Careful Surgical Staging Research Articles

Unilateral lateral mass fixation of cervical spinal low-grade chondrosarcoma with intralesional resection: A case report.

In total, ~10% of chondrosarcomas arise from the mobile spine, and these are prone to local recurrence despite being low-grade malignant tumors. Almost all patients will present with pain and a palpable mass in the area of the lesion. For adequate management of the disease, an early diagnosis and careful surgical staging are important. The present study reports a case of cervical spinal low-grade chondrosarcoma in a young female presenting with a slow-growing mass that had not metastasized during a 3-year period. A unilateral lateral mass fixation system of screws and rods was installed following an intralesional resection of the tumor. At present, two years following the surgery, the patient exhibits no neurological deficiency symptoms. Therefore, unilateral fixation presents an effective alternative technique for the treatment of patients with a lesion on the cervical spine.

Spinal Osteosarcoma

Although osteosarcoma represents the second most common primary bone tumor, spinal involvement is rare, accounting for 3%–5% of all osteosarcomas. The most frequent symptom of osteosarcoma is pain, which appears in almost all patients, whereas more than 70% exhibit neurologic deficit. At a molecular level, it is a tumor of great genetic complexity and several genetic disorders have been associated with its appearance. Early diagnosis and careful surgical staging are the most important factors in accomplishing sufficient management. Even though overall prognosis remains poor, en-block tumor removal combined with adjuvant radiotherapy and chemotherapy is currently the treatment of choice. This paper outlines histopathological classification, epidemiology, diagnostic procedures, and current concepts of management of spinal osteosarcoma.

Malignant ovarian germ-cell tumours

Malignant ovarian germ-cell tumours account for about 5% of all ovarian malignancies and typically present in the teenage years. They are almost always unilateral and are exquisitely chemosensitive. As such, the surgical approach in young women with such tumours confined to a single ovary should aim to preserve fertility. In early disease, a unilateral salpingo-oophorectomy with careful surgical staging is of great importance in selecting appropriate adjuvant therapy. In advanced disease, the role of aggressive cytoreducation is not well defined, and removal of both ovaries does not confer improvement in outcome. Bleomycin, etoposide and cisplatin combination chemotherapy is regarded as the gold standard for adjuvant therapy. Studies evaluating ovarian and reproductive capacity after conservative surgery and chemotherapy for malignant ovarian germ-cell tumours have consistently demonstrated excellent prognosis, with the return of normal menstrual function and fertility rates in these women with no increase in the risk of teratogenicity.

Spinal chondrosarcoma: a review.

Chondrosarcoma is the third most common primary malignant bone tumor. Yet the spine represents the primary location in only 2% to 12% of these tumors. Almost all patients present with pain and a palpable mass. About 50% of patients present with neurologic symptoms. Chemotherapy and radiotherapy are generally unsuccessful while surgical resection is the treatment of choice. Early diagnosis and careful surgical staging are important to achieve adequate management. This paper provides an overview of the histopathological classification, clinical presentation, and diagnostic procedures regarding spinal chondrosarcoma. We highlight specific treatment modalities and discuss which is truly the most suitable approach for these tumors. s and original articles in English investigating these tumors were searched and analyzed with the use of the PubMed and Scopus databases with “chondrosarcoma and spine” as keywords.

Non-epithelial ovarian cancer: ESMO Clinical Recommendations for diagnosis, treatment and follow-up

Non-epithelial ovarian cancer: ESMO Clinical Recommendations for diagnosis, treatment and follow-up

Clinical and morphological features of ovarian pure dysgerminoma: a report of a 14 years old girl

Dysgerminoma is best known as the ovarian counterpart of seminoma of the testis Relatively uncommon tumors, dysgerminomas account for less than 2% of all ovarian cancer. We report a case of a 14 years old girl with a large and rapidly growing unilaleral ovarian dysgerminoma. Examination of the surgical specimen showed a tumor of 27x17x8 cm in size and 4800 gr. in weight. It was oval in shape with a slightly glistening fibrous capsule, soft but solid and hemorrhagic. The mass arose from the right ovary and did not invade any surrounding structures. The tumor and the ovary were torqued with its fallopian tube. Microscopic examination showed typical characteristics of ovarian dysgerminoma, with a micrometastasis in the omentum (in the vicinity of the tumor). The patient underwent a right salpingo-oophorectomy, had an uncomplicated postoperative course and received radio and chemotherapy Thirty months after the operation, the patient is in good health and with normal ultrasound and laboratory results. We believe that conservative surgery followed by adjuvant radiotherapy and chemotherapy seems to be ideal treatment in case of pure ovarian dysgerminoma when careful surgical staging confirmed the unilaterality of disease.

Chondrosarcoma of the mobile spine: report on 22 cases.

A retrospective review of 22 cases of chondrosarcoma arising from the mobile spine. To evaluate the role of oncologic and surgical staging in correlating management and outcome of chondrosarcoma involving the spine. Approximately 10% of chondrosarcomas arise from the mobile spine, occurring mainly in adults, particularly elderly men. The course of the disease depends on the aggressiveness of the tumor, but also is influenced by the management. Intralesional surgery is followed almost constantly by local recurrence even with adjuvant therapy. All charts, radiographs, and images were reviewed. The composite information provided by this review allowed for oncologic and surgical staging of the reviewed cases. According to Enneking criteria, the surgical procedures were defined as curettage (piecemeal excision) or en blocexcision. The margins were submitted to histologic study and reported as intralesional, marginal, or wide. - As primary management, 10 intralesional curettages (follow-up period, 2-119 months; average, 61 months) and 12 en bloc excisions (follow-up period, 39-207 months; average, 97 months) were performed. A total of 33 procedures were performed, including the management of the recurrences (18 curettages and 15 en bloc excisions: one for soft tissue recurrence). A clinical and radiographic follow-up period of of 2 to 236 months (average, 81 months; minimal follow-up period for survivors, 30 months; average follow-up period for survivors, 115 months) was available for all the patients. Three recurrences occurred in 14 patients treated by en bloc excision at onset or for recurrence, two in cases of histologically proven contaminated or intralesional margins. All but one patient were alive at final follow-up evaluation. Conversely, all the patients treated by one or more curettages (with or without adjuvant radiation therapy) had at least one recurrence, and 8 of 10 of these patients died of the disease. At final follow-up evaluation, nine patients had died of the disease; nine were continuously disease free (but one had died of another unrelated malignancy); and four were symptom free after management for recurrences (one was found alive 155 months after a soft-tissue metastasis en-bloc excision). En bloc excision, with wide or marginal histologic margins, is the suggested management for chondrosarcomas of the spine. Early diagnosis and careful surgical staging and planning are necessary for conducting adequate management. However, tumor contamination of the specimen margins, even in a small area, or spreading of the tumor myxoid content can worsen the prognosis.

Ovarian Endometrioid-like Yolk Sac Tumor Treated by Surgery Alone, with Recurrence at 12 Years

We describe the case of a stage Ia endometrioid-like yolk sac tumor (YST) of the ovary, which was originally misdiagnosed as a malignant struma ovarii and not treated with adjuvant chemotherapy. After 12 years, a contralateral dermoid cyst was excised along with a small omental nodule of partially necrotic and calcified endometrioid-like YST. No tumor was detected in several other biopsy specimens, and a peritoneal lavage was negative for tumor cells. Since there was no evidence of remaining tumor and the serum α-fetoprotein (AFP) level was normal after the second operation, the patient was followed. Serial serum AFP levels remained normal for 4 months. At a second-look laparotomy after 4 months, a small tumor nodule was removed from the cul-de-sac. Postoperatively, the patient received three cycles of BEP chemotherapy. The long disease-free interval after the first operation in spite of the presence of occult spread to the omentum and to the pouch of Douglas in this case indicates that some endometrioid-like YSTs may have an indolent course. The present case underscores the importance of careful surgical staging and of long-term follow-up in cases of primitive germ cell tumors of the ovary.

Chordoma of the spine above the sacrum. Treatment and outcome in 21 cases.

Twenty-one cases of chordoma arising in the mobile spine were retrospectively reviewed. All the cases were submitted to oncologic and surgical staging to correlate treatment and outcome. Excluding plasmacytomas, chordoma is the most frequent primary malignant tumor of the spine, occurring mainly in elderly men. The course of the disease is slow, metastases occur late, and death can result from complications related to local extension of the disease. Complete excision of the tumor according to oncologic criteria can be hampered by extension of the tumor and by anatomic constraints in the mobile spine. All charts, radiographs, and images were reviewed. The composite information provided by this review allowed for oncologic and surgical staging of these cases. Treatment was defined according to Ennekings criteria. All the patients were followed for determination of their status clinically and radiographically. Ten patients died (1 to 137 months after treatment, mean 65 months); four patients are alive with the disease; only seven patients (33%) are symptom free at the final follow-up (39 to 112 months after treatment, mean 65 months). Conventional radiation therapy was not effective in eradicating the tumor, even if associated with palliative or debulking surgery: of 15 cases, 12 were associated with recurrence or progression. Intralesional surgery also was not effective (two recurrences in two cases, 18 to 41 months later). En bloc excision of the lesion, sometimes combined with radiation therapy as an adjuvant, obtained the best results (four patients disease free at 39 to 112 months, mean 77 months). En bloc excision--even if marginal--is the treatment of choice of chordomas of the spine. Early diagnosis and careful surgical staging and planning are necessary. Megavoltage radiation can be administered as an adjuvant.

Impact of combined modality therapy on the treatment of adenocarcinoma of the colon.

An emphasis on careful surgical staging of adenocarcinoma of the colon has improved the predictive value of tumor staging systems. As a result of improved staging and carefully conducted randomized clinical trials, adjuvant therapy of locally advanced colon cancer, based on 5-fluorouracil chemotherapy, has been proven to substantially reduce recurrence rates and significantly increase overall survival for selected patients. Improved treatments and schedules are currently being studied in randomized trials and may increase the efficacy of this adjuvant therapy. Radiation therapy has not as yet been integrated into the adjuvant treatment of colon carcinoma. The application of a combined approach of surgery and chemotherapy in selected patients with liver metastases may also improve cure rates and long-term survival. The developing understanding of molecular determinants for the biological behavior of these cancers will increase the opportunities to identify, on the one hand, those patients who will benefit from specific therapies, and, on the other hand, new therapeutic strategies and treatments.

Management of Early-Stage Oyarian Cancer

Approximately 30% of patients with epithelial ovarian cancer present with localized or early-stage disease. Accuracy of staging is dependent on careful surgical staging. Subsets of patients with specific prognostic factors have now been identified who do not require additional therapy after proper primary surgical staging. Poor prognosis patients do require adjuvant therapy. Whole abdominal irradiation, intraperitoneal P32, and single agent and combination chemotherapy have been utilized. The optimal therapy or whether any therapy is truly effective remains unknown.

Watch and wait after careful surgical treatment and staging in well-differentiated early ovarian cancer

Patients with well-differentiated epithelial ovarian cancer Stages Ia, Ib, Ic, and IIa (FIGO 1976) were observed after surgical treatment without adjuvant therapy. Careful surgical staging was required, and the extent of the staging procedure was assessed in each individual patient. There were 107 patients entered in the study by nine Dutch oncology centers. Of these 107, 21 did not fulfill all of the inlet criteria of the study and were excluded. Central pathologic review was performed in the remaining 86 cases, revealing that there was borderline tumor in seven patients, moderately or poorly differentiated tumor in nine patients, and tumor of nonepithelial histologic cell type in one patient. In two cases, no material for histologic review was available. After exclusion of these 19 cases, 67 patients were further analyzed. None of these 67 patients was lost during the follow-up period that ranged from 19 to 99 months (mean, 50 months). Tumor recurrence was found in four patients after 11, 25, 34, and 34 months of follow-up, all of whom died shortly after diagnosis of the recurrence without satisfactory response to secondary treatment. For the patients who underwent the most extensive staging procedure, disease-free 5-year survival was 100%. For the patients who were inaccurately staged, disease-free 5-year survival was 88%. It was concluded that well-differentiated early stage (Ia-IIa) ovarian cancer carries an excellent prognosis after surgical treatment and complete surgical staging, with the possible exception of patients with Stage Ic disease with malignant peritoneal washings. Furthermore, it was considered that the application of more objective and consistent ways of assessing tumor grade should be encouraged. Surgical staging should be regarded as the golden standard in defining subsets of low-risk patients and should be included and clearly defined in future trials on early ovarian cancer.

Experience with stromal tumors and germ-cell tumors of the ovary

Thirty patients with tumors of the ovarian stroma (28 granulosa cell tumors, two androblastomas) and 12 women with germ-cell tumors (nine dysgerminomas, two teratomas, one endodermal sinus tumor) were treated at the Department of Obstetrics and Gynecology of the University in Graz between 1972 and 1989. Of the 28 patients with granulosa-cell tumors, 24 (86%) had stage I disease, 27 were primarily treated by surgery, and seven (25%) developed a recurrence (three stage I, three stage III and one stage IV). There were three recurrences in the peritoneal cavity and two in the paraaortic nodes; six of the seven patients died of recurrent disease.Four of nine patients with stage I dysgerminomas developed recurrences, two of which were located in the para-aortic nodes. Three patients with recurrence after stage Ia disease are currently alive without evidence of disease; one patient with stage Ib disease died 11 months after a paraaortic recurrence.Wider use of cytostatic combinations and careful surgical staging, including lymphadenectomy, may improve the survival of patients with stromal or germ-cell tumors.

5 - Importance of Proper Staging in Ovarian Carcinoma

Therefore, on discovery of a clinical Stage I or II ovarian carcinoma through a previously made subumbilical incision, the incision should be extended above the umbilicus to enable one to inspect the diaphragm and remove the omentum from the transverse colon. Biopsy of any raised lesion of the diaphragm can easily be done with laparoscopic biopsy forceps and is associated with minimal morbidity. Routine biopsy of a normal appearing diaphragm is not advocated. Pelvic and paracolic washings for cytological evaluation for malignant cells are obtained by instilling 100-200 cm3 of saline into the pelvis and a similar amount into the right and left paracolic spaces, respectively, and aspirating the fluid for cytological evaluation. Most women with ovarian cancers are still primarily operated on by gynaecologists who are not trained in para-aortic and pelvic lymph node sampling. Ideally, however, women with clinical Stage I or II ovarian cancers should have biopsy of any palpable para-aortic or pelvic lymph node. Such careful surgical staging will: define those patients who are apt to truly have Stage I or II ovarian cancer; improve and refine adjuvant therapy for Stage I and II ovarian cancer; and allow for adjuvant therapy for patients found to have Stage III ovarian cancer, discovered at the time of surgical staging for presumed localized ovarian cancer. The significance of the latter is seen in Table 10 and in the fact that with the subsequent increase to 61 patients evaluated by the Ovarian Cancer Study Group, the incidence of occult metastases from Stage I and II ovarian cancer remain strikingly unchanged (Young et al, 1983, unpublished observations).

Computed tomography of bladder: Staging of bladder cancer using low density opacification technique

In the course of computed tomographic (CT) evaluations involving 200 patients with suspected pelvic disease we have found that scan quality is often suboptimal. A preliminary report employing a low density bladder opacification method is presented whereby an indwelling catheter is inserted to control bladder volume and facilitate the instillation of low density iodinated contrast agent (0.6% Renografin-60). The patient remains supine throughout the twenty-five-minute procedure. Observations during the CT staging and follow-up of a controlled group of 8 patients undergoing immunotherapy and/or radiation therapy for bladder carcinoma indicate that this is a simple, safe, and effective staging procedure. We have obtained reliable clinical-radiologic-pathologic correlation as a result of careful surgical staging and biopsy, followed by open surgery and full pathologic examination. It is hoped that this information will help initiate other similar studies to determine the diagnostic accuracy of this method and thus its use in pretherapeutic evaluation of the bladder lesion and its subsequent response to treatment.