Bilateral Dissection Research Articles

A Retrospective Analysis of Carcinoma Penis Patients Treated at a Cancer Center in Nepal in a Period of Five Years

Introduction: Carcinoma Penis is not an uncommon condition in a developing country like Nepal and comprises 1-10% of all the malignancies in males. In this study we analyzed the demographic and clinicopathological profile of penile cancer patients who visited our cancer center during specified period.
 Methods: This is a descriptive cross-sectional study, that altogether included 218 patients from January 2012 to December 2016 with penile cancer conducted at B P Koirala Memorial Cancer Hospital, Nepal. All the demographic and clinico-pathological data were collected and analyzed using SPSS 16.0 software. Tumor staging was standardized according to the American Joint Committee on Cancer system. Quantitative data were represented as mean and standard deviation whereas categorical variables were expressed as frequencies and percentages of an appropriate denominator.
 Results: Among 218 patients, the mean ± SD age was 53.94 ± 13.69 years. Most were married (88.07%), smokers (67.88%), had poor personal hygiene (70.64%) and had not completed primary school (71.64%). The predominant profession was agriculture (81.65%). Most of the patients (56.88%) were diagnosed in clinical stage III b (T1-3, N2). Management was circumcision alone in 5.5%, Wide local excision in 6.88%, partial penectomy in 66.97% patients, total penectomy with perineal urethrostomy in 11% of patients and 9.63% patients were sent for chemotherapy after initial biopsy for fixed and fungating inguinal nodes. Bilateral inguinal lymph node dissection was performed in 87.15% patients. Most of our patients were uncircumcised (90.82%) Squamous cell carcinoma was the commonest histopathology (98.6%).
 Conclusion: Penile cancer is more common among farmer with low socioeconomic status. The disease is already locally advanced and at the time of diagnosis. Surgery is the main modality of treatment.

P2.18-08 The Necessity and Technique of the Upper Zone Lymph Node Dissection for Non-Small-Cell Carcinoma of the Left Upper Lobe

The removal of the whole regional lymphatic system together with primary tumor is one of the important rules in oncological surgery. According to the study of regional lymphatic drainage, we considered reasonable lymphadenectomy contributes the post-operative survival of the Left lung cancer patients with mediastinal lymph node metastasis. Due to anatomical limitations imposed by arch of aorta, it is difficult to perform complete dissection of upper zone mediastinal lymph nodes through the left thoracotomy in the left lung cancer. We had devised Systematic extended bilateral mediastinal dissection through a median sternotomy (ND3 operation) for patient with NSCLC of the left lung. This report aimed to introduce procedure of our operation and investigate the prognostic impact of Upper zone lymph node dissection for left upper lobe NSCLC. The our operative procedure is as follows. In the supine position, made a median sternotomy. We dissect the meidastinal nodes before pulmonary resection. The dissection is started on the highest area. Tape the right and left recurrent laryngeal nerve and dissect the highest paratracheal lymph nodes in the thoracic inlet. After making the pericardiotomy, the ascending aorta is retracted to the left. Remove the whole upper zone tissue lying in front of the trachea. And dissect the pre and paratracheal nodes, together with bilateral highest nodes. Then, dissect the subcarinal nodes. Tie off the blood vessels (arteries and veins) and airways leading to the affected lobe, and then remove the lobe. We retrospectively studied 213 patients [157 male and 61 female, mean ages 60.4 years (range, 29-75)], underwent ND3 operation due to NSCLC of the left upper lobe, from January 1990 till December 2017. The patients with NSCLC who are estimated to be able to conventional radical operation and aged 75 year-old or less becomes the adaptation of our operation. Overall 5-year survival rate in the 218 patients of left upper lung primary was 65.1%. Operative mortality in 218 patients was 2.8%. Lymph node metastasis to the mediastinum was confirmed in 70 (32.1%) patients (pN2 was 43, pN3α was 18, pN3γ was 9). According to pathological stages, five-year survival rate was 92.7% in stage IA ,80.1% in stage IB, 53.8% in stage IIA, 66.7% in stageIIB, 51.7% in stageIIIA, 38.4% in stageIIIB. And it was 52.1% in pN2 cases, and 55.0% in pN3α cases. Five-year disease free survival rate was was 85.6% in p-stage IA ,74.0% in p-stage IB,49.7% in p-stage IIA, 49.4% in p-stageIIB, 33.3% in p-stageIIIA, 19.4% in p-stageIIIB, 32.6% in pN2 cases, and 27.8% in pN3α cases. In this nonrandomized comrarision, the post-operative survival of patients with pN2 and pN3α NSCLC of the left upper lung primary would be remarkably improved by our Systematic Bilateral Mediastinal Dissection. And better local tumor control by our operation does not increase mortality. When faced with a patient with resectable mediastinal lymph node metastasis, we should consider Extended bilateral mediastinal lymph node dissection through a median sternotomy. To improve survival rate, it is important to perform curative operation with upper zone mediastinal dissection.

Left Subclavian-Bilateral External Carotid Artery Bypass for Symptomatic Carotid Artery Dissection Secondary to Open Repair of Type A Aortic Dissection.

Symptomatic carotid dissection, secondary to surgical repair of Stanford type A acute aortic dissection (AAD), requires prompt intervention. A 56-year-old man who underwent total arch replacement with frozen elephant trunk for AAD presented with left hemiplegia and unilateral spatial neglect 16 h after the surgery. Cerebral computed tomography (CT) revealed no fresh lesions, and CT angiography showed severe bilateral carotid dissection. The patient’s neurological symptoms improved soon after left subclavian-bilateral external carotid artery bypass to correct symptomatic severe right cerebral ischemia. Therefore, this technique can be a good option for symptomatic carotid dissection in selected patients.

Cancer de la vulve : stades diagnostiques, traitement et survie dans un pays aux ressources limitées (Burkina Faso)

Vulvar cancer is rare and belatedly diagnosed in Africa. We describe its diagnostic stages, therapeutic and evolution features in a country with limited resources. Forty-seven cases of vulvar cancer diagnosed between 2013 and 2018 in Burkina Faso, were analyzed retrospectively. The diagnostic stages, therapeutic and evolution terms were considered. Survival was calculated through the Kaplan Meier Method and compared using the Logrank technique. Stages IA and IB accounted for 10.6%. Radiotherapy was not available and chemotherapy was done in 9 cases. Full vulvectomy with bilateral inguino-femoral dissection was performed in 11 cases. Average survival was 41 months with a median of 52 months. The difference in survival according to the diagnostic stages were highly significant statistically (P=0.000). Cancer of the vulva is rare and raises major therapeutic difficulties in countries with limited resources. Surgery is the only affordable weapon. Evolution would be better if radiochemotherapy was possible. Radiochemotherapy cannot be done due to the lack of a radiotherapy unit and the high cost of cytotoxics. Surgery is largely palliative and/or mutilating. Survival is modest. An early diagnosis could help promote conserving treatments.

Vascular Pseudoinvasion: A Case Report and Review of Literature

Abstract In the era of minimally invasive procedures, laparoscopic hysterectomy is preferred over total abdominal hysterectomy as the primary treatment of endometrioid cancer limited to the uterus. Lymphovascular invasion (LVSI) is an important prognostic indicator for this tumor. Studies have observed presence of vascular pseudoinvasion in the surgical specimen excised via laparoscopic hysterectomy. Some studies have reported no increase in LVSI after minimally invasive surgery, implying that there is no vascular pseudoinvasion. Here, we present a 59-year-old female with history of obesity, hypertension, diabetes mellitus, asthma, and biopsy-proven well-differentiated endometrioid adenocarcinoma who underwent total laparoscopic hysterectomy with bilateral salpingo-oophorectomy and sentinel node dissection. An ill-defined friable mass (2.1 cm in maximum dimension) was present in the posterior lower uterine segment and had the morphology of endometrioid adenocarcinoma, grade 1 out of 3, invasive into the outer half of myometrium. There was no true vessel invasion but rather abundant contamination—smearing of tumor into vascular spaces. An immunostain for D2-40 identified no lymphatic invasion. Immunostains for CD31 and CD34 highlighted tumor cells present in vascular spaces consistent with pseudoinvasion. No regional lymph node metastasis was seen. Peritoneal fluid did not show malignant cells. After surgery, the patient received radiotherapy and had no evidence of recurrent disease. It has been proposed that the artifact of vascular invasion as seen in our case could be associated with the technique of laparoscopic hysterectomy. Substantial LVSI, in contrast to focal or no LVSI, has been shown to be the strongest independent prognostic factor for pelvic regional recurrence, distant metastasis, and overall survival. Its presence is a deciding factor for the type of adjuvant therapy. Therefore, it is important to recognize vascular pseudoinvasion to avoid misdiagnosis of LVSI.

Direct Suturing of Sciatic Nerve Defects in High-degree Knee Flexion: An Experimental Study

We sought to elucidate the conditions of direct suturing of sciatic nerve defects in high-degree knee flexion. We aimed to establish a correlation among the defect length, defect location, degree of knee flexion, and eventual need for hip immobilization in extension. We performed an experimental study by completing bilateral dissection of the sciatic nerve in 6 cadavers. Three groups of lesions were identified: at the buttock (BG), in the thigh (TG), and in the popliteal fossa (PG). For each defect, a direct, tensionless suture was performed with minimal knee flexion. Next, the hip was progressively flexed until rupture. The nerve defect length correlated with the degree of knee flexion and hip extension required to perform and protect the installed sutures. A 30° knee flexion allowed for direct suturing of defects >2 cm in the 3 groups. The largest suturable nerve defects measured 7 cm in the TG and PG and 6 cm in the BG. When considering the same-size defects, the required knee flexion tended to be significantly greater in the BG. A bowstringing effect was noted at the buttock and popliteal levels. Hip flexion placed tension on the nerve suture at all locations. The middle third of the thigh was the most compliant level, because the largest defects will be suturable without a visible bowstringing effect. Hip immobilization should be considered as soon as the defect has exceeded 2 cm, regardless of the location.

A case of bilateral vertebral artery dissection

A case of bilateral vertebral artery dissection

A Case Series Representing Dissections in the Abdominal Aorta and Common Carotid Arteries

Dissections have the potential to occur in a variety of segments throughout the vascular tree. More than 95% of aortic dissections begin within a few centimeters of the aortic valve in the ascending aorta and beyond the branch of the subclavian artery. However, less common dissections are sometimes seen in the descending aorta. Carotid dissections are considered quite uncommon. Yet, they are estimated to be responsible for 5% to 20% of strokes in people under the age of 45. Three cases are presented, which demonstrate dissections in uncommon anatomical locations using diagnostic medical sonography and computed tomographic angiography (CTA). The first two cases demonstrate abdominal aortic dissections. The third case demonstrates a bilateral carotid dissection. One of the abdominal aortic dissections was seen clearly on corresponding CTA, while the other aortic dissection was noticed on sonography, but not on CTA. All three cases are discussed with details of patient clinical findings as well as their medical and surgical histories.

Identifying an optimal lymph node yield for penile squamous cell carcinoma: prognostic impact of surgical dissection.

To evaluate the prognostic impact of lymph node yield (LNY) on survival outcomes for penile squamous cell carcinoma (SCC). In all, 532 patients who underwent inguinal LN dissection (ILND) across tertiary referral centres from Europe, China, Brazil and North America were retrospectively evaluated. From this cohort, 198 patients received pelvic LND (PLND).We identified threshold values for ILND and PLND using receiver operating characteristic curves. We tested prognostic value of LNY for recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival (OS) using the Kaplan-Meir method and Cox proportional hazard regression models. The median (interquartile [IQR]) age was 59(49-68)years and the median (IQR) follow-up after ILND was 28(12-68.2)months. Overall, 85% of the patients had bilateral dissections. The median (IQR) number of inguinal LNs removed was 15(10-22). Of those receiving PLND, The median (IQR) number of LNs was 13(8-19). A LNY of ≥15 was used for dichotomisation of ILND patients, and a LNY of ≥9 was used in the PLND cohort. Patients with a LNY ≥15 had significantly better 5-year OS vs patients with a LNY <15 (70.1% vs 58.7%). On multivariable analyses, a LNY ≥15 was a predictor of OS (hazard ratio [HR] 0.68, P=0.029). For cN0 patients, a LNY ≥15 was an independent predictor of RFS (HR 0.52, P=0.043) and OS (HR 0.53, P=0.021). In the PLND cohort, a LNY ≥9 was a predictor of RFS (HR 0.53, P=0.032). Using one of the largest LND datasets to date, we found LNY to be a significant predictor of outcomes after lymphatic staging for penile SCC. Prospective validation is warranted.

Safety and oncological efficacy of bilateral recurrent laryngeal nerve lymph-node dissection after neoadjuvant chemoradiotherapy in esophageal squamous cell carcinoma: a propensity-matched analysis.

BackgroundWe sought to evaluate the safety and oncological efficacy of bilateral recurrent laryngeal nerve (RLN) lymph-node dissection (LND) in patients with esophageal squamous cell carcinoma (ESCC) who had undergone neoadjuvant chemoradiotherapy (nCRT).MethodsWe retrospectively examined the records of ESCC patients who were judged to be ycN-RLN(-) following nCRT. Patients were divided into two groups according to the extent of LND [standard two-field LND (STL group) versus total two-field LND (TTL group)]. Only lower mediastinal and upper abdominal lymph nodes were removed in the STL group. In addition to the standard procedure, patients in the TTL group underwent resection of upper mediastinal lymph nodes located along the bilateral RLN. Using propensity score matching, 29 pairs were identified and compared with regard to perioperative complications, lymph-node metastases rates, overall survival (OS), and disease-specific survival (DSS).ResultsNo significant intergroup differences were identified in terms of in-hospital mortality and morbidity. Metastases to the RLN lymph nodes were identified in 20.7% (6/29) of TTL patients, being the only site of lymph-node metastases in three of them. TTL was associated with lower upper mediastinal lymph-node recurrence rate (6.5%) compared with STL (21.5%, p = 0.134), although the overall recurrence rate was similar (STL, 44.8% versus TTL, 46.4%). No significant intergroup differences were also evident with regard to 3-year DSS and OS rates.ConclusionsRLN LND can be safely performed in ESCC patients who had undergone nCRT, ultimately resulting in an improved local control, and should be practiced as part of the surgical routine.Electronic supplementary materialThe online version of this article (10.1007/s10388-019-00688-7) contains supplementary material, which is available to authorized users.

Motor and Sensory Impairments of the Lower Extremities After L2 Nerve Root Transection During Total en Bloc Spondylectomy.

Retrospective study. The purpose of this study was to examine motor and sensory impairments of the lower extremities after L2 nerve root transection during total en bloc spondylectomy (TES) for spinal tumors. At our institute, for TES at L3 to L5 lumbar levels, the nerve roots are preserved. However, at the level of L1 and L2, the vertebral resection and spinal reconstruction via a posterior approach is employed with transection of the nerve roots during dissection and resection of the vertebra. This study included 13 patients who had undergone TES for spinal tumors involving L2 between 2007 and 2016. Postoperative motor function of the lower extremities was quantified using the Manual Muscle Testing grade for the iliopsoas (IP) and quadriceps femoris (QF) muscles, and a grade of the modified Frankel Classification. Postoperative sensory impairment was quantified by the sites of lower extremity pain and numbness. An initial decrease in strength of the IP and QF muscles in more than 60% of the patients, with a decline in the modified Frankel grade in 76.9%, was observed at 1-week after surgery. All patients recovered by the final follow-up, with 12 of the 13 patients walking without a gait aid. The other patient, who had undergone a bilateral dissection of L3 nerve root during TES of L2 and L3, had a mild QF muscle weakness, requiring a cane for walking. Eleven of 13 patients developed pain or numbness in the groin or thigh area after surgery, with the most common area being the anterior aspect of the thigh. Although IP and QF weakness was observed in the majority of patients who underwent bilateral transection of L2 nerve roots during TES, these deficits recovered over time and did not finally affect activities of daily living. 4.

Risk factors and prognostic significance of lateral pelvic lymph node metastasis in advanced rectal cancer.

The aim of this study was to elucidate the risk factors for and prognostic value of lateral pelvic lymph node (LPLN) metastasis in advanced rectal cancer patients, including those with stage IV disease. The treatment outcomes of 78 patients with advanced rectal cancer, the lower margin of which was located at or below the peritoneal reflection, who underwent curative-intent surgery with bilateral LPLN dissection from 2005 to 2018 were retrospectively analyzed. In total, 78 rectal cancer patients, including 13 patients with stage IV tumors, 9 patients (11.5%) had LPLN metastasis. A multivariate analysis to identify preoperative clinical factors associated with LPLN metastasis showed that tumor location (below the peritoneal reflection: Rb), LPLN metastasis on preoperative imaging and distant metastasis were independent predictors of LPLN metastasis. In addition, metastasis at the regional lymph nodes in the mesorectum was significantly associated with LPLN metastasis. Both the disease-free survival (DFS) and cancer-specific survival (CSS) of patients with LPLN metastasis were significantly worse in comparison to patients without LPLN metastasis, and the CSS of stage IV patients with LPLN metastasis was significantly worse in comparison to stage IV patients without LPLN metastasis. Tumor location (Rb), LPLN metastasis on preoperative imaging and distant metastasis were risk factors for LPLN metastasis. The prognosis of rectal cancer patients with LPLN metastasis is poor. There may not be the indication of LPLN dissection in stage IV lower rectal cancer except cases having complaints due to LPLN metastasis.

Anatomical consideration of the cardiac plexus to prevent grave bradycardiac arrhythmias associated with lung cancer surgery: a case report

BackgroundArrhythmias are known as one of the complications of lung cancer surgery, and most of them are not lethal. Life-threatening arrhythmias have been reported in the literature but in reality very rare.Case presentationA 67-year-old Japanese man with a history of hypertension was diagnosed with squamous cell carcinoma in left lower lobe underwent a left lower lobectomy and bilateral mediastinal lymph node dissection through a median sternotomy. During lymph node dissection along the right vagus nerve, the patient’s heart rate and blood pressure dropped suddenly and an electrocardiogram monitor showed ST elevation. These abnormalities returned to normal soon after cardiac massage was performed and a coronary vasodilator was given. A temporary pacing wire was inserted at the end of the surgery. The postoperative course was uneventful and the patient was discharged on postoperative day 11 without a need for permanent pacemaker.ConclusionsWe present a patient who was complicated with lethal arrhythmias during lung cancer surgery for the purpose of elucidating, from anatomical viewpoint, the relationship between arrhythmias and the involvement of cardiac plexus during lymph node dissection. The result showed that arrhythmia was inadvertently elicited by cardiac plexus stimulation during lymph nodes dissection around the vagus nerve. It is important to be familiar not only with the course of phrenic, vagus, and recurrent laryngeal nerve but also the anatomy of cardiac plexus to prevent arrhythmic complications in lung cancer surgery.

Subarachnoid hemorrhage due to de novo dissecting vertebral artery aneurysm in a patient with Guillain‐Barré syndrome

AbstractA 51‐year‐old man with Guillain‐Barré syndrome developed a dissecting vertebral artery aneurysm. Initial magnetic resonance angiography showed no abnormality, including dissecting aneurysm of the bilateral vertebral arteries. He developed subarachnoid hemorrhage. Radiological examination revealed bilateral dissecting vertebral artery aneurysms. The left ruptured dissecting vertebral artery aneurysm was treated by stent‐assisted coil embolization with preservation of the affected vertebral artery. Although it is rare, there is a possibility that dissection of the intracranial artery might occur in a patient with Guillain‐Barré syndrome in a short period of time. The dissecting aneurysm might be formed by external force to the vertebral artery, and the aneurysm might subsequently rupture due to hypertension.

Vulval Cancer: When should I Stop Resecting? Identifying the Factors that Predict Recurrence

Abstract Context: Vulval cancer surgery has become more conservative and it is important to understand whether resection margins alone influence recurrence rates or whether other prognostic factors should be considered when planning treatment. Aims: The aim of this study is to define factors that predict vulval cancer recurrence, enabling development of a recurrence prediction model. Settings and Design: This was a Aretrospective descriptive analysis of new vulval squamous cell carcinoma cases in a gynecological oncology center (January 1, 2007 to December 31, 2013). Subjects and Methods: Analysis of tumor characteristics and treatments. Patient outcomes were recorded, identifying recurrences, and subsequent interventions. Statistical Analysis Used: Univariable and multivariable logistic regression tools applied to determine recurrence risk factors. Results: Seventy patients underwent primary vulval surgery. Bilateral groin node dissection was performed in 26/70 (37.1%) cases and unilateral groin node dissection in 9/70 (12.9%) cases. 57/70 (82%) cases had a negative vulval resection margin, with 67% &lt;8-mm margin. 18/70 (26%) patients underwent adjuvant treatment. Overall recurrence rate of 21/70 (30%): 14/70 locally and 7/70 at the groin. Median survival was 84.2 months and median disease-free interval was 19.1 months. Factors that were statistically significant in predicting recurrence were positive groin histology, lymphovascular space invasion (LVSI), and disease stage. Conclusions: We reported a reduction in the size of tumor-free margins at primary excision. The recurrence rate of 30% is within the previously reported range, suggesting that factors aside from resection margin (LVSI, stage, and groin node involvement) are also important in predicting recurrence. These factors should be incorporated into a prediction model when planning adjuvant treatment.

Dynamic Nasolabial Growth After Primary Surgery for Patients With Bilateral Cleft Lip: A Five-Year Follow-Up Study

Bilateral complete cleft lip (BCCL) causes severe tissue deficit and usually requires multiple revisions after primary repair. In the present study, we aimed to illustrate the nasolabial changes after primary BCCL correction. The present retrospective cohort study compared patients who had undergone BCCL and palate (BCCLP) and cleft palate only (CPO). All included patients had undergone surgery at the same treatment center (West China Hospital of Stomatology) from 2007 to 2012. The patients returned for follow-up surgery at 6months and 5years after their primary repair surgery. We retrieved the facial plaster casts of the enrolled patients and recorded the key nasolabial measurements. The outcome variables included the prolabial length (PL), peak distance, nasal width, and columellar length (CL). The data were analyzed using a general linear model for repeated measures, and the linear association was tested using SPSS. The level of testing efficiency (P value) was set at .05. A total of 160 patients, 80 who had undergone BCCLP and 80 CPO controls, were included. All nasolabial measurements in the BCCLP group had increased during the 5-year follow-up period. The PL of the BCCLP group had increased more quickly than the PL of the CPO group (P=.000<.05), but the CL had increased nearly as much (P=.270). For the primary correction of bilateral cleft lip nose deformity, dissection and repositioning of the cleft lip and nose did not significantly inhibit the growth of the nasolabial region in the first 5years after surgery. Nose deformities should not remain uncorrected after primary surgical repair. In contrast, cleft surgeons should focus on the finer adjustment of columella with less doubt regarding adverse effects.

Safety and Efficacy of Pre-Operative, Short Course Radiation Therapy for Prostate Cancer: Results From a Phase I Trial

Up to 60% of patients (pts) with prostate cancer that extends beyond the prostatic capsule will have positive resection margins following radical prostatectomy. Post-operative radiation therapy (PostOp) is routinely offered to those pts. Although this improves local control and overall survival, it results in significantly more late toxicity than surgery alone. Pre-operative radiation therapy (PreOp) has become the standard for soft tissue sarcoma and rectal cancer, improving local control and reducing toxicity compared to PostOp. We report the results of a Phase I trial, investigating the use of PreOp for prostate pts at high risk of extra-capsular extension. Following REB approval, prostate cancer pts at high risk of extra-capsular extension were prospectively identified for inclusion based on T-stage, N-stage, PSA and Gleason score. Since this was a Phase I study of safety and efficacy for a novel treatment regimen, a small sample size was used (15 pts). Patients received 25 Gy in 5 daily fractions to the prostate-only, followed by a radical prostatectomy 1-2 weeks after RT completion. Study endpoints were descriptive in nature due to the small sample size, and included intra-operative morbidity, early, late and ultra-late urinary (U) and gastrointestinal (GI) toxicity (using RTOG and CTCAE grading (G) systems). Between 2001 and 2004, 15 pts enrolled in the trial and all received 25 Gy over 5 consecutive fractions. Fourteen pts were irradiated with a 6-field conformal plan, and one with IMRT. Planning constraints were used to limit the dose to the femoral heads, bladder and rectal walls. Patients were treated with a full bladder / empty rectum protocol, employing daily portal image guidance based on intra-prostatic markers. G2 diarrhea (1 pt) and G2 cystitis (1 pt) were reported during RT. Fourteen pts went on to receive a non-nerve sparing radical retropubic prostatectomy, which included bilateral lymph node dissection for 13 pts. Four pts required a blood transfusion, and 3 pts had adhesions surrounding the prostate. Surgical margins were positive in 7 pts, PSA was detectable immediately after surgery in 5 pts. By 45 months, one patient had reported one episode of rectal bleeding that resolved with corticosteroids. Eleven pts reported urinary incontinence (73%), 3 had a urethral stricture (20%), and 1 reported G2 intermittent haematuria. To date, the median follow-up is 147 months. Two pts (14%) report G2 U toxicity, and 6 pts (43%) G3 U toxicity. One patient experienced transient G2 proctitis. At last follow-up, 8 (57%) and 6 (43%) pts have biochemical and metastatic progression, respectively. There were two prostate cancer related deaths. Delivery of short-course radiation therapy followed by an immediate prostatectomy is feasible. However, the incidence of late U toxicity is approximately 3-fold higher in this study than in Phase III trials of PostOp, with no appreciable benefit in biochemical or metastases free survival compared to those PostOp studies. Future studies of this regimen must be cautiously considered, and should include radiotherapy and surgical advances that might reduce toxicity, and multiparametric and/or molecular imaging to more precisely identify pts who may benefit from such an approach. This study emphasizes the need for long term follow-up data to fully appreciate the toxicity of such novel approaches.

Is total thyroidectomy and bilateral central lymph node dissection essential for patients with unilateral cN1a papillary thyroid carcinoma?

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Robotic Postchemotherapy Retroperitoneal Lymph Node Dissection for Testicular Cancer

BackgroundPostchemotherapy retroperitoneal lymph node dissection (pcRPLND) is mandated in patients with nonseminomatous germ cell tumor found to have residual masses after chemotherapy. Performed via the open approach, pcRPLND can incur significant perioperative morbidity. ObjectiveTo demonstrate the feasibility of robotic pcRPLND (r-pcRPLND) and provide evidence for its selection criteria. Design, setting, and participantsA retrospective search identified 93 patients undergoing pcRPLND between April 2007 and March 2018, comprising 30 r-pcRPLND and 63 open pcRPLND (o-pcRPLND) procedures performed by a single surgeon. Interventionr-pcRPLND and o-pcRPLND. Outcome measurements and statistical analysisBaseline clinicopathologic characteristics and intraoperative variables including operating room (OR) time, estimated blood loss (EBL), resection of adjacent organs, and intraoperative consultation with other surgical services were recorded. Hospital length of stay (LOS) and perioperative complications were assessed as per the Clavien-Dindo classification, and oncologic outcomes such as nodal yield, histologic distribution, pathologic staging, time to recurrence, and cancer-specific survival were compared. Results and limitationsr-pcRPLND was performed in a well-selected cohort with lower clinical stage (p=0.006), favorable International Germ Cell Cancer Collaborative Group classification (p=0.01), and smaller retroperitoneal mass (p=0.001). o-pcRPLND required more frequent bilateral template dissection (88.9% vs 43.3%; p<0.001), resection of adjacent organs (36.5% vs 10%; p=0.007), consultation with other surgical services (46% vs 2%; p<0.001), and auxiliary procedures (54.0% vs 20%; p=0.003) to achieve complete oncologic control. OR time was similar between the two groups (o-pcRPLND 375min vs r-pcRPLND 388min; p=0.16) and EBL was significantly lower in r-pcRPLND (234 vs 825ml; p<0.001). Median LOS was significantly shorter after r-pcRPLND (2 vs 7d; p<0.001). A total of 31 patients (33%) suffered postoperative complications, of whom 18 (19.4%) had major complications. Nodal yield was similar (o-pcRPLND 23 vs r-pcRPLND 24; p=0.8). The distribution of lesion histology (necrosis/teratoma/GCT) was also similar pcRPLND (o-pcRPLND 25.4%/57.1%/17.4% vs r-pcPLND 33.3%/50%/16.7%; p=0.51). Overall, tumor recurred in 15 patients (16.1%), including three following r-pcRPLND (10%), all outside the operative field. On univariate analysis, surgical approach was not a significant predictor of time to recurrence (p=0.34). One limitation was that antegrade ejaculation was not assessed. ConclusionsWith rigorous patient selection, r-pcRPLND can be safely performed and may reduce perioperative morbidity while maintaining oncologic proficiency. Patient summaryResection of residual retroperitoneal mass after chemotherapy in patients with metastatic testicular cancer can be performed safely via a robotic approach. Robotic surgery can reduce the morbidity of the procedure.

A phase I pilot study of preoperative radiotherapy for prostate cancer: Long-term toxicity and oncologic outcomes.

60 Background: Pre-operative radiotherapy (PreORT) improves local control in various cancer types, and has become an established oncologic treatment strategy. During 2001-2004, we conducted a phase I pilot study assessing the role of short-course PreORT for men with unfavourable intermediate- and high-risk localized prostate cancer (PCa). We present long-term follow-up toxicity and oncologic outcomes. Methods: Eligible patients had histologically proven PCa, cT1-T2N0M0, PSA &gt; 15-35 ng/ml with any Gleason score, or PSA 10-15 ng/ml with Gleason score ≥7. Patients received 25 Gy in five consecutive daily fractions to the prostate, followed by radical prostatectomy (RadP) within 14 days after RT completion. Primary outcomes were intra-operative morbidity, and late genitourinary (GU) and gastrointestinal (GI) toxicities. Acute toxicity was assessed during radiotherapy treatment on daily basis using RTOG grade scoring scale. Patients were assessed post-RadP clinically and with PSA at 1 and 6 months, and every 6 months. Intra- and Post-RadP toxicity was documented prospectively and scored as per Common Terminology Criteria for Adverse Events v4.0. Biochemical failure (BF) was determined based on two consecutive post-RadP PSA &gt; 0.2 ng/ml. Results: Fifteen patients were enrolled; 14 patients completed PreORT followed by RadP, which also included bilateral lymph node dissections in 13 cases. Median follow-up was 12.2 years (range 6.7-16.3 years). Late GU toxicity was common, with 2 patients (14.3%) experiencing G2 toxicity, and 6 patients (42.8%) G3 toxicity. There were no G4-5 late GU toxicity. Late GI toxicity was infrequent, with only 1 patient (7.1%) experiencing transient G2 proctitis. At last follow-up, 8 (57.1%) and 6 (42.8%) patients experienced BF and metastatic disease recurrence, respectively. Conclusions: The use of PreORT in men with high-risk PCa is associated with unexpected high-rates of late GU toxicity. Future studies examining the role of RT pre-RadP must cautiously select RT technique and dose schedule. Importantly, long-term follow-up data is essential to fully determine the therapeutic index of PreORT in the management of localized PCa. Clinical trial information: NCT00252447.