Surgery for gynecologic cancer

Surgery is an integral part of staging procedures for ovarian, endometrial, and vulvar cancers, with a move toward surgicopathologic rather than clinical staging in cervical cancer. Morbidity can be reduced without compromising patient cure by individualizing surgery for patients with early vulvar cancer, and reproductive potential can be maintained in some women with early ovarian cancer. The place of prophylactic oophorectomy and primary and secondary surgery in ovarian cancer remain controversial and await prospective study. Recent developments in laparoscopic techniques have been applied to a number of problems in gynecologic cancer surgery, and the feasibility of laparoscopic lymphadenectomy and radical pelvic surgery has been demonstrated. Care must be taken, however, to ensure that the tenets of surgical oncology are not sacrificed in order to offer minimal-access surgery to women with gynecologic cancer.     

Surgical treatment of hydatid disease of the liver: an experience from outside the endemic area

BACKGROUND/AIMS: Hydatid disease is quite rare in European countries outside the endemic area around the Mediterranean Sea. Most of the cases observed in Central and Northern Europe occur in emigrants from the endemic area, whose number has been increasing over the last decade. In Switzerland about twenty-five new cases are being diagnosed per year, an incidence of about 0.33 cases per 10(5) inhabitants. Surgery remains the principal treatment modality of hydatid liver disease. There is still debate about conservative surgery as opposed to radical surgical treatment in which the cyst is totally removed including the pericyst by total cystoperi-cystectomy, partial hepatectomy or a combination of both. Surgeons working inside the endemic area tend to favor conservative methods, whereas those outside the endemic area have the tendency to favor radical surgery. This article reviews the results of surgery for liver hydatid disease obtained in a country outside the endemic area. PATIENTS AND METHODS: In our institution 24 patients (12 female, 12 male) have been treated for liver hydatid disease from 6/1983 to 2/1995. Twenty-two patients were immigrants from the endemic area. Surgery indication was primary liver hydatid disease in 23 patients, and recurrent disease in one. RESULTS: Twenty-one patients underwent radical procedures, and three were treated by cystectomy, unroofing and omentoplasty. Radical procedures were pericystectomy in 11 patients, partial hepatectomy in five and pericystectomy combined with partial hepatectomy in five. There was no operative mortality in 23 patients operated on for primary disease, but the only patient operated upon for recurrence died from anaphylactic shock. Eighteen of the 23 surviving patients could be followed up for a median time of 6.5 years (eight months to 12.5 years). Sixteen of 18 patients have remained free of recurrence. One has been reoperated for a retrocaval recurrence four years after right hepatectomy, and one patient is being observed for suspected recurrence after unroofing and omentoplasty. CONCLUSIONS: The policy of applying radical surgery whenever feasible can be followed with acceptable morbidity and near zero mortality. Radical surgery has, however, to be applied judiciously, and there is still an important role for conservative surgery.     

Symposium on the management of early breast cancer (stages I and II). Part II: Clinical experience with treatment methods. 3. Conventional surgery and radiotherapy

Conservative surgery (local tumour excision) for early breast cancer gives long-term survival rates comparable to those after radical treatment. Irradiation postoperatively reduces recurrence in the breast by at least 50%. The value of irradiating the internal mammary nodes in patients whose lymphoscintogram confirms the presence of cancer in these nodes remains to be determined. Radical surgery does not improve the survival rate and excessively radical radiotherapy may induce morbidity equal to the operation it is intended to replace. The demise of radical surgery is predicted and a plea made for the use of adjuvant chemotherapy or hormonal therapy, or both, for high-risk patients following conservative treatment.     

Evidence for antiaggressive property of some calcium channel blockers

A retrospective study was carried out on 20 patients with transitional cell ureteral tumours (TCUT). Surgical exploration of the tumour was performed in 17 patients. Biopsies for frozen section were evaluated for decision concerning the extent of operative intervention. If radical excision of the tumour could be done, and if the ureteral defect could be bridged, a conservative procedure was chosen. Thus, segmental resection of the ureter and primary end-to-end closure of the ureter was performed in 5 patients and ureteroneocystostomy in 3 patients. In nine patients local tumour excision was not feasible and nephroureterectomy was done. The survival rate at 3 and 10 years after ureteral resection as well as after nephroureterectomy was the same, 66% and 16%, respectively. Local excision of non-invasive low-grade ureteral tumours could be safely performed in selected patients, based on local findings and frozen section at the time of surgery.     

Ayurveda''s role in preventing disease

PURPOSE: To assess the value of preoperative axillary sonography possibly malignant for breast tumours. METHOD: We performed preoperative axillary sonography on 89 patients with suspicious breast tumours. In 78 cases, among which there were 74 invasive carcinomas, the surgery that followed included an axillary lymph node dissection and a comparison with the histology was possible. RESULTS: The sonographic detection of axillary lymph node metastases has a sensitivity of 90% and a specificity of 91.7% in relation to all tumour stages and a sensitivity of 100% and specificity of 89.6% in relation to T1 tumours. In our analysis, therefore, it is vastly superior to a clinical examination of the axilla. CONCLUSION: Ultrasonography is an accurate imaging method for the diagnosis of axillary lymph node metastases. Broadening this analysis to include more patients will validate this conclusion. The results of our preliminary study suggest that this diagnostic method could help reduce unnecessary radical surgery in the treatment of breast cancer.     

Back pain in patients with ductal pancreatic cancer. Its impact on resectability and prognosis after resection

BACKGROUND: Back pain is a frequent and often ominous clinical sign in patients with ductal pancreatic cancer. METHODS: From 1971 to 1993 a pancreatic carcinoma could be resected in 192 patients, whereas 261 patients underwent either probatory laparotomy alone or palliative bypass procedures. In a retrospective study including uni- and multi-variate survival analysis we have determined the impact of preoperative back pain on both resectability and long-term prognosis after resection. RESULTS: Among the presenting symptoms of patients with ductal pancreatic cancer back pain was a predictive sign of irresectability. In the presence of preoperative back pain the long-term prognosis after resection of the tumour was also significantly impaired. In a multivariate analysis it could be demonstrated that the prognostic impact of back pain was as strong as the influence of residual tumour, tumour grading, and tumour size. CONCLUSIONS: Back pain often indicates irresectability of ductal pancreatic carcinoma and also impairs the long-term prognosis even after curative resection.     

Liver metastases from colon cancer with intra-bile duct tumor growth: radiologic features

PURPOSE: Our goal was to characterize the radiologic features of liver metastases from colon cancer with intrahepatic bile duct (IHBD) dilatation. METHOD: Radiologic findings of liver metastases from colon cancer with IHBD dilatation of four patients were compared with pathologic findings. RESULTS: The cause of bile duct dilatation in all cases was due to papillary tumor growth in the bile duct. In two patients, intra-bile duct tumor growth (IBDTG) was observed on imaging. In the other two patients, IBDTG was not observed, but a nontapered abrupt obstruction of a dilated bile duct was seen, corresponding to the microscopically proven papillary tumor growth in the ductal lumen. In three patients who underwent an extensive hepatic resection, there has been no recurrence. In one patient who had a nonanatomic limited resection, a recurrence was seen 1 year after surgery. CONCLUSION: When liver tumor with IBDTG is suspected on imaging, liver metastases should be considered in the differential diagnosis besides hepatocellular carcinoma or cholangiocellular carcinoma. Careful preoperative assessment for IBDTG by imaging is essential to determine the extent of surgical resection.     

Obesity in childhood craniopharyngioma: relation to post-operative hypothalamic damage shown by magnetic resonance imaging

OBJECTIVE: To quantify the extent of hypothalamic damage after surgery for craniopharyngioma using magnetic resonance imaging (MRI) and to relate the findings to changes in body mass index (BMI). PATIENTS: Sixty-three survivors (36 males, 27 females) of childhood cramopharyngioma were treated surgically between 1973 and early 1994. METHODS: Cranial MRI was performed at a structured follow-up assessment 1.5-19.2 yr after the initial surgery. Hypothalamic damage was scored as 0 (no visible damage), 1 (intermediate), or 2 (severe). RESULTS: After surgery there was an increase in BMI standard deviation (SD) from diagnosis to study assessment in all but 7 patients. However, patients with MRI scores of 2 (n = 17) had a significantly greater increase in median BMI SD score at follow-up (+5.5 SD score), compared with +2.5 SD score and +1.1 SD score for patients with MRI scores of 1 or 0, respectively. Of the 17 cases with MRI scores of 2, 10 had a history of extreme weight loss or weight gain at presentation; preoperative neuroimaging demonstrated extensive hypothalamic infiltration by tumor in these cases. CONCLUSION: MRI gives sufficient anatomical definition to allow assessment of the extent of hypothalamic damage and, thereby, prediction of the patients most at risk for severe post-operative weight gain.     

Conservative surgery for stage I ovarian carcinoma in women of childbearing age

OBJECTIVE: To assess the results of a policy of tailored conservative surgical management for young women with stage I ovarian carcinomas. DESIGN: Retrospective study. PARTICIPANTS: Ninety-nine women aged 40 years or younger who underwent either primary surgery in our department or were referred after primary surgery performed elsewhere. METHODS: Of the 99 women in our study, 56 underwent fertility-sparing surgery and 43 more radical surgery. Minimal requirements for conservative management were adequate staging and complete information about the therapeutic options. Factors important in the choice of the treatment were, age, wish to preserve fertility, histologic type and grade, and the stage of the tumour. RESULTS: Conservative treatment was conducted in 84% of nulliparous and in 33% of parous women; 62% of grade 1 tumours, 48% of grade 2, and 50% of grade 3 were treated conservatively. With a median follow up of seven years, we observed five recurrences (9%) of carcinoma in women treated conservatively and five (12%) in those treated more radically. Two women (one in each treatment arm) were saved after recurrence. Two recurrences after conservative surgery involved the residual ovary (3.6%). Two women developed borderline tumour in the contralateral ovary and both were treated by surgery. CONCLUSION: After adequate staging and accurate information is given to the patient, conservative treatment may be safe in some women with early ovarian cancer. The risk of recurrence in the contralateral ovary is low. Conservative surgery may be also considered in some Stage I grade 3 tumours and in some women with stage JC tumours.     

Preoperative carcinoembryonic antigen is related to tumour stage and long-term survival in colorectal cancer

Evidence as to the value of preoperative carcinoembryonic antigen (CEA) in guiding treatment for patients with colorectal cancer is conflicting. The aim of this prospective study was to investigate the value of preoperative CEA in predicting tumour factors of proven prognostic value and long-term survival in patients undergoing surgery for colorectal cancer. Preoperative serum CEA, tumour ploidy, stage and grade were ascertained in 277 patients undergoing colorectal cancer surgery. This cohort of patients were followed up for a minimum of 5 years, or until death, in a dedicated colorectal clinic. Patients with an elevated CEA had a 5 year survival of 39%. This increased to 57% if the CEA was normal (P=0.001). The proportion of patients with a raised CEA increased with a more advanced tumour stage (P < 0.000001) and a poorly differentiated tumour grade (P < 0.005). Once stage had been controlled for, CEA was not a predictor of survival. No relationship between tumour ploidy and CEA was found. In conclusion, a raised preoperative serum CEA is likely to be associated with advanced tumour stage and poor long-term survival, compared with patients with a normal value.     

-Inguinal irradiation versus no lymph node therapy in small vulvar carcinoma with clinically negative lymph nodes (T1, NO-1)-

OBJECTIVE: The objective of this retrospective study was to determine if groin radiation was superior to no therapy in patients with small vulvar cancer with not palpable or not suspicious inguinal lymph nodes (T1, N0-N1). METHODS: From 1974 to 1990, 135 patients with invasive T1, NO-1 vulvar cancer underwent radical vulvectomy with hot knife, groin nodes were left in situ. In 65 patients vulvectomy was followed by inguinofemoral irradiation: 70 patients had none. There were more cases with clitoris carcinoma (p < 0.04) in the group with groin irradiation but no other significant difference in prognostic factors was found. RESULTS: The actuarial 5-year survival was 93.7% with groin irradiation versus 92.4% without lymph node therapy. Inguinal relapses occurred in only 4.6% of cases with groin irradiation versus 10% without lymph node treatment (n.s.). CONCLUSIONS: Radiation therapy to the groin seems to reduce groin relapses in early vulvar cancer.     

Radical vulvectomy with postoperative irradiation for vulvar cancer: therapeutic implications of a central block

PURPOSE/OBJECTIVE: To report the long-term results of vulvectomy, node dissection, and postoperative nodal irradiation using a midline vulvar block in patients with node positive vulvar cancer. METHODS AND MATERIALS: From 1971 through 1992, 27 patients with carcinoma of the vulva and histologically involved inguinal lymph nodes were treated postoperatively with radiation therapy after radical vulvectomy and bilateral lymphadenectomy (n = 25), radical vulvectomy and unilateral lymphadenectomy (n = 1), or hemivulvectomy and bilateral lymphadenectomy (n = 1). Federation Internationale de Gynecologic et d'Obstetrique stages were III (n = 14), IVA (n = 8), and IVB (n = 5) squamous cell carcinoma. Inguinal lymph nodes were involved with tumor in all patients (average number positive = 4, range 1-15). Postoperative irradiation was directed at the bilateral groin and pelvic nodes (n = 19), unilateral groin and pelvic nodes (n = 6), or unilateral groin only (n = 1). These 26 patients had the midline blocked. In addition, one patient received irradiation to the entire pelvis and perineum. Doses ranged from 10.8 to 50.7 Gy (median 45.5) with all patients except 1 receiving > or = 42.0 Gy. RESULTS: Actuarial 5-year overall survival and disease-free survival estimates were 40% and 35%, respectively. Recurrences developed in 63% (17/27) of the patients at a median of 9 months from surgery (range 3 months to 6 years) and 15 of these have died; two patients with recurrences are surviving at 24 and 96 months after further surgery and radiation therapy. Central recurrences (under the midline block) were present in 13 of these 17 patients (76%), either as central only (n = 8), central and regional (n = 4), or central and distant (n = 1). Additionally, three patients developed regional recurrences and one patient developed a concurrent regional and distant relapse. One patient developed a squamous cell cancer of the anus under the midline block 54 months after the initial vulvar cancer and an additional patient developed transitional cell carcinoma of the ureter (outside the radiation field) 12 months after diagnosis. Factors associated with a decreased relapse-free survival included increasing Federation Internationale de Gynecologic et d'Obstetrique stage (p = 0.01) and invasion of the tumor into the subcutaneous (SC) fat or deep soft tissue (p = 0.05). Chronic lower extremity edema developed in four patients, but there have been no other complications. CONCLUSIONS: Radical vulvectomy has often been considered sufficient central treatment for vulvar carcinoma, with postoperative irradiation directed only to the nodes. Although designed to protect the radiosensitive vulva, use of a midline block in this series resulted in a 48% (13/27) central recurrence rate, much higher than the 8.5% rate previously reported with this technique. Routine use of the midline block should be abandoned and, instead, postoperative irradiation volumes should be tailored to the individual patient.     

A highly differentiated exocrine pancreatic tumour in a young boy

A primary pancreatic tumour in a 6-year-old boy was removed by radical excision. From both light and electron microscopic observations the tumour was considered to be of exocrine origin, with some differentiation towards acinar cells. Although the tumour was highly differentiated, it was regarded as probably malignant because of tumour growth into the surrounding fibrous capsule. The case is discussed in relation to earlier rare reports of pancreatic tumours in infants and children.     

Fertility after conservative and radical surgery for tubal pregnancy

A retrospective cohort study was set up to evaluate the effectiveness of conservative and radical surgery for tubal pregnancy towards subsequent fertility. Consecutive patients undergoing conservative or radical surgery for tubal pregnancy between January 1990 and August 1993 in two university hospitals were included in the study. Outcome measures were spontaneous intrauterine pregnancy (IUP) and repeat ectopic pregnancy (EP). Of the 135 patients analysed, 56 underwent conservative surgery and 79 underwent radical surgery. Patients treated with conservative surgery achieved a higher 3-year cumulative pregnancy rate than those treated radically (P < 0.001, log-rank test). In patients treated conservatively, there was only one spontaneous IUP in the period between 18 months and 3 years after the tubal pregnancy. In contrast, patients treated radically continued to conceive in this period. Multivariate analysis showed a fecundity rate ratio (FRR) of 1.9 [95% confidence interval (CI): 0.91 to 3.8] for IUP after conservative surgery in the first 18 months of follow-up. In patients with a history of bilateral tubal disease the FRR was 3.1 (95% CI: 0.76 to 12), whereas in patients without a history of bilateral tubal disease the FRR was 1.4 (95% CI: 0.13 to 16). The FRR for repeat EP was 2.4 (95% CI: 0.57 to 11). Our data indicate a beneficial effect of conservative surgery towards subsequent fertility that was not, however, statistically significant in the multivariate analysis. In view of these inconclusive data and the importance of this major health problem, randomized studies are required to assess whether conservative surgery really improves the fertility prospects of patients with tubal pregnancy.     

Quality of life of patients with renal cell carcinoma or prostate cancer after radical surgery

OBJECTIVES: To study the impact of radical tumour surgery in prostate and renal cell cancer patients on quality of life (QOL). METHODS: In 38 male patients suffering from organ-confined prostate or renal cell cancer, a prospective study was performed. For the evaluation of QOL, we used the EMPK (Erfassung multipler psychischer Konstrukte). Urologic symptoms were evaluated with a specially designed symptom score. The test instrument was filled out the day before surgery and one year after operation. RESULTS: The EMPK was able to detect and describe significant changes in certain aspects of QOL in renal cell cancer and prostate cancer patients. Moreover, there seems to be a difference between the two groups. A direct relation between QOL and the different quality and quantity of operation-related symptoms, however, could not be proven. CONCLUSIONS: In this pilot study, radical surgical therapy did not significantly change QOL in prostate cancer patients, but seemed to have a positive influence on the QOL of renal cell cancer patients.     

Transcranial Doppler ultrasound battery reliably identifies severe internal carotid artery stenosis

BACKGROUND: The clinical significance of plasma concentration of matrix metalloproteinase 9 (MMP-9) was investigated in patients with gastric cancer. METHODS: Plasma was obtained from 138 healthy individuals and 70 patients who underwent gastrectomy for gastric cancer at Aichi Cancer Centre between August 1994 and July 1995. Plasma concentrations of MMP-9 were measured using a one-step sandwich enzyme immunoassay employing monoclonal antibodies. RESULTS: Patients with gastric cancer had plasma higher concentrations of MMP-9 than normal subjects. Postoperative concentrations of MMP-9 were lower than preoperative levels. In addition to patients with advanced cancer, those with early gastric cancer also exhibited higher mean values of and positivity rates for MMP-9 than healthy individuals. Preoperative plasma MMP-9 concentration correlated closely with Union Internacional Contra la Cancrum tumour node metastasis (pTNM) stage, severity of T, N and M classification, and tumour size. CONCLUSION: Plasma MMP-9 concentration can be used for detection of primary or recurrent gastric cancer, and for estimation of tumour extent.     

Elderly patients with vulvar carcinoma: should we use standard treatment?

Invasive squamous cell cancer of the vulva is predominantly a disease of older women. Current standard treatment entails a radical local excision with bilateral groin node dissection through separate incisions. In individual patients with superficially invasive small tumors the groin dissection can be omitted and in patients with well lateralized tumors a contralateral groin dissection is not always necessary. In the past the 'en bloc' resection of the vulva and groin nodes was the standard treatment for every patient. With the introduction of the above mentioned modifications, resulting in less morbidity, more older patients can now get the standard treatment. A retrospective analysis of all patients with vulvar cancer registered in a region in the Netherlands was carried out. The objective was to determine the referral pattern and the number of patients who received standard treatment. Sixty-seven of the 138 patients were not referred to a gynecological oncology center. Of this group the patients with squamous cell cancer (n = 36) 80% did not get standard treatment. Compared with the group of patients who did get standard treatment, these patients were older (median 81 years) and had an earlier stage of the disease. A higher than expected recurrence rate of 46% and a lower than expected survival rate of 68% was found. During follow-up several patients were found to be medically fit enough to undergo extensive salvage surgery for this recurrence. From the results of this study it can be concluded that deviation from standard treatment in early vulvar cancer only on the basis of old age results in decreased survival. Only the performance status of the patient combined with clinical and pathological prognostic variables should be used to decide what treatment is best for which patient.     

Value of reduction mammoplasty in the conservative treatment of breast neoplasms. Apropos of 70 cases

Breast cancer surgery is on the increase. Until now conservative treatment has been limited to tumors less than 3 cm; it is now extending to surgery on reduced tumors after chemotherapy or radiotherapy. Some cancers still require mastectomy because a carcinologic satisfactory tumorectomy would create a major deformity not compatible with conservative treatment. It is technically possible to perform major tumor resection with good cosmetic results using the reduction mammoplasty technique well known in plastic surgery. Between 1983 and 1991, 70 patients were treated at Henri Mondor Hospital for breast cancer with breast reduction mammoplasty and irradiation. We present the result with an average five years follow-up in terms of the cosmetic results relapses and survival rate. The actuarial local relapse was less than 10%, the survival with local relapse was 86% after 5 years, cosmetic results were good in 81% of cases. The association of reduction mammoplasty and radiotherapy seems to be a good extension of conservative treatment in some large breast tumors.     

Calciphylaxis: pathogenesis and therapy

Twenty-one patients with histologically proven locally advanced breast cancer (LABC) were treated with a combined modality approach based on primary chemotherapy and radical modified mastectomy followed by adjuvant chemotherapy. Surgery was performed by using radioimmunoguided surgery (RIGS) technique with the preoperative injection of Iodine-125 labeled monoclonal antibodies (MoAbs) B72.3 anti-TAG (11 patients, Group A) and FO23C5 anti-carcinoembryonic antigen (CEA; 10 patients, Group B). The role of RIGS was defined at surgery by using an intraoperative hand-held gamma-detecting probe (GDP) to locate the primary tumor, possible clinically occult multicentric foci and ipsilateral lymph node metastases. In Group A, RIGS correctly defined the primary tumor in seven out of 11 patients (63.3%) and was able to find multicentric tumors in two out of four patients (50%). Positive lymph nodes were identified by RIGS in three out of eight patients (37.5%). In Group B, patients RIGS correctly located the primary in 4/10 cases (40%); in two RIGS-positive cases, the tumor was clinically not evident after primary chemotherapy (yT0). RIGS correctly identified multicentric foci of tumor in one out of two cases (50%). Correct lymph nodal RIGS assessment was observed in three out of nine patients (33.3%). No RIGS false-positive findings occurred in the 21 patients included in the study. RIGS appears to be a reliable technique for the intraoperative diagnosis and staging of breast cancer with a potential role especially when conservative surgery is planned after primary chemotherapy in LABC.     

Effects of extensive oral surgery and hemorrhage on coagulation and fibrinolysis

The changes in coagulation and fibrinolytic activity in 22 patients with oral cancer undergoing extensive surgical procedures were studied. The patients were divided into two groups: group I patients suffered blood loss of less than 2,000 mL and group II patients had blood loss of more than 2,000 mL. The platelet count decreased significantly during surgery, at the end of surgery and on the 1st postoperative day in both groups. Fibrinogen was decreased during and at the end of surgery in both groups, but increased significantly on the 3rd postoperative day and reached about two times the preoperative levels on the 7th postoperative day. Fibrin degradation products increased significantly after surgery and reached the maximum value on the 1st postoperative day in both groups. Plasmin inhibitor complex and plasminogen increased significantly on the 3rd and 7th postoperative days. There was no clear evidence regarding the influence of blood loss on coagulation and fibrinolytic factors except for platelets. It was concluded that coagulation and fibrinolysis are enhanced between the 3rd and 7th postoperative days.