Adequate Oncological Clearance Research Articles

The Functional Outcome of Limb Salvage of Proximal Femur Tumors With Modular Endoprosthesis: A Prospective Study.

Introduction The proximal femur is a common siteforprimary bone sarcomas, includingEwing's sarcoma, chondrosarcoma, osteosarcoma, and giant celltumors (GCT). Extensive resections arechallengingto reconstruct because the size of the tumormay necessitate an extensive resection ofthefemur to achieve adequate oncologic clearance. The resection of the proximal femur can result inhip jointinstabilitydue totheloss of the strong native hipcapsule orhip abductor strength. With a wide range of reconstruction options,such asresection arthrodesis, allograft-prosthetic composite (APC),andendoprosthesis,we can achieve limb salvage with good functionaloutcomes. Objective The objective of this case series isto evaluate the clinical outcomes and complications associatedwith endoprosthesis replacement in patients with proximal femur tumors. Methods A prospective analysis was conducted with 32 patients who underwent modular endoprosthesis replacement for proximal femoral tumors at our institution. Patient data, tumor characteristics, surgicaldetails, and postoperative outcomes were collected and analyzed. Results The study involved 32 patientswho met theinclusion criteria.Theywere assessed usingthe MusculoskeletalTumor Society Score (MSTS), which showedgoodfunctional outcomesin72.84%of the patients. The study highlights the functionaloutcomes and potential complications associated with the use of modular prostheses. Conclusion Endoprosthesis replacement in proximal femur tumors is a viable treatment option, providinggood functional outcomes and an acceptable method for limb salvage, which enhances the quality of life.

Anatomical Description of Anterior Parametrium: AProbable Answer to Pelvic Recurrence Following Radical Hysterectomy.

A prospective analysis of a retrospective data of patients with cervix carcinoma treated by minimal invasive surgery at high-volume gynecology oncology center analyzing that minimal access surgery is an acceptable treatment modality in cervix carcinoma. The study included 423 patients who underwent laparoscopic/robotic radical hysterectomy after pre-operative evaluation after taking their consent and obtaining ethical approval from the IRB. Post-operatively, patients were followed up at regular intervals for clinical examination and ultrasonography for a median range of 36months. A PET scan was done only if there was any suspicious finding on clinical examination or ultrasonography. Patients with parametrial involvement, positive vaginal margins, and nodal involvement were treated with chemotherapy/radiotherapy. Four hundred twenty-three patients of cervix carcinoma were treated with minimal access surgery. Average duration of surgeries was 92min. Median range of duration of post-operative follow-up was 36months. None of the patients had positive resection margins indicating adequate parametrectomy with complete oncological clearance. On post-operative follow-up, only 2 patients had vaginal recurrence which is comparable to that observed in open surgery and no pelvic recurrence. With the understanding of the anatomical landmarks of the anterior parametrium and development of skills for adequate oncological clearance, minimal access surgery should be the preferred surgical modality in carcinoma of the cervix.

Breast conserving surgery with immediate partial breast reconstruction using a latissimus dorsi mini flap: oncological clearance and cosmetic outcomes

Background: In our center, a breast conserving surgery (BCS) with immediate partial breast reconstruction using a latissimus dorsi mini flap (LDMF) is performed in women with a large tumor-to-breast-size ratio who declined mastectomy. We conducted a study to assess the oncological clearance and cosmetic outcomes following a BCS with immediate LDMF partial breast reconstruction in women with various breast pathologies. Methods: A cross-sectional study was conducted involving patients who underwent a BCS with immediate LDMF reconstruction between January 2016 and January 2021 in the hospital Kuala Lumpur, Malaysia. The demographic data, tumor characteristics, operative details and post-operative complications were documented. The histopathological reports were reviewed to determine the oncological clearance. Patient’s satisfaction on the cosmetic outcomes evaluated using a standard breast-Q questionnaire.Results: Thirty patients with various breast pathologies were recruited; invasive carcinoma (n=26, 86.7%), ductal carcinoma in-situ (DCIS) (n=1, 3.3%), phyllodes tumor (n=2, 6.7%), and dermatofibrosarcoma protuberans (n=1, 3.3%). The mean tumor size was 4.92 cm, giving the mean specimen weight of 224 g. Adequate oncological clearance was obtained in 96.7% of all cases. Seventeen of the patients (n=17, 56.6 %) were deeply satisfied and the remaining patients were satisfied (n=13, 43.3 %).Conclusions: In a stage II/III breast cancer, a BCS with immediate partial breast reconstruction using a LDMF can be safely performed with satisfactory cosmetic outcomes in women with a large tumor-to-breast-size ratio.

V-OG02 Video Demonstration Of Abdominal Lymphadenectomy In A Robotically Assisted Oesophagectomy

Abstract Background Lymphadenectomy is essential for adequate oncological clearance and accurate staging during oesophagectomy for malignant disease. Adequate lymph node clearance has implications on patient outcomes and confers a survival benefit. Abdominal lymph node clearance may be technically challenging due to the location of nodes along key structures such as the common hepatic artery and splenic vessels. Robotic assistance during abdominal lymphadenectomy permits improved 3-D visualisation and instrument articulation in a potentially constricted space. This video demonstrates a technique for robotic abdominal lymphadenectomy during oesophagectomy. Methods This video demonstrates a technique for coeliac axis lymph node clearance during the abdominal phase of an oesophagectomy, as practiced at this institution. The intention for such a video is for ongoing appraisal and refinement of robotic techniques within the unit, as well as for teaching and training. The video was edited using iOS software, and text has been used to explain each step in conjunction with the images. Results Dissection of all relevant coeliac axis nodal stations is successfully demonstrated, with the lymph nodes resected en-bloc with the specimen. Text has also been used to explain the steps seen in the video images. Conclusions Robotic assistance permits safe and adequate lymphadenectomy during minimally invasive oesophagectomy, as demonstrated in this video.

Comparison of MRI and Histopathology with regard to Intramedullary Extent of Disease in Bone Sarcomas

In today's era, limb salvage surgery is the procedure of choice and current standard of care in appropriately selected patients of bone sarcomas. For adequate oncologic clearance, preoperative evaluation of the extent of tumor is mandatory. The present study was done to compare measurements of bone sarcomas (osteosarcoma, Ewing's sarcoma, and chondrosarcoma) as determined by magnetic resonance imaging (MRI) with the histopathological extent seen on resected specimens. We prospectively evaluated 100 consecutive patients with a diagnosis of bone sarcoma who underwent limb salvage surgery between May 2014 and December 2014. The maximum longitudinal (cranio-caudal) dimension of tumor on the noncontrast T1-WI sequence of MRI (irrespective of whether it was pre/postchemotherapy) was compared with the gross dimensions of the tumor on histopathology. The arithmetic mean difference, Wilcoxon signed-rank test, and Spearman's correlation analysis were used to test the differences and correlation between groups. Mean tumor size on MRI based on the largest extent on MRI was 12.1 ± 4.85 cm (mean ± standard deviation), while it was 10.77 ± 4.6 cm (mean ± standard deviation) on histopathology. In 79 cases, MRI overestimated the extent of disease; the mean was 1.79 cm with a standard deviation of 1.56 cm. When the disease extent was underestimated on MRI (13 cases), the mean was 0.58 cm with a standard deviation of 0.43 cm. In 8 cases (osteosarcoma (7), Ewing's sarcoma (1)), MRI measurement was equal to histopathology. The Spearman correlation analysis showed a high correlation of tumor length on histopathology with the MRI for all patients (R = 0.948, P < 0.0001). We thus conclude that MRI is accurate in delineating the extent of bone sarcomas. A margin of 2 cm from the maximum tumor extent is adequate to ensure appropriate surgical resection.

Management of low-grade malignant dermatofibrosarcoma protuberans without compromising oncologic clearance despite financial constraints

Dermatofibrosarcoma protuberans (DFSP) is a rare, locally aggressive soft-tissue tumor with high recurrence. Tissue biopsy, imaging, and staging form the diagnostic pathway, but sometimes investigations deter patients from low socioeconomic background. We present a case of malignant DFSP with adequate oncologic clearance despite financial constraints. A young male presented with a swelling over the right hip for 8 years. Although fine-needle aspiration, core biopsy, magnetic resonance imaging, and staging computerized axial tomography scan are the ideal management pathway, the patient refused these for an excision biopsy which would have sufficed if histology was benign. Histology reported a malignant fibrosarcomatous variant of DFSP. Wide excision of previous biopsy site and flap reconstruction was done as advised by the skin oncology multidisciplinary team (MDT) which confirmed oncologic clearance. We would ideally advocate a proper oncologic pathway, but in patients where finances restrict investigations oncologic clearance can still be achieved.

Analysis of wedge resection of gallbladder bed and lymphadenectomy on adequate oncologic clearance for gallbladder cancer.

Surgery (R0 resection) is the mainstay of treatment of gallbladder cancer (GBC) as GBC is relatively resistant to currently known chemotherapy and radiotherapy regimens. to assess if wedge resection of the gallbladder bed achieves an adequate oncological clearance in GBC (namely T1 and T2) and some T3 GBC with minimal liver infiltration. Patients with GBC who underwent radical cholecystectomy (en bloc cholecystectomy, wedge resection of the gallbladder fossa with a ≥2 cm rim of nonneoplastic liver tissue, and regional lymph node dissection) between October 2012 and June 2015 after obtaining informed consent. Of thirty patients, mean age of 52 years, 5 had T1b, 13 T2, and 12 T3 GBC. R0 resection was achieved in all thirty GBC patients. Hepatic invasion was found in seven patients. The depth of hepatic invasion ranged from 0 to 9 mm. Follow-up ranged from a minimum of 12 to 43 months. Nineteen (63%) patients had N0 and 11 (37%) had N1 GBC. Total lymph node (TLND) count ranged from 1 to 12/patient with a median of 3. There was no local recurrence or systemic relapse of the disease. Wedge resection of the gallbladder bed achieves an adequate oncological clearance in early GBC. TLND counts remain poor even after a thorough standard lymph node dissection for resectable GBC.

The Surgical Treatment and Outcome of Nonmetastatic Extremity Osteosarcoma with Pathological Fractures.

Background:Recent studies have suggested that the presence of a pathological fracture does not impact on oncologic outcomes and the feasibility of limb salvage surgery (LSS) in appropriately selected patients when combined with neoadjuvant chemotherapy. These have largely been single institutional studies with limited numbers. The Eastern Asian Musculoskeletal Oncology Group reviewed the data from three large volume Asian orthopedic oncology centers to determine whether the presence of a pathologic fracture affected outcomes in osteosarcoma patients.Methods:A retrospective review of the data was conducted. Ninety-five cases of nonmetastatic extremity osteosarcoma with a pathological fracture and 887 cases without fracture treated during the same period were compared.Results:In the fracture group, the LSS rate was 62.1%, and the rate of amputation was 37.9%. In the nonfracture group, the LSS rate was 74.7%, and the amputation was 25.3%. In patients with a pathologic fracture, the rate of local recurrence for LSS and amputation groups was 8.5% and 2.8%, respectively. In this group, the 5-year survival in the LSS group was 66% as against. 46.8% in the amputation group.Conclusions:Our study suggests that surgically treated patients with pathologic fractures in osteosarcoma have adequate local control and do not have a poorer outcome compared to patients without a fracture. Though osteosarcoma with a pathologic fracture is not a contraindication for limb salvage, appropriate case selection is important when deciding local control options to ensure adequate oncologic clearance.

Nipple delay prior to completion mastectomy for oncoplastic surgery

Oncoplastic breast surgery is becoming increasingly popular, aiming to provide adequate oncological clearance of a tumour, whilst devoting attention to breast aesthetics. There are instances, however, where completion mastectomy is necessary, and this poses a threat to nipple viability due to the previous oncoplastic procedure. Delay is a technique used to axialise the blood supply of an angiosome, providing more reliable supply to a distal segment of tissue. This report details two cases where the technique of nipple delay was used to ensure nipple-areolar viability prior to proceeding with completion mastectomy. Nipple delay assists in the decision-making process for completion mastectomy in this setting, anticipating the results of complete oncological clearance whilst ensuring the best aesthetic outcome.

The results of total humeral replacement following excision for primary bone tumour

Rarely, the extent of a malignant bone tumour may necessitate resection of the complete humerus to achieve adequate oncological clearance. We present our experience with reconstruction in such cases using a total humeral endoprosthesis (THER) in 20 patients (12male and eight female) with a mean age of 22 years (6 to 59). We assessed the complications, the oncological and functional outcomes and implant survival. Surgery was performed between June 2001 and October 2009. The diagnosis included osteosarcoma in nine, Ewing's sarcoma in eight and chondrosarcoma in three. One patient was lost to follow-up. The mean follow-up was 41 months (10 to 120) for all patients and 56 months (25to 120) in survivors. There were five local recurrences (26.3%) and 11 patients were alive at time of last follow-up, with overall survival for all patients being 52% (95% confidence interval (CI) 23.8 to 74) at five years. The mean Musculoskeletal Tumor Society score for the survivors was 22 (73%; 16 to 23). The implant survival was 95% (95% CI 69.5 to 99.3) at fiveyears. The use of a THER in the treatment of malignant tumours of bone is oncologically safe; it gives consistent and predictable results with low rates of complication.

Functional and oncologic outcomes after excision of the total femur in primary bone tumors: Results with a low cost total femur prosthesis

Background:The extent of tumor may necessitate resection of the complete femur rarely to achieve adequate oncologic clearance in bone sarcomas. We present our experience with reconstruction in such cases using an indigenously manufactured, low-cost, total femoral prosthesis (TFP). We assessed the complications of the procedure, the oncologic and functional outcomes, and implant survival.Materials and Methods:Eight patients (four males and four females) with a mean age of 32 years, operated between December 2003 and June 2009, had a TFP implanted. The diagnosis included osteogenic sarcoma (5), Ewing's sarcoma (1), and chondrosarcoma (2). Mean followup was 33 months (9–72 months) for all and 40 months (24–72 months) in survivors. They were evaluated by Musculoskeletal Tumor Society score, implant survival as well as patient survival.Results:There was one local recurrence and five of seven patients are currently alive at the time of last followup. The Musculoskeletal Tumor Society score for patients ranged from 21 to 25 with a mean of 24 (80%). The implant survival was 88% at 5 years with only one TFP needing removal because of infection.Conclusions:A TFP in appropriately indicated patients with malignant bone tumors is oncologically safe. A locally manufactured, cost-effective implant provided consistent and predictable results after excision of the total femur with good functional outcomes.

Current concepts in surgical treatment of osteosarcoma.

Osteosarcoma is the most common malignant primary neoplasm of bone. For an optimal oncological outcome, surgical removal of tumor is an essential component of its multidisciplinary treatment. Limb salvage surgery has long been established as the standard of care for osteosarcoma. While limb-salvaging techniques have acceptable rates of disease control, amputation remains a valid procedure in selected cases. In current orthopedic oncology practice, the focus is on optimizing the balance between preservation of form and function of the limb and adequate oncological clearance at the same time. Improving the functional outcome and longevity of reconstructive procedures also remains a challenge.

The Endoscopic Surgical Skill Qualification System for gastric surgery in Japan

Laparoscopic surgery has been increasing in popularity in recent years. In 2004, the Japan Society for Endoscopic Surgery developed its Endoscopic Surgical Skill Qualification System (ESSQS) to assess surgeons. To earn the ESSQS accreditation, applicants must submit an unedited operative video in which they perform either a distal gastrectomy or pylorus-preserving gastrectomy with lymph node dissection for gastric cancer. The videos are assessed by two separate judges based on detailed criteria for common and procedure-specific technical-grade slips. Common criteria from all fields of gastrointestinal and general surgery are used to evaluate the basic laparoscopic surgical skills and autonomy of the operator. The target organ determines the procedure-specific criteria are set to assess whether or not adequate oncological clearance has been achieved. Between 2004 and 2009, 154 (44.6%) out of 345 applicant surgeons assessed under the ESSQS for gastric surgery have been accredited. Interrater agreement was acceptable and ranged between 0.21 and 0.59. The ESSQS system may facilitate improvement in surgical technique and the standardization of laparoscopic surgery in Japan.

Short-term outcomes following laparoscopic resection for colon cancer

Laparoscopic resection for colon cancer has been proven to have a similar oncological efficacy compared to open resection. Despite this, it is performed by a minority of colorectal surgeons. The aim of our study was to evaluate the short-term clinical, oncological and survival outcomes in all patients undergoing laparoscopic resection for colon cancer. From July 2005 to December 2008, 202 consecutive patients underwent laparoscopic resection for colon cancer. Surgery was analysed on an intention to treat basis. The mean follow-up was 24.3 months. Two hundred twenty-two patients underwent resection for colon cancer. Two hundred two underwent laparoscopic resection (91%). One hundred sixteen were male patients. Mean age was 65.9 years (range = 24-91). The median length of stay was 6.6 days (mean = 7.1 days). One hundred eighty-eight of 202 (93.1%) were completed laparoscopically. Fourteen (6.9%) were converted. The overall morbidity rate was 15.8%. There were three clinically apparent anastomotic leaks. The 30-day mortality was 1 (0.5%). The mean nodal yield was 13.4 (range = 8-37) nodes. There were no positive margins detected. Overall survival in laparoscopically treated colon cancer was 88.1%. In those patients with non-metastatic disease, the overall survival was 90.7% (165/182). Laparoscopic resection for colon cancer is achievable in 85% (188/222) of patients. This facilitates adequate oncological clearance. It is associated with a low morbidity rate and favourable short-term survival outcomes. This data reflects the potential outcomes dedicated MIS colorectal units will have to offer colon cancer patients once laparoscopic colorectal surgery becomes the de facto surgical approach.

Preservation of the lateral thoracic vein in axillary dissection – Its role in breast reconstruction using the DIEP flap

Axillary clearance is still an integral part of the surgical treatment of breast cancer. Despite evolution in surgical technique, some accessory axillary structures such as the lateral throacic vein, may be sacrificied in order to achieve and adequate oncological clearance. Recent years have seen rapid advances in onco-plastic surgery and its involvement in breast cancer patients. As many onco-plastic procedures necessitate an adequate blood supply, structures which were thought to be expendable such as the lateral thoracic vein, are now viewed as useful vessels for success. We describe the use of the lateral thoracic vein as a salvage option in the Deep Inferior Epigastric Perforator (DIEP) flap and encourage surgeons to preserve this vessels when appropriate and safe to do so.

Low section of the rectum during laparoscopic total mesorectal excision using the ContourTM device

The advantages of the laparoscopic approach for colon cancer have been clearly demonstrated, and there is now growing evidence for the possible role of this type of surgery for rectal cancer [2, 3]. Initial reports show the technical feasibility of total mesorectal excision, with adequate oncologic clearance and optimal immediate and long-term outcome. The conversion rate ranges between 0% and 20%, and anastomotic leakage is below 20% [1–4]. The laparoscopic approach facilitates the procedure, as magnification permits dissection of the lower rectum as far as the supra levator level. Local anatomy (male versus female pelvis, prostate volume, and size of the tumor) may impair adequate dissection, but the most challenging step could be the transection of the lower rectum. Available devices (30, 45, or 60 mm endostaplers, straight or flexible) reach the transection line in an oblique direction when introduced through the right iliac fossa or through a suprapubic trocar. More than one staple loader is usually required to complete the transection, obtaining a zigzag staple line. The distal rectal stump acquires an asymmetric trapezoidal shape whose corners may be poorly irrigated. The usual neoadjuvant therapy with chemoradiotherapy may increase the risk of staple line failure. A stapler and cutting device for section of the distal rectum has recently been designed for open surgery (Contour, Ethicon). Using the curved end of this instrument makes it possible to encircle the distal rectum and perform a uniform horizontal stapling line with a single shot. Despite its shortcomings as a device specifically designed for open surgery, the Contour device may be adequately adapted to endoscopic surgery. This report aims to show the possible utility of this device in endoscopic surgery and illustrate the need for improved staplers to ameliorate the complexity of the surgical task when operating in the low rectum.

The extent of resection influences outcome following hepatectomy for colorectal liver metastases

Background. The acceptable indications for liver resection in patients with colorectal metastases have increased significantly in the last decade. It is thus becoming more difficult to ascertain the limitations for selection as the boundaries have been greatly extended. This has resulted in not only more extensive resections, but more atypical and bilobar resections. The aim of this study was to compare the outcome of patients undergoing different extent of liver resection in a specialist unit. Methods. All patients undergoing liver resection for colorectal metastases at the Royal Infirmary of Edinburgh between October 1988 and April 2001 were reviewed. Patients were allocated into one of three groups: standard group, extended group, and segmental group. Patient information was collected from a prospectively completed database. Results. One hundred and thirty-seven patients had liver resections for colorectal metastases during the study period. There were 69 standard hepatectomies, 41 extended resections and 27 segmental resections. CEA level was significantly lower in the segmental group ( p=0.012). There was a significant difference between the groups in terms of median operating time ( p<0.0001, Kruskal–Wallis test), operative blood loss ( p=0.006, Kruskal–Wallis test) and post-operative stay ( p=0.036, Kruskal–Wallis test). Major post-operative complications were similar between standard and extended resections but less following segmental resection ( p=0.050). Predicted median survival was 51 months following standard resection, 23 months following extended resection and 59 months after segmental resection ( p=0.037, log rank test), however, there was no difference between the three groups for actual 5-year survival ( p=0.662, Pearson chi-square test). Conclusion. Morbidity and mortality rates were comparable with other previous studies as was overall survival, although survival in patients undergoing extended resections was reduced. There was an acceptable level of morbidity and mortality for all three groups. Patients undergoing segmental resection had fewer complications, shorter length of stay, and the longest median survival suggesting adequate oncological clearance. Segmental resection has a role for favourably placed tumour deposits if oncological clearance can be ensured. Extended liver resections have a role for selected patients with bilobar colorectal metastases or large solitary deposits close to the hepatic vein confluence.

Technical considerations for coloanal anastomosis and J-pouch

Most patients with midrectal cancer undergo a sphincter-preserving operation using modern bowel stapling techniques. In patients with bulky tumors or unfavorable pelvic anatomy, however, abdominoperineal resection with permanent colostomy may be performed for technical reasons, not based on oncologic clearance needs. In addition, low-lying tumors treated initially with preoperative chemoradiation are often downstaged, increasing the opportunity for restorative procedures. Treatment by total proctectomy and peranal sutured coloanal reconstruction fulfills the need for adequate oncologic clearance and satisfactory bowel function. Sharp pelvic dissection with removal of the entire rectal mesentery, adequate mobilization of the left colon, and precise anastomotic technique are required for optimal results. Creation of a colon J-pouch increases the capacity of the reconstructed rectum and greatly reduces the time required for functional adaptation in the postoperative period. Although irregular evacuation and other minor problems can persist, permanent colostomy is avoided, and patient satisfaction is high. For cancers of the middle and distal rectum, total proctectomy with coloanal reconstruction is an important treatment option that can improve quality of life without compromising cancer treatment.