiation of postoperative radiation therapy is unclear, the assessment of indications for adjuvant or salvage radiation for organ-limited prostate cancer with positive resection margins should be made after an individual patient consultation and under consideration of the recurrence risk factors, such as the Gleason grade and the localization and extent of the resection margins.

[Soft tissue sarcoma of the upper extremities. Analysis of factors relevant for prognosis in 160 patients].

PubMed

Lehnhardt, M; Hirche, C; Daigeler, A; Goertz, O; Ring, A; Hirsch, T; Drücke, D; Hauser, J; Steinau, H U

2012-02-01

Soft tissue sarcomas (STS) are a rare entity with reduced prognosis due to their aggressive biology. For an optimal treatment of STS identification of independent prognostic factors is crucial in order to reduce tumor-related mortality and recurrence rates. The surgical oncological concept includes wide excisions with resection safety margins >1 cm which enables acceptable functional results and reduced rates of amputation of the lower extremities. In contrast, individual anatomy of the upper extremities, in particular of the hand, leads to an intentional reduction of resection margins in order to preserve the extremity and its function with the main intention of tumor-free resection margins. In this study, the oncological safety and outcome as well as functional results were validated by a retrospective analysis of survival rate, recurrence rate and potential prognostic factors. A total of 160 patients who had been treated for STS of the upper extremities were retrospectively included. Independent prognostic factors were analyzed (primary versus recurrent tumor, tumor size, resection status, grade of malignancy, additional therapy, localization in the upper extremity). Kaplan-Meier analyses for survival rate and local control were calculated. Further outcome measures were functional results validated by the DASH score and rate of amputation. In 130 patients (81%) wide tumor excision (R0) was performed and in 19 patients (12%) an amputation was necessary. The 5-year overall survival rate was 70% and the 5-year survival rate in primary tumors was 81% whereas in recurrences 55% relapsed locally. The 10-year overall survival rate was 45% and the 5-year recurrence rate was 18% for primary STS and 43% for recurrent STS. Variance analysis revealed primary versus recurrent tumor, tumor size, resection status and grade of malignancy as independent prognostic factors. Analysis of functional results showed a median DASH score of 37 (0-100; 0=contralateral extremity). The 5-year survival and local recurrence rates are comparable to STS wide resections with safety margins >1 cm for the lower extremities and the trunk. Analysis of prognostic factors revealed resection status and the tumor-free resection margins to be the main goals in STS resection of upper extremity.

Systematic review and meta-analysis of prognostic role of splenic vessels infiltration in resectable pancreatic cancer.

PubMed

Crippa, Stefano; Cirocchi, Roberto; Maisonneuve, Patrick; Partelli, Stefano; Pergolini, Ilaria; Tamburrino, Domenico; Aleotti, Francesca; Reni, Michele; Falconi, Massimo

2018-01-01

Identification of factors associated with dismal survival after surgery in resectable pancreatic ductal adenocarcinoma is important to select patients for neoadjuvant treatment. The present meta-analysis aimed to compare the results of distal pancreatectomy for resectable adenocarcinoma of the pancreatic body-tail with and without splenic vessels infiltration. A systematic search was performed of PubMed, Embase and the Cochrane Library in accordance with PRISMA guidelines. The inclusion criteria were studies including patients who underwent distal pancreatectomy for pancreatic cancer with or without splenic vessels infiltration. 5-year overall survival (OS) was the primary outcomes. Meta-analysis was carried out applying time-to-event method. Six articles with 423 patients were analysed. Patients with pathological splenic artery invasion had a worse survival compared with those without infiltration (Hazard ratio 1.76, 95% CI 1.36-2.28; P < 0.0001). A similar results was found when considering pathological splenic vessels infiltration, showing that survival was significantly poorer when splenic vein infiltration was present (Hazard ratio 1.51, 95% CI 1.19-1.93; P = 0.0009). This meta-analysis showed worse survival for patients with splenic vessels infiltration undergoing distal pancreatectomy for pancreatic cancer. Splenic vessels infiltration represents the stigmata of a more aggressive disease, although resectable. Copyright © 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Diaphragmatic resection preserving and repairing pericardium, splenectomy and distal pancreatectomy for ınterval debulkıng surgery of ovarıan cancer.

PubMed

Vatansever, Dogan; Atici, Ali Emre; Sozen, Hamdullah; Sakin, Onder

2016-07-01

The majority of ovarian cancer patients are initially diagnosed at an advanced-stage [1]. Upper abdominal bulky metastasis cephalad to the greater omentum reported to be present in 42% of patients [2]. Many complex surgical procedures such as splenectomy, pancreatectomy, mobilization and partial resection of liver, porta hepatis dissection, diaphragmatic peritonectomy and resection are frequently performed to achieve complete resection of metastatic disease [3]. Our aim in this surgical film is to show the resection of a left sided diaphragmatic implant located beneath the heart, with dissection from the pericardium after entrance to the pericardial cavity. Additionally, step by step splenectomy with distal pancreatectomy also presented. A 67years-old woman referred to our clinic for interval debulking for advanced stage suboptimally debulked high grade serous ovarian carcinoma. The tumor invading distal pancreas, hilum and parenchyma of spleen is clearly seen on magnetic resonance imaging. Another implant was also visible on left side of the diaphragm. We achieved complete cytoreduction with no macroscopic disease at the end of the surgery. She stayed at the intensive care unit for two days and in our clinic for seven days. We did not encounter any grade 3 or 4 adverse event in post-operative period. The surgical treatment of ovarian cancer has evolved in time in favor of radical surgery. The surgical team should be highly motivated, skilled and experienced for this complex procedures, since being able to reach complete cytoreduction is the most important predictor of survival in ovarian cancer patients. Copyright © 2016 Elsevier Inc. All rights reserved.

Transhepatic Hilar Approach for Perihilar Cholangiocarcinoma: Significance of Early Judgment of Resectability and Safe Vascular Reconstruction.

PubMed

Kuriyama, Naohisa; Isaji, Shuji; Tanemura, Akihiro; Iizawa, Yusuke; Kato, Hiroyuki; Murata, Yasuhiro; Azumi, Yoshinori; Kishiwada, Masashi; Mizuno, Shugo; Usui, Masanobu; Sakurai, Hiroyuki

2017-03-01

In the most common surgical procedure for perihilar cholangiocarcinoma, the margin status of the proximal bile duct is determined at the final step. Our procedure, the transhepatic hilar approach, confirms a cancer-negative margin status of the proximal bile duct first. We first performed a partial hepatic parenchymal transection to expose the hilar plate, and then transected the proximal bile duct to confirm margin status. Then, divisions of the hepatic artery and portal vein of the future resected liver are performed, followed by the residual hepatic parenchymal transection. The transhepatic hilar approach offers a wide surgical field for safe resection and reconstruction of the portal vein in the middle of the hepatectomy. We reviewed 23 patients with perihilar cholangiocarcinoma who underwent major hepatectomy using our procedure from 2011 to 2015. A combined vascular resection and reconstruction was carried out in 14 patients (60.9%). R0 resection was achieved in 17 patients (73.9%), and the overall 3-year survival rate was 52.9% (median survival time 52.4 months). The transhepatic hilar approach is useful and practicable regardless of local tumor extension, enabling us to determine tumor resectability and perform safe resection and reconstruction of the portal vein early in the operation.

Limited resection for duodenal gastrointestinal stromal tumors: Surgical management and clinical outcome

PubMed Central

Hoeppner, Jens; Kulemann, Birte; Marjanovic, Goran; Bronsert, Peter; Hopt, Ulrich Theodor

2013-01-01

AIM: To analyze our experience in patients with duodenal gastrointestinal stromal tumors (GIST) and review the appropriate surgical approach. METHODS: We retrospectively reviewed the medical records of all patients with duodenal GIST surgically treated at our medical institution between 2002 and 2011. Patient files, operative reports, radiological charts and pathology were analyzed. For surgical therapy open and laparoscopic wedge resections and segmental resections were performed for limited resection (LR). For extended resection pancreatoduodenectomy was performed. Age, gender, clinical symptoms of the tumor, anatomical localization, tumor size, mitotic count, type of resection resectional status, neoadjuvant therapy, adjuvant therapy, risk classification and follow-up details were investigated in this retrospective study. RESULTS: Nine patients (5 males/4 females) with a median age of 58 years were surgically treated. The median follow-up period was 45 mo (range 6-111 mo). The initial symptom in 6 of 9 patients was gastrointestinal bleeding (67%). Tumors were found in all four parts of the duodenum, but were predominantly located in the first and second part of the duodenum with each 3 of 9 patients (33%). Two patients received neoadjuvant medical treatment with 400 mg imatinib per day for 12 wk before resection. In one patient, the GIST resection was done by pancreatoduodenectomy. The 8 LRs included a segmental resection of pars 4 of the duodenum, 5 wedge resections with primary closure and a wedge resection with luminal closure by Roux-Y duodeno-jejunostomy. One of these LRs was done minimally invasive; seven were done in open fashion. The median diameter of the tumors was 54 mm (14-110 mm). Using the Fletcher classification scheme, 3/9 (33%) tumors had high risk, 1/9 (11%) had intermediate risk, 4/9 (44%) had low risk, and 1/9 (11%) had very low risk for aggressive behaviour. Seven resections showed microscopically negative transsection margins (R0), two showed positive margins (R1). No patient developed local recurrence during follow-up. The one patient who underwent pancreatoduodenectomy died due to progressive disease with hepatic metastasis but without evidence of local recurrence. Another patient died in complete remission due to cardiac disease. Seven of the nine patients are alive disease-free. CONCLUSION: In patients with duodenal GIST, limited surgical resection with microscopically negative margins, but also with microscopically positive margins, lead to very good local and systemic disease-free survival. PMID:23515427

Liver tumor boundaries identified intraoperatively using real-time indocyanine green fluorescence imaging.

PubMed

Zhang, Ya-Min; Shi, Rui; Hou, Jian-Cun; Liu, Zi-Rong; Cui, Zi-Lin; Li, Yang; Wu, Di; Shi, Yuan; Shen, Zhong-Yang

2017-01-01

Clear delineation between tumors and normal tissues is ideal for real-time surgical navigation imaging. We investigated applying indocyanine green (ICG) fluorescence imaging navigation using an intraoperative administration method in liver resection. Fifty patients who underwent liver resection were divided into two groups based on clinical situation and operative purpose. In group I, sizes of superficial liver tumors were determined; tiny tumors were identified. In group II, the liver resection margin was determined; real-time navigation was performed. ICG was injected intravenously at the beginning of the operation; the liver surface was observed with a photodynamic eye (PDE). Liver resection margins were determined using PDE. Fluorescence contrast between normal liver and tumor tissues was obvious in 32 of 35 patients. A boundary for half the liver or specific liver segments was determined in nine patients by examining the portal vein anatomy after ICG injection. Eight small tumors not observed preoperatively were detected; the smallest was 2 mm. ICG fluorescence imaging navigation is a promising, simple, and safe tool for routine real-time intraoperative imaging during hepatic resection and clinical exploration in hepatocellular carcinoma, enabling high sensibility for identifying liver resection margins and detecting tiny superficial tumors.

Impact of Resection Margin Distance on Survival of Pancreatic Cancer: A Systematic Review and Meta-Analysis

PubMed Central

Kim, Kyung Su; Kwon, Jeanny; Kim, Kyubo; Chie, Eui Kyu

2017-01-01

Purpose While curative resection is the only chance of cure in pancreatic cancer, controversies exist about the impact of surgical margin status on survival. Non-standardized pathologic report and different criteria on the R1 status made it difficult to implicate adjuvant therapy after resection based on the margin status. We evaluated the influence of resection margins on survival by meta-analysis. Materials and Methods We thoroughly searched electronic databases of PubMed, EMBASE, and Cochrane Library. We included studies reporting survival outcomes with different margin status: involved margin (R0 mm), margin clearance with ≤ 1 mm (R0-1 mm), and margin with > 1 mm (R>1 mm). Hazard ratio (HR) for overall survival was extracted, and a random-effects model was used for pooled analysis. Results A total of eight retrospective studies involving 1,932 patients were included. Pooled HR for overall survival showed that patients with R>1 mm had reduced risk of death than those with R0-1 mm (HR, 0.74; 95% confidence interval [CI], 0.61 to 0.88; p=0.001). In addition, patients with R0-1 mm had reduced risk of death than those with R0 mm (HR, 0.81; 95% CI, 0.72 to 0.91; p < 0.001). There was no heterogeneity between the included studies (I2 index, 42% and 0%; p=0.10 and p=0.82, respectively). Conclusion Our results suggest that stratification of the patients based on margin status is warranted in the clinical trials assessing the role of adjuvant treatment for pancreatic cancer. PMID:27561314

Role of imprint/exfoliative cytology in ulcerated skin neoplasms.

PubMed

Ramakrishnaiah, Vishnu Prasad Nelamangala; Babu, Ravindra; Pai, Dinker; Verma, Surendra Kumar

2013-12-01

Imprint cytology is a method of studying cells by taking an imprint from the cut surface of a wedge biopsy specimen or from the resected margins of a surgical specimen. It is rapid, simple and fairly accurate. Exfoliative cytology is an offshoot from the imprint cytology where in cells obtained from the surface of ulcers, either by scrape or brush, are analyzed for the presence of malignant cells. We undertook this study to see the role of imprint/exfoliative cytology in the diagnosis of ulcerated skin neoplasm and to check the adequacy of resected margins intra-operatively. This was a prospective investigative study conducted from September 2003 to July 2005. All patients presenting to surgical clinic with ulcerated skin and soft tissue tumours were included in the study. A wedge biopsy obtained from the ulcer and imprint smears were taken from the cut surface. Exfoliative cytology was analyzed from the surface smears. Wedge biopsy specimen was sent for histopathological (HPE) examination. The cytology and HPE were analyzed by a separate pathologist. Imprint cytology was also used to check the adequacy of resected margins in case of wide excision. This was compared with final HPE. Total of 107 patients was included in the present study and 474 imprint smears were done, with an average of 4.43 slides per lesion. Out of 59 wide excision samples, 132 imprint smears were prepared for assessing resected margins accounting for an average of 2.24 slides per each excised lesion. On combining imprint cytology with exfoliative cytology the overall sensitivity, specificity and positive predictive value were 90.38 %, 100 % and 90.38 % respectively. Only one out of 59 cases had a positive resected margin which was not picked by imprint cytology. Imprint cytology can be used for rapid and accurate diagnosis of various skin malignancies. It can also be used to check the adequacy of the resected margin intraoperatively.

Tumor resection at the pelvis using three-dimensional planning and patient-specific instruments: a case series.

PubMed

Jentzsch, Thorsten; Vlachopoulos, Lazaros; Fürnstahl, Philipp; Müller, Daniel A; Fuchs, Bruno

2016-09-21

Sarcomas are associated with a relatively high local recurrence rate of around 30 % in the pelvis. Inadequate surgical margins are the most important reason. However, obtaining adequate margins is particularly difficult in this anatomically demanding region. Recently, three-dimensional (3-D) planning, printed models, and patient-specific instruments (PSI) with cutting blocks have been introduced to improve the precision during surgical tumor resection. This case series illustrates these modern 3-D tools in pelvic tumor surgery. The first consecutive patients with 3-D-planned tumor resection around the pelvis were included in this retrospective study at a University Hospital in 2015. Detailed information about the clinical presentation, imaging techniques, preoperative planning, intraoperative surgical procedures, and postoperative evaluation is provided for each case. The primary outcome was tumor-free resection margins as assessed by a postoperative computed tomography (CT) scan of the specimen. The secondary outcomes were precision of preoperative planning and complications. Four patients with pelvic sarcomas were included in this study. The mean follow-up was 7.8 (range, 6.0-9.0) months. The combined use of preoperative planning with 3-D techniques, 3-D-printed models, and PSI for osteotomies led to higher precision (maximal (max) error of 0.4 centimeters (cm)) than conventional 3-D planning and freehand osteotomies (max error of 2.8 cm). Tumor-free margins were obtained where measurable (n = 3; margins were not assessable in a patient with curettage). Two insufficiency fractures were noted postoperatively. Three-dimensional planning as well as the intraoperative use of 3-D-printed models and PSI are valuable for complex sarcoma resection at the pelvis. Three-dimensionally printed models of the patient anatomy may help visualization and precision. PSI with cutting blocks help perform very precise osteotomies for adequate resection margins.

Is computer navigation when used in the surgery of iliosacral pelvic bone tumours safer for the patient?

PubMed

Laitinen, M K; Parry, M C; Albergo, J I; Grimer, R J; Jeys, L M

2017-02-01

Due to the complex anatomy of the pelvis, limb-sparing resections of pelvic tumours achieving adequate surgical margins, can often be difficult. The advent of computer navigation has improved the precision of resection of these lesions, though there is little evidence comparing resection with or without the assistance of navigation. Our aim was to evaluate the efficacy of navigation-assisted surgery for the resection of pelvic bone tumours involving the posterior ilium and sacrum. Using our prospectively updated institutional database, we conducted a retrospective case control study of 21 patients who underwent resection of the posterior ilium and sacrum, for the treatment of a primary sarcoma of bone, between 1987 and 2015. The resection was performed with the assistance of navigation in nine patients and without navigation in 12. We assessed the accuracy of navigation-assisted surgery, as defined by the surgical margin and how this affects the rate of local recurrence, the disease-free survival and the effects on peri-and post-operative morbidity. The mean age of the patients was 36.4 years (15 to 66). The mean size of the tumour was 10.9 cm. In the navigation-assisted group, the margin was wide in two patients (16.7%), marginal in six (66.7%) and wide-contaminated in one (11.1%) with no intralesional margin. In the non-navigated-assisted group; the margin was wide in two patients (16.7%), marginal in five (41.7%), intralesional in three (25.0%) and wide-contaminated in two (16.7%). Local recurrence occurred in two patients in the navigation-assisted group (22.2%) and six in the non-navigation-assisted group (50.0%). The disease-free survival was significantly better when operated with navigation-assistance (p = 0.048). The blood loss and operating time were less in the navigated-assisted group, as was the risk of a foot drop post-operatively. The introduction of navigation-assisted surgery for the resection of tumours of the posterior ilium and sacrum has increased the safety for the patients and allows for a better oncological outcome. Cite this article: Bone Joint J 2017;99-B:261-6. ©2017 The British Editorial Society of Bone & Joint Surgery.

Ultrasound-guided breast-sparing surgery to improve cosmetic outcomes and quality of life. A prospective multicentre randomised controlled clinical trial comparing ultrasound-guided surgery to traditional palpation-guided surgery (COBALT trial)

PubMed Central

2011-01-01

Background Breast-conserving surgery for breast cancer was developed as a method to preserve healthy breast tissue, thereby improving cosmetic outcomes. Thus far, the primary aim of breast-conserving surgery has been the achievement of tumour-free resection margins and prevention of local recurrence, whereas the cosmetic outcome has been considered less important. Large studies have reported poor cosmetic outcomes in 20-40% of patients after breast-conserving surgery, with the volume of the resected breast tissue being the major determinant. There is clear evidence for the efficacy of ultrasonography in the resection of nonpalpable tumours. Surgical resection of palpable breast cancer is performed with guidance by intra-operative palpation. These palpation-guided excisions often result in an unnecessarily wide resection of adjacent healthy breast tissue, while the rate of tumour-involved resection margins is still high. It is hypothesised that the use of intra-operative ultrasonography in the excision of palpable breast cancer will improve the ability to spare healthy breast tissue while maintaining or even improving the oncological margin status. The aim of this study is to compare ultrasound-guided surgery for palpable tumours with the standard palpation-guided surgery in terms of the extent of healthy breast tissue resection, the percentage of tumour-free margins, cosmetic outcomes and quality of life. Methods/design In this prospective multicentre randomised controlled clinical trial, 120 women who have been diagnosed with palpable early-stage (T1-2N0-1) primary invasive breast cancer and deemed suitable for breast-conserving surgery will be randomised between ultrasound-guided surgery and palpation-guided surgery. With this sample size, an expected 20% reduction of resected breast tissue and an 18% difference in tumour-free margins can be detected with a power of 80%. Secondary endpoints include cosmetic outcomes and quality of life. The rationale, study design and planned analyses are described. Conclusion The COBALT trial is a prospective, multicentre, randomised controlled study to assess the efficacy of ultrasound-guided breast-conserving surgery in patients with palpable early-stage primary invasive breast cancer in terms of the sparing of breast tissue, oncological margin status, cosmetic outcomes and quality of life. Trial Registration Number Netherlands Trial Register (NTR): NTR2579 PMID:21410949

Challenges of local recurrence and cure in low grade malignant tumors of the spine.

PubMed

Boriani, Stefano; Saravanja, Davor; Yamada, Yoshiya; Varga, Peter Pal; Biagini, Roberto; Fisher, Charles G

2009-10-15

Systematic review and ambispective multicenter cohort study. 1. To compare the effects of wide/marginal (en bloc) resection with intralesional resection on local recurrence and survival for chordomas and chondrosarcomas of the spine. 2. To determine the influence of radiation therapy in the management of chordomas and chondrosarcomas. Chordomas and chondrosarcomas of the spine are prone to local recurrence and death despite being low-grade malignant tumors. No study to date has enough numbers or adequate scientific rigor to determine the influence of resection or radiation therapy on outcome. A systematic review was performed to evaluate the 2 objectives. In addition an ambispective multicenter cohort analysis of chordomas and chondrosarcomas was performed. The GRADE system of analysis integrating the results of the systematic review, the multicenter cohort study and the expert opinion of the Spine Oncology Study Group (SOSG) was used to arrive at treatment recommendations. A total of 63 articles were included in the systematic reviews. Evidence was low quality. En bloc resection appeared to improve both local recurrence and disease free survival in Chordoma and Chondrosarcoma. Radiation therapy had a positive impact on the management of Chordoma and Chondrosarcoma with predictably low side effects. The cohort analysis showed significantly decreased local recurrence for Chordoma (P < 0.0001) and Chondrosarcoma (P < 0.0001) with en bloc resection, and significantly decreased death for both Chordoma (P = 0.0001) and Chondrosarcoma (P = 0.0015) with en bloc resection. When wide or marginal margins (en bloc) are achieved in surgical resection of chordomas and chondrosarcomas of the spine there is a decrease in local recurrence and mortality. Therefore, en bloc resection should be undertaken for the treatment of chordomas and chondrosarcomas of the spine. Strong Recommendation, Moderate Quality Evidence.Radiation therapy of at least 60 to 65 Gy equivalents is indicated as an adjuvant treatment for chordoma and chondrosarcoma of the spine when there has been incomplete resection or an intralesional margin. Weak Recommendation, Low Quality Evidence.

Robotic surgery for rectal cancer: a single center experience of 100 consecutive cases.

PubMed

Stănciulea, O; Eftimie, M; David, L; Tomulescu, V; Vasilescu, C; Popescu, I

2013-01-01

Minimally invasive techniques have revolutionized the field of general surgery over the few last decades. Despite its advantages, in complex procedures such as rectal surgery, laparoscopy has not achieved a high penetration rate because of its steep learning curve, its relatively high conversion rate and technical challenges. The aim of this study was to present a single center experience with robotic surgery for rectal cancer focusing mainly on early and mid-term postoperative outcome. A series of 100 consecutive patients who underwent robotic rectal surgery between January 2008 and June 2012 was analyzed retrospectively in terms of demographics, pathological data, surgical and oncological outcomes. Seventy-seven patients underwent robotic sphincter-saving resection, and 23 patients underwent robotic abdominoperineal resection. There were 4 conversions. The median operative time for sphincter-saving procedures was 180 min. The median time for robotic abdominoperineal resection was 160 min. The median distal resection margin of the operative specimen was 3 cm. The median number of retrieved lymph nodes was 14. The median hospital stay was 10 days. In-hospital mortality was nil. The overall morbidity was 30%. Four patients presented transitory postoperative urinary dysfunction. Severe erectile dysfunction was reported by 3 patients. The median length of follow-up was 24 months. The 3-year overall survival rate was 90%. Robotic surgery is advantageous for both surgeons (in that it facilitates dissection in a narrow pelvis) and patients (in that it affords a very good quality of life via the preservation of sexual and urinary function in the vast majority of patients and it has low morbidity and good midterm oncological outcomes). In rectal cancer surgery, the robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field. Celsius.

Prevalence and predictive factors for the detection of carcinoma in cavity margin performed at the time of breast lumpectomy.

PubMed

Tengher-Barna, Iulia; Hequet, Delphine; Reboul-Marty, Jeanne; Frassati-Biaggi, Annonciade; Seince, Nathalie; Rodrigues-Faure, Anabela; Uzan, Michèle; Ziol, Marianne

2009-02-01

Margin resection status is a major risk factor for the development of local recurrence in breast conservation therapy for carcinoma. Tumor bed excision sent as separate orientated cavity margins represents a tool to verify the completeness of the carcinoma resection. We aimed to (1) determine the prevalence of positive cavity margin and its influence on subsequent surgical treatment and (2) identify potential predictive factors for positive cavity margins. From 2003 to 2006, 107 (57 years; 30-88) consecutive patients who underwent a lumpectomy for carcinoma with four orientated cavity margins for carcinoma were selected. Preoperative clinical, radiological and histological data, perioperative macroscopic characteristics and definitive histological analysis results were recorded. Lumpectomy or cavity margins were considered as positive when the distance from carcinoma to the margin was less than or equal to 3 mm. Histological examination of cavity margins showed carcinoma in 38 patients (35%), therefore modifying subsequent surgical therapy in 33 cases. Examination of the cavity margins led (1) to avoiding surgical re-excision in 20 cases (lumpectomy margins were positive and the cavity margins negative), (2) to performing a mastectomy or a re-excision in 13 cases (carcinoma was detected in the cavity margins although the lumpectomy margins were negative or tumor size was superior to 3 cm). Between preoperative and perioperative parameters, US scan and macroscopic size of the tumor were predictive factors for positive cavity margins whereas characteristics of the carcinoma determined on biopsy samples and macroscopic status of the lumpectomy margins were not. Our study confirms that the systematic practice of cavity margin resection avoids surgical re-excision and reduces the likelihood of underestimating the extent of the tumor.

Transoral robotic surgery for neurogenic tumors of the prestyloid parapharyngeal space.

PubMed

Lee, Hyoung Shin; Kim, Jinna; Lee, Hyun Jin; Koh, Yoon Woo; Choi, Eun Chang

2012-08-01

The parapharyngeal space is a difficult area for a surgical approach due to anatomical complexity. We performed a minimally invasive and precise surgical technique to remove neurogenic tumors of the prestyloid parapharyngeal space using transoral robotic instrumentation. The mass was successfully removed in the two cases with three-dimensional visualization providing an excellent view of the resection margin and the dissection plane preserving the vital structures. An adequate resection margin was acquired, and no violation of the tumor capsule occurred. No significant complications were noted. Transoral robotic surgery was feasible for neurogenic tumors of the prestyloid parapharyngeal space, providing a sufficient resection margin and delicate dissection through excellent surgical views and instrumentation. Copyright © 2012. Published by Elsevier Ireland Ltd.

The distal fascicle of the anterior inferior tibio-fibular ligament as a cause of anterolateral ankle impingement: results of arthroscopic resection.

PubMed

Akseki, D; Pinar, H; Bozkurt, M; Yaldiz, K; Araç, S

1999-10-01

We arthroscopically resected the impinged distal fascicle of the anterior inferior tibiofibular ligament (AIT-FL) in 21 patients (mean age 31 (11-68) years, 14 women) with chronic ankle pain after an ankle sprain. Clinical tests revealed moderate laxity in 2 and severe laxity in another 2, the remaining 17 ankles showing only mild laxity. During arthroscopy, an impinging distal fascicle of the AITFL was found in all cases. Following anterolateral synovectomy, the fascicle was excised. At the follow-up after mean 3 (2-4) years, good-to-excellent results were obtained in 17 patients. 19 patients were satisfied with the procedure and 17 patients returned to their previous level of activity. 2 patients who had mild laxity were graded as poor because of neuromas of the terminal branches of the superficial peroneal nerve. These patients became asymptomatic after an injection of steroids.

Is Duodenal Invasion a Relevant Prognosticator in Patients Undergoing Adjuvant Chemoradiotherapy for Distal Common Bile Duct Cancer?

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kim, Kyubo; Chie, Eui Kyu, E-mail: ekchie93@snu.ac.k; Jang, Jin-Young

2010-07-15

Purpose: To analyze the outcome of adjuvant chemoradiotherapy for patients with distal common bile duct (CBD) cancer who underwent curative surgery, and to identify the prognostic factors for these patients. Methods and Materials: Between January 1991 and December 2002, 38 patients with adenocarcinoma of the distal CBD underwent curative resection followed by adjuvant chemoradiotherapy. There were 27 men and 11 women, and the median age was 60 years (range, 34-73). Adjuvant radiotherapy was delivered to the tumor bed and regional lymph nodes up to 40 Gy at 2 Gy/fraction with a 2-week planned rest. Intravenous 5-fluorouracil (500mg/m{sup 2}/day) was givenmore » on day 1 to day 3 of each split course. The median follow-up period was 39 months. Results: The 5-year overall survival rate of all patients was 49.1%. On univariate analysis, only histologic differentiation (p = 0.0005) was associated with overall survival. Tumor size ({<=}2cm vs. >2cm) had a marginally significant impact on the treatment outcome (p = 0.0624). However, there was no difference in overall survival rates between T3 and T4 tumors (p = 0.6189), for which the main determinants were pancreatic and duodenal invasion, respectively. On multivariate analysis, histologic differentiation (p = 0.0092) and tumor size (p = 0.0046) were independent risk factors for overall survival. Conclusions: Long-term survival can be expected in patients with distal CBD cancer undergoing curative surgery and adjuvant chemoradiotherapy. Histologic differentiation and tumor size were significant prognostic factors predicting overall survival, whereas duodenal invasion was not. This finding suggests the need for further refinement in tumor staging.« less

Hilar cholangiocarcinoma: controversies on the extent of surgical resection aiming at cure.

PubMed

Xiang, Shuai; Lau, Wan Yee; Chen, Xiao-ping

2015-02-01

Hilar cholangiocarcinoma is the most common malignant tumor affecting the extrahepatic bile duct. Surgical treatment offers the only possibility of cure, and it requires removal of all tumoral tissues with adequate resection margins. The aims of this review are to summarize the findings and to discuss the controversies on the extent of surgical resection aiming at cure for hilar cholangiocarcinoma. The English medical literatures on hilar cholangiocarcinoma were studied to review on the relevance of adequate resection margins, routine caudate lobe resection, extent of liver resection, and combined vascular resection on perioperative and long-term survival outcomes of patients with resectable hilar cholangiocarcinoma. Complete resection of tumor represents the most important prognostic factor of long-term survival for hilar cholangiocarcinoma. The primary aim of surgery is to achieve R0 resection. When R1 resection is shown intraoperatively, further resection is recommended. Combined hepatic resection is now generally accepted as a standard procedure even for Bismuth type I/II tumors. Routine caudate lobe resection is also advocated for cure. The extent of hepatic resection remains controversial. Most surgeons recommend major hepatic resection. However, minor hepatic resection has also been advocated in most patients. The decision to carry out right- or left-sided hepatectomy is made according to the predominant site of the lesion. Portal vein resection should be considered when its involvement by tumor is suspected. The curative treatment of hilar cholangiocarcinoma remains challenging. Advances in hepatobiliary techniques have improved the perioperative and long-term survival outcomes of this tumor.

Whipple Resection: Concordance Between Frozen Section And Permanent Section Diagnosis Of Surgical Margins.

PubMed

Bilal, Muhammad; Tariq, Hina; Mamoon, Nadira

2018-01-01

Margin assessment is done in Whipple procedures which are usually performed to resect tumours of head of pancreas and ampullary/periampullary region. Aims and objective of the study are to determine the concordance between frozen sections (FS) and permanent sections (PS) of surgical margins in Whipple resections. It is a retrospective study, from January 2008 to January 2015 (07 years). It includes the specimen with malignancy in final report and for which FS of pancreatic and/or CBD margin(s) were requested. Data was retrieved from Laboratory information system (LIS) database. Of the 41 bile duct margins in cases of ampullary tumours, 03 were positive on FS as well as PS, 35 were negative on FS as well as on PS. Results showed 100% sensitivity, 92.1% specificity, 50% PPV and 100% NPV. Results of 36 pancreatic margins in cases of ampullary showed 100% sensitivity, 97.1% specificity, 50% PPV and 100% NPV. In pancreatic carcinoma cases, none of CBD margins were reported as positive on FS, 02 margins reported as negative were found positive on PS, while 17 were negative on FS as well as PS. Results showed 100% specificity and 89.5% NPV. Of the 27 pancreatic margins tested in pancreatic tumours 100% sensitivity, 94.1% specificity, 88.9% PPV and 100% NPV was found. Factors such as absent prior tissue diagnosis and/or inflammatory processes make margin diagnosis difficult. However, a high concordance was observed between our FS and PS diagnosis.

Giardia muris and Giardia duodenalis groups: ultrastructural differences between the trophozoites.

PubMed

Sogayar, M I; Gregório, E A

1989-01-01

Trophozoites of the Giardia muris group from hamsters, domestic rats and mice and of the Giardia duodenalis group from hamsters and domestic rats were examined by transmission electron microscopy. The basic ultrastructure of the trophozoites was similar. Differences were shown in the morphology of the ventrolateral flange of the trophozoites of Giardia muris and Giardia duodenalis groups. Marginal plates are less developed in the species of the Giardia duodenalis group. In this group, the distal extremity of the lateral flange is short and thick and the marginal plate does not penetrate into the distal extremity of the flange. In the Giardia muris group, the ventro-lateral flange is well developed and narrow and the marginal plate penetrates the distal extremity of the flange. The osmiophilic lamella, which accompanies the dorsal surface of the marginal plate is seen only in the Giardia muris group.

Impact of fecal immunochemical test-based screening programs on proximal and distal colorectal cancer surgery rates: A natural multiple-baseline experiment.

PubMed

Fedeli, Ugo; Zorzi, Manuel; Urso, Emanuele D L; Gennaro, Nicola; Dei Tos, Angelo P; Saugo, Mario

2015-11-15

Colorectal cancer (CRC) screening programs based on the fecal immunochemical test (FIT) were found to reduce overall CRC surgery rates, but to the authors' knowledge data by subsite are lacking. The objective of the current study was to assess the impact of FIT-based screening on proximal and distal CRC surgical resection rates. The Veneto region in Italy can be subdivided into 3 areas with staggered introduction of FIT-based screening programs: early (2002-2004), intermediate (2005-2007), and late (2008-2009) areas. Time series of proximal and distal CRC surgery were investigated in the 3 populations between 2001 and 2012 by Joinpoint regression analysis and segmented Poisson regression models. The impact of screening was similar in the study populations. Rates of distal CRC surgical resection were stable before screening, increased at the time of screening implementation (rate ratio [RR], 1.25; 95% confidence interval [95% CI], 1.14-1.37), and thereafter declined by 10% annually (RR, 0.90; 95% CI, 0.88-0.92). Rates of proximal CRC surgical resection increased by 4% annually before screening (RR, 1.04; 95% CI, 1.03-1.05) but, after a peak at the time of screening initiation, the trend was reversed. The percentage represented by proximal CRC surgery rose from 28% in 2001 to 41% in 2012. In this natural multiple-baseline experiment, consistent findings across each time series demonstrated that FIT-based screening programs have an impact both on proximal and distal CRC surgery rates. However, underlying preexisting epidemiological trends are leading to a rapidly increasing percentage of proximal CRC. © 2015 American Cancer Society.

Role of Adjuvant Treatment in Esophageal Cancer With Incidental Pathologic Node Positivity.

PubMed

Gao, Sarah J; Park, Henry S; Corso, Christopher D; Rutter, Charles E; Kim, Anthony W; Johung, Kimberly L

2017-07-01

The optimal adjuvant treatment for cT1-2 N0 esophageal cancer patients found to have pathologic nodal involvement after an upfront operation is unclear. This study investigated the effects of postoperative chemotherapy and chemoradiation therapy on overall survival in cT1-2 N0 patients with incidental pN + disease stratified by margin status. We identified cT1-2 N0 M0 esophageal carcinoma patients from 2004 to 2012 from the National Cancer Data Base. Patients were categorized as having received surgical resection alone, surgical resection followed by chemotherapy (S+CT), and surgical resection followed by concurrent chemoradiation therapy (S+CRT). Subset analyses were conducted on margin-negative and margin-positive patients. Overall survival was compared by Kaplan-Meier estimation, the log-rank test, and multivariable Cox regression analysis. Among 443 patients, 52.6% received surgical resection alone, 18.7% received S+CT, and 28.6% received S+CRT. Significantly more adenocarcinoma patients received adjuvant treatment (50.8%) than squamous cell carcinoma patients (27.7%, p = 0.001). On multivariable analysis, S+CT (hazard ratio, 0.64; 95% confidence interval, 0.45 to 0.91; p = 0.014) and S+CRT (hazard ratio, 0.73; 95% confidence interval,. 0.55 to 0.98; p = 0.038) both were associated with significantly increased overall survival. These findings persisted among margin-negative patients. However, in margin-positive patients, S+CRT (hazard ratio, 0.29; p = 0.002) was the only treatment arm that was associated with significantly improved survival compared with surgical resection alone. Among cT1-2 N0 pN + esophageal cancer patients, adjuvant chemotherapy may be sufficient for margin-negative patients, whereas adjuvant chemoradiation therapy appears necessary for margin-positive patients. Further prospective studies are needed to confirm the results. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Using fluorescence lymphangiography to define the ileocolic mesentery: proof of concept for the watershed area using real-time imaging.

PubMed

Keller, D S; Joshi, H M; Rodriguez-Justo, M; Walsh, D; Coffey, J C; Chand, M

2017-09-01

Recent advances in mesenteric science have demonstrated that the mesentery is a continuous structure with a 'watershed' area at the mesenteric apex between the right colon and terminal ileum, where lymphatic flow can proceed either proximally or distally. With this new understanding of the anatomy, functional features are emerging, which can have an impact on surgical management. Fluorescence lymphangiography or lymphoscintigraphy with indocyanine green allows real-time visualization of lymphatic channels, which highlights sentinel lymph nodes and may facilitate identification of the ideal margins for mesenteric lymphadenectomy during bowel resection for colon cancer. By using this novel technology, it is possible to demonstrate a watershed area in the ileocolic region and may facilitate more precise mesenteric dissection. In the present study, we provide proof of concept for the ileocolic watershed area using fluorescence lymphangiography.

Early Stage olfactory neuroblastoma and the impact of resecting dura and olfactory bulb.

PubMed

Mays, Ashley C; Bell, Diana; Ferrarotto, Renata; Phan, Jack; Roberts, Dianna; Fuller, Clifton D; Frank, Steven J; Raza, Shaan M; Kupferman, Michael E; DeMonte, Franco; Hanna, Ehab Y; Su, Shirley Y

2018-06-01

Compare outcomes of patients with olfactory neuroblastoma (ONB) without skull base involvement treated with and without resection of the dura and olfactory bulb. Retrospective review of ONB patients treated from 1992 to 2013 at the MD Anderson Cancer Center (The University of Texas, Houston, Texas, U.S.A.). Primary outcomes were overall and disease-free survival. Thirty-five patients were identified. Most patients had Kadish A/B. tumors (97%), Hyams grade 2 (70%), with unilateral involvement (91%), and arising from the nasal cavity (68%). Tumor involved the mucosa abutting the skull base in 42% of patients. Twenty-five patients (71%) received surgery and radiation, whereas the remainder had surgery alone. Five patients (14%) had bony skull base resection, and eight patients (23%) had resection of bony skull base, dura, and olfactory bulb. Surgical margins were grossly positive in one patient (3%) and microscopically positive in four patients (12%). The 5- and 10-year overall survival were 93% and 81%, respectively. The 5- and 10-year disease-free survival (DFS) were 89% and 78%, respectively. Bony cribriform plate resection was associated with better DFS (P = 0.05), but dura and olfactory bulb resection was not (P = 0.11). There was a trend toward improved DFS in patients with negative resection margins (P = 0.19). Surgical modality (open vs. endoscopic) and postoperative radiotherapy did not impact DFS. Most Kadish A/B ONB tumors have low Hyams grade, unilateral involvement, and favorable survival outcomes. Resection of the dura and olfactory bulb is not oncologically advantageous in patients without skull base involvement who are surgically treated with negative resection margins and cribriform resection. 4. Laryngoscope, 128:1274-1280, 2018. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.

Significance of R1 Resection for Advanced Colorectal Liver Metastases in the Era of Modern Effective Chemotherapy.

PubMed

Laurent, Christophe; Adam, Jean-Philippe; Denost, Quentin; Smith, Denis; Saric, Jean; Chiche, Laurence

2016-05-01

The prognosis impact of positive margins after resection of colorectal liver metastases (CLM) in patients treated with modern effective chemotherapy has not been elucidated. The objective was to compare oncologic outcomes after R0 and R1 resections in the era of modern effective chemotherapy. Between 1999 and 2010, all consecutive patients undergoing liver resection for CLM were analyzed retrospectively. Patients with extrahepatic metastases, macroscopic residual tumor, treated with combined radiofrequency, or not treated with chemotherapy were excluded. Survival and recurrence after R0 (tumor-free margin >0 mm) and R1 resections were analyzed. Among 466 patients undergoing hepatectomy for CLM, 191 were eligible. Of them, 164 (86 %) received preoperative chemotherapy and 105 (55 %) received postoperative chemotherapy. R1 resection (10 %) was comparable in patients treated or not by preoperative chemotherapy. R1 status was associated with more intrahepatic recurrences. Overall survival (OS) (44 vs. 61 %; p = 0.047) and disease-free survival (DFS) (8 vs. 26 %; p = 0.082) were lower in patients after R1 compared to R0 resection (32 months of median follow-up). Preoperative chemotherapy and major hepatectomy were prognostic factors of survival, whereas postoperative chemotherapy was a protective factor from recurrences. In patients treated with preoperative chemotherapy, OS and DFS were similar between R1 and R0 resections (40 vs. 55 %, p = 0.104 and 9 vs. 22 %, p = 0.174, respectively). In the era of modern effective chemotherapy, R1 resection leads to more intrahepatic recurrences but did not affect OS in selected patient responders to neoadjuvant chemotherapy. Postoperative chemotherapy protects from recurrences whatever the margin resection status.

Shoulder reconstruction after tumor resection by pedicled scapular crest graft.

PubMed

Amin, Sherif N; Ebeid, Walid A

2002-04-01

The current authors present and evaluate a technique for reconstructing proximal humeral defects that result after resection of malignant bone tumors. Sixteen patients were included in this study with an average followup of 3 years (range, 12-76 months). Twelve patients had intraarticular resections, two had extraarticular resections, and two had intercalary resections. Reconstruction was done at the lateral border of the scapula (based on the circumflex scapular vessels) that was osteotomized and mobilized to bridge the resultant defect. Shoulder arthrodesis was done in 14 patients and the shoulder was spared in the two patients who had intercalary resections. Function was evaluated according to the Musculoskeletal Tumor Society scoring system. The average time for union of the graft proximally and distally was 6 months after which the graft started to hypertrophy. The average functional score was 22.5 points (75%) with a minimum score of 18 points (60%) and a maximum score of 27 points (90%). Nonunion of the distal host-graft junction occurred in two patients; both patients required iliac crest bone grafting and both achieved clinical and radiographic union without additional intervention. In three patients, the proximal fixation became loose but had no effect on function. The authors conclude that this technique is inexpensive, effective, and a durable reconstructive option for proximal humeral defects that are less than 15 cm. It has a predictable functional outcome (60%-90%) that is comparable with other reconstructive options.

[PERSONALIZED DISTAL FEMORAL VALGUS RESECTION ANGLE IN PRIMARY TOTAL KNEE ARTHROPLASTY].

PubMed

Wang, Xilong; Shang, Xifu; Ll, Guoyuan; He, Rui; Zheng, Jie

2015-01-01

To investigate the feasibility and effectiveness of a personalized distal femoral valgus resection angle for improving postoperative coronal alignment of lower limb in total knee arthroplasty (TKA). A retrospective analysis was made on the clinical data of 50 patients who received primary TKA between January 2013 and February 2013. There were 11 male and 39 female patients with degenerative knee osteoarthritis. The patients were divided into 2 groups. In test group (n=25), the resection angle was adjusted to the femoral mechanical anatomical angle (FMA); in control group (n=25), a fixed distal valgus resection angle of 5° was used. There was no significant difference in gender, age, body mass index, disease duration, sides, grade, preoperative FMA, mechanical femorotibial angle (MFT), and preoperative Knee Society Score (KSS) between 2 groups (P > 0.05). Whole long X-ray film was taken to measure FMA and MFT at 3 days after operation, postoperative KSS was used to evaluate the knee function after 6 and 15 months. MFT was (-0.20 ± 1.87)° in test group and was (1.71 ± 3.67)° in control group, showing significant difference between 2 groups (t = 2.32, P = 0.02). The ideal MFT angle (0 ± 3)° was achieved in 22 patients (88%) of test group and in 16 patients (64%) of control group, showing significant difference between 2 groups (χ2 = 2.32, P = 0.02). Primary healing of incision was obtained in all patients of 2 groups. No deep venous thrombosis occurred. The patients of 2 groups were followed up 15 months after operation. There was significant difference in KSS between test and control groups at 6 months (88.23 ± 2.57 vs. 82.92 ± 2.59) (t = 7.26, P = 0.00) and at 15 months (90.76 ± 2.77 vs. 88.65 ± 1.77) (t = 3.20, P = 0.02). No sign of prosthesis loosening was observed by X-ray examination. Compared with using of a fixed distal femoral resection angle, an individual FMA can significantly improve the postoperative MFT and promote early recovery of the knee function.

Determinants of survival after liver resection for metastatic colorectal carcinoma.

PubMed

Parau, Angela; Todor, Nicolae; Vlad, Liviu

2015-01-01

Prognostic factors for survival after liver resection for metastatic colorectal cancer identified up to date are quite inconsistent with a great inter-study variability. In this study we aimed to identify predictors of outcome in our patient population. A series of 70 consecutive patients from the oncological hepatobiliary database, who had undergone curative hepatic surgical resection for hepatic metastases of colorectal origin, operated between 2006 and 2011, were identified. At 44.6 months (range 13.7-73), 30 of 70 patients (42.85%) were alive. Patient demographics, primary tumor and liver tumor factors, operative factors, pathologic findings, recurrence patterns, disease-free survival (DFS), overall survival (OS) and cancer-specific survival (CSS) were analyzed. Clinicopathologic variables were tested using univariate and multivariate analyses. The 3-year CSS after first hepatic resection was 54%. Median CSS survival after first hepatic resection was 40.2 months. Median CSS after second hepatic resection was 24.2 months. The 3-year DFS after first hepatic resection was 14%. Median disease free survival after first hepatic resection was 18 months. The 3-year DFS after second hepatic resection was 27% and median DFS after second hepatic resection 12 months. The 30-day mortality and morbidity rate after first hepatic resection was 5.71% and 12.78%, respectively. In univariate analysis CSS was significantly reduced for the following factors: age >53 years, advanced T stage of primary tumor, moderately- poorly differentiated tumor, positive and narrow resection margin, preoperative CEA level >30 ng/ml, DFS <18 months. Perioperative chemotherapy related to metastasectomy showed a trend in improving CSS (p=0.07). Perioperative chemotherapy improved DFS in a statistically significant way (p=0.03). Perioperative chemotherapy and achievement of resection margins beyond 1 mm were the major determinants of both CSS and DFS after first liver resection in multivariate analysis. In our series predictors of outcome in multivariate analysis were resection margins beyond 1mm and perioperative chemotherapy. Studies on larger population and analyses of additional clinicopathologic factors like genetic markers could contribute to development of clinical scoring models to assess the risk of relapse and survival.

Malignant conversion of a solitary papilloma in the distal trachea: Report of a case

PubMed Central

Lioulias, Achilleas; Misthos, Panagiotis; Papagiannakis, Georgios; Mermigkis, Dimitrios; Karagianidis, Napoleon; Neofotistos, Kostas; Kokotsakis, John

2008-01-01

A solitary papilloma versus the usual multiple lesions of papillomatosis is extremely rare. Even more infrequent is a solitary papilloma of the trachea in an adult patient. In the present report, a case of a solitary papilloma in the distal trachea is presented. After two unsuccessful sessions of laser ablation, resection of the lower one-third of the trachea was performed through a right posterolateral thoracotomy. Postoperative histology results disclosed a malignant degeneration into squamous cell carcinoma. The patient had an excellent outcome after resection of the affected portion of the trachea. There was no evidence of recurrence after 20 months of follow-up. PMID:18949108

A pilot study of sphincter-sparing management of adenocarcinoma of the rectum.

PubMed

Steele, G; Busse, P; Huberman, M S; LeClair, J M; Falchuk, Z M; Mayer, R J; Bothe, A; Ravikumar, T S; Stone, M; Jessup, J M

1991-06-01

After analysis of 26 prospectively accrued patients with distal rectal adenocarcinomas who underwent sphincter preservation treatment, we have concluded that tumors that invade only the submucosa can safely be treated with surgery alone and that tumors that invade the muscularis or further can be safely treated with surgery combined with chemoradiotherapy. None of the patients had either local or distant recurrence, with a median follow-up of 21 months. All patients have been fully continent. The results, although preliminary, imply that resection of distal rectal adenocarcinoma with sphincter preservation, and adjuvant therapy when appropriate, have achieved local and distant control equal to the conventional Miles' abdominoperineal resection, but without the need for a permanent colostomy.

Evaluation of margins in head and neck squamous cell carcinoma from the surgeon's perspective.

PubMed

Baumeister, Philipp; Baumüller, Konstantin; Harréus, Ulrich; Reiter, Maximilian; Welz, Christian

2018-05-01

The surgeon's evaluation of resection status based on frozen section analysis during operation and pathological examination of resected specimens often differ. For this study, we recapitulated the surgeon's perspective during an operation, accordingly classified the evaluation of margins by the surgeon, and analyzed its impact on the outcome compared with the pathological results. This was a retrospective analysis. As data sources, paper-based and digital patient files, as well as the Munich Cancer Registry database were used. Three hundred ninety-six cases were included in this analysis. Only the evaluation of margins by the surgeon influenced local control, and the pathological results influenced disease-free survival (DFS). Surprisingly, margins of >5 mm of normal tissue to cancer growth led to local control and overall survival (OS) significantly worse than 1 to 5-mm resections. The evaluation of margins by the surgeon is of significant importance for local control and OS. It is largely based on frozen section analysis, which, therefore, should be used whenever possible. © 2018 Wiley Periodicals, Inc.

Meta-analysis of robotic and laparoscopic surgery for treatment of rectal cancer.

PubMed

Lin, Shuang; Jiang, Hong-Gang; Chen, Zhi-Heng; Zhou, Shu-Yang; Liu, Xiao-Sun; Yu, Ji-Ren

2011-12-21

To conduct a meta-analysis to determine the relative merits of robotic surgery (RS) and laparoscopic surgery (LS) for rectal cancer. A literature search was performed to identify comparative studies reporting perioperative outcomes for RS and LS for rectal cancer. Pooled odds ratios and weighted mean differences (WMDs) with 95% confidence intervals (95% CIs) were calculated using either the fixed effects model or random effects model. Eight studies matched the selection criteria and reported on 661 subjects, of whom 268 underwent RS and 393 underwent LS for rectal cancer. Compared the perioperative outcomes of RS with LS, reports of RS indicated favorable outcomes considering conversion (WMD: 0.25; 95% CI: 0.11-0.58; P = 0.001). Meanwhile, operative time (WMD: 27.92, 95% CI: -13.43 to 69.27; P = 0.19); blood loss (WMD: -32.35, 95% CI: -86.19 to 21.50; P = 0.24); days to passing flatus (WMD: -0.18, 95% CI: -0.96 to 0.60; P = 0.65); length of stay (WMD: -0.04; 95% CI: -2.28 to 2.20; P = 0.97); complications (WMD: 1.05; 95% CI: 0.71-1.55; P = 0.82) and pathological details, including lymph nodes harvested (WMD: 0.41, 95% CI: -0.67 to 1.50; P = 0.46), distal resection margin (WMD: -0.35, 95% CI: -1.27 to 0.58; P = 0.46), and positive circumferential resection margin (WMD: 0.54, 95% CI: 0.12-2.39; P = 0.42) were similar between RS and LS. RS for rectal cancer is superior to LS in terms of conversion. RS may be an alternative treatment for rectal cancer. Further studies are required.

Can Tooth Preparation Design Affect the Fit of CAD/CAM Restorations?

PubMed

Roperto, Renato Cassio; Oliveira, Marina Piolli; Porto, Thiago Soares; Ferreira, Lais Alaberti; Melo, Lucas Simino; Akkus, Anna

2017-03-01

The purpose of this study was to evaluate if the marginal fit of computer-aided design and computer-aided manufacturing (CAD/CAM) restorations manufactured with CAD/CAM systems can be affected by different tooth preparation designs. Twenty-six typodont (plastic) teeth were divided into two groups (n = 13) according to the occlusal curvature of the tooth preparation. These were the group 1 (control group) (flat occlusal design) and group 2 (curved occlusal design). Scanning of the preparations was performed, and crowns were milled using ceramic blocks. Blocks were cemented using epoxy glue on the pulpal floor only, and finger pressure was applied for 1 minute. On completion of the cementation step, poor fits between the restoration and abutment were measured by microphotography and the silicone replica technique using light-body silicon material on mesial, distal, buccal, and lingual surfaces. Two-way ANOVA analysis did not reveal a statistical difference between flat (83.61 ± 50.72) and curved (79.04 ± 30.97) preparation designs. Buccal, mesial, lingual, and distal sites on the curved design preparation showed less of a gap when compared with flat design. No difference was found on flat preparations among mesial, buccal, and distal sites (P < .05). The lingual aspect had no difference from the distal side but showed a statistically significant difference from mesial and buccal (P < .05). Difference in occlusal design did not significantly impact the marginal fit. Marginal fit was significantly affected by the location of the margin; lingual and distal locations exhibited greater margin gap values compared with buccal and mesial sites regardless of the preparation design.

Toe amputations and ray resections.

PubMed

Pulla, R J; Kaminsky, K M

1997-10-01

Loss of a part of the lower extremity is an unfortunate complication of diabetes. Indications and general principles of amputation have been established. Distal limb salvage procedures include forefoot amputation alternatives, digital amputations, and ray resections. A variety of risks and complications are associated with these procedures. Postoperative management including prosthetic and accommodative therapy may enhance the successful outcomes of these procedures.

Principles of treatment for soft tissue sarcoma.

PubMed

Dernell, W S; Withrow, S J; Kuntz, C A; Powers, B E

1998-02-01

Soft tissue sarcomas (STS) are mesenchymal tumors arising from connective tissue elements and are grouped together based on a common biologic behavior. The most common histologic types include malignant peripheral nerve sheath tumors (schwannoma and neurofibrosarcoma) "hemangiopericytoma," fibrosarcoma, and malignant fibrous histiocytoma. These tumors are relatively slow growing yet locally invasive with a high rate of recurrence following conservative management. Appropriate preoperative planning and aggressive surgical resection often result in long-term remission or cure. Identification and evaluation of resection margins are paramount in appropriate case management. The addition of radiotherapy after surgical resection can aid in remission for incompletely resected masses. Systemic chemotherapy for STS should be considered for high-grade tumors with a moderate metastatic potential. Potential prognostic factors include grade, resection margins, size, location, histologic type, and previous treatment, with grade and margins being the most important. Tumor types classified as STS that differ slightly in their presentation or treatment, including synovial cell sarcoma, rhabdomyosarcoma, liposarcoma, and vaccine-associated STS in cats, are discussed. Soft tissue sarcomas can be a frustrating disease to treat, but adherence to solid surgical oncology principles can greatly increase the odds of good disease control.

Effectiveness of navigation-guided cyst aspiration before resection of large cystic brain tumors: a proof of concept for more radical surgery.

PubMed

Roh, Tae Hoon; Sung, Kyoung Su; Kang, Seok-Gu; Moon, Ju Hyung; Kim, Eui Hyun; Kim, Sun Ho; Chang, Jong Hee

2017-10-01

Resection of tumors close to the corticospinal tract (CST) carries a high risk of damage to the CST. For cystic tumors, aspirating the cyst before resection may reduce the risk of damage to vital structures. This study evaluated the effectiveness of cyst aspiration, by comparing the results before and after aspiration of diffusion tensor image (DTI) tractography. This study enrolled 23 patients with large cystic brain tumors (>20 cm 3 ) between 2012 and 2016. All underwent magnetic resonance imaging (MRI), including DTI tractography, followed by navigation-guided aspiration of the cyst and subsequent tumor resection via craniotomy. Distances between the tumor margin and CST before and after cyst aspiration, volume reduction, and postoperative outcomes were assessed. Median tumor volume decreased from 88 cm 3 (range, 25-153) to 29 cm 3 (range, 20-80) and distances between tumor margins and the CST increased from 5.7 mm (range, 0.6-22.0) to 14.8 mm (range, 0.6-41.4) after aspiration. Neurological symptoms of patients immediately improved after cyst aspiration. All patients, except for one with a secondary glioblastoma, underwent gross total resection of the tumor. No neurological deterioration was observed after tumor resection. Navigation-guided cyst aspiration followed by resection is a useful and safe procedure for brain tumors with large cystic components. Cyst aspiration resulted in expansion of the compressed brain tissue between the tumor margins and vital structures, making maximal safe resection possible.

Factors associated with a primary surgical approach for sinonasal squamous cell carcinoma.

PubMed

Cracchiolo, Jennifer R; Patel, Krupa; Migliacci, Jocelyn C; Morris, Luc T; Ganly, Ian; Roman, Benjamin R; McBride, Sean M; Tabar, Viviane S; Cohen, Marc A

2018-03-01

Primary surgery is the preferred treatment of T1-T4a sinonasal squamous cell carcinoma (SNSCC). Patients with SNSCC in the National Cancer Data Base (NCDB) were analyzed. Factors that contributed to selecting primary surgical treatment were examined. Overall survival (OS) in surgical patients was analyzed. Four-thousand seven hundred and seventy patients with SNSCC were included. In T1-T4a tumors, lymph node metastases, maxillary sinus location, and treatment at high-volume centers were associated with selecting primary surgery. When primary surgery was utilized, tumor factors and positive margin guided worse OS. Adjuvant therapy improved OS in positive margin resection and advanced T stage cases. Tumor and non-tumor factors are associated with selecting surgery for the treatment of SNSCC. When surgery is selected, tumor factors drive OS. Negative margin resection should be the goal of a primary surgical approach. When a positive margin resection ensues, adjuvant therapy may improve OS. © 2017 Wiley Periodicals, Inc.

Liver metastasis resection: a simple technique that makes it easier.

PubMed

de Santibañes, Eduardo; Sánchez Clariá, Rodrigo; Palavecino, Martín; Beskow, Axel; Pekolj, Juan

2007-09-01

Liver resection is the only therapeutic option that achieves long-term survival for patients with hepatic metastases. We propose a technique that causes traction and countertraction on the resection area, thus easily exposing the structures to be ligated. Because the parenchyma protrudes like a cork from a bottle, we named this procedure the "corkscrew technique". The objective of this work was to describe an original surgical technique to resect liver metastases. We delimit the resection area at 2 cm from the tumor. We place separated stitches, in a radiate way. The needle diameter must allow passing far from the deepest margin of the tumor. The stitches must be tractioned all together to separate the tumor from the normal parenchyma. Between the years 1983 and 2006, we perform 1,270 liver resections. We used the corkscrew technique-like procedure in only 612 patients, whereas in 129 patients, we associated it to an anatomic resection. Mortality was 1%. Morbidity was 16% with a reoperation rate of 3%. The corkscrew technique is simple and safe, spares surgical time, avoids blood loss, ensures free tumor margins, and is easy to perform.

Detection of tumor DNA at the margins of colorectal cancer liver metastasis

PubMed Central

Holdhoff, Matthias; Schmidt, Kerstin; Diehl, Frank; Aggrawal, Nishant; Angenendt, Philipp; Romans, Katharine; Edelstein, Daniel L.; Torbenson, Michael; Kinzler, Kenneth W.; Vogelstein, Bert; Choti, Michael A.; Diaz, Luis A.

2012-01-01

Purpose Defining an adequate resection margin of colorectal cancer liver metastases is essential for optimizing surgical technique. We have attempted to evaluate the resection margin through a combination of histopathologic and genetic analyses. Experimental Design We evaluated 88 samples of tumor margins from 12 patients with metastatic colon cancer who each underwent partial hepatectomy of one to six liver metastases. Punch biopsies of surrounding liver tissue were obtained at 4, 8, 12 and 16 mm from the tumor border. DNA from these biopsies was analyzed by a sensitive PCR-based technique, called BEAMing, for mutations of KRAS, PIK3CA, APC, or TP53 identified in the corresponding tumor. Results Mutations were identified in each patient’s resected tumor and used to analyze the 88 samples circumscribing the tumor-normal border. Tumor-specific mutant DNA was detectable in surrounding liver tissue in five of these 88 samples, all within 4 mm of the tumor border. Biopsies that were 8, 12, and 16 mm from the macroscopic visible margin were devoid of detectable mutant tumor DNA as well as of microscopically visible cancer cells. Tumors with a significant radiologic response to chemotherapy were not associated with any increase in mutant tumor DNA in beyond 4 mm of the main tumor. Conclusions Mutant tumor-specific DNA can be detected beyond the visible tumor margin, but never beyond 4 mm, even in patients whose tumors were larger prior to chemotherapy. These data provide a rational basis for determining the extent of surgical excision required in patients undergoing resection of liver metastases. PMID:21531819

Positive Margins by Oropharyngeal Subsite in Transoral Robotic Surgery for T1/T2 Squamous Cell Carcinoma.

PubMed

Persky, Michael J; Albergotti, William G; Rath, Tanya J; Kubik, Mark W; Abberbock, Shira; Geltzeiler, Mathew; Kim, Seungwon; Duvvuri, Umamaheswar; Ferris, Robert L

2018-04-01

Objective To compare positive margin rates between the 2 most common subsites of oropharyngeal transoral robotic surgery (TORS), the base of tongue (BOT) and the tonsil, as well as identify preoperative imaging characteristics that predispose toward positive margins. Study Design Case series with chart review. Setting Tertiary care referral center. Subjects and Methods We compared the final and intraoperative positive margin rate between TORS resections for tonsil and BOT oropharyngeal squamous cell carcinoma (OPSCC), as well as the effect of margins on treatment. A blinded neuroradiologist examined the preoperative imaging of BOT tumors to measure their dimensions and patterns of spread and provided a prediction of final margin results. Results Between January 2010 and May 2016, a total of 254 patients underwent TORS for OPSCC. A total of 140 patients who underwent TORS for T1/T2 OPSCC met inclusion criteria. A final positive margin is significantly more likely for BOT tumors than tonsil tumors (19.6% vs 4.5%, respectively, P = .004) and likewise for intraoperative margins of BOT and tonsil tumors (35.3% vs 12.4%, respectively; P = .002). A positive final margin is 10 times more likely to receive chemoradiation compared to a negative margin, controlling for extracapsular spread and nodal status (odds ratio, 9.6; 95% confidence interval, 1.6-59.6; P = .02). Preoperative imaging characteristics and subjective radiologic examination of BOT tumors did not correlate with final margin status. Conclusion Positive margins are significantly more likely during TORS BOT resections compared to tonsil resections. More research is needed to help surgeons predict which T1/T2 tumors will be difficult to completely extirpate.

Clinical outcome of dedifferentiated liposarcoma in the extremities: A retrospective case series of 7 patients.

PubMed

Kito, Munehisa; Yoshimura, Yasuo; Isobe, Ken'ichi; Aoki, Kaoru; Suzuki, Shuichiro; Tanaka, Atsushi; Okamoto, Masanori; Sano, Kenji; Kato, Hiroyuki

2016-09-01

Wide resection is the generally recommended surgical treatment for dedifferentiated liposarcoma (DDLPS) in the extremities. However, it may be appropriate to distinguish the surgical margin of low-grade atypical lipomatous tumor (ALT)/well-differentiated liposarcoma (WDLPS) area from the high-grade dedifferentiated area, because the low- and high-grade areas can be clearly separated, both radiologically and histologically. This study re-evaluated the details of surgical margin of DDLPS in the extremities, and aimed to investigate the optimal surgical margin and the usefulness of adjuvant therapy for DDLPS in the extremities. Seven patients diagnosed with DDLPS in the extremities and treated between 1995 and 2013 were analyzed. The use of adjuvant therapy before and after surgery was assessed, and the surgical margins for the ALT/WDLPS and dedifferentiated areas were re-evaluated by using the specimens resected at surgery. Subsequently, the recurrence rates, metastatic rates, and oncological outcomes were examined. Four and three patients had wide (adequate wide margin, n = 3; inadequate wide margin, n = 1) and marginal margins for the dedifferentiated area, respectively, while three and four patients had wide (adequate wide margin, n = 2; inadequate wide margin, n = 1) and marginal margins for the ALT/WDLPS area, respectively. Postoperative radiotherapy was performed in three patients with an inadequate wide margin or a marginal margin for the dedifferentiated area. No patient had local recurrence. Distant metastases occurred in two patients. These patients died of their disease. The other five patients were disease-free. The ALT/WDLPS and dedifferentiated areas in the tumor margin may be better to be considered separately in determining the appropriate resection extent for DDLPS in the extremities. Postoperative radiotherapy may provide good local control for cases with a narrow surgical margin. Copyright © 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.

Impact of margin status and lymphadenectomy on clinical outcomes in resected pancreatic adenocarcinoma: implications for adjuvant radiotherapy.

PubMed

Osipov, Arsen; Naziri, Jason; Hendifar, Andrew; Dhall, Deepti; Rutgers, Joanne K; Chopra, Shefali; Li, Quanlin; Tighiouart, Mourad; Annamalai, Alagappan; Nissen, Nicholas N; Tuli, Richard

2016-04-01

Adjuvant chemoradiotherapy (CRT) in the treatment of pancreatic ductal adenocarcinoma (PDA) is controversial. Minimal data exists regarding the clinical significance of margin clearance distance and lymph node (LN) parameters, such as extent of dissection and LN ratio. We assessed the impact of these variables on clinical outcomes to more clearly define the subset of patients who may benefit from adjuvant radiotherapy (RT). We identified 106 patients with resected stage 1-3 PDA from 2007-2013. Resection margins were categorized as positive (tumor at ink), ≤1, or >1 mm. LN evaluation included total number examined (NE), number of positive nodes (NP), ratio of NP to NE (NR), extent of dissection, and positive periportal LNs. The impact of these variables was assessed on disease-free survival (DFS) and overall survival (OS) using multivariate cox proportional hazards modeling. In patients receiving adjuvant chemotherapy (CT) alone, greater margin clearance led to improved DFS (P=0.0412, HR =0.51). Range of NE was 4-37, with a mean of 19. NE was not associated with DFS or OS, yet absolute NP of 5 or more was associated with a significantly worse DFS (P=0.005). Whereas periportal lymphadenectomy did not result in improved DFS or OS, patients with positive periportal LN had worse clinical outcomes (DFS, P=0.0052; OS, P=0.023). The use of adjuvant CRT was associated with improved OS (P=0.049; HR=0.29). In patients receiving adjuvant CT alone, there was a clinically significant benefit to clearing the surgical margin beyond tumor at ink. Having ≥5 NP and positive periportal LN led to significantly worse clinical outcomes. The addition of adjuvant RT to CT in resected PDA improved OS. A comprehensive evaluation of resection margin distance and LN parameters may identify more patients at risk for locoregional failure who may benefit from adjuvant CRT.

Impact of margin status and lymphadenectomy on clinical outcomes in resected pancreatic adenocarcinoma: implications for adjuvant radiotherapy

PubMed Central

Osipov, Arsen; Naziri, Jason; Hendifar, Andrew; Dhall, Deepti; Rutgers, Joanne K.; Chopra, Shefali; Li, Quanlin; Tighiouart, Mourad; Annamalai, Alagappan; Nissen, Nicholas N.

2016-01-01

Background Adjuvant chemoradiotherapy (CRT) in the treatment of pancreatic ductal adenocarcinoma (PDA) is controversial. Minimal data exists regarding the clinical significance of margin clearance distance and lymph node (LN) parameters, such as extent of dissection and LN ratio. We assessed the impact of these variables on clinical outcomes to more clearly define the subset of patients who may benefit from adjuvant radiotherapy (RT). Methods We identified 106 patients with resected stage 1-3 PDA from 2007-2013. Resection margins were categorized as positive (tumor at ink), ≤1, or >1 mm. LN evaluation included total number examined (NE), number of positive nodes (NP), ratio of NP to NE (NR), extent of dissection, and positive periportal LNs. The impact of these variables was assessed on disease-free survival (DFS) and overall survival (OS) using multivariate cox proportional hazards modeling. Results In patients receiving adjuvant chemotherapy (CT) alone, greater margin clearance led to improved DFS (P=0.0412, HR =0.51). Range of NE was 4-37, with a mean of 19. NE was not associated with DFS or OS, yet absolute NP of 5 or more was associated with a significantly worse DFS (P=0.005). Whereas periportal lymphadenectomy did not result in improved DFS or OS, patients with positive periportal LN had worse clinical outcomes (DFS, P=0.0052; OS, P=0.023). The use of adjuvant CRT was associated with improved OS (P=0.049; HR=0.29). Conclusions In patients receiving adjuvant CT alone, there was a clinically significant benefit to clearing the surgical margin beyond tumor at ink. Having ≥5 NP and positive periportal LN led to significantly worse clinical outcomes. The addition of adjuvant RT to CT in resected PDA improved OS. A comprehensive evaluation of resection margin distance and LN parameters may identify more patients at risk for locoregional failure who may benefit from adjuvant CRT. PMID:27034792

Treatment of gastric remnant cancer post distal gastrectomy by endoscopic submucosal dissection using an insulation-tipped diathermic knife

PubMed Central

Hirasaki, Shoji; Kanzaki, Hiromitsu; Matsubara, Minoru; Fujita, Kohei; Matsumura, Shuji; Suzuki, Seiyuu

2008-01-01

AIM: To evaluate the effectiveness of endoscopic submucosal dissection using an insulation-tipped diathermic knife (IT-ESD) for the treatment of patients with gastric remnant cancer. METHODS: Thirty-two patients with early gastric cancer in the remnant stomach, who underwent distal gastrectomy due to gastric carcinoma, were treated with endoscopic mucosal resection (EMR) or ESD at Sumitomo Besshi Hospital and Shikoku Cancer Center in the 10-year period from January 1998 to December 2007, including 17 patients treated with IT-ESD. Retrospectively, patient backgrounds, the one-piece resection rate, complete resection (CR) rate, operation time, bleeding rate, and perforation rate were compared between patients treated with conventional EMR and those treated with IT-ESD. RESULTS: The CR rate (40% in the EMR group vs 82% in the IT-ESD group) was significantly higher in the IT-ESD group than in the EMR group; however, the operation time was significantly longer for the IT-ESD group (57.6 ± 31.9 min vs 21.1 ± 12.2 min). No significant differences were found in the rate of underlying cardiopulmonary disease (IT-ESD group, 12% vs EMR group, 13%), one-piece resection rate (100% vs 73%), bleeding rate (18% vs 6.7%), and perforation rate (0% vs 0%) between the two groups. CONCLUSION: IT-ESD appears to be an effective treatment for gastric remnant cancer post distal gastrectomy because of its high CR rate. It is useful for histological confirmation of successful treatment. The long-term outcome needs to be evaluated in the future. PMID:18442204

An evaluation of brachytherapy and external beam radiation used with wide-margin surgical resection in the treatment of extra-abdominal desmoid tumors.

PubMed

Husain, Zain; Benevenia, Joseph; Uglialoro, Anthony D; Beebe, Kathleen S; Patterson, Francis R; Hameed, Meera R; Cathcart, Charles S

2011-05-01

Surgical resection has had control rates of 53% to 77% in the treatment of extra-abdominal desmoid tumors. Surgical excision combined with external beam radiation therapy (EBRT) has had local control rates of up to 83% in some series. The purpose of this study was to evaluate the effectiveness of resection combined with radiotherapy (brachytherapy, EBRT, or both) in the treatment of extra-abdominal desmoid tumors. We retrospectively reviewed the charts of 24 consecutive patients (27 histologically confirmed extra-abdominal desmoid tumors). Patients were included in the study if they had a lesion that was potentially resectable with a wide margin, allowing for limb salvage, and if they did not have a contraindication to radiotherapy. Limb functioning was assessed with the Musculoskeletal Tumor Society (MSTS) scoring system. Seventeen patients (7 men, 10 women) with 19 tumors met the inclusion criteria. Mean age at diagnosis was 23.4 years. Follow-up (mean, 4.28 years) involved serial clinical examinations and magnetic resonance imaging of tumor sites. After surgery, the tumors were treated with brachytherapy (n = 6), EBRT (n = 10), or both (n = 3). Two of the 17 tumors in patients with negative margins of resection recurred locally (local control rate, 88.2%). Mean MSTS score was 29/30 (96.7%). The role of surgery, radiotherapy, chemotherapy, hormone therapy, and other treatments for extra-abdominal desmoid tumors is not well defined. When wide-margin resection and radiotherapy can be performed with limb preservation surgery, local control and complication rates compare favorably with those of other reported methods of treatment. Given the results and limitations of our study, we cannot make a definitive recommendation as to which modality--brachytherapy or EBRT--should be used in the treatment of extra-abdominal desmoid tumors.

Clinical outcomes of Kyocera Modular Limb Salvage system after resection of bone sarcoma of the distal part of the femur: the Japanese Musculoskeletal Oncology Group study.

PubMed

Nakamura, Tomoki; Matsumine, Akihiko; Uchida, Atsumasa; Kawai, Akira; Nishida, Yoshihiro; Kunisada, Toshiyuki; Araki, Nobuhito; Sugiura, Hideshi; Tomita, Masato; Yokouchi, Masahiro; Ueda, Takafumi; Sudo, Akihiro

2014-04-01

The Japanese Musculoskeletal Oncology Group have developed an original prosthesis called the Kyocera Modular Limb Salvage system (KMLS system). This prosthesis has a semi-rotating hinge joint and is particularly designed for people with an Asian body type. The metallic parts of the prosthesis are made entirely of titanium alloy. The purpose of this study is to evaluate the clinical outcomes of treatment using this system following tumour resection of primary bone sarcoma of the distal femur. Between 2002 and 2010, 82 patients with primary bone sarcomas of the distal femur were treated. Seventeen patients underwent stem cementation, while 65 patients were treated with cementless prostheses. The mean follow-up period after surgery was 61 months. Complications were observed in 28 of the 82 patients. Forty-one complications occurred in these 28 patients. Thirteen prostheses (16%) required revision surgery due to complications, including five cases of stem breakage, three deep infections, three cases of aseptic loosening, one case of displacement of the shaft cap and one case of breakage of the tibial tray. The five-year overall prosthetic survival rate was 80.0%. Four of the 82 patients underwent subsequent amputation due to local recurrence. The five-year limb salvage rate was 94.5%. The mean function score according to the scoring system of the Musculoskeletal Tumour Society was 21.8 points (72.5%). Although further follow-up is required to determine the performance, this prosthesis is considered to be satisfactory for reconstruction of the distal femur after resection of bone sarcoma.

Parenchyma-sparing pancreatectomy for presumed noninvasive intraductal papillary mucinous neoplasms of the pancreas.

PubMed

Sauvanet, Alain; Gaujoux, Sébastien; Blanc, Benjamin; Couvelard, Anne; Dokmak, Safi; Vullierme, Marie-Pierre; Ruszniewski, Philippe; Belghiti, Jacques; Lévy, Philippe

2014-08-01

To assess the feasibility and outcomes of parenchyma-sparing pancreatectomy (PSP), including enucleation (EN), resection of uncinate process (RUP), and central pancreatectomy (CP), as an alternative to standard pancreatectomy for presumed noninvasive intraductal papillary and mucinous neoplasms (IPMNs). Pancreaticoduodenectomy and distal pancreatectomy are associated with significant perioperative morbidity, a substantial risk of pancreatic insufficiency, and may overtreat noninvasive IPMNs. From 1999 to 2011, PSP was attempted in 91 patients with presumed noninvasive IPMNs, after complete preoperative work-up including computed tomography, magnetic resonance imaging, and endoscopic ultrasonography. Intraoperative frozen section examination was routinely performed to assess surgical margins and rule out invasive malignancy. Follow-up included clinical, biochemical, and radiological assessments. Overall PSP was achieved with a feasibility rate of 89% (n = 81), including 44 ENs, 5 RUPs, and 32 CPs. Postoperative mortality rate was 1.3% (n = 1), and overall morbidity was noteworthy (61%; n = 47). Definitive pathological examination confirmed IPMN diagnosis in 95% of patients (n = 77), all except 2 (3%), without invasive component. After a median follow-up of 50 months, both pancreatic endocrine/exocrine functions were preserved in 92% of patients. Ten-year progression-free survival was 76%, and reoperation for recurrence was required in 4% of patients (n = 3). In selected patients, PSP for presumed noninvasive IPMN in experienced hands is highly feasible and avoids inappropriate standard resections for IPMN-mimicking lesions. Early morbidity is greater than that after standard resections but counterbalanced by preservation of pancreatic endocrine/exocrine functions and a low rate of reoperation for tumor recurrence.

[Resection of the Distal Part of the Gastric Tube for the Gastric Tube Cancer after Esophagectomy - A Case Report].

PubMed

Makutani, Yusuke; Shiraishi, Osamu; Iwama, Mitsuru; Hiraki, Yoko; Kato, Hiroaki; Yasuda, Atsushi; Shinkai, Masayuki; Imano, Motohiro; Kimura, Yutaka; Imamoto, Haruhiko; Yasuda, Takushi

2017-11-01

A 76-year-old man was admitted to our hospital for treatment of gastric tube cancer(cT2N0M0, cStage II A)detected by a screening upper gastrointestinal endoscopy. Seven years previously, he had undergone subtotal esophagectomy for esophageal cancer with gastric pull-up via the retrosternal route. At that time, he experienced cardiopulmonary arrest due to ventric- ular tachycardia. He was in a state of poor nutrition(BMI 15 kg/m2). Therefore, reducing operative stress as much as possible, minimizing complications after surgery, and aiming for a satisfactory postoperative course are all important goals. Based on his past history, we performed distal gastrectomy(resection of the distal part of the gastric tube)without excision of the right gastroepiploic artery. The postoperative course was uneventful. He was discharged 40 days after surgery. By considering the risks of surgery due to cardiac dysfunction and malnutrition, we were able to provide effective and safe therapy for the patient.

Combined Endoscopic-Radiological Rendezvous for Distal Tail Postoperative Pancreatic Fistula (POPF)

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lucatelli, Pierleone, E-mail: pierleone.lucatelli@gmail.com; Sacconi, Beatrice, E-mail: beatrice.sacconi@fastwebnet.it; Cereatti, Fabrizio, E-mail: fcereatti@yahoo.com

Postoperative pancreatic fistula (POPF) with leakage of pancreatic juice is a rare, severe complication following pancreatic resection or, less commonly, splenectomy. Definitive treatment can require multidisciplinary approaches. We report a case of stenosis of the main pancreatic duct with distal tail GRADE C POPF, occurred after splenectomy for Hodgkin lymphoma, successfully treated with combined radiological-endoscopic approach.

Successful Resection of a Growing Distal Medial Lenticulostriate Artery Pseudoaneurysm Presenting with Isolated Intraventricular Hemorrhage.

PubMed

Sato, Yosuke; Ando, Kazuhiro; Kawaguchi, Makoto; Kakinuma, Kenichi

2017-10-01

Distal medial lenticulostriate artery (LSA) aneurysms associated with isolated intraventricular hemorrhage (IVH) are extremely rare. We report a very rare case of the isolated IVH due to the rupture of the distal medial LSA pseudoaneurysm that was not visible at the initial angiography but later emerged and grew. A 61-year-old woman with a history of hypertension had sudden onset of severe headache and mild consciousness disturbance. The computed tomography scan revealed the IVH, but the initial angiographies showed no evidence of aneurysm. The follow-up magnetic resonance imaging revealed that an intraventricular mass, arising from the right distal medial LSA, emerged and grew into the right anterior horn. Considering the risk of rebleeding, we resected the mass lesion via the transsulcal transventricular approach. The postoperative imaging showed complete obliteration of the mass lesion. Histopathological analysis indicated the pseudoaneurysm. The patient was discharged without any neurological deficit. The careful and repetitive follow-up imaging should be done in the cases with isolated IVH even if the initial image evaluations are unrevealing. The transsulcal transventricular approach can be the most minimally invasive surgical option for intraventricular lesion. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Periosteal pseudotumor in complex total knee arthroplasty resembling a neoplastic process.

PubMed

Chowdhry, Madhav; Dipane, Matthew V; McPherson, Edward J

2018-05-18

This case report describes in detail an erosive distal diaphyseal pseudotumor that occurred 6 years after a complex endoprosthetic hinge total knee arthroplasty (TKA). A female patient had conversion of a knee fusion to an endoprosthetic hinge TKA at the age of 62. At her scheduled 6-year follow-up, she presented with mild distal thigh pain and radiographs showing a 6-7 cm erosive lytic diaphyseal lesion that looked very suspicious for a neoplastic process. An en bloc resection of the distal femur and femoral endoprosthesis was performed. Histologic review showed the mass to be a pseudotumor with the wear debris emanating from within the femoral canal due to distal stem loosening. We deduce that mechanized stem abrasion created microscopic titanium alloy particles that escaped via a small diaphyseal crack and stimulated an inflammatory response resulting in a periosteal erosive pseudotumor. The main lesson of this report is that, in the face of a joint replacement surgery of the knee, pseudotumor formation is a more likely diagnosis than a neoplastic process when encountering an expanding bony mass. Thus, a biopsy prior to en bloc resection, would be our recommended course of action any time a suspicious mass is encountered close to a TKA.

The Prognostic Value of Varying Definitions of Positive Resection Margin in Patients with Colorectal Cancer Liver Metastases.

PubMed

Wang, Jane; Margonis, Georgios Antonios; Amini, Neda; Andreatos, Nikolaos; Yuan, Chunhui; Damaskos, Christos; Antoniou, Efstathios; Garmpis, Nikolaos; Buettner, Stefan; Barbon, Carlotta; Deshwar, Amar; He, Jin; Burkhart, Richard; Pawlik, Timothy M; Wolfgang, Christopher L; Weiss, Matthew J

2018-04-09

Varying definitions of resection margin clearance are currently employed among patients with colorectal cancer liver metastases (CRLM). Specifically, a microscopically positive margin (R1) has alternatively been equated with an involved margin (margin width = 0 mm) or a margin width < 1 mm. Consequently, patients with a margin width of 0-1 mm (sub-mm) are inconsistently classified in either the R0 or R1 categories, thus obscuring the prognostic implications of sub-mm margins. Six hundred thirty-three patients who underwent resection of CRLM were identified. Both R1 definitions were alternatively employed and multivariable analysis was used to determine the predictive power of each definition, as well as the prognostic implications of a sub-mm margin. Five hundred thirty-nine (85.2%) patients had a margin width ≥ 1 mm, 42 had a sub-mm margin width, and 52 had an involved margin (0 mm). A margin width ≥ 1 mm was associated with improved survival vs. a sub-mm margin (65 vs. 36 months; P = 0.03) or an involved margin (65 vs. 33 months; P < 0.001). No significant difference in survival was detected between patients with involved vs. sub-mm margins (P = 0.31). A sub-mm margin and an involved margin were both independent predictors of worse OS (HR 1.66, 1.04-2.67; P = 0.04, and HR 2.14, 1.46-3.16; P < 0.001, respectively) in multivariable analysis. Importantly, after combining the two definitions, patients with either an involved margin or a sub-mm margin were associated with worse OS in multivariable analysis (HR 1.94, 1.41-2.65; P < 0.001). Patients with involved or sub-mm margins demonstrated a similar inferior OS vs. patients with a margin width > 1 mm. Consequently, a uniform definition of R1 as a margin width < 1 mm should perhaps be employed by future studies.

Impact of using different four-dimensional computed tomography data sets to design proton treatment plans for distal esophageal cancer.

PubMed

Pan, Xiaoning; Zhang, Xiaodong; Li, Yupeng; Mohan, Radhe; Liao, Zhongxing

2009-02-01

To study the impact of selecting different data sets from four-dimensional computed tomography (4D CT) imaging during proton treatment planning in patients with distal esophageal cancer. We examined the effects of changes in 4D CT data set and smearing margins in proton treatment planning for 5 patients with distal esophageal cancer whose diaphragms were in the beam path and could move several centimeters during respiration. Planning strategies based on (1) average, (2) inspiration, and (3) expiration CT were evaluated in terms of their coverage on the internal clinic target volume (ICTV) at the prescribed dose. For Strategy 1, increasing the smearing margin caused an increase in the ICTV prescription dose coverage (PDC) at the end-exhalation phase for all patients, whereas the ICTV PDC decreased for some patients at the end-inhalation phase. For Strategy 2, a smearing margin in the range of 1.0 to 3.5 cm caused the ICTV PDC to remain essentially unchanged, regardless of which phase of 4D CT was used for dose calculation, for all patients. For Strategy 3, the ICTV coverage was adequate for 2 of the 5 patients when a smearing margin of less than 1.0 cm was used, but was not adequate for the other 3 patients regardless of the smearing margin. Using the inspiration CT plus a smearing margin can lead to adequate ICTV coverage in treatment plans for patients with distal esophageal tumors surrounded by tissue that is subject to large changes in density during a proton treatment.

Fluorescence-guided resection of intracranial VX2 tumor in a preclinical model using 5-aminolevulinic acid (ALA): preliminary results

NASA Astrophysics Data System (ADS)

Bogaards, Arjen; Varma, Abhay; Moriyama, Eduardo H.; Lin, Annie; Giles, Anoja; Bisland, Stuart K.; Lilge, Lothar D.; Bilbao, G. M.; Muller, Paul J.; Wilson, Brian C.

2003-06-01

Fluorescence-guided brain tumor resection may help the neurosurgeon to identify tumor margins that merge imperceptibly into the normal brain tissue and are difficult to identify under white light illumination even using an operating microscope. We compared the amount of residual tumor after white light resection using an operating microscope versus that after fluorescnece-guided resection of an intracranial VX2 tumor in a preclinical model using our previously developed co-axial fluorscence imaging and spectroscopy system, exciting and detecting PpIX fluorescence at 405nm and 635nm respectively. Preliminary results: No fluorescence was present in 3 non-tumor-bearing animals. Fluorescence was present in all 15 tumor-bearing animals after white light resection was completed. To date in 4 rabbits, a decrease in residual tumor was found when using additional fluorescence guided resection compared to white light resection only. Conclusions: ALA induced PpIX fluorescence detects tumor margins not seen under an operation microscope using while light. Using fluorescence imaging to guide tumor resection resulted in a 3-fold decrease in the amount of residual timor. However, these preliminary results indicate that also an additional amount of normal brain is resected, which will be further investigated.

Determination of safe margin in the surgical pathologic specimens of non-small cell carcinoma of the lung.

PubMed

Feizi, Iraj; Sokouti, Mohsen; Golzari, Samad E J; Gojazede, Morteza; Farahnak, Mohammad Reza; Hashemzadeh, Shahriar; Rahimi-Rad, Mohammad Hossein

2013-01-01

Local recurrences of the tumor at the surgical margin are serious problems in pulmonary resections for lung cancer. The aim of this study is to determine the involved margins and safe distances of the resection sites from tumor for prevention of local recurrences. In this prospective study, 66 patients operated for non-small cell lung carcinoma (NSCLC) from Jan 2006 to Sep 2008 were evaluated. After performing pulmonary resections, multiple biopsies were taken up from 5 mm (A), 10 mm (B), 15 mm (C), and 20 mm (D) distance from tumor. The specimens were studied histopathologically. From a total of66 patients with NSCLC admitted to our referral hospital, 25 (38%) had adenocarcinoma, 18 (27.3%) squamous cell carcinoma, 5 (7.5%) large cell carcinoma, 4 (6%) bronchoalveolar cell carcinoma, 4 (6%) adenoid cystic carcinoma, 3 (4.6%) malignant carcinoid tumor and 7 (10.6%) had metastasis. The most common symptoms were dyspnea and cough. Histopathologically tumor positive margins were found in 84.8% (A), 10.6% (B), 4.5% (C), and 0% (D). There was a significant statistically difference between tumor involvement at distances 5 mm (A) versus 10-20 mm (B-D) (P <0.001). A 20 mm distance from the gross tumor is considered as a safe surgical margin in any type of malignant pulmonary resections for prevention of local surgical recurrences if there was no pathologic examination before surgery.

Redefining the Positive Margin in Pancreatic Cancer: Impact on Patterns of Failure, Long-Term Survival and Adjuvant Therapy.

PubMed

Osipov, Arsen; Nissen, Nicholas; Rutgers, Joanne; Dhall, Deepti; Naziri, Jason; Chopra, Shefali; Li, Quanlin; Hendifar, Andrew Eugene; Tuli, Richard

2017-11-01

There is debate regarding the definition and clinical significance of margin clearance in pancreatic ductal adenocarcinoma (PDA). A comprehensive archival analysis of surgical resection margins was performed to determine the effect on locoregional recurrence and survival, and the impact of adjuvant therapy in PDA. We identified 105 patients with resected PDA. Pancreatic, anterior, bile duct, and posterior surgical resection margins (PM; posterior surface, uncinate and vascular groove) were identified. Three pathologists reviewed all archival surgical specimens and recategorized each margin as tumor at ink/transected, <0.5, 0.5-1, >1-2, or >2 mm from the inked surface. The impact of these and other clinical variables was assessed on local control, disease-free survival (DFS), and overall survival (OS). Among all margins, PM clearance up to 2 mm was prognostic of DFS (p = 0.01) and OS (p = 0.01). Dichotomizing the PM at 2 mm revealed it to be an independent predictor of local recurrence-free survival [hazard ratio HR] 0.20, 95% confidence interval [CI] 0.048-0.881, p = 0.033), DFS (HR 0.46, 95% CI 0.22-0.96, p = 0.03), and OS (HR 0.31, 95% CI 0.14-0.74, p = 0.008). A margin status of >2 mm was also prognostic of OS in patients who received adjuvant chemotherapy (HR 0.31, 95% CI 0.11-0.89, p = 0.03), however this difference was mitigated in patients receiving adjuvant chemoradiotherapy (HR 0.40, 95% CI 0.10-1.58, p = 0.19). These data highlight the clinical significance of the PM and the lack of significance of other resection margins. Clearance in excess of 2 mm should be considered to improve long-term clinical outcomes. The use of adjuvant radiotherapy should be strongly considered in patients with PMs <2 mm.

Aggressive resection at the infiltrative margins of glioblastoma facilitated by intraoperative fluorescein guidance.

PubMed

Neira, Justin A; Ung, Timothy H; Sims, Jennifer S; Malone, Hani R; Chow, Daniel S; Samanamud, Jorge L; Zanazzi, George J; Guo, Xiaotao; Bowden, Stephen G; Zhao, Binsheng; Sheth, Sameer A; McKhann, Guy M; Sisti, Michael B; Canoll, Peter; D'Amico, Randy S; Bruce, Jeffrey N

2017-07-01

OBJECTIVE Extent of resection is an important prognostic factor in patients undergoing surgery for glioblastoma (GBM). Recent evidence suggests that intravenously administered fluorescein sodium associates with tumor tissue, facilitating safe maximal resection of GBM. In this study, the authors evaluate the safety and utility of intraoperative fluorescein guidance for the prediction of histopathological alteration both in the contrast-enhancing (CE) regions, where this relationship has been established, and into the non-CE (NCE), diffusely infiltrated margins. METHODS Thirty-two patients received fluorescein sodium (3 mg/kg) intravenously prior to resection. Fluorescence was intraoperatively visualized using a Zeiss Pentero surgical microscope equipped with a YELLOW 560 filter. Stereotactically localized biopsy specimens were acquired from CE and NCE regions based on preoperative MRI in conjunction with neuronavigation. The fluorescence intensity of these specimens was subjectively classified in real time with subsequent quantitative image analysis, histopathological evaluation of localized biopsy specimens, and radiological volumetric assessment of the extent of resection. RESULTS Bright fluorescence was observed in all GBMs and localized to the CE regions and portions of the NCE margins of the tumors, thus serving as a visual guide during resection. Gross-total resection (GTR) was achieved in 84% of the patients with an average resected volume of 95%, and this rate was higher among patients for whom GTR was the surgical goal (GTR achieved in 93.1% of patients, average resected volume of 99.7%). Intraoperative fluorescein staining correlated with histopathological alteration in both CE and NCE regions, with positive predictive values by subjective fluorescence evaluation greater than 96% in NCE regions. CONCLUSIONS Intraoperative administration of fluorescein provides an easily visualized marker for glioma pathology in both CE and NCE regions of GBM. These findings support the use of fluorescein as a microsurgical adjunct for guiding GBM resection to facilitate safe maximal removal.

Laparoscopic repair of indirect inguinal hernia in children: does partial resection of the sac make any impact on outcome?

PubMed

Borkar, Nitinkumar B; Pant, Nitin; Ratan, Simmi; Aggarwal, Satish K

2012-04-01

To test the hypothesis that during laparoscopic hernia repair, partial resection of the distal sac along with suture ligation of the neck is better than simple transection and ligation. The following two techniques of laparoscopic hernia repair were compared: Group I, circumferential incision of peritoneum at the deep ring and partial resection of the distal sac and suture ligation at the neck; versus Group II, circumferential incision of the peritoneum at the deep ring and suture ligation at the neck. Twenty-five cases of inguinal hernia were randomly selected in each group between the age group of 6 months to 12 years. The outcome measures were recurrence, intra- or postoperative complications, and time taken for surgery. There were no recurrences in either group. Other parameters for comparison were also not statistically different between the two groups. There was no conversion. Although partial resection of the sac has been an essential step in open hernia repair over five decades, its value has been questioned by our study, because omitting this step during laparoscopic repair has not adversely affected the outcomes. Partial resection of the sac is not a necessary component of hernia repair. It is a technical necessity of the open approach. Therefore, omitting this step in laparoscopic repair does not adversely affect the outcome.

Augmented reality in bone tumour resection: An experimental study.

PubMed

Cho, H S; Park, Y K; Gupta, S; Yoon, C; Han, I; Kim, H-S; Choi, H; Hong, J

2017-03-01

We evaluated the accuracy of augmented reality (AR)-based navigation assistance through simulation of bone tumours in a pig femur model. We developed an AR-based navigation system for bone tumour resection, which could be used on a tablet PC. To simulate a bone tumour in the pig femur, a cortical window was made in the diaphysis and bone cement was inserted. A total of 133 pig femurs were used and tumour resection was simulated with AR-assisted resection (164 resection in 82 femurs, half by an orthropaedic oncology expert and half by an orthopaedic resident) and resection with the conventional method (82 resection in 41 femurs). In the conventional group, resection was performed after measuring the distance from the edge of the condyle to the expected resection margin with a ruler as per routine clinical practice. The mean error of 164 resections in 82 femurs in the AR group was 1.71 mm (0 to 6). The mean error of 82 resections in 41 femurs in the conventional resection group was 2.64 mm (0 to 11) (p < 0.05, one-way analysis of variance). The probabilities of a surgeon obtaining a 10 mm surgical margin with a 3 mm tolerance were 90.2% in AR-assisted resections, and 70.7% in conventional resections. We demonstrated that the accuracy of tumour resection was satisfactory with the help of the AR navigation system, with the tumour shown as a virtual template. In addition, this concept made the navigation system simple and available without additional cost or time. Cite this article: H. S. Cho, Y. K. Park, S. Gupta, C. Yoon, I. Han, H-S. Kim, H. Choi, J. Hong. Augmented reality in bone tumour resection: An experimental study. Bone Joint Res 2017;6:137-143. © 2017 Cho et al.

Augmented reality in bone tumour resection

PubMed Central

Park, Y. K.; Gupta, S.; Yoon, C.; Han, I.; Kim, H-S.; Choi, H.; Hong, J.

2017-01-01

Objectives We evaluated the accuracy of augmented reality (AR)-based navigation assistance through simulation of bone tumours in a pig femur model. Methods We developed an AR-based navigation system for bone tumour resection, which could be used on a tablet PC. To simulate a bone tumour in the pig femur, a cortical window was made in the diaphysis and bone cement was inserted. A total of 133 pig femurs were used and tumour resection was simulated with AR-assisted resection (164 resection in 82 femurs, half by an orthropaedic oncology expert and half by an orthopaedic resident) and resection with the conventional method (82 resection in 41 femurs). In the conventional group, resection was performed after measuring the distance from the edge of the condyle to the expected resection margin with a ruler as per routine clinical practice. Results The mean error of 164 resections in 82 femurs in the AR group was 1.71 mm (0 to 6). The mean error of 82 resections in 41 femurs in the conventional resection group was 2.64 mm (0 to 11) (p < 0.05, one-way analysis of variance). The probabilities of a surgeon obtaining a 10 mm surgical margin with a 3 mm tolerance were 90.2% in AR-assisted resections, and 70.7% in conventional resections. Conclusion We demonstrated that the accuracy of tumour resection was satisfactory with the help of the AR navigation system, with the tumour shown as a virtual template. In addition, this concept made the navigation system simple and available without additional cost or time. Cite this article: H. S. Cho, Y. K. Park, S. Gupta, C. Yoon, I. Han, H-S. Kim, H. Choi, J. Hong. Augmented reality in bone tumour resection: An experimental study. Bone Joint Res 2017;6:137–143. PMID:28258117

Evaluation of intraoperative fluorescence imaging-guided surgery in cancer-bearing dogs: a prospective proof-of-concept phase II study in 9 cases.

PubMed

Cabon, Quentin; Sayag, David; Texier, Isabelle; Navarro, Fabrice; Boisgard, Raphaël; Virieux-Watrelot, Dorothée; Ponce, Frédérique; Carozzo, Claude

2016-04-01

The objective was to prospectively evaluate the application of intraoperative fluorescence imaging (IOFI) in the surgical excision of malignant masses in dogs, using a novel lipid nanoparticle contrast agent. Dogs presenting with spontaneous soft-tissue sarcoma or subcutaneous tumors were prospectively enrolled. Clinical staging and whole-body computed tomography (CT) were performed. All the dogs received an intravenous injection of dye-loaded lipid nanoparticles, LipImage 815. Wide or radical resection was realized after CT examination. Real-time IOFI was performed before skin incision and after tumor excision. In cases of radical resection, the lymph nodes (LNs) were imaged. The margin/healthy tissues fluorescence ratio or LN/healthy tissues fluorescence ratio was measured and compared with the histologic margins or LN status. Nine dogs were included. Limb amputation was performed in 3 dogs, and wide resection in 6. No adverse effect was noted. Fluorescence was observed in all 9 of the tumors. The margins were clean in 5 of 6 dogs after wide surgical resection, and the margin/healthy tissues fluorescence ratio was close to 1.0 in all these dogs. Infiltrated margins were observed in 1 case, with a margin/healthy tissues fluorescence ratio of 3.2. Metastasis was confirmed in 2 of 3 LNs, associated with LN/healthy tissues fluorescence ratios of 2.1 and 4.2, whereas nonmetastatic LN was associated with a ratio of 1.0. LipImage 815 used as a contrast agent during IOFI seemed to allow for good discrimination between tumoral and healthy tissues. Future studies are scheduled to evaluate the sensitivity and specificity of IOFI using LipImage 815 as a tracer. Copyright © 2016 Elsevier Inc. All rights reserved.

Risk factors and management of positive horizontal margin in early gastric cancer resected by en bloc endoscopic submucosal dissection.

PubMed

Numata, Norifumi; Oka, Shiro; Tanaka, Shinji; Kagemoto, Kenichi; Sanomura, Yoji; Yoshida, Shigeto; Arihiro, Koji; Shimamoto, Fumio; Chayama, Kazuaki

2015-04-01

Although endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric cancer (EGC), there is no consensus regarding the management of positive horizontal margin (HM) despite en bloc ESD. The aim of the current study was to identify the risk factors and optimal management of positive HM in EGCs resected by en bloc ESD. A total of 890 consecutive patients with 1,053 intramucosal EGCs resected by en bloc ESD between April 2005 and June 2011. Clinicopathological data were retrieved retrospectively to assess the positive HM rate, local recurrence rate, risk factors for positive HM, and outcomes of treatment for local recurrent tumor. Positive HM was defined as a margin with direct tumor invasion (type A), the presence of cancerous cells on either end of 2-mm-thick cut sections (type B), or an unclear tumor margin resulting from crush or burn damage (type C). The positive HM rate was 2.0% (21/1,053). The local recurrence rate was 0.3% (3/1,053). All local recurrent tumors were intramucosal carcinomas, and were resected curatively by re-ESD. Multivariate analysis with logistic regression showed tumor location in the upper third of the stomach and lesions not matching the absolute indication to be independent risk factors for positive HM. The risk factors for HM positivity in cases of EGC resected by en bloc ESD are tumor location in the upper third of the stomach and dissatisfaction of the absolute indication for curative ESD.

Study Suggests Smaller Melanoma Excision Margins May Be Option for Some Patients

Cancer.gov

A randomized controlled trial of patients with stage IIA–C cutaneous melanoma thicker than 2-mm found that a 2-cm surgical resection margin is sufficient and is as safe for patients as a 4-cm margin.

Impact of Using Different Four-Dimensional Computed Tomography Data Sets to Design Proton Treatment Plans for Distal Esophageal Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pan Xiaoning; Zhang Xiaodong; Li Yupeng

2009-02-01

Purpose: To study the impact of selecting different data sets from four-dimensional computed tomography (4D CT) imaging during proton treatment planning in patients with distal esophageal cancer. Methods and Materials: We examined the effects of changes in 4D CT data set and smearing margins in proton treatment planning for 5 patients with distal esophageal cancer whose diaphragms were in the beam path and could move several centimeters during respiration. Planning strategies based on (1) average, (2) inspiration, and (3) expiration CT were evaluated in terms of their coverage on the internal clinic target volume (ICTV) at the prescribed dose. Results:more » For Strategy 1, increasing the smearing margin caused an increase in the ICTV prescription dose coverage (PDC) at the end-exhalation phase for all patients, whereas the ICTV PDC decreased for some patients at the end-inhalation phase. For Strategy 2, a smearing margin in the range of 1.0 to 3.5 cm caused the ICTV PDC to remain essentially unchanged, regardless of which phase of 4D CT was used for dose calculation, for all patients. For Strategy 3, the ICTV coverage was adequate for 2 of the 5 patients when a smearing margin of less than 1.0 cm was used, but was not adequate for the other 3 patients regardless of the smearing margin. Conclusion: Using the inspiration CT plus a smearing margin can lead to adequate ICTV coverage in treatment plans for patients with distal esophageal tumors surrounded by tissue that is subject to large changes in density during a proton treatment.« less

Multicenter study of outcome in relation to the type of resection in rectal cancer.

PubMed

Ortiz, Hector; Wibe, Arne; Ciga, Miguel Angel; Kreisler, Esther; Garcia-Granero, Eduardo; Roig, Jose Vicente; Biondo, Sebastiano

2014-07-01

A surgical teaching and auditing program has been implemented to improve the results of treatment for patients with rectal cancer. The aim of this study was to assess the treatment and outcome in patients resected for rectal cancer, focusing on differences relating to the type of resection. This was an observational study. The study took place throughout the network of hospitals that compose the National Health Service in Spain. This study included a consecutive cohort of 3355 patients from the Spanish Rectal Cancer Project. The data of patients who were operated on electively, with curative intent, by anterior resection (n = 2333 [69.5%]), abdominoperineal excision (n = 774 [23.1%]), and Hartmann procedure (n = 248 [7.4%]) between March 2006 and May 2010 were analyzed. Clinical, pathologic, and outcome results were analyzed in relation to the type of surgery performed. After a median follow-up time of 37 months (interquartile range, 30-48 months), bowel perforations were found to be more common in the Hartmann procedure (12.6%) and abdominoperineal groups (10.1%) than in the anterior resection group (2.3%; p < 0.001). Involvement of the circumferential resection margin was also more common in the Hartmann (16.6%) and abdominoperineal groups (14.3%) than in the anterior resection group (6.6%; p < 0.001). Multivariate analysis showed a negative influence on local recurrence, metastasis, survival for advanced stage, intraoperative perforation, invaded circumferential margin, and Hartmann procedure. However, abdominoperineal excision did not significantly influence local recurrence (HR, 0.945; 95% CI, 0.571-1.563; p = 0.825). The main weakness of this study was the voluntary nature of registration in the Spanish Rectal Cancer Project. Although bowel perforation and involvement of the circumferential resection margin were more common after abdominoperineal excision than after anterior resection, this study did not identify abdominoperineal excision as a determinant of local recurrence in the context of 3 years of median follow-up.

Laparoscopic resection of hilar cholangiocarcinoma.

PubMed

Lee, Woohyung; Han, Ho-Seong; Yoon, Yoo-Seok; Cho, Jai Young; Choi, YoungRok; Shin, Hong Kyung; Jang, Jae Yool; Choi, Hanlim

2015-10-01

Laparoscopic resection of hilar cholangiocarcinoma is technically challenging because it involves complicated laparoscopic procedures that include laparoscopic hepatoduodenal lymphadenectomy, hemihepatectomy with caudate lobectomy, and hepaticojejunostomy. There are currently very few reports describing this type of surgery. Between August 2014 and December 2014, 5 patients underwent total laparoscopic or laparoscopic-assisted surgery for hilar cholangiocarcinoma. Two patients with type I or II hilar cholangiocarcinoma underwent radical hilar resection. Three patients with type IIIa or IIIb cholangiocarcinoma underwent extended hemihepatectomy together with caudate lobectomy. The median (range) age, operation time, blood loss, and length of hospital stay were 63 years (43-76 years), 610 minutes (410-665 minutes), 650 mL (450-1,300 mL), and 12 days (9-21 days), respectively. Four patients had a negative margin, but 1 patient was diagnosed with high-grade dysplasia on the proximal resection margin. The median tumor size was 3.0 cm. One patient experienced postoperative biliary leakage, which resolved spontaneously. Laparoscopic resection is a feasible surgical approach in selected patients with hilar cholangiocarcinoma.

Differences in proximal (cardia) versus distal (antral) gastric carcinogenesis via retinoblastoma pathway

PubMed Central

Gulmann, Christian; Hegarty, Helen; Grace, Antoinette; Leader, Mary; Patchett, Stephen; Kay, Elaine

2004-01-01

AIM: Disruption of cell cycle regulation is a critical event in carcinogenesis, and alteration of the retinoblastoma (pRb) tumour suppressor pathway is frequent. The aim of this study was to compare alterations in this pathway in proximal and distal gastric carcinogenesis in an effort to explain the observed striking epidemiological differences. METHODS: Immunohistochemistry was performed to investigate expression of p16 and pRb in the following groups of both proximal (cardia) and distal (antral) tissue samples: (a) biopsies showing normal mucosa, (b) biopsies showing intestinal metaplasia and, (c) gastric cancer resection specimens including uninvolved mucosa and tumour. RESULTS: In the antrum there were highly significant trends for increased p16 expression with concomitant (and in the group of carcinomas inversely proportional) decreased pRb expression from normal mucosa to intestinal metaplasia to uninvolved mucosa (from cancer resections) to carcinoma. In the cardia, there were no differences in p16 expression between the various types of tissue samples whereas pRb expression was higher in normal mucosa compared with intestinal metaplasia and tissue from cancer resections. CONCLUSION: Alterations in the pRb pathway appear to play a more significant role in distal gastric carcinogenesis. It may be an early event in the former location since the trend towards p16 overexpression with concomitant pRb underexpression was seen as early as between normal mucosa and intestinal metaplasia. Importantly, the marked differences in expression of pRb and p16 between the cardia and antrum strongly support the hypothesis that tumours of the two locations are genetically different which may account for some of the observed epidemiological differences. PMID:14695761

Biology of Adenoid Cystic Carcinoma of the Tracheobronchial Tree and Principles of Management.

PubMed

Maziak, Donna E

2018-05-01

Adenoid cystic carcinoma of the trachea is a rare tumor. The mainstay of treatment remains surgical resection, even in the presence of positive margins or metastatic disease. Perineural involvement commonly causes positive margins and should not deter from resection. Knowledge of releasing maneuvers is essential for surgical success. Long-term follow-up is required with patients presenting late and surviving with recurrent disease for years. Copyright © 2018 Elsevier Inc. All rights reserved.

[Trans-suture mechanical colorectal anastomosis using a double stapler in the anterior resection of the rectum. Technical note].

PubMed

Saviano, M S; Ricchi, E

1990-04-30

The spread of mechanical staplers now makes it possible to perform anastomoses in anterior resections of the rectum that are easier and safer than manual ones. Certain related problems are well known, particularly in patients with narrow pelvis and, in low anastomoses, the fashioning of the tobacco pouch on the distal rectal stump. The technique of transutural mechanical colorectal anastomosis with circular stapler after closure of the rectal stump with linear stapler is described in detail. Advantages of the technique are: anastomoses that are technically easier and safer because making of the tobacco pouch on the distal rectal stump is avoided; pollution of the operating field is reduced to the minimum; there are no problems related to differences in lumen of the colorectal stumps.

A quantitative microscopic approach to predict local recurrence based on in vivo intraoperative imaging of sarcoma tumor margins

PubMed Central

Mueller, Jenna L.; Fu, Henry L.; Mito, Jeffrey K.; Whitley, Melodi J.; Chitalia, Rhea; Erkanli, Alaattin; Dodd, Leslie; Cardona, Diana M.; Geradts, Joseph; Willett, Rebecca M.; Kirsch, David G.; Ramanujam, Nimmi

2015-01-01

The goal of resection of soft tissue sarcomas located in the extremity is to preserve limb function while completely excising the tumor with a margin of normal tissue. With surgery alone, one-third of patients with soft tissue sarcoma of the extremity will have local recurrence due to microscopic residual disease in the tumor bed. Currently, a limited number of intraoperative pathology-based techniques are used to assess margin status; however, few have been widely adopted due to sampling error and time constraints. To aid in intraoperative diagnosis, we developed a quantitative optical microscopy toolbox, which includes acriflavine staining, fluorescence microscopy, and analytic techniques called sparse component analysis and circle transform to yield quantitative diagnosis of tumor margins. A series of variables were quantified from images of resected primary sarcomas and used to optimize a multivariate model. The sensitivity and specificity for differentiating positive from negative ex vivo resected tumor margins was 82% and 75%. The utility of this approach was tested by imaging the in vivo tumor cavities from 34 mice after resection of a sarcoma with local recurrence as a bench mark. When applied prospectively to images from the tumor cavity, the sensitivity and specificity for differentiating local recurrence was 78% and 82%. For comparison, if pathology was used to predict local recurrence in this data set, it would achieve a sensitivity of 29% and a specificity of 71%. These results indicate a robust approach for detecting microscopic residual disease, which is an effective predictor of local recurrence. PMID:25994353

Partial nephrectomy for renal tumors: lack of correlation between margin status and local recurrence.

PubMed

Antic, Tatjana; Taxy, Jerome B

2015-05-01

To evaluate the relationship between a positive resection margin in partial nephrectomy (PN) and local recurrence. From January 2005 through December 2012, there were 473 PNs in 466 patients at the University of Chicago. A positive margin was defined as tumor extending to the inked specimen edge, either the parenchymal interface or the peripheral fibroadipose tissue. A local recurrence was defined as an ipsilateral tumor of identical histologic type. Renal cell carcinoma (RCC) accounted for 406 tumors: 243 clear cell RCCs (CRCCs), 77 papillary RCCs (PRCCs), and 47 chromophobe RCCs (CHRCCs). Sixty-one RCCs had positive margins: 43 CRCCs, six PRCCs, nine CHRCCs, and three miscellaneous cell types. Of the 61 positive margins, four CRCCs (all originally multifocal) had a local recurrence, two of which occurred in the same patient. One translocation RCC also recurred. Six cases with negative resection margins had a recurrence. A literature review of 3,803 cases, including our study, shows positive margins in 173, of which 13 recurred; however, 39 with negative margins also recurred. A positive margin in PN seldom correlates with a local recurrence. However, protection from recurrence is not ensured by a negative margin. Copyright© by the American Society for Clinical Pathology.

A new improved technique for placement of a pursestring suture on the edge of the distal part of the rectal stump using a skin stapler for low anterior resection.

PubMed

Kumashiro, R; Sano, C; Ugaeri, H; Madokoro, S; Maekawa, T; Kumamoto, M; Hideshima, T; Inutsuka, S

1994-04-01

Instead of a linear stapler or manual pursestring suture onto the lower part of the rectum, we placed a No. 2-0 Prolene suture on the edge of the rectal stump, using 12 to 16 clips and a disposable skin stapler. This technique is satisfactory for very low anterior resection.

Tectono-magmatic evolution at distal magma-poor rifted margins: insights of the lithospheric breakup at the Australia-Antarctica margins.

NASA Astrophysics Data System (ADS)

Gillard, Morgane; Autin, Julia; Manatschal, Gianreto

2015-04-01

The discovery of large domains of hyper-extended continental crust and exhumed mantle along many present-day magma-poor rifted margins questions the processes that play during the lithospheric breakup and the onset of seafloor spreading. In particular, the amount of magma and its relation to tectonic structures is yet little understood. Trying to find answers to these questions asks to work at the most distal parts of rifted margins where the transition from rifting to steady state seafloor spreading occurred. The Australian-Antarctic conjugated margins provide an excellent study area. Indeed, the central sector of the Great Australian Bight/Wilkes Land developed in a magma-poor probably ultra-slow setting and displays a complex and not yet well understood Ocean-Continent Transition (OCT). This distal area is well imaged by numerous high quality seismic lines covering the whole OCT and the steady-state oceanic crust. The deformation recorded in the sedimentary units along these margins highlights a migration of the deformation toward the ocean and a clear polyphase evolution. In particular, the observation that each tectono-sedimentary unit downlaps oceanwards onto the basement suggests that final rifting is associated with the creation of new depositional ground under conditions that are not yet those of a steady state oceanic crust. These observations lead to a model of evolution for these distal margins implying the development of multiple detachment systems organizing out-of-sequence, each new detachment fault developing into the previously exhumed basement. This spatial and temporal organization of fault systems leads to a final symmetry of exhumed domains at both conjugated margins. Magma appears to gradually increase during the margin development and is particularly present in the more distal domain where we can observe clear magma/fault interactions. We propose that the evolution of such rifted margins is linked to cycles of delocalisation/re-localisation of the deformation which could be mainly influenced by magma and by the decoupling between the upper brittle deformation and the asthenospheric uplift. In this context, the lithospheric breakup appears to be triggered by progressive syn-extensional thermal and magmatic weakening. However, the observation of continentward dipping reflectors interpreted as flip-flop detachment systems suggests that the localisation of the spreading centre and the onset of the steady state oceanic spreading will not be necessarily associated with a clear magmatic oceanic crust. In case of a low magmatic budget we can rather observe the onset of steady state amagmatic oceanic spreading, similar to what is expected at ultra-slow spreading ridges. This model of evolution (Gillard, 2014, PhD thesis) could well explain the fact that most magma-poor margins display symmetric exhumed domains on conjugate margins. However it raises the question of the nature of magnetic anomalies in ocean-continent transitions and their value for the interpretation of the kinematic evolution of conjugate rifted margins.

[Short-term efficacy of da Vinci robotic surgical system on rectal cancer in 101 patients].

PubMed

Zeng, Dong-Zhu; Shi, Yan; Lei, Xiao; Tang, Bo; Hao, Ying-Xue; Luo, Hua-Xing; Lan, Yuan-Zhi; Yu, Pei-Wu

2013-05-01

To investigate the feasibility and safety of da Vinci robotic surgical system in rectal cancer radical operation, and to summarize its short-term efficacy and clinical experience. Data of 101 cases undergoing da Vinci robotic surgical system for rectal cancer radical operation from March 2010 to September 2012 were retrospectively analyzed. Evaluation was focused on operative procedure, complication, recovery and pathology. All the 101 cases underwent operation successfully and safely without conversion to open procedure. Rectal cancer radical operation with da Vinci robotic surgical system included 73 low anterior resections and 28 abdominoperineal resections. The average operative time was (210.3±47.2) min. The average blood lose was (60.5±28.7) ml without transfusion. Lymphadenectomy harvest was 17.3±5.4. Passage of first flatus was (2.7±0.7) d. Distal margin was (5.3±2.3) cm without residual cancer cells. The complication rate was 6.9%, including anastomotic leakage(n=2), perineum incision infection(n=2), pulmonary infection (n=2), urinary retention (n=1). There was no postoperative death. The mean follow-up time was(12.9±8.0) months. No local recurrence was found except 2 cases with distant metastasis. Application of da Vinci robotic surgical system in rectal cancer radical operation is safe and patients recover quickly The short-term efficacy is satisfactory.

Primary malignant perivascular epithelioid cell neoplasm (PEComa) of the bone mimicking granular cell tumor in core biopsy: A case report and literature review

PubMed Central

Sadigh, Sam; Shah, Preya; Weber, Kristy; Sebro, Ronnie; Zhang, Paul J.

2018-01-01

The present study investigated the case of a 46-year-old female with primary malignant perivascular epithelioid cell neoplasm (PEComa) of the femur. The patient presented with a 5-month history of right distal thigh pain following trauma. Radiographs of the right distal femur revealed a mixed lytic and sclerotic lesion with subtle areas of cortical destruction and soft tissue extension, consistent with an aggressive tumor. A core biopsy revealed an epithelioid tumor with granular cell features, but a definitive diagnosis could not be made. Due to the aggressive features on radiologic evaluation, the patient underwent a resection of the distal femur and reconstruction with a distal femoral megaprosthesis and hinged knee replacement. The post-resection pathology led to a final diagnosis of primary bone PEComa, with histologic features including epithelioid, granular cell and spindled cell morphologies and biphasic immunoreactivity for melanocytic and smooth muscle markers. The large tumor size (>5 cm), rapid mitotic rate, infiltrative growth pattern, high nuclear grade and cellularity, and the presence of necrosis rendered this a malignant PEComa. The present study discussed the case, including radiographic (radiographs, magnetic resonance imaging and positron emission tomography scans) and histologic appearance and a literature review. PMID:29435023

Single-port plus an additional port robotic complete mesocolic excision and intracorporeal anastomosis using a robotic stapler for right-sided colon cancer

PubMed Central

Bae, Sung Uk; Jeong, Woon Kyung

2016-01-01

The concept of complete mesocolic excision and central vascular ligation for colonic cancer has been recently introduced. The paper describes a technique of right-sided complete mesocolic excision and intracorporeal anastomosis by using a single-port robotic approach with an additional conventional robotic port. We performed a single-port plus an additional port robotic surgery using the Da Vinci Single-Site platform via the Pfannenstiel incision and the wristed robotic instruments via an additional robotic port in the left lower quadrant. The total operative and docking times were 280 and 25 minutes, respectively. The total number of lymph nodes harvested was 36 and the proximal and distal resection margins were 31 and 50 cm, respectively. Single-port plus an additional port robotic surgery for right-sided complete mesocolic excision and intracorporeal anastomosis appears to be feasible and safe. This system can overcome certain limitations of the previous robotic systems and conventional single-port laparoscopic surgery. PMID:27757400

Single-port plus an additional port robotic complete mesocolic excision and intracorporeal anastomosis using a robotic stapler for right-sided colon cancer.

PubMed

Bae, Sung Uk; Jeong, Woon Kyung; Baek, Seong Kyu

2016-10-01

The concept of complete mesocolic excision and central vascular ligation for colonic cancer has been recently introduced. The paper describes a technique of right-sided complete mesocolic excision and intracorporeal anastomosis by using a single-port robotic approach with an additional conventional robotic port. We performed a single-port plus an additional port robotic surgery using the Da Vinci Single-Site platform via the Pfannenstiel incision and the wristed robotic instruments via an additional robotic port in the left lower quadrant. The total operative and docking times were 280 and 25 minutes, respectively. The total number of lymph nodes harvested was 36 and the proximal and distal resection margins were 31 and 50 cm, respectively. Single-port plus an additional port robotic surgery for right-sided complete mesocolic excision and intracorporeal anastomosis appears to be feasible and safe. This system can overcome certain limitations of the previous robotic systems and conventional single-port laparoscopic surgery.

Predictors of circumferential resection margin involvement in surgically resected rectal cancer: A retrospective review of 23,464 patients in the US National Cancer Database.

PubMed

Al-Sukhni, Eisar; Attwood, Kristopher; Gabriel, Emmanuel; Nurkin, Steven J

2016-04-01

The circumferential resection margin (CRM) is a key prognostic factor after rectal cancer resection. We sought to identify factors associated with CRM involvement (CRM+). A retrospective review was performed of the National Cancer Database, 2004-2011. Patients with rectal cancer who underwent radical resection and had a recorded CRM were included. Multivariable analysis of the association between clinicopathologic characteristics and CRM was performed. Tumor <1 mm from the cut margin defined CRM+. Of 23,464 eligible patients, 13.3% were CRM+. Factors associated with CRM+ were diagnosis later in the study period, lack of insurance, advanced stage, higher grade, undergoing APR, and receiving radiation. Nearly half of CRM+ patients did not receive neoadjuvant therapy. CRM+ patients who did not receive neoadjuvant therapy were more likely to be female, older, with more comorbidities, smaller tumors, earlier clinical stage, advanced pathologic stage, and CEA-negative disease compared to those who received it. Factors associated with CRM+ include features of advanced disease, undergoing APR, and lack of health insurance. Half of CRM+ patients did not receive neoadjuvant treatment. These represent cases where CRM status may be modifiable with appropriate pre-operative selection and multidisciplinary management. Copyright © 2016 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

Positron emission tomography and optical tissue imaging

DOEpatents

Falen, Steven W [Carmichael, CA; Hoefer, Richard A [Newport News, VA; Majewski, Stanislaw [Yorktown, VA; McKisson, John [Hampton, VA; Kross, Brian [Yorktown, VA; Proffitt, James [Newport News, VA; Stolin, Alexander [Newport News, VA; Weisenberger, Andrew G [Yorktown, VA

2012-05-22

A mobile compact imaging system that combines both PET imaging and optical imaging into a single system which can be located in the operating room (OR) and provides faster feedback to determine if a tumor has been fully resected and if there are adequate surgical margins. While final confirmation is obtained from the pathology lab, such a device can reduce the total time necessary for the procedure and the number of iterations required to achieve satisfactory resection of a tumor with good margins.

Refining the 'cucumber' technique for laryngeal biopsy.

PubMed

Robertson, S; Cooper, L; McPhaden, A; MacKenzie, K

2011-06-01

To refine the case selection process for the 'cucumber' mounting system for laryngeal biopsies. We conducted a retrospective audit of cucumber technique specimens taken between January 2002 and December 2008. We analysed the clinical indications for biopsy and the pathological diagnosis, for each specimen, in order to inform our case selection process. The cucumber technique was used for 125 laryngeal specimens. 60 specimens were taken for diagnostic sampling, 46 were taken during endoscopic laser resection, and 19 for overtly benign pathology. The cucumber technique was most useful for the interpretation of margins in endoscopic laser resection specimens. The cucumber technique is most useful for endoscopic resection cases in which tumour, dysplasia or suspicious lesions have been excised. Detailed information on resection margins is invaluable during multidisciplinary team discussions on patient management. Detailed photography of mounted specimens enables both laryngologist and pathologist to orientate and interpret specimens accurately.

Effects of exogenous glucagon-like peptide-2 and distal bowel resection on intestinal and systemic adaptive responses in rats.

PubMed

Lai, Sarah W; de Heuvel, Elaine; Wallace, Laurie E; Hartmann, Bolette; Holst, Jens J; Brindle, Mary E; Chelikani, Prasanth K; Sigalet, David L

2017-01-01

To determine the effects of exogenous glucagon-like peptide-2 (GLP-2), with or without massive distal bowel resection, on adaptation of jejunal mucosa, enteric neurons, gut hormones and tissue reserves in rats. GLP-2 is a gut hormone known to be trophic for small bowel mucosa, and to mimic intestinal adaptation in short bowel syndrome (SBS). However, the effects of exogenous GLP-2 and SBS on enteric neurons are unclear. Sprague Dawley rats were randomized to four treatments: Transected Bowel (TB) (n = 8), TB + GLP-2 (2.5 nmol/kg/h, n = 8), SBS (n = 5), or SBS + GLP-2 (2.5 nmol/kg/h, n = 9). SBS groups underwent a 60% jejunoileal resection with cecectomy and jejunocolic anastomosis. All rats were maintained on parenteral nutrition for 7 d. Parameters measured included gut morphometry, qPCR for hexose transporter (SGLT-1, GLUT-2, GLUT-5) and GLP-2 receptor mRNA, whole mount immunohistochemistry for neurons (HuC/D, VIP, nNOS), plasma glucose, gut hormones, and body composition. Resection increased the proportion of nNOS immunopositive myenteric neurons, intestinal muscularis propria thickness and crypt cell proliferation, which were not recapitulated by GLP-2 therapy. Exogenous GLP-2 increased jejunal mucosal surface area without affecting enteric VIP or nNOS neuronal immunopositivity, attenuated resection-induced reductions in jejunal hexose transporter abundance (SGLT-1, GLUT-2), increased plasma amylin and decreased peptide YY concentrations. Exogenous GLP-2 attenuated resection-induced increases in blood glucose and body fat loss. Exogenous GLP-2 stimulates jejunal adaptation independent of enteric neuronal VIP or nNOS changes, and has divergent effects on plasma amylin and peptide YY concentrations. The novel ability of exogenous GLP-2 to modulate resection-induced changes in peripheral glucose and lipid reserves may be important in understanding the whole-body response following intestinal resection, and is worthy of further study.

Effects of exogenous glucagon-like peptide-2 and distal bowel resection on intestinal and systemic adaptive responses in rats

PubMed Central

de Heuvel, Elaine; Wallace, Laurie E.; Hartmann, Bolette; Holst, Jens J.; Brindle, Mary E.; Chelikani, Prasanth K.; Sigalet, David L.

2017-01-01

Objective To determine the effects of exogenous glucagon-like peptide-2 (GLP-2), with or without massive distal bowel resection, on adaptation of jejunal mucosa, enteric neurons, gut hormones and tissue reserves in rats. Background GLP-2 is a gut hormone known to be trophic for small bowel mucosa, and to mimic intestinal adaptation in short bowel syndrome (SBS). However, the effects of exogenous GLP-2 and SBS on enteric neurons are unclear. Methods Sprague Dawley rats were randomized to four treatments: Transected Bowel (TB) (n = 8), TB + GLP-2 (2.5 nmol/kg/h, n = 8), SBS (n = 5), or SBS + GLP-2 (2.5 nmol/kg/h, n = 9). SBS groups underwent a 60% jejunoileal resection with cecectomy and jejunocolic anastomosis. All rats were maintained on parenteral nutrition for 7 d. Parameters measured included gut morphometry, qPCR for hexose transporter (SGLT-1, GLUT-2, GLUT-5) and GLP-2 receptor mRNA, whole mount immunohistochemistry for neurons (HuC/D, VIP, nNOS), plasma glucose, gut hormones, and body composition. Results Resection increased the proportion of nNOS immunopositive myenteric neurons, intestinal muscularis propria thickness and crypt cell proliferation, which were not recapitulated by GLP-2 therapy. Exogenous GLP-2 increased jejunal mucosal surface area without affecting enteric VIP or nNOS neuronal immunopositivity, attenuated resection-induced reductions in jejunal hexose transporter abundance (SGLT-1, GLUT-2), increased plasma amylin and decreased peptide YY concentrations. Exogenous GLP-2 attenuated resection-induced increases in blood glucose and body fat loss. Conclusions Exogenous GLP-2 stimulates jejunal adaptation independent of enteric neuronal VIP or nNOS changes, and has divergent effects on plasma amylin and peptide YY concentrations. The novel ability of exogenous GLP-2 to modulate resection-induced changes in peripheral glucose and lipid reserves may be important in understanding the whole-body response following intestinal resection, and is worthy of further study. PMID:28738080

Systematic review on the use of matrix-bound sealants in pancreatic resection.

PubMed

Smits, F Jasmijn; van Santvoort, Hjalmar C; Besselink, Marc G H; Borel Rinkes, Inne H M; Molenaar, I Quintus

2015-11-01

Pancreatic fistula is a potentially life-threatening complication after a pancreatic resection. The aim of this systematic review was to evaluate the role of matrix-bound sealants after a pancreatic resection in terms of preventing or ameliorating the course of a post-operative pancreatic fistula. A systematic search was performed in the literature from May 2005 to April 2015. Included were clinical studies using matrix-bound sealants after a pancreatic resection, reporting a post-operative pancreatic fistula (POPF) according to the International Study Group on Pancreatic Fistula classification, in which grade B and C fistulae were considered clinically relevant. Two were studies on patients undergoing pancreatoduodenectomy (sealants n = 67, controls n = 27) and four studies on a distal pancreatectomy (sealants n = 258, controls n = 178). After a pancreatoduodenectomy, 13% of patients treated with sealants versus 11% of patients without sealants developed a POPF (P = 0.76), of which 4% versus 4% were clinically relevant (P = 0.87). After a distal pancreatectomy, 42% of patients treated with sealants versus 52% of patients without sealants developed a POPF (P = 0.03). Of these, 9% versus 12% were clinically relevant (P = 0.19). The present data do not support the routine use of matrix-bound sealants after a pancreatic resection, as there was no effect on clinically relevant POPF. Larger, well-designed studies are needed to determine the efficacy of sealants in preventing POPF after a pancreatoduodenectomy. © 2015 International Hepato-Pancreato-Biliary Association.

Toward real-time tumor margin identification in image-guided robotic brain tumor resection

NASA Astrophysics Data System (ADS)

Hu, Danying; Jiang, Yang; Belykh, Evgenii; Gong, Yuanzheng; Preul, Mark C.; Hannaford, Blake; Seibel, Eric J.

2017-03-01

For patients with malignant brain tumors (glioblastomas), a safe maximal resection of tumor is critical for an increased survival rate. However, complete resection of the cancer is hard to achieve due to the invasive nature of these tumors, where the margins of the tumors become blurred from frank tumor to more normal brain tissue, but in which single cells or clusters of malignant cells may have invaded. Recent developments in fluorescence imaging techniques have shown great potential for improved surgical outcomes by providing surgeons intraoperative contrast-enhanced visual information of tumor in neurosurgery. The current near-infrared (NIR) fluorophores, such as indocyanine green (ICG), cyanine5.5 (Cy5.5), 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX), are showing clinical potential to be useful in targeting and guiding resections of such tumors. Real-time tumor margin identification in NIR imaging could be helpful to both surgeons and patients by reducing the operation time and space required by other imaging modalities such as intraoperative MRI, and has the potential to integrate with robotically assisted surgery. In this paper, a segmentation method based on the Chan-Vese model was developed for identifying the tumor boundaries in an ex-vivo mouse brain from relatively noisy fluorescence images acquired by a multimodal scanning fiber endoscope (mmSFE). Tumor contours were achieved iteratively by minimizing an energy function formed by a level set function and the segmentation model. Quantitative segmentation metrics based on tumor-to-background (T/B) ratio were evaluated. Results demonstrated feasibility in detecting the brain tumor margins at quasi-real-time and has the potential to yield improved precision brain tumor resection techniques or even robotic interventions in the future.

[A new technique for ensuring negative surgical margins during partial nephrectomy: the ex vivo ultrasound control].

PubMed

Desmonts, A; Tillou, X; Le Gal, S; Secco, M; Orczyk, C; Bensadoun, H; Doerfler, A

2013-10-01

To evaluate the feasibility and the efficiency of intraoperative ex vivo ultrasound of resection margins in patients undergoing partial nephrectomy by urologist. Patients undergoing partial nephrectomy from July 2010 to November 2012 for T1-T2 renal tumors were included in analysis. Tumor margin status was immediately determined by ex vivo ultrasound done by the surgeon himself. Results were compared with margin status on definitive pathological evaluation. A total of 26 men and 15 women with a median age of 61 (30-82) years old were included in analysis. Intraoperative ex vivo ultrasound revealed negative surgical margins in 38 cases and positive margins in two. Final pathological results revealed negative margins in all except one case. Ultrasound sensitivity and specificity were 100% and 97%, respectively. Mean ultrasound duration was 1minute±1. Mean tumor and margin sizes were 3.4±1.8cm and 2.38±1.76mm, respectively. Intraoperative ex vivo ultrasound of resection margins in patients undergoing partial nephrectomy by a urologist seemed to be feasible, efficient and easy. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

HIRSCHSPRUNG'S DISEASE—The Clinical Differentiation and Treatment of Children with Hirschsprung's Disease and Pseudo-Hirschsprung's Disease

PubMed Central

Ravitch, Mark M.

1958-01-01

Hirschsprung's disease is marked by constipation from the time of birth, with the development, if uncorrected, of a protuberant abdomen and flared costal margins. The rectal ampulla is empty and the abdomen is filled with fecal masses. Pain is not prominent. Flatus is passed in large amounts. Encopresis does not occur. Barium enema shows the characteristic narrowed distal rectal segment and biopsy of the rectum shows absence of the ganglion cells of the myenteric plexus. Treatment is operative resection of the distal narrow segment and a primary anastomosis. Hirschsprung's disease may be mimicked in children with: 1. Psychogenic constipation—pseudo-Hirschsprung's disease. Unlike Hirschsprung's disease, symptoms do not appear at birth, encopresis is common, and the barium enema shows no narrow distal segment. 2. Mental retardation and cerebral defect. 3. Corrected imperforate anus—on the basis of stenosis, imperfect innervation or poor habit training. 4. Cretinism—with severe constipation and intestinal dilatation perhaps the presenting symptoms. Treatment of these four groups of children with severe constipation not due to Hirschsprung's disease is: For Group 1, open discussion with parent and child. Assumption by the physician of full control of the details of treatment, and relegation of parent to the role of the physician's agent in following the prescribed regimen. For Group 2, an enema regimen. Whereas fairly rapid restoration (and then persistence) of normal bowel habit can be expected in Group 1, the basic defects in Group 2 may require indefinite continuation of treatment. For Group 3, regular enema regimen, in the less severe cases—one identical with that used in Group 1, and dilatation of strictures or anoplasty. In Group 4, thyroid hormone therapy relieves the constipation of hypothyroidism and causes reversion of radiographic changes in the colon and rectum. PMID:13561108

Prognostic Value of National Comprehensive Cancer Network Lung Cancer Resection Quality Parameters

PubMed Central

Osarogiagbon, Raymond U.; Ray, Meredith A.; Faris, Nicholas R.; Div, M.; Smeltzer, Matthew P.; Stat, M.; Fehnel, Carrie; Houston-Harris, Cheryl; Signore, Raymond S.; McHugh, Laura M.; Levy, Paul; Wiggins, Lynn; Sachdev, Vishal; Robbins, Edward T.

2017-01-01

Background The National Comprehensive Cancer Network (NCCN) surgical resection guidelines for non-small-cell lung cancer (NSCLC) recommend anatomic resection, negative margins, examination of hilar/intrapulmonary lymph nodes, and examination of 3 or more mediastinal nodal stations. We examined the survival impact of these guidelines. Methods Population-based observational study using patient-level data from all curative-intent NSCLC resections from 2004–2013 at 11 institutions in 4 contiguous Dartmouth Hospital Referral Regions in 3 US states. We used an adjusted Cox proportional hazards model to assess the overall survival impact of attaining NCCN guidelines. Results Of 2,429 eligible resections,91% were anatomic, 94% had negative margins, 51% sampled hilar nodes, and 26% examined three or more mediastinal nodal stations. Only 17% of resections met all four criteria, however there was a significant increasing trend from 2% in 2004 to 39% in 2013 (p<0.001). Compared to patients whose surgery missed one or more parameters, the hazard ratio for patients whose surgery met all four criteria was 0.71 (95% confidence interval: 0.59–0.86, p<0.001). Margin status and the nodal staging parameters were most strongly linked with survival. Conclusions Attainment of NCCN surgical quality guidelines was low, but improving, over the past decade in this cohort from a high lung cancer mortality region of the US. The NCCN quality criteria, especially the nodal examination criteria, were strongly associated with survival. The quality of nodal examination should be a focus of quality improvement in NSCLC care. PMID:28366464

Invasive vulvar carcinoma and the question of the surgical margin.

PubMed

Palaia, Innocenza; Bellati, Filippo; Calcagno, Marco; Musella, Angela; Perniola, Giorgia; Panici, Pierluigi B

2011-08-01

To assess the discrepancy between width of surgical margin measured with the naked eye/ruler by a surgeon before removing an invasive vulvar carcinoma, and width of margin measured under microscope by pathologist after fixation of the resected lesion with formalin. Potential relationships between discrepancy and disease recurrence were also investigated. This prospective study was conducted with resected lesions from 86 women who underwent surgery for primary/recurrent invasive vulvar carcinoma. After the surgeon removed the lesions surrounded by 1-2-cm margins, the pathologist determined margin width at the 4 cardinal points of 86 lesions (for a total of 344 margin assessments), first macroscopically and then under the microscope. A safety margin of 0.8 cm on microscopic view was achieved in 83% of cases (112 of 135) when the macroscopic measurement was 1cm, in 91% of cases (58 of 64) when it was 1.5 cm, and 98% of cases (105 of 107) when it was 2 cm. There was a small discrepancy between the surgeon's intent and the microscopic margin measurement, mostly related to tissue shrinkage. A 1-cm surgical margin corresponded to a 0.8-cm margin in microscopic view (the "safe margin") in most cases. Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Resection of isolated pelvic recurrences after colorectal surgery: long-term results and predictors of improved clinical outcome.

PubMed

Henry, Leonard R; Sigurdson, Elin; Ross, Eric A; Lee, John S; Watson, James C; Cheng, Jonathan D; Freedman, Gary M; Konski, Andre; Hoffman, John P

2007-07-01

Recurrence in the pelvis after resection of a rectal or rectosigmoid cancer presents a dilemma. Resection offers the only reasonable probability for cure, but at the cost of perioperative morbidity and potential mortality. Clinical decision making remains difficult. Patients resected with curative intent for isolated pelvic recurrences after curative colorectal surgery from 1988 through 2003 were reviewed retrospectively. Clinical and pathologic factors, salvage operations, and complications were recorded. The primary measured outcome was overall survival. Univariate and multivariate analyses were conducted to identify prognostic factors of improved outcome. Ninety patients underwent an attempt at curative resection of a pelvic recurrence with median follow-up of 31 months. Complications occurred in 53% of patients. Operative mortality was 4.4% (4 of 90). Median overall survival was 38 months, and estimated 5-year survival was 40%. A total of 51 of 86 patients had known recurrences (15 local, 16 distant, 20 both). Multivariate analysis revealed that preoperative carcinoembryonic antigen level and final margin status were statistically significant predictors of outcome. The resection of pelvic recurrences after colorectal surgery for cancer can be performed with low mortality and good long-term outcome; however, morbidity from such procedures is high. Low preoperative carcinoembryonic antigen and negative margin of resection predict improved survival.

Resection of isolated pelvic recurrences after colorectal surgery: long-term results and predictors of improved clinical outcome.

PubMed

Henry, Leonard R; Sigurdson, Elin; Ross, Eric A; Lee, John S; Watson, James C; Cheng, Jonathan D; Freedman, Gary M; Konski, Andre; Hoffman, John P

2007-03-01

Recurrence in the pelvis after resection of a rectal or rectosigmoid cancer presents a dilemma. Resection offers the only reasonable probability for cure, but at the cost of marked perioperative morbidity and potential mortality. Clinical decision making remains difficult. Patients who underwent resection with curative intent for isolated pelvic recurrences after curative colorectal surgery from 1988 through 2003 were reviewed retrospectively. Clinical and pathological factors, salvage operations, and complications were recorded. The primary measured outcome was overall survival. Univariate and multivariate analyses were conducted to identify prognostic factors of improved outcome. Ninety patients underwent an attempt at curative resection of a pelvic recurrence; median follow-up was 31 months. Complications occurred in 53% of patients. Operative mortality occurred in 4 (4.4%) of 90 patients. Median overall survival was 38 months, and estimated 5-year survival was 40%. A total of 51 of 86 patients had known recurrences (15 local, 16 distant, 20 both). Multivariate analysis revealed that preoperative carcinoembryonic antigen level and final margin status were statistically significant predictors of outcome. The resection of pelvic recurrences after colorectal surgery for cancer can be performed with low mortality and good long-term outcome; however, morbidity from such procedures is high. Low preoperative carcinoembryonic antigen and negative margin of resection predict improved survival.

Perioperative BRAF inhibitors in locally advanced stage III melanoma.

PubMed

Zippel, Douglas; Markel, Gal; Shapira-Frommer, Roni; Ben-Betzalel, Guy; Goitein, David; Ben-Ami, Eytan; Nissan, Aviram; Schachter, Jacob; Schneebaum, Schlomo

2017-12-01

Stage III malignant melanoma is a heterogeneous disease where those cases deemed marginally resectable or irresecatble are frequently incurable by surgery alone. Targeted therapy takes advantage of the high incidence of BRAF mutations in melanomas, most notably the V600E mutation. These agents have rarely been used in a neoadjuvant setting prior to surgery. Thirteen consecutive patients with confirmed BRAF V600E regionally advanced melanoma deemed marginally resectable or irrresectable, were treated with BRAF inhibiting agents, prior to undergoing surgery. The primary outcome measures were a successful resection and pathological response. Disease-free survival was a secondary outcome measure. Overall, 12/13 patients showed a marked clinical responsiveness to medical treatment, enabling a macroscopically successful resection in all cases. Four patients had a complete pathological response with no viable tumor evident in the resected specimens and eight patients showed evidence of minimally residual tumor with extensive tumoral necrosis and fibrosis. One patient progressed and died before surgery. At a median follow up of 20 months, 10 patients remain free of disease. Perioperative treatment with BRAF inhibiting agents in BRAFV600E mutated Stage III melanoma patients facilitates surgical resection and affords satisfactory disease free survival. © 2017 Wiley Periodicals, Inc.

Combined abdominal and perineal approach for delayed restoration of bowel continuity after low anterior resection in females.

PubMed

Abou-Zeid, Ahmed A; Makki, Mahmoud T

2007-04-01

Restoration of bowel continuity after Hartmann's operation is the surgeon's goal and the patient's hope. This operation is technically demanding with reportedly high morbidity and mortality. A short distal rectal stump often makes the operation more difficult. In this article, we describe a combined abdominal and perineal approach, which can possibly make delayed restoration of bowel continuity after low anterior rectal resection an easier procedure.

Borderline resectable pancreatic cancer: conceptual evolution and current approach to image-based classification.

PubMed

Gilbert, J W; Wolpin, B; Clancy, T; Wang, J; Mamon, H; Shinagare, A B; Jagannathan, J; Rosenthal, M

2017-09-01

Diagnostic imaging plays a critical role in the initial diagnosis and therapeutic monitoring of pancreatic adenocarcinoma. Over the past decade, the concept of 'borderline resectable' pancreatic cancer has emerged to describe a distinct subset of patients existing along the spectrum from resectable to locally advanced disease for whom a microscopically margin-positive (R1) resection is considered relatively more likely, primarily due to the relationship of the primary tumor with surrounding vasculature. This review traces the conceptual evolution of borderline resectability from a radiological perspective, including the debates over the key imaging criteria that define the thresholds between resectable, borderline resectable, and locally advanced or metastatic disease. This review also addresses the data supporting neoadjuvant therapy in this population and discusses current imaging practices before and during treatment. A growing body of evidence suggests that the borderline resectable group of patients may particularly benefit from neoadjuvant therapy to increase the likelihood of an ultimately margin-negative (R0) resection. Unfortunately, anatomic and imaging criteria to define borderline resectability are not yet universally agreed upon, with several classification systems proposed in the literature and considerable variance in institution-by-institution practice. As a result of this lack of consensus, as well as overall small patient numbers and lack of established clinical trials dedicated to borderline resectable patients, accurate evidence-based diagnostic categorization and treatment selection for this subset of patients remains a significant challenge. Clinicians and radiologists alike should be cognizant of evolving imaging criteria for borderline resectability given their profound implications for treatment strategy, follow-up recommendations, and prognosis. © The Author 2017. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Laparoscopic enucleation of liver tumors. Corkscrew technique revisited.

PubMed

Makdissi, Fabio F; Surjan, Rodrigo C T; Machado, Marcel Autran C

2009-03-01

Enucleation of small lesions located near the hepatic surface can be achieved with low morbidity and mortality. This article describes a simple laparoscopic technique for enucleation of liver tumors. After inspection and intraoperative ultrasonography, Glisson's capsule is marked with eletrocautery 2 cm away from the tumor margin. Ultrasonography is used to ascertain surgical margin right before liver transection. Hemihepatic ischemia is applied and marked area is anchored by stitches. The suture is held together by metallic clips and upward traction is performed, facilitating the transection of the parenchyma and correct identification of vascular and biliary structures. This technique has been successfully employed in six consecutive patients. There were four men and two women, mean age 50.3 years. Four patients underwent liver resection for malignant disease and two for benign liver neoplasm. Pathologic surgical margins were free in all cases and mean hospital stay was 2 days. No postoperative mortality was observed. This technique may facilitate laparoscopic nonanatomical liver resection and reduce risk of positive surgical margins. It is also useful in combination with anatomical laparoscopic liver resections such as right or left hemihepatectomies in patients with bilateral liver tumors as occurred in one of our patients.

[Resection of a carpal bone row in a Pustertaler Sprinze cow with chronic purulent arthritis of the carpal joint and osteomyelitis].

PubMed

Kofler, J; Peterbauer, C

2014-01-01

This case report describes the clinical and radiographic findings and the surgical treatment of a serofibrinous arthritis of the antebrachiocarpal joint and of a chronic purulent arthritis of the intercarpal and carpometacarpal joints with osteomyelitis of the distal carpal bones and subchondral osteomyelitis of the proximal metacarpal bones in a cow of the breed "Pustertaler Sprinze". The therapy comprised an arthrotomy of both joint spaces and the resection of the distal row of the carpal bones. The right forelimb had been immobilised for 70 days by a full limb cast. After this period, radiographs revealed an ob- vious ankylosis of the carpal joint, and the cow showed only a slight lameness. Six years postoperatively this cow was still in the herd and had produced six calves.

Tectono-thermal Evolution of a Distal Rifted Margin: Constraints From the Calizzano Massif (Prepiedmont-Briançonnais Domain, Ligurian Alps)

NASA Astrophysics Data System (ADS)

Decarlis, Alessandro; Fellin, Maria Giuditta; Maino, Matteo; Ferrando, Simona; Manatschal, Gianreto; Gaggero, Laura; Seno, Silvio; Stuart, Finlay M.; Beltrando, Marco

2017-12-01

The thermal evolution of distal domains along rifted margins is at present poorly constrained. In this study, we show that a thermal pulse, most likely triggered by lithospheric thinning and asthenospheric rise, is recorded at upper crustal levels and may also influence the diagenetic processes in the overlying sediments, thus representing a critical aspect for the evaluation of hydrocarbon systems. The thermal history of a distal sector of the Alpine Tethys rifted margin preserved in the Ligurian Alps (Case Tuberto-Calizzano unit) is investigated with thermochronological methods and petrologic observations. The studied unit is composed of a polymetamorphic basement and a sedimentary cover, providing a complete section through the prerift, synrift, and postrift system. Zircon fission track analyses on basement rocks samples suggest that temperatures exceeding 240 ± 25°C were reached before 150-160 Ma (Upper Jurassic) at few kilometer depth. Neoformation of green biotite, stable at temperatures of 350 to 450°C, was synkinematic with this event. The tectonic setting of the studied unit suggests that the heating-cooling cycle took place during the formation of the distal rifted margin and terminated during Late Jurassic (150-160 Ma). Major crustal and lithospheric thinning likely promoted high geothermal gradients ( 60-90°C/km) and triggered the circulation of hot, deep-seated fluids along brittle faults, causing the observed thermal anomaly. Our results suggest that rifting can generate thermal perturbations at relatively high temperatures (between 240 and 450°C) at less than 3 km depth in the distal domains during major crustal thinning preceding breakup and onset of seafloor spreading.

Postoperative dysesthesia in lumbar three-column resection osteotomies.

PubMed

Zhang, Zhengfeng; Wang, Honggang; Zheng, Wenjie

2016-08-01

Three-column lumbar spinal resection osteotomies including pedicle subtraction osteotomy (PSO), vertebral column resection (VCR), and total en bloc spondylectomy (TES) can potentially lead to dorsal root ganglion (DRG) injury which may cause postoperative dysesthesia (POD). The purpose of retrospective study was to describe the uncommon complication of POD in lumbar spinal resection osteotomies. Between January 2009 and December 2013, 64 patients were treated with lumbar three-column spinal resection osteotomies (PSO, n = 31; VCR, n = 29; TES, n = 4) in investigator group. POD was defined as dysesthetic pain or burning dysesthesia at a proper DRG innervated region, whether spontaneous or evoked. Non-steroidal antiinflammatory drugs, central none-opioid analgesic agent, neuropathic pain drugs and/or intervertebral foramen block were selectively used to treat POD. There were 5 cases of POD (5/64, 7.8 %), which consisted of 1 patient in PSO (1/31, 3.2 %), 3 patients in PVCR (3/29, 10.3 %), and 1 patient in TES (1/4, 25 %). After the treatment by drugs administration plus DRG block, all patients presented pain relief with duration from 8 to 38 days. A gradual pain moving to distal end of a proper DRG innervated region was found as the beginning of end. Although POD is a unique and rare complication and maybe misdiagnosed as nerve root injury in lumbar spinal resection osteotomies, combination drug therapy and DRG block have an effective result of pain relief. The appearance of a gradual pain moving to distal end of a proper DRG innervated region during recovering may be used as a sign for the good prognosis.

Comparison of Perioperative Outcomes between Open, Laparoscopic, and Robotic Distal Pancreatectomy: an Analysis of 1815 Patients from the ACS-NSQIP Procedure-Targeted Pancreatectomy Database.

PubMed

Xourafas, Dimitrios; Ashley, Stanley W; Clancy, Thomas E

2017-09-01

Robotic surgery is gaining acceptance for distal pancreatectomy (DP). Nevertheless, no multi-institutional data exist to demonstrate the ideal clinical circumstances for use and the efficacy of the robot compared to the open or laparoscopic techniques, in terms of perioperative outcomes. The 2014 ACS-NSQIP procedure-targeted pancreatectomy data for patients undergoing DP were analyzed. Demographics and clinicopathological and perioperative variables were compared between the three approaches. Univariate and multivariable analyses were used to evaluate outcomes. One thousand eight hundred fifteen DPs comprised 921 open distal pancreatectomies (ODPs), 694 laparoscopic distal pancreatectomies (LDPs), and 200 robotic distal pancreatectomies (RDPs). The three groups were comparable with respect to demographics, ASA score, relevant comorbidities, and malignant histology subtype. Compared to the ODP group, patients undergoing RDP had lower T-stages of disease (P = 0.0192), longer operations (P = 0.0030), shorter hospital stays (P < 0.0001), and lower postoperative 30-day morbidity (P = 0.0476). Compared to the LDP group, RDPs were longer operations (P < 0.0001) but required fewer concomitant vascular resections (P = 0.0487) and conversions to open surgery (P = 0.0068). On multivariable analysis, neoadjuvant therapy (P = 0.0236), malignant histology (P = 0.0124), pancreatic reconstruction (P = 0.0006), and vascular resection (P = 0.0008) were the strongest predictors of performing an ODP. The open, laparoscopic, and robotic approaches to distal pancreatectomy offer particular advantages for well-selected patients and specific clinicopathological contexts; therefore, clearly demonstrating the most suitable use and superiority of one technique over another remains challenging.

Multimodality Management of "Borderline Resectable" Pancreatic Neuroendocrine Tumors: Report of a Single-Institution Experience.

PubMed

Ambe, Chenwi M; Nguyen, Phuong; Centeno, Barbara A; Choi, Junsung; Strosberg, Jonathan; Kvols, Larry; Hodul, Pamela; Hoffe, Sarah; Malafa, Mokenge P

2017-01-01

Pancreatic neuroendocrine tumors (PanNETs) constitute approximately 3% of pancreatic neoplasms. Like patients with pancreatic ductal adenocarcinoma (PDAC), some of these patients present with "borderline resectable disease." For these patients, an optimal treatment approach is lacking. We report our institution's experience with borderline resectable PanNETs using multimodality treatment. We identified patients with borderline resectable PanNETs who had received neoadjuvant therapy at our institution between 2000 and 2013. The definition of borderline resectability was based on National Comprehensive Cancer Network criteria for PDAC. Neoadjuvant regimen, radiographic response, pathologic response, surgical margins, nodal retrieval, number of positive nodes, and recurrence were documented. Statistics were descriptive. Of 112 patients who underwent surgical resection for PanNETs during the study period, 23 received neoadjuvant therapy, 6 of whom met all inclusion criteria and had borderline resectable disease. These 6 patients received at least 1 cycle of temozolomide and capecitabine, with 3 also receiving radiation. All had radiographic evidence of treatment response. Four (67%) had negative-margin resections. Four patients had histologic evidence of a moderate response. Follow-up (3.0-4.3 years) indicated that all patients were alive, with 5/6 free of disease (1 patient with metastatic disease still on treatment without progression). A multimodality treatment strategy (neoadjuvant temozolomide and capecitabine ± radiation) can be successfully applied to patients with PanNETs who meet NCCN borderline resectable criteria for PDAC. To our knowledge, this is the first report of the use of a multimodality protocol in the treatment of patients with borderline resectable PanNETs.

Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial.

PubMed

Quirke, Phil; Steele, Robert; Monson, John; Grieve, Robert; Khanna, Subhash; Couture, Jean; O'Callaghan, Chris; Myint, Arthur Sun; Bessell, Eric; Thompson, Lindsay C; Parmar, Mahesh; Stephens, Richard J; Sebag-Montefiore, David

2009-03-07

Local recurrence rates in operable rectal cancer are improved by radiotherapy (with or without chemotherapy) and surgical techniques such as total mesorectal excision. However, the contributions of surgery and radiotherapy to outcomes are unclear. We assessed the effect of the involvement of the circumferential resection margin and the plane of surgery achieved. In this prospective study, the plane of surgery achieved and the involvement of the circumferential resection margin were assessed by local pathologists, using a standard pathological protocol in 1156 patients with operable rectal cancer from the CR07 and NCIC-CTG CO16 trial, which compared short-course (5 days) preoperative radiotherapy and selective postoperative chemoradiotherapy, between March, 1998, and August, 2005. All analyses were by intention to treat. This trial is registered, number ISRCTN 28785842. 128 patients (11%) had involvement of the circumferential resection margin, and the plane of surgery achieved was classified as good (mesorectal) in 604 (52%), intermediate (intramesorectal) in 398 (34%), and poor (muscularis propria plane) in 154 (13%). We found that both a negative circumferential resection margin and a superior plane of surgery achieved were associated with low local recurrence rates. Hazard ratio (HR) was 0.32 (95% CI 0.16-0.63, p=0.0011) with 3-year local recurrence rates of 6% (5-8%) and 17% (10-26%) for patients who were negative and positive for circumferential resection margin, respectively. For plane of surgery achieved, HRs for mesorectal and intramesorectal groups compared with the muscularis propria group were 0.32 (0.16-0.64) and 0.48 (0.25-0.93), respectively. At 3 years, the estimated local recurrence rates were 4% (3-6%) for mesorectal, 7% (5-11%) for intramesorectal, and 13% (8-21%) for muscularis propria groups. The benefit of short-course preoperative radiotherapy did not differ in the three plane of surgery groups (p=0.30 for trend). Patients in the short-course preoperative radiotherapy group who had a resection in the mesorectal plane had a 3-year local recurrence rate of only 1%. In rectal cancer, the plane of surgery achieved is an important prognostic factor for local recurrence. Short-course preoperative radiotherapy reduced the rate of local recurrence for all three plane of surgery groups, almost abolishing local recurrence in short-course preoperative radiotherapy patients who had a resection in the mesorectal plane. The plane of surgery achieved should therefore be assessed and reported routinely.

Role of tumour-free margin distance for loco-regional control in vulvar cancer-a subset analysis of the Arbeitsgemeinschaft Gynäkologische Onkologie CaRE-1 multicenter study.

PubMed

Woelber, Linn; Griebel, Lis-Femke; Eulenburg, Christine; Sehouli, Jalid; Jueckstock, Julia; Hilpert, Felix; de Gregorio, Nikolaus; Hasenburg, Annette; Ignatov, Atanas; Hillemanns, Peter; Fuerst, Sophie; Strauss, Hans-Georg; Baumann, Klaus H; Thiel, Falk C; Mustea, Alexander; Meier, Werner; Harter, Philipp; Wimberger, Pauline; Hanker, Lars Christian; Schmalfeldt, Barbara; Canzler, Ulrich; Fehm, Tanja; Luyten, Alexander; Hellriegel, Martin; Kosse, Jens; Heiss, Christoph; Hantschmann, Peer; Mallmann, Peter; Tanner, Berno; Pfisterer, Jacobus; Richter, Barbara; Neuser, Petra; Mahner, Sven

2016-12-01

A tumour-free pathological resection margin of ≥8 mm is considered state-of-the-art. Available evidence is based on heterogeneous cohorts. This study was designed to clarify the relevance of the resection margin for loco-regional control in vulvar cancer. AGO-CaRE-1 is a large retrospective study. Patients (n = 1618) with vulvar cancer ≥ FIGO stage IB treated at 29 German gynecologic-cancer-centres 1998-2008 were included. This subgroup analysis focuses on solely surgically treated node-negative patients with complete tumour resection (n = 289). Of the 289 analysed patients, 141 (48.8%) had pT1b, 140 (48.4%) pT2 and 8 (2.8%) pT3 tumours. One hundred twenty-five (43.3%) underwent complete vulvectomy, 127 (43.9%) partial vulvectomy and 37 (12.8%) radical local excision. The median minimal resection margin was 5 mm (1 mm-33 mm); all patients received groin staging, in 86.5% with full dissection. Median follow-up was 35.1 months. 46 (15.9%) patients developed recurrence, thereof 34 (11.8%) at the vulva, after a median of 18.3 months. Vulvar recurrence rates were 12.6% in patients with a margin <8 mm and 10.2% in patients with a margin ≥8 mm. When analysed as a continuous variable, the margin distance had no statistically significant impact on local recurrence (HR per mm increase: 0.930, 95% CI: 0.849-1.020; p = 0.125). Multivariate analyses did also not reveal a significant association between the margin and local recurrence neither when analysed as continuous variable nor categorically based on the 8 mm cutoff. Results were consistent when looking at disease-free-survival and time-to-recurrence at any site (HR per mm increase: 0.949, 95% CI: 0.864-1.041; p = 0.267). The need for a minimal margin of 8 mm could not be confirmed in the large and homogeneous node-negative cohort of the AGO-CaRE database. Copyright © 2016 Elsevier Ltd. All rights reserved.

Robot-assisted Versus Laparoscopic Surgery for Rectal Cancer: A Phase II Open Label Prospective Randomized Controlled Trial.

PubMed

Kim, Min Jung; Park, Sung Chan; Park, Ji Won; Chang, Hee Jin; Kim, Dae Yong; Nam, Byung-Ho; Sohn, Dae Kyung; Oh, Jae Hwan

2018-02-01

The phase II randomized controlled trial aimed to compare the outcomes of robot-assisted surgery with those of laparoscopic surgery in the patients with rectal cancer. The feasibility of robot-assisted surgery over laparoscopic surgery for rectal cancer has not been established yet. Between February 21, 2012 and March 11, 2015, patients with rectal cancer (cT1-3NxM0) were enrolled. Patients were randomized 1:1 to either robot-assisted or laparoscopic surgery, and stratified per sex and administration of preoperative chemoradiotherapy. The primary outcome was the quality of total mesorectal excision (TME) specimen. Secondary outcomes were the circumferential and distal resection margins, the number of harvested lymph nodes, morbidity, bowel function recovery, and quality of life. A total of 163 patients were randomly assigned to the robot-assisted (n = 81) and laparoscopic (n = 82) surgery groups, and 139 patients were eligible for the analyses (73 vs 66, respectively). One patient (1.2%) in the robot-assisted group was converted to open surgery. The TME quality did not differ between the robot-assisted and laparoscopic groups (80.3% vs 78.1% complete TME, respectively; 18.2% vs 21.9% nearly complete TME, respectively; P = 0.599). The resection margins, number of harvested lymph nodes, morbidity, and bowel function recovery also were not significantly different. On analyzing quality of life, scores of the European Organization for Research and Treatment of Cancer Quality of Life (EORTC QLQ C30) and EORTC QLQ CR38 were similar in the 2 groups, but in the EORTC QLQ CR 38 questionnaire, sexual function 12 months postoperatively was better in the robot-assisted group than in the laparoscopic group (P = 0.03). Robot-assisted surgery in rectal cancer showed TME quality comparable with that of laparoscopic surgery, and it demonstrated similar postoperative morbidity, bowel function recovery, and quality of life.

Hanging Maneuver for Stomach Traction in Laparoscopic Distal Pancreatic Resections: An Original Technique Applied in 218 Patients.

PubMed

Dokmak, Safi; Aussilhou, Béatrice; Ftériche, Fadhel Samir; Belghiti, Jacques; Sauvanet, Alain

2017-01-01

Stomach traction done to expose the pancreas is still a problem in laparoscopic left pancreatic resections. We developed a simple hanging maneuver to retract the stomach rapidly and effectively. After dividing the gastrocolic ligament, the stomach was encircled with a tape, turned along its horizontal axis and pulled with an epigastric trocar, which was later removed. This technique was used in all patients who underwent laparoscopic left pancreatic resections including 165 distal pancreatectomies (DP), 35 central pancreatectomies (CP) and 18 enucleations (En). Demographics, surgical and postoperative outcome data were recorded. There were no mortalities. The mean operative time for DP, CP and En were 174, 191 and 104 min, respectively. The transfusion (0-4%) and conversion (0-3%) rates were low for all procedures. Morbidity was mainly represented by pancreatic fistula and grades (B + C) for DP, CP and En were observed in 26, 22 and 17%, respectively. No complication related to hanging of the stomach, like gastric perforation, was observed. Re-intervention and the mean hospital stay for DP, CP and En were observed in 5, 11 and 0% and were 16, 22 and 12, respectively. The readmission rate was low (0-9%). Hanging maneuver of the stomach is a simple procedure to rapidly, safely and effectively retract the stomach during left laparoscopic pancreatic resections. © 2016 S. Karger AG, Basel.

Intraoperative Molecular Imaging of Lung Adenocarcinoma Can Identify Residual Tumor Cells at the Surgical Margins

PubMed Central

Keating, Jane J.; Okusanya, Olugbenga T.; De Jesus, Elizabeth; Judy, Ryan; Jiang, Jack; Deshpande, Charuhas; Nie, Shuming; Low, Philip; Singhal, Sunil

2017-01-01

Purpose During lung surgery, identification of surgical margins is challenging. We hypothesized that molecular imaging with a fluorescent probe to pulmonary adenocarcinomas could enhance residual tumor during resection. Procedures Mice with flank tumors received a contrast agent targeting folate receptor alpha. Optimal dose and time of injection was established. Margin detection was compared using traditional methods versus molecular imaging. A pilot study was then performed in 3 humans with lung adenocarcinoma. Results The peak tumor-to background ratio (TBR) of murine tumors was 3.9. Fluorescence peaked at 2 hours and was not improved beyond 0.1 mg/kg. Traditional inspection identified 30% of mice with positive margins. Molecular imaging identified an additional 50% of residual tumor deposits (P<0.05). The fluorescent probe visually enhanced all human tumors with a mean TBR of 3.5. Conclusions Molecular imaging is an important adjunct to traditional inspection to identify surgical margins after tumor resection. PMID:26228697

Giant Spontaneous Greater Saphenous Vein Aneurysm.

PubMed

Lim, Sungho; Halandras, Pegge; Hershberger, Richard; Aulivola, Bernadette; Crisostomo, Paul

2017-07-01

Venous aneurysm, a rare venous anomaly, poses increased risk of distal thromboembolic event. Superficial venous aneurysm, such as greater saphenous vein aneurysm, is an uncommon subset with nonspecific symptoms and often a delay in diagnosis. Symptomatic patients or patients with a thromboembolic event may benefit from surgical intervention with low morbidity. This case report describes an isolated spontaneous greater saphenous vein aneurysm which was successfully ligated and resected for symptomatic relief and prevention of distal thromboembolism. Published by Elsevier Inc.

Prognosis of Primary and Recurrent Chondrosarcoma of the Rib.

PubMed

Roos, Eva; van Coevorden, Frits; Verhoef, Cornelis; Wouters, Michel W; Kroon, Herman M; Hogendoorn, Pancras C W; van Houdt, Winan J

2016-03-01

Chondrosarcoma of the rib is a rare disease. Although surgery is the only curative treatment option, rib resection with an adequate margin can be challenging and local recurrence is a frequent problem. In this study, the prognosis of primary and recurrent chondrosarcoma of the rib is reported. Retrospective analysis was performed of patients treated for chondrosarcoma of the rib between 1984 and 2014 in three major tertiary referral centers in The Netherlands. Clinical and histopathological features were analyzed for their prognostic value using Kaplan-Meier and Cox proportional hazard analysis. Endpoints were set at local recurrent disease, metastasis rate, or death. Overall, 76 patients underwent a resection for a primary chondrosarcoma, and 26 patients underwent a resection for a recurrent chondrosarcoma. Five-year overall survival in the primary group was 90%, local recurrence rate was 17%, and metastasis rate was 12%. The 5-year outcome after recurrent chondrosarcoma was lower, with an overall survival of 65%, local recurrence rate of 27%, and metastasis rate of 27%. For primary chondrosarcoma, tumor size >5 cm and a positive resection margin were correlated with worse overall survival [hazard ratio (HR) 3.28, 95% confidence interval (CI) 1.03-10.44; HR 2.92, 95% CI 1.03-8.25). A higher histological grade was correlated with a higher local recurrence and metastasis rate (HR 5.92, 95% CI 1.11-31.65; HR 6.96, 95% CI 1.15-42.60). Surgical resection of both primary and recurrent chondrosarcoma of the rib is an effective treatment strategy. The oncological outcome after surgery is worse in tumors >5 cm, in tumors with positive resection margins and grade 3 chondrosarcoma.

Outcome of bone recycling using liquid nitrogen as bone reconstruction procedure in malignant and recurrent benign aggressive bone tumour of distal tibia: A report of four cases.

PubMed

Gede, Eka Wiratnaya I; Ida Ayu, Arrisna Artha; Setiawan I Gn, Yudhi; Aryana Ign, Wien; I Ketut, Suyasa; I Ketut, Siki Kawiyana; Putu, Astawa

2017-01-01

Amputation still considered as primary choice of malignancy treatment in distal tibia. Bone recycling with liquid nitrogen for reconstruction following resection of malignant bone tumours offers many advantages. We presented four patients with osteosarcoma, Ewing sarcoma, adamantinoma and recurrent giant cell tumour over distal tibia. All of the patients underwent wide excision and bone recycling using liquid nitrogen as bone reconstruction. The mean functional Musculoskeletal Tumor Society (MSTS) score was 75% with no infection and local recurrent. The reconstruction provides good local control and functional outcome.

Systematic review on the use of matrix-bound sealants in pancreatic resection

PubMed Central

Smits, F Jasmijn; van Santvoort, Hjalmar C; Besselink, Marc G H; Borel Rinkes, Inne H M; Molenaar, I Quintus

2015-01-01

Background Pancreatic fistula is a potentially life-threatening complication after a pancreatic resection. The aim of this systematic review was to evaluate the role of matrix-bound sealants after a pancreatic resection in terms of preventing or ameliorating the course of a post-operative pancreatic fistula. Methods A systematic search was performed in the literature from May 2005 to April 2015. Included were clinical studies using matrix-bound sealants after a pancreatic resection, reporting a post-operative pancreatic fistula (POPF) according to the International Study Group on Pancreatic Fistula classification, in which grade B and C fistulae were considered clinically relevant. Results Two were studies on patients undergoing pancreatoduodenectomy (sealants n = 67, controls n = 27) and four studies on a distal pancreatectomy (sealants n = 258, controls n = 178). After a pancreatoduodenectomy, 13% of patients treated with sealants versus 11% of patients without sealants developed a POPF (P = 0.76), of which 4% versus 4% were clinically relevant (P = 0.87). After a distal pancreatectomy, 42% of patients treated with sealants versus 52% of patients without sealants developed a POPF (P = 0.03). Of these, 9% versus 12% were clinically relevant (P = 0.19). Conclusions The present data do not support the routine use of matrix-bound sealants after a pancreatic resection, as there was no effect on clinically relevant POPF. Larger, well-designed studies are needed to determine the efficacy of sealants in preventing POPF after a pancreatoduodenectomy. PMID:26292846

In vivo study of partial liver resection on pigs using a 1.9 μm thulium fiber laser

NASA Astrophysics Data System (ADS)

Theisen-Kunde, D.; Wolken, H.; Danicke, V.; Brinkmann, R.; Bruch, H.; Kleemann, M.

2011-07-01

Dissection of liver tissue can be performed by different techniques (ultrasound, mono and bipolar dissection, water jet dissection and by stapler). In this animal study the potential of a Thulium fiber laser system was investigated for open parenchyma dissection. Based on a cw Thulium fiber laser (IPG laser GmbH, Burbach, Germany), emitting a wavelength at 1.9 μm and a maximal power at 50 W, a surgical dissection device was developed at the Medical Laser Centre Luebeck. Cw laser radiation (40 Watt) was transmitted via a 365 μm fiber with a polished distal fiber tip. Procedure was performed in contact mode; irradiance at the distal fiber tip was 38.2 kW/cm2. After general anesthesia and a median laparotomy an atypical laser resection of the liver was performed in 3 pigs. Healing process was controlled after 2-3 weeks by histological analysis (H&E staining). The final evaluation data included total resection time, blood loss, bile leakage and mass of dissected tissue. All animals treated in this study were cared for in accordance to the European convention on animal care. In general the dissection with the 1.9 μm laser radiation was easily performed. Hemostasis was highly sufficient so blood loss and bile leakage was negligible. Total resection time including hemostasis of the remaining tissue was 26 +/- 12 min. Weight of resected tissue was 17 +/- 8 g. During survival period no complications (bleeding or inflammation) occurred. After 2 weeks histology showed ongoing scar formation about 1 - 2 mm in depth of the dissected area.

[Experimental rationale for a procedure for correction of the residual cavity in hydatidectomy].

PubMed

Biriukov, Iu V; Streliaeva, A V; Sadykov, R V; Lazareva, N B; Sadykov, V M; Chebyshev, N V

2010-01-01

Thirty-six piglets (15 days old) were inoculated with Echinococcus according to the authors' procedure. Hepatic hydatid cyst growth in the piglets was ultrasonographically monitored 3 months after inoculation. In 15 piglets, the size of hepatic hydatid cysts was as high as 6.5 x 8.5 cm 5 months after infection. The cavity of larvocystic fibrous capsule was eliminated, by inverting the resection margins inward with interrupted catgut sutures. For content aspiration, the cystic bed was occasionally drained by a polyvinyl chloride tube with two side holes, which was brought outward through an individual incision. Thesubhepatic area was also drained by a "cigar" tampon through an individual incision. The wound healed in layers, tightly. Marginal resection of the liver was performed to stimulate regenerative processes in the resected area.

[A Distal Bile Duct Carcinoma Patient Who Underwent Surgical Resection for Liver Metastasis].

PubMed

Komiyama, Sosuke; Izumiya, Yasuhito; Kimura, Yu; Nakashima, Shingo; Kin, Syuichi; Kawakami, Sadao

2018-03-01

A 70-year-old man with distal bile duct carcinoma underwent a subtotal stomach-preserving pancreaticoduodenectomy without adjuvant chemotherapy. One and a half years after the surgery, elevated levels of serum SPan-1(38.1 U/mL)were observed and CT scans demonstrated a solitary metastasis, 25mm in size, in segment 8 of the liver. The patient received 2 courses of gemcitabine-cisplatin combination chemotherapy. No new lesions were detected after chemotherapy and the patient underwent a partial liver resection of segment 8. The pathological examination revealed a metachronous distant metastasis originating from the bile duct carcinoma. Subsequently, the patient received S-1 adjuvant chemotherapy for 6 months. Following completion of all therapies, the patient survived without tumor recurrence for 3 years and 10 months after the initial operation. Thus, surgical interventions might be effective in improving prognosis among selected patients with postoperative liver metastasis of bile duct carcinoma.

A novel approach emphasising intra-operative superficial margin enhancement of head-neck tumours with narrow-band imaging in transoral robotic surgery.

PubMed

Vicini, C; Montevecchi, F; D'Agostino, G; DE Vito, A; Meccariello, G

2015-06-01

The primary goal of surgical oncology is to obtain a tumour resection with disease-free margins. Transoral robotic surgery (TORS) for surgical treatment of head-neck cancer is commensurate with standard treatments. However, the likelihood of positive margins after TORS is up to 20.2% in a recent US survey. The aim of this study is to evaluate the efficacy and the feasibility of narrow-band imaging (NBI) during TORS in order to improve the ability to achieve disease-free margins during tumour excision. The present study was conducted at the ENT, Head- Neck Surgery and Oral Surgery Unit, Department of Special Surgery, Morgagni Pierantoni Hospital, Azienda USL Romagna. From March 2008 to January 2015, 333 TORS were carried out for malignant and benign diseases. For the present study, we retrospectively evaluated 58 biopsy-proven squamous cell carcinoma patients who underwent TORS procedures. Patients were divided into 2 groups: (1) 32 who underwent TORS and intra-operative NBI evaluation (NBI-TORS); (2) 21 who underwent TORS with standard intra-operative white-light imaging (WLITORS). Frozen section analysis of margins on surgical specimens showed a higher rate of negative superficial lateral margins in the NBI-TORS group compared with the WLI-TORS group (87.9% vs. 57.9%, respectively, p = 0.02). The sensitivity and specificity of intra-operative use of NBI, respectively, were 72.5% and 66.7% with a negative predictive value of 87.9%. Tumour margin enhancement provided by NBI associated with magnification and 3-dimensional view of the surgical field might increase the capability to achieve an oncologically-safe resection in challenging anatomical areas where minimal curative resection is strongly recommended for function preservation.

The Status of Contemporary Image-Guided Modalities in Oncologic Surgery

PubMed Central

Rosenthal, Eben L; Warram, Jason M; Bland, Kirby I; Zinn, Kurt R

2014-01-01

Surgical resection remains the cornerstone of therapy for patients with early stage solid malignancies and more than half of all cancer patients undergo surgery each year. The technical ability of the surgeon to obtain clear surgical margins at the initial resection remains crucial to improve overall survival and long-term morbidity. Current resection techniques are largely based on subjective and subtle changes associated with tissue distortion by invasive cancer. As a result, positive surgical margins occur in a significant portion of tumor resections, which is directly correlated with a poor outcome. A variety of cancer imaging techniques have been adapted or developed for intraoperative surgical guidance that have been shown to improve functional and oncologic outcomes in randomized clinical trials. There are also a large number of novel, cancer-specific contrast agents that are in early stage clinical trials and preclinical development that demonstrate significant promise to improve real-time detection of subclinical cancer in the operative setting. PMID:25599326

Duct-to-duct biliary reconstruction after radical resection of Bismuth IIIa hilar cholangiocarcinoma.

PubMed

Wu, Wen-Guang; Gu, Jun; Dong, Ping; Lu, Jian-Hua; Li, Mao-Lan; Wu, Xiang-Song; Yang, Jia-Hua; Zhang, Lin; Ding, Qi-Chen; Weng, Hao; Ding, Qian; Liu, Ying-Bin

2013-04-21

At present, radical resection remains the only effective treatment for patients with hilar cholangiocarcinoma. The surgical approach for R0 resection of hilar cholangiocarcinoma is complex and diverse, but for the biliary reconstruction after resection, almost all surgeons use Roux-en-Y hepaticojejunostomy. A viable alternative to Roux-en-Y reconstruction after radical resection of hilar cholangiocarcinoma has not yet been proposed. We report a case of performing duct-to-duct biliary reconstruction after radical resection of Bismuth IIIa hilar cholangiocarcinoma. End-to-end anastomosis between the left hepatic duct and the distal common bile duct was used for the biliary reconstruction, and a single-layer continuous suture was performed along the bile duct using 5-0 prolene. The patient was discharged favorably without biliary fistula 2 wk later. Evidence for tumor recurrence was not found after an 18 mo follow-up. Performing bile duct end-to-end anastomosis in hilar cholangiocarcinoma can simplify the complex digestive tract reconstruction process.

Correlation between Resection Margin and Disease Recurrence with a Restricted Cubic Spline Model in Patients with Resected Hepatocellular Carcinoma.

PubMed

Lee, Woohyung; Han, Ho-Seong; Ahn, Soyeon; Yoon, Yoo-Seok; Cho, Jai Young; Choi, YoungRok

2018-01-17

The relationship between resection margin (RM) and recurrence of resected hepatocellular carcinoma (HCC) is unclear. We reviewed clinical data for 419 patients with HCC. The oncologic outcomes were compared between 2 groups of patients classified according to the inflexion point of the restricted cubic spline plot. The patients were divided according to an RM of <1 cm (n = 233; narrow RM group) or ≥1 cm (n = 186; wide RM group). The 5-year recurrence-free survival (RFS) rate was lower (34.8 vs. 43.8%, p = 0.042) and recurrence near the resection site was more frequent (4.7 vs. 0%, p = 0.010) in the narrow RM group. Patients with multiple lesions, or prior transarterial chemoembolization (TACE) or radiofrequency ablation (RFA) were excluded from subgroup analyses. In patients with a 2-5 cm HCC, the 5-year RFS was greater in the wide RM group (54.4 vs. 32.5%, p = 0.036). Narrow RM (hazard ratio 1.750, 95% CI 1.029-2.976, p = 0.039) was independently associated with disease recurrence. In patients with a single 2-5 cm HCC without prior TACE/RFA, an RM of ≥1 cm was associated with lower risk of recurrence after liver resection. © 2018 S. Karger AG, Basel.

What is the significance of a microscopically positive resection margin in the curative-intent treatment of rectal adenocarcinoma? A retrospective study.

PubMed

Fekete, Z; Muntean, A; Irimie, A; Hica, S; Resiga, L; Todor, N; Nagy, V

2013-01-01

The aim of this study was to analyze the characteristics of patients with rectal cancer operated with a microscopic positive margin (R1) and thus avoid these situations or adapt treatment in these particular cases. We reviewed all the pathology data of resected specimens from patients with rectal or recto-sigmoid cancer operated with curative intent at the Institute of Oncology "Prof. Dr. Ion Chiricuta" between 2000-2011 (763 patients in 12 years) and the pathology files of patients from other institutions referred for adjuvant treatment to our hospital (318 patients). We included patients with anterior resection, Hartmann's procedure and abdomino-perineal resection, but we excluded patients with local excision and patients with R2/R1 at first, but R0 after re-resection (56 patients). We have identified 31 patients with R1, but had to exclude one case from analysis because this patient was lost to follow-up. With surgery alone the local relapse (LR) was unavoidable. In the neoadjuvant chemoradiation (CRT) group 85.7% of the patients did not develop LR despite of R1. In the adjuvant CRT cohort 50% of the patients were LR-free at 2 years after conventional radiotherapy (p<0.01). Based on these results it is concluded that a clear resection margin is extremely important for the local control of rectal cancer, because it cannot be always compensated by adjuvant CRT. In R1 cases neoadjuvant CRT seems to offer better prognosis than adjuvant CRT. To avoid R1 and its consequences a good quality control of total mesorectal excision (TME) is needed and CRT should be done before and not after surgery. R1 after primary surgery needs to be compensated by re-resection if possible, otherwise probably high dose radiotherapy with chemotherapy is needed.

Arteriography after embolization before distal pancreatectomy with en bloc celiac axis resection.

PubMed

Yamagami, Takuji; Yoshimatsu, Rika; Kajiwara, Kenji; Ishikawa, Masaki; Murakami, Yoshiaki; Uemura, Kenichiro; Awai, Kazuo

2015-01-01

To evaluate hemodynamics by arteriographic examinations with and without CT in the stomach wall and liver after preoperative embolization to redistribute blood flow to the stomach and liver, which is unified to be supplied from the superior mesenteric artery, before distal pancreatectomy with en bloc celiac axis resection (DP-CAR). In six patients with locally advanced cancer of the pancreatic body in whom DP-CAR was planned, the left gastric artery and common hepatic artery were embolized with coils. Celiac arteriography and superior mesenteric arteriography with and without CT were performed after embolization. In all six patients, intrahepatic arteries and the left gastric artery were not visualized on celiac arteriography. On both superior mesenteric arteriography and CT obtained while contrast medium was infused via the superior mesenteric artery and which was performed immediately after embolization procedures, the right gastric artery, gastroepiploic artery, gastroduodenal artery, and all hepatic arterial branches were clearly detected. Also the distal part of the left gastric artery close to the embolized point was detected with at least one of the imaging modalities. It was clarified radiologically that preoperative embolization results in increased blood supply to the stomach wall and liver through the pancreatic arcade.

Assessment of margins in resection specimens for head and neck malignancies.

PubMed

Janjua, Omer Sefvan; Ahmed, Waseem; Qureshi, Sana Mehmood; Khan, Tariq Sarfaraz; Ahmed, Ashfaq; Alamgir, Wajiha

2013-04-01

To determine the relative frequency of clear, close and involved margins in resection specimens for head and neck malignancies. An observational study. The Department of Oral and Maxillofacial Surgery, Armed Forces Institute of Dentistry, Rawalpindi and the Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi, from January 2008 to December 2010. Tumour registers and computer data bases in the department of Histopathology of Armed Forces Institute of Pathology, Rawalpindi, were analyzed for the cases of malignancies involving head and neck region that were sent for histopathological analysis after resection in the last three years. Histopathology reports were obtained. The data regarding age, gender, site, type of malignancy and margin status (clear, close or involved) was recorded on specially designed proformas for the study and later on analyzed by using SPSS version 17.0. Results were expressed. A total of 319 cases were registered in the study duration. The age of the patients ranged from 22-90 years (mean 59.5 + 14.1 years). Male to female ratio was 1.53:1. One hundred and thirty six (42.6%) were squamous cell carcinoma (SCC), 163 were basal cell carcinomas (BCC, 51.0%); the rest included 18 salivary gland malignancies (5.7%) and one carcino-sarcoma (0.31%) and chondrosarcoma each. All margins were found clear in 137 patients (42.9%); involved in 168 cases (52.7%) and close in 14 cases (4.4%). Margin clearance could not be achieved in more than 50% cases, this can lead to poor prognosis. Hence, methods should be adopted to improve the margin clearance in various head and neck malignancies.

Management and prognosis of locally recurrent rectal cancer - A national population-based study.

PubMed

Westberg, Karin; Palmer, Gabriella; Hjern, Fredrik; Johansson, Hemming; Holm, Torbjörn; Martling, Anna

2018-01-01

The rate of local recurrence of rectal cancer (LRRC) has decreased but the condition remains a therapeutic challenge. This study aimed to examine treatment and prognosis in patients with LRRC in Sweden. Special focus was directed towards potential differences between geographical regions and time periods. All patients with LRRC as first event, following primary surgery for rectal cancer performed during the period 1995-2002, were included in this national population-based cohort-study. Data were collected from the Swedish Colorectal Cancer Registry and from medical records. The cohort was divided into three time periods, based on the date of diagnosis of the LRRC. In total, 426 patients fulfilled the inclusion criteria. Treatment with curative intent was performed in 149 patients (35%), including 121 patients who had a surgical resection of the LRRC. R0-resection was achieved in 64 patients (53%). Patients with a non-centrally located tumour were more likely to have positive resection margins (R1/R2) (OR 5.02, 95% CI:2.25-11.21). Five-year survival for patients resected with curative intent was 43% after R0-resection and 14% after R1-resection. There were no significant differences in treatment intention or R0-resection rate between time periods or regions. The risk of any failure was significantly higher in R1-resected patients compared with R0-resected patients (HR 2.04, 95% CI:1.22-3.40). A complete resection of the LRRC is essential for potentially curative treatment. Time period and region had no influence on either margin status or prognosis. Copyright © 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Variations in pelvic dimensions do not predict the risk of circumferential resection margin (CRM) involvement in rectal cancer.

PubMed

Salerno, G; Daniels, I R; Brown, G; Norman, A R; Moran, B J; Heald, R J

2007-06-01

The objective of this study was to assess the value of preoperative pelvimetry, using magnetic resonance imaging (MRI), in predicting the risk of an involved circumferential resection margin (CRM) in a group of patients with operable rectal cancer. A cohort of 186 patients from the MERCURY study was selected. These patients' histological CRM status was compared against 14 pelvimetry parameters measured from the preoperative MRI. These measurements were taken by one of the investigators (G.S.), who was blinded to the final CRM status. There was no correlation between the pelvimetry and the CRM status. However, there was a difference in the height of the rectal cancer and the positive CRM rate (p = 0.011). Of 61 patients with low rectal cancer, 10 had positive CRM at histology (16.4% with CI 8.2%-22.1%) compared with 5 of 110 patients with mid/upper rectal cancers (4.5% with CI 0.7%-8.4%). Magnetic resonance imaging can predict clear margins in most cases of rectal cancer. Circumferential resection margin positivity cannot be predicted from pelvimetry in patients with rectal cancer selected for curative surgery. The only predictive factor for a positive CRM in the patients studied was tumor height.

Traumatic tracheobronchial stricture treated with the Eder-Puestow dilator.

PubMed

Erichsen, H G

1980-09-01

A case of tracheobronchial stenosis secondary to trauma is presented. Primary reconstruction resulted in stricture in the distal part of the trachea. Resection and anastomosis was followed by restenosis, which had to be treated endoscopically. Endobronchial resections and forceful dilatations with stiff bronchoscopes were done weekly for about 11 months without lasting benefit. After changing to Eder-Puestow dilators, the dilatations could be done at steadily increasing intervals. This method of dilatation was found to be safe, effective and less traumatic.

What is the best surgical margin for a Basal cell carcinoma: a meta-analysis of the literature.

PubMed

Gulleth, Yusuf; Goldberg, Nelson; Silverman, Ronald P; Gastman, Brian R

2010-10-01

Current management of basal cell carcinoma is surgical excision. Most resections use predetermined surgical margins. The basis of ideal resection margins is almost completely from retrospective data and mainly from small case series. This article presents a systematic analysis from a large pool of data to provide a better basis of determining ideal surgical margin. A systematic analysis was performed on data from 89 articles from a larger group of 973 articles selected from the PubMed database. Relevant inclusion and exclusion criteria were applied to all articles reviewed and the data were entered into a database for statistical analysis. The total number of lesions analyzed was 16,066; size ranged from 3 to 30 mm (mean, 11.7 ± 5.9 mm). Surgical margins ranged from 1 to 10 mm (mean, 3.9 ± 1.4 mm). Negative surgical margins ranged 45 to 100 percent (mean, 86 ± 12 percent). Recurrence rates for 5-, 4-, 3-, and 2-mm surgical margins were 0.39, 1.62, 2.56, and 3.96 percent, respectively. Pooled data for incompletely excised margins have an average recurrence rate of 27 percent. A 3-mm surgical margin can be safely used for nonmorpheaform basal cell carcinoma to attain 95 percent cure rates for lesions 2 cm or smaller. A positive pathologic margin has an average recurrence rate of 27 percent.

The role of adjuvant treatment in early-stage oral cavity squamous cell carcinoma: An international collaborative study.

PubMed

Fridman, Eran; Na'ara, Shorook; Agarwal, Jaiprakash; Amit, Moran; Bachar, Gideon; Villaret, Andrea Bolzoni; Brandao, Jose; Cernea, Claudio R; Chaturvedi, Pankaj; Clark, Jonathan; Ebrahimi, Ardalan; Fliss, Dan M; Jonnalagadda, Sashikanth; Kohler, Hugo F; Kowalski, Luiz P; Kreppel, Matthias; Liao, Chun-Ta; Patel, Snehal G; Patel, Raj P; Robbins, K Thomas; Shah, Jatin P; Shpitzer, Thomas; Yen, Tzu-Chen; Zöller, Joachim E; Gil, Ziv

2018-05-14

Up to half of patients with oral cavity squamous cell carcinoma (OCSCC) have stage I to II disease. When adequate resection is attained, no further treatment is needed; however, re-resection or radiotherapy may be indicated for patients with positive or close margins. This multicenter study evaluated the outcomes and role of adjuvant treatment in patients with stage I to II OCSCC. Overall survival (OS), disease-specific survival, local-free survival, and disease-free survival rates were calculated with Kaplan-Meier analysis. Of 1257 patients with T1-2N0M0 disease, 33 (2.6%) had positive margins, and 205 (16.3%) had close margins. The 5-year OS rate was 80% for patients with clear margins, 52% for patients with close margins, and 63% for patients with positive margins (P < .0001). In a multivariate analysis, age, depth of invasion, and margins were independent predictors of outcome. Close margins were associated with a >2-fold increase in the risk of recurrence (P < .0001). The multivariate analysis revealed that adjuvant treatment significantly improved the outcomes of patients with close/positive margins (P = .002 to .03). Patients with stage I to II OCSCC and positive/close margins have poor long-term outcomes. For this population, adjuvant treatment may be associated with improved survival. Cancer 2018. © 2018 American Cancer Society. © 2018 American Cancer Society.

Robot-assisted pancreatic surgery: a systematic review of the literature.

PubMed

Strijker, Marin; van Santvoort, Hjalmar C; Besselink, Marc G; van Hillegersberg, Richard; Borel Rinkes, Inne H M; Vriens, Menno R; Molenaar, I Quintus

2013-01-01

To potentially improve outcomes in pancreatic resection, robot-assisted pancreatic surgery has been introduced. This technique has possible advantages over laparoscopic surgery, such as its affordance of three-dimensional vision and increased freedom of movement of instruments. A systematic review was performed to assess the safety and feasibility of robot-assisted pancreatic surgery. The literature published up to 30 September 2011 was systematically reviewed, with no restrictions on publication date. Studies reporting on over five patients were included. Animal studies, studies not reporting morbidity and mortality, review articles and conference abstracts were excluded. Data were extracted and weighted means were calculated. A total of 499 studies were screened, after which eight cohort studies reporting on a total of 251 patients undergoing robot-assisted pancreatic surgery were retained for analysis. Weighted mean operation time was 404 ± 102 min (510 ± 107 min for pancreatoduodenectomy only). The rate of conversion was 11.0% (16.4% for pancreatoduodenectomy only). Overall morbidity was 30.7% (n = 77), most frequently involving pancreatic fistulae (n = 46). Mortality was 1.6%. Negative surgical margins were obtained in 92.9% of patients. The rate of spleen preservation in distal pancreatectomy was 87.1%. Robot-assisted pancreatic surgery seems to be safe and feasible in selected patients and, in left-sided resections, may increase the rate of spleen preservation. Randomized studies should compare the respective outcomes of robot-assisted, laparoscopic and open pancreatic surgery. © 2012 International Hepato-Pancreato-Biliary Association.

Robot-assisted pancreatic surgery: a systematic review of the literature

PubMed Central

Strijker, Marin; van Santvoort, Hjalmar C; Besselink, Marc G; van Hillegersberg, Richard; Borel Rinkes, Inne HM; Vriens, Menno R; Molenaar, I Quintus

2013-01-01

Background To potentially improve outcomes in pancreatic resection, robot-assisted pancreatic surgery has been introduced. This technique has possible advantages over laparoscopic surgery, such as its affordance of three-dimensional vision and increased freedom of movement of instruments. A systematic review was performed to assess the safety and feasibility of robot-assisted pancreatic surgery. Methods The literature published up to 30 September 2011 was systematically reviewed, with no restrictions on publication date. Studies reporting on over five patients were included. Animal studies, studies not reporting morbidity and mortality, review articles and conference abstracts were excluded. Data were extracted and weighted means were calculated. Results A total of 499 studies were screened, after which eight cohort studies reporting on a total of 251 patients undergoing robot-assisted pancreatic surgery were retained for analysis. Weighted mean operation time was 404 ± 102 min (510 ± 107 min for pancreatoduodenectomy only). The rate of conversion was 11.0% (16.4% for pancreatoduodenectomy only). Overall morbidity was 30.7% (n = 77), most frequently involving pancreatic fistulae (n = 46). Mortality was 1.6%. Negative surgical margins were obtained in 92.9% of patients. The rate of spleen preservation in distal pancreatectomy was 87.1%. Conclusions Robot-assisted pancreatic surgery seems to be safe and feasible in selected patients and, in left-sided resections, may increase the rate of spleen preservation. Randomized studies should compare the respective outcomes of robot-assisted, laparoscopic and open pancreatic surgery. PMID:23216773

Solid pseudopapillary neoplasm of the pancreas: CT imaging features and radiologic-pathologic correlation.

PubMed

Anil, Gopinathan; Zhang, Junwei; Al Hamar, Nawal Ebrahim; Nga, Min En

2017-01-01

We aimed to evaluate the imaging features of solid pseudopapillary neoplasm (SPN) of the pancreas with an emphasis on radiologic-pathologic correlation. Ten patients (all female; mean age, 32 years) with histologic or cytologic diagnosis of SPN encountered between January 2007 and December 2013 were included in this study. Preoperative computed tomography (CT) images were reviewed for location, attenuation, enhancement pattern, margin, shape, size, morphology, presence of capsule and calcification. CT appearances were correlated with histopathologic findings. Tumors in the distal pancreatic body and tail had a tendency to be larger (mean size 12.6 cm vs. 4.0 cm). Six of the nine tumors that were resected had a fibrous pseudocapsule at histology, five of which could be identified on CT scan. Eight lesions had mixed hypoenhancing solid components and cystic areas corresponding to tumor necrosis and hemorrhage. The two smallest lesions were purely solid and nonencapsulated. Varied patterns of calcification were seen in four tumors. Three of the four pancreatic tail tumors invaded the spleen. At a median follow-up of 53 months, there was no evidence of recurrence in the nine patients who underwent surgical resection of the tumor. A mixed solid and cystic pancreatic mass in a young woman is suggestive of SPN. However, smaller lesions may be completely solid. Splenic invasion can occur in pancreatic tail SPNs; however, in this series it did not adversely affect the long-term outcome.

Osteosarcoma of the spine: prognostic variables for local recurrence and overall survival, a multicenter ambispective study.

PubMed

Dekutoski, Mark B; Clarke, Michelle J; Rose, Peter; Luzzati, Alessandro; Rhines, Laurence D; Varga, Peter P; Fisher, Charles G; Chou, Dean; Fehlings, Michael G; Reynolds, Jeremy J; Williams, Richard; Quraishi, Nasir A; Germscheid, Niccole M; Sciubba, Daniel M; Gokaslan, Ziya L; Boriani, Stefano

2016-07-01

OBJECTIVE Primary spinal osteosarcomas are rare and aggressive neoplasms. Poor outcomes can occur, as obtaining marginal margins is technically demanding; further Enneking-appropriate en bloc resection can have significant morbidity. The goal of this study is to identify prognostic variables for local recurrence and mortality in surgically treated patients diagnosed with a primary osteosarcoma of the spine. METHODS A multicenter ambispective database of surgically treated patients with primary spine osteosarcomas was developed by AOSpine Knowledge Forum Tumor. Patient demographic, diagnosis, treatment, perioperative morbidity, local recurrence, and cross-sectional survival data were collected. Tumors were classified in 2 cohorts: Enneking appropriate (EA) and Enneking inappropriate (EI), as defined by pathology margin matching Enneking-recommended surgical margins. Prognostic variables were analyzed in reference to local recurrence and survival. RESULTS Between 1987 and 2012, 58 patients (32 female patients) underwent surgical treatment for primary spinal osteosarcoma. Patients were followed for a mean period of 3.5 ± 3.5 years (range 0.5 days to 14.3 years). The median survival for the entire cohort was 6.7 years postoperative. Twenty-four (41%) patients died, and 17 (30%) patients suffered a local recurrence, 10 (59%) of whom died. Twenty-nine (53%) patients underwent EA resection while 26 (47%) patients underwent EI resection with a postoperative median survival of 6.8 and 3.7 years, respectively (p = 0.048). EI patients had a higher rate of local recurrence than EA patients (p = 0.001). Patient age, previous surgery, biopsy type, tumor size, spine level, and chemotherapy timing did not significantly influence recurrence and survival. CONCLUSIONS Osteosarcoma of the spine presents a significant challenge, and most patients die in spite of aggressive surgery. There is a significant decrease in recurrence and an increase in survival with en bloc resection (EA) when compared with intralesional resection (EI). The effect of adjuvant and neoadjuvant chemotherapeutics, as well as method of biopsy, requires further exploration.

A multicenter cohort study of spinal osteoid osteomas: results of surgical treatment and analysis of local recurrence.

PubMed

Quraishi, Nasir A; Boriani, Stefano; Sabou, Silviu; Varga, Peter P; Luzzati, Alessandro; Gokaslan, Ziya L; Fehlings, Michael G; Fisher, Charles G; Dekutoski, Mark B; Rhines, Laurence D; Reynolds, Jeremy J; Germscheid, Niccole M; Bettegowda, Chetan; Williams, Richard P

2017-03-01

Spinal osteoid osteomas are benign primary tumors arising predominantly from the posterior column of the spine. These "osteoblastic" lesions have traditionally been treated with intralesional excision. The purpose of the present study was to review the treatment and local recurrence rates for symptomatic spinal osteoid osteomas. Multicenter ambispective cross-sectional observational cohort study. During the study period, a total of 84 patients (65 males, 19 females) were diagnosed with a spinal osteoid osteoma and received surgical treatment. The mean age at surgery was 21.8 ± 9.0 years (range: 6.7-52.4 years) and the mean follow-up was 2.7 years (13 days-14.5 years). Local recurrence, perioperative morbidity, and cross-sectional survival. Using the AOSpine Knowledge Forum Tumor multicenter ambispective database, surgically treated osteoid osteoma cases were identified. Patient demographic, clinical and diagnostic, treatment, local recurrence, perioperative morbidity, and cross-sectional survival data were collected and retrieved. Descriptive statistics were summarized using mean/standard deviation or frequency/percentage. In our study, most of the tumors were localized in the mobile spine (81 of 84 [96%]); all patients reported pain as a symptom. According to the postoperative assessment, 10 (12%) patients received an en bloc resection with marginal or wide margins, whereas two (2%) patients received en bloc resections with intralesional margins, 69 (82%) patients were treated by piecemeal "intralesional" resection, and three (4%) patients were not assessed. A total of six patients (7%) experienced a local recurrence, all of which occurred in patients who had received an intralesional resection. Benign bone-forming tumors of the spine are uncommon. Most patients in our series underwent a piecemeal resection with intralesional margins. This remains safe with a low local recurrence rate. En bloc excision may provide more chance of complete excision of the nidus but is not mandatory. The importance of complete excision of the nidus cannot be overemphasized. Copyright © 2016 Elsevier Inc. All rights reserved.

Adenoid cystic carcinoma of the skull base: results with an aggressive multidisciplinary approach.

PubMed

Ramakrishna, Rohan; Raza, Shaan M; Kupferman, Michael; Hanna, Ehab; DeMonte, Franco

2016-01-01

OBJECT Adenoid cystic carcinoma (ACC) is a locally aggressive tumor of salivary gland origin. Little data exist to guide treatment when this tumor extends to involve the structures of the skull base. METHODS Fifty-one patients with a diagnosis of ACC affecting the skull base were identified from a prospective database at MD Anderson Cancer Center (from 1992 to 2010). RESULTS Median follow-up for study patients was 6.75 years. The 5- and 10-year overall survival (OS) rates were 78% and 50%, respectively. Sixty-six percent of patients had progression of their disease. The 5- and 10-year progression-free survival (PFS) rates were 46.7% and 21.0%, respectively. Gross-total resection was achieved in 75% of patients, with 49% having microscopically negative margins at the time of first operation. On univariate analysis, resections with microscopically negative margins were associated with a significant OS advantage (20.1 ± 3.3 years) compared with resections that left residual disease, even if microscopic (10.3 ± 1.6 years, p = 0.035). In patients who underwent reoperation, the effect persisted, with improved OS in those with negative margins (21.4 ± 0.0 vs 16.7 ± 4.0 years, p = 0.06). The use of adjuvant radiotherapy was associated with an OS advantage (16.2 ± 2.5 vs 5.5 ± 2.2 years, p = 0.03) at initial diagnosis and improved PFS (7.8 ± 1.0 vs 2.1 ± 0.62 years, p = 0.005), whereas repeat irradiation provided no benefit. The use of adjuvant chemotherapy at diagnosis or at recurrence was not associated with any significant advantage. Multivariate analysis revealed margin-negative resection at initial operation and at recurrence retained OS significance, even after controlling for age, radiation therapy, and T stage. CONCLUSIONS ACC of the skull base is best treated with a multidisciplinary approach aimed at maximal, safe resection. Adjuvant radiotherapy should be offered, whereas chemotherapy does not confer benefit.

Dna2 initiates resection at clean DNA double-strand breaks

PubMed Central

Paudyal, Sharad C.; Li, Shan; Yan, Hong; Hunter, Tony

2017-01-01

Abstract Nucleolytic resection of DNA double-strand breaks (DSBs) is essential for both checkpoint activation and homology-mediated repair; however, the precise mechanism of resection, especially the initiation step, remains incompletely understood. Resection of blocked ends with protein or chemical adducts is believed to be initiated by the MRN complex in conjunction with CtIP through internal cleavage of the 5′ strand DNA. However, it is not clear whether resection of clean DSBs with free ends is also initiated by the same mechanism. Using the Xenopus nuclear extract system, here we show that the Dna2 nuclease directly initiates the resection of clean DSBs by cleaving the 5′ strand DNA ∼10–20 nucleotides away from the ends. In the absence of Dna2, MRN together with CtIP mediate an alternative resection initiation pathway where the nuclease activity of MRN apparently directly cleaves the 5′ strand DNA at more distal sites. MRN also facilitates resection initiation by promoting the recruitment of Dna2 and CtIP to the DNA substrate. The ssDNA-binding protein RPA promotes both Dna2- and CtIP–MRN-dependent resection initiation, but a RPA mutant can distinguish between these pathways. Our results strongly suggest that resection of blocked and clean DSBs is initiated via distinct mechanisms. PMID:28981724

Safety of laparoscopic colorectal surgery in a low-volume setting: review of early and late outcome.

PubMed

Gandy, Robert C; Berney, Christophe R

2014-01-01

Background. There is increasing evidence suggesting that the laparoscopic technique is the treatment of choice for large bowel resection, including for malignancy. The purpose of the study was to assess whether general surgeons, with particular skills in advanced laparoscopy, can adequately provide safe laparoscopic colorectal resections in a low-volume setting. Methods. A retrospective review of prospectively collected case series of all laparoscopic colorectal resections performed under the care of a single general surgeon is presented. The primary endpoint was postoperative clinical outcome in terms of morbidity and mortality. Secondary endpoints were adequacy of surgical margins and number of lymph nodes harvested for colorectal cancer cases. Results. Seventy-three patients underwent 75 laparoscopic resections between March, 2003, and May, 2011. There was no elective mortality and the overall 30-day postoperative morbidity was 9.3%. Conversion and anastomotic leakage rates were both 1.3%, respectively. None of the malignant cases had positive margins and the median number of lymph nodes retrieved was 17. Conclusions. Our results support the view that general surgeons with advanced skills in minimally invasive surgery may safely perform laparoscopic colorectal resection in a low-volume setting in carefully selected patient cases.

Safety of Laparoscopic Colorectal Surgery in a Low-Volume Setting: Review of Early and Late Outcome

PubMed Central

Gandy, Robert C.; Berney, Christophe R.

2014-01-01

Background. There is increasing evidence suggesting that the laparoscopic technique is the treatment of choice for large bowel resection, including for malignancy. The purpose of the study was to assess whether general surgeons, with particular skills in advanced laparoscopy, can adequately provide safe laparoscopic colorectal resections in a low-volume setting. Methods. A retrospective review of prospectively collected case series of all laparoscopic colorectal resections performed under the care of a single general surgeon is presented. The primary endpoint was postoperative clinical outcome in terms of morbidity and mortality. Secondary endpoints were adequacy of surgical margins and number of lymph nodes harvested for colorectal cancer cases. Results. Seventy-three patients underwent 75 laparoscopic resections between March, 2003, and May, 2011. There was no elective mortality and the overall 30-day postoperative morbidity was 9.3%. Conversion and anastomotic leakage rates were both 1.3%, respectively. None of the malignant cases had positive margins and the median number of lymph nodes retrieved was 17. Conclusions. Our results support the view that general surgeons with advanced skills in minimally invasive surgery may safely perform laparoscopic colorectal resection in a low-volume setting in carefully selected patient cases. PMID:24799890

Site-specific range uncertainties caused by dose calculation algorithms for proton therapy

NASA Astrophysics Data System (ADS)

Schuemann, J.; Dowdell, S.; Grassberger, C.; Min, C. H.; Paganetti, H.

2014-08-01

The purpose of this study was to assess the possibility of introducing site-specific range margins to replace current generic margins in proton therapy. Further, the goal was to study the potential of reducing margins with current analytical dose calculations methods. For this purpose we investigate the impact of complex patient geometries on the capability of analytical dose calculation algorithms to accurately predict the range of proton fields. Dose distributions predicted by an analytical pencil-beam algorithm were compared with those obtained using Monte Carlo (MC) simulations (TOPAS). A total of 508 passively scattered treatment fields were analyzed for seven disease sites (liver, prostate, breast, medulloblastoma-spine, medulloblastoma-whole brain, lung and head and neck). Voxel-by-voxel comparisons were performed on two-dimensional distal dose surfaces calculated by pencil-beam and MC algorithms to obtain the average range differences and root mean square deviation for each field for the distal position of the 90% dose level (R90) and the 50% dose level (R50). The average dose degradation of the distal falloff region, defined as the distance between the distal position of the 80% and 20% dose levels (R80-R20), was also analyzed. All ranges were calculated in water-equivalent distances. Considering total range uncertainties and uncertainties from dose calculation alone, we were able to deduce site-specific estimations. For liver, prostate and whole brain fields our results demonstrate that a reduction of currently used uncertainty margins is feasible even without introducing MC dose calculations. We recommend range margins of 2.8% + 1.2 mm for liver and prostate treatments and 3.1% + 1.2 mm for whole brain treatments, respectively. On the other hand, current margins seem to be insufficient for some breast, lung and head and neck patients, at least if used generically. If no case specific adjustments are applied, a generic margin of 6.3% + 1.2 mm would be needed for breast, lung and head and neck treatments. We conclude that the currently used generic range uncertainty margins in proton therapy should be redefined site specific and that complex geometries may require a field specific adjustment. Routine verifications of treatment plans using MC simulations are recommended for patients with heterogeneous geometries.

Midterm Follow-up of Treating Volar Marginal Rim Fractures with Variable Angle Lcp Volar Rim Distal Radius Plates.

PubMed

Goorens, Chul Ki; Geeurickx, Stijn; Wernaers, Pascal; Staelens, Barbara; Scheerlinck, Thierry; Goubau, Jean

2017-06-01

Specific treatment of the volar marginal rim fragment of distal radius fractures avoids occurance of volar radiocarpal dislocation. Although several fixation systems are available to capture this fragment, adequately maintaining internal fixation is difficult. We present our experience of the first 10 cases using the 2.4 mm variable angle LCP volar rim distal radius plate (Depuy Synthes®, West Chester, US), a low-profile volar rim-contouring plate designed for distal plate positioning and stable buttressing of the volar marginal fragment. Follow-up patient satisfaction, range of motion, grips strength, functional scoring with the QuickDASH and residual pain with a numeric rating scale were assessed. Radiological evaluation consisted in evaluating fracture consolidation, ulnar variance, volar angulation and maintenance of the volar rim fixation. The female to male ratio was 5:5 and the mean age was 52.2 (range, 17-80) years. The mean follow-up period was 11 (range, 5-19) months postoperatively. Patient satisfaction was high. The mean total flexion/extension range was 144° (range, 100-180°) compared to the contralateral uninjured side 160° (range, 95-180°). The mean total pronation/supination range was 153° (range, 140-180°) compared to the contralateral uninjured side 170° (range, 155-180°). Mean grip strength was 14 kg (range, 9-22), compared to the contralateral uninjured side 20 kg (range, 12-25 kg). Mean pre-injury level activity QuickDASH was 23 (range, 0-34.1), while post-recovery QuickDASH was 25 (range 0-43.2). Residual pain was 1.5 on the visual numerical pain rating scale. Radiological evaluation revealed in all cases fracture consolidation, satisfactory reconstruction of ulnar variance, volar angulation and volar rim. We encountered no flexor tendon complications, although plate removal was systematically performed after fracture consolidation. The 2.4 mm variable angle LCP volar rim distal radius plates is a valid treatment option for treating the volar marginal fragment in distal radius fractures.

Independent Predictors of Prognosis Based on Oral Cavity Squamous Cell Carcinoma Surgical Margins.

PubMed

Buchakjian, Marisa R; Ginader, Timothy; Tasche, Kendall K; Pagedar, Nitin A; Smith, Brian J; Sperry, Steven M

2018-05-01

Objective To conduct a multivariate analysis of a large cohort of oral cavity squamous cell carcinoma (OCSCC) cases for independent predictors of local recurrence (LR) and overall survival (OS), with emphasis on the relationship between (1) prognosis and (2) main specimen permanent margins and intraoperative tumor bed frozen margins. Study Design Retrospective cohort study. Setting Tertiary academic head and neck cancer program. Subjects and Methods This study included 426 patients treated with OCSCC resection between 2005 and 2014 at University of Iowa Hospitals and Clinics. Patients underwent excision of OCSCC with intraoperative tumor bed frozen margin sampling and main specimen permanent margin assessment. Multivariate analysis of the data set to predict LR and OS was performed. Results Independent predictors of LR included nodal involvement, histologic grade, and main specimen permanent margin status. Specifically, the presence of a positive margin (odds ratio, 6.21; 95% CI, 3.3-11.9) or <1-mm/carcinoma in situ margin (odds ratio, 2.41; 95% CI, 1.19-4.87) on the main specimen was an independent predictor of LR, whereas intraoperative tumor bed margins were not predictive of LR on multivariate analysis. Similarly, independent predictors of OS on multivariate analysis included nodal involvement, extracapsular extension, and a positive main specimen margin. Tumor bed margins did not independently predict OS. Conclusion The main specimen margin is a strong independent predictor of LR and OS on multivariate analysis. Intraoperative tumor bed frozen margins do not independently predict prognosis. We conclude that emphasis should be placed on evaluating the main specimen margins when estimating prognosis after OCSCC resection.

Role of specimen US for predicting resection margin status in breast conserving therapy.

PubMed

Moschetta, M; Telegrafo, M; Introna, T; Coi, L; Rella, L; Ranieri, V; Cirili, A; Stabile Ianora, A A; Angelelli, G

2015-01-01

To assess the diagnostic accuracy of specimen ultrasound (US) for predicting resection margin status in women undergoing breast conserving therapy for US-detected cancer, having the histological findings as the reference standard. A total of 132 consecutive patients (age range, 34-87 years; mean, 51 years) underwent breast-conserving surgery for US-detected invasive breast cancer. All surgical specimens underwent US examination. The presence of lesion within the specimen and its distance from the specimen margins were assessed considering a threshold distance between the lesion and specimen margins of 10 mm. US findings were then compared with the pathological ones and specimen US. Sensitivity, specificity, diagnostic accuracy, positive (PPV) and negative predictive values (NPV) for predicting histological margin status were evaluated, having the histological findings as the reference standard. The histological examination detected invasive ductal carcinoma in 96/132 (73%) cases, invasive lobular carcinoma in 32/132 (24%), mucinous carcinoma in 4/132 (3%). The pathological margin analysis revealed 96/132 (73%) negative margins and 36 (27%) close/positive margins. US examination detected all 132 breast lesions within the surgical specimens. 110 (83%) negative margins and 22 (17%) positive margins were found on US. Sensitivity, specificity, diagnostic accuracy, PPV and NPV of 44%, 94%, 80%, 73% and 82%, respectively, were found for specimen US. Specimen US represents a time and cost saving imaging tool for evaluating the presence of US detected-breast lesion within surgical specimen and for predicting the histological margin status.

21 CFR 888.3810 - Wrist joint ulnar (hemi-wrist) polymer prosthesis.

Code of Federal Regulations, 2014 CFR

2014-04-01

... polyethylene intended to be implanted into the intramedullary canal of the bone and held in place by a suture. Its purpose is to cover the resected end of the distal ulna to control bone overgrowth and to provide...

21 CFR 888.3810 - Wrist joint ulnar (hemi-wrist) polymer prosthesis.

Code of Federal Regulations, 2010 CFR

2010-04-01

... polyethylene intended to be implanted into the intramedullary canal of the bone and held in place by a suture. Its purpose is to cover the resected end of the distal ulna to control bone overgrowth and to provide...

21 CFR 888.3810 - Wrist joint ulnar (hemi-wrist) polymer prosthesis.

Code of Federal Regulations, 2013 CFR

2013-04-01

... polyethylene intended to be implanted into the intramedullary canal of the bone and held in place by a suture. Its purpose is to cover the resected end of the distal ulna to control bone overgrowth and to provide...

21 CFR 888.3810 - Wrist joint ulnar (hemi-wrist) polymer prosthesis.

Code of Federal Regulations, 2011 CFR

2011-04-01

... polyethylene intended to be implanted into the intramedullary canal of the bone and held in place by a suture. Its purpose is to cover the resected end of the distal ulna to control bone overgrowth and to provide...

21 CFR 888.3810 - Wrist joint ulnar (hemi-wrist) polymer prosthesis.

Code of Federal Regulations, 2012 CFR

2012-04-01

... polyethylene intended to be implanted into the intramedullary canal of the bone and held in place by a suture. Its purpose is to cover the resected end of the distal ulna to control bone overgrowth and to provide...

Detection of esophageal fiducial marker displacement during radiation therapy with a 2-dimensional on-board imager: analysis of internal margin for esophageal cancer.

PubMed

Fukada, Junichi; Hanada, Takashi; Kawaguchi, Osamu; Ohashi, Toshio; Takeuchi, Hiroya; Kitagawa, Yuko; Seki, Satoshi; Shiraishi, Yutaka; Ogata, Haruhiko; Shigematsu, Naoyuki

2013-03-15

To quantify the interfraction displacement of esophageal fiducial markers for primary esophageal cancer radiation therapy. Orthogonal 2-dimensional (2D) matching records fused to vertebrae were analyzed in clinically staged T1/2N0 esophageal cancer patients undergoing endoscopic clipping as fiducial metal markers. Displacement of the markers between the digitally reconstructed radiographs and on-board kilovoltage images during radiation therapy was analyzed according to direction and esophageal site. Forty-four patients, with 81 markers (10 proximal, 42 middle, and 29 distal), underwent 367 2D matching sessions during radiation therapy. The mean (SD) absolute marker displacement was 0.26 (0.30) cm in the right-left (RL), 0.50 (0.39) cm in the superior-inferior (SI), and 0.24 (0.21) cm in the anterior-posterior (AP) direction. Displacement was significantly larger in the SI than in the RL and AP directions (P<.0001). In the SI direction, mean absolute displacements of the distal, middle, and proximal esophagus were 0.67 (0.45) cm, 0.42 (0.32) cm, and 0.36 (0.30) cm, respectively. Distal esophagus displacement was significantly larger than those of the middle and proximal esophagus (P<.0001). The estimated internal margin to cover 95% of the cases was 0.75 cm in the RL and AP directions. In the SI direction, the margin was 1.25 cm for the proximal and middle esophagus and 1.75 cm for the distal esophagus. The magnitude of interfraction displacement of esophageal clips was larger in the SI direction, particularly in the distal esophagus, but substantial displacement was observed in other directions and at other esophageal sites. It is practical to take estimated movements into account with internal margins, even if vertebrae-based 2D matching is performed. Copyright © 2013 Elsevier Inc. All rights reserved.

TH-A-19A-06: Site-Specific Comparison of Analytical and Monte Carlo Based Dose Calculations

DOE Office of Scientific and Technical Information (OSTI.GOV)

Schuemann, J; Grassberger, C; Paganetti, H

2014-06-15

Purpose: To investigate the impact of complex patient geometries on the capability of analytical dose calculation algorithms to accurately predict dose distributions and to verify currently used uncertainty margins in proton therapy. Methods: Dose distributions predicted by an analytical pencilbeam algorithm were compared with Monte Carlo simulations (MCS) using TOPAS. 79 complete patient treatment plans were investigated for 7 disease sites (liver, prostate, breast, medulloblastoma spine and whole brain, lung and head and neck). A total of 508 individual passively scattered treatment fields were analyzed for field specific properties. Comparisons based on target coverage indices (EUD, D95, D90 and D50)more » were performed. Range differences were estimated for the distal position of the 90% dose level (R90) and the 50% dose level (R50). Two-dimensional distal dose surfaces were calculated and the root mean square differences (RMSD), average range difference (ARD) and average distal dose degradation (ADD), the distance between the distal position of the 80% and 20% dose levels (R80- R20), were analyzed. Results: We found target coverage indices calculated by TOPAS to generally be around 1–2% lower than predicted by the analytical algorithm. Differences in R90 predicted by TOPAS and the planning system can be larger than currently applied range margins in proton therapy for small regions distal to the target volume. We estimate new site-specific range margins (R90) for analytical dose calculations considering total range uncertainties and uncertainties from dose calculation alone based on the RMSD. Our results demonstrate that a reduction of currently used uncertainty margins is feasible for liver, prostate and whole brain fields even without introducing MC dose calculations. Conclusion: Analytical dose calculation algorithms predict dose distributions within clinical limits for more homogeneous patients sites (liver, prostate, whole brain). However, we recommend treatment plan verification using Monte Carlo simulations for patients with complex geometries.« less

Detection of Esophageal Fiducial Marker Displacement During Radiation Therapy With a 2-dimensional On-board Imager: Analysis of Internal Margin for Esophageal Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Fukada, Junichi, E-mail: fukada@rad.med.keio.ac.jp; Hanada, Takashi; Kawaguchi, Osamu

Purpose: To quantify the interfraction displacement of esophageal fiducial markers for primary esophageal cancer radiation therapy. Methods and Materials: Orthogonal 2-dimensional (2D) matching records fused to vertebrae were analyzed in clinically staged T1/2N0 esophageal cancer patients undergoing endoscopic clipping as fiducial metal markers. Displacement of the markers between the digitally reconstructed radiographs and on-board kilovoltage images during radiation therapy was analyzed according to direction and esophageal site. Results: Forty-four patients, with 81 markers (10 proximal, 42 middle, and 29 distal), underwent 367 2D matching sessions during radiation therapy. The mean (SD) absolute marker displacement was 0.26 (0.30) cm in themore » right–left (RL), 0.50 (0.39) cm in the superior–inferior (SI), and 0.24 (0.21) cm in the anterior–posterior (AP) direction. Displacement was significantly larger in the SI than in the RL and AP directions (P<.0001). In the SI direction, mean absolute displacements of the distal, middle, and proximal esophagus were 0.67 (0.45) cm, 0.42 (0.32) cm, and 0.36 (0.30) cm, respectively. Distal esophagus displacement was significantly larger than those of the middle and proximal esophagus (P<.0001). The estimated internal margin to cover 95% of the cases was 0.75 cm in the RL and AP directions. In the SI direction, the margin was 1.25 cm for the proximal and middle esophagus and 1.75 cm for the distal esophagus. Conclusions: The magnitude of interfraction displacement of esophageal clips was larger in the SI direction, particularly in the distal esophagus, but substantial displacement was observed in other directions and at other esophageal sites. It is practical to take estimated movements into account with internal margins, even if vertebrae-based 2D matching is performed.« less

Gallbladder Cancer: expert consensus statement

PubMed Central

Aloia, Thomas A; Járufe, Nicolas; Javle, Milind; Maithel, Shishir K; Roa, Juan C; Adsay, Volkan; Coimbra, Felipe J F; Jarnagin, William R

2015-01-01

An American Hepato-Pancreato-Biliary Association (AHPBA)-sponsored consensus meeting of expert panellists was convened on 15 January 2014 to review current evidence on the management of gallbladder carcinoma in order to establish practice guidelines. In summary, within high incidence areas, the assessment of routine gallbladder specimens should include the microscopic evaluation of a minimum of three sections and the cystic duct margin; specimens with dysplasia or proven cancer should be extensively sampled. Provided the patient is medically fit for surgery, data support the resection of all gallbladder polyps of >1.0 cm in diameter and those with imaging evidence of vascular stalks. The minimum staging evaluation of patients with suspected or proven gallbladder cancer includes contrasted cross-sectional imaging and diagnostic laparoscopy. Adequate lymphadenectomy includes assessment of any suspicious regional nodes, evaluation of the aortocaval nodal basin, and a goal recovery of at least six nodes. Patients with confirmed metastases to N2 nodal stations do not benefit from radical resection and should receive systemic and/or palliative treatments. Primary resection of patients with early T-stage (T1b–2) disease should include en bloc resection of adjacent liver parenchyma. Patients with T1b, T2 or T3 disease that is incidentally identified in a cholecystectomy specimen should undergo re-resection unless this is contraindicated by advanced disease or poor performance status. Re-resection should include complete portal lymphadenectomy and bile duct resection only when needed to achieve a negative margin (R0) resection. Patients with preoperatively staged T3 or T4 N1 disease should be considered for clinical trials of neoadjuvant chemotherapy. Following R0 resection of T2–4 disease in N1 gallbladder cancer, patients should be considered for adjuvant systemic chemotherapy and/or chemoradiotherapy. PMID:26172135

Gallbladder cancer: expert consensus statement.

PubMed

Aloia, Thomas A; Járufe, Nicolas; Javle, Milind; Maithel, Shishir K; Roa, Juan C; Adsay, Volkan; Coimbra, Felipe J F; Jarnagin, William R

2015-08-01

An American Hepato-Pancreato-Biliary Association (AHPBA)-sponsored consensus meeting of expert panellists was convened on 15 January 2014 to review current evidence on the management of gallbladder carcinoma in order to establish practice guidelines. In summary, within high incidence areas, the assessment of routine gallbladder specimens should include the microscopic evaluation of a minimum of three sections and the cystic duct margin; specimens with dysplasia or proven cancer should be extensively sampled. Provided the patient is medically fit for surgery, data support the resection of all gallbladder polyps of >1.0 cm in diameter and those with imaging evidence of vascular stalks. The minimum staging evaluation of patients with suspected or proven gallbladder cancer includes contrasted cross-sectional imaging and diagnostic laparoscopy. Adequate lymphadenectomy includes assessment of any suspicious regional nodes, evaluation of the aortocaval nodal basin, and a goal recovery of at least six nodes. Patients with confirmed metastases to N2 nodal stations do not benefit from radical resection and should receive systemic and/or palliative treatments. Primary resection of patients with early T-stage (T1b-2) disease should include en bloc resection of adjacent liver parenchyma. Patients with T1b, T2 or T3 disease that is incidentally identified in a cholecystectomy specimen should undergo re-resection unless this is contraindicated by advanced disease or poor performance status. Re-resection should include complete portal lymphadenectomy and bile duct resection only when needed to achieve a negative margin (R0) resection. Patients with preoperatively staged T3 or T4 N1 disease should be considered for clinical trials of neoadjuvant chemotherapy. Following R0 resection of T2-4 disease in N1 gallbladder cancer, patients should be considered for adjuvant systemic chemotherapy and/or chemoradiotherapy. © 2015 International Hepato-Pancreato-Biliary Association.

Enucleation and limited pancreatic resection provide long-term cure for insulinoma in multiple endocrine neoplasia type 1.

PubMed

Bartsch, Detlef K; Albers, Max; Knoop, Richard; Kann, Peter H; Fendrich, Volker; Waldmann, Jens

2013-01-01

To assess the characteristics and long-term outcome after surgery in patients with multiple endocrine neoplasia type 1 (MEN1)-associated insulinoma. Retrospective analysis of prospectively collected data of MEN1 patients with organic hyperinsulinism at a tertiary referral center. Thirteen (17%) of 74 patients with MEN1 had organic hyperinsulinism. The median age at diagnosis was 27 (range 9-48) years. In 7 patients insulinoma was the first manifestation of the syndrome. All patients had at least one pancreatic neuroendocrine neoplasm (pNEN) upon imaging, including CT, MRI or endoscopic ultrasonography. Seven patients had solitary lesions upon imaging, 4 patients had one dominant tumor with coexisting multiple small pNENs, and 2 patients had multiple lesions without dominance. Eight patients had limited resections (1 segmental resection, 7 enucleations), 4 subtotal distal pancreatectomies, and 1 patient a partial duodenopancreatectomy. There was no postoperative mortality. Six patients experienced complications, including pancreatic fistula in 5 patients. Pathological examination revealed median three (range 1-14) macro-pNENs sized between 6 and 40 mm, and a total of 14 potentially benign insulinomas were detected in the 13 patients. After median follow-up of 156 months, only 1 patient developed recurrent hyperinsulinism after initial enucleation. Twelve patients developed new pNENs in the pancreatic remnant and 4 patients underwent reoperations (3 for metastatic ZES, 1 for recurrent hyperinsulinism). One of 5 patients with an initial extended pancreatic resection developed insulin-dependent diabetes mellitus. Enucleation and limited resection provide long-term cure for MEN1 insulinoma in patients with solitary or dominant tumors. Subtotal distal pancreatectomy should thus be preserved for patients with multiple pNENs without dominance given the risk of exocrine and endocrine pancreas insufficiency in the mostly young patients. © 2013 S. Karger AG, Basel.

Postoperative Outcomes of Enucleation and Standard Resections in Patients with a Pancreatic Neuroendocrine Tumor.

PubMed

Jilesen, Anneke P J; van Eijck, Casper H J; Busch, Olivier R C; van Gulik, Thomas M; Gouma, Dirk J; van Dijkum, Els J M Nieveen

2016-03-01

Either enucleation or more extended resection is performed to treat patients with pancreatic neuroendocrine tumor (pNET). Aim was to analyze the postoperative complications for each operation separately. Furthermore, independent risk factors for complications and incidence of pancreatic insufficiency were analyzed. Retrospective all resected patients from two academic hospitals in The Netherlands between 1992 and 2013 were included. Postoperative complications were scored by both ISGPS and Clavien-Dindo criteria. Based on tumor location, operations were compared. Independent risk factors for overall complications were identified. During long-term follow-up, pancreatic insufficiency and recurrent disease were analyzed. Tumor enucleation was performed in 60/205 patients (29%), pancreatoduodenectomy in 65/205 (31%), distal pancreatectomy in 72/205 (35%) and central pancreatectomy in 8/205 (4%) patients. Overall complications after tumor enucleation of the pancreatic head and pancreatoduodenectomy were comparable, 24/35 (69%) versus 52/65 (80%). The same was found after tumor enucleation and resection of the pancreatic tail (36 vs.58%). Number of re-interventions and readmissions were comparable between all operations. After pancreatoduodenectomy, 33/65 patients had lymph node metastasis and in patients with tumor size ≤2 cm, 55% had lymph node metastasis. Tumor in the head and BMI ≥25 kg/m(2) were independent risk factors for complications after enucleation. During follow-up, incidence of exocrine and endocrine insufficiency was significant higher after pancreatoduodenectomy (resp. 55 and 19%) compared to the tumor enucleation and distal pancreatectomy (resp. 5 and 7% vs. 8 and 13%). After tumor enucleation 19% developed recurrent disease. Since the complication rate, need for re-interventions and readmissions were comparable for all resections, tumor enucleation may be regarded as high risk. Appropriate operation should be based on tumor size, location, and functional status of the pNET.

Radiographic Outcomes of Dorsal Distraction Distal Radius Plating for Fractures With Dorsal Marginal Impaction.

PubMed

Huish, Eric G; Coury, John G; Ibrahim, Mohamed A; Trzeciak, Marc A

2017-04-01

The purpose of this study is to compare radiographic outcomes of patients treated with dorsal spanning plates with previously reported normal values of radiographic distal radius anatomy and compare the results with prior publications for both external fixation and internal fixation with volar locked plates. Patients with complex distal radius fractures including dorsal marginal impaction pattern necessitating dorsal distraction plating at the discretion of the senior authors (M.A.T. and M.A.I.) from May 30, 2013, to December 29, 2015, were identified and included in the study. Retrospective chart and radiograph review was performed on 19 patients, 11 male and 8 female, with mean age of 47.83 years (22-82). No patients were excluded from the study. All fractures united prior to plate removal. The average time the plate was in place was 80.5 days (49-129). Follow-up radiographs showed average radial inclination of 20.5° (13.2°-25.5°), radial height of 10.7 mm (7.5-14 mm), ulnar variance of -0.3 mm (-2.1 to 3.1 mm), and volar tilt of 7.9° (-3° to 15°). One patient had intra-articular step-off greater than 2 mm. Dorsal distraction plating of complex distal radius fractures yields good radiographic results with minimal complications. In cases of complex distal radius fractures including dorsal marginal impaction where volar plating is not considered adequate, a dorsal distraction plate should be considered as an alternative to external fixation due to reduced risk for infection and better control of volar tilt.

[Pelvic reconstructions after bone tumor resection].

PubMed

Anract, Philippe; Biau, David; Babinet, Antoine; Tomeno, Bernard

2014-02-01

The three more frequent primitive malignant bone tumour which concerned the iliac bone are chondrosarcoma, following Ewing sarcoma and osteosarcoma. Wide resection remains the most important part of the treatment associated with chemotherapy for osteosarcoma and the Ewing sarcoma. Iliac wing resections and obdurate ring don't required reconstruction. However, acetabular resections and iliac wing resection with disruption of the pelvic ring required reconstruction to provide acceptable functional result. Acetabular reconstruction remains high technical demanding challenge. After isolated acetabular resection or associated to obdurate ring, our usual method of reconstruction is homolateral proximal femoral autograft and total hip prosthesis but it is possible to also used : saddle prosthesis, Mac Minn prosthesis with auto or allograft, modular prosthesis or custom made prosthesis, massive allograft with or without prosthesis and femoro-ilac arthrodesis. After resection of the iliac wing plus acetabulum, reconstruction can be performed by femoro-obturatrice and femora-sacral arthrodesis, homolateral proximal femoral autograft and prosthesis, femoral medialisation, massive allograft and massive allograft. Carcinological results are lesser than resection for distal limb tumor, local recurrence rate range 17 to 45%. Functional results after Iliac wing and obdurate ring are good. However, acetabular reconstruction provide uncertain functional results. The lesser results arrive after hemipelvic or acetabular and iliac wing resection-reconstruction, especially when gluteus muscles were also resected. The most favourable results arrive after isolated acetabular or acetabular plus obturateur ring resection-reconstruction.

Combined open proximal and stent-graft distal repair for distal arch aneurysms: an alternative to total debranching.

PubMed

Zierer, Andreas; Sanchez, Luis A; Moon, Marc R

2009-07-01

We present herein a novel, combined, simultaneous open proximal and stent-graft distal repair for complex distal aortic arch aneurysms involving the descending aorta. In the first surgical step, the transverse arch is opened during selective antegrade cerebral perfusion, and a Dacron graft (DuPont, Wilmington, DE) is positioned down the descending aorta in an elephant trunk-like fashion with its proximal free margin sutured circumferentially to the aorta just distal to the left subclavian or left common carotid artery. With the graft serving as the new proximal landing zone, subsequent endovascular repair is performed antegrade during rewarming through the ascending aorta.

Proposal for a new T-stage classification system for distal cholangiocarcinoma: a 10-institution study from the U.S. Extrahepatic Biliary Malignancy Consortium.

PubMed

Postlewait, Lauren M; Ethun, Cecilia G; Le, Nina; Pawlik, Timothy M; Buettner, Stefan; Poultsides, George; Tran, Thuy; Idrees, Kamran; Isom, Chelsea A; Fields, Ryan C; Krasnick, Bradley; Weber, Sharon M; Salem, Ahmed; Martin, Robert C G; Scoggins, Charles; Shen, Perry; Mogal, Harveshp D; Schmidt, Carl; Beal, Eliza; Hatzaras, Ioannis; Vitiello, Gerardo; Cardona, Kenneth; Maithel, Shishir K

2016-10-01

Seventh AJCC distal cholangiocarcinoma T-stage classification inadequately separates patients by survival. This retrospective study aimed to define a novel T-stage system to better stratify patients after resection. Curative-intent pancreaticoduodenectomies for distal cholangiocarcinoma (1/2000-5/2015) at 10 US institutions were included. Relationships between tumor characteristics and overall survival (OS) were assessed and incorporated into a novel T-stage classification. 176 patients (median follow-up: 24mo) were included. Current AJCC T-stage was not associated with OS (T1: 23mo, T2: 20mo, T3: 25mo, T4: 12mo; p = 0.355). Tumor size ≥3 cm and presence of lymphovascular invasion (LVI) were associated with decreased OS on univariate and multivariable analyses. Patients were stratified into 3 groups [T1: size <3 cm and (-)LVI (n = 69; 39.2%); T2: size ≥3 cm and (-)LVI or size <3 cm and (+)LVI (n = 82; 46.6%); and T3: size ≥3 cm and (+)LVI (n = 25; 14.2%)]. Each progressive proposed T-stage was associated with decreased median OS (T1: 35mo; T2: 20mo; T3: 8mo; p = 0.002). Current AJCC distal cholangiocarcinoma T-stage does not adequately stratify patients by survival. This proposed T-stage classification, based on tumor size and LVI, better differentiates patient outcomes after resection and could be considered for incorporation into the next AJCC distal cholangiocarcinoma staging system. Copyright © 2016 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.

Iatrogenic salivary duct injury in head and neck cancer patients: Report of four cases and review of the literature

PubMed Central

Kulyapina, Alena; Ochandiano-Caicoya, Santiago; Navarro-Cuellar, Carlos; Navarro-Vila, Carlos

2014-01-01

Introduction: The lesions of the salivary ducts may be idiopathic, post- traumatic, or iatrogenic and lead to sialocele formation with persistent painful facial swelling or cutaneous fistula formation. No consensus on treatment of this condition exists: the options of treatment include needle aspiration, pressure dressings, antisialogogue therapy, radiotherapy, botulinum toxin and surgical approaches as duct repair, diversion, ligation, different drainage systems and even parotidectomy/submaxilectomy. The management and special features of iatrogenic salivary duct injury in patients with oral cancer who underwent head and neck reconstructive surgery has not been described yet. Material and Methods: We present four cases of iatrogenic lesions of salivary ducts and its management in patients with oral cancer. Conclusions: The iatrogenic lesions of salivary ducts are to be taken into account in patients with oral cancer as the distal ends of salivary ducts could be involved in the margins of surgical resection. Different options of treatment of this complication are described. Key words:Sialocele, oral cancer, salivary duct. PMID:25136433

Optical see-through cancer vision goggles enable direct patient visualization and real-time fluorescence-guided oncologic surgery

PubMed Central

Mondal, Suman B.; Gao, Shengkui; Zhu, Nan; Hebimana-Griffin, LeMoyne; Akers, Walter J.; Liang, Rongguang; Gruev, Viktor; Margenthaler, Julie; Achilefu, Samuel

2017-01-01

Background The inability to directly visualize the patient and surgical site limits the use of current near infrared fluorescence-guided surgery systems for real-time sentinel lymph node biopsy and tumor margin assessment. Methods We evaluated an optical see-through goggle augmented imaging and navigation system (GAINS) for near-infrared fluorescence-guided surgery. Tumor-bearing mice injected with a near infrared cancer-targeting agent underwent fluorescence-guided tumor resection. Female Yorkshire pigs received hind leg intradermal indocyanine green injection and underwent fluorescence-guided popliteal lymph node resection. Four breast cancer patients received 99mTc-sulfur colloid and indocyanine green retroareolarly, before undergoing sentinel lymph node biopsy using radioactive tracking and fluorescence imaging. Three other breast cancer patients received indocyanine green retroareolarly before undergoing standard-of-care partial mastectomy, followed by fluorescence imaging of resected tumor and tumor cavity for margin assessment. Results Using near-infrared fluorescence from the dyes, the optical see-through GAINS accurately identified all mouse tumors, pig lymphatics, and 4 pig popliteal lymph nodes with high signal-to-background ratio. In 4 human breast cancer patients, 11 sentinel lymph nodes were identified with a detection sensitivity of 86.67± 0.27% for radioactive tracking and 100% for GAINS. Tumor margin status was accurately predicted by GAINS in all three patients, including clear margins in patients 1 and 2 and positive margins in patient 3 as confirmed by paraffin embedded section histopathology. Conclusions The optical see-through GAINS prototype enhances near infrared fluorescence-guided surgery for sentinel lymph node biopsy and tumor margin assessment in breast cancer patients without disrupting the surgical workflow in the operating room. PMID:28213790

PubMed Central

VICINI, C.; MONTEVECCHI, F.; D'AGOSTINO, G.; DE VITO, A.

2015-01-01

SUMMARY The primary goal of surgical oncology is to obtain a tumour resection with disease-free margins. Transoral robotic surgery (TORS) for surgical treatment of head-neck cancer is commensurate with standard treatments. However, the likelihood of positive margins after TORS is up to 20.2% in a recent US survey. The aim of this study is to evaluate the efficacy and the feasibility of narrow-band imaging (NBI) during TORS in order to improve the ability to achieve disease-free margins during tumour excision. The present study was conducted at the ENT, Head- Neck Surgery and Oral Surgery Unit, Department of Special Surgery, Morgagni Pierantoni Hospital, Azienda USL Romagna. From March 2008 to January 2015, 333 TORS were carried out for malignant and benign diseases. For the present study, we retrospectively evaluated 58 biopsy-proven squamous cell carcinoma patients who underwent TORS procedures. Patients were divided into 2 groups: (1) 32 who underwent TORS and intra-operative NBI evaluation (NBI-TORS); (2) 21 who underwent TORS with standard intra-operative white-light imaging (WLITORS). Frozen section analysis of margins on surgical specimens showed a higher rate of negative superficial lateral margins in the NBI-TORS group compared with the WLI-TORS group (87.9% vs. 57.9%, respectively, p = 0.02). The sensitivity and specificity of intra-operative use of NBI, respectively, were 72.5% and 66.7% with a negative predictive value of 87.9%. Tumour margin enhancement provided by NBI associated with magnification and 3-dimensional view of the surgical field might increase the capability to achieve an oncologically-safe resection in challenging anatomical areas where minimal curative resection is strongly recommended for function preservation. PMID:26246659

Lack of independent significance of a close (<1 mm) circumferential resection margin involvement in esophageal and junctional cancer.

PubMed

O'Farrell, N J; Donohoe, C L; Muldoon, C; Costelloe, J M; King, S; Ravi, N; Reynolds, J V

2013-08-01

For rectal cancer, an involved circumferential resection margin (CRM), defined as tumor cells within 1 mm of the CRM, is of established prognostic significance. This definition for the esophagus, however, is controversial, with the UK Royal College of Pathologists (RCP) recommending the 1 mm definition, while the College of American Pathologists (CAP) advises that only tumor cells at the cut margin (0 mm) define an incomplete (R1) resection. The aim of this study was to compare the clinical significance of both definitions in patients with pT3 tumors. CAP- and RCP-defined CRM status in patients treated by surgery only or by multimodal therapy was recorded prospectively in a comprehensive database from May 2003 to May 2011. Kaplan-Meier survival curves were generated, and factors affecting survival were assessed by univariate and multivariate analysis. A total of 157 of 340 patients had pT3 esophageal tumors, with RCP-positive CRM in 60 %, and 18 % by CAP. There were no significant differences between RCP-positive CRM and negative margins for node-positive disease, local recurrence, and survival. CAP-positive CRM was associated with positive nodes (P = 0.036) and poorer survival (P = 0.023). Multivariate analysis revealed nodal invasion to be the only independent prognostic variable (P = 0.004). A CRM margin of <1 mm is common in pT3 esophageal tumors, a finding consistent with other reports. The <1 mm definition was not associated with node positivity, local recurrence, or survival, in contrast to actual involvement at the margin, suggesting lack of independent prognostic significance of the RCP definition and possible superiority of the CAP criteria for prospective registration of CRM.

In vivo assessment of high-grade glioma biochemistry using microdialysis: a study of energy-related molecules, growth factors and cytokines.

PubMed

Marcus, Hani J; Carpenter, Keri L H; Price, Stephen J; Hutchinson, Peter J

2010-03-01

Microdialysis enables measurement of the chemistry of the cerebral extracellular fluid. This study's objective was to utilise microdialysis to monitor levels of glucose, lactate, pyruvate, glutamate and glycerol in patients following surgery for intrinsic brain tumours, and to assess the concentration of growth factors, cytokines and other proteins involved in the pathogenesis of high-grade gliomas in vivo. Eight patients with suspected high-grade gliomas were studied. Seven of these underwent resection with one microdialysis catheter placed at the tumour resection margin and, in six of these seven cases, a second microdialysis catheter in macroscopically normal peritumour tissue. The remaining glioma patient had an image-guided biopsy with a single catheter inserted stereotactically at the tumour margin. Histology demonstrated WHO IV glioblastoma in five cases, WHO III anaplastic astrocytoma in two cases, and one cerebral lymphoma. In the high-grade gliomas (WHO IV and III), tumour margin microdialysates consistently showed significantly lower glucose, higher lactate/pyruvate (L/P) ratio, higher glutamate and higher glycerol, relative to peritumour microdialysates (P < 0.05). These results indicate that malignant glioma margin tissue is metabolically extremely active. There was great variability in the microdialysate concentrations of growth factors (TGFalpha, EGF, VEGF), cytokines (IL-1alpha, IL-1beta, IL-1ra, IL-6, IL-8), matrix metalloproteinases (MMP-2, MMP-9) and their endogenous inhibitors (TIMP-1, TIMP-2). Notably, microdialysates from the glioma resection margin demonstrated significantly higher IL-8 concentration and higher MMP-2/TIMP-1 ratio when compared to peritumour microdialysates (P < 0.05), suggesting an environment favouring invasion and angiogenesis at the tumour margin. Microdialysis is a promising technique to study in vivo glioma metabolism, and may assist in the development of new therapies.

Optical See-Through Cancer Vision Goggles Enable Direct Patient Visualization and Real-Time Fluorescence-Guided Oncologic Surgery.

PubMed

Mondal, Suman B; Gao, Shengkui; Zhu, Nan; Habimana-Griffin, LeMoyne; Akers, Walter J; Liang, Rongguang; Gruev, Viktor; Margenthaler, Julie; Achilefu, Samuel

2017-07-01

The inability to visualize the patient and surgical site directly, limits the use of current near infrared fluorescence-guided surgery systems for real-time sentinel lymph node biopsy and tumor margin assessment. We evaluated an optical see-through goggle augmented imaging and navigation system (GAINS) for near-infrared, fluorescence-guided surgery. Tumor-bearing mice injected with a near infrared cancer-targeting agent underwent fluorescence-guided, tumor resection. Female Yorkshire pigs received hind leg intradermal indocyanine green injection and underwent fluorescence-guided, popliteal lymph node resection. Four breast cancer patients received 99m Tc-sulfur colloid and indocyanine green retroareolarly before undergoing sentinel lymph node biopsy using radioactive tracking and fluorescence imaging. Three other breast cancer patients received indocyanine green retroareolarly before undergoing standard-of-care partial mastectomy, followed by fluorescence imaging of resected tumor and tumor cavity for margin assessment. Using near-infrared fluorescence from the dyes, the optical see-through GAINS accurately identified all mouse tumors, pig lymphatics, and four pig popliteal lymph nodes with high signal-to-background ratio. In 4 human breast cancer patients, 11 sentinel lymph nodes were identified with a detection sensitivity of 86.67 ± 0.27% for radioactive tracking and 100% for GAINS. Tumor margin status was accurately predicted by GAINS in all three patients, including clear margins in patients 1 and 2 and positive margins in patient 3 as confirmed by paraffin-embedded section histopathology. The optical see-through GAINS prototype enhances near infrared fluorescence-guided surgery for sentinel lymph node biopsy and tumor margin assessment in breast cancer patients without disrupting the surgical workflow in the operating room.

Margin adaptation of indirect composite inlays fabricated on flexible dies.

PubMed

Price, R B; Gerrow, J D

2000-03-01

Indirect composite restorations can be made in 1 appointment using a flexible die. Interactions between different impression materials and flexible die materials may affect the accuracy of fit and margin adaptation of the restoration. This study compared the margin adaptation of composite inlays made using the following 5 impression/flexible die material combinations; condensation silicone/polyvinyl siloxane (CS/PVS), wash viscosity polyvinyl siloxane/medium or heavy viscosity polyvinyl siloxane (PVS/PVS), irreversible hydrocolloid impression/medium viscosity polyvinyl siloxane (IH/PVS), wash viscosity polyvinyl siloxane impression/polyether (PVS/PE), with composite inlays made using a control system of a wash viscosity polyvinyl siloxane impression and a type IV stone die. For each test and control system, 10 impressions were made of a class II composite inlay preparation in a metal master die. One die was made from each impression and one composite inlay was made and finished on each die (a total of 60 inlays). Inlays were placed on the master die and the margin opening at the buccal, distal, and gingival sites was recorded with a measuring microscope (x40 magnification). The overall mean +/- SD margin openings of inlays made from the systems were as follows: PVS wash/PVS heavy viscosity 149.5 +/- 107. 4 microm; PVS wash/PVS medium viscosity 87.4 +/- 63.0 microm; IH/PVS medium viscosity 76.7 +/- 48.9 microm; CS/PVS 73.3 +/- 48.7 microm, PVS wash viscosity/PE 64.0 +/- 44.3 microm, PVS wash viscosity/stone 53.9 +/- 48.3 microm. Composite inlays made using the PVS wash viscosity/PVS heavy viscosity system had significantly larger distal, gingival, and overall mean margin openings than all other inlays (ANOVA and Fisher PLSD test; P =.05). The separating medium required between some impression and die materials did not work consistently. Composite inlays fabricated on dies made of material different than the impression material had mean buccal, distal, gingival, and overall margin openings < or =100 microm. Composite inlays made on the CS/PVS, IH/PVS medium viscosity, PVS wash viscosity/PE flexible dies, and control PVS wash viscosity/stone dies had statistically similar (P =.05) mean buccal, distal, gingival, and overall mean margin openings that were < or =100 microm. Composite inlays made on dies that were made of the same type of material as the impression material (PVS/PVS) had mean gingival margin openings >100 microm that were significantly larger than all other systems tested (P =.05).

A comparison of the marginal fit of In-Ceram, IPS Empress, and Procera crowns.

PubMed

Sulaiman, F; Chai, J; Jameson, L M; Wozniak, W T

1997-01-01

The in vitro marginal fit of three all-ceramic crown systems (In-Ceram, Procera, and IPS Empress) was compared. All crown systems were significantly different from each other at P = 0.05. In-Ceram exhibited the greatest marginal discrepancy (161 microns), followed by Procera (83 microns), and IPS Empress (63 microns). There were no significant differences among the various stages of the crown fabrication: core fabrication, porcelain veneering, and glazing. The facial and lingual margins exhibited significantly larger marginal discrepancies than the mesial and distal margins.

Complete resection of a rectus abdominis muscle invaded by desmoid tumors and subsequent management with an abdominal binder: a case report.

PubMed

Ogawa, Tatsuhiko

2018-02-07

Desmoid-type fibromatosis is characterized by desmoid tumors, which are benign soft tissue tumors that can be locally aggressive but typically do not metastasize. Desmoid tumors can manifest anywhere in the body, and those in the abdominal cavity account for approximately 30 to 50% of all such tumors. Complete resection with free margins has been the standard treatment, but non-surgical therapies have been implemented recently. However, if tumors are strongly invasive and/or persistently recur, radical surgical resection with free margins remains the primary treatment. Unfortunately, radical resection may cause large abdominal defects and hinder reconstruction. Several reports and recommendations have addressed this issue; however, to the best of our knowledge, few reports have described complete resection and the subsequent reconstruction of the rectus abdominis muscle. A 35-year-old Asian woman presented at our hospital with a chief complaint of abdominal pain. She had abdominal desmoid tumors that required complete resection of her rectus abdominis muscle. Due to necrosis in her own reconstructed tissue, we failed to cover her anterior abdominal wall; thus, we used an abdominal binder as a substitute material to avoid exacerbating the incisional hernia and help her generate intra-abdominal pressure. This case report may be informative and helpful for the treatment of patients with desmoid tumors, as managing desmoid-type fibromatosis is difficult.

Sustained methylene blue staining to guide anatomic hepatectomy for hepatocellular carcinoma: Initial experience and technical details.

PubMed

Shou-wang, Cai; Shi-zhong, Yang; Wen-ping, Lv; Geng, Chen; Wan-qing, Gu; Wei-dong, Duan; Wei-yi, Wang; Zhi-qiang, Huang; Jia-hong, Dong

2015-07-01

The boundary of the target hepatic segment within the liver parenchyma cannot be marked by the use of a conventional anatomic hepatectomy approach. This study describes a novel methylene blue staining technique for guiding the anatomic resection of hepatocellular carcinoma (HCC). Between February 2009 and February 2012, anatomic hepatectomy was performed in 106 patients with HCC via a novel, sustained methylene blue staining technique. Sustained staining was achieved by injecting methylene blue into the distal aspect of the portal vein after exposing Glisson's sheath. The hepatic pedicle was immediately ligated, and the hepatic parenchymal transection was performed along the interface between methylene blue stained tissue and unstained tissue. Anatomic hepatectomies included subsegmentectomy (n = 16), monosegmentectomy (n = 57), multisegmentectomy (n = 27), and hemihepatectomy (n = 6). The portal vein was injected successfully with methylene blue in 100% of cases, and complete staining of the target hepatic segment was achieved in 98 of 106 (92.5%) cases. Mean intraoperative bleeding was 360 ± 90 mL, and the postoperative complication rate was 24.5% (26/106). No perioperative mortality occurred. Operative margins were all negative on pathologic examination. Mean duration of postoperative follow-up was 40 months (range, 24-60). No local recurrence (around the operative margin) occurred. This novel technique of achieving sustained staining by injecting methylene blue then immediately ligating the hepatic pedicle is simple and feasible. It can guide the selection of the operative margin during hepatic parenchyma transection to improve the accuracy of anatomic hepatectomy for the treatment of HCC. Copyright © 2015 Elsevier Inc. All rights reserved.

Multicolour versus monocolour inking specimens after pancreaticoduodenectomy for periampullary cancer: A single centre prospective randomised clinical trial.

PubMed

Casadei, Riccardo; Ricci, Claudio; Taffurelli, Giovanni; Pacilio, Carlo Alberto; Santini, Donatella; Di Marco, Mariacristina; Minni, Francesco

2018-03-01

R status represents an important prognostic factors in periampullary cancers. Thus, it is useful to verify if it can be influenced by different techniques of margination. Single-centre, randomised clinical trial of patients affected by periampullary cancer who underwent pancreaticoduodenectomies which included two different types of margination: arm A (multicolour inking) and arm B (monocolour inking). The primary endpoint was the overall R1 resection rate and its difference between the two arms. The secondary endpoints were the R1 resection rate in each margin and its difference between the two arms, and the impact of margin status on survival. Fifty patients were randomised, 41 analysed: 22 in arm A, 19 arm B. The overall R1 status was 61%, without significant differences between the two arms. The margin most commonly involved was the superior mesenteric artery (SMA) (36.6%). A trend in favour of arm B was shown for the superior mesenteric artery margin (arm A = 22.7% versus arm B = 52.6%; P = 0.060). The anterior surface (P = 0.015), SMA (P = 0.047) and pancreatic remnant (P = 0.018) margins significantly influenced disease-free survival. The R status was not influenced by different techniques of margination using a standardised pathological protocol. The SMA margin seemed to be the most important margin for evaluating both R status and disease-free survival. Copyright © 2018. Published by Elsevier Ltd.

Laparoscopic liver resection for malignancy: A review of the literature

PubMed Central

Alkhalili, Eyas; Berber, Eren

2014-01-01

AIM: To review the published literature about laparoscopic liver resection for malignancy. METHODS: A PubMed search was performed for original published studies until June 2013 and original series containing at least 30 patients were reviewed. RESULTS: All forms of hepatic resections have been described ranging from simple wedge resections to extended right or left hepatectomies. The usual approach is pure laparoscopic, but hand-assisted, as well as robotic approaches have been described. Most studies showed comparable results to open resection in terms of operative blood loss, postoperative morbidity and mortality. Many of them showed decreased postoperative pain, shorter hospital stays, and even lower costs. Oncological results including resection margin status and long-term survival were not inferior to open resection. CONCLUSION: In the hands of experienced surgeons, laparoscopic liver resection for malignant lesions is safe and offers some short-term advantages over open resection. Oncologically, similar survival rates have been observed in patients treated with the laparoscopic approach when compared to their open resection counterparts. PMID:25309091

Laparoscopic liver resection for malignancy: a review of the literature.

PubMed

Alkhalili, Eyas; Berber, Eren

2014-10-07

To review the published literature about laparoscopic liver resection for malignancy. A PubMed search was performed for original published studies until June 2013 and original series containing at least 30 patients were reviewed. All forms of hepatic resections have been described ranging from simple wedge resections to extended right or left hepatectomies. The usual approach is pure laparoscopic, but hand-assisted, as well as robotic approaches have been described. Most studies showed comparable results to open resection in terms of operative blood loss, postoperative morbidity and mortality. Many of them showed decreased postoperative pain, shorter hospital stays, and even lower costs. Oncological results including resection margin status and long-term survival were not inferior to open resection. In the hands of experienced surgeons, laparoscopic liver resection for malignant lesions is safe and offers some short-term advantages over open resection. Oncologically, similar survival rates have been observed in patients treated with the laparoscopic approach when compared to their open resection counterparts.

A Compressive Sensing Approach for Glioma Margin Delineation Using Mass Spectrometry

PubMed Central

Gholami, Behnood; Agar, Nathalie Y. R.; Jolesz, Ferenc A.; Haddad, Wassim M.; Tannenbaum, Allen R.

2013-01-01

Surgery, and specifically, tumor resection, is the primary treatment for most patients suffering from brain tumors. Medical imaging techniques, and in particular, magnetic resonance imaging are currently used in diagnosis as well as image-guided surgery procedures. However, studies show that computed tomography and magnetic resonance imaging fail to accurately identify the full extent of malignant brain tumors and their microscopic infiltration. Mass spectrometry is a well-known analytical technique used to identify molecules in a given sample based on their mass. In a recent study, it is proposed to use mass spectrometry as an intraoperative tool for discriminating tumor and non-tumor tissue. Integration of mass spectrometry with the resection module allows for tumor resection and immediate molecular analysis. In this paper, we propose a framework for tumor margin delineation using compressive sensing. Specifically, we show that the spatial distribution of tumor cell concentration can be efficiently reconstructed and updated using mass spectrometry information from the resected tissue. In addition, our proposed framework is model-free, and hence, requires no prior information of spatial distribution of the tumor cell concentration. PMID:22255629

Semi-Autonomous Electrosurgery for Tumor Resection Using a Multi-Degree of Freedom Electrosurgical Tool and Visual Servoing*

PubMed Central

Opfermann, Justin D.; Leonard, Simon; Decker, Ryan S.; Uebele, Nicholas A.; Bayne, Christopher E.; Joshi, Arjun S.; Krieger, Axel

2017-01-01

This paper specifies a surgical robot performing semi-autonomous electrosurgery for tumor resection and evaluates its accuracy using a visual servoing paradigm. We describe the design and integration of a novel, multi-degree of freedom electrosurgical tool for the smart tissue autonomous robot (STAR). Standardized line tests are executed to determine ideal cut parameters in three different types of porcine tissue. STAR is then programmed with the ideal cut setting for porcine tissue and compared against expert surgeons using open and laparoscopic techniques in a line cutting task. We conclude with a proof of concept demonstration using STAR to semi-autonomously resect pseudo-tumors in porcine tissue using visual servoing. When tasked to excise tumors with a consistent 4mm margin, STAR can semi-autonomously dissect tissue with an average margin of 3.67 mm and a standard deviation of 0.89mm. PMID:29503760

Indocyanine Green Fluorescence Navigation Thoracoscopic Metastasectomy for Pulmonary Metastasis of Hepatocellular Carcinoma.

PubMed

Kawakita, Naoya; Takizawa, Hiromitsu; Kondo, Kazuya; Sakiyama, Shoji; Tangoku, Akira

2016-12-20

Indocyanine green can selectively accumulate in primary hepatocellular carcinoma (HCC) and extrahepatic metastases. We report a patient who underwent resection of pulmonary metastasis of HCC using a thoracoscopic near-infrared imaging system and fluorescent navigation surgery. A 66-year-old man with suspicion of pulmonary metastasis of HCC was referred to our hospital. Indocyanine green was injected intravenously at a dose of 0.5 mg/kg body weight, 20 h before thoracoscopic surgery. An endoscopic indocyanine green near-infrared fluorescence imaging system showed clear blue fluorescence, indicating pulmonary metastasis of HCC in a lingular segment. We performed wide wedge resection using the fluorescence image for navigation to confirm the surgical margins. The specimen was histologically confirmed as a pulmonary metastasis of HCC. In conclusion, thoracoscopic indocyanine green near-infrared fluorescence imaging for pulmonary metastases of HCC is useful in identifying tumor locations and ensuring resection margins.

Near-infrared autofluorescence spectroscopy of in vivo soft tissue sarcomas

PubMed Central

Nguyen, John Quan; Gowani, Zain; O'Connor, Maggie; Pence, Isaac; Nguyen, The-Quyen; Holt, Ginger; Mahadevan-Jansen, Anita

2016-01-01

Soft tissue sarcomas (STS) are a rare and heterogeneous group of malignant tumors that are often treated via surgical resection. Inadequate resection can lead to local recurrence and decreased survival rates. In this study, we investigate the hypothesis that near-infrared (NIR) autofluorescence can be utilized for tumor margin analysis by differentiating STS from the surrounding normal tissue. Intraoperative in vivo measurements were acquired from 30 patients undergoing STS resection and were characterized to differentiate between normal tissue and STS. Overall, normal muscle and fat were observed to have the highest and lowest autofluorescence intensities, respectively, with STS falling in between. With the exclusion of well-differentiated liposarcomas, the algorithm's accuracy for classifying muscle, fat, and STS was 93%, 92%, and 88%, respectively. These findings suggest that NIR autofluorescence spectroscopy has potential as a rapid and nondestructive surgical guidance tool that can inform surgeons of suspicious margins in need of immediate re-excision. PMID:26625035

Differentiating retroperitoneal liposarcoma tumors with optical coherence tomography

NASA Astrophysics Data System (ADS)

Lev, Dina; Baranov, Stepan A.; Carbajal, Esteban F.; Young, Eric D.; Pollock, Raphael E.; Larin, Kirill V.

2011-03-01

Liposarcoma (LS) is a rare and heterogeneous group of malignant mesenchymal neoplasms exhibiting characteristics of adipocytic differentiation. Currently, radical surgical resection represents the most effective and widely used therapy for patients with abdominal/retroperitoneal LS, but the presence of contiguous essential organs, such as the kidney, pancreas, spleen, adrenal glands, esophagus or colon, as well as often reoccurrence of LS in A/RP calls for the enhancement of surgical techniques to minimize resection and avoid LS reoccurrences. Difficulty in detecting the margins of neoplasms due to their affinity to healthy fat tissue accounts for the high reoccurrence of LS within A/RP. Nowadays, the microscopic detection of margins is possible only by use of biopsy, and the minimization of surgical resection of healthy tissues is challenging. In this presentation we'll demonstrate the initial OCT results for the imaging and distinction of LS and normal human fat tissues and clear detection of tumor boundaries.

Critical analysis and systematization of rat pancreatectomy terminology.

PubMed

Eulálio, José Marcus Raso; Bon-Habib, Assad Charbel Chequer; Soares, Daiane de Oliveira; Corrêa, Paulo Guilherme Antunes; Pineschi, Giovana Penna Firme; Diniz, Victor Senna; Manso, José Eduardo Ferreira; Schanaider, Alberto

2016-10-01

To critically analyze and standardize the rat pancreatectomy nomenclature variants. It was performed a review of indexed manuscripts in PUBMED from 01/01/1945 to 31/12/2015 with the combined keywords "rat pancreatectomy" and "rat pancreas resection". The following parameters was considered: A. Frequency of publications; B. Purpose of the pancreatectomy in each article; C. Bibliographic references; D. Nomenclature of techniques according to the pancreatic parenchyma resection percentage. Among the 468, the main objectives were to surgically induce diabetes and to study the genes regulations and expressions. Five rat pancreatectomy technique references received 15 or more citations. Twenty different terminologies were identified for the pancreas resection: according to the resected parenchyma percentage (30 to 95%); to the procedure type (total, subtotal and partial); or based on the selected anatomical region (distal, longitudinal and segmental). A nomenclature systematization was gathered by cross-checking information between the main surgical techniques, the anatomic parameters descriptions and the resected parenchyma percentages. The subtotal pancreatectomy nomenclature for parenchymal resection between 80 and 95% establishes a surgical parameter that also defines the total and partial pancreatectomy limits and standardizes these surgical procedures in rats.

Root resection under the surgical field employed for extraction of impacted tooth and management of external resorption.

PubMed

Pai, Ar Vivekananda; Khosla, Manak

2012-07-01

This case report illustrates determination of prognosis and immediate resection carried out, before completing the endodontic therapy, during the surgery employed for managing a nonperiodontal problem. This case showed external pressure resorption in the distobuccal root of maxillary second molar caused by the impingement of impacted third molar. Extraction of third molar was decided when healing was not seen, despite initiating endodontic therapy in second molar. Following elevation of flap and extraction of third molar, the poor prognosis due to severe bone loss around the resorbed root was evident. But due to strategic value of second molar, it was found beneficial to employ resection. Therefore, immediate resection was carried out in the same surgical field before the completion of endodontic therapy. This prevented the need for another surgical entry with its associated trauma to carry out resection separately later. Resection followed by the completion of endodontic therapy and full crown assisted in salvaging the remaining functional portion of the tooth and prevented the occurrence of distal extension with its potential drawbacks.

Drain data to predict clinically relevant pancreatic fistula

PubMed Central

Moskovic, Daniel J; Hodges, Sally E; Wu, Meng-Fen; Brunicardi, F Charles; Hilsenbeck, Susan G; Fisher, William E

2010-01-01

Background Post-operative pancreatic fistula (POPF) is a common and potentially devastating complication of pancreas resection. Management of this complication is important to the pancreas surgeon. Objective The aim of the present study was to evaluate whether drain data accurately predicts clinically significant POPF. Methods A prospectively maintained database with daily drain amylase concentrations and output volumes from 177 consecutive pancreatic resections was analysed. Drain data, demographic and operative data were correlated with POPF (ISGPF Grade: A – clinically silent, B – clinically evident, C – severe) to determine predictive factors. Results Twenty-six (46.4%) out of 56 patients who underwent distal pancreatectomy and 52 (43.0%) out of 121 patients who underwent a Whipple procedure developed a POPF (Grade A-C). POPFs were classified as A (24, 42.9%) and C (2, 3.6%) after distal pancreatectomy whereas they were graded as A (35, 28.9%), B (15, 12.4%) and C (2, 1.7%) after Whipple procedures. Drain data analysis was limited to Whipple procedures because only two patients developed a clinically significant leak after distal pancreatectomy. The daily total drain output did not differ between patients with a clinical leak (Grades B/C) and patients without a clinical leak (no leak and Grade A) on post-operative day (POD) 1 to 7. Although the median amylase concentration was significantly higher in patients with a clinical leak on POD 1–6, there was no day that amylase concentration predicted a clinical leak better than simply classifying all patients as ‘no leak’ (maximum accuracy =86.1% on POD 1, expected accuracy by chance =85.6%, kappa =10.2%). Conclusion Drain amylase data in the early post-operative period are not a sensitive or specific predictor of which patients will develop clinically significant POPF after pancreas resection. PMID:20815856

A "conservative" method of thoracic wall dissection: a proposal for teaching human anatomy.

PubMed

Barberini, Fabrizio; Brunone, Francesca

2008-01-01

The common methods of dissection exposing the thoracic organs include crossing of the wall together with wide resection of its muscular planes. In order to preserve these structures, a little demolishing technique of the thoracic wall is proposed, entering the thoracic cavity without extensive resection of the pectoral muscles. This method is based on the fact that these muscles rise up from the wall, like a bridge connecting the costal plane with the upper limb, and that the pectoralis major shows a segmental constitution. SUPERIOR LIMIT: Resect the sternal manubrium transversely between the 1st and the 2nd rib. The incision is prolonged along the 1st intercostal space, separating the first sterno-costal segment of the pectoralis major from the second one, and involving the intercostal muscles as far as the medial margin of the pectoralis minor. This muscle must be raised up, and the transverse resection continued below its medial margin latero-medially along the 1st intercostal space, to rejoin the cut performed before. Then, the incision of the 1st intercostal space is prolonged below the lateral margin of the pectoralis minor, which must be kept raised up, medio-laterally as far as the anterior axillary line. INFERIOR LIMIT: It corresponds to the inferior border of the thoracic cage, resected from the xiphoid process to the anterior axillary line, together with the sterno-costal insertions of the diaphragm. Then, an incision of the sterno-pericardial ligaments and a median sternotomy from the xiphoid process to the transverse resection of the manubrium should be performed. LATERAL LIMIT: From the point of crossing of the anterior axillary line with the inferior limit, resect the ribs from the 10th to the 2nd one. The lateral part of the pectoralis major must be raised up, so that the costal resection may be continued below it. Then, at the lateral extremity of the superior incision, the first and the second sternocostal segment of the pectoralis major must be divaricated, to resect the 2nd and the 3rd rib. It is helpful increasing the distance between pectoralis major and thoracic wall by adducing the arm on the chest. Finally, open the two halves of the thoracic wall, like shutters of a window rotating on the hinges, formed by the non-resected intercostal muscles and by the intercostal portions of the serratus anterior, along the anterior axillary line.

Effects on the Distal Radioulnar Joint of Ablation of Triangular Fibrocartilage Complex Tears With Radiofrequency Energy.

PubMed

Huber, Michaela; Loibl, Markus; Eder, Christoph; Kujat, Richard; Nerlich, Michael; Gehmert, Sebastian

2016-11-01

This cadaver study investigated the temperature profile in the wrist joint and distal radioulnar joint (DRUJ) during radiofrequency energy (RFE) application for triangular fibrocartilage complex resection. An arthroscopic partial resection of the triangular fibrocartilage complex using monopolar and bipolar RFE was simulated in 14 cadaver limbs. The temperature was recorded simultaneously in the DRUJ and at 6 other anatomic locations of the wrist during RFE application. The mean temperature in the DRUJ was 43.3 ± 8.2°C for the bipolar system in the ablation mode (60 W) and 30.4 ± 3.4°C for the monopolar system in the cut mode (20 W) after 30 seconds. The highest measured temperature in the DRUJ was 54.3°C for the bipolar system and 68.1°C for the monopolar system. The application of RFE for debridement or resection of the triangular fibrocartilage complex in a clinical setting can induce peak temperatures that might cause damage to the cartilage of the DRUJ. Bipolar systems produce higher mean temperatures than monopolar devices. RFE application increases the mean temperature in the DRUJ after 30 seconds to a level that may jeopardize cartilage tissue. Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Effect of proximal versus distal 50% enterectomy on nutritional parameters in rats preconditioned with a high-fat diet or regular chow.

PubMed

Yanala, Ujwal R; Reidelberger, Roger D; Thompson, Jon S; Shostrom, Valerie K; Carlson, Mark A

2015-11-27

Obesity may protect against the nutritional consequences of short bowel syndrome. We hypothesized that rats preconditioned with an obesogenic diet would have better outcomes after surgical induction of short bowel syndrome compared to rats on regular chow. Rats were fed a high-fat diet or regular rat chow for six months, and then underwent 50% proximal, 50% distal, or sham enterectomy. Food intake, weight, and body composition were monitored before and for 4 weeks after surgery. The high-fat diet consistently produced obesity (>25% body fat). All procedures induced weight loss, but there was no discernable difference between resection vs. sham resection. Rats on the high-fat diet had a greater post-resection loss of body fat compared to rats on chow (36 vs. 26 g, respectively). There was a nonsignificant trend of less lean mass loss in the former compared to the latter rats (16 vs. 33 g, respectively). Enterectomy moderated serum ghrelin, GIP, PPY, insulin, and leptin. Intestinal adaptation was not different between obese vs. non-obese rats. Rats preconditioned with the high-fat diet may have had better retention of lean body mass after a surgical procedure compared to rats on chow. The effect of 50% enterectomy was less than expected.

Important technical remarks on distal pancreatectomy with en-bloc celiac axis resection for locally advanced pancreatic body cancer (with video).

PubMed

Tanaka, Eiichi; Hirano, Satoshi; Tsuchikawa, Takahiro; Kato, Kentaro; Matsumoto, Joe; Shichinohe, Toshiaki

2012-03-01

We have already reported the feasibility, safety, and excellent long-term results of distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) for locally advanced pancreatic body cancer. An international standard for the surgical technique of DP-CAR has yet to be established. DP-CAR was carefully performed in 42 patients in Hokkaido University Hospital from 1998 to July 2007. Arterial blood flow alteration and collateral flow development toward the liver and stomach was obtained following preoperative routine transcatheter arterial embolization of the common hepatic artery. The right-sided approach to the superior mesenteric artery and celiac artery, and the preservation of the inferior pancreatoduodenal artery during the dissection of the plexus around the pancreatic head, are the key techniques in DP-CAR. The operative morbidity and mortality were 43 and 4.8%, respectively. R0 resection could be done in 39 (93%) patients. Median operation time and intraoperative blood loss were 478 min and 1030 ml, respectively. Ischemic gastropathy was complicated in 5 (12%) patients, but liver abscess was found in only one patient and no liver failure was encountered. We emphasize again the feasibility and safety of DP-CAR; it should be a treatment of choice for locally advanced pancreatic body cancer.

Does Wrist Arthrodesis With Structural Iliac Crest Bone Graft After Wide Resection of Distal Radius Giant Cell Tumor Result in Satisfactory Function and Local Control?

PubMed

Wang, Tao; Chan, Chung Ming; Yu, Feng; Li, Yuan; Niu, Xiaohui

2017-03-01

Many techniques have been described for reconstruction after distal radius resection for giant cell tumor with none being clearly superior. The favored technique at our institution is total wrist fusion with autogenous nonvascularized structural iliac crest bone graft because it is structurally robust, avoids the complications associated with obtaining autologous fibula graft, and is useful in areas where bone banks are not available. However, the success of arthrodesis and the functional outcomes with this approach, to our knowledge, have only been limitedly reported. (1) What is the success of union of these grafts and how long does it take? (2) How effective is the technique in achieving tumor control? (3) What complications occur with this type of arthrodesis? (4) What are the functional results of wrist arthrodesis by this technique for treating giant cell tumor of the distal radius? Between 2005 and 2013, 48 patients were treated for biopsy-confirmed Campanacci Grade III giant cell tumor of the distal radius. Of those, 39 (81% [39 of 48]) were treated with wrist arthrodesis using autogenous nonvascularized iliac crest bone graft. Of those, 27 (69% [27 of 39]) were available for followup at a minimum of 24 months (mean, 45 months; range, 24-103 months). During that period, the general indications for this approach were Campanacci Grade III and estimated resection length of 8 cm or less. Followup included clinical and radiographic assessment and functional assessment using the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Musculoskeletal Tumor Society (MSTS) score, grip strength, and range of motion at every followup by the treating surgeon and his team. All functional results were from the latest followup of each patient. Union of the distal junction occurred at a mean of 4 months (± 2 months) and union of the proximal junction occurred at a mean of 9 months (± 5 months). Accounting for competing events, at 12 months, the rate of proximal junction union was 56% (95% confidence interval [CI], 35%-72%), whereas it was 67% (95% CI, 45%-82%) at 18 months. In total, 11 of the 27 patients (41%) underwent repeat surgery on the distal radius, including eight patients (30%) who had complications and three (11%) who had local recurrence. The mean DASH score was 9 (± 7) (value range, 0-100, with lower scores representing better function), and the mean MSTS 1987 score was 29 (± 1) (value range, 0-30, with higher scores representing better function) as well as 96% (± 4%) of mean MSTS 1993 score (value range, 0%-100%, with higher scores representing better function). The mean grip strength was 51% (± 23%) of the uninvolved side, whereas the mean arc of forearm rotation was 113° (± 49°). Reconstruction of defects after resection of giant cell tumor of the distal radius with autogenous structural iliac crest bone graft is a facile technique that can be used to achieve favorable functional results with complications and recurrences comparable to those of other reported techniques. We cannot show that this technique is superior to other options, but it seems to be a reasonable option to consider when other reconstruction options such as allografts are not available. Level IV, therapeutic study.

Long-term outcomes in primary spinal osteochondroma: a multicenter study of 27 patients

PubMed Central

Sciubba, Daniel M.; Macki, Mohamed; Bydon, Mohamad; Germscheid, Niccole M.; Wolinsky, Jean-Paul; Boriani, Stefano; Bettegowda, Chetan; Chou, Dean; Luzzati, Alessandro; Reynolds, Jeremy J.; Szövérfi, Zsolt; Zadnik, Patti; Rhines, Laurence D.; Gokaslan, Ziya L.; Fisher, Charles G.; Varga, Peter Paul

2016-01-01

OBJECT Clinical outcomes in patients with primary spinal osteochondromas are limited to small series and sporadic case reports. The authors present data on the first long-term investigation of spinal osteochondroma cases. METHODS An international, multicenter ambispective study on primary spinal osteochondroma was performed. Patients were included if they were diagnosed with an osteochondroma of the spine and received surgical treatment between October 1996 and June 2012 with at least 1 follow-up. Perioperative prognostic variables, including patient age, tumor size, spinal level, and resection, were analyzed in reference to long-term local recurrence and survival. Tumor resections were compared using Enneking appropriate (EA) or Enneking inappropriate surgical margins. RESULTS Osteochondromas were diagnosed in 27 patients at an average age of 37 years. Twenty-two lesions were found in the mobile spine (cervical, thoracic, or lumbar) and 5 in the fixed spine (sacrum). Twenty-three cases (88%) were benign tumors (Enneking tumor Stages 1–3), whereas 3 (12%) exhibited malignant changes (Enneking tumor Stages IA–IIB). Sixteen patients (62%) underwent en bloc treatment—that is, wide or marginal resection—and 10 (38%) underwent intralesional resection. Twenty-four operations (92%) followed EA margins. No one received adjuvant therapy. Two patients (8%) experienced recurrences: one in the fixed spine and one in the mobile spine. Both recurrences occurred in latent Stage 1 tumors following en bloc resection. No osteochondroma-related deaths were observed. CONCLUSIONS In the present study, most patients underwent en bloc resection and were treated as EA cases. Both recurrences occurred in the Stage 1 tumor cohort. Therefore, although benign in character, osteochondromas still require careful management and thorough follow-up. PMID:25793467

Current Dosing Paradigm for Stereotactic Radiosurgery Alone After Surgical Resection of Brain Metastases Needs to Be Optimized for Improved Local Control

DOE Office of Scientific and Technical Information (OSTI.GOV)

Prabhu, Roshan; Shu, Hui-Kuo; Winship Cancer Institute, Emory University, Atlanta, GA

2012-05-01

Purpose: To describe the use of radiosurgery (RS) alone to the resection cavity after resection of brain metastases as an alternative to adjuvant whole-brain radiotherapy (WBRT). Methods and Materials: Sixty-two patients with 64 cavities were treated with linear accelerator-based RS alone to the resection cavity after surgical removal of brain metastases between March 2007 and August 2010. Fifty-two patients (81%) had a gross total resection. Median cavity volume was 8.5 cm{sup 3}. Forty-four patients (71%) had a single metastasis. Median marginal and maximum doses were 18 Gy and 20.4 Gy, respectively. Sixty-one cavities (95%) had gross tumor volume to planningmore » target volume expansion of {>=}1 mm. Results: Six-month and 1-year actuarial local recurrence rates were 14% and 22%, respectively, with a median follow-up period of 9.7 months. Six-month and 1-year actuarial distant brain recurrence, total intracranial recurrence, and freedom from WBRT rates were 31% and 51%, 41% and 63%, and 91% and 74%, respectively. The symptomatic cavity radiation necrosis rate was 8%, with 2 patients (3%) undergoing surgery. Of the 11 local failures, 8 were in-field, 1 was marginal, and 2 were both (defined as in-field if {>=}90% of recurrence within the prescription isodose and marginal if {>=}90% outside of the prescription isodose). Conclusions: The high rate of in-field cavity failure suggests that geographic misses with highly conformal RS are not a major contributor to local recurrence. The current dosing regimen derived from Radiation Therapy Oncology Group protocol 90-05 should be optimized in this patient population before any direct comparison with WBRT.« less

High- and low-dose-rate intraoperative radiotherapy for thoracic malignancies resected with close or positive margins.

PubMed

Fleming, Christopher; Rimner, Andreas; Cohen, Gil'ad N; Woo, Kaitlin M; Zhang, Zhigang; Rosenzweig, Kenneth E; Alektiar, Kaled M; Zelefsky, Michael J; Bains, Manjit S; Wu, Abraham J

2016-01-01

Local recurrence is a significant problem after surgical resection of thoracic tumors. As intraoperative radiotherapy (IORT) can deliver radiation directly to the threatened margin, we have used this therapy in an attempt to reduce local recurrence, using high-dose-rate (HDR) as well as low-dose-rate (LDR) techniques. We performed a retrospective review of patients undergoing LDR ((125)I) mesh placement or HDR ((192)Ir) afterloading therapy during lung tumor resection between 2001 and 2013 at our institution. Competing risks methods were used to estimate the cumulative incidence of local failure. We also assessed possible predictive factors of local failure. Fifty-nine procedures (41 LDR and 18 HDR) were performed on 58 patients. Median follow-up was 55.1 months. Cumulative incidence of local failure at 1, 2, and 3 years was 28.5%, 34.2%, and 34.2%, respectively. Median overall survival was 39.9 months. There was no significant difference in local failure according to margin status, HDR vs. LDR, use of adjuvant external beam radiotherapy, or metastatic vs. primary tumor. Two patients (3.4%) experienced Grade 3+ toxicities likely related to brachytherapy. Additionally, 7 patients experienced Grade 3+ postsurgical complications unlikely related to brachytherapy. IORT is associated with good local control after resection of thoracic tumors otherwise at very high risk for local recurrence. There is a low incidence of severe toxicity attributable to brachytherapy. HDR-IORT appears to have equivalent outcomes to LDR-IORT. HDR or LDR-IORT can, therefore, be considered in situations where the oncologic completeness of thoracic tumor resection is in doubt. Copyright © 2016 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

Salvage Surgery for Locoregional Failure in Anal Squamous Cell Carcinoma.

PubMed

Guerra, Glen R; Kong, Joseph C; Bernardi, Maria-Pia; Ramsay, Robert G; Phillips, Wayne A; Warrier, Satish K; Lynch, A Craig; Ngan, Samuel Y; Heriot, Alexander G

2018-02-01

Anal squamous cell carcinoma is a rare cancer with a high cure rate, making research into the treatment of locoregional failure difficult. The purpose of this study was to examine factors related to local treatment failure and determine the outcomes of patients undergoing local salvage resection. This was a retrospective cohort study. This study was conducted at a quaternary referral center. Patients with anal squamous cell carcinoma treated with chemoradiotherapy between January 1983 and December 2015 were included. The influence of patient-, tumor-, and treatment-related factors on the primary outcome measures of locoregional failure, overall survival, and disease-free survival were investigated. Of 467 patients with anal squamous cell carcinoma, 63 experienced locoregional failure with 41 undergoing salvage resection. Twenty-seven patients (38%) had persistent disease and 36 (62%) developed locoregional recurrence. Multivariate analysis identified tumor stage (HR, 3.16; p < 0.002) as an independent predictor of locoregional failure. Thirty abdominoperineal resections and 11 pelvic exenterations were undertaken with no surgical mortality. At a median follow-up of 20 months (range, 4-150 months), 5-year overall and disease-free survival for the salvage cohort was 51% and 47%. Margin positivity was an independent predictor for relapse post-salvage surgery on multivariate analysis (HR, 20.1; p = 0.027). Nineteen patients (48%) developed further relapse, which included all 10 patients with a positive resection margin, 3 of whom underwent re-resection. Of the 19 patients with relapse, 3 remain alive and 2 have persistent disease. Limitations include the retrospective nature of the database, the prolonged time period of the study, and episodes of incomplete data. Advanced T stage is an independent predictor of local failure in anal squamous cell carcinoma. Most patients can be salvaged, with a positive resection margin being a strong predictor of further relapse and poor outcome. See Video Abstract at http://links.lww.com/DCR/A515.

Improvement of surgical margin with a coupled saline-radio-frequency device for multiple colorectal liver metastases.

PubMed

Ogata, Satoshi; Kianmanesh, Reza; Varma, Deepak; Belghiti, Jacques

2005-01-01

Complete resection of colorectal liver metastases (LM) has been the only curative treatment. However, when LM are multiple and bilobar, only a few patients are candidates for curative surgery. We report on a 53-year-old woman with synchronous multiple and bilobar LM from sigmoidal cancer who became resectable after a multimodal strategy including preoperative systemic chemotherapy and two-step surgery. The spectacular decrease in tumor size after systemic chemotherapy led us to perform two-step surgery, including right portal-vein ligation and left liver metastasectomies, with a coupled saline-radiofrequency device, in order to improve the surgical margin. An extended right hepatectomy was performed later to remove the remaining right liver lesions. The patient was discharged after 28 days without major complication and was recurrence-free 14 months later. We conclude that improving the surgical margin with a coupled saline-radiofrequency device is feasible and effective, avoiding small remnant liver even after multiple tumorectomies. The multimodal strategy, including preoperative chemotherapy, two-step surgery, and tumorectomies, using a coupled saline-radiofrequency device, could increase the number of patients with diffuse bilobar liver metastases who can benefit from liver resection.

Vertical marginal gap evaluation of conventional cast and computer numeric controlled-milled titanium full-arch implant-supported frameworks.

PubMed

Alfadda, Sara A

2014-01-01

To use a novel approach to measure the amount of vertical marginal gap in computer numeric controlled (CNC)-milled titanium frameworks and conventional cast frameworks. Ten cast frameworks were fabricated on the mandibular master casts of 10 patients. Then, 10 CNC-milled titanium frameworks were fabricated by laser scanning the cast frameworks. The vertical marginal gap was measured and analyzed using the Contura-G2 coordinate measuring machine and special computer software. The CNC-milled titanium frameworks showed an overall reduced mean vertical gap compared with the cast frameworks in all five analogs. This difference was highly statistically significant in the distal analogs. The largest mean gap in the cast framework was recorded in the most distal analogs, and the least amount was in the middle analog. Neither of the two types of frameworks provided a completely gap-free superstructure. The CNCmilled titanium frameworks showed a significantly smaller vertical marginal gap than the cast frameworks.

Changes in Sunken Eyes Combined with Blepharoptosis after Levator Resection.

PubMed

Mawatari, Yuki; Fukushima, Mikiko; Kawaji, Takahiro

2017-12-01

This study aims to report the changes in sunken eyes combined with blepharoptosis after levator resection. Analysis involved 60 eyes from 32 patients with sunken eyes combined with blepharoptosis. Advancement of the levator aponeurosis and the Müller's muscle complex (levator resection) was performed in these patients. Area of upper eyelid sulcus (AES) was defined as the area of the upper eyelid shadow. The digital images were converted to black and white using image-processing software (Adobe Photoshop), and the AES was calculated using ImageJ software. In addition, margin reflex distance, eyebrow height (EBH), and AES were measured before and 3 months after surgery to assess the changes in the eyelids. Preoperative AES was significantly correlated to age ( P < 0.0001; r = 0.8062). Sunken eyes were remarkably improved after levator resection in all patients. Mean margin reflex distance significantly increased, whereas mean EBH and mean AES significantly decreased at 3 months after surgery ( P < 0.0001). The AES change was significantly correlated to the EBH change ( P < 0.0001; r = 0.5184). The principal aim of levator resection is to improve upper eyelid height and visual fields; however, this technique can alter the location of the eyebrow and upper orbital fat. The effects fill the hollowness of the upper eyelid and can remarkably improve sunken eyes.

Impact of adjuvant treatment modalities on survival outcomes in curatively resected pancreatic and periampullary adenocarcinoma

PubMed Central

Benekli, Mustafa; Unal, Olcun Umit; Unek, İlkay Tugba; Tastekin, Didem; Dane, Faysal; Algın, Efnan; Ulger, Sukran; Eren, Tulay; Topcu, Turkan Ozturk; Turkmen, Esma; Babacan, Nalan Akgül; Tufan, Gulnihal; Urakci, Zuhat; Ustaalioglu, Basak Oven; Uysal, Ozlem Sonmez; Ercelep, Ozlem Balvan; Taskoylu, Burcu Yapar; Aksoy, Asude; Canhoroz, Mustafa; Demirci, Umut; Dogan, Erkan; Berk, Veli; Balakan, Ozan; Ekinci, Ahmet Şiyar; Uysal, Mukremin; Petekkaya, İbrahim; Ozturk, Selçuk Cemil; Tonyalı, Önder; Çetin, Bülent; Aldemir, Mehmet Naci; Helvacı, Kaan; Ozdemir, Nuriye; Oztop, İlhan; Coskun, Ugur; Uner, Aytug; Ozet, Ahmet; Buyukberber, Suleyman

2015-01-01

Background We examined the impact of adjuvant modalities on resected pancreatic and periampullary adenocarcinoma (PAC). Methods A total of 563 patients who were curatively resected for PAC were retrospectively analyzed between 2003 and 2013. Results Of 563 patients, 472 received adjuvant chemotherapy (CT) alone, chemoradiotherapy (CRT) alone, and chemoradiotherapy plus chemotherapy (CRT-CT) were analyzed. Of the 472 patients, 231 were given CRT-CT, 26 were given CRT, and 215 were given CT. The median recurrence-free survival (RFS) and overall survival (OS) were 12 and 19 months, respectively. When CT and CRT-CT groups were compared, there was no significant difference with respect to both RFS and OS, and also there was no difference in RFS and OS among CRT-CT, CT and CRT groups. To further investigate the impact of radiation on subgroups, patients were stratified according to lymph node status and resection margins. In node-positive patients, both RFS and OS were significantly longer in CRT-CT than CT. In contrast, there was no significant difference between groups when patients with node-negative disease or patients with or without positive surgical margins were considered. Conclusions Addition of radiation to CT has a survival benefit in patients with node-positive disease following pancreatic resection. PMID:26361410

Role of specimen US for predicting resection margin status in breast conserving therapy

PubMed Central

MOSCHETTA, M.; TELEGRAFO, M.; INTRONA, T.; COI, L.; RELLA, L.; RANIERI, V.; CIRILLI, A.; IANORA, A.A. STABILE; ANGELELLI, G.

2015-01-01

Aim To assess the diagnostic accuracy of specimen ultrasound (US) for predicting resection margin status in women undergoing breast conserving therapy for US-detected cancer, having the histological findings as the reference standard. Patients and methods A total of 132 consecutive patients (age range, 34–87 years; mean, 51 years) underwent breast-conserving surgery for US-detected invasive breast cancer. All surgical specimens underwent US examination. The presence of lesion within the specimen and its distance from the specimen margins were assessed considering a threshold distance between the lesion and specimen margins of 10 mm. US findings were then compared with the pathological ones and specimen US. Sensitivity, specificity, diagnostic accuracy, positive (PPV) and negative predictive values (NPV) for predicting histological margin status were evaluated, having the histological findings as the reference standard. Results The histological examination detected invasive ductal carcinoma in 96/132 (73%) cases, invasive lobular carcinoma in 32/132 (24%), mucinous carcinoma in 4/132 (3%). The pathological margin analysis revealed 96/132 (73%) negative margins and 36 (27%) close/positive margins. US examination detected all 132 breast lesions within the surgical specimens. 110 (83%) negative margins and 22 (17%) positive margins were found on US. Sensitivity, specificity, diagnostic accuracy, PPV and NPV of 44%, 94%, 80%, 73% and 82%, respectively, were found for specimen US. Conclusions Specimen US represents a time and cost saving imaging tool for evaluating the presence of US detected-breast lesion within surgical specimen and for predicting the histological margin status. PMID:26712255

Cryo-Assisted Resection En Bloc, and Cryoablation In Situ, of Primary Breast Cancer Coupled With Intraoperative Ultrasound-Guided Tracer Injection: A Preliminary Clinical Study.

PubMed

Korpan, Nikolai N; Xu, Kecheng; Schwarzinger, Philipp; Watanabe, Masashi; Breitenecker, Gerhard; Patrick, Le Pivert

2018-01-01

The aim of the study was to perform cryosurgery on a primary breast tumor, coupled with simultaneous peritumoral and intratumoral tracer injection of a blue dye, to evaluate lymphatic mapping. We explored the ability of our strategy to prevent tumor cells, but not that of injected tracers, to migrate to the lymphovascular drainage during conventional resection of frozen breast malignancies. Seventeen patients aged 51 (14) years (mean [standard deviation]), presenting primary breast cancer with stage I to IV, were randomly selected and treated in The Rudolfinerhaus Private Clinic in Vienna, Austria, and included in this preliminary clinical study. Under intraoperative ultrasound, 14 patients underwent curative cryo-assisted tumor resection en bloc, coupled with peritumoral tracer injection, which consisted of complete tumor freezing and concomitant peritumor injection with a blue dye, before resection and sentinel lymph node dissection (group A). Group B consists of 3 patients previously refused any standard therapy and had palliative tumor cryoablation in situ combined with intratumoral tracer injection. The intraoperative ultrasound facilitated needle positioning and dye injection timing. In group A, the frozen site extruded the dye that was distributed through the unfrozen tumor, the breast tissue, and the resection cavity for 12 patients. One to 4 lymph nodes were stained for 10 of 14 patients. The resection margin was evaluable. Our intraoperative ultrasound-guided performance revealed the injection and migration of a blue dye during the frozen resection en bloc and cryoablation in situ of primary breast tumors. Sentinel lymph node mapping, pathological determination of the tumor, and resection margins were achievable. The study paves the way for intraoperative cryo-assisted therapeutic strategies for breast cancer.

Automating the design of resection guides specific to patient anatomy in knee replacement surgery by enhanced 3D curvature and surface modeling of distal femur shape models.

PubMed

Cerveri, Pietro; Manzotti, Alfonso; Confalonieri, Norberto; Baroni, Guido

2014-12-01

Personalized resection guides (PRG) have been recently proposed in the domain of knee replacement, demonstrating clinical outcome similar or even superior to both manual and navigated interventions. Among the mandatory pre-surgical steps for PRG prototyping, the measurement of clinical landmarks (CL) on the bony surfaces is recognized as a key issue due to lack of standardized methodologies, operator-dependent variability and time expenditure. In this paper, we focus on the reliability and repeatability of an anterior-posterior axis, also known as Whiteside line (WL), of the distal femur proposing automatic surface processing and modeling methods aimed at overcoming some of the major concerns related to the manual identification of such CL on 2D images and 3D models. We show that the measurement of WL, exploiting the principle of mean-shifting surface curvature, is highly repeatable and coherent with clinical knowledge. Copyright © 2014 Elsevier Ltd. All rights reserved.

Overall survival after resection of retroperitoneal sarcoma at academic cancer centers versus community cancer centers: An analysis of the National Cancer Data Base.

PubMed

Berger, Nicholas G; Silva, Jack P; Mogal, Harveshp; Clarke, Callisia N; Bedi, Manpreet; Charlson, John; Christians, Kathleen K; Tsai, Susan; Gamblin, T Clark

2018-02-01

Operative resection remains the definitive curative therapy for retroperitoneal sarcoma. Data published recently show a correlation between improved outcomes for complex oncologic operations and treatment at academic centers. For large retroperitoneal sarcomas, operative resection can be complex and require multidisciplinary care. We hypothesized that survival rates vary between type of treating center for patients undergoing resection for retroperitoneal sarcoma. Patients with stage I to III nonmetastatic retroperitoneal sarcomas who underwent operative resection were identified from the National Cancer Database during the years 2004-2013. Treating centers were categorized as academic cancer centers or community cancer centers. Overall survival was analyzed by log-rank test and graphed using Kaplan-Meier method. A total of 2,762 patients were identified. A majority of patients (59.4%, n = 1,642) underwent resection at an academic cancer centers. Median age at diagnosis was 63 years old. Neoadjuvant radiotherapy was more common at academic cancer centers, while adjuvant radiotherapy was more common at community cancer centers. Improved overall survival was seen at academic cancer centers across all stages compared with community cancer centers (P = .014) but, after multivariable Cox regression analysis, was not a significant independent predictor of survival (hazard ratio = 0.91, 95% confidence interval, 0.79-1.04, P = .171). Academic cancer centers exhibited a greater rate of R0 resection (55.9% vs 47.0%, P < .001) and a lesser odds of positive margins (odds ratio 0.83, 95% confidence interval, 0.69-0.99, P = .044) after multivariable logistic regression. Resection for retroperitoneal sarcoma performed at academic cancer centers was an independent predictor of margin-negative resection but was not a statistically significant factor for survival. This observation suggests that site of care may contribute to some aspect of improved oncologic resection for retroperitoneal sarcoma. Copyright © 2017 Elsevier Inc. All rights reserved.

[Free microvascular fibula graft for skeletal reconstruction of the distal radius: 5 years follow-up after en-bloc resection of a giant cell tumour].

PubMed

Franz, T; Krawczyk, T; Eggli, S; Wartburg, U von

2010-10-01

A giant cell tumour of the distal radius or of the carpal bones, verified by incisional biopsies, should be approached as a low-grade malignancy. Lesions that arise in the bones of the hand or the wrist have a greater propensity to metastasise, and have a higher risk of local recurrence. In this case report we describe a 54-year-old women with a giant cell tumour of the distal radius (Campanacci grade III lesion), having a follow-up of five years without signs of local recurrence or metastatic disease. The general principles of and options for surgical treatment are discussed. © Georg Thieme Verlag KG Stuttgart · New York.

Designing a wearable navigation system for image-guided cancer resection surgery

PubMed Central

Shao, Pengfei; Ding, Houzhu; Wang, Jinkun; Liu, Peng; Ling, Qiang; Chen, Jiayu; Xu, Junbin; Zhang, Shiwu; Xu, Ronald

2015-01-01

A wearable surgical navigation system is developed for intraoperative imaging of surgical margin in cancer resection surgery. The system consists of an excitation light source, a monochromatic CCD camera, a host computer, and a wearable headset unit in either of the following two modes: head-mounted display (HMD) and Google glass. In the HMD mode, a CMOS camera is installed on a personal cinema system to capture the surgical scene in real-time and transmit the image to the host computer through a USB port. In the Google glass mode, a wireless connection is established between the glass and the host computer for image acquisition and data transport tasks. A software program is written in Python to call OpenCV functions for image calibration, co-registration, fusion, and display with augmented reality. The imaging performance of the surgical navigation system is characterized in a tumor simulating phantom. Image-guided surgical resection is demonstrated in an ex vivo tissue model. Surgical margins identified by the wearable navigation system are co-incident with those acquired by a standard small animal imaging system, indicating the technical feasibility for intraoperative surgical margin detection. The proposed surgical navigation system combines the sensitivity and specificity of a fluorescence imaging system and the mobility of a wearable goggle. It can be potentially used by a surgeon to identify the residual tumor foci and reduce the risk of recurrent diseases without interfering with the regular resection procedure. PMID:24980159

Designing a wearable navigation system for image-guided cancer resection surgery.

PubMed

Shao, Pengfei; Ding, Houzhu; Wang, Jinkun; Liu, Peng; Ling, Qiang; Chen, Jiayu; Xu, Junbin; Zhang, Shiwu; Xu, Ronald

2014-11-01

A wearable surgical navigation system is developed for intraoperative imaging of surgical margin in cancer resection surgery. The system consists of an excitation light source, a monochromatic CCD camera, a host computer, and a wearable headset unit in either of the following two modes: head-mounted display (HMD) and Google glass. In the HMD mode, a CMOS camera is installed on a personal cinema system to capture the surgical scene in real-time and transmit the image to the host computer through a USB port. In the Google glass mode, a wireless connection is established between the glass and the host computer for image acquisition and data transport tasks. A software program is written in Python to call OpenCV functions for image calibration, co-registration, fusion, and display with augmented reality. The imaging performance of the surgical navigation system is characterized in a tumor simulating phantom. Image-guided surgical resection is demonstrated in an ex vivo tissue model. Surgical margins identified by the wearable navigation system are co-incident with those acquired by a standard small animal imaging system, indicating the technical feasibility for intraoperative surgical margin detection. The proposed surgical navigation system combines the sensitivity and specificity of a fluorescence imaging system and the mobility of a wearable goggle. It can be potentially used by a surgeon to identify the residual tumor foci and reduce the risk of recurrent diseases without interfering with the regular resection procedure.

Differences in displacement of the proximal and distal ends of mid-upper thoracic esophageal squamous cell carcinoma.

PubMed

Qiu, Guoqin; Wen, Dengshun; DU, Xianghui; Sheng, Liming; Zhou, Xia; Ji, Yongling; Bao, Wuan; Zhang, Danhong; Cheng, Lei

2016-07-01

In the present study, clips were used as markers to evaluate displacement differences between proximal and distal ends of esophageal tumors and to test whether their internal target volume (ITV) margins should be determined separately. A total of 23 patients with mid-upper thoracic esophageal squamous-cell carcinoma, a tumor length of ≤8 cm and an esophageal lumen suitable for endoscopic ultrasonography were recruited for the present study. Clips were implanted endoscopically at the proximal and distal ends of the esophageal tumor (upper and lower clips). In a further exploratory study on 16 of the patients, a third clip was placed at the distal esophagus 2 cm above the gastro-esophageal junction (GEJ) (cardiac clip). The clips were contoured for all 10 phases of the four-dimensional computed tomography and the maximum displacements of the clip centroids among different breathing phases in left-right (LR), superior-inferior (SI) and anterior-posterior (AP) directions were marked as x, y and z, respectively. The ITV margins that covered 95% of the LR, SI and AP motion were 2.89, 5.00 and 2.36 mm, respectively. Axial displacement (y) was greater than radial displacement (x, z; P<0.05). It was also revealed that LR(x), SI(y) and AP(z) displacement of cardiac clips was greater than that of upper or lower clips (P<0.05). Differences in the axial and radial displacement of the upper and lower clips indicated that axial and radial ITV margins should be determined separately. However, further study is required on patients in whom the distal tumor end is located in proximity to the GEJ.

Polyphase tectono-magmatic and fluid history related to mantle exhumation in an ultra-distal rift domain: example of the fossil Platta domain, SE Switzerland

NASA Astrophysics Data System (ADS)

Epin, Marie-Eva; Manatschal, Gianreto; Amann, Méderic; Lescanne, Marc

2017-04-01

Despite the fact that many studies have investigated mantle exhumation at magma-poor rifted margins, there are still numerous questions concerning the 3D architecture, magmatic, fluid and thermal evolution of these ultra-distal domains that remain unexplained. Indeed, it has been observed in seismic data from ultra-distal magma-poor rifted margins that top basement is heavily structured and complex, however, the processes controlling the morpho-tectonic and magmatic evolution of these domains remain unknown. The aim of this study is to describe the 3D top basement morphology of an exhumed mantle domain, exposed over 200 km2 in the fossil Platta domain in SE Switzerland, and to define the timing and processes controlling its evolution. The examined Platta nappe corresponds to a remnant of the former ultra-distal Adriatic margin of the Alpine Tethys. The rift-structures are relatively well preserved due to the weak Alpine tectonic and metamorphic overprint during the emplacement in the Alpine nappe stack. Detailed mapping of parts of the Platta nappe enabled us to document the top basement architecture of an exhumed mantle domain and to investigate its link to later, rift/oceanic structures, magmatic additions and fluids. Our observations show a polyphase and/or complex: 1) deformation history associated with mantle exhumation along low-angle exhumation faults overprinted by later high-angle normal faults, 2) top basement morphology capped by magmato-sedimentary rocks, 3) tectono-magmatic evolution that includes gabbros, emplaced at deeper levels and subsequently exhumed and overlain by younger extrusive magmatic additions, and 4) fluid history including serpentinization, calcification, hydrothermal vent, rodingitization and spilitization affecting exhumed mantle and associated magmatic rocks. The overall observations provide important information on the temporal and spatial evolution of the tectonic, magmatic and fluid systems controlling the formation of ultra-distal magma-poor rifted margins as well as the processes controlling lithospheric breakup. In this context, our field observations can help to better understand the tectono-magmatic processes associated to these, not yet drilled domains that may form in young, narrow rifted margins (e.g. Red Sea, Gulf of Aden) or may represent the Ocean-Continent Transition in more mature, magma-poor Atlantic type systems.

Laparoscopic revision of Billroth II with Braun anastomosis into Roux-en-Y anatomy in a patient with intestinal malrotation.

PubMed

Garofalo, Fabio; Abouzahr, Omar; Atlas, Henri; Denis, Ronald; Garneau, Pierre; Huynh, Hai; Pescarus, Radu

2018-01-01

Various reconstructions of the gastro-intestinal tract have been described in the past after distal gastrectomy. Among these, a Billroth II (BII) anastomosis can be performed with the addition of the Omega entero-enterostomy that may theoretically reduce the alkaline reflux. Given the significant complications associated with this procedure such as biliary reflux, marginal ulceration, and afferent loop syndrome, a revision into a Roux-en-Y anatomy is generally recommended. A 73-year-old healthy male was referred to our foregut surgery service for treatment of severe biliary gastritis. The patient previously underwent an open distal gastrectomy with a BII reconstruction followed by a Braun-type entero-enterostomy 6 months later. His main complaint was worsening daily biliary reflux with constant regurgitations, which were non-responsive to medical treatment. The preoperative endoscopy confirmed the diagnosis of severe biliary gastritis secondary to alkaline reflux. The distance between the gastro-jejunostomy and the Braun anastomosis was also measured with a pediatric colonoscope and the length of the efferent limb was estimated to be 80 cm. Identification of the afferent and efferent limb was complicated by the patient's incomplete intestinal malrotation with the angle of Treitz being present in the right hypochondrium. Intra-operative gastroscopy enabled visualization of the jejuno-jejunostomy and ensured correct interpretation of the anatomy. Subsequently, resection of the afferent limb completed the revision into a Roux-en-Y anatomy. The patient recovered well after the surgery and was discharged home on post-operative day 2. At 6 months follow-up, the patient's reflux symptoms have completely disappeared. BII reconstruction with or without Braun entero-enterostomy is a classic historical option following distal gastrectomy. Surgical revision of a BII into a Roux-en-Y anatomy is a good solution for severe biliary reflux and other long-term complications. Intra-operative endoscopy is a great adjunct to laparoscopic exploration in case of complex surgical procedures.

Attachment Levels and Crevicular Depths at the Distal of Mandibular Second Molars Following Removal of Adjacent Third Molars.

DTIC Science & Technology

1981-02-01

attachment by determining the distance between the bottom of the crevice and the cemento -enamel junction prior to surgery were unsuccessful, but they were...measuring from the tips of the distolingual and distobuccal cusps and the midpoint of the distal marginal ridge (the cemento -enamel junction could not be...The cemento -enamel junction, usually used as a refer- ence point for determining attachment level, could not be visualized on the distal of the

[Strategy of liver resection during chemotherapy for otherwise unresectable colorectal metastases].

PubMed

Tanaka, Kuniya; Kumamoto, Takafumi; Takeda, Kazuhisa; Nojiri, Kazunori; Endo, Itaru

2013-07-01

With multidisciplinary management of patients with effective chemotherapy that can downstage metastases, more patients with previously inoperable disease can benefit from surgery. Surgery in isolation may be approaching technical limits, but now is likely to help more patients because of success of complementary strategies, particularly newer chemotherapy and targeted therapy. Leaving behind disappearing metastases after chemotherapy, margin-positive resection, staged liver resection, and liver-first reversed management permit potentially curative surgery for patients previously unable to survive resection. Further, survival benefit from maximum debulking surgery, like ovarian cancer, for colorectal liver metastases is uncertain at present, but likely. Individualized multidisciplinary treatment planning using such strategies is essential.

Mandibular angle resection and masticatory muscle hypertrophy - a technical note and morphological optimization.

PubMed

Andreishchev, A R; Nicot, R; Ferri, J

2014-11-01

Mandibular angle resection is rarely used, but is a highly effective means of correcting facial defects. We report a mandibular angle resection technique associated with the removal of a part of hypertrophic masseter muscles and resection of buccal fat pad. Anatomical reminders: the most important entities are the facial artery and vein, crossing the lower margin of the jaw just in front of the anterior boarder of the masseter muscle and the temporomaxillary vein, passing through the temporomaxillary fossa; preoperative aspects: the preoperative examination included a radiological assessment of the shape and size of the mandibular angle; surgical technique: an intra-oral approach was usually used. The most effective and convenient method for the osteotomy was using a reciprocating saw. This technique allowed achieving a smooth contour of masseter muscles during masticatory movements or at rest. Eleven mandibular angle resections were performed from 2001 to 2009. The surgery was supplemented by remodeling the lower margin of the jaw for 5 other patients. No permanent facial palsy was noted. One patient presented a unilateral long-term loss of sensitivity of the lower lip and chin. This surgical technique if simple even requires using good technical equipment, and observing a set of rules. Using these principles allows simplifying the surgical technique, and decreasing its morbidity. A part of the masseter muscles and the buccal fat pad can sometimes be resected to improve the morphological results. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Adjuvant Gemcitabine and Gemcitabine-based Chemoradiotherapy Versus Gemcitabine Alone After Pancreatic Cancer Resection: The Indiana University Experience.

PubMed

Khawaja, Muhammad R; Kleyman, Svetlana; Yu, Zhangsheng; Howard, Thomas; Burns, Matthew; Nakeeb, Attila; Loehrer, Patrick J; Cardenes, Higinia R; Chiorean, Elena Gabriela

2017-02-01

Adjuvant therapy after surgical resection is the current standard for pancreatic adenocarcinoma; however, the role of chemoradiotherapy (CRT) remains unclear. This study was conducted to compare the efficacy outcomes with adjuvant gemcitabine and gemcitabine-based CRT (CT-CRT) versus gemcitabine chemotherapy (CT) alone after pancreaticoduodenectomy. Among 165 patients who underwent surgical resection for pancreatic cancer at Indiana University Medical Center between 2004 and 2008, we retrospectively identified 53 consecutive patients who received adjuvant therapy (CT-CRT=34 patients; CT=19 patients) and had adequate follow-up medical records. The median follow-up was 19.1 months. Median disease-free (DFS) and overall survival (OS) were determined using Kaplan-Meier method, and a Cox-regression model was used to compare survival outcomes after adjusting for age, status of resection margins, and lymph node involvement. The OS for the CT-CRT group was significantly higher compared with the CT group (median, 20.4 vs. 16.6 mo; hazard ratio, 2.42; 95% CI, 1.17-5.01). The median DFS for the CT-CRT group was 13.7 versus 11.1 months for the CT group (hazard ratio, 2.88; 95% CI, 1.37-6.06). On subgroup analyses, significantly superior OS and DFS were observed among patients younger than 65 years, T3/T4 tumor stage, negative resection margins, and positive lymph node involvement. Gemcitabine plus gemcitabine-based CRT compared with gemcitabine alone leads to superior DFS and OS for patients with resected pancreatic cancer.

Laparoscopic versus open distal pancreatectomy-a propensity score-matched analysis from the German StuDoQ|Pancreas registry.

PubMed

Wellner, Ulrich Friedrich; Lapshyn, Hryhoriy; Bartsch, Detlef K; Mintziras, Ioannis; Hopt, Ulrich Theodor; Wittel, Uwe; Krämling, Hans-Jörg; Preissinger-Heinzel, Hubert; Anthuber, Matthias; Geissler, Bernd; Köninger, Jörg; Feilhauer, Katharina; Hommann, Merten; Peter, Luisa; Nüssler, Natascha C; Klier, Thomas; Mansmann, Ulrich; Keck, Tobias

2017-02-01

The aim of this study was to assess intraoperative, postoperative, and oncologic outcome in patients undergoing laparoscopic distal pancreatectomy (LDP) versus open distal pancreatectomy (ODP) for benign and malignant lesions of the pancreas. Data from patients undergoing distal pancreatic resection were extracted from the StuDoQ|Pancreas registry of the German Society for General and Visceral Surgery. After propensity score case matching, groups of LDP and ODP were compared regarding demography, comorbidities, operative details, histopathology, and perioperative outcome. At the time of data extraction, the StuDoQ|Pancreas registry included over 3000 pancreatic resections from over 50 surgical departments in Germany. Data from 353 patients undergoing ODP (n = 254) or LDP (n = 99) from September 2013 to February 2016 at 29 institutions were included in the analysis. Baseline data showed a strong selection bias in LDP patients, which disappeared after 1:1 propensity score matching. A comparison of the matched groups disclosed a significantly longer operation time, higher rate of spleen preservation, more grade A pancreatic fistula, shorter hospital stay, and increased readmissions for LDP. In the small group of patients operated for pancreatic cancer, a lower lymph node yield with a lower lymph node ratio was apparent in LDP. LDP needed more time but potential advantages include increased spleen preservation and shorter hospital stay, as well as a trend for less transfusion, ventilation, and mortality. LDP for pancreatic cancer was performed rarely and will need critical evaluation in the future. Data from a prospective randomized registry trial is needed to confirm these results.

Coblation-assisted endonasal endoscopic resection of juvenile nasopharyngeal angiofibroma.

PubMed

Ye, L; Zhou, X; Li, J; Jin, J

2011-09-01

Juvenile nasopharyngeal angiofibroma may be successfully resected using endoscopic techniques. However, the use of coblation technology for such resection has not been described. This study aimed to document cases of Fisch class I juvenile nasopharyngeal angiofibroma with limited nasopharyngeal and nasal cavity extension, which were completely resected using an endoscopic coblation technique. We retrospectively studied 23 patients with juvenile nasopharyngeal angiofibroma who underwent resection with either traditional endoscopic instruments (n = 12) or coblation (n = 11). Intra-operative blood loss and overall operative time were recorded. The mean tumour resection time for coblation and traditional endoscopic instruments was 87 and 136 minutes, respectively (t = 9.962, p < 0.001). Mean intra-operative blood loss was 121 and 420 ml, respectively (t = 28.944, p < 0.001), a significant difference. Both techniques achieved complete tumour resection with minimal damage to adjacent tissues, and no recurrence in any patient. Coblation successfully achieves transnasal endoscopic resection of juvenile nasopharyngeal angiofibroma (Fisch class I), with good surgical margins and minimal blood loss.

Mesozoic carbonate-siliciclastic platform to basin systems of a South Tethyan margin (Egypt, East Mediterranean)

NASA Astrophysics Data System (ADS)

Tassy, Aurélie; Crouzy, Emmanuel; Gorini, Christian; Rubino, Jean-Loup

2015-04-01

The Mesozoïc Egyptian margin is the south margin of a remnant of the Neo-Tethys Ocean, at the African northern plate boundary. East Mediterranean basin developed during the late Triassic-Early Jurassic rifting with a NW-SE opening direction (Frizon de Lamotte et al., 2011). During Mesozoïc, Egypt margin was a transform margin with a NW-SE orientation of transform faults. In the Eastern Mediterranean basin, Mesozoïc margins are characterized by mixed carbonate-siliciclastics platforms where subsidence and eustacy are the main parameters controlling the facies distribution and geometries of the platform-to-basin transition. Geometries and facies on the platform-slope-basin system, today well constrained on the Levant area, where still poorly known on the Egyptian margin. Geometries and stratigraphic architecture of the Egyptian margin are revealed, thanks to a regional seismic and well data-base provided by an industrial-academic group (GRI, Total). The objective is to understand the sismostratigraphic architecture of the platform-slope-basin system in a key area from Western Desert to Nile delta and Levant margin. Mapping of the top Jurassic and top Cretaceous show seismic geomorphology of the margin, with the cartography of the hinge line from Western Desert to Sinaï. During the Jurassic, carbonate platform show a prograding profile and a distally thickening of the external platform, non-abrupt slope profiles, and palaeovalleys incisions. Since the Cretaceous, the aggrading and retrograding mixed carbonate-siliciclastic platform show an alternation of steep NW-SE oblique segments and distally steepened segments. These structures of the platform edge are strongly controlled by the inherited tethyan transform directions. Along the hinge line, embayments are interpreted as megaslides. The basin infilling is characterised by an alternation of chaotic seismic facies and high amplitude reflectors onlaping the paleoslopes. MTC deposits can mobilize thick sedimentary series (up to 3500 m) as a mixed combination of debris flows, internal preserved blocks, and/or compressively-deformed distal allochthonous masses. Transported material have proceeded from the dismantling of the Mesozoic mixed carbonate-siliciclastic platform. They can spread down slope over areas as large as 70000 of km2. According to stratigraphic correlations with global sea-level positions, platform instability would have been triggered by the gravitational collapse of the carbonate-siliciclastic platform under its own weight after successive subaerial exposures which were able to generate karstification processes. Seismic interpretation is constrained by a detailed assessment of the Egyptian margin paleogeography supported by wells. This margin segment is briefly compared to the outcropping Apulian margin in Italy.

Pulmonary Metastasis After Resection of Cholangiocarcinoma: Incidence, Resectability, and Survival.

PubMed

Yamada, Mihoko; Ebata, Tomoki; Yokoyama, Yukihiro; Igami, Tsuyoshi; Sugawara, Gen; Mizuno, Takashi; Yamaguchi, Junpei; Nagino, Masato

2017-06-01

There are few reports on pulmonary metastasis from cholangiocarcinoma; therefore, its incidence, resectability, and survival are unclear. Patients who underwent surgical resection for cholangiocarcinoma, including intrahepatic, perihilar, and distal cholangiocarcinoma were retrospectively reviewed, and this study focused on patients with pulmonary metastasis. Between January 2003 and December 2014, 681 patients underwent surgical resection for cholangiocarcinoma. Of these, 407 patients experienced disease recurrence, including 46 (11.3%) who developed pulmonary metastasis. Of these 46 patients, 9 underwent resection for pulmonary metastasis; no resection was performed in the remaining 37 patients. R0 resection was achieved in all patients, and no complications related to pulmonary metastasectomy were observed. The median time to recurrence was significantly longer in the 9 patients who underwent surgery than in the 37 patients without surgery (2.5 vs 1.0 years, p < 0.010). Survival after surgery for primary cancer and survival after recurrence were significantly better in the former group than in the latter group (after primary cancer: 66.7 vs 0% at 5 years, p < 0.001; after recurrence: 40.0 vs 8.7% at 3 years, p = 0.003). Multivariate analysis identified the time to recurrence and resection for pulmonary metastasis as independent prognostic factors for survival after recurrence. Resection for pulmonary metastasis originating from cholangiocarcinoma can be safely performed and confers survival benefits for select patients, especially those with a longer time to recurrence after initial surgery.

Risk analysis factors for local recurrence in Ewing's sarcoma: when should adjuvant radiotherapy be administered?

PubMed

Albergo, J I; Gaston, C L L; Parry, M C; Laitinen, M K; Jeys, L M; Tillman, R M; Abudu, A T; Grimer, R J

2018-02-01

The aim of this study was to analyse a group of patients with non-metastatic Ewing's sarcoma at presentation and identify prognostic factors affecting the development of local recurrence, in order to assess the role of radiotherapy. A retrospective review of all patients with a Ewing's sarcoma treated between 1980 and 2012 was carried out. Only those treated with chemotherapy followed by surgery and/or radiotherapy were included. Patients were grouped according to site (central or limb) for further analysis of the prognostic factors. A total of 388 patients were included in the study. Of these, 60 (15%) developed local recurrence at a mean median of 27 months (sd 24, range 7 to 150) and the five-year local recurrence-free survival (5yrLRFS) was 83%. For central tumours, the size of the tumour and histological response to chemotherapy were found to be significant factors for local recurrence. For limb tumours, local recurrence was affected by intralesional and marginal resections, but not by the histological response to chemotherapy. Radiotherapy in those with a marginal resection reduced the risk of local recurrence (5yrLRFS: 96% versus 81%, p = 0.044). Local recurrence significantly affects the overall survival in patients with a Ewing's sarcoma. For those with a tumour in a limb, radiotherapy reduced the risk of local recurrence, especially in those with a marginal margin of excision, but the effect in central tumours was less clear. Radiotherapy for those who have had a wide margin of resection does not reduce the risk of local recurrence, regardless of the histological response to chemotherapy. Cite this article: Bone Joint J 2018;100-B: 247-55. ©2018 The British Editorial Society of Bone & Joint Surgery.

Radioactive Seed Localization or Wire-guided Localization of Nonpalpable Invasive and In Situ Breast Cancer: A Randomized, Multicenter, Open-label Trial.

PubMed

Langhans, Linnea; Tvedskov, Tove F; Klausen, Thomas L; Jensen, Maj-Britt; Talman, Maj-Lis; Vejborg, Ilse; Benian, Cemil; Roslind, Anne; Hermansen, Jonas; Oturai, Peter S; Bentzon, Niels; Kroman, Niels

2017-07-01

To compare the rate of positive resection margins between radioactive seed localization (RSL) and wire-guided localization (WGL) after breast conserving surgery (BCS). WGL is the current standard for localization of nonpalpable breast lesions in BCS, but there are several difficulties related to the method. From January 1, 2014 to February 4, 2016, patients with nonpalpable invasive breast cancer or DCIS visible on ultrasound were enrolled in this randomized, multicenter, open-label clinical trial, and randomly assigned to RSL or WGL. The primary outcome was margin status after BCS. Secondary outcomes were duration of the surgical procedure, weight of surgical specimen, and patients' pain perception. Analyses were performed by intention-to-treat (ITT) and per protocol. Out of 444 eligible patients, 413 lesions representing 409 patients were randomized; 207 to RSL and 206 to WGL. Twenty-three did not meet inclusion criteria, chose to withdraw, or had a change in surgical management and were excluded. The remaining 390 lesions constituted the ITT population. Here, resection margins were positive in 23 cases (11.8%) in the RSL group compared with 26 cases (13.3%) in the WGL group (P = 0.65). The per-protocol analysis revealed no difference in margin status (P = 0.62). There were no significant differences in the duration of the surgical procedure (P = 0.12), weight of the surgical specimen (P = 0.54) or the patients' pain perception (P = 0.28). RSL offers a major logistic advantage, as localization can be done several days before surgery without any increase in positive resection margins compared with WGL.

Extreme hepatic resections for the treatment of advanced hepatoblastoma: Are planned close margins an acceptable approach?

PubMed

Fonseca, Adriana; Gupta, Abha; Shaikh, Furqan; Ramphal, Raveena; Ng, Vicky; McGilvray, Ian; Gerstle, J Ted

2018-02-01

Orthotopic liver transplantation (OLT) is considered the standard for children with hepatoblastoma (HB) in whom complete surgical resection is not possible. However, OLT is not always available or feasible. To describe the outcome of children with HB who were initially deemed unresectable and underwent complex hepatectomy with planned close margins, and ultimately avoided OLT. Demographic data, surgical and pathologic details, and survival information were collected from children treated for HB between January 2010 to December 2015. Among six children (median age 12 months (3-41 months)), PRETEXT classification was III (n = 2), III/IV (n = 1), and IV (n = 3). Patients received a median of six cycles (range 4-7) of platinum-based induction chemotherapy; five received doxorubicin. Experienced pediatric surgeons performed extended right and left hepatectomy in five and one patients, respectively, with assistance of an experienced liver transplant surgeon (n = 4). Microscopic margins were positive (n = 2) and negative but close (n = 4; 2-5 mm). Two patients required vascular reconstruction of the vena cava. At median follow-up of 3.3 years (1.7-4.6 years), there was no evidence of local recurrence. One patient had recurrence of pulmonary disease 3 months after surgery. Patients with advanced HB treated with complex surgical resections with positive or close negative margins had good outcomes without OLT. We suggest that planned positive or close microscopic margins in highly selected HB patients may spare the morbidity of OLT and offer an alternative for those ineligible for OLT. Our experience illustrates the importance of a multidisciplinary team specialized in the management of liver tumors. © 2017 Wiley Periodicals, Inc.

HPV-testing versus HPV-cytology co-testing to predict the outcome after conization.

PubMed

Bruhn, Laerke Valsøe; Andersen, Sisse Josephine; Hariri, Jalil

2018-06-01

The purpose of this study was to determine the feasibility of human Papillomavirus (HPV) testing alone as a prognostic tool to predict recurrent disease within a three-year follow-up period after treatment for cervical intraepithelial neoplasia (CIN)2 + . Retrospectively, 128 women with histologically verified CIN2 + who had a conization performed at Southern Jutland Hospital in Denmark between 1 January 2013 and 31 December 2013 were included. Histology, cytology and HPV test results were obtained for a three-year follow-up period. 4.7% (6/128) of the cases developed recurrent disease during follow-up. Of the cases without free margins, recurrent dysplasia was detected normal in 10.4% (5/48), whereas in the group with free margins it was 1.3% (1/80). The post-conization HPV test was negative in 67.2% (86/128) and Pap smear normal in 93.7% (120/128). Combining resection margins, cytology and HPV had sensitivity for prediction of recurrent dysplasia of 100%. Specificity was 45.8%, positive predictive value (PPV) 8.5% and negative predictive value (NPV) 100%. Using HPV test alone as a predictor of recurrent dysplasia gave a sensitivity of 83.3%, specificity 69.7%, PPV 11.9% and NPV 98.8%. Combining resection margin and HPV test had a sensitivity of 100%, specificity 45.9%, PPV 8.3% and NPV 100%. HPV test at six months control post-conization gave an NPV of 98.8% and can be used as a solitary test to identify women at risk for recurrent disease three years after treatment for precursor lesions. Using both resection margin and HPV test had a sensitivity of 100% and NPV 100%. Adding cytology did not increase the predictive value. © 2018 Nordic Federation of Societies of Obstetrics and Gynecology.

Standardized reporting of resection technique during nephron-sparing surgery: the surface-intermediate-base margin score.

PubMed

Minervini, Andrea; Carini, Marco; Uzzo, Robert G; Campi, Riccardo; Smaldone, Marc C; Kutikov, Alexander

2014-11-01

A standardized reporting system of nephron-sparing surgery resection techniques is lacking. The surface-intermediate-base scoring system represents a formal reporting instrument to assist in interpretation of reported data and to facilitate comparisons in the urologic literature. Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Qualitative and quantitative comparison of colonic microendoscopy image features to histopathology

NASA Astrophysics Data System (ADS)

Prieto, Sandra P.; Powless, Amy J.; Lai, Keith; Laryea, Jonathan A.; Mizell, Jason S.; Muldoon, Timothy J.

2015-03-01

Colorectal cancer is the second leading cause of cancer deaths in the United States, affecting more than 130,000 Americans every year1. Determining tumor margins prior to surgical resection is essential to providing optimal treatment and reducing recurrence rates. Colorectal cancer recurrence can occur in up to 20% of cases, commonly within three years after curative treatment. Typically, when colorectal cancers are resected, a margin of normal tissue on both sides of the tumor is required. The minimum margin required for colon cancer is 5 cm and for the lower rectum 2 cm. However, usually more normal tissue is taken on both sides of the tumor because the blood supply to the entire segment is removed with the surgery and therefore the entire segment must be removed. Anastomotic recurrences may result from inadequate margins. Pathologists look at the margins to ensure that there is no residual tumor and this is usually documented in the pathology report. We have developed a portable, point-of-care fiber bundle microendoscopy imaging system for detection of abnormalities in colonic epithelial microstructure. The system comprises a laptop, a modified fiber bundle image guide with a 1mm active area diameter and custom LabVIEW interface, and is approved for imaging surgically resected colon tissue at the University of Arkansas for Medical Sciences. The microendoscopy probe provides high-resolution images of superficial epithelial histology in real-time to assist surgical guidance and to localize occult regions of dysplasia which may not be visible. Microendoscopy images of freshly resected human colonic epithelium were acquired using the microendoscopy device and subsequently mosaicked using custom post-processing software. Architectural changes in the glands were mapped to histopathology H&E slides taken from the precise location of the microendoscopy images. Qualitatively, glandular distortion and placement of image guide was used to map normal and dysplastic areas of the colonic tumor and surrounding region from microendoscopy images to H&E slides. Quantitative metrics for correlating images were also explored and were obtained by analyzing glandular diameter and spatial distribution as well as image texture.

Assessment of Surgical Learning Curves in Transoral Robotic Surgery for Squamous Cell Carcinoma of the Oropharynx

PubMed Central

Albergotti, William G.; Gooding, William E.; Kubik, Mark W.; Geltzeiler, Mathew; Kim, Seungwon; Duvvuri, Umamaheswar; Ferris, Robert L.

2017-01-01

IMPORTANCE Transoral robotic surgery (TORS) is increasingly employed as a treatment option for squamous cell carcinoma of the oropharynx (OPSCC). Measures of surgical learning curves are needed particularly as clinical trials using this technology continue to evolve. OBJECTIVE To assess learning curves for the oncologic TORS surgeon and to identify the number of cases needed to identify the learning phase. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of all patients who underwent TORS for OPSCC at the University of Pittsburgh Medical Center between March 2010 and March 2016. Cases were excluded for involvement of a subsite outside of the oropharynx, for nonmalignant abnormality or nonsquamous histology, unknown primary, no tumor in the main specimen, free flap reconstruction, and for an inability to define margin status. EXPOSURES Transoral robotic surgery for OPSCC. MAIN OUTCOMES AND MEASURES Primary learning measures defined by the authors include the initial and final margin status and time to resection of main surgical specimen. A cumulative sum learning curve was developed for each surgeon for each of the study variables. The inflection point of each surgeon’s curve was considered to be the point signaling the completion of the learning phase. RESULTS There were 382 transoral robotic procedures identified. Of 382 cases, 160 met our inclusion criteria: 68 for surgeon A, 37 for surgeon B, and 55 for surgeon C. Of the 160 included patients, 125 were men and 35 were women. The mean (SD) age of participants was 59.4 (9.5) years. Mean (SD) time to resection including robot set-up was 79 (36) minutes. The inflection points for the final margin status learning curves were 27 cases (surgeon A) and 25 cases (surgeon C). There was no inflection point for surgeon B for final margin status. Inflection points for mean time to resection were: 39 cases (surgeon A), 30 cases (surgeon B), and 27 cases (surgeon C). CONCLUSIONS AND RELEVANCE Using metrics of positive margin rate and time to resection of the main surgical specimen, the learning curve for TORS for OPSCC is surgeon-specific. Inflection points for most learning curves peak between 20 and 30 cases. PMID:28196200

Lung segment geometry study: simulation of largest possible tumours that fit into bronchopulmonary segments.

PubMed

Welter, S; Stöcker, C; Dicken, V; Kühl, H; Krass, S; Stamatis, G

2012-03-01

Segmental resection in stage I non-small cell lung cancer (NSCLC) has been well described and is considered to have similar survival rates as lobectomy but with increased rates of local tumour recurrence due to inadequate parenchymal margins. In consequence, today segmentectomy is only performed when the tumour is smaller than 2 cm. Three-dimensional reconstructions from 11 thin-slice CT scans of bronchopulmonary segments were generated, and virtual spherical tumours were placed over the segments, respecting all segmental borders. As a next step, virtual parenchymal safety margins of 2 cm and 3 cm were subtracted and the size of the remaining tumour calculated. The maximum tumour diameters with a 30-mm parenchymal safety margin ranged from 26.1 mm in right-sided segments 7 + 8 to 59.8 mm in the left apical segments 1-3. Using a three-dimensional reconstruction of lung CT scans, we demonstrated that segmentectomy or resection of segmental groups should be feasible with adequate margins, even for larger tumours in selected cases. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Towards real-time detection of tumor margins using photothermal imaging of immune-targeted gold nanoparticles

PubMed Central

Jakobsohn, Kobi; Motiei, Menachem; Sinvani, Moshe; Popovtzer, Rachela

2012-01-01

Background One of the critical problems in cancer management is local recurrence of disease. Between 20% and 30% of patients who undergo tumor resection surgery require reoperation due to incomplete excision. Currently, there are no validated methods for intraoperative tumor margin detection. In the present work, we demonstrate the potential use of gold nanoparticles (GNPs) as a novel contrast agent for photothermal molecular imaging of cancer. Methods Phantoms containing different concentrations of GNPs were irradiated with continuous-wave laser and measured with a thermal imaging camera which detected the temperature field of the irradiated phantoms. Results The results clearly demonstrate the ability to distinguish between cancerous cells specifically targeted with GNPs and normal cells. This technique, which allows highly sensitive discrimination between adjacent low GNP concentrations, will allow tumor margin detection while the temperature increases by only a few degrees Celsius (for GNPs in relevant biological concentrations). Conclusion We expect this real-time intraoperative imaging technique to assist surgeons in determining clear tumor margins and to maximize the extent of tumor resection while sparing normal background tissue. PMID:22956871

Microsurgical resection of intramedullary spinal cord hemangioblastoma.

PubMed

McCormick, Paul C

2014-09-01

Spinal cord hemangioblastomas account for about 10% of spinal cord tumors. They usually arise from the dorsolateral pia mater and are characterized by their significant vascularity. The principles and techniques of safe resection are different than those employed for the more commonly occurring intramedullary glial tumors (e.g. ependymoma, astrocytoma) and consist of circumferential detachment of the tumor margin from the surrounding normal pia. This video demonstrates the microsurgical techniques of resection of a thoracic spinal cord hemangioblastoma. The video can be found here: http://youtu.be/yT5KLi4VyAo.

Two new species of Melanorivulus (Cyprinodontiformes: Cynolebiidae) from Rio Verde drainage, Upper Rio Paraná basin, Brazil.

PubMed

Volcan, Matheus Vieira; Klotzel, Bruno; Lanés, Luis Esteban Krause

2017-02-21

Two new species of the genus Melanorivulus are herein described from the middle Rio Verde drainage, upper Rio Paraná basin, Mato Grosso do Sul, Brazil. Both new species are members of the Melanorivulus pictus clade, diagnosed by having ventral process of angulo-articular vestigial and flanks intense greenish blue or greenish golden to purplish blue above anal fin base in males. Melanorivulus nigropunctatus, new species, from wetlands of a small drainage tributary of right side of the Rio Verde, differs from all other congeners by possessing black dots over the head and body in both sexes and pectoral fin orange with a dark grey margin in males. Melanorivulus ofaie, new species, is found in a similar environment, but at the opposite margin of the Rio Verde. It is distinguished by males presenting flank greenish blue to light blue, with seven to nine oblique chevron-like red bars, ventral portion of head whitish with dark brown spots, dorsal fin yellow with two to three transverse broad red oblique stripes and distal region red, anal fin light orangish yellow, basal area light blue with short red bars and distal portion with a dark red margin, and caudal fin yellow or orangish yellow with three to four vertical red bars in the dorsal and middle portions, sometimes with a orange distal margin. Both new species are considered endangered due to the loss and degradation of their habitat.

Palliative photodynamic therapy for biliary tract carcinoma may improve survival and has a similar outcome to attempted curative surgery with positive resection margins

NASA Astrophysics Data System (ADS)

Pereira, Stephen P.; Matull, W. Rudiger; Dhar, Dipok K.; Ayaru, Laskshmana; Sandanayake, Neomal S.; Chapman, Michael H.

2009-06-01

There is a need for better management strategies to improve survival and quality of life in patients with biliary tract cancer (BTC). We compared treatment outcomes in 321 patients (median age 65 years, range 29-102; F:M; 1:1) with a final diagnosis of BTC (cholangiocarcinoma n=237, gallbladder cancer n=84) seen in a tertiary referral cancer centre between 1998-2007. Of 89 (28%) patients who underwent surgical intervention with curative intent, 38% had R0 resections and had the most favourable outcome, with a 3 year survival of 57%. Even though PDT patients had more advanced clinical T-stages, their survival was similar to those treated with attempted curative surgery which resulted in R1/2 resections (median survival 12 vs. 13 months, ns). In a subgroup of 36 patients with locally advanced BTC treated with PDT as part of a prospective phase II study, the median survival was 12 (range 2-51) months, compared with 5 months in matched historical controls treated with stenting alone (p < 0.0001). In this large UK series, long-term survival with BTC was only achieved in surgical patients with R0 resection margins. Palliative PDT resulted in similar survival to those with curatively intended R1/R2 resections.

Surgical Stress Abrogates Pre-Existing Protective T Cell Mediated Anti-Tumor Immunity Leading to Postoperative Cancer Recurrence

PubMed Central

Lansdell, Casey; Alkayyal, Almohanad A.; Baxter, Katherine E.; Angka, Leonard; Zhang, Jiqing; Tanese de Souza, Christiano; Stephenson, Kyle B.; Parato, Kelley; Bramson, Jonathan L.; Bell, John C.; Lichty, Brian D.; Auer, Rebecca C.

2016-01-01

Anti-tumor CD8+ T cells are a key determinant for overall survival in patients following surgical resection for solid malignancies. Using a mouse model of cancer vaccination (adenovirus expressing melanoma tumor-associated antigen (TAA)—dopachrome tautomerase (AdDCT) and resection resulting in major surgical stress (abdominal nephrectomy), we demonstrate that surgical stress results in a reduction in the number of CD8+ T cell that produce cytokines (IFNγ, TNFα, Granzyme B) in response to TAA. This effect is secondary to both reduced proliferation and impaired T cell function following antigen binding. In a prophylactic model, surgical stress completely abrogates tumor protection conferred by vaccination in the immediate postoperative period. In a clinically relevant surgical resection model, vaccinated mice undergoing a positive margin resection with surgical stress had decreased survival compared to mice with positive margin resection alone. Preoperative immunotherapy with IFNα significantly extends survival in surgically stressed mice. Importantly, myeloid derived suppressor cell (MDSC) population numbers and functional impairment of TAA-specific CD8+ T cell were altered in surgically stressed mice. Our observations suggest that cancer progression may result from surgery-induced suppression of tumor-specific CD8+ T cells. Preoperative immunotherapies aimed at targeting the prometastatic effects of cancer surgery will reduce recurrence and improve survival in cancer surgery patients. PMID:27196057

Defining Hepatoblastoma Responsiveness to Induction Therapy as Measured by Tumor Volume and Serum α-fetoprotein Kinetics

PubMed Central

Lovvorn, Harold N.; Ayers, Dan; Zhao, Zhiguo; Hilmes, Melissa; Prasad, Pinki; Shinall, Myrick C.; Berch, Barry; Neblett, Wallace W.; O'Neill, James A.

2010-01-01

Purpose Hepatoblastoma is commonly unresectable at presentation, necessitating induction chemotherapy before definitive resection. To refine the paradigm for timing of resection, we questioned whether a plateau in hepatoblastoma responsiveness to neoadjuvant therapy could be detected by calculating tumor volume (TV) and serum α-fetoprotein (sAFP) kinetics. Methods To calculate TV and sAFP as measures of treatment responsiveness over time, infants having initially unresectable epithelial-type hepatoblastomas were identified at a single institution (1996-2008). Effects of therapy type, therapy duration, and lobe of liver involvement on TV, sAFP, margin status, and toxicity were analyzed. Results Of 24 infants treated for epithelial-type hepatoblastoma during this interval, 5 were resected primarily, and 15 had complete digital films for kinetics analysis. Both TV and sAFP decreased dramatically over time (p<0.0001). No statistically significant difference in mean TV or sAFP was detected after chemotherapy cycle 2. Left lobe tumors had greater presenting levels of and significantly slower decay in sAFP compared to right lobe tumors (p=0.005), although no statistically significant differences in TV existed between liver lobes. Resection margins did not change with therapy duration. Conclusions Measuring TV and sAFP kinetics accurately reflects hepatoblastoma responsiveness to induction therapy. Treatment toxicities may be reduced by earlier resection and tailoring of chemotherapeutic regimens. PMID:20105591

Extent of field change in colorectal cancers with BRAF mutation

PubMed Central

Poh, Aaron; Chang, Heidi Sian Ying; Tan, Kok Yang; Sam, Xin Xiu; Khoo, Avery; Choo, Shoa Nian; Nga, Min En; Wan, Wei Keat

2018-01-01

INTRODUCTION Sporadic colorectal cancers with BRAF mutations constitute two distinct subgroups of colorectal cancers. Recent studies have linked the presence of the BRAF mutation to a familial inheritance pattern. This was a proof-of-concept study that aimed to examine: (a) the extent of field change in sporadic colorectal cancers with BRAF mutation; and (b) the extent of resection margins required and the pattern of DNA mismatch repair protein loss in these tumours. METHODS Eight microsatellite instability-high tumours with positive BRAF mutation from an existing histopathological database were selected for BRAF mutation and mismatch repair protein analysis. RESULTS All the resection margins were negative for BRAF mutation. Three tumours had loss of MLH1 and PMS2 expressions, and five tumours had no protein loss. Six peritumoral tissues were negative and one was positive for BRAF mutation. CONCLUSION The results suggest that any early field change effect is restricted to the immediate vicinity of the tumour and is not a pan-colonic phenomenon. Current guidelines on resection margins are adequate for BRAF mutation-positive colorectal cancers. Any suggestion of a hereditary link to these tumours is likely not related to germline BRAF gene mutations. The pattern of protein loss reinforces previous findings for the two subgroups of BRAF mutation-positive colorectal cancers. PMID:28210747

Development and evaluation of a connective tissue phantom model for subsurface visualization of cancers requiring wide local excision

NASA Astrophysics Data System (ADS)

Samkoe, Kimberley S.; Bates, Brent D.; Tselepidakis, Niki N.; DSouza, Alisha V.; Gunn, Jason R.; Ramkumar, Dipak B.; Paulsen, Keith D.; Pogue, Brian W.; Henderson, Eric R.

2017-12-01

Wide local excision (WLE) of tumors with negative margins remains a challenge because surgeons cannot directly visualize the mass. Fluorescence-guided surgery (FGS) may improve surgical accuracy; however, conventional methods with direct surface tumor visualization are not immediately applicable, and properties of tissues surrounding the cancer must be considered. We developed a phantom model for sarcoma resection with the near-infrared fluorophore IRDye 800CW and used it to iteratively define the properties of connective tissues that typically surround sarcoma tumors. We then tested the ability of a blinded surgeon to resect fluorescent tumor-simulating inclusions with ˜1-cm margins using predetermined target fluorescence intensities and a Solaris open-air fluorescence imaging system. In connective tissue-simulating phantoms, fluorescence intensity decreased with increasing blood concentration and increased with increasing intralipid concentrations. Fluorescent inclusions could be resolved at ≥1-cm depth in all inclusion concentrations and sizes tested. When inclusion depth was held constant, fluorescence intensity decreased with decreasing volume. Using targeted fluorescence intensities, a blinded surgeon was able to successfully excise inclusions with ˜1-cm margins from fat- and muscle-simulating phantoms with inclusion-to-background contrast ratios as low as 2∶1. Indirect, subsurface FGS is a promising tool for surgical resection of cancers requiring WLE.

Hilar cholangiocarcinoma: diagnosis, treatment options, and management

PubMed Central

Soares, Kevin C.; Kamel, Ihab; Cosgrove, David P.; Herman, Joseph M.

2014-01-01

Hilar cholangiocarcinoma (HC) is a rare disease with a poor prognosis which typically presents in the 6th decade of life. Of the 3,000 cases seen annually in the United States, less than one half of these tumors are resectable. A variety of risk factors have been associated with HC, most notably primary sclerosing cholangitis (PSC), biliary stone disease and parasitic liver disease. Patients typically present with abdominal pain, pruritis, weight loss, and jaundice. Computed topography (CT), magnetic resonance imaging (MRI), and ultrasound (US) are used to characterize biliary lesions. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) assess local ductal extent of the tumor while allowing for therapeutic biliary drainage. MRCP has demonstrated similar efficacies to PTC and ERCP in identifying anatomic extension of tumors with less complications. Treatment consists of surgery, radiation, chemotherapy and photodynamic therapy. Biliary drainage of the future liver remnant should be performed to decrease bilirubin levels thereby facilitating future liver hypertrophy. Standard therapy consists of surgical margin-negative (R0) resection with extrahepatic bile duct resection, hepatectomy and en bloc lymphadenectomy. Local resection should not be undertaken. Lymph node invasion, tumor grade and negative margins are important prognostic indicators. In instances where curative resection is not possible, liver transplantation has demonstrated acceptable outcomes in highly selected patients. Despite the limited data, chemotherapy is indicated for patients with unresectable tumors and adequate functional status. Five-year survival after surgical resection of HC ranges from 10% to 40% however, recurrence can be as high as 50-70% even after R0 resection. Due to the complexity of this disease, a multi-disciplinary approach with multimodal treatment is recommended for this complex disease. PMID:24696835

Total robotic radical rectal resection with da Vinci Xi system: single docking, single phase technique.

PubMed

Tamhankar, Anup Sunil; Jatal, Sudhir; Saklani, Avanish

2016-12-01

This study aims to assess the advantages of Da Vinci Xi system in rectal cancer surgery. It also assesses the initial oncological outcomes after rectal resection with this system from a tertiary cancer center in India. Robotic rectal surgery has distinct advantages over laparoscopy. Total robotic resection is increasing following the evolution of hybrid technology. The latest Da Vinci Xi system (Intuitive Surgical, Sunnyvale, USA) is enabled with newer features to make total robotic resection possible with single docking and single phase. Thirty-six patients underwent total robotic resection in a single phase and single docking. We used newer port positions in a straight line. Median distance from the anal verge was 4.5 cm. Median robotic docking time and robotic procedure time were 9 and 280 min, respectively. Median blood loss was 100 mL. One patient needed conversion to an open approach due to advanced disease. Circumferential resection margin and longitudinal resection margins were uninvolved in all other patients. Median lymph node yield was 10. Median post-operative stay was 7 days. There were no intra-operative adverse events. The latest Da Vinci Xi system has made total robotic rectal surgery feasible in single docking and single phase. With the new system, four arm total robotic rectal surgery may replace the hybrid technique of laparoscopic and robotic surgery for rectal malignancies. The learning curve for the new system appears to be shorter than anticipated. Early perioperative and oncological outcomes of total robotic rectal surgery with the new system are promising. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

Laser-supported diaphanoscopy: an innovative technique for locating gastric stromal tumors in gastroscopic-laparoscopic rendezvous: a case series.

PubMed

Patrzyk, M; Schreiber, A; Heidecke, C D; Glitsch, A

2009-12-01

Development of an innovative method of endoscopic laser-supported diaphanoscopy, for precise demonstration of the location of gastrointestinal stromal tumors (GISTs) at laparoscopy is described. The equipment consists of a light transmission cable with an anchoring system for the gastric mucosa, a connecting system for the light source, and the laser light source itself. During surgery, transillumination by laser is used to show the shape of the tumor. The resection margins are then marked by electric coagulation. Ten patients have been successfully treated using this technique in laparoscopic-endoscopic rendezvous procedures. Average time of surgery was 123 minutes. The time for marking the shape of the tumor averaged 16 minutes. Depending on tumor location and size, 4-7 marks were used, and resection margins were 4-15 mm. This new and effective technique facilitates precise locating of gastric GISTs leading to exact and tissue-sparing transmural laparoscopic resections. Georg Thieme Verlag KG Stuttgart New York.

Ten-Year Follow-Up of Desarthrodesis of the Knee Joint 41 Years after Original Arthrodesis for a Bone Tumor

PubMed Central

Kassem Abdelaal, Ahmed Hamed; Yamamoto, Norio; Hayashi, Katsuhiro; Takeuchi, Akihiko; Miwa, Shinji; Inatani, Hiroyuki; Tsuchiya, Hiroyuki

2015-01-01

Introduction. The main indication for knee arthrodesis in tumor surgery is a tumor that requires an extensive resection in which the joint surface cannot be preserved. We report a patient that had knee desarthrodesis 41 years after giant cell tumor resection followed by a knee arthrodesis. This is the longest reported follow-up after desarthrodesis and conversion to total knee arthroplasty (TKA), almost ten years. Case Report. A 71-year-old man with a distal femoral giant cell tumor had undergone a resection of the distal femur and knee arthrodesis using Kuntscher nail in 1962. In July 2003 he experienced gradually increasing pain of his left knee. We performed a desarthrodesis and conversion to TKA in 2005. The postoperative period passed uneventfully as his pain and gait improved, with gradually increasing range of motion (ROM) and no infection. He now walks independently, with no brace or contractures. Conclusion. Desarthrodesis of the knee joint and conversion to TKA are a difficult surgical choice with a high complication risk. However, our patient's life style has improved, he has no pain, and he can ascend and descend stairs more easily. The surgeon has to be very meticulous in selecting a patient for knee arthrodesis and counseling them to realize that their expectations may not be achievable. PMID:26688766

Ten-Year Follow-Up of Desarthrodesis of the Knee Joint 41 Years after Original Arthrodesis for a Bone Tumor.

PubMed

Kassem Abdelaal, Ahmed Hamed; Yamamoto, Norio; Hayashi, Katsuhiro; Takeuchi, Akihiko; Miwa, Shinji; Inatani, Hiroyuki; Tsuchiya, Hiroyuki

2015-01-01

Introduction. The main indication for knee arthrodesis in tumor surgery is a tumor that requires an extensive resection in which the joint surface cannot be preserved. We report a patient that had knee desarthrodesis 41 years after giant cell tumor resection followed by a knee arthrodesis. This is the longest reported follow-up after desarthrodesis and conversion to total knee arthroplasty (TKA), almost ten years. Case Report. A 71-year-old man with a distal femoral giant cell tumor had undergone a resection of the distal femur and knee arthrodesis using Kuntscher nail in 1962. In July 2003 he experienced gradually increasing pain of his left knee. We performed a desarthrodesis and conversion to TKA in 2005. The postoperative period passed uneventfully as his pain and gait improved, with gradually increasing range of motion (ROM) and no infection. He now walks independently, with no brace or contractures. Conclusion. Desarthrodesis of the knee joint and conversion to TKA are a difficult surgical choice with a high complication risk. However, our patient's life style has improved, he has no pain, and he can ascend and descend stairs more easily. The surgeon has to be very meticulous in selecting a patient for knee arthrodesis and counseling them to realize that their expectations may not be achievable.

Fluorescence detection of malignant liver tumors using 5-aminolevulinic acid-mediated photodynamic diagnosis: principles, technique, and clinical experience.

PubMed

Inoue, Yoshihiro; Tanaka, Ryo; Komeda, Koji; Hirokawa, Fumitoshi; Hayashi, Michihiro; Uchiyama, Kazuhisa

2014-07-01

Photoactive drugs selectively accumulate in malignant tissue specimens and cause drug-induced fluorescence. Photodynamic diagnosis (PDD) and fluorescence can distinguish normal from malignant tissue. From May 2012 to September 2013, a total of 70 patients underwent hepatic resections using 5-ALA-mediated PDD for liver tumors at our hospital. 5-ALA fluorescence was detected in all hepatocellular carcinoma cases with serosa invasion. In liver metastasis from colorectal cancer cases with serosa invasion, 18 patients (85.7 %) were detected, and three patients (14.2 %) whose tumors showed complete response to neoadjuvant chemotherapy showed no fluorescence. Both superficial and deep malignant liver tumors were detected with 92.5 % sensitivity. Using 5-ALA-mediated PDD, tumors remaining at the cut surface and postoperative bile leakage were less frequent than in our previous hepatic resections using conventional white-light observation. Moreover, all malignant liver tumors were completely removed with a clear microscopic margin using 5-ALA, with a significant difference in resection margin width between 5-ALA-mediated PDD (6.7 ± 6.9 mm) and white-light observation (9.2 ± 7.0 mm; p = 0.0083). With the detection of malignant liver tumors, residual tumor and bile leakage at the cut surface of the remnant liver were improved by PDD with 5-ALA. This procedure may provide greater sensitivity than the conventional procedure. Furthermore, 5-ALA-mediated PDD can ensure histological clearance regardless of the resection margin and preserve as much liver parenchyma as possible in patients with impaired liver function.

Mini-Laparotomy for Superior Mesenteric Artery Aneurysm Due to Takayasu's Arteritis.

PubMed

Matsumoto, Takatsugu; Ishizuka, Mitsuru; Iso, Yukihiro; Kita, Junji; Kubota, Keiichi

2015-04-01

Superior mesenteric artery aneurysm (SMAA) is reported to be the third-most common type of visceral aneurysm (VA), accounting for 5% of all VAs. The etiology of SMAA is commonly thought to be infection, and it usually exists in the proximal part of the superior mesenteric artery, which is suitable for endovascular treatment. We herein report an extremely rare case of the distal part of SMAA caused by Takayasu's arteritis (TA), which was successfully resected using a mini-laparotomy method without impairing the intestinal blood supply. A 51-year-old woman was admitted to our hospital with sustained fever and lower back pain. Physical examination showed that she had a discrepancies in blood pressure between both arms. Contrast-enhanced whole-body computed tomography showed stenosis of the thoracic aorta and an aneurysm located in the distal part of the superior mesenteric artery. The diameter of the aneurysm was 4.5 cm. The aneurysm was resected via 4-cm mini-laparotomy, and the vascularity of the intestine was successfully preserved. The postoperative course was uneventful, and the patient was diagnosed as having TA based on both clinical and pathologic findings. Additional corticosteroid therapy was started to treat the arteritis, and at 3-month follow-up she was without critical incidents. Mini-laparotomy is a safe and less-invasive approach to treat SMAA, especially when the lesion is located in the distal part of the artery.

Fluorophore-conjugated antibodies for imaging and resection of GI tumors

NASA Astrophysics Data System (ADS)

Bouvet, Michael; Hoffman, Robert M.

2016-03-01

Negative surgical margins are critical to prevent recurrence in cancer surgery. This is because with current technology in many cases negative margins are impossible due the inability of the surgeon to detect the margin. Our laboratory has developed fluorophore-labeled monoclonal antibodies to aid in cancer visualization in orthotopic nude mouse models of human gastrointestinal (GI) cancer in order to achieve negative margins in fluorescence-guided surgery (FGS). The technologies described herein have the potential to change the paradigm of surgical oncology to engender significantly improved outcomes.

Surgery for Locally Recurrent Rectal Cancer: Tips, Tricks, and Pitfalls.

PubMed

Warrier, Satish K; Heriot, Alexander G; Lynch, Andrew Craig

2016-06-01

Rectal cancer can recur locally in up to 10% of the patients who undergo definitive resection for their primary cancer. Surgical salvage is considered appropriate in the curative setting as well as select cases with palliative intent. Disease-free survival following salvage resection is dependent upon achieving an R0 resection margin. A clear understanding of applied surgical anatomy, appropriate preoperative planning, and a multidisciplinary approach to aggressive soft tissue, bony, and vascular resection with appropriate reconstruction is necessary. Technical tips, tricks, and pitfalls that may assist in managing these cancers are discussed and the roles of additional boost radiation and intraoperative radiation therapy in the management of such cancers are also discussed.

Near-infrared intraoperative imaging during resection of an anterior mediastinal soft tissue sarcoma.

PubMed

Predina, Jarrod D; Newton, Andrew D; Desphande, Charuhas; Singhal, Sunil

2018-01-01

Sarcomas are rare malignancies that are generally treated with multimodal therapy protocols incorporating complete local resection, chemotherapy and radiation. Unfortunately, even with this aggressive approach, local recurrences are common. Near-infrared intraoperative imaging is a novel technology that provides real-time visual feedback that can improve identification of disease during resection. The presented study describes utilization of a near-infrared agent (indocyanine green) during resection of an anterior mediastinal sarcoma. Real-time fluorescent feedback provided visual information that helped the surgeon during tumor localization, margin assessment and dissection from mediastinal structures. This rapidly evolving technology may prove useful in patients with primary sarcomas arising from other locations or with other mediastinal neoplasms.

Distal extension mandibular removable partial denture with implant support

PubMed Central

Bural, Canan; Buzbas, Begum; Ozatik, Sebnem; Bayraktar, Gulsen; Emes, Yusuf

2016-01-01

This case report describes the fabrication of a distal extension removable partial denture (RPD) of a 65-year-old man with implant support. Loss of fibroelasticity of the peripheral tissues and reduced mandibular vestibular sulcular depth due to a previous surgical resection and radiotherapy at the right side were the main clinical factors that created difficulty for denture retention and stability. The fabrication of a mandibular RPD supported by anterior teeth and two bilaterally placed implants in the molar area to convert from Kennedy Class 1 design to Kennedy Class 3 implant-bounded RPD is reported. Retention and stability of the denture were improved with implant support on the distal extension site of the RPD. The common clinical problems about distally extended RPDs are lack of retention and stability due to the movement around the rotational axis. Dental implant placement to the distal edentulous site minimizes the potential dislodgement of the RPD is popular. Implant-supported RPD can be suggested as an advantageous and cost-effective treatment option for the partially edentulous patients. PMID:28042277

Uncemented three-dimensional-printed prosthetic replacement for giant cell tumor of distal radius: a new design of prosthesis and surgical techniques.

PubMed

Lu, Minxun; Min, Li; Xiao, Cong; Li, Yongjiang; Luo, Yi; Zhou, Yong; Zhang, Wenli; Tu, Chongqi

2018-01-01

Currently, it is challenging to treat giant cell tumor (GCT) of distal radius. For Campanacci grade III or recurrent GCTs, en bloc resection has been accepted as a better treatment option. Although numerous methods are available for reconstruction, all of them have some limitations in joint function and complications. In this study, our aims were to treat the GCT of distal radius with uncemented three-dimensional (3D)-printed prosthesis and to present and evaluate the surgical techniques and short-term outcomes. Between September 2015 and March 2017, 11 patients with distal radius GCTs were treated with personalized uncemented 3D-printed prosthesis. The preoperative/postoperative pain, range of motion, and grip strengths of all patients were evaluated. Oncological results, complications, and degenerative changes in the wrist joint were evaluated. Functional outcomes were assessed according to the disabilities of the arm, shoulder, and hand (DASH) questionnaire and Mayo wrist scoring systems. The average follow-up was 14.45 months (range, 8-18 months). There was a significant decrease in the mean postoperative visual analog scale score (2.33) compared with the preoperative score (5.22; p <0.001). The mean DASH score and Mayo wrist score of the wrist joint function were 18.7 and 72, respectively. There was no local recurrence or lung metastasis. No complication associated with prosthesis was observed, including aseptic loosening, subluxation, and breakage. Joint space narrowing, or disuse osteoporosis, was also not found in all cases. En bloc resection and reconstruction with a personalized uncemented 3D-printed prosthesis can be alternative options to treat Campanacci grade III or recurrent GCTs of distal radius and can result in short-term oncologic salvage, good postoperative function, and low complication rate. However, a long-term follow-up is required to determine the outcome.

The Likely Sites of Nodal Metastasis Differs According to the Tumor Extent in Distal Bile Duct Cancer.

PubMed

Kato, Yuichiro; Takahashi, Shinichiro; Gotohda, Naoto; Konishi, Masaru

2016-09-01

In the revised Japanese and Worldwide TNM classification of distal bile duct cancer, the lymph node status is defined as N0 or N1 without reference to the tumor location or extent, according to the presence/absence of metastasis to the regional lymph nodes. Data of 94 patients with distal bile duct cancer who had undergone pancreaticoduodenectomy were reviewed retrospectively. In formalin-fixed specimens, we measured the longitudinal lengths from the papilla to the lower and upper margins of the tumor, in order to investigate the correlation of the tumor extent with the likely sites of nodal metastasis. The frequencies of metastasis to the posterior pancreaticoduodenal nodes (7.1 %) and superior mesenteric artery nodes (0.0 %) were significantly lower in the cases in which the length from the papilla to the lower margin of the tumor was ≥30 mm. The frequencies of nodal metastasis to the common hepatic artery nodes (0.0 %) and hepatoduodenal ligament nodes (6.7 %) were significantly lower in the cases in which the length from the papilla to the upper margin was <40 mm. The likely sites of nodal metastasis differ according to the extent of the tumor in cases of bile duct cancer.

En bloc spondylectomy in malignant tumors of the spine

PubMed Central

Lerner, Thomas; Halm, Henry; Buerger, Horst; Gosheger, Georg; Winkelmann, Winfried

2008-01-01

En bloc spondylectomy is a technique that enables wide or marginal resection of malignant lesions of the spine. Both all posterior techniques as well as combined approaches are reported. Aim of the present study was to analyse the results of 21 patients with malignant lesions of the spine, all treated with en bloc excision in a combined posteroanterior (n = 19) or all posterior approach (n = 2). Twenty-one consecutive patients, operated between 1997 and 2005, were included into this retrospective study. Thirteen patients had primary malignant lesions, eight patients had solitary metastases, all located in the thoracolumbar spine. There were 16 single level, three two-level, one three-level and one four-level spondylectomy. The patients were followed clinically and radiographically (including CT studies) with an average follow-up of 4 years. Out of 11 patients with primary Ewing or osteosarcoma seven patients are alive without any evidence of disease. One patient died after 5 years from other causes and three are alive with evidence of disease. Latter had either a poor histologic response to the preoperative chemotherapy (n = 2) or an intralesional resection (n = 1). All three patients with solitary spinal metastases of Ewing or osteosarcoma died of the disease. Five patients with solitary metastases of mainly hypernephroma are alive. In total, six resections were intralesional, mainly due to large intraspinal tumor masses, with two patients having had previous surgery. In the remaining cases, wide (n = 10) or marginal (n = 5) resection was accomplished. There were one pseudarthrosis requiring extension of the fusion and two cases with local recurrences and repeated excisional surgery. At follow-up CT studies, all cages were fused. Health related quality of life analysis (SF-36) revealed only slightly decreased physical component and normal mental component scores compared to normals in those patients with no evidence of disease. En bloc spondylectomy enables wide or marginal resection of malignant lesions of the spine in most cases with acceptable morbidity. Intralesional resection, poor histologic response, and solitary spinal metastases of Ewing and osteosarcoma are associated with a poor prognosis. PMID:18214553

Technical aspects of virtual liver resection planning.

PubMed

Glombitza, G; Lamadé, W; Demiris, A M; Göpfert, M R; Mayer, A; Bahner, M L; Meinzer, H P; Richter, G; Lehnert, T; Herfarth, C

1998-01-01

Operability of a liver tumor is depending on its three dimensional relation to the intrahepatic vascular trees which define autonomously functioning liver (sub-)segments. Precise operation planning is complicated by anatomic variability, distortion of the vascular trees by the tumor or preceding liver resections. Because of the missing possibility to track the deformation of the liver during the operation an integration of the resection planning system into an intra-operative navigation system is not feasible. So the main task of an operation planning system in this domain is a quantifiable patient selection by exact prediction of post-operative liver function and a quantifiable resection proposal. The system quantifies the organ structures and resection volumes by means of absolute and relative values. It defines resection planes depending on security margins and the vascular trees and presents the data in visualized form as a 3D movie. The new 3D operation planning system offers quantifiable liver resection proposals based on individualized liver anatomy. The results are visualized in digital movies as well as in quantitative reports.

A missing link between RON expression and oncological outcomes in resected left-sided pancreatic cancer.

PubMed

Han, Dai Hoon; Kang, Chang Moo; Lee, Sung Whan; Hwang, Ho Kyoung; Lee, Woo Jung

2017-10-01

Alteration and activation of recepteur d'origine nantais (RON) expression is known to be associated with cancer progression and decreased survival in various types of human cancer, including pancreatic cancer. Therefore, in the present study, RON expression levels were determined in resected left-sided pancreatic cancer to evaluate the potential oncological role of RON in the clinical setting of distal pancreatic cancer. From January 2005 to December 2011, a total of 57 patients underwent radical distal pancreatectomy for left-sided pancreatic cancer. Ductal adenocarcinoma was confirmed in all patients. Among these patients, 17 patients who received preoperative neoadjuvant treatment and 7 patients without available paraffin-embedded tissue blocks were excluded from the present study. RON expression in a the pancreatic cancer cell lines ASPC-1, BxPC-3, MiaPaCa-3 and Panc-1, as well as in resected left-sided pancreatic cancer specimens was determined by Western blot analysis. RON and vascular endothelial growth factor (VEGF) overexpression in resected left-sided pancreatic cancer was also evaluated by immunohistochemistry using pre-diluted anti-RON and anti-VEGF antibodies. An association was identified between the oncological outcome and RON overexpression. Increased levels of RON expression were observed in two pancreatic cancer cell lines, AsPC-1 and BxPC-3. RON overexpression was detected in specimens from 15/33 patients (45.5%) using immunohistochemistry. No significant association was identified between RON overexpression and VEGF overexpression (25.5 vs. 87.9%; P=0.667). No significant differences in disease-free survival or disease-specific survival associated with RON overexpression were identified. Although the results of previous studies have suggested that RON is a potential target for the treatment of pancreatic cancer, in the present study no association between RON overexpression and any adverse oncological effect was identified.

Tips and tricks of the surgical technique for borderline resectable pancreatic cancer: mesenteric approach and modified distal pancreatectomy with en-bloc celiac axis resection.

PubMed

Hirono, Seiko; Yamaue, Hiroki

2015-02-01

Borderline resectable (BR) pancreatic cancer involves the portal vein and/or superior mesenteric vein (PV/SMV), major arteries including the superior mesenteric artery (SMA) or common hepatic artery (CHA), and sometimes includes the involvement of the celiac axis. We herein describe tips and tricks for a surgical technique with video assistance, which may increase the R0 rates and decrease the mortality and morbidity for BR pancreatic cancer patients. First, we describe the techniques used for the "artery-first" approach for BR pancreatic cancer with involvement of the PV/SMV and/or SMA. Next, we describe the techniques used for distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) and tips for decreasing the delayed gastric emptying (DGE) rates for advanced pancreatic body cancer. The mesenteric approach, followed by the dissection of posterior tissues of the SMV and SMA, is a feasible procedure to obtain R0 rates and decrease the mortality and morbidity, and the combination of this aggressive procedure and adjuvant chemo(radiation) therapy may improve the survival of BR pancreatic cancer patients. The DP-CAR procedure may increase the R0 rates for pancreatic cancer patients with involvement within 10 mm from the root of the splenic artery, as well as the CHA or celiac axis, and preserving the left gastric artery may lead to a decrease in the DGE rates in cases where there is more than 10 mm between the tumor edge and the root of the left gastric artery. The development of safer surgical procedures is necessary to improve the survival of BR pancreatic cancer patients. © 2014 Japanese Society of Hepato-Biliary-Pancreatic Surgery.

[Mini-subvastus approach for total knee replacement].

PubMed

Halder, Andreas; Beier, Alexander; Neumann, Wolfram

2009-03-01

Total knee replacement in minimally invasive technique without any trauma to the extensor apparatus and with soft-tissue-referenced bone resections. Only the subvastus approach preserves the integrity of the extensor apparatus and has therefore been modified to become a minimally invasive technique with a shorter skin incision and lateralization instead of eversion of the patella. Soft-tissue balancing is done through this direct anterior approach. Mild to moderate varus osteoarthritis of the knee up to 15 degrees of malalignment, mild and passively correctable valgus osteoarthritis of the knee up to 10 degrees of malalignment. Severe, contract varus osteoarthritis of the knee, severe and moderate, contract valgus osteoarthritis of the knee, severe obesity, exceptionally muscular patients, decreased skin perfusion. Central skin incision from the superior pole of the patella to the tibial tubercle. Exposure of the medial retinaculum and mobilization of the vastus medialis muscle subcutaneously. Incision of the medial retinaculum and blunt separation of the vastus medialis muscle from the intermuscular septum. Lateralization of the patella and flexion of the knee joint. Resection of the tibia perpendicular to the diaphysis. Adjustment of the anteroposterior (AP) resection block at the level of the anterior femoral cortex and of rotation by applying equal tension to the collateral ligaments. Balancing of soft-tissue tension in flexion gap by release, if necessary. After AP resection fixation of distal resection block in planned valgus angle. Balancing of soft-tissue tension in extension gap by release, if necessary. After distal femur resection facet resection, adaptation of posterior femoral condyles, and implantation of prosthesis. Check on stability and range of motion. Wound closure. Full weight bearing from the 1st postoperative day, CPM (continuous passive motion) with up to 90 degrees flexion with peridural anesthesia as tolerated, stair climbing starting on the 7th postoperative day. 100 patients were randomized to total knee replacement via a parapatellar or subvastus approach. Radiologically, there were no differences in operative precision or leg alignment. Patients treated minimally invasively suffered less pain and achieved a higher flexion of 110 degrees versus 95 degrees 6 weeks postoperatively. However, there were two cases of delayed wound healing in this group. The surgical technique is demanding and the operating time is longer. Long-term results are still missing.

Long-term Outcomes of One Stage Surgery Using Transanal Colorectal Tube for Acute Colorectal Obstruction of Stage II/III Distal Colon Cancer.

PubMed

Okuda, Yusuke; Yamada, Tomonori; Hirata, Yoshikazu; Shimura, Takaya; Yamaguchi, Ryuzo; Sakamoto, Eiji; Sobue, Satoshi; Nakazawa, Takahiro; Kataoka, Hiromi; Joh, Takashi

2018-06-06

Since oncological outcomes of transanal colorectal tube (TCT) placement, an endoscopic treatment for colorectal cancer (CRC) with acute colorectal obstruction (ACO), remain unknown, this study analyzed long-term outcomes of TCT placement for stage II/III CRC with ACO. Data were retrospectively reviewed from consecutive patients with distal stage II/III CRC who underwent surgery between January 2007 and December 2011 at two Japanese hospitals. One hospital conducted emergency surgery and the other performed TCT placement as the standard treatment for all CRCs with ACO. Propensity score (PS) matching was used to adjust baseline characteristics between two groups. Among 754 patients with distal stage II/III CRC, 680 did not have ACO (non-ACO group) and 74 had ACO (ACO group). The PS matching between both hospitals identified 234 pairs in the non-ACO group and 23 pairs in the ACO group. In the non-ACO group, the surgical quality was equivalent between the two institutions, with no significant differences in overall survival (OS) and disease-free survival (DFS). In the ACO group, the rate of primary resection/anastomosis was higher in the TCT group than in the surgery group (87.0% vs. 26.1%; p < 0.001). No significant differences were noted between the surgery and the TCT groups in OS (5-year OS, 61.9% vs. 51.5%; p=0.490) and DFS (5-year DFS, 45.9% vs. 38.3%; p=0.658). TCT placement can achieve similar long-term outcomes to emergency surgery, with a high rate of primary resection/anastomosis for distal stage II/III colon cancer with ACO.

Preoperative selection of patients with colorectal cancer liver metastasis for hepatic resection

PubMed Central

Mattar, Rafif E; Al-alem, Faisal; Simoneau, Eve; Hassanain, Mazen

2016-01-01

Surgical resection of colorectal liver metastases (CRLM) has a well-documented improvement in survival. To benefit from this intervention, proper selection of patients who would be adequate surgical candidates becomes vital. A combination of imaging techniques may be utilized in the detection of the lesions. The criteria for resection are continuously evolving; currently, the requirements that need be met to undergo resection of CRLM are: the anticipation of attaining a negative margin (R0 resection), whilst maintaining an adequate functioning future liver remnant. The timing of hepatectomy in regards to resection of the primary remains controversial; before, after, or simultaneously. This depends mainly on the tumor burden and symptoms from the primary tumor. The role of chemotherapy differs according to the resectability of the liver lesion(s); no evidence of improved survival was shown in patients with resectable disease who received preoperative chemotherapy. Presence of extrahepatic disease in itself is no longer considered a reason to preclude patients from resection of their CRLM, providing limited extra-hepatic disease, although this currently is an area of active investigations. In conclusion, we review the indications, the adequate selection of patients and perioperative factors to be considered for resection of colorectal liver metastasis. PMID:26811608

Surgical technique and clinical results for scapular allograft reconstruction following resection of scapular tumors.

PubMed

Zhang, Kaiwei; Duan, Hong; Xiang, Zhou; Tu, Chongqi

2009-04-01

Progress in developing effective surgical techniques, such as scapular allograft reconstruction, enhance shoulder stability and extremity function, in patients following scapular tumor resection. Case details from seven patients who underwent scapular allograft reconstruction following scapular tumor resection were reviewed. A wide marginal resection (partial scapulectomy) was performed in all patients and all affected soft tissues were resected to achieve a clean surgical margin. The glenoid-resected and glenoid-saved reconstructions were performed in three and four patients, respectively. The residual host scapula were fixed to the size-matched scapular allografts with plates and screws. The rotator cuff was affected frequently and was mostly resected. The deltoid and articular capsule were infrequently involved, but reconstructed preferentially. The remaining muscles were reattached to the allografts. The median follow-up was 26 months (range, 14-50 months). The average function scores were 24 points (80%) according to the International Society of Limb Salvage criteria. The range of active shoulder abduction and forward flexion motion were 40 degrees -110 degrees and 30 degrees -90 degrees, respectively. There was no difference between the glenoid-saved and glenoid-resected reconstructions in the total scores (mean, 24.5 points/81% versus 24 points/79%), but the glenoid-saved procedure was superior to the later in terms of abduction/flexion motion (mean, 72 degrees /61 degrees versus 55 degrees /43 degrees). During the study follow-up period, one patient died following a relapse, one patient lived despite of local recurrence, and five patients survived with no evidence of recurrence of the original cancer. Post-surgical complications such as shoulder dislocations, non-unions, and articular degeneration were not noted during this study period. Scapular allograft reconstruction had a satisfactory functional, cosmetic, and oncological outcome in this case series. Preservation and reconstruction of the articular capsule and deltoid are proposed to be a prerequisite for using scapular allografts and rotator cuff reconstruction is recommended, although technically challenging to perform.

Surgical technique and clinical results for scapular allograft reconstruction following resection of scapular tumors

PubMed Central

Zhang, Kaiwei; Duan, Hong; Xiang, Zhou; Tu, Chongqi

2009-01-01

Background Progress in developing effective surgical techniques, such as scapular allograft reconstruction, enhance shoulder stability and extremity function, in patients following scapular tumor resection. Methods Case details from seven patients who underwent scapular allograft reconstruction following scapular tumor resection were reviewed. A wide marginal resection (partial scapulectomy) was performed in all patients and all affected soft tissues were resected to achieve a clean surgical margin. The glenoid-resected and glenoid-saved reconstructions were performed in three and four patients, respectively. The residual host scapula were fixed to the size-matched scapular allografts with plates and screws. The rotator cuff was affected frequently and was mostly resected. The deltoid and articular capsule were infrequently involved, but reconstructed preferentially. The remaining muscles were reattached to the allografts. Results The median follow-up was 26 months (range, 14–50 months). The average function scores were 24 points (80%) according to the International Society of Limb Salvage criteria. The range of active shoulder abduction and forward flexion motion were 40°–110° and 30°–90°, respectively. There was no difference between the glenoid-saved and glenoid-resected reconstructions in the total scores (mean, 24.5 points/81% versus 24 points/79%), but the glenoid-saved procedure was superior to the later in terms of abduction/flexion motion (mean, 72°/61° versus 55°/43°). During the study follow-up period, one patient died following a relapse, one patient lived despite of local recurrence, and five patients survived with no evidence of recurrence of the original cancer. Post-surgical complications such as shoulder dislocations, non-unions, and articular degeneration were not noted during this study period. Conclusion Scapular allograft reconstruction had a satisfactory functional, cosmetic, and oncological outcome in this case series. Preservation and reconstruction of the articular capsule and deltoid are proposed to be a prerequisite for using scapular allografts and rotator cuff reconstruction is recommended, although technically challenging to perform. PMID:19338652

The effects of implementing synoptic pathology reporting in cancer diagnosis: a systematic review.

PubMed

Sluijter, Caro E; van Lonkhuijzen, Luc R C W; van Slooten, Henk-Jan; Nagtegaal, Iris D; Overbeek, Lucy I H

2016-06-01

Pathology reporting is evolving from a traditional narrative report to a more structured synoptic report. Narrative reporting can cause misinterpretation due to lack of information and structure. In this systematic review, we evaluate the impact of synoptic reporting on completeness of pathology reports and quality of pathology evaluation for solid tumours. Pubmed, Embase and Cochrane databases were systematically searched to identify studies describing the effect of synoptic reporting implementation on completeness of reporting and quality of pathology evaluation of solid malignant tumours. Thirty-three studies met the inclusion criteria. All studies, except one, reported an increased overall completeness of pathology reports after introduction of synoptic reporting (SR). Most frequently studied cancers were breast (n = 9) and colorectal cancer (n = 16). For breast cancer, narrative reports adequately described 'tumour type' and 'nodal status'. Synoptic reporting resulted in improved description of 'resection margins', 'DCIS size', 'location' and 'presence of calcifications'. For colorectal cancer, narrative reports adequately reported 'tumour type', 'invasion depth', 'lymph node counts' and 'nodal status'. Synoptic reporting resulted in increased reporting of 'circumferential margin', 'resection margin', 'perineural invasion' and 'lymphovascular invasion'. In addition, increased numbers of reported lymph nodes were found in synoptic reports. Narrative reports of other cancer types described the traditional parameters adequately, whereas for 'resection margins' and '(lympho)vascular/perineural invasion', implementation of synoptic reporting was necessary. Synoptic reporting results in improved reporting of clinical relevant data. Demonstration of clinical impact of this improved method of pathology reporting is required for successful introduction and implementation in daily pathology practice.

Aggressive Surgical Resection of Pulmonary Artery Intimal Sarcoma.

PubMed

Yamamoto, Yoko; Shintani, Yasushi; Funaki, Soichiro; Taira, Masaki; Ueno, Takayoshi; Kawamura, Tomohiro; Kanzaki, Ryu; Minami, Masato; Sawa, Yoshiki; Okumura, Meinoshin

2018-05-03

Intimal sarcoma of the pulmonary artery is a rare and highly malignant neoplasm. We herein report a case of a 30-year-old woman with an extensive right pulmonary artery tumor who underwent an emergent operation. The tumor was aggressively resected with right pneumonectomy and reconstruction of the right ventricle outflow tract and left pulmonary artery. Although the resected margin at the left pulmonary artery was positive, as confirmed by Mouse double minute type 2 homolog staining, she is doing well and remains free of relapse at 16 months after the operation. Copyright © 2018. Published by Elsevier Inc.

DNA Damage Response Factors from Diverse Pathways, Including DNA Crosslink Repair, Mediate Alternative End Joining

PubMed Central

Howard, Sean M.; Yanez, Diana A.; Stark, Jeremy M.

2015-01-01

Alternative end joining (Alt-EJ) chromosomal break repair involves bypassing classical non-homologous end joining (c-NHEJ), and such repair causes mutations often with microhomology at the repair junction. Since the mediators of Alt-EJ are not well understood, we have sought to identify DNA damage response (DDR) factors important for this repair event. Using chromosomal break reporter assays, we surveyed an RNAi library targeting known DDR factors for siRNAs that cause a specific decrease in Alt-EJ, relative to an EJ event that is a composite of Alt-EJ and c-NHEJ (Distal-EJ between two tandem breaks). From this analysis, we identified several DDR factors that are specifically important for Alt-EJ relative to Distal-EJ. While these factors are from diverse pathways, we also found that most of them also promote homologous recombination (HR), including factors important for DNA crosslink repair, such as the Fanconi Anemia factor, FANCA. Since bypass of c-NHEJ is likely important for both Alt-EJ and HR, we disrupted the c-NHEJ factor Ku70 in Fanca-deficient mouse cells and found that Ku70 loss significantly diminishes the influence of Fanca on Alt-EJ. In contrast, an inhibitor of poly ADP-ribose polymerase (PARP) causes a decrease in Alt-EJ that is enhanced by Ku70 loss. Additionally, the helicase/nuclease DNA2 appears to have distinct effects from FANCA and PARP on both Alt-EJ, as well as end resection. Finally, we found that the proteasome inhibitor Bortezomib, a cancer therapeutic that has been shown to disrupt FANC signaling, causes a significant reduction in both Alt-EJ and HR, relative to Distal-EJ, as well as a substantial loss of end resection. We suggest that several distinct DDR functions are important for Alt-EJ, which include promoting bypass of c-NHEJ and end resection. PMID:25629353

Flowable resin and marginal gap on tooth third medial cavity involving enamel and radicular cementum: a SEM evaluation of two restoration techniques.

PubMed

Lo Giudice, G; Cicciù, M; Cervino, G; Lizio, A; Visco, A M

2012-01-01

The aim of this study is to investigate the presence and the extent of a possible marginal gap after the interposition of a flowable composite between the composite restoration and the dental structures (enamel and cementum). This technique is also used to eliminate the infiltration in a zone of the cavity preparation that is frequently at a risk of secondary decay. Fifteen human premolars extracted for orthodontic reasons were used for the study. A cavity with mesial and distal margin in enamel and cementum was realized in every tooth. The cavities were then restored with an adhesive system (ScotchBond 3MÔ) and composite (Filtek Supreme 3MÔ); and, a fine layer of flowable composite was applied in the distal margin of each cavity. Scanning electron microscopy (SEM) in secondary electron imaging (S.E.I.) modality was used for the study and identifying the marginal gaps in the composite restorations. Data was investigated on the mesial and distal margin of each cavity at the restoration-enamel interface, and at the restoration-cementum interface. The interfaces were divided in four groups: Group A (enamel/composite); Group B (enamel/flow/composite); Group C (cementum/composite); and, Group D (cementum/flow/composite). By the comparison of the gap's average width found in each group, it is evidenced that the average width of the gap increases when the interface moves from the coronal to the radicular end (Group A 0,1 ± 0,4 μm Vs Group C 12,3 ± 11,6 μm; Group B 0,2 ± 0,8 μm Vs Group D 2,8 ± 6,6 μm). Correlating the measurements of the marginal gap's average width among the Group A and Group B, no significant variations were obtained; and instead, on comparing Group C with Group D, the gap's average width decreases. The interposition of a low elastic modulus composite between the adhesive layer and the composite resin allows an improvement of the cementum-restoration interface by the means of a lower shrinkage stress during polymerization.

Development of continental margins of the Atlantic Ocean and successive breakup of the Pangaea-3 supercontinent

NASA Astrophysics Data System (ADS)

Melankholina, E. N.; Sushchevskaya, N. M.

2017-01-01

Comparative tectonic analysis of passive margins of the Atlantic Ocean has been performed. Tectonotypes of both volcanic and nonvolcanic margins are described, and their comparison with other passive Atlantic margins is given. The structural features of margins, peculiarities of magmatism, its sources and reasons for geochemical enrichment of melts are discussed. The important role of melting of the continental lithosphere in the development of magmatism is demonstrated. Enriched EM I and EM II sources are determined for the lower parts of the volcanic section, and a depleted or poorly enriched source is determined for the upper parts of the volcanic section based on isotope data. The conclusions of the paper relate to tectonic settings of the initial occurrence of magmatism and rifting and breakup during the period of opening of the Mesozoic Ocean. It was found out that breakup and magmatism at proximal margins led only to insignificant structural transformations and reduction of the thickness of the ancient continental crust, while very important magmatic events happened later in the distal zone. New growth of magmatic crust at the stage of continental breakup is determined as a typical feature of distal zones of the margins under study. The relationship of development of margins with the impact of deep plumes as the source of magmatic material or a heat source only is discussed. Progradation of the zone of extension and breakup into the areas of cold lithosphere of the Atlantic and the formation of a single tectonomagmatic system of the ocean are under consideration.

Magnetic resonance imaging (MRI)-based indication for neoadjuvant treatment of rectal carcinoma and the surrogate endpoint CRM status.

PubMed

Strassburg, Joachim; Junginger, Theo; Trinh, Trong; Püttcher, Olaf; Oberholzer, Katja; Heald, Richard J; Hermanek, Paul

2008-11-01

Is it possible to reduce the frequency of neoadjuvant therapy for rectal carcinoma and nevertheless achieve a rate of more than 90% circumferential resection margin (CRM)-negative resection specimens by a novel concept of magnetic resonance imaging (MRI)-based therapy planning? One hundred eighty-one patients from Berlin and Mainz, Germany, with primary rectal carcinoma, without distant metastasis, underwent radical surgery with curative intention. Surgical procedures applied were anterior resection with total mesorectal excision (TME) or partial mesorectal excision (PME; PME for tumours of the upper rectum) or abdominoperineal excision with TME. With MRI selection of the highest-risk cases, neoadjuvant therapy was given to only 62 of 181 (34.3%). The rate of CRM-negative resection specimens on histology was 170 of 181 (93.9%) for all patients, and in Berlin, only 1 of 93 (1%) specimens was CRM-positive. Patients selected for primary surgery had CRM-negative specimens on histology in 114 of 119 (95.8%). Those selected for neoadjuvant therapy had a lower rate of clear margin: 56 of 62 (90%). By applying a MRI-based indication, the frequency of neoadjuvant treatment with its acute and late adverse effects can be reduced to 30-35% without reduction of pathologically CRM-negative resection specimens and, thus, without the danger of worsening the oncological long-term results. This concept should be confirmed in prospective multicentre observation studies with quality assurance of MRI, surgery and pathology.

Role of hilar resection in the treatment of hilar cholangiocarcinoma.

PubMed

Otani, Kazuhiro; Chijiiwa, Kazuo; Kai, Masahiro; Ohuchida, Jiro; Nagano, Motoaki; Kondo, Kazuhiro

2012-05-01

The aim of this study was to clarify the role of bile duct resection without hepatectomy (hilar resection) in hilar cholangiocarcinoma. We retrospectively compared surgical results for hilar cholangiocarcinoma between 8 patients treated with hilar resection and 21 patients treated with hepatectomy. All hilar resections were performed for Bismuth type I or II tumors with T2 or less lesions, whereas hepatectomy was done for type III or IV tumors excluding one type II tumor. R0 resection was equally achieved in both groups (62.5% in hilar resection group and 76.2% in hepatectomy group, p=0.469) and overall 5-year survival rates were comparable (21.9% vs. 23.6%, p=0.874). With respect to gross tumor appearance, R0 resection was achieved in all patients with papillary tumor in both groups with the excellent 5-year survivals (100% vs. 100%). In patients with nodular and flat tumors, R0 resection was achieved less frequently in the hilar resection vs. hepatectomy group (50% vs. 77.8%) mainly due to failure to clear the proximal ductal margin, resulting in poorer 5-year survival (0% vs. 18.7%). Hilar resection may be indicated for papillary T1 or 2 tumors in Bismuth type I or II cholangiocarcinoma.

A novel surgical marking system for small peripheral lung nodules based on radio frequency identification technology: Feasibility study in a canine model.

PubMed

Kojima, Fumitsugu; Sato, Toshihiko; Takahata, Hiromi; Okada, Minoru; Sugiura, Tadao; Oshiro, Osamu; Date, Hiroshi; Nakamura, Tatsuo

2014-04-01

We investigated the feasibility and accuracy of a novel surgical marking system based on radiofrequency identification (RFID) technology for the localization of small peripheral lung nodules (SPLNs) in a canine model. The system consists of 4 components: (1) micro RFID tags (13.56 MHz, 1.0 × 1.0 × 0.8 mm), (2) a tag delivery system with a bronchoscope, (3) a wand-shaped locating probe (10-mm diameter), and (4) a signal processing unit with audio interface. Before the operation, pseudolesions mimicking SPLNs were prepared in 7 dogs by injecting colored collagen. By use of a computed tomographic (CT) guide, an RFID tag was placed via a bronchoscope close to each target lesion. This was then followed by scanning with the locating probe, and wedge resection was performed when possible. Operators can locate the tag by following the sound emitted by the system, which exhibits tone changes according to the tag-probe distance. The primary outcome measure was the rate of wedge resection with good margins. A total of 10 pseudolesions imitating SPLNs were selected as targets. During thoracoscopic procedures, 9 of 10 tags were detected by the system within a median of 27 seconds. Wedge resections were performed for these 9 lesions with a median margin of 11 mm. The single failure was caused by tag dislocation to the central airway. Successful localization and wedge resection of pseudolesions with appropriate margins were accomplished in an experimental setting. Our RFID marking system has future applications for accurately locating SPLNs in a clinical setting. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

The Unresolved Case of Sacral Chordoma: From Misdiagnosis to Challenging Surgery and Medical Therapy Resistance

PubMed Central

Garofalo, Fabio; Christoforidis, Dimitrios; di Summa, Pietro G.; Gay, Béatrice; Cherix, Stéphane; Raffoul, Wassim; Matter, Maurice

2014-01-01

Purpose A sacral chordoma is a rare, slow-growing, primary bone tumor, arising from embryonic notochordal remnants. Radical surgery is the only hope for cure. The aim of our present study is to analyse our experience with the challenging treatment of this rare tumor, to review current treatment modalities and to assess the outcome based on R status. Methods Eight patients were treated in our institution between 2001 and 2011. All patients were discussed by a multidisciplinary tumor board, and an en bloc surgical resection by posterior perineal access only or by combined anterior/posterior accesses was planned based on tumor extension. Results Seven patients underwent radical surgery, and one was treated by using local cryotherapy alone due to low performance status. Three misdiagnosed patients had primary surgery at another hospital with R1 margins. Reresection margins in our institution were R1 in two and R0 in one, and all three recurred. Four patients were primarily operated on at our institution and had en bloc surgery with R0 resection margins. One had local recurrence after 18 months. The overall morbidity rate was 86% (6/7 patients) and was mostly related to the perineal wound. Overall, 3 out of 7 resected patients were disease-free at a median follow-up of 2.9 years (range, 1.6-8.0 years). Conclusion Our experience confirms the importance of early correct diagnosis and of an R0 resection for a sacral chordoma invading pelvic structures. It is a rare disease that requires a challenging multidisciplinary treatment, which should ideally be performed in a tertiary referral center. PMID:24999463

The impact of a dedicated multidisciplinary team on the management of early rectal cancer.

PubMed

Vaughan-Shaw, P G; Wheeler, J M D; Borley, N R

2015-08-01

Local excision of early rectal cancer (ERCa) offers comparable survival and reduced operative morbidity compared with radical surgery, yet it risks an adverse oncological outcome if performed in the wrong setting. This retrospective review considers the impact of the introduction of a specialist early rectal cancer multidisciplinary team (ERCa MDT) on the investigation and management of ERCa. A retrospective comparative cohort study was undertaken. Patients with a final diagnosis of pT1 rectal cancer at our unit were identified for two 12-month periods before and after the introduction of the specialist ERCa MDT. Data on investigations and therapeutic interventions were compared. Nineteen patients from 2006 and 24 from 2011 were included. In 2006, 12 patients underwent MRI and four transrectal ultrasound (TRUS) examination, while in 2011, 18 and 20, respectively, received MRI and TRUS. In 2006 four patients underwent incidental ERCa polypectomy, with all having a positive resection margin leading to anterior resection. In 2011 only one case with a positive margin following extended endoscopic mucosal resection was identified. Definitive local excision without subsequent resection occurred in two patients in 2006 and in 16 in 2011. The study demonstrates an improvement in preoperative ERCa staging, a reduction in margin positivity and an increase in the use of local excision following the implementation of a specialist ERCa MDT. The increased detection of rectal neoplasms through screening and surveillance programmes requires further investigation and management. A specialist ERCa MDT will improve management and should be available to all practitioners involved with patients with ERCa. Colorectal Disease © 2015 The Association of Coloproctology of Great Britain and Ireland.

[Surgical treatment and prognosis of Borrmann type IIII( gastric cancer involving the whole stomach].

PubMed

Dong, Ruizeng; Zhang, Zewei; Zhou, Yiming; Hua, Yonghong; Guo, Jianmin

2018-02-25

To explore the surgical treatment and prognosis of Borrmann type IIII( gastric cancer involving the whole stomach. Clinicopathological characteristics and survival data of 223 patients with Borrmann type IIII( gastric cancer involving the whole stomach (defined as the tumor infiltrating 3 regions of the stomach) receiving surgical treatment at the Department of Abdominal Surgery of Zhejiang Cancer Hospital between January 2002 and December 2015 were analyzed retrospectively. The survival time of patients with different clinicopathological features and different treatment methods was compared. Cox regression was used to analyze the independent prognostic factors. Two hundred and twenty-three patients with Borrmann type IIII( gastric cancer involving the whole stomach accounted for 24.0% (223/930) of all Borrmann type IIII( gastric cancer cases undergoing surgical resection at the same period. There were 147 males and 76 females with an average age of 57.8 years. All the patients underwent total gastrectomy. Of these patients, radical resection was performed in 149 cases(66.8%) and palliative resection in 74 cases (33.2%). Combined organ resection was performed in 43 patients (19.3%), including 25 splenectomies, 6 pancreatic body and tail plus spleen and transverse colon resections, 2 transverse colon plus spleen resections, 2 right colon resections, 2 transverse colon resections, 2 ovariectomies, 1 partial jejunal resection, 1 pancreatoduodenectomy, 1 pancreatic tail plus transverse colon resection, and 1 partial pancreatectomy. Postoperative complications occurred in 28 patients(12.6%), including 10 patients with combined organ resection. Esophagojejunal fistula was the most frequent complication, accounting for 39.3%(11/28). Perioperative mortality occurred in 3 patients (1.3%). Thirty-nine patients underwent preoperative adjuvant chemotherapy (clinical stage: cT4aN0M0 in 1 patient, cT4bN1-2M0 in 12 patients, cT4aN1-2M0 in 20 patients, and cT4aN3M0 in 6 patients). Among these 39 patients, post-chemotherapeutic degenerative response was detected in 25 postoperative pathological specimens (64.1%), radical resection was performed in 21 patients (53.8%), distant metastasis was observed in 7 patients (17.9%) and peritoneal metastasis was found in 17 patients (43.6%) during operation. The average maximal tumor diameter was 13.2 cm (range from 6 to 22). Histological types included 23 moderate-poorly differentiated adenocarcinomas (10.3%), 146 poorly differentiated adenocarcinomas (65.5%), 41 signet ring cell carcinomas (18.4%), 11 mucinous adenocarcinomas(4.9%), 1 squamous cell carcinoma (0.4%) and 1 undifferentiated carcinoma (0.4%). Tumor-infiltrating duodenum was found in 57 patients (25.6%) and tumor-infiltrating esophagus in 132 patients (59.2%). The positive margin was found in 66 patients (29.6%): upper margin in 35 patients (15.7%), lower margin in 22 patients (9.9%), and both margins in 9 patients(4.0%). Immunohistochemical positive HER2(3+) was detected in 4 patients (1.8%). Tumor infiltrating into serosa(T4a) was found in 197 patients (88.3%) and infiltrating into adjacent organ (T4b) in 26 patients(11.7%). One hundred and forty-three cases (64.1%) had lymphatic or venous invasion, 187 (83.9%) had neural invasion, and 35 (15.7%) had cancer nodules. Of 149 patients undergoing radical resection, 5 patients were stage II(b, 9 patients were III(a, 20 patients were III(b and 115 patients were III(c. Of 145 patients(65.0%) undergoing postoperative chemotherapy, the average cycles of chemotherapy was 3.6 (median 3 cycles) and only 69 patients (47.6%) completed 4 cycles or more. Patients were followed up for 1-102 months (average 17.3 months). The median overall survival time was 13.8 months and the 1-, 3-, and 5-year survival rate was 57.9%, 14.1% and 6.8% respectively. The median survival time of the 149 cases with radical resection was 16.7 months and the 1-, 3- and 5-year survival rate was 67.5%, 16.5% and 8.4% respectively; the median survival time of the 74 cases with palliative resection was 10.3 months and the 1-, 3- and 5-year survival rate was 42.6%, 8.5% and 1.7% respectively, whose differences were statistically significant (all P=0.000). Multivariate analysis showed that tumor staging (P=0.005), radical resection (P=0.009), lymphatic or venous invasion (P=0.017) and postoperative chemotherapy (P=0.001) were independent prognostic factors. Surgical treatment for Borrmann type IIII( gastric cancer involving the whole stomach is safe. Radical resection can improve the prognosis though the overall survival is poor.

Total mesorectal excision for mid and low rectal cancer: Laparoscopic vs robotic surgery

PubMed Central

Feroci, Francesco; Vannucchi, Andrea; Bianchi, Paolo Pietro; Cantafio, Stefano; Garzi, Alessia; Formisano, Giampaolo; Scatizzi, Marco

2016-01-01

AIM: To compare the short- and long-term outcomes of laparoscopic and robotic surgery for middle and low rectal cancer. METHODS: This is a retrospective study on a prospectively collected database containing 111 patients who underwent minimally invasive rectal resection with total mesorectal excision (TME) with curative intent between January 2008 and December 2014 (robot, n = 53; laparoscopy, n = 58). The patients all had a diagnosis of middle and low rectal adenocarcinoma with stage I-III disease. The median follow-up period was 37.4 mo. Perioperative results, morbidity a pathological data were evaluated and compared. The 3-year overall survival and disease-free survival rates were calculated and compared. RESULTS: Patients were comparable in terms of preoperative and demographic parameters. The median surgery time was 192 min for laparoscopic TME (L-TME) and 342 min for robotic TME (R-TME) (P < 0.001). There were no differences found in the rates of conversion to open surgery and morbidity. The patients who underwent laparoscopic surgery stayed in the hospital two days longer than the robotic group patients (8 d for L-TME and 6 d for R-TME, P < 0.001). The pathologic evaluation showed a higher number of harvested lymph nodes in the robotic group (18 for R-TME, 11 for L-TME, P < 0.001) and a shorter distal resection margin for laparoscopic patients (1.5 cm for L-TME, 2.5 cm for R-TME, P < 0.001). The three-year overall survival and disease-free survival rates were similar between groups. CONCLUSION: Both L-TME and R-TME achieved acceptable clinical and oncologic outcomes. The robotic technique showed some advantages in rectal surgery that should be validated by further studies. PMID:27053852

Simple instruments facilitating achievement of transanal total mesorectal excision in male patients.

PubMed

Xu, Chang; Song, Hua-Yu; Han, Shao-Liang; Ni, Shi-Chang; Zhang, Hu-Xiang; Xing, Chun-Gen

2017-08-21

To assess the efficacy of a modified approach with transanal total mesorectal excision (taTME) using simple customized instruments in male patients with low rectal cancer. A total of 115 male patients with low rectal cancer from December 2006 to August 2015 were retrospectively studied. All patients had a bulky tumor (tumor diameter ≥ 40 mm). Forty-one patients (group A) underwent a classical approach of transabdominal total mesorectal excision (TME) and transanal intersphincteric resection (ISR), and the other 74 patients (group B) underwent a modified approach with transabdominal TME, transanal ISR, and taTME. Some simple instruments including modified retractors and an anal dilator with a papilionaceous fixture were used to perform taTME. The operative time, quality of mesorectal excision, circumferential resection margin, local recurrence, and postoperative survival were evaluated. All 115 patients had successful sphincter preservation. The operative time in group B (240 min, range: 160-330 min) was significantly shorter than that in group A (280 min, range: 200-360 min; P = 0.000). Compared with group A, more complete distal mesorectum and total mesorectum were achieved in group B (100% vs 75.6%, P = 0.000; 90.5% vs 70.7%, P = 0.008, respectively). After 46.1 ± 25.6 mo follow-up, group B had a lower local recurrence rate and higher disease-free survival rate compared with group A, but these differences were not statistically significant (5.4% vs 14.6%, P = 0.093; 79.5% vs 65.1%, P = 0.130). Retrograde taTME with simple customized instruments can achieve high-quality TME, and it might be an effective and economical alternative for male patients with bulky tumors.

Submucosal nerve diameter of greater than 40 μm is not a valid diagnostic index of transition zone pull-through.

PubMed

Kapur, Raj P

2016-10-01

Submucosal nerve hypertrophy is a feature of the transition zone in Hirschsprung disease and has been used as a primary diagnostic feature of transition zone pull-through for patients with persistent obstructive symptoms after their initial surgery. Most published criteria for identification of hypertrophy rely on a nerve diameter of greater than 40μm, based primarily on data from a relatively small number of infants with Hirschsprung disease and controls. The validity of these objective measures has not been validated in appropriate controls for post-pull-through patients. The primary pull-through specimens and post pull-through biopsies +/- redo pull-through resections from a series of 9 patients with Hirschsprung disease were reviewed to assess the prevalence of submucosal nerves >40μm in diameter and 400× microscopic fields containing two or more such nerves. Similar data from multiple colonic locations were collected from a series of 40 non-Hirschsprung autopsy and surgical controls. The overwhelming majority of Hirschsprung patients harbored submucosal nerves >40μm in their post-pull-through specimens independent of other features of transition zone pathology, and despite normal innervation at the proximal margins of their initial resections. Measurement of submucosal nerve diameters in autopsy and surgical non-Hirschsprung control samples indicated that nerves >40μm are normal in the distal rectum after 1year of age and are found in more proximal colon at older ages. These results suggest that diagnostic criteria currently used to recognize submucosal nerve hypertrophy in the neorectum after a pull-through for Hirschsprung disease are not justified and should not be regarded as definitive evidence for transition zone pull-through. Copyright © 2016 Elsevier Inc. All rights reserved.

Simple instruments facilitating achievement of transanal total mesorectal excision in male patients

PubMed Central

Xu, Chang; Song, Hua-Yu; Han, Shao-Liang; Ni, Shi-Chang; Zhang, Hu-Xiang; Xing, Chun-Gen

2017-01-01

AIM To assess the efficacy of a modified approach with transanal total mesorectal excision (taTME) using simple customized instruments in male patients with low rectal cancer. METHODS A total of 115 male patients with low rectal cancer from December 2006 to August 2015 were retrospectively studied. All patients had a bulky tumor (tumor diameter ≥ 40 mm). Forty-one patients (group A) underwent a classical approach of transabdominal total mesorectal excision (TME) and transanal intersphincteric resection (ISR), and the other 74 patients (group B) underwent a modified approach with transabdominal TME, transanal ISR, and taTME. Some simple instruments including modified retractors and an anal dilator with a papilionaceous fixture were used to perform taTME. The operative time, quality of mesorectal excision, circumferential resection margin, local recurrence, and postoperative survival were evaluated. RESULTS All 115 patients had successful sphincter preservation. The operative time in group B (240 min, range: 160-330 min) was significantly shorter than that in group A (280 min, range: 200-360 min; P = 0.000). Compared with group A, more complete distal mesorectum and total mesorectum were achieved in group B (100% vs 75.6%, P = 0.000; 90.5% vs 70.7%, P = 0.008, respectively). After 46.1 ± 25.6 mo follow-up, group B had a lower local recurrence rate and higher disease-free survival rate compared with group A, but these differences were not statistically significant (5.4% vs 14.6%, P = 0.093; 79.5% vs 65.1%, P = 0.130). CONCLUSION Retrograde taTME with simple customized instruments can achieve high-quality TME, and it might be an effective and economical alternative for male patients with bulky tumors. PMID:28883706

New Technique for Liver Resection Using Heat Coagulative Necrosis

PubMed Central

Weber, Jean-Christophe; Navarra, Giuseppe; Jiao, Long R.; Nicholls, Joanna P.; Jensen, Steen Lindkaer; Habib, Nagy A.

2002-01-01

Objective To assess a new bloodless technique using radiofrequency energy for segmental liver resection of hepatic tumors. Summary Background Data Liver resection remains a formidable surgical procedure; safe performance requires a high level of training and skill. Intraoperative blood loss during liver resection remains a major concern because it is associated with a higher rate of postoperative complications and shorter long-term survival. Methods From January 2000 to June 2001, 15 patients with various hepatic tumors were operated on using radiofrequency energy to remove the tumor in its entirety. Radiofrequency energy was applied along the margins of the tumor to create “zones of necrosis” before resection with a scalpel. Results No blood transfusions were required. The mean blood loss during resection was 30 ± 10 mL. No mortality or morbidity was observed. The median postoperative stay was 8 days (range 5–9). No liver recurrence was detected in patients undergoing resection with this technique during follow-up periods ranging from 2 to 20 months. Conclusions Segmental and wedge liver resection assisted by radiofrequency is safe. This novel technique offers a new method for transfusion-free resection. PMID:12409660

Development and evaluation of a connective tissue phantom model for subsurface visualization of cancers requiring wide local excision.

PubMed

Samkoe, Kimberley S; Bates, Brent D; Tselepidakis, Niki N; DSouza, Alisha V; Gunn, Jason R; Ramkumar, Dipak B; Paulsen, Keith D; Pogue, Brian W; Henderson, Eric R

2017-12-01

Wide local excision (WLE) of tumors with negative margins remains a challenge because surgeons cannot directly visualize the mass. Fluorescence-guided surgery (FGS) may improve surgical accuracy; however, conventional methods with direct surface tumor visualization are not immediately applicable, and properties of tissues surrounding the cancer must be considered. We developed a phantom model for sarcoma resection with the near-infrared fluorophore IRDye 800CW and used it to iteratively define the properties of connective tissues that typically surround sarcoma tumors. We then tested the ability of a blinded surgeon to resect fluorescent tumor-simulating inclusions with ∼1-cm margins using predetermined target fluorescence intensities and a Solaris open-air fluorescence imaging system. In connective tissue-simulating phantoms, fluorescence intensity decreased with increasing blood concentration and increased with increasing intralipid concentrations. Fluorescent inclusions could be resolved at ≥1-cm depth in all inclusion concentrations and sizes tested. When inclusion depth was held constant, fluorescence intensity decreased with decreasing volume. Using targeted fluorescence intensities, a blinded surgeon was able to successfully excise inclusions with ∼1-cm margins from fat- and muscle-simulating phantoms with inclusion-to-background contrast ratios as low as 2∶1. Indirect, subsurface FGS is a promising tool for surgical resection of cancers requiring WLE. (2017) COPYRIGHT Society of Photo-Optical Instrumentation Engineers (SPIE).

Mechanical Strength of the Proximal Femur After Arthroscopic Osteochondroplasty for Femoroacetabular Impingement: Finite Element Analysis and 3-Dimensional Image Analysis.

PubMed

Oba, Masatoshi; Kobayashi, Naomi; Inaba, Yutaka; Choe, Hyonmin; Ike, Hiroyuki; Kubota, So; Saito, Tomoyuki

2018-06-21

To examine the influence of femoral neck resection on the mechanical strength of the proximal femur in actual surgery. Eighteen subjects who received arthroscopic cam resection for cam-type femoroacetabular impingement (FAI) were included. Finite element analyses (FEAs) were performed to calculate changes in simulative fracture load between pre- and postoperative femur models. The finite element femur models were constructed from computed tomographic images; thus, the models represented the shape of the original femur, including the bone resection site. Three-dimensional image analysis of the bone resection site was performed to identify morphometric factors that affect strength in the postoperative femur model. Four oblique sagittal planes running perpendicular to the femoral neck axis were used as reference planes to measure the bone resection site. At the transcervical reference plane, both the bone resection depth and the cross-sectional area at the resection site correlated strongly with postoperative changes in the simulated fracture load (R 2  = 0.6, P = .0001). However, only resection depth was significantly correlated with the simulated fracture load at the reference plane for the head-neck junction. The resected bone volume did not correlate with the postoperative changes in the simulated fracture load. The results of our FEA suggest that the bone resection depth measured at the head-neck junction and transcervical reference plane correlates with fracture risk after osteochondroplasty. By contrast, bone resection at more proximal areas did not have a significant effect on the postoperative femur model strength in our FEA. The total volume of resected bone was also not significantly correlated with postoperative changes in femur model strength. This biomechanical study using FEA suggest that there is a risk of femoral neck fracture after arthroscopic cam resection, particularly when the resected lesion is located distally. Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Climatic controls on arid continental basin margin systems

NASA Astrophysics Data System (ADS)

Gough, Amy; Clarke, Stuart; Richards, Philip; Milodowski, Antoni

2016-04-01

Alluvial fans are both dominant and long-lived within continental basin margin systems. As a result, they commonly interact with a variety of depositional systems that exist at different times in the distal extent of the basin as the basin evolves. The deposits of the distal basin often cycle between those with the potential to act as good aquifers and those with the potential to act as good aquitards. The interactions between the distal deposits and the basin margin fans can have a significant impact upon basin-scale fluid flow. The fans themselves are commonly considered as relatively homogeneous, but their sedimentology is controlled by a variety of factors, including: 1) differing depositional mechanisms; 2) localised autocyclic controls; 3) geometrical and temporal interactions with deposits of the basin centre; and, 4) long-term allocyclic climatic variations. This work examines the basin margin systems of the Cutler Group sediments of the Paradox Basin, western U.S.A and presents generalised facies models for the Cutler Group alluvial fans as well as for the zone of interaction between these fans and the contemporaneous environments in the basin centre, at a variety of scales. Small-scale controls on deposition include climate, tectonics, base level and sediment supply. It has been ascertained that long-term climatic alterations were the main control on these depositional systems. Models have been constructed to highlight how both long-term and short-term alterations in the climatic regime can affect the sedimentation in the basin. These models can be applied to better understand similar, but poorly exposed, alluvial fan deposits. The alluvial fans of the Brockram Facies, northern England form part of a once-proposed site for low-level nuclear waste decommissioning. As such, it is important to understand the sedimentology, three-dimensional geometry, and the proposed connectivity of the deposits from the perspective of basin-scale fluid flow. The developed models suggest that the deposits of the Brockram alluvial fans have the potential to contain numerous preferential flow zones. Where these flow zones are adjacent to the unique deposits of the zone of interaction it affects basin-scale fluid flow by: 1) interconnecting decent reservoirs in the distal extent of the basin; 2) creating flow pathways away from these reservoirs; 3) introducing secondary baffles into the system; and, 4) creating a bypass to charge these distal reservoirs.

Histopathologic patterns as markers of prognosis in patients undergoing hepatectomy for colorectal cancer liver metastases - Pushing growth as an independent risk factor for decreased survival.

PubMed

Falcão, Daniela; Alexandrino, Henrique; Caetano Oliveira, Rui; Martins, João; Ferreira, Luís; Martins, Ricardo; Serôdio, Marco; Martins, Mónica; Tralhão, José Guilherme; Cipriano, Maria Augusta; Castro E Sousa, Francisco

2018-04-11

Liver resection combined with neoadjuvant chemotherapy (NAC) has reported notable results in patients with colorectal liver metastases (CRLM). Tumoral response to NAC is associated with specific histopathologic patterns with prognostic implications. The main objective of this study was to evaluate the influence of pathological findings on overall survival (OS), disease-free survival (DFS) and liver recurrence-free survival (LRFS). Analysis of clinical and outcome data from 110 patients who underwent first CRLM resection between January 2010 and July 2013. Blinded pathological review of histological material of several parameters: resection margin, tumor regression grade (TRG), tumor thickness at the tumor-normal interface (TTNI) and the growth pattern (GP). The median survival following hepatic resection was 52 months and 3- and 5- year Kaplan-Meier estimates were 69 and 48%, respectively. Seventy-four patients developed recurrent disease. Oxaliplatin-based chemotherapy was significantly associated with a pushing GP. A positive resection margin was an independent predictor of decreased DFS (p = 0.018) but not of decreased OS. LRFS was strongly reduced by the absence of histologic tumor response (p = 0.018). The pushing pattern had an adverse impact on both OS (p = 0.007) and DFS (p = 0.004) on multivariate analysis. The prognostic value of histopathological features in patients who underwent CRLM's resection is undeniable. The pushing GP was related with worse prognosis. Further studies are required to clarify the biological mechanisms underlying these findings in order to enhance a more personalized and efficient treatment of these patients. Copyright © 2018 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Lower esophageal palisade vessels and the definition of Barrett's esophagus.

PubMed

Ogiya, K; Kawano, T; Ito, E; Nakajima, Y; Kawada, K; Nishikage, T; Nagai, K

2008-01-01

The designated area of the columnar-lined esophagus (CLE) is anatomically defined by the distal limit of the lower esophageal palisade vessels (LEPV) and the term 'Barrett's esophagus' is equally used along with the name CLE in Japan. The aim of this study was to investigate the actual prevalence of CLE based on the Japanese criteria and to evaluate the criteria per se. A total of 42 esophagi consecutively resected at this institute were included. All subjects underwent a surgical resection for squamous cell carcinoma of the esophagus. The position of the LEPV, squamocolumnar junction, the prevalence of CLE and intestinal metaplasia were investigated both pre- and postoperatively. Preoperative endoscopy revealed CLE based on the Japanese criteria in half of all patients. In the resected specimens the distal limit of LEPV was lower than the squamocolumnar junction in 95.2%. In other words, almost all cases had CLE (equivalent to Barrett's mucosa in Japanese criteria). However, most of the CLE areas were very short and their average maximum length was only about 5 mm. In addition, no intestinal metaplasia was observed in any of the CLE cases. Almost all individuals might therefore be diagnosed to have CLE or Barrett's mucosa based on precise endoscopic observations in Japan. The CLE located in a small area, e.g. less than 5 mm, defined according to the LEPV criteria without any other factor concerning typical Barrett's esophagus such as signs of gastroesophageal reflux should therefore be excluded from consideration as a high-risk mucosa.

Isolated Roux-en-Y anastomosis of the pancreatic stump in a duct-to-mucosa fashion in patients with distal pancreatectomy with en-bloc celiac axis resection.

PubMed

Okada, Ken-Ichi; Kawai, Manabu; Tani, Masaji; Hirono, Seiko; Miyazawa, Motoki; Shimizu, Atsushi; Kitahata, Yuji; Yamaue, Hiroki

2014-03-01

A pancreatic fistula is one of the most serious complications in distal pancreatectomy with en bloc celiac axis resection (DP-CAR), because the pancreatic transection is performed on the right side of the portal vein, which results in a large cross-section surface, and because post-pancreatectomy hemorrhage is hard to treat by interventional radiology. Therefore, a procedure to decrease the incidence of postoperative pancreatic fistula is urgently needed. Twenty-six consecutive patients who underwent DP-CAR between April 2008 and August 2012 were reviewed retrospectively. The first 13 consecutive patients underwent DP-CAR with no anastomosis, and the subsequent 13 consecutive patients were treated with Roux-en-Y pancreaticojejunostomy (PJ) in a duct-to-mucosa fashion. Extremely high amylase levels (>4000 IU/l) of all drainage fluid specimens on postoperative day (POD) 1, 3 and 4 were detected more frequently in cases with no anastomosis (n = 7) compared to those with PJ (n = 1) (P = 0.056). The incidence of grade B/C pancreatic fistulas was 15.4% in cases with isolated Roux-en-Y anastomosis of the pancreatic stump performed in a duct-to-mucosa fashion, and we are currently examining whether this anastomosis method reduces the pancreatic fistula rate in a multicenter, randomized controlled trial for distal pancreatectomy patients (ClinicalTrials.gov NCT01384617). © 2013 Japanese Society of Hepato-Biliary-Pancreatic Surgery.

Linking the tectonic evolution with fluid history in magma-poor rifted margins: tracking mantle- and continental crust-related fluids

NASA Astrophysics Data System (ADS)

Pinto, V. H. G.; Manatschal, G.; Karpoff, A. M.

2014-12-01

The thinning of the crust and the exhumation of subcontinental mantle is accompanied by a series of extensional detachment faults. Exhumation of mantle and crustal rocks is intimately related to percolation of fluids along detachment faults leading to changes in mineralogy and chemistry of the mantle, crustal and sedimentary rocks. Field observation, analytical methods, refraction/reflection and well-core data, allowed us to investigate the role of fluids in the Iberian margin and former Alpine Tethys distal margins and the Pyrenees rifted system. In the continental crust, fluid-rock interaction leads to saussuritization that produces Si and Ca enriched fluids found in forms of veins along the fault zone. In the zone of exhumed mantle, large amounts of water are absorbed in the first 5-6 km of serpentinized mantle, which has the counter-effect of depleting the mantle of elements (e.g., Si, Ca, Mg, Fe, Mn, Ni and Cr) forming mantle-related fluids. Using Cr-Ni-V and Fe-Mn as tracers, we show that in the distal margin, mantle-related fluids used detachment faults as pathways and interacted with the overlying crust, the sedimentary basin and the seawater, while further inward parts of the margin, continental crust-related fluids enriched in Si and Ca impregnated the fault zone and may have affected the sedimentary basin. The overall observations and results enable us to show when, where and how these interactions occurred during the formation of the rifted margin. In a first stage, continental crust-related fluids dominated the rifted systems. During the second stage, mantle-related fluids affected the overlying syn-tectonic sediments through direct migration along detachment faults at the future distal margin. In a third stage, these fluids reached the seafloor, "polluted" the seawater and were absorbed by post-tectonic sediments. We conclude that a significant amount of serpentinization occurred underneath the thinned continental crust, that the mantle-related fluids might have modified the chemical composition of the sediments and seawater. We propose that the chemical signature of serpentinization that occurs during the mantle exhumation is recorded in the sediments and may serve as a proxy to date serpentinization and mantle exhumation in present day magma-poor rifted margins.

Management of non metastatic phyllodes tumors of the breast: review of the literature.

PubMed

Khosravi-Shahi, Parham

2011-12-01

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. Copyright © 2011 Elsevier Ltd. All rights reserved.

Economic Implications of Widespread Expansion of Frozen Section Margin Analysis to Guide Surgical Resection in Women With Breast Cancer Undergoing Breast-Conserving Surgery.

PubMed

Boughey, Judy C; Keeney, Gary L; Radensky, Paul; Song, Christine P; Habermann, Elizabeth B

2016-04-01

In the current health care environment, cost effectiveness is critically important in policy setting and care of patients. This study performed a health economic analysis to assess the implications to providers and payers of expanding the use of frozen section margin analysis to minimize reoperations for patients undergoing breast cancer lumpectomy. A health care economic impact model was built to assess annual costs associated with breast lumpectomy procedures with and without frozen section margin analysis to avoid reoperation. If frozen section margin analysis is used in 20% of breast lumpectomies and under a baseline assumption that 35% of initial lumpectomies without frozen section analysis result in reoperations, the potential annual cost savings are $18.2 million to payers and $0.4 million to providers. Under the same baseline assumption, if 100% of all health care facilities adopted the use of frozen section margin analysis for breast lumpectomy procedures, the potential annual cost savings are $90.9 million to payers and $1.8 million to providers. On the basis of 10,000 simulations, use of intraoperative frozen section margin analysis yields cost saving for payers and is cost neutral to slightly cost saving for providers. This economic analysis indicates that widespread use of frozen section margin evaluation intraoperatively to guide surgical resection in breast lumpectomy cases and minimize reoperations would be beneficial to cost savings not only for the patient but also for payers and, in most cases, for providers. Copyright © 2016 by American Society of Clinical Oncology.

Laparoscopic vs open total mesorectal excision for rectal cancer: an evaluation of the mesorectum's macroscopic quality.

PubMed

Breukink, S O; Grond, A J K; Pierie, J P E N; Hoff, C; Wiggers, T; Meijerink, W J H J

2005-03-01

Next to surgical margins, yield of lymph nodes, and length of bowel resected, macroscopic completeness of mesorectal excision may serve as another quality control of total mesorectal excision (TME). In this study, the macroscopic completeness of laparoscopic TME was evaluated. A series of 25 patients with rectal cancer were managed laparoscopically (LTME) and included in this study. The pathologic specimens of the LTME group were prospectively examined and matched with a historical group of resection specimens from patients who had undergone open TME (OTME). The two groups were matched for gender and type of resection (low anterior or abdominoperineal resection). Special care was given to the macroscopic judgment concerning the completeness of the mesorectum. A three-grade scoring system showed no differences between the LTME and OTME groups. The current study supports the hypothesis that oncologic resection using laparoscopic TME is feasible and adequate.

Outcomes following attempted en bloc resection of cervical chordomas in the C-1 and C-2 region versus the subaxial region: a multiinstitutional experience.

PubMed

Molina, Camilo A; Ames, Christopher P; Chou, Dean; Rhines, Laurence D; Hsieh, Patrick C; Zadnik, Patricia L; Wolinsky, Jean-Paul; Gokaslan, Ziya L; Sciubba, Daniel M

2014-09-01

Chordomas involving the mobile spine are ideally managed via en bloc resection with reconstruction to optimize local control and possibly offer cure. In the cervical spine, local anatomy poses unique challenges, limiting the feasibility of aggressive resection. The authors present a multi-institutional series of 16 cases of cervical chordomas removed en bloc. Particular attention was paid to clinical outcome, complications, and recurrence. In addition, outcomes were assessed according to position of tumor at the C1-2 level versus the subaxial (SA) spine (C3-7). The authors reviewed cases involving patients who underwent en bloc resection of cervical chordoma at 4 large spine centers. Patients were included if the lesion epicenter involved the C-1 to C-7 vertebral bodies. Demographic data and details of surgery, follow-up course, exposure to adjuvant therapy, and complications were obtained. Outcome was correlated with presence of tumor in C1-2 versus subaxial spine via a Student t-test. Sixteen patients were identified (mean age at presentation 55 ± 14 years). Seven cases (44%) cases involved C1-2, and 16 involved the subaxial spine. Median survival did not differ significantly different between the C1-2 (72 months) and SA (60 months) groups (p = 0.65). A combined (staged anteroposterior) approach was used in 81% of the cases. Use of the combined approach was significantly more common in treatment of subaxial than C1-2 tumors (100% vs 57%, p = 0.04). En bloc resection was attempted via an anterior approach in 6% of cases (C1-2: 14.3%; SA: 0%; p = 0.17) and a posterior approach in 13% of cases (C1-2: 29%; SA: 0%; p = 0.09). The most commonly reported margin classification was marginal (56% of cases), followed by violated (25%) and wide (19%). En bloc excision of subaxial tumors was significantly more likely to result in marginal margins than excision of C1-2 tumors (C1-2: 29%; SA: 78%; p = 0.03). C1-2 tumors were associated with significantly higher rates of postoperative complications (C1-2: 71%; SA: 22%; p = 0.03). Both local and distant tumor recurrence was greatest for C1-2 tumors (local C1-2: 29%; local SA: 11%; distant C1-2: 14%; distant SA: 0%). Statistical analysis of tumor recurrence based on tumor location was not possible due to the small number of cases. There was no between-groups difference in exposure to postoperative adjuvant radiotherapy. There was no difference in median survival between groups receiving proton beam radiotherapy or intensity-modulated radiotherapy versus no radiation therapy (p = 0.8). Compared with en bloc resection of chordomas involving the subaxial cervical spine, en bloc resection of chordomas involving the upper cervical spine (C1-2) is associated with poorer outcomes, such as less favorable margins, higher rates of complications, and increased tumor recurrence. Data from this cohort do not support a statistically significant difference in survival for patients with C1-2 versus subaxial disease, but larger studies are needed to further study survival differences.

Thermochronological Record of a Jurassic Heating-Cooling Cycle Within a Distal Rifted Margin (Calizzano Massif, Ligurian Alps)

NASA Astrophysics Data System (ADS)

Seno, S.; Decarlis, A.; Fellin, M. G.; Maino, M.; Beltrando, M.; Ferrando, S.; Manatschal, G.; Gaggero, L.; Stuart, F. M.

2017-12-01

The aim of the present study is to analyse, through thermochronological investigations, the thermal evolution of a fossil distal margin owing to the Alpine Tethys rifting system. The studied distal margin section consists of a polymetamorphic basement (Calizzano basement) and of a well-developed Mesozoic sedimentary cover (Case Tuberto unit) of the Ligurian Alps (NW Italy). The incomplete reset of zircon (U-Th)/He ages and the non-reset of the zircon fission track ages during the Alpine metamorphism indicate that during the subduction and the orogenic stages these rocks were subjected to temperatures lower than 200 ºC. Thus, the Alpine metamorphic overprint occurred during a short-lived, low temperature pulse. The lack of a pervasive orogenic reset, allowed the preservation of an older heating-cooling event that occurred during Alpine Tethys rifting. Zircon fission-track data indicate, in fact, that the Calizzano basement records a cooling under 240 °C, at 156 Ma (early Upper Jurassic). This cooling followed a Middle Jurassic syn-rift heating at temperatures of about 300-350°C, typical of greenschist facies conditions occurred at few kilometres depth, as indicated by stratigraphic and petrologic constraints. Thus, in our interpretation, major crustal thinning likely promoted high geothermal gradients ( 60-90°C/km) triggering the circulation of hot, deep-seated fluids along brittle faults, causing the observed thermal anomaly at shallow crustal level.

Local resection of the stomach for gastric cancer.

PubMed

Kinami, Shinichi; Funaki, Hiroshi; Fujita, Hideto; Nakano, Yasuharu; Ueda, Nobuhiko; Kosaka, Takeo

2017-06-01

The local resection of the stomach is an ideal method for preventing postoperative symptoms. There are various procedures for performing local resection, such as the laparoscopic lesion lifting method, non-touch lesion lifting method, endoscopic full-thickness resection, and laparoscopic endoscopic cooperative surgery. After the invention and widespread use of endoscopic submucosal dissection, local resection has become outdated as a curative surgical technique for gastric cancer. Nevertheless, local resection of the stomach in the treatment of gastric cancer in now expected to make a comeback with the clinical use of sentinel node navigation surgery. However, there are many issues associated with local resection for gastric cancer, other than the normal indications. These include gastric deformation, functional impairment, ensuring a safe surgical margin, the possibility of inducing peritoneal dissemination, and the associated increase in the risk of metachronous gastric cancer. In view of these issues, there is a tendency to regard local resection as an investigative treatment, to be applied only in carefully selected cases. The ideal model for local resection of the stomach for gastric cancer would be a combination of endoscopic full-thickness resection of the stomach using an ESD device and hand sutured closure using a laparoscope or a surgical robot, for achieving both oncological safety and preserved functions.

Margins in Skin Excision Biopsies: Principles and Guidelines

PubMed Central

Ranjan, Richa; Singh, Lavleen; Arava, Sudheer K; Singh, Manoj Kumar

2014-01-01

Skin biopsies are usually undertaken to confirm a clinical diagnosis, to remove a lesion, and to determine the adequacy of excised tissue margin. A surgical margin is technically defined as the “edge” of the tissue removed. The term is especially pertinent when the tissue excised is suspected of being involved by a malignant process. One of the most important predictive and prognostic factors of a malignant lesion is whether the margins of the resected specimen are involved by the tumor or not. The purpose of this review is to provide an insight into grossing of a skin biopsy specimen with emphasis on techniques and reporting of excision biopsy margins. PMID:25484385

Pseudotumor of the distal common bile duct at endoscopic retrograde cholangiopancreatography

PubMed Central

Tan, Justin H.; Coakley, Fergus V; Wang, Zhen J.; Poder, Liina; Webb, Emily; Yeh, Benjamin M.

2010-01-01

Background Prior studies have described a pseudocalculus appearance in the distal common bile duct as a normal variant at cholangiography. The objective of this study is to describe the occurrence of pseudotumor in the distal common bile duct at endoscopic retrograde cholangiopancreatography (ERCP). Methods Nine patients who underwent ERCP between May 2004 and July 2008 were identified as having a transient eccentric mural-based filling defect in the distal common bile duct. A single reader systematically reviewed all studies and recorded the imaging findings. Results The mean diameter of the filling defect was 9 mm (range, 5 to 11). Eight patients had resolution of the filling defect during the same ERCP or on a subsequent ERCP, and in 2 of these patients the inferior border of the filling defect was not well visualized. The other patient underwent surgical resection of a presumed tumor with no evidence of malignancy on surgical pathology. Conclusion An eccentric mural-based filling defect in the distal common bile duct can be artifactual in nature and may reflect transient contraction of the sphincter of Oddi. Recognition of this pseudotumor may help avoid unnecessary surgery. PMID:21724120

Histopathological Validation of the Surface-Intermediate-Base Margin Score for Standardized Reporting of Resection Technique during Nephron Sparing Surgery.

PubMed

Minervini, Andrea; Campi, Riccardo; Kutikov, Alexander; Montagnani, Ilaria; Sessa, Francesco; Serni, Sergio; Raspollini, Maria Rosaria; Carini, Marco

2015-10-01

The surface-intermediate-base margin score is a novel standardized reporting system of resection techniques during nephron sparing surgery. We validated the surgeon assessed surface-intermediate-base score with microscopic histopathological assessment of partial nephrectomy specimens. Between June and August 2014 data were prospectively collected from 40 consecutive patients undergoing nephron sparing surgery. The surface-intermediate-base score was assigned to all cases. The score specific areas were color coded with tissue margin ink and sectioned for histological evaluation of healthy renal margin thickness. Maximum, minimum and mean thickness of healthy renal margin for each score specific area grade (surface [S] = 0, S = 1 ; intermediate [I] or base [B] = 0, I or B = 1, I or B = 2) was reported. The Mann-Whitney U and Kruskal-Wallis tests were used to compare the thickness of healthy renal margin in S = 0 vs 1 and I or B = 0 vs 1 vs 2 grades, respectively. Maximum, minimum and mean thickness of healthy renal margin was significantly different among score specific area grades S = 0 vs 1, and I or B = 0 vs 1, 0 vs 2 and 1 vs 2 (p <0.001). The main limitations of the study are the low number of the I or B = 1 and I or B = 2 samples and the assumption that each microscopic slide reflects the entire score specific area for histological analysis. The surface-intermediate-base scoring method can be readily harnessed in real-world clinical practice and accurately mirrors histopathological analysis for quantification and reporting of healthy renal margin thickness removed during tumor excision. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Reimplantation of the resected tumour-bearing segment after recycling using liquid nitrogen for osteosarcoma.

PubMed

Abdel Rahman, Mohamed; Bassiony, Ayman; Shalaby, Hisham

2009-10-01

Reconstruction after en block resection of malignant tumours is still the subject of debate. We questioned the effectiveness of reconstruction by reimplanting the tumour-bearing segment after recycling in liquid nitrogen. Ten patients with osteosarcoma around the knee were included, with a mean age of 21 years. The operative technique included wide en bloc excision, debridement, and management of the resected segment with liquid nitrogen followed by reimplantation and internal fixation. At a mean follow-up of 4.5 years there was no local or systemic recurrence and the mean functional score was 82.4%. The frozen graft united proximally and distally in all but one patient in a period ranging from six to ten months. The effectiveness of this reconstruction technique in properly selected patients with osteosarcoma is comparable to other techniques of biological reconstruction with the added benefit of being simple, cheap and durable.

Single-stage anterior high sacrectomy for locally recurrent rectal cancer.

PubMed

Fawaz, Khaled; Khaled, Fawaz; Smith, Myles J; Moises, Cukier; Smith, Andrew J; Yee, Albert J M

2014-03-01

A review of prospectively collected data on a consecutive series of patients undergoing single-stage anterior high sacrectomy for locally recurrent rectal carcinoma (LRRC). To determine the clinical outcome of patients who underwent anterior high sacrectomy for LRRC. High sacrectomy for oncological resection remains technically challenging. Surgery has the potential to achieve cure in carefully selected patients. Complete (R0) tumor excision in LRRC may require sacrectomy. High sacral resections (S3 and above) typically require a combined anterior/supine and posterior/prone procedure. We investigated our experience performing single-stage anterior high sacrectomy for LRRC. A consecutive series of patients with LRRC without systemic metastases who underwent resection with curative intent requiring high sacrectomy were identified. A review of a prospectively maintained colorectal and spine cancer database data was performed. An oblique dome high sacral osteotomy was performed during a single-stage anterior procedure. Outcome measures included surgical resection margin status, hospital length of stay, postoperative complications, physical functioning status, and overall survival. Nineteen consecutive patients were treated between 2002 and 2011. High sacrectomy was performed at sacral level S1-S2 in 4 patients, S2-S3 in 9 patients, and through S3 in 6 patients. An R0 resection margin was achieved histologically in all 19 cases. There was 1 early (<30 d) postoperative death (1/19, 5%). At median follow-up of 38 months, 13 patients had no evidence of residual disease, 1 was alive with disease, and 4 had died of disease. Morbidities occurred in 15 of the 19 patients (79%). Although high sacrectomy may require a combined anterior and posterior surgical approach, our series demonstrates the feasibility of performing single-stage anterior high sacrectomy in LRRC, with acceptable risks and outcomes compared with the literature. The procedure described by us for LRRC lessens the need for a simultaneous or staged prone posterior resection, with favorable R0 tumor resections, patient survival, and clinical outcomes. N/A.

Distal Hemorrhoidectomy With ALTA Injection: A New Method for Hemorrhoid Surgery

PubMed Central

Abe, Tatsuya; Hachiro, Yoshikazu; Ebisawa, Yoshiaki; Hishiyama, Houhei; Kunimoto, Masao

2014-01-01

Aluminum potassium sulfate and tannic acid injection (ALTA) is a useful and less-invasive treatment for internal hemorrhoids. However, it is not a treatment option for external hemorrhoidal diseases, including mixed hemorrhoids. Distal hemorrhoidectomy with ALTA injection involves surgical resection of external piles, followed by injection therapy on internal piles. We report technical details and the short-term results of this procedure in patients with mixed hemorrhoids. Seventy-two patients with mixed hemorrhoids treated between 2010 and 2011 were included. The main outcome measures were the short-term response and complication rates. At 28 days after surgery, the disappearance rate of prolapse was 100%. Three patients (4%) had postoperative complications, all minor in nature. No prolapse recurrence was observed within a median follow-up period of 6 months. Distal hemorrhoidectomy with ALTA injection appears to be a promising treatment option for patients with mixed hemorrhoids. PMID:24833156

Hand and digital ischemia due to arteriosclerosis and thromboembolization in young adults: pathologic features with clinical correlations.

PubMed

Guarda, L A; Borrero, J L

1990-11-01

Twenty young adult patients with hand and digital ischemia were found to have obstructive arterial disease. All patients were surgically explored, and the occluded vessels were resected and by-passed. Eighteen patients had obstruction at the level of the distal ulnar artery and palmar arch, and 12 had obstruction of the common digital and digital proper arteries. Occlusive arteriosclerotic lesions were found in all patients; these lesions were characterized by prominent fibromuscular intimal plaques with superimposed thrombosis. Six patients had also thromboembolism to distal digital vessels. Vasculitis, calcifications, cholesterol deposits, and atheromatous emboli were not observed. Five patients had transmural neovascularization of the lesions in a similar manner to that described in coronary artery lesions. Obstructive lesions due to fibromuscular intimal proliferation with associated thrombosis and/or distal thromboembolization affecting arteries of hands and digits appear to be an important lesion that can affect young patients.

Role of intraoperative radiotherapy in the treatment of sacral chordoma.

PubMed

Jullien-Petrelli, Ariel Christian; García-Sabrido, J L; Orue-Echebarria, M I; Lozano, P; Álvarez, A; Serrano, J; Calvo, F M; Calvo-Haro, J A; Lasso, J M; Asencio, J M

2018-04-01

Sacral chordoma is a rare entity with high local recurrence rates when complete resection is not achieved. To date, there are no series available in literature combining surgery and intraoperative radiotherapy (IORT). The objective of this study was to report the experience of our center in the management of sacral chordoma combining radical resection with both external radiotherapy and IORT. This is a retrospective case series. The patient sample included 15 patients with sacral chordoma resected in our center from 1998 to 2015. The outcome measures were overall survival (OS), disease-free survival (DFS), and rates of local and distant recurrences. We retrospectively reviewed the records of all the patients with sacral chordoma resected in our center from 1998 to December 2015. Overall survival, DFS, and rates of local and distant recurrences were calculated. Results between patients treated with or without IORT were compared. A total of 15 patients were identified: 8 men and 7 women. The median age was 59 years (range 28-77). Intraoperative radiotherapy was applied in nine patients and six were treated with surgical resection without IORT. In 13 patients, we performed the treatment of the primary tumor, and in two patients, we performed the treatment of recurrence disease. A posterior approach was used in four patients. Wide surgical margins (zero residue) were achieved in six patients, marginal margins (microscopic residue) were achieved in seven patients, and there were no patients with intralesional (R2) margins. At a median follow-up of 38 months (range 11-209 months), the 5-year OS in the IORT group was 100% versus 53% in the group of non-IORT (p=.05). The median DFS in the IORT group was 85 months, and that in the non-IORT group was 41 months. In the group without IORT, two patients died and nobody died during the follow-up in the group treated with IORT. High-sacrectomy treated patients had a median survival of 41 months, and low-sacrectomy treated patients had a median survival of 90 months. Disease-free survival in patients without gluteal involvement was 100% at 5 years, and that in patients with gluteal involvement was 40%. All patients with a recurrence in our study had gluteal involvement. Multidisciplinary management of sacral chordoma seems to improve local control. The use of IORT, in our experience, is associated with an increase in OS and DFS. The level of resection and gluteal involvement seems to affect survival. The posterior approach is useful in selected cases. Multicenter studies should be performed to confirm the utility of IORT. Copyright © 2017 Elsevier Inc. All rights reserved.

Endoscopic submucosal dissection for locally recurrent colorectal lesions after previous endoscopic mucosal resection.

PubMed

Zhou, Pinghong; Yao, Liqing; Qin, Xinyu; Xu, Meidong; Zhong, Yunshi; Chen, Weifeng

2009-02-01

The objective of this study was to determine the efficacy and safety of endoscopic submucosal dissection for locally recurrent colorectal cancer after previous endoscopic mucosal resection. A total of 16 patients with locally recurrent colorectal lesions were enrolled. A needle knife, an insulated-tip knife and a hook knife were used to resect the lesion along the submucosa. The rate of the curative resection, procedure time, and incidence of complications were evaluated. Of 16 lesions, 15 were completely resected with endoscopic submucosal dissection, yielding an en bloc resection rate of 93.8 percent. Histologic examination confirmed that lateral and basal margins were cancer-free in 14 patients (87.5 percent). The average procedure time was 87.2 +/- 60.7 minutes. None of the patients had immediate or delayed bleeding during or after endoscopic submucosal dissection. Perforation in one patient (6.3 percent) was the only complication and was managed conservatively. The mean follow-up period was 15.5 +/- 6.8 months; none of the patients experienced lesion residue or recurrence. Endoscopic submucosal dissection appears to be effective for locally recurrent colorectal cancer after previous endoscopic mucosal resection, making it possible to resect whole lesions and provide precise histologic information.

Tailored Treatment Strategy for Locally Advanced Rectal Carcinoma Based on the Tumor Response to Induction Chemotherapy: Preliminary Results of the French Phase II Multicenter GRECCAR4 Trial.

PubMed

Rouanet, Philippe; Rullier, Eric; Lelong, Bernard; Maingon, Philippe; Tuech, Jean-Jacques; Pezet, Denis; Castan, Florence; Nougaret, Stéphanie

2017-07-01

Preoperative radiochemotherapy and total mesorectal excision are the standard-of-care for locally advanced rectal carcinoma, but some patients could be over- or undertreated. This study aimed to assess the feasibility of radiochemotherapy tailored based on the tumor response to induction chemotherapy (FOLFIRINOX) to obtain a minimum R0 resection rate of 90% in the 4 arms of the study. This study is a multicenter randomized trial (NCT01333709). This study was conducted at 16 French cancer specialty centers. Two hundred six patients with locally advanced rectal carcinoma were enrolled between 2011 and 2014. Good responders (≥75% tumor volume reduction) were randomly assigned to immediate surgery (arm A) or standard radiochemotherapy (Cap 50: 50 Gy irradiation and 1600 mg/m oral capecitabine daily) plus surgery (arm B). Poor responders were randomly assigned to Cap 50 (arm C) or intensive radiochemotherapy (Cap 60, 60 Gy irradiation, arm D) before surgery. The primary end point was a R0 resection rate (circumferential resection margin >1 mm). The experimental strategies were to be considered effective if at least 28 successes (R0 resection) among 31 patients in each arm of stratum I and 34 successes among 40 patients in each arm of stratum II were reported (Simon 2-stage design). After induction treatment (good compliance), 194 patients were classified as good (n = 30, 15%) or poor (n = 164, 85%) responders who were included in arms A and B (16 and 14 patients) and arms C and D (113 and 51 patients). The trial was prematurely stopped because of low accrual in arms A and B and recruitment completion in arms C and D. Data from 133 randomly assigned patients were analyzed: 11, 19, 52, and 51 patients in arms A, B, C, and D. Good responders had smaller tumors than poor responders (23 cm vs 45 cm; p < 0.001). The surgical procedure was similar among groups. The R0 resection rates [90% CI] were 100% [70-100], 100% [85-100], 83% [72-91], and 88% [77-95]. Among the first 40 patients, 34 successes were reported in arms C and D (85% R0 resection rate). The circumferential resection margin ≤1 rates were 0%, 0%, 12%, and 5% in arms A, B, C, and D. The rate of transformation from positive to negative circumferential resection margin was 93%. There was low accrual in arms A and B. Tailoring preoperative radiochemotherapy based on the induction treatment response appears safe for poor responders and promising for good responders. Long-term clinical results are needed to confirm its efficacy. See Video Abstract at http://links.lww.com/DCR/A359.

A novel hand-assisted laparoscopic versus conventional laparoscopic right hemicolectomy for right colon cancer: study protocol for a randomized controlled trial.

PubMed

Yang, Xuyang; Wu, Qingbin; Jin, Chengwu; He, Wanbin; Wang, Meng; Yang, Tinghan; Wei, Mingtian; Deng, Xiangbing; Meng, Wenjian; Wang, Ziqiang

2017-07-26

Although conventional laparoscopic and hand-assisted laparoscopic surgery for colorectal cancer is widely used today, there remain many technical challenges especially for right colon cancer in obese patients. Herein, we develop a novel hand-assisted laparoscopic surgery (HALS) with complete mesocolic excision (CME), D3 lymphadenectomy, and a total "no-touch" isolation technique (HALS-CME) in right hemicolectomy to overcome these issues. According to previous clinic practice, this novel procedure is not only feasible and safe but has several technical merits. However, the feasibility, short-term minimally invasive virtues, long-term oncological superiority, and potential total "no-touch" isolation technique benefits of HALS-CME should be confirmed by a prospective randomized controlled trial. This is a single-center, open-label, noninferiority, randomized controlled trial. Eligible participants will be randomly assigned to the HALS-CME group or to the laparoscopic surgery with CME, D3 lymphadenectomy, and total "no-touch" isolation technique (LAP-CME) group, or to conventional laparoscopic surgery with CME and D3 lymphadenectomy (cLAP) group at a 1:1:1 ratio using a centralized randomization list. Primary endpoints include safety, efficacy, and being oncologically clear, and 3-year disease-free, progression-free, and overall survival. Second endpoints include operative outcomes (operation time, blood loss, and incision length), pathologic evaluation (grading the plane of surgery, length of proximal and distal resection margins, distance between the tumor and the central arterial high tie, distance between the nearest bowel wall and the same high tie, area of mesentery resected, width of the chain of lymph-adipose tissue, length of the central lymph-adipose chain, number of harvested lymph nodes), and postoperative outcomes (pain intensity, postoperative inflammatory and immune responses, postoperative recovery). This trial will provide valuable clinical evidence for the feasibility, safety, and potential total "no-touch" isolation technique benefits of HALS-CME for right hemicolectomy. The hypothesis is that HALS-CME is feasible for the radical D3 resection of right colon cancer and offers short-term safety and long-term oncological superiority compared with conventional laparoscopic surgery. ClinicalTrials.gov, NCT02625272 . Registered on 8 December 2015.

Clinical usefulness of extending the proximal margin in total gastrectomies for gastric adenocarcinoma.

PubMed

Clemente-Gutiérrez, U; Sánchez-Morales, G; Santes, O; Medina-Franco, H

2018-05-09

Surgical resection with negative margins is part of the curative treatment of gastric adenocarcinoma. Positive surgical margins are associated with worse outcome. The aim of the present study was to determine the clinical usefulness of extending the proximal surgical margin in patients undergoing total gastrectomy for gastric adenocarcinoma. A retrospective analysis of patients that underwent total gastrectomy within the time frame of 2002 and 2017 was conducted. Patients diagnosed with adenocarcinoma that underwent curative surgery were included. Patients were divided into three groups, depending on proximal surgical margin status: negative margin (R0), positive margin with additional resection to achieve negative margin (R1-R0), and positive margin (R1). Demographic and clinical variables were analyzed. The outcome measures to evaluate were recurrence, disease-free survival, and overall survival. Forty-eight patients were included in the study. Thirty-seven were classified as R0, 9 as R1-R0, and 2 as R1. Fifty-two percent of the patients had clinical stage III disease. The overall surgical mortality rate was 2% and the morbidity rate was higher than 29%. The local recurrence rate was 0% in the R1-R0 group vs. 50% in the R1 group (p = 0.02). Disease-free survival was 49 months in the R1-R0 group vs. 32 months in the R1 group (p = 0.6). Overall survival was 51 months for the R1-R0 group vs. 35 months for the R1 group (p = 0.5). Intraoperative extension of the positive surgical margin improved the local recurrence rate but was not associated with improvement in overall survival or disease-free survival and could possibly increase postoperative morbidity. Copyright © 2018 Asociación Mexicana de Gastroenterología. Publicado por Masson Doyma México S.A. All rights reserved.

Impact of preoperative levels of hemoglobin and albumin on the survival of pancreatic carcinoma.

PubMed

Ruiz-Tovar, J; Martín-Pérez, E; Fernández-Contreras, M E; Reguero-Callejas, M E; Gamallo-Amat, C

2010-11-01

Pancreatic cancer presents the worst survival rates of all neoplasms. Surgical resection is the only potentially curative treatment, but is associated with high complication rates and outcome is bad even in those resected cases. Therefore, candidates amenable for resection must be carefully selected. Identification of prognostic factors preoperatively may help to improve the treatment of these patients, focusing on individually management based on the expected response. We perform a retrospective study of 59 patients with histological diagnosis of pancreatic carcinoma between 1999 and 2003, looking for possible prognostic factors. We analyze 59 patients, 32 males and 27 females with a mean age of 63.8 years. All the patients were operated, performing palliative surgery in 32% and tumoral resection in 68%, including pancreaticoduodenectomies in 51% and distal pancreatectomy in 17%. Median global survival was 14 months (Range 1-110).We observed that preoperative levels of hemoglobin under 12 g/dl (p = 0.0006) and serum albumina under 2.8 g/dl (p = 0.021) are associated with worse survival. Preoperative levels of hemoglobin and serum albumina may be prognostic indicators in pancreatic cancer.

Meta-analysis and cost effective analysis of portal-superior mesenteric vein resection during pancreatoduodenectomy: Impact on margin status and survival.

PubMed

Bell, Richard; Ao, Braden Te; Ironside, Natasha; Bartlett, Adam; Windsor, John A; Pandanaboyana, Sanjay

2017-03-01

The benefit of portal-superior mesenteric vein resection (PSMVR) with pancreatoduodenectomy (PD) remains controversial. This study assesses the impact of PSMVR on resection margin status and survival. An electronic search was performed to identify relevant articles. Pooled odds ratios were calculated for outcomes using the fixed or random-effects models for meta-analysis. A decision analytical model was developed for estimating cost effectiveness. Sixteen studies with 4145 patients who underwent pancreatoduodenectomy were included: 1207 patients had PSMVR and 2938 patients had no PSMVR. The R1 resection rate and post-operative mortality was significantly higher in PSMVR group (OR1.59[1.35, 1.86] p=<0.0001, and OR1.72 [1.02,2.92] p = 0.04 respectively). The overall survival at 5-years was worse in the PSMVR group (HR0.20 [0.07,0.55] P = 0.020). Tumour size (p = 0.030) and perineural invasion (P = 0.009) were higher in the PSMVR group. Not performing PSMVR yielded cost savings of $1617 per additional month alive without reduction in overall outcome. On the basis of retrospective data this study shows that PD with PSMVR is associated with a higher R1 rate, lower 5-year survival and is not cost-effective. It appears that PD with PSMVR can only be justified if R0 resection can be achieved. The continuing challenge is accurate selection of these patients. Copyright © 2017 Elsevier Ltd. All rights reserved.

Laparoscopic versus robotic surgery for hepatocellular carcinoma: the first 46 consecutive cases.

PubMed

Magistri, Paolo; Tarantino, Giuseppe; Guidetti, Cristiano; Assirati, Giacomo; Olivieri, Tiziana; Ballarin, Roberto; Coratti, Andrea; Di Benedetto, Fabrizio

2017-09-01

Hepatocellular carcinoma has a growing incidence worldwide, and represents a leading cause of death in patients with cirrhosis. Nowadays, minimally invasive approaches are spreading in every field of surgery and in liver surgery as well. We retrospectively reviewed demographics, clinical, and pathologic characteristics and short-term outcomes of patients who had undergone minimally invasive resections for hepatocellular carcinoma at our institution between June 2012 and May 2016. No significant differences in demographics and comorbidities were found between patients in the laparoscopic (n = 24) and robotic (n = 22) groups, except for the rates of cirrhotic patients (91.7% and 68.2%, respectively, P = 0.046). Perioperative data analysis showed that the operative time (mean, 211 and 318 min, respectively, P < 0.001) was the only parameter in favor of laparoscopy. Conversely, robotic-assisted resections were related to less Clavien I-II postoperative complications (22 cases versus 13 cases; P = 0.03). As regards resection margins, the two groups were similar with no statistically significant differences in rates of disease-free resection margins. A modern hepatobiliary center should offer both open and minimally invasive approaches to liver disease to provide the best care for each patient, according to the individual comorbidities, risk factors, and personal quality of life expectations. Our results show that the robotic approach is a reliable tool for accurate oncologic surgery, comparable to the laparoscopic approach. Robotic surgery also allows the surgeon to safely approach liver segments that are difficult to resect in laparoscopy, namely segments I-VII-VIII. Copyright © 2017 Elsevier Inc. All rights reserved.

Giant cell tumour 2nd metatarsal-Result with en-bloc excision and autologous fibular grafting.

PubMed

Agarwal, Saurabh; Chawla, Sumit; Agarwal, Sippy; Agarwal, Puneet

2015-12-01

Giant cell tumour (GCT) of the small bones is relatively uncommon tumour. It occurs most commonly in the distal portions of femur and radius and proximal end of tibia. GCT of small bones presents at advanced stages with major bony destruction. These tumours represent more aggressive course; associated with increased local recurrence rates (40%) and metastasis. Various treatment modalities like en-bloc resection, cryosurgery, intralesional curettage with burring/phenolization or bone cement are available. In our case en-bloc resection with reconstruction using nonvascular autogenous fibular strut graft was used in patient of 2nd metatarsal GCT and a favourable functional outcome was observed. Copyright © 2015 Elsevier Ltd. All rights reserved.

Hand-assisted Approach as a Model to Teach Complex Laparoscopic Hepatectomies: Preliminary Results.

PubMed

Makdissi, Fabio F; Jeismann, Vagner B; Kruger, Jaime A P; Coelho, Fabricio F; Ribeiro-Junior, Ulysses; Cecconello, Ivan; Herman, Paulo

2017-08-01

Currently, there are limited and scarce models to teach complex liver resections by laparoscopy. The aim of this study is to present a hand-assisted technique to teach complex laparoscopic hepatectomies for fellows in liver surgery. Laparoscopic hand-assisted approach for resections of liver lesions located in posterosuperior segments (7, 6/7, 7/8, 8) was performed by the trainees with guidance and intermittent intervention of a senior surgeon. Data as: (1) percentage of time that the senior surgeon takes the surgery as main surgeon, (2) need for the senior surgeon to finish the procedure, (3) necessity of conversion, (4) bleeding with hemodynamic instability, (5) need for transfusion, (6) oncological surgical margins, were evaluated. In total, 12 cases of complex laparoscopic liver resections were performed by the trainee. All cases included deep lesions situated on liver segments 7 or 8. The senior surgeon intervention occurred in a mean of 20% of the total surgical time (range, 0% to 50%). A senior intervention >20% was necessary in 2 cases. There was no need for conversion or reoperation. Neither major bleeding nor complications resulted from the teaching program. All surgical margins were clear. This preliminary report shows that hand-assistance is a safe way to teach complex liver resections without compromising patient safety or oncological results. More cases are still necessary to draw definitive conclusions about this teaching method.

Laparoscopic diagnosis of retrograde peristalsis and intussusception in Roux-en-Y limb after laparoscopic gastrectomy: A case report.

PubMed

Yoshiyama, Shigeyuki; Toiyama, Yuji; Ichikawa, Takashi; Shimura, Tadanobu; Yasuda, Hiromi; Hiro, Jun-Ichiro; Ohi, Masaki; Araki, Toshimitsu; Kusunoki, Masato

2018-06-05

The cause of jejunojejunal intussusception, a rare complication after Roux-en-Y gastric surgery, remains unclear. Here, we present a case of retrograde jejunojejunal intussusception that occurred after laparoscopic distal gastrectomy with Roux-en-Y reconstruction. A 51-year-old woman who had undergone laparoscopic distal gastrectomy and Roux-en-Y reconstruction for early gastric cancer 6 years previously was admitted to our hospital with abdominal pain. Abdominal CT revealed the "target sign," and she was diagnosed as having small bowel intussusception. Laparoscopic surgery resulted in a diagnosis of retrograde intussusception of the distal jejunum of the Roux-en-Y anastomosis with retrograde peristalsis in the same area. The Roux-en-Y anastomosis site and intussuscepted segment were resected laparoscopically. To the best of our knowledge, this is the first report of laparoscopic diagnosis of retrograde peristalsis in the distal jejunum of a Roux-en-Y anastomosis. Additionally, relevant published reports concerning this unusual condition are discussed. © 2018 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.

Development of Postoperative Diabetes Mellitus in Patients Undergoing Distal Pancreatectomy versus Whipple Procedure.

PubMed

Nguyen, Adrienne; Demirjian, Aram; Yamamoto, Maki; Hollenbach, Kathryn; Imagawa, David K

2017-10-01

Because the islets of Langerhans are more prevalent in the body and tail of the pancreas, distal pancreatectomy (DP) is believed to increase the likelihood of developing new onset diabetes mellitus (NODM). To determine whether the development of postoperative diabetes was more prevalent in patients undergoing DP or Whipple procedure, 472 patients undergoing either a DP (n = 122) or Whipple (n = 350), regardless of underlying pathology, were analyzed at one month postoperatively. Insulin or oral hypoglycemic requirements were assessed and patients were stratified into preoperative diabetic status: NODM or preexisting diabetes. A retrospective chart review of the 472 patients between 1996 and 2014 showed that the total rate of NODM after Whipple procedure was 43 per cent, which was not different from patients undergoing DP (45%). The incidence of preoperative diabetes was 12 per cent in patients undergoing the Whipple procedure and 17 per cent in the DP cohort. Thus, the overall incidence of diabetes after Whipple procedure was 54 and 49 per cent in the DP group. The development of diabetes was unrelated to the type of resection performed. Age more than 65 and Caucasian ethnicity were associated with postoperative diabetes regardless of the type of resection performed.

Is complete resection of high-risk stage IV neuroblastoma associated with better survival?

PubMed

Yeung, Fanny; Chung, Patrick Ho Yu; Tam, Paul Kwong Hang; Wong, Kenneth Kak Yuen

2015-12-01

The role of surgery in the management of stage IV neuroblastoma is controversial. In this study, we attempted to study if complete tumor resection had any impact on event-free survival (EFS) and overall survival (OS). A retrospective analysis of patients with stage IV neuroblastoma between November 2000 and July 2014 in a tertiary referral center was performed. Demographics data, extent of surgical resection, and outcomes were analyzed. A total of 34 patients with stage IV neuroblastoma according to International Neuroblastoma Staging System (INSS) were identified. The median age at diagnosis and operation was 3.5 (±1.9) years and 3.8 (±2.0) years, respectively. Complete gross tumor resection (CTR) was achieved in twenty-four patients (70.1%), in which one of the patients had nephrectomy and another had distal pancreatectomy. Gross total resection (GTR) with removal of >95% of tumor was performed in six patients (17.6%) and subtotal tumor resection (STR) with removal of >50%, but <95% of tumor was performed in four patients (11.8%). There was no statistical significance in terms of 5-year EFS and OS among the 3 groups. There was no surgery-related mortality or morbidity. From our center's experience, as there was no substantial survival benefit in stage IV neuroblastoma patients undergoing complete tumor resection, organ preservation and minimalization of morbidity should also be taken into consideration. Copyright © 2015. Published by Elsevier Inc.

Stereotactic Body Radiation Therapy for Locally Advanced and Borderline Resectable Pancreatic Cancer Is Effective and Well Tolerated

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chuong, Michael D.; Springett, Gregory M.; Freilich, Jessica M.

Purpose: Stereotactic body radiation therapy (SBRT) provides high rates of local control (LC) and margin-negative (R0) resections for locally advanced pancreatic cancer (LAPC) and borderline resectable pancreatic cancer (BRPC), respectively, with minimal toxicity. Methods and Materials: A single-institution retrospective review was performed for patients with nonmetastatic pancreatic cancer treated with induction chemotherapy followed by SBRT. SBRT was delivered over 5 consecutive fractions using a dose painting technique including 7-10 Gy/fraction to the region of vessel abutment or encasement and 5-6 Gy/fraction to the remainder of the tumor. Restaging scans were performed at 4 weeks, and resectable patients were considered formore » resection. The primary endpoints were overall survival (OS) and progression-free survival (PFS). Results: Seventy-three patients were evaluated, with a median follow-up time of 10.5 months. Median doses of 35 Gy and 25 Gy were delivered to the region of vessel involvement and the remainder of the tumor, respectively. Thirty-two BRPC patients (56.1%) underwent surgery, with 31 undergoing an R0 resection (96.9%). The median OS, 1-year OS, median PFS, and 1-year PFS for BRPC versus LAPC patients was 16.4 months versus 15 months, 72.2% versus 68.1%, 9.7 versus 9.8 months, and 42.8% versus 41%, respectively (all P>.10). BRPC patients who underwent R0 resection had improved median OS (19.3 vs 12.3 months; P=.03), 1-year OS (84.2% vs 58.3%; P=.03), and 1-year PFS (56.5% vs 25.0%; P<.0001), respectively, compared with all nonsurgical patients. The 1-year LC in nonsurgical patients was 81%. We did not observe acute grade ≥3 toxicity, and late grade ≥3 toxicity was minimal (5.3%). Conclusions: SBRT safely facilitates margin-negative resection in patients with BRPC pancreatic cancer while maintaining a high rate of LC in unresectable patients. These data support the expanded implementation of SBRT for pancreatic cancer.« less

Surgical Exposure to Control the Distal Internal Carotid Artery at the Base of the Skull during Carotid Aneurysm Repair.

PubMed

Davis, Laura; Zeitouni, Anthony; Makhoul, Nicholas; Steinmetz, Oren K

2016-07-01

Extracranial carotid artery aneurysms are rare. Treatment options for these lesions include endovascular interventions, such as coiling and stenting, or surgical reconstruction, such as resection and primary reanastomosis, or interposition bypass grafting. In this report, we describe the surgical technique used to perform surgical repair of an internal carotid artery aneurysm extending up to the base of the skull. Anterior exposure of the infratemporal fossa and distal control of the carotid artery at the level of the carotid canal was achieved through a transcervical approach, performing double mandibular osteotomies with superior reflection of the middle mandibular section. Copyright © 2016 Elsevier Inc. All rights reserved.

Antegrade bowel intussusception after remote Whipple and Puestow procedures for treatment of pancreas divisum.

PubMed

Gigena, Manuel; Villar, Hugo V; Knowles, Negar G; Cunningham, John T; Outwater, Erik K; Leon, Luis R

2007-11-28

To date, antegrade intussusception involving a Roux-en-Y reconstruction has been reported only once. We report a case of acute bowel obstruction due to an intussusception involving two Roux-en-Y limbs in a 40-year-old woman with a history of chronic pancreatitis due to pancreas divisum. Four years preceding this event, the patient had undergone a Whipple procedure, and three years prior to that, a Puestow operation. The patient was successfully treated with bowel resection and a side-to-side anastomosis between the most distal aspect of the bowel and the most distal Roux-en-Y reconstruction, which preserved both Roux-en-Y reconstructions.

Antegrade bowel intussusception after remote Whipple and Puestow procedures for treatment of pancreas divisum

PubMed Central

Gigena, Manuel; Villar, Hugo V; Knowles, Negar G; Cunningham, John T; Outwater, Erik K; Leon Jr, Luis R

2007-01-01

To date, antegrade intussusception involving a Roux-en-Y reconstruction has been reported only once. We report a case of acute bowel obstruction due to an intussusception involving two Roux-en-Y limbs in a 40-year-old woman with a history of chronic pancreatitis due to pancreas divisum. Four years preceding this event, the patient had undergone a Whipple procedure, and three years prior to that, a Puestow operation. The patient was successfully treated with bowel resection and a side-to-side anastomosis between the most distal aspect of the bowel and the most distal Roux-en-Y reconstruction, which preserved both Roux-en-Y reconstructions. PMID:17990363

Distal Ulnar Artery Aneurysm Repair by End-to-End Technique: A Case Report.

PubMed

Cotroneo, Attilio; Barillà, David; Armienti, Felice; Martinelli, Gian Luca; Diena, Marco

2018-01-01

We report the case of a 33-year-old man presented with a posttraumatic 20-mm left ulnar artery aneurysm without intraluminal thrombus in the left hypothenar eminence. The patient reported left hand paresthesia. Because of symptoms and the embolic risk, we decide to plan an aneurysm resection and an interposition graft with inverted basilic vein for adequacy diameter (∼2 mm), but an end-to-end anastomosis was performed instead. We think that the posttraumatic distal artery aneurysm could be treated without a bypass but, after a meticulous anatomic dissection, with a microvascular anastomosis between the artery stumps. Copyright © 2017 Elsevier Inc. All rights reserved.

Radiation therapy and surgery for fibrosarcoma in 33 cats.

PubMed

Cronin, K; Page, R L; Spodnick, G; Dodge, R; Hardie, E N; Price, G S; Ruslander, D; Thrall, D E

1998-01-01

Thirty-three cats with histologically confirmed fibrosarcomas were treated with radiation therapy followed by surgery. The median (95% confidence interval) disease free interval and overall survival were 398 (261,924) and 600 (lower limit 515) days, respectively. There were 19 treatment failures; 11 cats had only local recurrence, 4 cats developed metastatic disease, 3 cats had local recurrence followed by metastasis, and 1 cat developed simultaneous local and distant disease. Twelve cats are alive and disease free. Two cats died without evidence of treatment failure. The presence of tumor cells at the margin of resected tissue after radiation was the only variable which influenced treatment success. The median (95% confidence interval) disease free interval in 5 cats with tumor cells at the margin of the resected specimen was 112 (94,150) days versus 700 (lower limit 328) days for 26 cats with negative tumor margins, p < 0.0001. We did not identify a relationship between tumor volume, number of prior tumor excisions, concomitant use of chemotherapy or various descriptors of the radiation therapy technique and disease free interval.

Risk factor assessment of endoscopically removed malignant colorectal polyps.

PubMed

Netzer, P; Forster, C; Biral, R; Ruchti, C; Neuweiler, J; Stauffer, E; Schönegg, R; Maurer, C; Hüsler, J; Halter, F; Schmassmann, A

1998-11-01

Malignant colorectal polyps are defined as endoscopically removed polyps with cancerous tissue which has invaded the submucosa. Various histological criteria exist for managing these patients. To determine the significance of histological findings of patients with malignant polyps. Five pathologists reviewed the specimens of 85 patients initially diagnosed with malignant polyps. High risk malignant polyps were defined as having one of the following: incomplete polypectomy, a margin not clearly cancer-free, lymphatic or venous invasion, or grade III carcinoma. Adverse outcome was defined as residual cancer in a resection specimen and local or metastatic recurrence in the follow up period (mean 67 months). Malignant polyps were confirmed in 70 cases. In the 32 low risk malignant polyps, no adverse outcomes occurred; 16 (42%) of the 38 patients with high risk polyps had adverse outcomes (p<0.001). Independent adverse risk factors were incomplete polypectomy and a resected margin not clearly cancer-free; all other risk factors were only associated with adverse outcome when in combination. As no patients with low risk malignant polyps had adverse outcomes, polypectomy alone seems sufficient for these cases. In the high risk group, surgery is recommended when either of the two independent risk factors, incomplete polypectomy or a resection margin not clearly cancer-free, is present or if there is a combination of other risk factors. As lymphatic or venous invasion or grade III cancer did not have an adverse outcome when the sole risk factor, operations in such cases should be individually assessed on the basis of surgical risk.

[Retroperitoneal liposarcoma as etiology of abdominal pain. Case report and literature review].

PubMed

Pérez-Ponce, Yisvanth; Castellanos-Alejandre, Raúl; Guerrero-Romero, J Francisco; Estrada-León, Felipe; Torres-Lobatón, Alfonso

2008-01-01

Soft tissue sarcomas are very uncommon types of tumors, with their embryological origin in the mesoderm and in nerve structures of the neuroectodermic layer. They represent only 1.5% of cases in the National Registry of Malignant Tumors in Mexico. They can be encountered anywhere connective soft tissue is found. Because of their specialized localization, retroperitoneal soft tissue sarcomas have a propensity to remain asymptomatic for long periods of time and reach a large size before being diagnosed. The only accepted treatment is wide surgical excision with clear margins, without a clear benefit for adjuvant treatment. The very uncommon nature of these tumors and their varied histopathology, site and behavior classify them as a difficult entity in terms of treatment. We present here the case of a 66-year-old female with a left-side retroperitoneal tumor, complaining only of vague abdominal pain as the presenting symptom. A CT-guided needle biopsy reported a sarcoma and the patient was subjected to laparatomy with complete resection of the tumor (30 x 13 x 10 cm). Histopathological report demonstrated a low-grade retroperitoneal sarcoma and free macroscopic and microscopic borders, without obvious invasion except for left kidney and ureter. The patient refused adjuvant treatment, and she is disease-free 7 years after treatment. Retroperitoneal sarcomas can cause pain and reach very large sizes. The best treatment available is wide surgical resection with clear margins. The most important prognostic factors are free margins, type of resection, age of patient and tumor histology.

Liver resection for metastases of tracheal adenoid cystic carcinoma: Report of two cases.

PubMed

Hashimoto, Shintaro; Sumida, Yorihisa; Tobinaga, Shuichi; Wada, Hideo; Wakata, Kouki; Nonaka, Takashi; Kunizaki, Masaki; Hidaka, Shigekazu; Kinoshita, Naoe; Sawai, Terumitsu; Nagayasu, Takeshi

2018-05-16

Tracheal adenoid cystic carcinoma (ACC) is rare and accounts for <1% of all lung cancers. Although ACC is classified as a low-grade tumor, metastases are frequently identified in the late period. Extrapulmonary metastases are rare, and their resection has rarely been reported. Case 1: A 77-year-old man underwent tracheal resection for ACC with postoperative radiation (60 Gy) 14 years before　(at the age of 63). He underwent two subsequent pulmonary resections for metastases. Fourteen years after the first operation, he underwent extended right posterior segmentectomy with resection of segment IV and radiofrequency ablation for metastases of ACC to the liver. He was diagnosed with metastases to the kidney with peritoneal dissemination 4 years after the liver resection and died of pneumonia 2 years later. Case 2: A 53-year-old woman underwent a two-stage operation involving tracheal resection for ACC and partial resection of liver segments II and V for metastases of ACC to the liver. The tracheal margin was histopathologically positive. Postoperative radiation was performed, and she was tumor-free for 10 months after the liver resection. Complete resection of tracheal ACC provides better survival. Radiotherapy is also recommended. However, the optimal treatment for metastases of ACC is unclear, especially because liver resection for metastases of tracheal ACC is rarely reported. Our two cases of metastases of tracheal ACC were surgically managed with good outcomes. Liver resection for metastases of tracheal ACC may contribute to long survival. Copyright © 2018. Published by Elsevier Ltd.

Tissue preservation with mass spectroscopic analysis: Implications for cancer diagnostics.

PubMed

Hall, O Morgan; Peer, Cody J; Figg, William D

2018-05-17

Surgical intervention is a common treatment modality for localized cancer. Post-operative analysis involves evaluation of surgical margins to assess whether all malignant tissue has been resected because positive surgical margins lead to a greater likelihood of recurrence. Secondary treatments are utilized to minimize the negative effects of positive surgical margins. Recently, in Science Translational Medicine, Zhang et al describe a new mass spectroscopic technique that could potentially decrease the likelihood of positive surgical margins. Their nondestructive in vivo tissue sampling leads to a highly accurate and rapid cancer diagnosis with great precision between healthy and malignant tissue. This new tool has the potential to improve surgical margins and accelerate cancer diagnostics by analyzing biomolecular signatures of various tissues and diseases.

Early Oral Tongue Squamous Cell Carcinoma: Sampling of Margins From Tumor Bed and Worse Local Control.

PubMed

Maxwell, Jessica H; Thompson, Lester D R; Brandwein-Gensler, Margaret S; Weiss, Bernhard G; Canis, Martin; Purgina, Bibianna; Prabhu, Arpan V; Lai, Chi; Shuai, Yongli; Carroll, William R; Morlandt, Anthony; Duvvuri, Umamaheswar; Kim, Seungwon; Johnson, Jonas T; Ferris, Robert L; Seethala, Raja; Chiosea, Simion I

2015-12-01

Positive margins are associated with poor prognosis among patients with oral tongue squamous cell carcinoma (SCC). However, wide variation exists in the margin sampling technique. To determine the effect of the margin sampling technique on local recurrence (LR) in patients with stage I or II oral tongue SCC. A retrospective study was conducted from January 1, 1986, to December 31, 2012, in 5 tertiary care centers following tumor resection and elective neck dissection in 280 patients with pathologic (p)T1-2 pN0 oral tongue SCC. Analysis was conducted from June 1, 2013, to January 20, 2015. In group 1 (n = 119), tumor bed margins were not sampled. In group 2 (n = 61), margins were examined from the glossectomy specimen, found to be positive or suboptimal, and revised with additional tumor bed margins. In group 3 (n = 100), margins were primarily sampled from the tumor bed without preceding examination of the glossectomy specimen. The margin status (both as a binary [positive vs negative] and continuous [distance to the margin in millimeters] variable) and other clinicopathologic parameters were compared across the 3 groups and correlated with LR. Local recurrence. Age, sex, pT stage, lymphovascular or perineural invasion, and adjuvant radiation treatment were similar across the 3 groups. The probability of LR-free survival at 3 years was 0.9 and 0.8 in groups 1 and 3, respectively (P = .03). The frequency of positive glossectomy margins was lowest in group 1 (9 of 117 [7.7%]) compared with groups 2 and 3 (28 of 61 [45.9%] and 23 of 95 [24.2%], respectively) (P < .001). Even after excluding cases with positive margins, the median distance to the closest margin was significantly narrower in group 3 (2 mm) compared with group 1 (3 mm) (P = .008). The status (positive vs negative) of margins obtained from the glossectomy specimen correlated with LR (P = .007), while the status of tumor bed margins did not. The status of the tumor bed margin was 24% sensitive (95% CI, 16%-34%) and 92% specific (95% CI, 85%-97%) for detecting a positive glossectomy margin. The margin sampling technique affects local control in patients with oral tongue SCC. Reliance on margin sampling from the tumor bed is associated with worse local control, most likely owing to narrower margin clearance and greater incidence of positive margins. A resection specimen-based margin assessment is recommended.

Early Oral Tongue Squamous Cell Carcinoma Sampling of Margins From Tumor Bed and Worse Local Control

PubMed Central

Maxwell, Jessica H.; Thompson, Lester D. R.; Brandwein-Gensler, Margaret S.; Weiss, Bernhard G.; Canis, Martin; Purgina, Bibianna; Prabhu, Arpan V.; Lai, Chi; Shuai, Yongli; Carroll, William R.; Morlandt, Anthony; Duvvuri, Umamaheswar; Kim, Seungwon; Johnson, Jonas T.; Ferris, Robert L.; Seethala, Raja; Chiosea, Simion I.

2017-01-01

IMPORTANCE Positive margins are associated with poor prognosis among patients with oral tongue squamous cell carcinoma (SCC). However, wide variation exists in the margin sampling technique. OBJECTIVE To determine the effect of the margin sampling technique on local recurrence (LR) in patients with stage I or II oral tongue SCC. DESIGN, SETTING, AND PARTICIPANTS A retrospective study was conducted from January 1, 1986, to December 31, 2012, in 5 tertiary care centers following tumor resection and elective neck dissection in 280 patients with pathologic (p)T1-2 pN0 oral tongue SCC. Analysis was conducted from June 1, 2013, to January 20, 2015. INTERVENTIONS In group 1 (n = 119), tumor bed margins were not sampled. In group 2 (n = 61), margins were examined from the glossectomy specimen, found to be positive or suboptimal, and revised with additional tumor bed margins. In group 3 (n = 100), margins were primarily sampled from the tumor bed without preceding examination of the glossectomy specimen. The margin status (both as a binary [positive vs negative] and continuous [distance to the margin in millimeters] variable) and other clinicopathologic parameters were compared across the 3 groups and correlated with LR. MAIN OUTCOMES AND MEASURES Local recurrence. RESULTS Age, sex, pT stage, lymphovascular or perineural invasion, and adjuvant radiation treatment were similar across the 3 groups. The probability of LR-free survival at 3 years was 0.9 and 0.8 in groups 1 and 3, respectively (P = .03). The frequency of positive glossectomy margins was lowest in group 1 (9 of 117 [7.7%]) compared with groups 2 and 3 (28 of 61 [45.9%] and 23 of 95 [24.2%], respectively) (P < .001). Even after excluding cases with positive margins, the median distance to the closest margin was significantly narrower in group 3 (2 mm) compared with group 1 (3 mm) (P = .008). The status (positive vs negative) of margins obtained from the glossectomy specimen correlated with LR (P = .007), while the status of tumor bed margins did not. The status of the tumor bed margin was 24% sensitive (95% CI, 16%-34%) and 92% specific (95% CI, 85%-97%) for detecting a positive glossectomy margin. CONCLUSIONS AND RELEVANCE The margin sampling technique affects local control in patients with oral tongue SCC. Reliance on margin sampling from the tumor bed is associated with worse local control, most likely owing to narrower margin clearance and greater incidence of positive margins. A resection specimen–based margin assessment is recommended. PMID:26225798

CO2 laser versus cold steel margin analysis following endoscopic excision of glottic cancer

PubMed Central

2014-01-01

Objective To compare the suitability of CO2 laser with steel instruments for margin excision in transoral laser microsurgery. Methods Prospective randomized blinded study. Patients with glottic cancer undergoing laser resection were randomized to margin excision by either steel instruments or CO2 laser. Margins were analyzed for size, interpretability and degree of artifact by a pathologist who was blinded to technique. Results 45 patients were enrolled in the study with 226 total margins taken. 39 margins taken by laser had marked artifact and 0 were uninterpretable. 20 margins taken by steel instruments had marked artifact, and 2 were uninterpretable. Controlling for margin size, the laser technique was associated with increasing degrees of margin artifact (p = 0.210), but there was no difference in crude rates of uninterpretability (p = 0.24). Conclusion Laser margin excision is associated with a greater degree of artifact than steel instrument excision, but was not associated with higher rate of uninterpretability. PMID:24502856

[Does a sector resection of the breast cure nodal mastopathy?].

PubMed

Li, L A; Martyniuk, V V

1998-01-01

Results of the clinico-morphological investigation of 265 patients with localized mastopathy who were submitted to sectorial resection showed that in the margins of the operative wound there were morphological signs of mastopathy in 252 (95.1%) patients. The results obtained confirm the opinion that structural alterations of the tissues known to be the essential feature of fibroadenomatosis can not be local, they are of diffuse character. So, the sectorial resection performed for localized mastopathy can not be radical and is of no therapeutic significance. The indication to surgical intervention must be determined not so much by the necessary treatment as by the real risk of hypo-diagnosis of breast cancer. So, there is no need to fulfil the sectorial resection for localized mastopathy. It is enough to make operation of less volume (excision biopsy).

Population-Level Incidence and Predictors of Surgically Induced Diabetes and Exocrine Insufficiency after Partial Pancreatic Resection.

PubMed

Elliott, Irmina A; Epelboym, Irene; Winner, Megan; Allendorf, John D; Haigh, Philip I

2017-01-01

Endocrine and exocrine insufficiency after partial pancreatectomy affect quality of life, cardiovascular health, and nutritional status. However, their incidence and predictors are unknown. To identify the incidence and predictors of new-onset diabetes and exocrine insufficiency after partial pancreatectomy. We retrospectively reviewed 1165 cases of partial pancreatectomy, performed from 1998 to 2010, from a large population-based database. Incidence of new onset diabetes and exocrine insufficiency RESULTS: Of 1165 patients undergoing partial pancreatectomy, 41.8% had preexisting diabetes. In the remaining 678 patients, at a median 3.6 months, diabetes developed in 274 (40.4%) and pancreatic insufficiency developed in 235 (34.7%) patients. Independent predictors of new-onset diabetes were higher Charlson Comorbidity Index (CCI; hazard ratio [HR] = 1.62 for CCI of 1, p = 0.02; HR = 1.95 for CCI ≥ 2, p < 0.01) and pancreatitis (HR = 1.51, p = 0.03). There was no difference in diabetes after Whipple procedure vs distal pancreatic resections, or malignant vs benign pathologic findings. Independent predictors of exocrine insufficiency were female sex (HR = 1.32, p = 0.002) and higher CCI (HR = 1.85 for CCI of 1, p < 0.01; HR = 2.05 for CCI ≥ 2, p < 0.01). Distal resection and Asian race predicted decreased exocrine insufficiency (HR = 0.35, p < 0.01; HR = 0.54, p < 0.01, respectively). In a large population-based database, the rates of postpancreatectomy endocrine and exocrine insufficiency were 40% and 35%, respectively. These data are critical for informing patients' and physicians' expectations.

Smoothelin expression in the gastrointestinal tract: implication in colonic inertia.

PubMed

Chan, Owen T M; Chiles, Lauren; Levy, Mary; Zhai, Jing; Yerian, Lisa M; Xu, Haodong; Xiao, Shu-Yuan; Soffer, Edy E; Conklin, Jeffrey L; Dhall, Deepti; Kahn, Melissa E; Balzer, Bonnie L; Amin, Mahul B; Wang, Hanlin L

2013-10-01

Colonic inertia is a frustrating motility disorder to patients, clinicians, and pathologists. The pathogenesis is largely unknown. The aims of this study were to: (1) characterize the expression of smoothelin, a novel smooth muscle-specific contractile protein expressed only by terminally differentiated smooth muscle cells, in the normal gastrointestinal (GI) tract; and (2) determine whether smoothelin is aberrantly expressed in patients with colonic inertia. A total of 57 resections of the normal GI tract (distal esophagus to left colon) were obtained from patients without GI motor dysfunction. Sixty-one colon resections were obtained from patients with a clinical diagnosis of colonic inertia. Smoothelin immunostaining was conducted on full-thickness tissue sections. In the nondysmotile controls, strong and diffuse cytoplasmic staining for smoothelin was observed in both the inner circular and outer longitudinal layers of the muscularis propria (MP) throughout the entire GI tract. The muscularis mucosae (MM) and muscular vessel walls were either completely negative or only patchily and weakly stained. The 1 exception to this pattern was observed in the distal esophagus, in which the MM was also diffusely and strongly stained. In cases with colonic inertia, a moderate to marked reduction of smoothelin immunoreactivity was observed in 15 of 61 (24.6%) colon resections, selectively seen in the outer layer of the MP. The data demonstrate that smoothelin is differentially expressed in the MP and MM of the normal GI tract and suggest that defective smoothelin expression may play a role in the pathogenesis of colonic inertia in a subset of patients.

Distal Pancreatectomy with En Bloc Resection of the Celiac Axis with Preservation or Reconstruction of the Left Gastric Artery in Patients with Pancreatic Body Cancer.

PubMed

Sato, Takafumi; Saiura, Akio; Inoue, Yosuke; Takahashi, Yu; Arita, Junichi; Takemura, Nobuyuki

2016-09-01

A distal pancreatectomy with en bloc celiac axis resection (DP-CAR) is indicated for left-sided locally advanced pancreatic ductal adenocarcinoma. However, ischemic complication resulting from the sacrifice of the common hepatic artery and left gastric artery (LGA) remain problematic. The aim of this study was to analyze the feasibility of DP-CAR with preservation or reconstruction of the left gastric artery. Between April 2011 and December 2014, we treated 17 cases using DP-CAR with preservation or reconstruction of the LGA. If the tumor had involved the LGA, the LGA was dissected and reconstructed using the middle colic artery. We retrospectively analyzed the feasibility of this procedure. Among 17 consecutive patients who underwent DP-CAR, the LGA was preserved in 13 patients and reconstructed in four patients. Major postoperative complications were observed in seven cases (41 %). A pancreatic fistula (grade B/C) or delayed gastric emptying (grade B/C) occurred in 7 (41 %) and 2 (12 %) cases, respectively. The overall R0 resection rate was 94 % (16/17). Eleven cases developed recurrences (liver, n = 4; lymph nodes, n = 2; peritoneal dissemination, n = 2; lung, n = 2; local recurrence, n = 1). The overall 1- and 3-year postoperative survival rates were 74 and 45 %, respectively. Our preliminary data showed that DP-CAR with preservation or reconstruction of the LGA is a safe and feasible approach, and that this procedure may reduce the risk of ischemic complications.

Surgical resection of late solitary locoregional gastric cancer recurrence in stomach bed.

PubMed

Watanabe, Masanori; Suzuki, Hideyuki; Maejima, Kentaro; Komine, Osamu; Mizutani, Satoshi; Yoshino, Masanori; Bo, Hideki; Kitayama, Yasuhiko; Uchida, Eiji

2012-07-01

Late-onset and solitary recurrence of gastric signet ring cell (SRC) carcinoma is rare. We report a successful surgical resection of late solitary locoregional recurrence after curative gastrectomy for gastric SRC carcinoma. The patient underwent total gastrectomy for advanced gastric carcinoma at age 52. Seven years after the primary operation, he visited us again with sudden onset of abdominal pain and vomiting. We finally decided to perform an operation, based on a diagnosis of colon obstruction due to the recurrence of gastric cancer by clinical findings and instrumental examinations. The laparotomic intra-abdominal findings showed that the recurrent tumor existed in the region surrounded by the left diaphragm, colon of splenic flexure, and pancreas tail. There was no evidence of peritoneal dissemination, and peritoneal lavage fluid cytology was negative. We performed complete resection of the recurrent tumor with partial colectomy, distal pancreatectomy, and partial diaphragmectomy. Histological examination of the resected specimen revealed SRC carcinoma, identical in appearance to the previously resected gastric cancer. We confirmed that the intra-abdominal tumor was a locoregional gastric cancer recurrence in the stomach bed. The patient showed a long-term survival of 27 months after the second operation. In the absence of effective alternative treatment for recurrent gastric carcinoma, surgical options should be pursued, especially for late and solitary recurrence.

Microsurgical resection of intramedullary spinal cord ependymoma.

PubMed

McCormick, Paul C

2014-09-01

Ependymomas are the most commonly occurring intramedullary spinal cord tumor in adults. With few exceptions these tumors are histologically benign, although they exhibit some biologic variability with respect to growth rate. While unencapsulated, spinal ependymomas are non-infiltrative and present a clear margin of demarcation from the surrounding spinal cord that serves as an effective dissection plane. This video demonstrates the technique of microsurgical resection of an intramedullary ependymoma through a posterior midline myelotomy. The video can be found here: http://youtu.be/lcHhymSvSqU.

Session 3: Beyond the boundaries of Total Mesorectal Excision - where surgeons fear to tread.

PubMed

Patel, A; Holm, T; Wale, A; Rutten, H; Nicholls, J; Hawkins, M; Steele, R J C; Marks, J; Brown, G

2018-05-01

Approximately 10-15% of patients present with an advanced rectal cancer that extends beyond the conventional total mesorectal excision (TME) planes. In such cases extending the surgery to ensure resection with clear margins (R0 resection) is essential in order to achieve long-term cure. Professor Holm describes the techniques of beyond-TME exenterative surgery, the methods of patient selection and outcomes. Colorectal Disease © 2018 The Association of Coloproctology of Great Britain and Ireland.

Total humerus replacement for osteosarcoma with proximal part of humerus: a case report

PubMed Central

2012-01-01

Incisional biopsy and intramedullary pinning were performed for pathological fracture associated with a malignant bone tumor of the proximal humerus. Osteosarcoma, for which preoperative chemotherapy had been performed, was confirmed by postoperative pathological examination. To achieve wide resection and acquire a safe resected margin, total humerus replacement was performed, and the whole humerus was reconstructed using the Howmedica Modular Reconstruction system. The patient resumed normal activities, although mild contracture of the elbow joint remains 8 years after surgery. PMID:22333118

Influence of surgical and prosthetic techniques on marginal bone loss around titanium implants. Part I: immediate loading in fresh extraction sockets.

PubMed

Berberi, Antoine N; Tehini, Georges E; Noujeim, Ziad F; Khairallah, Alexandre A; Abousehlib, Moustafa N; Salameh, Ziad A

2014-10-01

Delayed placement of implant abutments has been associated with peri-implant marginal bone loss; however, long-term results obtained by modifying surgical and prosthetic techniques after implant placement are still lacking. This study aimed to evaluate the marginal bone loss around titanium implants placed in fresh extraction sockets using two loading protocols after a 5-year follow-up period. A total of 36 patients received 40 titanium implants (Astra Tech) intended for single-tooth replacement. Implants were immediately placed into fresh extraction sockets using either a one-stage (immediate loading by placing an interim prosthesis into functional occlusion) or a two-stage prosthetic loading protocol (insertion of abutments after 8 weeks of healing time). Marginal bone levels relative to the implant reference point were evaluated at four time intervals using intraoral radiographs: at time of implant placement, and 1, 3, and 5 years after implant placement. Measurements were obtained from mesial and distal surfaces of each implant (α = 0.05). One-stage immediate implant placement into fresh extraction sockets resulted in a significant reduction in marginal bone loss (p < 0.002) compared to the traditional two-stage technique. Whereas mesial surfaces remained stable for the 5-year observation period, significant marginal bone loss was observed on distal surfaces of implants after cementation of interim prostheses (p < 0.007) and after 12 months (p < 0.034). Within the limitations of this study, immediate loading of implants placed into fresh extraction sockets reduced marginal bone loss and did not compromise the success rate of the restorations. © 2014 by the American College of Prosthodontists.

Minimum Abutment Height to Eliminate Bone Loss: Influence of Implant Neck Design and Platform Switching.

PubMed

Spinato, Sergio; Galindo-Moreno, Pablo; Bernardello, Fabio; Zaffe, Davide

This retrospective study quantitatively analyzed the minimum prosthetic abutment height to eliminate bone loss after 4.7-mm-diameter implant placement in maxillary bone and how grafting techniques can affect the marginal bone loss in implants placed in maxillary areas. Two different implant types with a similar neck design were singularly placed in two groups of patients: the test group, with platform-switched implants, and the control group, with conventional (non-platform-switched) implants. Patients requiring bone augmentation underwent unilateral sinus augmentation using a transcrestal technique with mineralized xenograft. Radiographs were taken immediately after implant placement, after delivery of the prosthetic restoration, and after 12 months of loading. The average mesial and distal marginal bone loss of the control group (25 patients) was significantly more than twice that of the test group (26 patients), while their average abutment height was similar. Linear regression analysis highlighted a statistically significant inverse relationship between marginal bone loss and abutment height in both groups; however, the intercept of the regression line, both mesially and distally, was 50% lower for the test group than for the control group. The marginal bone loss was annulled with an abutment height of 2.5 mm for the test group and 3.0 mm for the control group. No statistically significant differences were found regarding marginal bone loss of implants placed in native maxillary bone compared with those placed in the grafted areas. The results suggest that the shorter the abutment height, the greater the marginal bone loss in cement-retained prostheses. Abutment height showed a greater influence in platform-switched than in non-platform-switched implants on the limitation of marginal bone loss.

Diagnosis and treatment of solid pseudopapillary tumor of the pancreas: experience of one single institution from Turkey

PubMed Central

2013-01-01

Background Solid pseudopapillary neoplasia (SPN) of the pancreas is an extremely rare epithelial tumor of low malignant potential. SPN accounts for less than 1% to 2% of exocrine pancreatic tumors. The aim of this study is to report our experience with SPN of the pancreas. It includes a summary of the current literature to provide a reference for the management of this rare clinical entity. Methods A retrospective analysis was performed of all patients diagnosed and treated for SPN in our hospital over the past 15 years (1998 to 2013). A database of the characteristics of these patients was developed, including age, gender, tumor location and size, treatment, and histopathological and immunohistochemical features. Results During this time period, 255 patients with pancreatic malignancy (which does not include ampulla vateri, distal choledocal and duodenal tumor) were admitted to our department, only 10 of whom were diagnosed as having SPN (2.5%). Nine patients were women (90%) and one patient was a man (10%). Their median age was 38.8 years (range 18 to 71). The most common symptoms were abdominal pain and dullness. Seven patients (70%) presented with abdominal pain or abdominal dullness and three patient (30%) were asymptomatic with the diagnosis made by an incidental finding on routine examination. Abdominal computed tomography and/or magnetic resonance imaging showed the typical features of solid pseudopapillary neoplasm in six (60%) of the patients. Four patients underwent distal pancreatectomy with splenectomy, one patient underwent a total mass excision, and one patient underwent total pancreatic resection. Two required extended distal pancreatectomy with splenectomy. Two underwent spleen-preserving distal pancreatectomy. Conclusions SPN is a rare neoplasm that primarily affects young women. The prognosis is favorable even in the presence of distant metastasis. Although surgical resection is generally curative, a close follow-up is advised in order to diagnose a local recurrence or distant metastasis and choose the proper therapeutic option for the patient. PMID:24289652

[Meta-analysis of risk factors of recurrence in patients with giant cell tumor on extremities].

PubMed

Li, Rongrui; Hu, Yongcheng

2014-12-23

To explore the risk factors of giant cell tumor on extremities for patients with postoperative recurrence. The literature reports published before June 2014 were searched in the electronic databases of CBM, CNKI, PUBNED, MEDLINE and EMBASE. Meta-analysis was performed by software Review Manager (Version 5.3). The odds ratios (OR) of gender, age, tumor site, Campanacci Classification, pathological fracture, selection of treatment and soft tissue invasion were analyzed with heterogeneity test. Publication bias were tested by funnel plot and fail-safe number.Sensitivity analysis was performed to assess the stability. A total of 15 case-control studies were identified. Age, location and type of surgery were associated with tumor recurrence. The combined OR (95%CI) was 1.83 (1.04-3.24) P = 0.04 for aged <20 years, 0.52(0.31-0.86) P = 0.01 for aged >40 years, 1.60 (1.06-2.42) P = 0.02 for distal radius, 0.35 (0.14-0.90) P = 0.03 for proximal humerus, 3.64 (1.88-7.04) P = 0.0001 for curettage,0.56 (0.35-0.91) P = 0.02 for curettage with PMMA, 1.79 (1.11-2.88) P = 0.02 for curettage with bone graft and adjuvant and 0.29 (0.12-0.66) P = 0.003 for resection respectively. There were not significant relationship between tumor recurrence and gender, tumor location (distal femur, proximal femur, distal tibia, proximal tibia), Jaffe staging, Campanacci classification,Enneking classification, pathological fracture, soft tissue invasion, extensive curettage, curettage with bone graft, curettage with polymethylmethacrylate and adjuvant (P > 0.05). Youth (aged <20 years), distal radius, curettage and curettage with bone graft and adjuvant are the risk factors for recurrence of giant cell tumor.However, advanced age (aged >40 years), proximal tibia, curettage with PMMA and resection appear to have lower risks for tumor recurrence.

Short-stem reconstruction for megaendoprostheses in case of an ultrashort proximal femur

PubMed Central

2014-01-01

Background Tumors of the distal femur and diaphysis with proximal metaphyseal extension into the femur present a challenge for limb salvage. The conventional treatment consists of limb salvage with total femur replacement. This case study aims to present preliminary results and experience with short-stem reconstruction, focusing on the mechanical stability of the procedure. Methods Sixteen short stems were implanted in 15 patients. The patients’ mean age was 33,3 years (range 11–73). In 10 patients, the stem was used for distal femur reconstruction, in one patient for diaphyseal reconstruction, and in four for a stump lengthening procedure. All of the patients had a primary sarcoma in their history. The mean follow-up period was 37 months (range 5–95 months). The clinical and functional follow-up data were analyzed. Results Ten patients (67%) were still alive at the time of evaluation. Three complications associated with the stem were noted. In one case, there was aseptic loosening after 58 months; in another, aseptic loosening occurred because the diameter of the stem had initially been too small; and in one case, there was breakage of the fixation screw, without any clinical symptoms. The average Musculoskeletal Tumor Society score for all patients was 23 (range 9–28). The mean result for the distal femur replacement was 24 (range 22–28). None of the surviving patients with distal femur replacements needed any crutches or had a Trendelenburg limp. Both living patients who underwent a stump lengthening procedure were able to walk with an exoprosthesis. Conclusions The short stem is a good solution that can prevent or delay proximal femur resection in patients with tumors extending into the proximal metaphyseal femur. Additional risks of proximal femur resection, such as dislocation, opening of another oncological compartment, Trendelenburg limp, and chondrolysis can be avoided. PMID:24885859

Robotic versus laparoscopic surgery for mid or low rectal cancer in male patients after neoadjuvant chemoradiation therapy: comparison of short-term outcomes.

PubMed

Serin, Kursat Rahmi; Gultekin, Fatma Ayca; Batman, Burçin; Ay, Serden; Kapran, Yersu; Saglam, Sezer; Asoglu, Oktar

2015-09-01

The aim of our study was to compare short-term outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision (TME) in male patients with mid-low rectal cancer (RC) after neadjuvant chemoradiotherapy (NCRT). The study was conducted as a retrospective review of a prospectively maintained database, and we analyzed 14 robotic and 65 laparoscopic sphincter saving TME (R-TME and L-TME, respectively) performed by one surgeon between 2005 and 2013. Patient characteristics, perioperative recovery, postoperative complications and and pathology results were compared between the two groups. The patient characteristics did not differ significantly between the two groups. Median operating time was longer in the R-TME than in the L-TME group (182 min versus 140 min). Only two conversions occurred in the L-TME group. No difference was found between groups regarding perioperative recovery and postoperative complication rates. The median number of harvested lymph nodes was higher in the RTME than in the L-TME group (32 versus 23, p = 0.008). The median circumferential margin (CRM) was 10 mm in the R-TME group, 6.5 mm in the L-TME group (p = 0.047. The median distal resection margin (DRM) was 27.5 mm in the R-TME, 15 mm in the L-TME group (p = 0.014). Macroscopic grading of the specimen in the R-TME group was complete in all patients. In the L-TME group, grading was complete in 52 (80%) and incomplete in 13 (20%) cases (p = 0.109). R-TME is a safe and feasible procedure that facilitates performing of TME in male patients with mid-low RC after NCRT.

Potential links between onshore tectonics and terrestrial organic carbon delivery to distal submarine fan environments: IODP Site U1417, Surveyor Fan, Gulf of Alaska

NASA Astrophysics Data System (ADS)

Childress, L. B.; Ridgway, K. D.; Blair, N. E.; Bahlburg, H.; Berbel, G.; Cowan, E. A.; Forwick, M.; Gulick, S. P.; Jaeger, J. M.; Maerz, C.; McClymont, E.; Moy, C. M.; Müller, J.; Nakamura, A.; Ribeiro, F.

2013-12-01

The sedimentary record at Integrated Ocean Drilling Program (IODP) Site U1417 is particularly well preserved and permits delineation of Neogene tectonic, climatic, and terrestrial organic carbon signals. Lithofacies in the 708 m-long, cored interval can be divided into 3 sedimentary packages that we interpret as linked to the tectonic convergence of the Yakutat Terrane with, and onset of tidewater glaciation along, the continental margin of northwestern Canada and southern Alaska. Previous studies have shown that development of the Surveyor Fan system was closely linked to transport of the Yakutat Terrane and development of the Cordilleran Ice Sheet. Initial shipboard measurements of total organic carbon and observed plant and coal fragments imply good preservation of terrestrial organic matter. Furthermore, documented preservation of terrestrial organic matter in modern sediment along the southern Alaskan continental margin and sediment routing through the Surveyor Channel from the Pleistocene to modern time implies a long-term conduit for this organic material to reach the distal portion of the Surveyor Fan system. We interpret the lower units of U1417 (late Miocene) to have been deposited when the Yakutat Terrane was located offshore of northern British Columbia and/or southeastern Alaska. Northward transport of the Yakutat Terrane during the late Miocene is interpreted to have resulted in uplift and erosion of the Eocene coal-bearing Kulthieth Formation. We infer that eroded rock carbon from this formation was transported from the shelf to the earliest, or precursor to, the Surveyor Fan with depocenters infilling between seamounts. Detailed geochemical/biomarker analysis of Kulthieth Formation coals will provide a chemical fingerprint by which to identify this source of late Miocene sediment at U1417. Continued Pliocene - early Pleistocene northward convergence resulted in recycling of organic carbon from the onshore Neogene thrust belt of the Yakutat Terrane and the older uplifted parts of the Mesozoic continental margin to the distal submarine fan system. Since the early Pleistocene, the distal fan has been sourced from tidewater glaciers transporting sediment from the continental margin of south-central Alaska through the Surveyor Channel and related sediment pathways, levees, and overbank systems. We hypothesize that tectonic transport of the Yakutat Terrane and the onset of tidewater glaciation resulted in variation of the geochemical signature of ancient carbon delivered to the distal parts of the Surveyor Fan. Biomarker differences between the Neogene coal-bearing Kulthieth Formation and the Mesozoic continental strata material will allow us to confirm source material to the fan over the last ~ 10 Ma.

Comparison of Salvage Total Pharyngolaryngectomy and Cervical Esophagectomy Between Hypopharyngeal Cancer and Cervical Esophageal Cancer.

PubMed

Takebayashi, Katsushi; Tsubosa, Yasuhiro; Kamijo, Tomoyuki; Iida, Yoshiyuki; Imai, Atsushi; Nagaoka, Masato; Kitani, Takashi; Niihara, Masahiro; Booka, Eisuke; Shimada, Ayako; Nakagawa, Masahiro; Onitsuka, Tetsuro

2017-03-01

Total pharyngolaryngectomy and cervical esophagectomy (TPLCE) after chemoradiotherapy remains a challenge because of the high rate of complications and few available data on outcomes and safety. The purpose of this study was to evaluate the clinical significance of salvage TPLCE and to compare treatment outcomes between hypopharyngeal cancer and cervical esophageal cancer. Data from 37 consecutive patients who were diagnosed with potentially resectable hypopharyngeal and cervical esophageal cancer after chemoradiotherapy were retrospectively analyzed. The survival and surgical outcomes were investigated between the hypopharyngeal cancer and cervical esophageal cancer groups. Twenty-six patients were included in hypopharyngeal cancer group and 11 patients were included in cervical esophageal cancer group. The baseline characteristics were balanced between the two groups. Compared to the hypopharyngeal cancer group, the cervical esophageal cancer group had significantly more frequent tracheal-related complications (p < 0.05) and stronger association of distal margin of the cervical esophagus and radiation field with tracheal ischemia after salvage surgery. Salvage TPLCE can offer the exclusive chance of prolonged survival. Association of tracheal ischemia with salvage TPLCE was seen more frequently for cervical esophageal cancer. Therefore, the indication for salvage TPLCE must be carefully considered to maintain the balance between curability and safety.

Biopsy forceps is inadequate for the resection of diminutive polyps.

PubMed

Efthymiou, M; Taylor, A C; Desmond, P V; Allen, P B; Chen, R Y

2011-04-01

Cold biopsy forceps polypectomy (CBP) is often used for the removal of diminutive polyps. The efficacy of the technique has not been thoroughly assessed. The aim of this study was to prospectively assess the efficacy of CBP for removing diminutive polyps. This was a prospective study from St Vincent's Hospital, a tertiary referral hospital in Melbourne, Australia. A total of 143 patients were screened and 52 patients with ≥ 1 diminutive polyps were enrolled. CBP was used to resect diminutive polyps until no polyp tissue was visible. The polyp base was then resected using endoscopic mucosal resection (EMR) with a 1 - 2-mm margin. The CBP and EMR samples were compared to assess completeness of the resection. Overall 39 % (21 / 54) of diminutive polyps were completely resected using CBP. After binary logistic regression analysis, polyp histology was found to be predictive of resection, with complete resection of 62 % (13 / 21) for adenomas and 24 % (8 / 33) for hyperplastic polyps (odds ratio 5.1; P = 0.008). The size and number of bites taken with the forceps were not predictive of complete response. Within the limitations of a modest sample size, CBP appears to be inadequate treatment for the removal of diminutive polyps. © Georg Thieme Verlag KG Stuttgart · New York.

Is the Clavicula Pro Humero Technique of Value for Reconstruction After Resection of the Proximal Humerus in Children?

PubMed

Barbier, Dominique; De Billy, Benoît; Gicquel, Philippe; Bourelle, Sophie; Journeau, Pierre

2017-10-01

There are several options for reconstruction of proximal humerus resections after wide resection for malignant tumors in children. The clavicula pro humero technique is a biologic option that has been used in the past, but there are only scant case reports and small series that comment on the results of the procedure. Because the longevity of children mandates a reconstruction with potential longevity not likely to be achieved by other techniques, the clavicula pro humero technique may be a potential option in selected patients. (1) How successful is the clavicula pro humero procedure in achieving local tumor control? (2) What is the frequency of nonunion? (3) What are the complications of the procedure? (4) What scores do patients achieve (on the Musculoskeletal Tumor Society (MSTS) and the Toronto Extremity Salvage Score (TESS) after this procedure? Four university hospitals performed the clavicula pro humero technique in eight children aged 8 to 18 years between June 2006 and February 2014. During that period, general indications for this approach included all reconstructions of the proximal humerus for malignant tumors in children older than 8 years. All patients were followed for a mean of 40 months (range, 25-86 months); one patient was lost to followup before 2 years. The tumor resections removed the rotator cuff muscles in all patients, glenohumeral joint in five, and deltoid muscle in three. The median length of the bone defect after resection was 20 cm (range, 7-25 cm). It was reduced to 9 cm (range, 0-17 cm) or 27% (range, 0%-64%) of the total humerus length after clavicular rotation. Direct osteosynthesis (one patient), induced membrane technique (one patient), or vascularized fibular autograft (six patients) was used to complete the defect after rotation of the clavicle if necessary. Presence of union (defined as bone healing before 10 months, as assessed by disappearance of the osteotomy on AP and lateral view radiographs), and complications were determined by chart review performed by a surgeon not involved in patient care. Function assessed by the MSTS and the TESS scores were determined by the patients with their families. None of the patients had tumor recurrence. One patient died of pulmonary metastases before the 2-year followup. Proximal and distal bone unions were achieved before 10 months without an additional surgical procedure in two and six of seven patients, respectively. Fourteen local complications occurred resulting in nine revision operations. The main complication was aseptic proximal pseudarthrosis (five patients); other complications included one proximal junction fracture, one clavicle fracture complicated by clavicle osteolysis, one distal junction fracture, one necrosis of the skin paddle of the fibular autograft, one glenoclavicular ossification, and one distal pseudarthrosis complicated by a fracture of this distal junction. Function, as assessed by the MSTS score, was a median of 23 of 30 (range, 11-27). The median TESS score was 82% (range, 75%-92%). Shoulder ROM (median; range) in abduction, front elevation, and external and internal rotations were 70°(30°-90°), 75°(30°-85°), 10°(0°-20°), and 80°(80°-100°), respectively. Three of the seven patients reported dissatisfaction with the cosmetic appearance. The clavicula pro humero technique achieved oncologic local control after resection and reconstruction of proximal humerus tumors in children. Although union times are approximately 2 years and some patients underwent augmentation with other grafts, it eventually provides a solid, painless, biologic, and stable reconstruction and creates a mobile acromioclavicular joint and generally good function. Nonunion of the proximal junction is the main complication of this technique. We cannot directly compare this technique with other reconstruction options, and longer followup is needed, but this may be a useful reconstruction option to consider in select pediatric patients with sarcomas of the proximal humerus. Level IV, therapeutic study.

Evaluating Surgical Margins with Optical Spectroscopy and Spectral Imaging Following Breast Cancer Resection

DTIC Science & Technology

2009-08-01

Raman spectral features of hydroxyapatite crystals (found in breast calcifications) through overlying lean chicken breast tissue [18]. Thus, the...form o f spectral imaging to examine entire margins in a single acquisition . 23 1. INTRODUCTION Of the approxim ately 180,000 patien ts each...ination sources into a single, 10-mm-core liquid light guide, which delivered the illumination light to the sample. 2.3 Data acquisition For lum

Frozen section analysis of margins for head and neck tumor resections: reduction of sampling errors with a third histologic level.

PubMed

Olson, Stephen M; Hussaini, Mohammad; Lewis, James S

2011-05-01

Frozen section analysis is an essential tool for assessing margins intra-operatively to assure complete resection. Many institutions evaluate surgical defect edge tissue provided by the surgeon after the main lesion has been removed. With the increasing use of transoral laser microsurgery, this method is becoming even more prevalent. We sought to evaluate error rates at our large academic institution and to see if sampling errors could be reduced by the simple method change of taking an additional third section on these specimens. All head and neck tumor resection cases from January 2005 through August 2008 with margins evaluated by frozen section were identified by database search. These cases were analyzed by cutting two levels during frozen section and a third permanent section later. All resection cases from August 2008 through July 2009 were identified as well. These were analyzed by cutting three levels during frozen section (the third a 'much deeper' level) and a fourth permanent section later. Error rates for both of these periods were determined. Errors were separated into sampling and interpretation types. There were 4976 total frozen section specimens from 848 patients. The overall error rate was 2.4% for all frozen sections where just two levels were evaluated and was 2.5% when three levels were evaluated (P=0.67). The sampling error rate was 1.6% for two-level sectioning and 1.2% for three-level sectioning (P=0.42). However, when considering only the frozen section cases where tumor was ultimately identified (either at the time of frozen section or on permanent sections) the sampling error rate for two-level sectioning was 15.3 versus 7.4% for three-level sectioning. This difference was statistically significant (P=0.006). Cutting a single additional 'deeper' level at the time of frozen section identifies more tumor-bearing specimens and may reduce the number of sampling errors.

Contralateral posterior interhemispheric approach to deep medial parietooccipital vascular malformations: surgical technique and results.

PubMed

Burkhardt, Jan-Karl; Winkler, Ethan A; Lawton, Michael T

2017-07-21

OBJECTIVE Deep medial parietooccipital arteriovenous malformations (AVMs) and cerebral cavernous malformations (CCMs) are traditionally resected through an ipsilateral posterior interhemispheric approach (IPIA), which creates a deep, perpendicular perspective with limited access to the lateral margins of the lesion. The contralateral posterior interhemispheric approach (CPIA) flips the positioning, with the midline positioned horizontally for retraction due to gravity, but with the AVM on the upper side and the approach from the contralateral, lower side. The aim of this paper was to analyze whether the perpendicular angle of attack that is used in IPIA would convert to a parallel angle of attack with the CPIA, with less retraction, improved working angles, and no significant increase in risk. METHODS A retrospective review of pre- and postoperative clinical and radiographic data was performed in 8 patients who underwent a CPIA. RESULTS Three AVMs and 5 CCMs were resected using the CPIA, with an average nidus size of 2.3 cm and CCM diameter of 1.7 cm. All lesions were resected completely, as confirmed on postoperative catheter angiography or MRI. All patients had good neurological outcomes, with either stable or improved modified Rankin Scale scores at last follow-up. CONCLUSIONS The CPIA is a safe alternative approach to the IPIA for deep medial parietooccipital vascular malformations that extend 2 cm or more off the midline. Contralaterality and retraction due to gravity optimize the interhemispheric corridor, the surgical trajectory to the lesion, and the visualization of the lateral margin, without resection or retraction of adjacent normal cortex. Although the falx is a physical barrier to accessing the lesion, it stabilizes the ipsilateral hemisphere while gravity delivers the dissected lesion through the transfalcine window. Patient positioning, CSF drainage, venous preservation, and meticulous dissection of the deep margins are critical to the safety of this approach.

Intraoperative Radiation Therapy Reduces Local Recurrence Rates in Patients With Microscopically Involved Circumferential Resection Margins After Resection of Locally Advanced Rectal Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Alberda, Wijnand J.; Verhoef, Cornelis; Nuyttens, Joost J.

Purpose: Intraoperative radiation therapy (IORT) is advocated by some for patients with locally advanced rectal cancer (LARC) who have involved or narrow circumferential resection margins (CRM) after rectal surgery. This study evaluates the potentially beneficial effect of IORT on local control. Methods and Materials: All surgically treated patients with LARC treated in a tertiary referral center between 1996 and 2012 were analyzed retrospectively. The outcome in patients treated with IORT with a clear but narrow CRM (≤2 mm) or a microscopically involved CRM was compared with the outcome in patients who were not treated with IORT. Results: A total of 409 patients underwent resectionmore » of LARC, and 95 patients (23%) had a CRM ≤ 2 mm. Four patients were excluded from further analysis because of a macroscopically involved resection margin. In 43 patients with clear but narrow CRMs, there was no difference in the cumulative 5-year local recurrence-free survival of patients treated with (n=21) or without (n=22) IORT (70% vs 79%, P=.63). In 48 patients with a microscopically involved CRM, there was a significant difference in the cumulative 5-year local recurrence-free survival in favor of the patients treated with IORT (n=31) compared with patients treated without IORT (n=17) (84 vs 41%, P=.01). Multivariable analysis confirmed that IORT was independently associated with a decreased local recurrence rate (hazard ratio 0.24, 95% confidence interval 0.07-0.86). There was no significant difference in complication rate of patients treated with or without IORT (65% vs 52%, P=.18) Conclusion: The current study suggests that IORT reduces local recurrence rates in patients with LARC with a microscopically involved CRM.« less

[Results of surgical treatment in ampullary and pancreatic carcinoma and its prognostic parameters after R0-resection].

PubMed

Ridwelski, K; Meyer, F; Schmidt, U; Lippert, H

2005-08-01

Resection is currently the only established reasonable therapeutic option with curative potential in pancreatic and ampullary carcinoma. The aim of the study was i) to analyze value and results of surgical therapy and ii) to detect the prognostic parameters, which determine significantly higher survival rates. Two-hundred-twenty patients with pancreatic and ampullary carcinoma (mean age, 61.4 years; 104 females/116 males) underwent surgery. Histologic investigation revealed 19 carcinomas of the papilla of Vater and 201 ductal pancreatic carcinomas. In 126 patients, stage IV a or b tumors were found, in addition, stage I (n =26), II (n = 17) and III (n = 51). Survival-rate was determined according to the method by Kaplan/Meier. Survival was compared using log-rank test. Association of several or multiple parameters with survival was tested using Cox model. Hundred-ten patients underwent tumor resection with primary curative intention (50 %): 96 resections of the pancreatic head, 2 total pancreatectomies and 12 left resections of the pancreas. R0-resection was achieved in 94 patients (42.7 %), whereas intervention was classified R1 in 10 and R2 in 6 cases. In addition, 60 palliative interventions (28 gastroenterostomies, 17 biliodigestive anastomoses, 15 anastomoses at both sites) and 50 explorative laparotomies were performed. In 42.3 % of patients, postoperative complications were found, but only 12/220 individuals died (overall letality, 5.4 %). Postoperative letality of curative pancreatic resections was 3.6 % (palliative intervention, 6.7 %; explorative laparotomy, 8.8 %). Five-year survival-rate of carcinoma of the papilla of Vater and pancreatic carcinoma was 73.3 % and 16.2 %, respectively (median survival time was 66.0 and 14.0 months, respectively). Taken together all other interventions, median survival time ranged between 4.0 (palliative intervention) to 10.0 months (R1-resection). No patient survived 5 years. Therefore, the most relevant prognostic factor was R0-resection. In addition, prognosis after successful R0-resection is determined significantly by tumor site, stage of the tumor (according to UICC), T- and N-category. Resection of pancreatic and ampullary carcinoma according to oncological criteria with tumor-free margins can be considered a treatment option with curative intention and potential. Despite relative high postoperative morbidity, only a low mortality rate was observed. The 5-year survival-rate of 16.2 % in ductal pancreatic carcinoma underlines the demand for the development of effective multimodal therapeutic concepts. Interventions with primary palliative intention or resections with microscopically or macroscopically detectable tumor residual in situ lead to no significant or only marginal prolongation of survival time. Such interventions in patients with pancreatic carcinoma are no reasonable treatment alternative. They are of value only for treatment of tumor-associated complications and problems.

Long-Term Outcomes With Intraoperative Radiotherapy as a Component of Treatment for Locally Advanced or Recurrent Uterine Sarcoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Barney, Brandon M., E-mail: barney.brandon@mayo.edu; Petersen, Ivy A.; Dowdy, Sean C.

2012-05-01

Purpose: To report our institutional experience with intraoperative radiotherapy (IORT) as a component of treatment for women with locally advanced or recurrent uterine sarcoma. Methods and Materials: From 1990 to 2010, 16 women with primary (n = 3) or locoregionally recurrent (n = 13) uterine sarcoma received IORT as a component of combined modality treatment. Tumor histology studies found leiomyosarcoma (n = 9), endometrial stromal sarcoma (n = 4), and carcinosarcoma (n = 3). Surgery consisted of gross total resection in 2 patients, subtotal resection in 6 patients, and resection with close surgical margins in 8 patients. The median IORTmore » dose was 12.5 Gy (range, 10-20 Gy). All patients received perioperative external beam radiotherapy (EBRT; median dose, 50.4 Gy; range, 20-62.5 Gy), and 6 patients also received perioperative systemic therapy. Results: Seven of the 16 patients are alive at a median follow-up of 44 months (range, 11-203 months). The 3-year Kaplan-Meier estimate of local relapse (within the EBRT field) was 7%, and central control (within the IORT field) was 100%. No local failures occurred in any of the 6 patients who underwent subtotal resection. The 3-year freedom from distant relapse was 48%, with failures occurring most frequently in the lungs or mediastinum. Median survival was 18 months, and 3-year Kaplan-Meier estimates of cause-specific and overall survival were 58% and 53%, respectively. Three patients (19%) experienced late Grade 3 toxicity. Conclusions: A combined modality approach with perioperative EBRT, surgery, and IORT for locally advanced or recurrent uterine sarcoma resulted in excellent local disease control with acceptable toxicity, even in patients with positive resection margins. With this approach, some patients were able to experience long-term freedom from recurrence.« less

Real-Time Intraoperative Detection of Breast Cancer using Near-infrared Fluorescence Imaging and Methylene Blue

PubMed Central

Tummers, Quirijn R.J.G.; Verbeek, Floris P.R.; Schaafsma, Boudewijn E.; Boonstra, Martin C.; van der Vorst, Joost R.; Liefers, Gerrit-Jan; van de Velde, Cornelis J.H.; Frangioni, John V.; Vahrmeijer, Alexander L.

2014-01-01

Background Despite recent developments in preoperative breast cancer imaging, intraoperative localization of tumor tissue can be challenging, resulting in tumor-positive resection margins during breast-conserving surgery. Based on certain physicochemical similarities between Technetium(99mTc)-sestamibi (MIBI), a SPECT radiodiagnostic with a sensitivity of 83–90% to detect breast cancer preoperatively, and the near-infrared (NIR) fluorophore Methylene Blue (MB), we hypothesized that MB might detect breast cancer intraoperatively using NIR fluorescence imaging. Methods Twenty-four patients with breast cancer, planned for surgical resection, were included. Patients were divided in 2 administration groups, which differed with respect to the timing of MB administration. N = 12 patients per group were administered 1.0 mg/kg MB intravenously either immediately or 3 h before surgery. The mini-FLARE imaging system was used to identify the NIR fluorescent signal during surgery and on post-resected specimens transferred to the pathology department. Results were confirmed by NIR fluorescence microscopy. Results 20/24 (83%) of breast tumors (carcinoma in N=21 and ductal carcinoma in situ in N=3) were identified in the resected specimen using NIR fluorescence imaging. Patients with non-detectable tumors were significantly older. No significant relation to receptor status or tumor grade was seen. Overall tumor-to-background ratio (TBR) was 2.4 ± 0.8. There was no significant difference between TBR and background signal between administration groups. In 2/4 patients with positive resection margins, breast cancer tissue identified in the wound bed during surgery would have changed surgical management. Histology confirmed the concordance of fluorescence signal and tumor tissue. Conclusions This feasibility study demonstrated an overall breast cancer identification rate using MB of 83%, with real-time intraoperative guidance having the potential to alter patient management. PMID:24862545

Real-time intraoperative detection of breast cancer using near-infrared fluorescence imaging and Methylene Blue.

PubMed

Tummers, Q R J G; Verbeek, F P R; Schaafsma, B E; Boonstra, M C; van der Vorst, J R; Liefers, G-J; van de Velde, C J H; Frangioni, J V; Vahrmeijer, A L

2014-07-01

Despite recent developments in preoperative breast cancer imaging, intraoperative localization of tumor tissue can be challenging, resulting in tumor-positive resection margins during breast conserving surgery. Based on certain physicochemical similarities between Technetium((99m)Tc)-sestamibi (MIBI), an SPECT radiodiagnostic with a sensitivity of 83-90% to detect breast cancer preoperatively, and the near-infrared (NIR) fluorophore Methylene Blue (MB), we hypothesized that MB might detect breast cancer intraoperatively using NIR fluorescence imaging. Twenty-four patients with breast cancer, planned for surgical resection, were included. Patients were divided in 2 administration groups, which differed with respect to the timing of MB administration. N = 12 patients per group were administered 1.0 mg/kg MB intravenously either immediately or 3 h before surgery. The mini-FLARE imaging system was used to identify the NIR fluorescent signal during surgery and on post-resected specimens transferred to the pathology department. Results were confirmed by NIR fluorescence microscopy. 20/24 (83%) of breast tumors (carcinoma in N = 21 and ductal carcinoma in situ in N = 3) were identified in the resected specimen using NIR fluorescence imaging. Patients with non-detectable tumors were significantly older. No significant relation to receptor status or tumor grade was seen. Overall tumor-to-background ratio (TBR) was 2.4 ± 0.8. There was no significant difference between TBR and background signal between administration groups. In 2/4 patients with positive resection margins, breast cancer tissue identified in the wound bed during surgery would have changed surgical management. Histology confirmed the concordance of fluorescence signal and tumor tissue. This feasibility study demonstrated an overall breast cancer identification rate using MB of 83%, with real-time intraoperative guidance having the potential to alter patient management. Copyright © 2014 Elsevier Ltd. All rights reserved.

Deep pelvic anatomy revisited for a description of crucial steps in extralevator abdominoperineal excision for rectal cancer.

PubMed

Stelzner, Sigmar; Holm, Torbjörn; Moran, Brendan J; Heald, Richard J; Witzigmann, Helmut; Zorenkov, Dimitri; Wedel, Thilo

2011-08-01

Extralevator abdominoperineal excision results in superior oncologic outcome for advanced low rectal cancer. The exact definition of surgical resection planes is pivotal to achieving negative circumferential resection margins. This study aims to describe the surrounding anatomical structures that are at risk for inadvertent damage during extralevator abdominoperineal excision. Joint surgical and macroanatomical dissection was performed in a university laboratory of clinical anatomy. A stepwise dissection study was conducted according to the technique of extralevator abdominoperineal excision by abdominal and perineal approaches in 4 human cadaveric pelvises. Muscular, fascial, tendinous, and neural structures were carefully exposed and related to the corresponding surgical resection planes. In addition to the autonomic nerves to be identified and preserved during total mesorectal excision, further structures endangered during extralevator abdominoperineal excision can be clearly identified. Terminal pudendal nerve branches come close to the surgical resection plane at the outer surface of the puborectal sling. Likewise, the pelvic plexus and its neurovascular bundles embedded within the parietal pelvic fascia extend close to the apex of the prostate where the parietal pelvic fascia has to be divided. These neural structures converge in the region of the perineal body, an area that provides no "self-opening" planes for surgical dissection. Thus, the necessity to sharply detach the anorectal specimen anteriorly from the perineal body and the superficial transverse perineal muscle bears the risk of both inadvertent damage of the aforementioned anatomical structures and perforation of the specimen. The study focused primarily on the macroscopic topography relevant to the surgical procedure, so that previously published histologic examinations were not performed. The present anatomical dissection study highlights those anatomical landmarks that require clear identification for the successful achievement of both negative circumferential resection margins and preservation of urogenital functions during extralevator abdominoperineal excision.

[The Efficiency and Complications of ESD and ESTD in the Treatment of Large Esophageal Mucosal Lesions].

PubMed

Wang, Jin; Qin, Jin-yu; Guo, Tian-jiao; Gan, Tao; Wang, Yi-ping; Wu, Jun-chao

2015-11-01

To study the efficiency and complications of endoscopic submucosal dissection (ESD) and endoscopic submucosal tunnel dissection (ESTD) in the treatment of large esophageal mucosal lesions. The clinical data were collected from the patients who received ESD or ESTD for the treatment of early esophageal lesions in our hospital during January 1, 2014 to July 15, 2015, including the en bloc resection rate, curative resection rate, postoperative complication rate, the risk factors of complications were explored by univariate and multivariate analysis. A total of 50 patients were involved in the study, ESD or ESTD were performed successfully in 53 times, including 6 cases of ESD,47 cases of ESTD, The average age was (61.9 +/- 6.8) yr., the average operating time was (83.57 +/- 32.33) min, the average dissected lesion was (14.82 +/- 3.18) cm2, En bloc resection rate was 94.34%, the curative rate was 84.90%. There were 1 case of bleeding, 1 case of perforation, 45 (84.90%) cases of fever, 13 cases (24.53%) of esophageal stricture. The severity of stricture was associated with the operation time Codds ratio (OR) = 1.040, 95% confidence interal (CI): 1.007-1.075) and esophageal circumference (OR=9.972, 95% CI: 1.221-81.416). The residual resection margin appeared in 8 patients, and the lesion area (OR=1.145, 95% CI: 1.013-1.294) was the only risk factor. ESD and ESTD are safe and effective in the treatment of early esophageal lesions, but seems have relatively high incidence of esopgageal stricture and residual resection margin in the treatment of large esophageal lesions.

Laparoscopic complete mesocolic excision with central vascular ligation in right colon cancer: Long-term oncologic outcome between mesocolic and non-mesocolic planes of surgery.

PubMed

Siani, L M; Pulica, C

2015-12-01

To analyze our experience in translating the concept of total mesorectal excision to "no-touch" complete removal of an intact mesocolonic envelope (complete mesocolic excision), along with central vascular ligation and apical node dissection, in the surgical treatment of right-sided colonic cancers, comparing "mesocolic" to less radical "non-mesocolic" planes of surgery in respect to quality of the surgical specimen and long-term oncologic outcome. A total of 115 patients with right-sided colonic cancers were retrospectively enrolled from 2008 to 2013 and operated on following the intent of minimally invasive complete mesocolic excision with central vascular ligation. Morbidity and mortality were 22.6% and 1.7%, respectively. Mesocolic, intramesocolic, and muscularis propria planes of resection were achieved in 65.2%, 21.7%, and 13% of cases, respectively, with significant impact for mesenteric plane of surgery on R0 resection rate (97.3%), circumferential resection margin <1 mm (2.6%), and consequent survival advantage (82.6% at 5 years) when compared to muscularis propria plane of surgery, with R0 resection rate and overall survival falling to 72% and 60%, respectively, and with circumferential resection margin <1 mm raising to 33.3%, all being statistically significant. Stratifying patients for stage of disease, laparoscopic complete mesocolic excision with central vascular ligation significantly impacted survival in patients with stage II, IIIA/B, and in a subgroup of IIIC patients with negative apical nodes. In our experience, minimally invasive complete mesocolic excision with central vascular ligation allows for both safety and higher quality of surgical specimens when compared to less radical intramesocolic or muscularis propria planes of "standard" surgery, significantly impacting loco-regional control and thus overall survival. © The Finnish Surgical Society 2014.

Upslope deposition of extremely distal turbidites: An example from the Tiburon Rise, west-central Atlantic

NASA Astrophysics Data System (ADS)

Dolan, James; Beck, Christian; Ogawa, Yujiro

1989-11-01

Terrigenous silt and sand turbidites recovered from the crest of the Tiburon Rise in the west-central Atlantic represent an unprecedented example of upslope turbidite deposition in an extremely distal setting. These Eocene-Oligocene beds, which were derived from South America more than 1000 km to the southeast, were probably deposited by extremely thick (>1500 m) turbidity currents that flowed parallel to the southern margin of the rise. We suggest that flow thickness was the dominant control on deposition of these beds, rather than true upslope flow. This interpretation points out the importance of local bathymetry on the behavior of even extremely distal turbidity currents.

[Hepatocellular carcinoma originated in the caudate lobe. Surgical strategy for resection. A propos of a case].

PubMed

Martínez-Mier, Gustavo; Esquivel-Torres, Sergio; Calzada-Grijalva, José Francisco; Grube-Pagola, Peter

2015-01-01

Hepatocellular carcinoma originating from the caudate lobe has a worse prognosis than other hepatocellular carcinoma in another segment of the liver. An isolated caudate lobe resection of the liver represents a significant technical challenge. Caudate lobe resection can be performed along with a lobectomy or as an isolated liver resection. There are very few reports about isolated caudate lobe liver resection. We report a case of successful isolated resection of hepatocellular carcinoma in the caudate lobe with excellent long-term survival. A 74 years old female with 8cm mass lesion in the caudate lobe without clinical or biochemical evidence of liver cirrhosis, serum alpha-fetoprotein 3.7 U/l, and negative hepatitis serology was evaluated for surgery. Complete resection of the lesion in 270minutes with Pringle maneuver for 13minutes was satisfactorily performed. Patient was discharged ten days after surgery without complications. Patient is currently asymptomatic, without deterioration of liver function and 48 month tumor free survival after the procedure. Isolated caudate lobe resection is an uncommon but technically possible procedure. In order to achieve a successful resection, one must have a detailed knowledge of complete liver anatomy. Tumor free margins must be obtained to provide long survival for these patients who have a malignancy in this anatomic location. Copyright © 2015. Published by Masson Doyma México S.A.

Patient-specific instrument can achieve same accuracy with less resection time than navigation assistance in periacetabular pelvic tumor surgery: a cadaveric study.

PubMed

Wong, Kwok-Chuen; Sze, Kwan-Yik; Wong, Irene Oi-Ling; Wong, Chung-Ming; Kumta, Shekhar-Madhukar

2016-02-01

Inaccurate resection in pelvic tumors can result in compromised margins with increase local recurrence. Navigation-assisted and patient-specific instrument (PSI) techniques have recently been reported in assisting pelvic tumor surgery with the tendency of improving surgical accuracy. We examined and compared the accuracy of transferring a virtual pelvic resection plan to actual surgery using navigation-assisted or PSI technique in a cadaver study. We performed CT scan in twelve cadaveric bodies including whole pelvic bones. Either supraacetabular or partial acetabular resection was virtually planned in a hemipelvis using engineering software. The virtual resection plan was transferred to a CT-based navigation system or was used for design and fabrication of PSI. Pelvic resections were performed using navigation assistance in six cadavers and PSI in another six. Post-resection images were co-registered with preoperative planning for comparative analysis of resection accuracy in the two techniques. The mean average deviation error from the planned resection was no different ([Formula: see text]) for the navigation and the PSI groups: 1.9 versus 1.4 mm, respectively. The mean time required for the bone resection was greater ([Formula: see text]) for the navigation group than for the PSI group: 16.2 versus 1.1 min, respectively. In simulated periacetabular pelvic tumor resections, PSI technique enabled surgeons to reproduce the virtual surgical plan with similar accuracy but with less bone resection time when compared with navigation assistance. Further studies are required to investigate the clinical benefits of PSI technique in pelvic tumor surgery.

Therapeutic outcomes of endoscopic submucosal dissection of differentiated early gastric cancer in a Western endoscopy setting (with video).

PubMed

Emura, Fabian; Mejía, Juan; Donneys, Alberto; Ricaurte, Orlando; Sabbagh, Luis; Giraldo-Cadavid, Luis; Oda, Ichiro; Saito, Yutaka; Osorio, Camilo

2015-11-01

Large multicenter gastric cancer endoscopic submucosal dissection (ESD) studies conducted at major Japanese institutions have reported en bloc resection, en bloc tumor-free margin resection, and curative resection rates of 92.7% to 96.1%, 82.6% to 94.5%, and 73.6% to 85.4%, respectively, with delayed bleeding and perforation rates of 0.6% to 6.0% and 3.6% to 4.7%, respectively. Although ESD is currently an alternative treatment in some countries, particularly in Asia, it remains uncertain whether ESD therapeutic outcomes in Western endoscopy settings can be comparable to those achieved in Japan. To evaluate the ESD therapeutic outcomes for differentiated early gastric cancer (EGC) in a Western endoscopy setting. Consecutive case series performed by an expertly trained Western endoscopist. Fifty-three patients with 54 lesions. ESD for early gastric cancers (T1) satisfying expanded inclusion criteria. En bloc resection, en bloc tumor-free margin resection, and curative resection rates were 98%, 93%, and 83%, respectively. The delayed bleeding rate was 7%, and the perforation rate was 4%. The mean patient age was 67 years, and the mean tumor size was 19.8 mm, with 54% of the lesions located in the lesser curvature. The median procedure time was 61 minutes, with ESD procedures 60 minutes or longer associated with submucosal fibrosis (P < .001) and tumor size 25 mm or larger (P = .03). In every ESD procedure, both circumferential incision and submucosal dissection were performed by using a single knife. Two of the 4 delayed bleeding cases required surgery, and all perforations were successfully managed by using endoscopic clips. Long-term outcome data are currently unavailable. ESD for differentiated EGC resulted in favorable therapeutic outcomes in a Western endoscopy setting comparable to those achieved at major Japanese institutions. Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.

Orbitopterional Approach for the Resection of a Suprasellar Craniopharyngioma: Adapting the Strategy to the Microsurgical and Pathologic Anatomy.

PubMed

Nguyen, Vincent; Basma, Jaafar; Klimo, Paul; Sorenson, Jeffrey; Michael, L Madison

2018-04-01

Objectives  To describe the orbitopterional approach for the resection of a suprasellar craniopharyngioma with emphasis on the microsurgical and pathological anatomy of such lesions. Design  After completing the orbitopterional craniotomy in one piece including a supraorbital ridge osteotomy, the Sylvian fissure was split in a distal to proximal direction. The ipsilateral optic nerve and internal carotid artery were identified. Establishing a corridor to the tumor through both the opticocarotid and optic cisterns allowed for a wide angle of attack. Using both corridors, a microsurgical gross total resection was achieved. A radical resection required transection of the stalk at the level of the hypothalamus. Photographs of the region are borrowed from Dr Rhoton's laboratory to illustrate the microsurgical anatomy. Understanding the cisternal and topographic relationships of the optic nerve, optic chiasm, and internal carotid artery is critical to achieving gross total resection while preserving normal anatomy. Participants  The surgery was performed by the senior author assisted by Dr. Jaafar Basma. The video was edited by Dr. Vincent Nguyen. Outcome Measures  Outcome was assessed with extent of resection and postoperative visual function. Results  A gross total resection of the tumor was achieved. The patient had resolution of her bitemporal hemianopsia. She had diabetes insipidus with normal anterior pituitary function. Conclusions  Understanding the microsurgical anatomy of the suprasellar region and the pathological anatomy of craniopharyngiomas is necessary to achieve a good resection of these tumors. The orbitopterional approach provides the appropriate access for such endeavor. The link to the video can be found at: https://youtu.be/Be6dtYIGqfs .

Using translational medicine to understand clinical differences between botulinum toxin formulations.

PubMed

Aoki, K R; Ranoux, D; Wissel, J

2006-12-01

When using botulinum toxin-based products, the physician must decide the optimal location and dose required to alleviate symptoms and improve the patient's quality of life. To deliver effective treatment, the physician needs to understand the importance of accurate target muscle selection and localization and the implications of each product's migration properties when diluted in different volumes. Pre-clinical mouse models of efficacy and safety have been utilized to compare local and distal muscle relaxation effects following defined intramuscular administration. Data from the model allow the products to be ranked based on their propensity for local efficacy versus their distal migration properties. Using standardized dilutions, the non-parallel dose-response curves for the various formulations demonstrate that they have different efficacy profiles. Distal effects were also noted at different treatment doses, which are reflected in the different safety and/or therapeutic margins. Based on these pre-clinical data, the safety and therapeutic margin rankings are ordered, largest to smallest, as BOTOX, Dysport and Myobloc. The results of subsequent clinical trials are variable and dose comparisons are inconclusive, thus supporting the regulatory position that the dose units of the individual preparations are unique and cannot be simply converted between products.

Multidetector CT evaluation of the postoperative pancreas.

PubMed

Yamauchi, Fernando I; Ortega, Cinthia D; Blasbalg, Roberto; Rocha, Manoel S; Jukemura, José; Cerri, Giovanni G

2012-01-01

Several pancreatic diseases may require surgical treatment, with most of these procedures classified as resection or drainage. Resection procedures, which are usually performed to remove pancreatic tumors, include pancreatoduodenectomy, central pancreatectomy, distal pancreatectomy, and total pancreatectomy. Drainage procedures are usually performed to treat chronic pancreatitis after the failure of medical therapy and include the Puestow and Frey procedures. The type of surgery depends not only on the patient's symptoms and the location of the disease, but also on the expertise of the surgeon. Radiologists should become familiar with these surgical procedures to better understand postoperative changes in anatomic findings. Multidetector computed tomography is the modality of choice for identifying normal findings after surgery, postoperative complications, and tumor recurrence in patients who have undergone pancreatic surgery. RSNA, 2012

Marginal bone levels at single tooth implants with a conical fixture design. The influence of surface macro- and microstructure.

PubMed

Norton, M R

1998-04-01

The concept of a conical implant design to accommodate single tooth replacement, has previously been shown to result in excessive bone loss, around the machined titanium conical collar, usually down to the 1st thread. This unusually aggressive loss of bone was shown to occur within a short period of time, post loading, with greater than 3 mm of bone loss occurring within the 1st 6 months to 1 year. The influence of implant design, surface texture and microleakage have all been highlighted as a potential cause. A modification of the surface structure, both at the macroscopic and microscopic level, as well as an altered fixture-abutment interface design has resulted in the maintenance of marginal bone around a single tooth titanium implant with a similar conical design. The radiographic follow-up of 33 implants loaded for up to 4 years, has revealed, by comparison, a most favourable maintenance of marginal bone around the conical collar, with a mean marginal bone loss of 0.32 mm mesially and 0.34 mm distally for the whole group. The cumulative mean marginal bone loss mesially and distally is 0.42 mm and 0.40 mm from 1 to 2 years, 0.54 mm and 0.43 mm from 2 to 3 years, 0.51 mm and 0.24 mm from 3 to 4 years, and 0.62 mm and 0.60 mm for implants past their 4 year recall.

Resection of complex pancreatic injuries: Benchmarking postoperative complications using the Accordion classification

PubMed Central

Krige, Jake E; Jonas, Eduard; Thomson, Sandie R; Kotze, Urda K; Setshedi, Mashiko; Navsaria, Pradeep H; Nicol, Andrew J

2017-01-01

AIM To benchmark severity of complications using the Accordion Severity Grading System (ASGS) in patients undergoing operation for severe pancreatic injuries. METHODS A prospective institutional database of 461 patients with pancreatic injuries treated from 1990 to 2015 was reviewed. One hundred and thirty patients with AAST grade 3, 4 or 5 pancreatic injuries underwent resection (pancreatoduodenectomy, n = 20, distal pancreatectomy, n = 110), including 30 who had an initial damage control laparotomy (DCL) and later definitive surgery. AAST injury grades, type of pancreatic resection, need for DCL and incidence and ASGS severity of complications were assessed. Uni- and multivariate logistic regression analysis was applied. RESULTS Overall 238 complications occurred in 95 (73%) patients of which 73% were ASGS grades 3-6. Nineteen patients (14.6%) died. Patients more likely to have complications after pancreatic resection were older, had a revised trauma score (RTS) < 7.8, were shocked on admission, had grade 5 injuries of the head and neck of the pancreas with associated vascular and duodenal injuries, required a DCL, received a larger blood transfusion, had a pancreatoduodenectomy (PD) and repeat laparotomies. Applying univariate logistic regression analysis, mechanism of injury, RTS < 7.8, shock on admission, DCL, increasing AAST grade and type of pancreatic resection were significant variables for complications. Multivariate logistic regression analysis however showed that only age and type of pancreatic resection (PD) were significant. CONCLUSION This ASGS-based study benchmarked postoperative morbidity after pancreatic resection for trauma. The detailed outcome analysis provided may serve as a reference for future institutional comparisons. PMID:28396721

Total mesorectal excision (TME)--twenty years on.

PubMed

Leong, A F P K

2003-03-01

The results of total mesorectal excision (TME) for rectal cancer were first reported 20 years ago. The superior outcome in the original two papers was attributed to the complete excision of the mesorectum, preference for anterior resection over abdominoperineal resection, application of cytotoxic solutions to eradicate exfoliated tumour cells and specialisation in rectal cancer surgery. A review was conducted to examine the evidence from the literature accumulated over the past 20 years in support of this thesis. A Medline search of all studies was carried out pertaining to the issues of mesorectal metastases, anterior resection versus abdominoperineal resection, exfoliated tumour cells in rectal cancer and specialisation in rectal cancer surgery. Mesorectal metastases can be found up to 5 cm from the apparent distal edge of a rectal cancer. They occur in pT3 and pT4 tumours. Their presence indicates a poorer prognosis. There is evidence that TME improves outcomes in mid- and low-rectal cancers but its role in upper rectal and rectosigmoid cancers is controversial. It has been difficult to demonstrate the superiority of anterior resection over abdominoperineal resection as comparative studies report similar outcomes. Exfoliated tumour cells have been demonstrated to contribute to anastomotic recurrence and this probability may be reduced by the use of cytotoxic agents to irrigate the rectal stump. Multiple studies have shown that specialisation in rectal cancer surgery result in lower postoperative morbidity and mortality, local and distant recurrence rates and higher rates of sphincter saving resections. The majority of tenets espoused in the original papers on TME have found support in follow-up studies since their publication.

250 Robotic Pancreatic Resections: Safety and Feasibility

PubMed Central

Zureikat, Amer H.; Moser, A. James; Boone, Brian A.; Bartlett, David L.; Zenati, Mazen; Zeh, Herbert J.

2015-01-01

Background and Objectives Computer Assisted Robotic Surgery allows complex resections and anastomotic reconstructions to be performed with nearly identical standards to open surgery. We applied this technology to a variety of pancreatic resections to assess the safety, feasibility, versatility and reliability of this technology. Methods A retrospective review of a prospective database of robotic pancreatic resections at a single institution between August 2008 and November 2012 was performed. Peri-operative outcomes were analyzed. Results 250 consecutive robotic pancreatic resections were analyzed; pancreaticoduodenectomy (PD =132), distal pancreatectomy (DP=83), central pancreatectomy (CP=13), pancreatic enucleation (10), total pancreatectomy (TP=5), Appleby resection (4), and Frey procedure (3). Thirty day and 90 day mortality was 0.8 % and 2.0%. Rate of Clavien 3 and 4 complications was 14 and 6 %. The ISGPF grade C fistula rate was 4%. Mean operative time for the two most common procedures was 529 ± 103 mins for PD, and 257 ± 93 mins for DP. Continuous improvement in operative times was observed over the course of the experience. Conversion to open procedure was required in 16 patients (6%);(11 PD, 2 DP, 2 CP, 1 TP) for failure to progress (14) and bleeding (2). Conclusions This represents to our knowledge the largest series of robotic pancreatic resections. Safety and feasibility metrics including the low incidence of conversion support the robustness of this platform and suggest no unanticipated risks inherent to this new technology. By defining these early outcome metrics this report begins to establish a framework for comparative effectiveness studies of this platform. PMID:24002300

Pancreatic and Gastric Heterotopia with Associated Submucosal Lipoma Presenting as a 7-cm Obstructive Tumor of the Ileum: Resection with Double Balloon Enteroscopy.

PubMed

Jiang, Kun; Stephen, F Otis; Jeong, Daniel; Pimiento, Jose M

2015-01-01

Pancreatic and gastric heterotopias are rare clinical entities which have been identified throughout the entire length of the gastrointestinal tract. Combined gastric and pancreatic heterotopias, although unusual, have been described in the duodenum and jejunum, and in other structures, including Meckel's diverticulum and the ampulla of Vater. We report a novel case of pancreatic and gastric heterotopia with an associated submucosal lipoma in a 38-year-old female with a recent history of rectal cancer and chronic crampy abdominal pain. On computed tomography, a 7-cm luminal polypoid mass extending into the distal ileum was discovered. The mass was successfully resected using retrograde double balloon enteroscopy. We believe this is the first report of all three histological entities co-existing in an obstructive ileal lesion in an adult. It highlights endoscopic resection trough double enteroscopy as a safe alternative to more invasive surgical approaches for this type of lesion.

[Experiences with 216 manual esophageal anastomoses and with mechanical single and double row suture technique (SPTU, EEA, ILS) in stomach cancers].

PubMed

Damanakis, K; Kantartzis, M; Schenk, R; Wissenberg, V

1992-01-01

From 1973 to 1990 we have performed 216 anastomoses of the oesophagus after resection of gastric malignancy. Both resection due to a carcinoma of the oesophagus and subtotal gastric resection due to distal carcinoma of the stomach have not been considered. In a retrospective study we present the results of our oesophageal anastomoses performed by hand-suture and stapling. The perioperative complications are shown with special regard to the insufficiency rate of the oesophageal anastomosis and the resulting mortality. In 70 by hand suturing performed anastomoses (1973-80) we have seen 3 (4.4%) leaks of the oesophagojejuno-/oesophagogastrostomy, in 146 stapled anastomoses (1980-90) 6 (4.2%) insufficiencies were seen. Two of 3 dehiscences in the hand-sewn group and one of the 6 leaks in the stapler group had a lethal outcome. The overall hospital mortality could be reduced from 18.5% to 6.9%.

[Oligometastasized colorectal cancer-modern treatment strategies].

PubMed

Binnebösel, M; Lambertz, A; Dejong, K; Neumann, U P

2018-06-05

The prognosis of colorectal cancer in UICC stage IV has been improved in the last decades by improvements in interdisciplinary treatment. Treatment strategies for oligometastasized colorectal cancer are developing more and more into an individualized treatment. An overview of the current literature of modern treatment concepts in oligometastasized colorectal cancer UICC stage IV is given. Surgery still has the supreme mandate in resectable colorectal liver metastases, as neoadjuvant and adjuvant treatment strategies to not provide any benefits for these patients. In marginal or non-resectable stages systemic treatment is superior in these patients depending on the prognostic parameters. Also in curative settings local treatment options should be considered as a reasonable additive tool. An interesting treatment approach for isolated liver metastases and non-resectable colorectal cancer is liver transplantation. Irrespective of new developments in treatment strategies for metastasized colorectal cancer, resection of colorectal liver metastases remains the gold standard whenever possible.

Current management of cholangiocarcinoma.

PubMed

Singh, Manoj K; Facciuto, Marcelo E

2012-01-01

Cholangiocarcinoma is the second most common primary hepatobiliary malignancy after hepatocellular carcinoma and remains among the most difficult management problems faced by surgeons. Curative surgery is achieved in only 25% to 30% of patients. Local tumor extent, such as portal vein invasion and hepatic lobar atrophy, does not preclude resection. Long-term survival has been seen only in patients who underwent extensive liver resections, suggesting that bile-duct excision alone is less effective. The majority of patients have unresectable disease, with 20% to 30% incidence of distant metastasis at presentation. Unresectable patients should be referred for nonsurgical biliary decompression, and in potential curative resection candidates the use of biliary stents should be reduced. Liver transplantation provides the option of wide resection margins, expanding the indication of surgical intervention for selected patients who otherwise are not surgical candidates due to lack of functional hepatic reserve. © 2012 Mount Sinai School of Medicine.

[Metastatic disease of the liver: surgical perspective].

PubMed

Mercado, M A; Medina, H; Rossano, A; Acosta, E; Rodríguez, M; Chan, C; Orozco, H

1997-01-01

Approximately half of patients with colorectal cancer will develop hepatic metastases and it is estimated that up to 10% of that group will have resectable liver disease. Surgical resection remains the first line treatment option of metastatic liver tumors and has yielded a 20 to 40% five year survival rate. Selection of appropriate patients for resection is critical to a successful outcome. The best results are obtained in patients with isolated metastases. Factors that are associated with a poorer results are the presence of four or more lesions or a surgical margin less than 1 cm. Endocrine metastases can be resected in a palliative fashion but each case has to be individualized. This is also true for non colorectal-nonendocrine metastases. For this tumors the experience is anecdotal and confined to limited reported series. Adjuvant treatment (infusional chemotherapy and chemoembolization) can also have a role in treatment as well as cryotherapy.

[Radiofrequency ablation of hepatocellular carcinoma].

PubMed

Widmann, Gerlig; Schullian, Peter; Bale, Reto

2013-03-01

Percutaneous radiofrequency ablation (RFA) is well established in the treatment of hepatocellular carcinoma (HCC). Due to its curative potential, it is the method of choice for non resectable BCLC (Barcelona Liver Clinic) 0 and A. RFA challenges surgical resection for small HCC and is the method of choice in bridging for transplantation and recurrence after resection or transplantation. The technical feasibility of RFA depends on the size and location of the HCC and the availability of ablation techniques (one needle techniques, multi-needle techniques). More recently, stereotactic multi-needle techniques with 3D trajectory planning and guided needle placement substantially improve the spectrum of treatable lesions including large volume tumors. Treatment success depends on the realization of ablations with large intentional margins of tumor free tissue (A0 ablation in analogy to R0 resection), which has to be documented by fusion of post- with pre-ablation images, and confirmed during follow-up imaging.

Robot-assisted radical prostatectomy: Multiparametric MR imaging-directed intraoperative frozen-section analysis to reduce the rate of positive surgical margins.

PubMed

Petralia, Giuseppe; Musi, Gennaro; Padhani, Anwar R; Summers, Paul; Renne, Giuseppe; Alessi, Sarah; Raimondi, Sara; Matei, Deliu V; Renne, Salvatore L; Jereczek-Fossa, Barbara A; De Cobelli, Ottavio; Bellomi, Massimo

2015-02-01

To investigate whether use of multiparametric magnetic resonance (MR) imaging-directed intraoperative frozen-section (IFS) analysis during nerve-sparing robot-assisted radical prostatectomy reduces the rate of positive surgical margins. This retrospective analysis of prospectively acquired data was approved by an institutional ethics committee, and the requirement for informed consent was waived. Data were reviewed for 134 patients who underwent preoperative multiparametric MR imaging (T2 weighted, diffusion weighted, and dynamic contrast-material enhanced) and nerve-sparing robot-assisted radical prostatectomy, during which IFS analysis was used, and secondary resections were performed when IFS results were positive for cancer. Control patients (n = 134) matched for age, prostate-specific antigen level, and stage were selected from a pool of 322 patients who underwent nerve-sparing robot-assisted radical prostatectomy without multiparametric MR imaging and IFS analysis. Rates of positive surgical margins were compared by means of the McNemar test, and a multivariate conditional logistic regression model was used to estimate the odds ratio of positive surgical margins for patients who underwent MR imaging and IFS analysis compared with control subjects. Eighteen patients who underwent MR imaging and IFS analysis underwent secondary resections, and 13 of these patients were found to have negative surgical margins at final pathologic examination. Positive surgical margins were found less frequently in the patients who underwent MR imaging and IFS analysis than in control patients (7.5% vs 18.7%, P = .01). When the differences in risk factors are taken into account, patients who underwent MR imaging and IFS had one-seventh the risk of having positive surgical margins relative to control patients (adjusted odds ratio: 0.15; 95% confidence interval: 0.04, 0.61). The significantly lower rate of positive surgical margins compared with that in control patients provides preliminary evidence of the positive clinical effect of multiparametric MR imaging-directed IFS analysis for patients who undergo prostatectomy. © RSNA, 2014.

Awake surgery for WHO Grade II gliomas within "noneloquent" areas in the left dominant hemisphere: toward a "supratotal" resection. Clinical article.

PubMed

Yordanova, Yordanka N; Moritz-Gasser, Sylvie; Duffau, Hugues

2011-08-01

It has been demonstrated that an extensive resection (total or subtotal) may significantly increase the overall survival in patients with WHO Grade II gliomas (low-grade gliomas [LGGs]). Yet, recent data have shown that conventional MR imaging underestimates the spatial extent of LGG, since tumor cells were found up to 20 mm around MR imaging abnormalities. Thus, it was hypothesized that an extended resection with a margin beyond MR imaging-defined abnormalities-a "supratotal" resection-might improve the outcome of LGG. However, because of the frequent location of LGG within "eloquent" brain areas, it is often difficult to achieve such a supratotal resection. This could nevertheless be possible when LGGs involve "noneloquent" areas, even in the left dominant hemisphere. The authors report on their use of awake electrical mapping to tailor the resection according to functional boundaries, that is, to pursue the resection beyond MR imaging-defined abnormalities, until corticosubcortical eloquent structures are encountered. Their aim was to apply this reliable surgical technique to LGGs located not within eloquent areas but distant from eloquent areas, to take a margin around the LGG visible on MR imaging while preserving brain function. Fifteen right-handed patients with a total of 17 tumors underwent resection of WHO Grade II gliomas involving nonfunctional areas within the left dominant hemisphere. In all patients, seizures were the initial manifestation of the tumors. Awake surgery with intraoperative electrostimulation was performed in all cases. The resection was continued until the surgeon reached cortical and subcortical areas crucial for brain function, especially language, as defined by the intrasurgical electrical mapping. The extent of resection was evaluated on postoperative FLAIR-weighted MR images. Despite transient neurological worsening in 60% of cases, all patients recovered and returned to a normal life. Seizure control was obtained in all patients with a decrease of antiepileptic drug therapy. Postoperative MR imaging showed that total resection was achieved in all 17 tumors and supratotal resection in 15. The average volume of the postoperative cavity (36.8 cm(3)) was significantly larger than the mean preoperative tumor volume (26.6 cm(3)) (p = 0.009). Neuropathological examination confirmed the diagnosis of WHO Grade II glioma in all cases. The mean duration of postoperative follow-up was 35.7 months (range 6-135 months). Only 4 of 15 patients experienced recurrence (without anaplastic transformation); the average time to recurrence in these cases was 38 months; radiotherapy was performed 6 years after the relapse in 1 case; no other patients received any adjuvant treatment. This series was compared with a control group of 29 patients who had "only" complete resection: anaplastic transformation was observed in 7 cases in the control group but not in any case in the series of patients who underwent supracomplete resection (p = 0.037). Furthermore, adjuvant treatment was administered in 10 patients in the control group compared with 1 patient who underwent supracomplete resection (p = 0.043). These findings support the usefulness of awake surgery with intraoperative functional (language) mapping with the attempt to perform supratotal resection of LGGs involving noneloquent areas in the left hemisphere. Indeed, the extent of resection was significantly increased in all cases but 2, with no additional permanent deficit and with control of seizures in all patients. The goal of supracomplete resection is currently to delay the anaplastic transformation, even if it does not (yet) enable a cure.

Hydronephrosis does not preclude curative resection of pelvic recurrences after colorectal surgery.

PubMed

Henry, Leonard R; Sigurdson, Elin; Ross, Eric; Hoffman, John P

2005-10-01

In one third of patients who die of rectal cancer, a pelvic recurrence after resection represents isolated disease for which re-resection may provide cure. These extensive resections can carry high morbidity. Proper patient selection is desirable but difficult. Hydronephrosis has been documented previously to portend a poor prognosis, and some consider it a contraindication to attempted resection. It was our goal to review our experience and either confirm or refute these conclusions. We performed a retrospective analysis of 90 patients resected with curative intent for pelvic recurrence at our center from 1988 through 2003. Seventy-one records documented the preoperative presence or absence of hydronephrosis. Clinical and pathologic data were recorded. The groups with and without hydronephrosis were compared. There were 15 patients with hydronephrosis in this study and 56 without. Although patients with hydronephrosis had shorter overall survival, disease-free survival, and rate of local control, none of these differences was statistically significant. Patients in the hydronephrosis group were younger and had higher-stage primary tumors and larger recurrent tumors. Subsequently, they underwent more extensive resections and were more likely to be treated with adjuvant therapies. There was no difference in the rate of margin-negative resections between the groups. Hydronephrosis correlates with younger patients with larger recurrent tumors undergoing more extensive operations and multimodality therapy but does not preclude curative (R0) resection or independently affect overall survival, disease-free survival, or local control. We believe that it should not be considered a contraindication to attempting curative resection.

[Surgical management of retroperitoneal soft-tissue sarcomas--an overview].

PubMed

Garlipp, B; Schulz, H-U; Zeile, M; Lippert, H; Meyer, F

2010-12-01

Retroperitoneal soft-tissue sarcomas (RSTS) represent a rare and heterogeneous class of diseases for which the clinical management is still largely non-standardised. Based on a selective review of recent publications, it was the purpose of the present review article to summarize the current concepts of disease classification, diagnostics and surgical as well as multimodal therapy for these tumors. A clinically based empirical review derived from a literature search focusing on publications from the past 5  years was carried out. Due to the paucity of randomised-controlled trials, therapy for RSTS is largely based on personal experience, retrospectively gathered data and historical controls. Pre-therapeutic planning requires precise information on the localisation, extension, and texture of the tumor through cross-sectional imaging (CT, MRI) as well as histological diagnosis through percutaneous or open biopsy. Complete tumor resection is crucial. Recent studies have confirmed the importance of microscopically negative resection margins which has subsequently led to a trend towards more radical resection. Chemotherapy does not play a role in the adjuvant setting except in clinical trials; however, radiotherapy has been controversely debated in adjuvant RSTS therapy. Efforts to limit radiation toxicity include modern techniques as well as a strategy of using pre-resection radiotherapy instead of postoperative radiation. Surgery is also the treatment of choice for locally recurrent RSTS and pulmonary metastases. The prognosis of RSTS depends on the quality of surgical care and several disease-specific factors (histological type, grading). The clinical management of RSTS is complex and can only partly be considered as evidence-based. Due to the required level of experience in the treatment of these tumor lesions and the involvement of several subspecialties, pre-therapeutic planning, treatment and follow-up should be limited to high-volume surgical centres. In order to achieve microscopically negative resection margins, multivisceral resections are a valuable option after thorough consideration of the risks and benefits. Adjuvant radiotherapy needs to be decided upon on an individual basis, taking into account patient- and tumor-specific factors as well as resection status. © Georg Thieme Verlag Stuttgart ˙ New York.

Raman spectroscopy reveals biophysical markers in skin cancer surgical margins

NASA Astrophysics Data System (ADS)

Feng, Xu; Moy, Austin J.; Nguyen, Hieu T. M.; Zhang, Yao; Fox, Matthew C.; Sebastian, Katherine R.; Reichenberg, Jason S.; Markey, Mia K.; Tunnell, James W.

2018-02-01

The recurrence rate of nonmelanoma skin cancer is highly related to the residual tumor after surgery. Although tissueconserving surgery, such as Mohs surgery, is a standard method for the treatment of nonmelanoma skin cancer, they are limited by lengthy and costly frozen-section histopathology. Raman spectroscopy (RS) is proving to be an objective, sensitive, and non-destructive tool for detecting skin cancer. Previous studies demonstrated the high sensitivity of RS in detecting tumor margins of basal cell carcinoma (BCC). However, those studies rely on statistical classification models and do not elucidate the skin biophysical composition. As a result, we aim to discover the biophysical differences between BCC and primary normal skin structures (including epidermis, dermis, hair follicle, sebaceous gland and fat). We obtained freshly resected ex vivo skin samples from fresh resection specimens from 14 patients undergoing Mohs surgery. Raman images were acquired from regions containing one or more structures using a custom built 830nm confocal Raman microscope. The spectra were grouped using K-means clustering analysis and annotated as either BCC or each of the five normal structures by comparing with the histopathology image of the serial section. The spectral data were then fit by a previously established biophysical model with eight primary skin constituents. Our results show that BCC has significant differences in the fit coefficients of nucleus, collagen, triolein, keratin and elastin compared with normal structures. Our study reveals RS has the potential to detect biophysical changes in resection margins, and supports the development of diagnostic algorithms for future intraoperative implementation of RS during Mohs surgery.

Results of NCCTG N0275 (Alliance) - a phase II trial evaluating resection followed by adjuvant radiation therapy for patients with desmoplastic melanoma.

PubMed

Rule, William G; Allred, Jacob B; Pockaj, Barbara A; Markovic, Svetomir N; DiCaudo, David J; Erickson, Lori A; Deming, Richard L; Schild, Steven E

2016-08-01

To examine, in a prospective fashion, the utilization and efficacy of adjuvant radiation therapy (RT) in patients with resected desmoplastic melanoma (DM). Adult patients with resected, margin-negative, and nonmetastatic DM were eligible for this single-arm prospective phase II study. Patients were to receive postoperative RT, 30 Gy in five fractions, to the operative bed with 2- to 3-cm margins (depending on the tumor location). Nodal basin RT was not allowed. The primary study endpoint was the 2-year local recurrence rate (LRR). Secondary endpoints included the incidence of regional and distant metastatic disease, progression-free survival, overall survival (OS), and treatment-related toxicity. Twenty patients with a single de novo DM lesion meeting trial eligibility criteria were enrolled and treated. The 2-year LRR was 10%, with two patients demonstrating a LR within 2 years of completion of protocol therapy. No regional or distant failures occurred. OS at 2 and 5 years was 95 and 77%, respectively. There were no grade 3 or higher acute or late adverse events that were related to the protocol therapy. Adjuvant RT after wide local excision (WLE) for DM is efficacious and well tolerated. It should be considered for DM patients after margin-negative WLE. Additional study is needed to further refine low-risk patient populations that can potentially have adjuvant RT omitted as part of the treatment plan. © 2016 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.

Prospective assessment of the influence of pancreatic cancer resection on exocrine pancreatic function.

PubMed

Sikkens, E C M; Cahen, D L; de Wit, J; Looman, C W N; van Eijck, C; Bruno, M J

2014-01-01

Exocrine insufficiency frequently develops in patients with pancreatic cancer owing to tumour ingrowth and pancreatic duct obstruction. Surgery might restore this function by removing the primary disease and restoring duct patency, but it may also have the opposite effect, as a result of resection of functional parenchyma and anatomical changes. This study evaluated the course of pancreatic function, before and after pancreatic resection. This prospective cohort study included patients with tumours in the pancreatic region requiring pancreatic resection in a tertiary referral centre between March 2010 and August 2012. Starting before surgery, exocrine function was determined monthly by measuring faecal elastase 1 levels (normal value over 0.200 µg per g faeces). Endocrine function, steatorrhoea-related symptoms and bodyweight were also evaluated before and after surgery. Subjects were followed from diagnosis until 6 months after surgery, or until death. Twenty-nine patients were included, 12 with pancreatic cancer, 14 with ampullary carcinoma and three with bile duct carcinoma (median tumour size 2.6 cm). Twenty-six patients underwent pancreaticoduodenectomy and three distal pancreatectomy. Thirteen patients had exocrine insufficiency at preoperative diagnosis. After a median follow-up of 6 months, this had increased to 24 patients. Diabetes was present in seven patients at diagnosis, and developed in one additional patient within 1 month after surgery. Most patients with tumours in the pancreatic region requiring pancreatic resection either had exocrine insufficiency at diagnosis or became exocrine-insufficient soon after surgical resection. © 2013 BJS Society Ltd. Published by John Wiley & Sons Ltd.

Cor triatriatum sinister identified after new onset atrial fibrillation in an elderly man.

PubMed

Zepeda, Ignacio A; Morcos, Peter; Castellanos, Luis R

2014-01-01

A 73-year-old man with new onset atrial fibrillation with rapid ventricular response underwent transthoracic echocardiography that revealed an echogenic linear structure along the left atrium, suggestive of cor triatriatum sinister (CTS). CTS was confirmed with transesophageal echocardiography which demonstrated a proximal accessory atrium receiving pulmonary venous flow separated from a distal true atrium by a fibromuscular membrane with a large fenestration allowing flow between the chambers. In CTS, the left atrium is divided into proximal and distal chambers by a fenestrated fibromuscular septum. This cardiac anomaly accounts for 0.1% of cases of congenital heart disease and rarely presents in adults. CTS is primarily diagnosed with echocardiography and is associated with left atrial enlargement and development of atrial fibrillation. Treatment options depend on size of the communication between proximal and distal chambers, the gradient across the membrane, and the position of pulmonary veins. In some instances, surgical resection of the membrane that divides the left atrium is warranted.

Cor Triatriatum Sinister Identified after New Onset Atrial Fibrillation in an Elderly Man

PubMed Central

Zepeda, Ignacio A.; Morcos, Peter; Castellanos, Luis R.

2014-01-01

A 73-year-old man with new onset atrial fibrillation with rapid ventricular response underwent transthoracic echocardiography that revealed an echogenic linear structure along the left atrium, suggestive of cor triatriatum sinister (CTS). CTS was confirmed with transesophageal echocardiography which demonstrated a proximal accessory atrium receiving pulmonary venous flow separated from a distal true atrium by a fibromuscular membrane with a large fenestration allowing flow between the chambers. In CTS, the left atrium is divided into proximal and distal chambers by a fenestrated fibromuscular septum. This cardiac anomaly accounts for 0.1% of cases of congenital heart disease and rarely presents in adults. CTS is primarily diagnosed with echocardiography and is associated with left atrial enlargement and development of atrial fibrillation. Treatment options depend on size of the communication between proximal and distal chambers, the gradient across the membrane, and the position of pulmonary veins. In some instances, surgical resection of the membrane that divides the left atrium is warranted. PMID:25614746

Microhomology-mediated end joining induces hypermutagenesis at breakpoint junctions

PubMed Central

Li, Fuyang; Villarreal, Diana; Shim, Jae Hoon; Myung, Kyungjae; Shim, Eun Yong; Lee, Sang Eun

2017-01-01

Microhomology (MH) flanking a DNA double-strand break (DSB) drives chromosomal rearrangements but its role in mutagenesis has not yet been analyzed. Here we determined the mutation frequency of a URA3 reporter gene placed at multiple locations distal to a DSB, which is flanked by different sizes (15-, 18-, or 203-bp) of direct repeat sequences for efficient repair in budding yeast. Induction of a DSB accumulates mutations in the reporter gene situated up to 14-kb distal to the 15-bp MH, but more modestly to those carrying 18- and 203-bp or no homology. Increased mutagenesis in MH-mediated end joining (MMEJ) appears coupled to its slower repair kinetics and the extensive resection occurring at flanking DNA. Chromosomal translocations via MMEJ also elevate mutagenesis of the flanking DNA sequences 7.1 kb distal to the breakpoint junction as compared to those without MH. The results suggest that MMEJ could destabilize genomes by triggering structural alterations and increasing mutation burden. PMID:28419093

Late differentiation of proximal and distal margins in the Gulf of Aden

NASA Astrophysics Data System (ADS)

Bache, F.; Leroy, S.; D'Acremont, E.; Autin, J.; Watremez, L.; Rouzo, S.

2009-04-01

Non-volcanic passive margins are usually described in three different domains (Boillot et al., 1988), namely (1) the continental domain, where the basement is structured in a series of basins and basement rises, (2) the true oceanic domain, where the bathymetry is relatively smooth, and (3) in between them, a transitional domain referred to as the oceanic-continental transition (OCT), where the basement is partly composed of exhumed mantle. The Gulf of Aden is a young and narrow oceanic basin formed in Oligo-Miocene time between the rifted margins of the Arabian and Somalian plates. The distal margin and particularly the OCT domain were previously studied considering a large set of data (Leroy et al., 2004; d'Acremont et al., 2005; d'Acremont et al., 2006; Autin, 2008). This study focalises on the sedimentary cover identified on seismic reflexion profiles acquired during Encens-Sheba (2000) and Encens (2006) cruises. Sedimentary stratal pattern and seismic facies succession suggest that the differentiation between the proximal and the distal margins occurred very late in the formation of the margin, after the deposition of ~2 km of "syn-OCT" sediments which filled the distal margin grabens. A high position of the proximal and distal margins during rifting and "syn-OCT" sediments deposition could be proposed. The major implication of this evolution should be a shallow nature of "syn-OCT" deposits. The lack of boreholes doesn't permit to affirm this last point. Comparable observations have been described on other passive margins (Moulin, 2003; Moulin et al., 2005; Labails, 2007; Aslanian et al., 2008; Bache, 2008). For some authors, it shows the persistence of a deep thermal anomaly during the early history of the margin (Steckler et al., 1988; Dupré et al., 2007). These observations could be a common characteristic of passive margins evolution and are of major interest for petroleum exploration. Aslanian, D., M. Moulin, O. J.L., P. Unternehr, F. Bache, I. Contrucci, F. Klingelhoefer, C. Labails, L. Matias, H. Nouzé, and M. Rabineau, 2008, Brazilian and African Passive Margins of the Central Segment of the South Atlantic Ocean: Kinematic constraints: Tectonophysics, v. doi: 10.1016/j.tecto.2008.12.016. Autin, J., 2008, Déchirure continentale et segmentation du Golfe d'Aden oriental en contexte de rifting oblique: Ph. D. thesis, Université Pierre et Marie Curie, Paris VI, 310 p. Bache, F., 2008, Evolution Oligo-Miocène des marges du micro océan Liguro Provençal.: Ph. D. thesis, Université de Bretagne Occidentale/CNRS/IFREMER. http://www.ifremer.fr/docelec/notice/2008/notice4768-EN.htm, Brest, 328 p. Boillot, G., J. Girardeau, and J. Kornprobst, 1988, The rifting of the Galicia margin: crustal thinning and emplacement of mantle rocks on the seafloor (ODP Leg 103). In Boillot, G., Winterer, E.L., et al., Proc. ODP, Sci. Results, v. 103, College Station, TX (Ocean Drilling Program), p. 741-756. d'Acremont, E., S. Leroy, M. O. Beslier, N. bellahsen, M. Fournier, C. Robin, M. Maia, and P. Gente, 2005, Structure and evolution of the eastern Gulf of Aden conjugate margins from seismic reflection data: Geophys. J. Int., v. 160, p. 869-890. d'Acremont, E., S. Leroy, M. Maia, P. Patriat, M. O. Beslier, N. Bellahsen, M. Fournier, and P. Gente, 2006, Structure and evolution of the eastern Gulf of Aden: insights from magnetic and gravity data (Encens-Sheba MD117 cruise): Geophys. J. Int., v. 165, p. 786-803. Dupré, S., G. Bertotti, and S. Cloetingh, 2007, Tectonic history along the South Gabon Basin: Anomalous early post-rift subsidence: Mar. Pet. Geol., v. 24, p. 151-172. Labails, C., 2007, La marge sud-marocaine et les premières phases d'ouverture de l'océan Atlantique Central: Ph. D. thesis, Université de Bretagne Occidentale, Brest. Leroy, S., P. Gente, M. Fournier, E. d'Acremont, P. Patriat, M. O. Beslier, N. Bellahsen, M. Maia, A. Blais, J. Perrot, A. Al-Kathiri, S. Merkouriev, J. M. Fleury, P. Y. Ruellan, C. Lepvrier, and P. Huchon, 2004, From rifting to spreading in the Gulf of Aden: a geophysical survey of a young oceanic basin from margin to margin: Terra Nova, v. 16, p. 185-192. Moulin, M., 2003, Etude géologique et géophysique des marges continentales passive: exemple de l'Angola et du Zaire: Ph. D. thesis, Université de Bretagne Occidentale/IFREMER. http://www.ifremer.fr/docelec/doc/2003/these-82.pdf., Brest, 320 p. Moulin, M., D. Aslanian, J. L. Olivet, I. Contrucci, L. Matias, L. Géli, F. Klingelhoefer, H. Nouzé, J. P. Réhault, and P. Unternehr, 2005, Geological constraints on the evolution of the Angolan margin based on reflection and refraction seismic data (Zaïango project): Geophys. J. Int., v. 162, p. 793-810. Steckler, M., A. B. Watts, and J. A. Thorne, 1988, Subsidence and basin modeling at the U.S. Atlantic passive margin, in R. E. Sheridan, and J. A. Grow, eds., The Atlantic Continental Margin: U.S., v. The Geology of Noth America, V1-2, Geological Society of America, p. 399-416.

Impact of surgical margins on survival of 37 dogs with massive hepatocellular carcinoma.

PubMed

Matsuyama, A; Takagi, S; Hosoya, K; Kagawa, Y; Nakamura, K; Deguchi, T; Takiguchi, M

2017-09-01

To compare the survival of dogs with completely resected massive hepatocellular carcinoma (HCC) with that of dogs in which HCC were incompletely excised. A retrospective cohort study was conducted. Dogs that underwent surgical excision of massive HCC between November 2006 and April 2015 were included. Dogs that died in the perioperative period or were lost to follow-up within 2 months after surgery were excluded. Data were collected from the medical records and a single pathologist examined all available histology slides to confirm the diagnosis of HCC. Surgical margins were defined as complete if no neoplastic cells were seen at the edge of excised tissues, based on original histopathology reports. Progression-free survival (PFS) and overall survival (OS) were compared between dogs with complete surgical margins (CM) and those with incomplete margins (IM) using a log-rank test. Of the 37 dogs included in the study, 25 were allocated to the CM group and 12 to the IM group. Progressive local disease developed after surgery in three dogs in the CM group and seven dogs in the IM group. Three dogs in the CM group and five dogs in the IM group died due to tumour progression. Median PFS was longer for dogs in the CM group (1,000 (95% CI=562-1,438) days) compared to dogs in the IM group (521 (95% CI=243-799) days; p=0.007). OS was also longer for dogs in the CM group (>1,836 days) compared to those in the IM group (median 765 (95% CI=474-1,056) days; p=0.02). Compared with complete resection, incomplete resection decreased PFS and OS in dogs with massive HCC. Dogs with incompletely excised HCC should be closely monitored for local recurrence, although median OS was >2 years following incomplete excision. Further prospective studies are warranted to confirm these findings.

Feasibility and accuracy of computational robot-assisted partial nephrectomy planning by virtual partial nephrectomy analysis.

PubMed

Isotani, Shuji; Shimoyama, Hirofumi; Yokota, Isao; China, Toshiyuki; Hisasue, Shin-ichi; Ide, Hisamitsu; Muto, Satoru; Yamaguchi, Raizo; Ukimura, Osamu; Horie, Shigeo

2015-05-01

To evaluate the feasibility and accuracy of virtual partial nephrectomy analysis, including a color-coded three-dimensional virtual surgical planning and a quantitative functional analysis, in predicting the surgical outcomes of robot-assisted partial nephrectomy. Between 2012 and 2014, 20 patients underwent virtual partial nephrectomy analysis before undergoing robot-assisted partial nephrectomy. Virtual partial nephrectomy analysis was carried out with the following steps: (i) evaluation of the arterial branch for selective clamping by showing the vascular-supplied area; (ii) simulation of the optimal surgical margin in precise segmented three-dimensional model for prediction of collecting system opening; and (iii) detailed volumetric analyses and estimates of postoperative renal function based on volumetric change. At operation, the surgeon identified the targeted artery and determined the surgical margin according to the virtual partial nephrectomy analysis. The surgical outcomes between the virtual partial nephrectomy analysis and the actual robot-assisted partial nephrectomy were compared. All 20 patients had negative cancer surgical margins and no urological complications. The tumor-specific renal arterial supply areas were shown in color-coded three-dimensional model visualization in all cases. The prediction value of collecting system opening was 85.7% for sensitivity and 100% for specificity. The predicted renal resection volume was significantly correlated with actual resected specimen volume (r(2) = 0.745, P < 0.001). The predicted estimated glomerular filtration rate was significantly correlated with actual postoperative estimated glomerular filtration rate (r(2) = 0.736, P < 0.001). Virtual partial nephrectomy analysis is able to provide the identification of tumor-specific renal arterial supply, prediction of collecting system opening and prediction of postoperative renal function. This technique might allow urologists to compare various arterial clamping methods and resection margins with surgical outcomes in a non-invasive manner. © 2015 The Japanese Urological Association.

[An experimental study on the effect of different optical impression methods on marginal and internal fit of all-ceramic crowns].

PubMed

Tan, Fa-Bing; Wang, Lu; Fu, Gang; Wu, Shu-Hong; Jin, Ping

2010-02-01

To study the effect of different optical impression methods in Cerec 3D/Inlab MC XL system on marginal and internal fit of all-ceramic crowns. A right mandibular first molar in the standard model was used to prepare full crown and replicated into thirty-two plaster casts. Sixteen of them were selected randomly for bonding crown and the others were used for taking optical impression, in half of which the direct optical impression taking method were used and the others were used for the indirect method, and then eight Cerec Blocs all-ceramic crowns were manufactured respectively. The fit of all-ceramic crowns were evaluated by modified United States Public Health Service (USPHS) criteria and scanning electron microscope (SEM) imaging, and the data were statistically analyzed with SAS 9.1 software. The clinically acceptable rate for all marginal measurement sites was 87.5% according to USPHS criteria. There was no statistically significant difference in marginal fit between direct and indirect method group (P > 0.05). With SEM imaging, all marginal measurement sites were less than 120 microm and no statistically significant difference was found between direct and indirect method group in terms of marginal or internal fit (P > 0.05). But the direct method group showed better fit than indirect method group in terms of mesial surface, lingual surface, buccal surface and occlusal surface (P < 0.05). The distal surface's fit was worse and the obvious difference was observed between mesial surface and distal surface in direct method group (P < 0.01). Under the conditions of this study, the optical impression method had no significant effect on marginal fit of Cerec Blocs crowns, but it had certain effect on internal fit. Overall all-ceramic crowns appeared to have clinically acceptable marginal fit.

Half forehead reconstruction with a single rotational scalp flap for dermatofibrosarcoma protuberans treatment.

PubMed

Mori, Stefano; Di Monta, Gianluca; Marone, Ugo; Chiofalo, Maria Grazia; Caracò, Corrado

2012-05-06

Dermatofibrosarcoma protuberans (DFSP) is a soft tissue neoplasm of intermediate to low-grade malignancy. Although metastasis rarely occurs, DFSP has a locally aggressive behavior with a high recurrence rate. In the head and neck area, resection involving a wide margin of healthy tissue can be difficult because of functional and cosmetic considerations. We describe a novel reconstructive method for half forehead defects with an innovative single local wide scalp flap following excision of DFSP with a 3 cm margin of healthy tissue. Two patients underwent wide resection of forehead DFSP and reconstruction with a single rotational scalp flap. The scalp flap blood supply was provided from three main vessels: the superficial temporal artery, occipital artery and posterior auricular artery. No early or late complications were observed in either patient with no local recurrence after 18 months of follow-up. The donor area could be closed primarily in both cases and the flaps survived completely. This innovative technique allowed a radical excision of forehead DFSP with sufficient healthy margins, thus potentially decreasing tumor recurrence rate. Reconstruction was achieved avoiding microsurgery, skin expanders and large skin grafts. Moreover, all main reconstructive criteria, such as functional and cosmetic tissue characteristics, were completely fulfilled.

Distal pancreatectomy with en bloc celiac axis resection performed while monitoring hepatic arterial flow by using a transonic flowmeter during operation.

PubMed

Shimura, Masahiro; Ito, Masahiro; Horiguchi, Akihiko; Miyakawa, Shuichi

2012-01-01

Pancreatic body cancer often involves the common hepatic artery and/or the celiac axis, and is regarded as an unresectable disease. Hepatic blood flow must be monitored while performing distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for managing the progression of pancreatic body cancer. We first confirmed a safe level of blood flow by monitoring hepatic venous oxygen saturation (ShvO2) to prevent hepatic ischemia caused by occlusion of the common hepatic artery. However, this method is technically difficult and a long period of time is required to insert the catheter. Thus, we monitored hepatic arterial flow by using a transonic flowmeter in the hepatic artery during operation. Between April 1992 and January 2011, 14 patients underwent DP-CAR. In 6 of these 14 patients we measured ShvO2. In 2 of the 14 patients, a transonic flowmeter was used for determining the hepatic arterial flow during operation. There were no complications during this operation. Operation time when the blood flow was monitored using a transonic flowmeter was less than that when ShvO2 was measured. Monitoring the transonic flowmeter hepatic artery is a useful and quick method for real-time evaluation of hepatic circulation during operation.

[Management and complications of tumor resections of the midface].

PubMed

Beule, Achim G

2018-05-24

Only about 8% of head and neck tumors affect the midface. This anatomical area is characterized by an enormous number of functionally important structures, and it is frequently only possible to achieve small resection margin distances. To avoid complications and unfavorable results, a dedicated preparation of both patient and surgeon is warranted. This review aims to provide encouragement for the postgraduate training of interested ENT specialists. Following the clinical course and based on recent literature, strategies to avoid complications of tumor surgery to the midface are given.

Systematic review and meta-analysis of prophylactic abdominal drainage after pancreatic resection

PubMed Central

Dou, Chang-Wei; Liu, Zhi-Kui; Jia, Yu-Li; Zheng, Xin; Tu, Kang-Sheng; Yao, Ying-Min; Liu, Qing-Guang

2015-01-01

AIM: To investigate whether prophylactic abdominal drainage is necessary after pancreatic resection. METHODS: PubMed, Web of Science, and the Cochrane Library were systematically searched to obtain relevant articles published before January 2014. Publications were retrieved if they met the selection criteria. The outcomes of interest included: mortality, morbidity, postoperative pancreatic fistula (POPF), clinically relevant pancreatic fistula (CR-PF), abdominal abscess, reoperation rate, the rate of interventional radiology drainage, and the length of hospital stay. Subgroup analyses were also performed for pancreaticoduodenectomy (PD) and for distal pancreatectomy. Begg’s funnel plot and the Egger regression test were employed to assess potential publication bias. RESULTS: Nine eligible studies involving a total of 2794 patients were identified and included in this meta-analysis. Of the included patients, 1373 received prophylactic abdominal drainage. A fixed-effects model meta-analysis showed that placement of prophylactic drainage did not have beneficial effects on clinical outcomes, including morbidity, POPF, CR-PF, reoperation, interventional radiology drainage, and length of hospital stay (Ps > 0.05). In addition, prophylactic drainage did not significantly increase the risk of abdominal abscess. Overall analysis showed that omitting prophylactic abdominal drainage resulted in higher mortality after pancreatectomy (OR = 1.56; 95%CI: 0.93-2.92). Subgroup analysis of PD showed similar results to those in the overall analysis. Elimination of prophylactic abdominal drainage after PD led to a significant increase in mortality (OR = 2.39; 95%CI: 1.22-4.69; P = 0.01). CONCLUSION: Prophylactic abdominal drainage after pancreatic resection is still necessary, though more evidence from randomized controlled trials assessing prophylactic drainage after PD and distal pancreatectomy are needed. PMID:25987799

Prognostic Significance of the Location of Lymph Node Metastases in Patients With Adenocarcinoma of the Distal Esophagus or Gastroesophageal Junction.

PubMed

Anderegg, Maarten C J; Lagarde, Sjoerd M; Jagadesham, Vamshi P; Gisbertz, Suzanne S; Immanuel, Arul; Meijer, Sybren L; Hulshof, Maarten C C M; Bergman, Jacques J G H M; van Laarhoven, Hanneke W M; Griffin, S Michael; van Berge Henegouwen, Mark I

2016-11-01

To identify the prognostic significance of the location of lymph node metastases in patients with esophageal or gastroesophageal junction (GEJ) adenocarcinoma treated with neoadjuvant therapy followed by esophagectomy. Detection of lymph node metastases in the upper mediastinum and around the celiac trunk after neoadjuvant therapy and resection does not alter the TNM classification of esophageal carcinoma. The impact of these distant lymph node metastases on survival remains unclear. Between March 2003 and September 2013, 479 consecutive patients with adenocarcinoma of the distal esophagus or GEJ who underwent transthoracic esophagectomy with en bloc 2-field lymphadenectomy after neoadjuvant therapy were included, and survival was analyzed according to the location of positive lymph nodes in the resection specimen. Two hundred fifty-three patients had nodal metastases in the resection specimen. Of these patients, 92 patients had metastases in locoregional nodes, 114 patients in truncal nodes, 21 patients in the proximal field of the chest, and 26 patients had both positive truncal and proximal field nodes. Median disease-free survival was 170 months in the absence of nodal metastases, 35 months for metastases limited to locoregional nodes, 16 months for positive truncal nodes, 15 months for positive nodes in the proximal field, and 8 months for nodal metastases in both truncal and the proximal field. On multivariate analysis, location of lymph node metastases was independently associated with survival. Location of lymph node metastases is an independent predictor for survival. Relatively distant lymph node metastases along the celiac axis and/or the proximal field have a negative impact on survival. Location of lymph node metastases should therefore be considered in future staging systems of esophageal and GEJ adenocarcinoma.

Robot-Assisted Versus Open Liver Resection in the Right Posterior Section

PubMed Central

Cipriani, Federica; Ratti, Francesca; Bartoli, Alberto; Ceccarelli, Graziano; Casciola, Luciano; Aldrighetti, Luca

2014-01-01

Background: Open liver resection is the current standard of care for lesions in the right posterior liver section. The objective of this study was to determine the safety of robot-assisted liver resection for lesions located in segments 6 and 7 in comparison with open surgery. Methods: Demographics, comorbidities, clinicopathologic characteristics, surgical treatments, and outcomes from patients who underwent open and robot-assisted liver resection at 2 centers for lesions in the right posterior section between January 2007 and June 2012 were reviewed. A 1:3 matched analysis was performed by individually matching patients in the robotic cohort to patients in the open cohort on the basis of demographics, comorbidities, performance status, tumor stage, and location. Results: Matched patients undergoing robotic and open liver resections displayed no significant differences in postoperative outcomes as measured by blood loss, transfusion rate, hospital stay, overall complication rate (15.8% vs 13%), R0 negative margin rate, and mortality. Patients undergoing robotic liver surgery had significantly longer operative time (mean, 303 vs 233 minutes) and inflow occlusion time (mean, 75 vs 29 minutes) compared with their open counterparts. Conclusions: Robotic and open liver resections in the right posterior section display similar safety and feasibility. PMID:25516700

Resection and drainage of hilar cholangiocarcinoma: an 11-year experience of a single center in mainland China.

PubMed

Zheng-Rong, Lian; Hai-Bo, You; Xin, Chen; Chuan-Xin, Wu; Zuo-Jin, Liu; Bing, Tu; Jian-Ping, Gong; Sheng-Wei, Li

2011-05-01

The purpose of this study is to provide appropriate approaches for resection and drainage of hilar cholangiocarcinomas. Surgical approaches and postoperative survival rates of the patients were analyzed retrospectively. The 1-, 3-, and 5-year cumulative survival rates for patients who underwent resection were 76.6, 36.2, and 10.6 per cent, which was higher than those of 60, 14.3, and 0 per cent, respectively, in palliative operation. Moreover, the 1-, 3-, and 5-year cumulative survival rates for patients who underwent R0 were 88.9, 44.4, and 13.9 per cent, which was improved compared with those of 36.4, 9.1, and 0 per cent, respectively, in nonR0 resection. In addition, the overall survival time of patients who underwent R0 resection combined with hemihepatectomy and caudate lobe resection was longer than of those who underwent R0 without this extra operation, especially within 3 years after operation. After endoscopic metal biliary endoprothesis for patients who were intolerant of resection, liver function was improved at 2 weeks postoperation and the 1-, 3-, and 5-year cumulative survival rates for these patients were 72.7, 18.2, and 0 per cent, respectively. Treatment should be personalized. Resection is the most efficacious therapy, and negative histologic margins should be achieved in radical operation and "skeletonized" surgical operation is the basic requirement of radical treatment of hilar cholangiocarcinoma. Portal vein resection is beneficial to long-term survival and R0 resection combined with caudate lobe resection and hemihepatectomy is more efficacious for patients with Bismuth-Corlette type III hilar cholangiocarcinoma. The preferred approach of drainage in palliative operation is endoscopic metal biliary endoprothesis, which is more appropriate than tumor resection for the patients who suffer from serious comorbidities.

Limited arthrodesis of the wrist for treatment of giant cell tumor of the distal radius.

PubMed

Flouzat-Lachaniette, Charles-Henri; Babinet, Antoine; Kahwaji, Antoine; Anract, Philippe; Biau, David-Jean

2013-08-01

To present the functional results of a technique of radiocarpal arthrodesis and reconstruction with a structural nonvascularized autologous bone graft after en bloc resection of giant cell tumors of the distal radius. A total of 13 patients with a mean age of 37 years with aggressive giant cell tumor (Campanacci grade III) of distal radius were managed with en bloc resection and reconstruction with a structural nonvascularized bone graft. The primary outcome measure was the disability evaluated by the Musculoskeletal Tumor Society rating score of limb salvage. Secondary outcomes included survival of the reconstruction measured from the date of the operation to revision procedure for any reason (mechanical, infectious, or oncologic). Other outcomes included active wrist motion and ability to resume work. Mean follow-up period was 6 years (range, 2-14 y). The median arc of motion at the midcarpal joint was 40°, median wrist flexion was 20°, and median extension was 10°. The median Musculoskeletal Tumor Society score based on the analysis of factors pertinent to the patient as a whole (pain, functional activities, and emotional acceptance) and specific to the upper limb (positioning of the hand, manual dexterity, and lifting ability) was 86%. Five patients underwent a second surgical procedure. The cumulative probability of reoperation for mechanical reason was 31% at similar follow-up times at 2, 5, and 10 years. This technique provided a stable wrist and partially restored wrist motion with limited pain. However, further surgical procedures may be necessary to reach this goal. Therapeutic IV. Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Discussion on final rifting evolution and breakup : insights from the Mid Norwegian - North East Greenland rifted system

NASA Astrophysics Data System (ADS)

Peron-Pinvidic, Gwenn; Terje Osmundsen, Per

2016-04-01

In terms of rifted margin studies, the characteristics of the distal and outer domains are among the today's most debated questions. The architecture and composition of deep margins are rarely well constrained and hence little understood. Except from in a handful number of cases (eg. Iberia-Newfoundland, Southern Australia, Red Sea), basement samples are not available to decipher between the various interpretations allowed by geophysical models. No consensus has been reached on the basement composition, tectonic structures, sedimentary geometries or magmatic content. The result is that non-unique end-member interpretations and models are still proposed in the literature. So, although these domains mark the connection between continents and oceans, and thus correspond to unique stages in the Earth's lithospheric life cycle, their spatial and temporal evolution are still unresolved. The Norwegian-Greenland Sea rift system represents an exceptional laboratory to work on questions related to rifting, rifted margin formation and sedimentary basin evolution. It has been extensively studied for decades by both the academic and the industry communities. The proven and expected oil and gas potentials led to the methodical acquisition of world-class geophysical datasets, which permit the detailed research and thorough testing of concepts at local and regional scales. This contribution is issued from a three years project funded by ExxonMobil aiming at better understanding the crustal-scale nature and evolution of the Norwegian-Greenland Sea. The idea was to take advantage of the data availability on this specific rift system to investigate further the full crustal conjugate scale history of rifting, confronting the various available datasets. In this contribution, we will review the possible structural and sedimentary geometries of the distal margin, and their connection to the oceanic domain. We will discuss the definition of 'breakup' and introduce a first order conceptual model that proposes a combined influence of tectonic and magmatic processes on the outbuilding of the distal, outer and oceanic domains.

A technique for laparoendoscopic resection of posterior fundic gastric GISTs without need for a gastrotomy.

PubMed

Maker, Ajay V

2013-12-01

The majority of gastrointestinal stromal tumors (GISTs) are located in the stomach. With greater experience in minimally invasive oncologic surgery, gastric GISTs are being increasingly approached laparoscopically. Posterior proximally located endophytic gastric GISTs can be challenging to approach laparoscopically and excise with an adequate margin without an anterior or posterior gastrotomy, or intragastric ports. The gastrocolic and gastrosplenic ligaments are divided up to the gastroesophageal junction. The left lateral segment of the liver is mobilized to allow anterior reflection of the gastric fundus. Intraoperative ultrasound confirms the location and extent of the tumor base. Upper endoscopy is performed to trans-illuminate, confirm tumor location, and search for multifocality. Traction sutures are placed around the tumor to distract endophytic lesions. With organo-axial rotation of the stomach using the stay sutures, an endoGIA stapler approximates the posterior fundic wall under the base of the lesion ensuring an adequate margin and eliminating the risk of gastric spillage. Appropriate stapler placement and margins are assisted real-time endoscopically with picture-in-picture. The stapleline is tested for leaks and inspected for hemostasis laparoendoscopically. Complete resection of GISTs with adequate margins is performed with sound oncologic principles and demonstrated in tumors of varying sizes and locations in the proximal posterior stomach, including near the GE junction. This video demonstrates a simple laparoendoscopic technique to quickly localize even small tumors, visually confirm adequate margins, and excise gastric GISTs without spillage or gastrotomy that are located in a typically difficult area of the stomach to approach laparoscopically.

Role of Adjuvant Therapy for Node-Negative Lung Cancer Invading the Chest Wall.

PubMed

Gao, Sarah J; Corso, Christopher D; Blasberg, Justin D; Detterbeck, Frank C; Boffa, Daniel J; Decker, Roy H; Kim, Anthony W

2017-03-01

The present study investigated the effect of adjuvant chemotherapy and radiation on survival among patients undergoing chest wall resection for T3N0 non-small cell lung cancer (NSCLC). Patients with T3N0 NSCLC who underwent chest wall resection were identified in the National Cancer Data Base in 2004 to 2012. The cohort was divided into patients who had received adjuvant chemotherapy, radiation therapy, chemoradiation therapy, or no adjuvant treatment. Kaplan-Meier and log-rank tests were used to compare overall survival, and a bootstrapped Cox proportional hazards model was used to determine the significant contributors to survival. A subset analysis was performed with stratification by margin status and tumor size. Of 759 patients identified, 42.0% underwent surgery alone, 23.3% underwent surgery followed by chemotherapy, 22.3% underwent surgery followed by chemoradiation therapy, and 12.3% underwent surgery followed by radiotherapy alone. Tumors > 4 cm benefited from adjuvant chemotherapy and radiation therapy in the multivariable analysis, and those ≤ 4 cm benefited only from adjuvant chemotherapy. The subgroup analysis by margin status identified that margin-positive patients with tumors > 4 cm benefited significantly from either adjuvant chemoradiation therapy or radiation therapy alone. T3N0 NSCLC with chest wall invasion requires unique management compared with other stage IIB tumors. An important determinant of management is tumor size, with tumors ≤ 4 cm benefiting from adjuvant chemotherapy and tumors > 4 cm benefiting from adjuvant chemotherapy if margin negative and adjuvant chemoradiation therapy or radiotherapy if margin positive. Copyright © 2016 Elsevier Inc. All rights reserved.