Complete Extirpation Research Articles

Malignant presternal goitre

Goitres usually enlarge and descend caudad into the substernal space and are not palpable. We report on a patient whose goitre spread downward but anterior to the sternum. The thyroid mass was subsequently removed and was proven to be a papillary thyroid carcinoma. The mechanism by which a presternal goitre develops is probably due to invasion and erosion of the strap muscles and the cervical linea alba. The clinical implication of this presentation is complete extirpation of the presternal goitre with a cuff of the strap muscles.

The “Stepped Caudal Exposure” Technique for Excision of Nasal Dermoids With Intracranial Extension

Nasal dermoid sinus cysts (NDSCs) are rare congenital malformations derived from ectodermal and mesodermal tissues. There are numerous reports on surgical approaches for extirpation of NDSCs with intracranial extension. Here we describe the "stepped caudal exposure" approach, a technique that minimizes the risk for bacterial infection of the central nervous system from the nasal space. This procedure involves a stepwise osteotomy of the frontal and nasal bones that permits sufficient exposure to allow complete extirpation of NDSCs; it was used successfully to treat a 20-month-old boy with NDSC extending into the intracranial space and an infectious abscess. After NDSC extirpation and debridement of the abscess, the anterior skull base was reconstructed with bone grafts placed on both the intracranial and intranasal sides of the widened foramen cecum. Thereafter, each graft was covered by frontal pericranial flaps for blood supply. These modified surgical techniques may enhance the safety of surgical removal of NDSC, particularly in cases accompanied by infectious lesions such as abscesses.

Thymektomie bei Myasthenie und/oder Thymom

Thymectomy, the surgical removal of the thymic gland, is essential in cases of thymoma. The majority of cases of a myasthenia gravis (MG) represent a relative indication for thymectomy which requires cooperation with specialized neurologists. Patients with MG may present with a tumor of the thymic gland. In case of suspicious thymoma, the resectability of the tumor has to be evaluated in the preoperative diagnostic. The clinical condition of patients with MG has to be stabilized preoperatively. The aim of thymectomy is the radical removal of thymoma and/or maximal improvement of MG symptoms. This requires the complete extirpation of the thymic gland including all ectopic thymic tissue in the anterior mediastinum. There is a variety of surgical techniques for performing a complete thymectomy. In addition to the conventional techniques with sternotomy, the significance of minimally-invasive approaches is increasing rapidly. Despite the ongoing scarcity of data of higher evidence concerning the procedure of thymectomy an increasing number of equivalent results with minimally-invasive operation techniques for MG and for thymoma are available. The successful surgical performance of a thymectomy is part of an interdisciplinary cooperation in the perioperative treatment of MG as well as the postoperative long-term care for patients with MG and/or thymoma.

Surgical management of a retro-rectal cystic hamartoma (tailgut cyst) using a trans-rectal approach: a case report and review of the literature

IntroductionRetro-rectal cystic hamartoma (tailgut cyst) is a rare congenital developmental lesion arising from post-natal primitive gut remnants in the retro-rectal space. The rarity of the lesion and its anatomical position usually leads to difficulty in diagnosis and surgical management. Complete surgical resection remains the cornerstone of treatment. A dozen or so surgical approaches have been described in the literature to date to make the operation as simple as possible, but the trans-rectal access route is extremely rarely reported and not well described. Here, we present a case that demonstrates the trans-rectal approach to a retro-rectal tumor is a feasible option in terms of surgical radicality, minimal invasiveness and safety for carefully selected patients with this rare type of retro-rectal cystic lesion.Case presentationA 29-year-old Caucasian woman was referred to our institution due to perineal pain extending to the right inguinal region. Her symptoms had been present for the last two months. She was first examined at her regional hospital for a suspected ruptured ovarian cyst; however, after consultation with a gynecologist and a computed tomography scan of her pelvis, a tumor in the retro-rectal space was discovered. Our patient was admitted to our hospital and when a pelvic magnetic resonance imaging study confirmed the diagnosis of the retro-rectal cystic formation, a complete extirpation of retro-rectal tumor fixed to the coccyx using trans-rectal approach was performed. The final pathological diagnosis was retro-rectal cystic hamartoma (tailgut cyst) with no evidence of malignancy. Her post-operative course was uneventful, and at four months after surgery our patient is symptom free with no evidence of recurrent or residual disease.ConclusionsTrans-rectal excision is feasible in terms of surgical radicality and is a simple to perform, minimally invasive and safe option, providing complete recovery for carefully selected patients with retro-rectal cystic hamartoma treated operatively.

Surgical Excision with Forehead Flap as Single Modality Treatment for Basal Cell Cancer of Central Face: Single Institutional Experience of 50 Cases

Basal cell carcinoma (BCC) is the most common skin cancer worldwide. The WHO has defined it as “a locally invasive, slowly spreading tumor which rarely metastasizes, arising in the epidermis or hair follicles and in which the peripheral cells usually simulate the basal cells of the epidermis.” Here we discuss the management of BCCs of central face with surgical excision and reconstruction with forehead flap as single modality treatment. Material and Methods. This is a retrospective review of 50 patients who underwent surgical excision of BCC involving the facial region followed by primary reconstruction using forehead flaps at a single institution. There were 20 males and 30 females, mean age of 59 years. Results. No recurrence at primary site was observed during the follow-up of 1–4 yrs. There was no ectropion or exposure sequela. However, epiphora was evident. Size of lesions ranged from 2 to 6 cm. Keloid formation was seen in 2 (4%) patients. Functional and cosmetic outcomes were satisfactory. Conclusion. For the face, the best reconstructive effort eventually fails in the face of tumor recurrence. The forehead flap represents one of the best methods for repair of extensive facial defects. Complete tumor extirpation, the primary event, is the key.

A modified single mini-incision complete urinary tract exenteration for urothelial carcinoma in dialysis patients.

Objective. To present our experience with single mini-incision complete urinary tract exenteration (CUTE) for female dialysis patients suffering from urothelial carcinoma (UC). Patients and Methods. Institutional review board approval was obtained. From 2005 through 2012, 14 female dialysis patients with UC underwent single mini-incision CUTE, in combination with radical hysterectomy and bilateral salpingo-oophorectomy. All were placed in the modified dorsal lithotomy position without repositioning. An infraumbilical midline mini-incision was made. Bilateral nephroureterectomy was first performed entirely extraperitoneally, followed by radical cystectomy with removal of the uterus and ovaries transperitoneally. Results. All procedures were done successfully without major complications. The median operative time was 242.5 minutes, and estimated blood loss was 500 mL. The median time to oral intake was 2 postoperative days; the median hospital stay was 11 days. Ten patients remained cancer-free at a median follow-up of 46.5 months; six patients were confirmed as having preoperatively undetectable UC or renal cell carcinoma, even after reviewing preoperative computed tomography. Conclusions. This modified technique provides a time-saving complete urinary tract extirpation to eliminate preoperatively undetectable malignancy, reduce metachronous recurrences, and avert perioperative complications associated with pneumoperitoneum and repositioning. Good cancer control and early convalescence can mutually be achieved in experienced hands.

Multiple Hydatid Cysts of the Pancreas: A Literature First

Context: Pancreatic hydatid disease is rare, occurring in less than 2% of all patients with hydatid disease. Multiple hydatid cysts of the pancreas have not been reported before. Case report: A 63 year old lady presented with chronic epigastric pain without weight loss, vomiting or jaundice. CT scan revealed multiple small cystic pancreatic lesions. There was no extra-pancreatic disease. Endoscopic ultrasound showed 10 cysts distributed throughout the pancreas with the largest being 1.3 cm. The aspirated fluid was mucin free, low in amylase and CEA. FNAC showed refractile structures and membranous remnants consistent with a hydatid cyst. The cyst distribution would have warranted a total pancreatectomy for complete extirpation. As the cysts were uncomplicated and relatively asymptomatic, a conservative non-operative approach was chosen. She has shown symptomatic improvement and has stable disease after 6 months with Albendazole treatment. Conclusion: Endoscopic ultrasound is useful in the diagnosis of pancreatic hydatid disease. In selected cases, non-operative management is an option that needs to be considered.

Multivisceral and extended resections during pancreatoduodenectomy increase morbidity and mortality

Improvements in outcomes after pancreatoduodenectomy (PD) have permitted more complex resections. Complete extirpation at PD may require multivisceral resection (MVR-PD); however, descriptions of morbidity of MVR-PD are limited to small, single-institution series. The National Surgical Quality Improvement Project database (2005-2011) was used to compare 30-day postoperative morbidity of PD with MVR-PD. Concurrent resection of colon, small bowel, stomach, kidney, or adrenal gland defined MVR-PD. Of 9,927 PDs, MVR-PD was performed in 273 patients (3%). MVR included colon (58%), small bowel (30%), and gastric (12%) resections. Preoperative comorbidities were similar between groups. Pancreatic, duodenal, or periampullary cancer was present in 75% of patients. Mortality (8.8% vs 2.9%) and major morbidity (56.8% vs 30.8%) were much greater for MVR-PD versus PD alone (P < .001). MVR-PD patients also experienced greater rates of wound, pulmonary, cardiac, thromboembolic, renal, and septic complications. On multivariable regression, MVR was an independent predictor of death (odds ratio [OR], 3.4; P < .001), overall morbidity (OR, 3.01; P < .001), major morbidity (OR, 3.21; P < .001), and minor morbidity (OR, 1.65; P = .03). Among patients undergoing PD+MVR, colectomy was an independent predictor of increased overall morbidity (OR, 1.96; P = .03) and major morbidity (OR, 1.90; P = .02). Margin-negative resection may require MVRs at the time of PD. MVR at is associated with 3-fold mortality and substantial morbidity after adjusting for comorbidities. Colectomy independently predicted major morbidity. At PD, the morbidity of MVR should be approached with caution when attempting margin-negative resection.

Principles of anterior skull base resection: Open and endoscopic techniques

Resection of a neoplasm is the most common indication for an anterior skull base approach. This surgery aims to obtain a complete extirpation (with negative histologic margins) yielding the best oncologic outcome, while producing the least degree of functional and cosmetic morbidity. Open or endoscopic endonasal routes, or both, may be used for the resection based on the tumor stage, histology, and patient's specific needs and characteristics, as well as the surgeon's training and preference. Traditional open craniofacial approaches require a craniotomy and maxillofacial osteotomies that include those necessary for a subfrontal approach. This technique remains one of the primary strategies to manage anterior cranial base lesions, especially those with significant extension or involving critical neurovascular structures. A significant recent development in cranial base surgery is the adoption of endonasal endoscopic approaches, which have been applied to resect the anterior cranial base. Its benefits include the minimal manipulation of the brain (no retraction), avoidance of maxillofacial osteotomies, and lack of cosmetic deficits. Endoscopic, endoscopic-assisted, and open approaches afford advantages and disadvantages and have different indications and limitations; therefore, the skull base surgeon (or the skull base surgery team) must be versed in all techniques.

Transmaxillary approach to the infratemporal fossa

The infratemporal fossa posses significant challenges to surgical access. Complete extirpation of the pathology in the region most be balanced with iatrogenic deficits and tumor biology. The advent of endoscopy has expanded the reach of anterior transnasal transmaxillary approaches. Herein we present a brief description of these techniques. The infratemporal fossa posses significant challenges to surgical access. Complete extirpation of the pathology in the region most be balanced with iatrogenic deficits and tumor biology. The advent of endoscopy has expanded the reach of anterior transnasal transmaxillary approaches. Herein we present a brief description of these techniques.

Range dynamics of the reindeer in Europe during the last 25,000 years

AbstractAimTo understand the role and significance of the reindeer, Rangifer tarandus (Linnaeus, 1758), as a specific indicator in terms of late Quaternary biogeography and to determine the effects of global climate change on its range and local extinction dynamics at the end of the Ice Age.LocationLate Pleistocene/early Holocene range of reindeer over all of central and western Europe, including southern Scandinavia and northern Iberia, but excluding Russia, Belarus and the Ukraine.MethodsRadiocarbon‐dated subfossil records of R. tarandus from both archaeological and natural deposits younger than 25,000 years were assembled in a database. The distribution area was divided into six representative regions. The 14C dates were calibrated and plotted chronologically in maps in order to compare presence and absence and regional extinction patterns from one region to another.ResultsAfter the Last Glacial Maximum, R. tarandus disappeared from south‐eastern Central Europe but survived in the south‐west until the Younger Dryas period. The ‘Allerød warming’ did not result in complete extirpation of reindeer in Central Europe. Reindeer probably disappeared c. 11,250 years ago in the North European Plain and c. 11,000 years ago in the British Isles. In southern Scandinavia the species survived until c. 10,300 years ago.Main conclusionsThe late Quaternary record for reindeer in Europe during the last 25 kyr shows a climate‐driven dispersal and retreat in response to climate change, with regional variations. The collapse of the mammoth steppe biome did not lead to the local extinction in Europe, as in the case of other megafaunal species. Rangifer tarandus co‐existed for about 3000 years during the Late Glacial and early Holocene with typical temperate species such as red deer and roe deer in non‐analogue faunal communities. The regional extinction at the end of the Pleistocene coincides with the transition from light open birch/pine forests to pine/deciduous forests.

Projected population persistence of eastern hellbenders (Cryptobranchus alleganiensis alleganiensis) using a stage-structured life-history model and population viability analysis

The population of eastern hellbenders (Cryptobranchus alleganiensis alleganiensis) in the Blue River, Indiana has undergone a dramatic decline over the last decade. Recruitment in these declining populations has been negligible, and populations are now composed almost entirely of older age classes (upwards of 20 years old). Given this dramatic decline, it is imperative to assess the impacts of these demographic patterns on population growth and long-term stability. Therefore, we developed a stage-structured, life-history model to examine the effects of varying levels of egg, juvenile, and adult survivorship on abundance, recruitment, and long-term population projections. We performed a sensitivity analysis of the model and determine which life-history parameters have the greatest potential to increase/stabilise hellbender population growth. Finally, we conducted a population viability analysis to determine the probability of extinction associated with varying management strategies. For eastern hellbender populations in Indiana, adults (especially females) are the most important component of long-term population viability. Sensitivity and elasticity analyses of the Lefkovitch matrix revealed that survival of adult and egg/larvae life-history stages are the most important for focused management efforts. Indeed, adults had the highest elasticity and reproductive value in the matrix model. Increasing survival by as little as 20% corresponded to the turning point at which the population ceased to decline and increased abundance (28% survival of egg/larvae). The importance of the transition from subadult to adult (transitional matrix element) was identified as an additional factor in maintaining abundance based on the relatively long period spent in this life-history stage (seven years for females). A population viability analysis was conducted to assess the likelihood and projected time frame of extinction for this population under no management (∼25 years to complete extirpation; probability of extinction=1) and if management efforts such as captive rearing and headstarting are undertaken (probability of extinction <0.2 at 25–30% survival of egg/larvae). Adult females had the greatest effect in reducing growth rate and population abundance when removed in exploitation simulations (91.3% versus 51.8% reduction in population growth rate), indicating translocation efforts should be designed to maintain females in the breeding pool. These models indicated that conservation management strategies aimed at ensuring the presence of adult females while concomitantly ameliorating survival at early life stages (population augmentation, translocations, introduction of artificial nest structures) are needed to stabilise the Indiana population of eastern hellbenders. This stage-structured model is the first to model eastern hellbenders and has broad implications for use across the geographic range where populations of eastern hellbenders are monitored and vital rates can be estimated.

Intraoperative indocyanine green video-angiography as an aid to the microsurgical treatment of spinal vascular malformations

Aims and Objectives. Intra-operative Indocyanine Green (ICG) video-angiography (ICG-VA) has become an established aid to cerebrovascular surgery. We describe our experience using this technique to define angio-architecture intraoperatively in a range of spinal vascular malformations. Methods. A retrospective review of notes and imaging was carried out from a prospectively maintained database. Our series comprises 27 patients who underwent surgical treatment between September 2007 and August 2012. We carried out a retrospective review of data from a prospectively maintained database. Results. For slow-flow Type 1 fistulae the ICG videoangiogram demonstrated conclusively that the arteriovenous shunt was obliterated. This is a consideration on the rare occasions where a second fistula is present, an example of which is included in this series. ICG-VA also helps to demonstrate normal vascular anatomy and distinguish these vessels from pathology. For Type II lesions it allowed orientation to the vascular anatomy as demonstrated by the pre-operative angiogram. In one of two cases in this series it ensured to the complete extirpation of a large arteriovenous malformation (AVM). However a second Type II case demonstrated its limitations, as a diffuse intramedullary component could not be identified. Two cases were explored where digital subtraction spinal angiography was not possible and incomplete understanding of the angio-architectures of the lesions were available from Time Resolved dynamic magnetic resonance angiography and/or multi-detector CT angiography. ICG-VA provided invaluable information on alterations in arterio-venous flow that allowed diagnosis and obliteration of the arteriovenous shunts in each case. Discussion. ICG video-angiography is a time-efficient and safe alternative to intra-operative spinal angiography. It provided useful information on haemodynamic changes intraoperatively and completeness of treatment. We discuss its limitations and role in the management of these lesions.

Die neue S2k AWMF Leitlinie zur Behandlung der obstruktiven Sialadenitis in kommentierter Kurzform

A new and interdisciplinary S2k AWMF guideline for the treatment of obstructive sialadenitis has been published. There have been several technical achievements, for instance in the field of ultrasonography, via sialendoscopy, or by MR-sialography, that have increased the possibilities for diagnosis and treatment of patients with obstructive sialadenitis. In the past, the treatment of choice in case of unsuccessful medical treatment was a complete extirpation of the affected salivary gland. Nowadays, using a variety of modern treatment options (like sialendoscopy, or extracorporeal shock-waves lithotripsy sometimes combined with salivary duct incision), it is possible in most patients, especially in cases of sialolithiasis, to preserve the affected gland. A functional recovery after gland-sparing surgery is described but more data is needed to finally evaluate the long-time results. The new guideline describes all relevant steps to diagnose an obstructive sialadenitis and values all diagnostic tools critically. Finally, all recommendable therapy options are described and valued, too.

Infraorbital Nerve Schwannoma Presenting as an Upper Lip Mass in an Adolescent Boy

Schwannomas of the head and neck are uncommon tumors that arise from the nerve sheath and may afflict peripheral, autonomic, or cranial nerves. It is important to consider the possible differential diagnoses of a nasolabial lump in a child because its appropriate treatment varies widely. The authors describe a case of a 12-year-old boy who presented with a 2.5-cm right nasolabial subcutaneous lump of 3 months in duration. Computed tomographic scan showed a homogeneously attenuated lesion. An intraoral incision was used for complete extirpation of this tumor while preserving the infraorbital nerve and facial aesthetics in this adolescent boy. Histopathologic examination showed palisades of spindle cells and Verocay bodies characteristic of schwannomas. The patient has been followed up for 2 years with no clinical evidence of recurrence. Only 9 cases of infraorbital nerve schwannoma have been described in literature, and the sublabial intraoral incision was attempted in only 1 case. The authors describe a rare case of an extraosseous schwannoma arising from the infraorbital nerve that presented as a cheek lump, its workup, its differentials, its treatment, and a review of literature. The use of a preoperative computed tomographic scan permitted the use of a sublabial intraoral incision with good visual access to the lesion and facilitated its complete extirpation without incurring external scars.

Superselective Shunt Occlusion for the Treatment of Cavernous Sinus Dural Arteriovenous Fistulae

In treating cavernous sinus dural arteriovenous fistulae (CSdAVFs), transvenous embolization of the whole affected sinus is usually performed, which may result in the disturbance of normal venous drainage or permanent cranial nerve palsy. To describe superselective shunt occlusion of CSdAVFs. Between July 2005 and August 2011, we had 20 consecutive cases of CSdAVFs. In 14 cases (70%), we could detect the restricted locus of arteriovenous shunts by 3-dimensional rotational angiography and/or superselective arteriography. After navigating the microcatheter to the shunt segment, consecutive superselective arteriovenography was performed to confirm the location of the microcatheter at the proper position. In 12 of 14 cases (85.7%) in which the shunt was restricted, coiling only in the small venous pouch or compartment, which was just downstream of the shunt point, led to complete disappearance of the shunt without obliterating the entire sinus. No recurrence or permanent cranial nerve palsy was observed during the follow-up period with a mean of 46 months (range, 3-69 months) in 12 cases treated by superselective shunt occlusion. This technique, which enables complete extirpation of shunts by small amounts of coils, is a feasible way to treat CSdAVFs with excellent mid- to long-term results. Understanding of the angioarchitecture by 3-dimensional rotational angiography and consecutive superselective arteriovenography was useful. This method should be considered before sinus packing or mere obliteration of dangerous venous outlets.

Inverted Papilloma: Prognostic Factors with Implications for Resection Margins

Background: Inverted papilloma (IP) of the sinonasal tract remains a surgical disease that requires complete extirpation because of high recurrence rates and significant potential for malignant transformation. Many methods of excision are used, ranging from endoscopic techniques to external-transfacial techniques, with similar recurrence rates regardless of surgical approach. Among these techniques, the impact of using surgical margins for confirmation of total resection is not standardized as its benefit is unproved. We aim to review our institution’s experience with treating IP and assess whether obtaining surgical margins reduces the rates of recurrence.

Commentary on “Applicability of robot-assisted laparoscopic radical prostatectomy in renal allograft recipients.” Wagener N, Nyarangi-Dix JN, Teber D, Zeier M, Hohenfellner M, Department of Urology, University of Heidelberg, Heidelberg, Germany: Transplant Proc 2012; 44(5):1287–92

PurposeTo evaluate the general applicability of robotic-assisted laparoscopic radical prostatectomy (RALP) in renal transplant recipients and potential surgical modifications due to the position of the transplanted kidney in the iliac fossa, as RALP has proven to be an effective and safe treatment option for prostate cancer (PCa) removal. ProceduresA 71-year-old patient who had undergone renal transplantation was diagnosed with biopsy-proven localized Gleason 7a PCa. The prostate-specific antigen value was 12.4ng/mL. RALP was performed by a transperitoneal approach using six ports. By partial mobilization of the bladder, the working space for the radical prostatectomy was created, while leaving the renal transplant and ureter untouched. Lymph node dissection was performed only on the contralateral side of the transplanted kidney. ResultsThe procedure concluded after 220 minutes and the estimated blood loss was 300mL. The perioperative clinical course was uneventful. The kidney function remained normal with a creatinine value of 1.2mg/dL. A complete extirpation of the prostate with negative surgical margins was achieved. After catheter removal, the patient was completely continent. ConclusionsRALP in renal transplant recipients is feasible and can be achieved with favorable oncological and functional outcome. No modifications to the standard RALP technique are required in these patients, except from a partial dissection of the bladder from the abdominal wall and a one-sided lymph node dissection.

Optical imaging with a high‐resolution microendoscope to identify cholesteatoma of the middle ear

High-resolution optical imaging is an imaging modality that allows visualization of structural changes in epithelial tissue in real time. Our prior studies using contrast-enhanced microendoscopy to image squamous cell carcinoma in the head and neck demonstrated that the contrast agent, proflavine, has high affinity for keratinized tissue. Thus, high-resolution microendoscopy with proflavine provides a potential mechanism to identify ectopic keratin production, such as that associated with cholesteatoma formation, and distinguish between uninvolved mucosa and residual keratin at the time of surgery. Ex vivo imaging of histopathologically confirmed samples of cholesteatoma and uninvolved middle ear epithelium. Seven separate specimens collected from patients who underwent surgical treatment for cholesteatoma were imaged ex vivo with the fiberoptic endoscope after surface staining with proflavine. Following imaging, the specimens were submitted for hematoxylin and eosin staining to allow histopathological correlation. Cholesteatoma and surrounding middle ear epithelium have distinct imaging characteristics. Keratin-bearing areas of cholesteatoma lack nuclei and appear as confluent hyperfluorescence, whereas nuclei are easily visualized in specimens containing normal middle ear epithelium. Hyperfluorescence and loss of cellular detail is the imaging hallmark of keratin, allowing for discrimination of cholesteatoma from normal middle ear epithelium. This study demonstrates the feasibility of high-resolution optical imaging to discriminate cholesteatoma from uninvolved middle ear mucosa based on the unique staining properties of keratin. Use of real-time imaging may facilitate more complete extirpation of cholesteatoma by identifying areas of residual disease. Laryngoscope, 2012.

The recurrent primary retroperitoneal liposarcoma

Describe a patient with multiple recurrences of the primary recurrent liposarcoma. A 60-years-old man complained of weight loss (BMI 18.4) with a palpable huge retroperitoneal tumour, which displaced left kidney, and was confirmed on USG and CT. Laboratory examination showed anaemia and pathological blood tests. Chest X-ray initially showed a negative finding. A complete transperitonealy surgical extirpation of the tumour with left side nephrectomy was performed on June 28, 2007. The tumour mass weight was 1900 g. It was lying on the posterior face of the kidney in diameters 170x120x120 mm, completely capsulated by thin grey-pink capsula with peripheral fat tissue on the section grey-pink, lobulary shaped, in ¾ parts with central necrotic changes. Histopathologically was confirmed the primary dedifferentiated (non-lipogenous) liposarcoma low grade of malignancy. Nephrectomy specimen was confirmed as age related finding. There was no evidence of positives surgical margins. Despite oncological and surgical treatment, followed repeated recurrence with eight transperitoneal surgeries in the retroperitoneum and abdomen with extirpation of the metastases, left side hemicolectomy, splenectomy and repeated extirpation tumour metastases from abdomen and radix mesenterii. Last tumour weighed 2900 grams. Patient died on January 9, 2011, after the eight surgeries on multiorgans failure due to hemorrhagic shock and persistent atrial fibrilaton by cardiopulmonary insufficiency. As a speciality, he was treated without transfusion because as Jehovah´s witness he refused blood derivates. Despite complex surgical and oncological treatment, the prognosis in patient with recurrent liposarcoma was fatal (Tab. 1, Fig. 5, Ref. 50).