Complete Tumor Removal Research Articles

Review of Intersphincteric Resections for Rectal Cancer Treatment

Colorectal cancer is the third most common cancer, second most common cancer in women, and the fourth leading cause of death in the world. Radical surgical treatment with Total Mesorectal Excision (TME) is considered the best treatment for cancer found in the lower third of the rectum and has benefits of complete tumor removal to reduce risk of recurrence and to improve survival. Advances in preoperative chemoradiation therapy have increased chances of achieving a 1 cm distal margin and allowed successful sphincter-preserving surgery by intersphincteric resection (ISR) and Coloanal Anastomosis (CAA) that allows normal defecation. MRI is particularly useful in evaluating localization of the tumor, involvement of anal sphincter (internal and external sphincters), levator ani muscles, and adjacent structures to the anus, with an accuracy of 85%, sensitivity of 87%, and specificity of 75%. Performing ISR with TME oncologic principles achieves similar results to Low Anterior Resection (LAR), but depends on the presence of sufficient Distal Rectal Margin (DRM); if a sufficient DRM cannot be achieved, then patients are offered an Abdominoperineal Resection (APR) with permanent colostomy and poor quality-of-life results.

Multi-Electrode Architecture Modeling and Optimization for Homogeneous Electroporation of Large Volumes of Tissue

Electroporation is a phenomenon that consists of increasing the permeability of the cell membrane by means of high-intensity electric field application. Nowadays, its clinical application to cancer treatment is one of the most relevant branches within the many areas of electroporation. In this area, it is essential to apply homogeneous treatments to achieve complete removal of tumors and avoid relapse. It is necessary to apply an optimized transmembrane potential at each point of the tissue by means of a homogenous electric field application and appropriated electric field orientation. Nevertheless, biological tissues are composed of wide variety, heterogeneous and anisotropic structures and, consequently, predicting the applied electric field distribution is complex. Consequently, by applying the parallel-needle electrodes and single-output generators, homogeneous and predictable treatments are difficult to obtain, often requiring several repositioning/application processes that may leave untreated areas. This paper proposes the use of multi-electrode structure to apply a wide range of electric field vectors to enhance the homogeneity of the treatment. To achieve this aim, a new multi-electrode parallel-plate configuration is proposed to improve the treatment in combination with a multiple-output generator. One method for optimizing the electric field pattern application is studied, and simulation and experimental results are presented and discussed, proving the feasibility of the proposed approach.

Multi-Lens Arrays (MLA)-Assisted Photothermal Effects for Enhanced Fractional Cancer Treatment: Computational and Experimental Validations.

Simple SummaryColorectal cancer is one of the most common cancers and the third leading cause of cancer-related deaths in the United States. As a non- or minimally invasive cancer treatment, photothermal therapy (PTT) has been widely used to generate irreversible thermal injuries in tumors. However, conventional PTT employs an end-firing flat fiber to deliver laser energy, leading to the incomplete removal of tumor tissues due to an uneven beam distribution over the tumor surface. Multi-lens arrays (MLA) generate multiple micro-beams to uniformly distribute laser energy on the tissue surface. Therefore, the application of MLA for PTT in cancer affords a spatially enhanced distribution of micro-beams and laser-induced temperature in the tumor. The purpose of the current study is to computationally and experimentally demonstrate the therapeutic benefits of MLA-assisted fractional PTT on colorectal cancer, in comparison to flat fiber-based PTT.Conventional photothermal therapy (PTT) for cancer typically employs an end-firing flat fiber (Flat) to deliver laser energy, leading to the incomplete treatment of target cells due to a Gaussian-shaped non-uniform beam profile. The purpose of the current study is to evaluate the feasibility of multi-lens arrays (MLA) for enhanced PTT by delivering laser light in a fractional micro-beam pattern. Computational and experimental evaluations compare the photothermal responses of gelatin phantoms and aqueous dye solutions to irradiations with Flat and MLA. In vivo colon cancer models have been developed to validate the therapeutic capacity of MLA-assisted irradiation. MLA yields 1.6-fold wider and 1.9-fold deeper temperature development in the gelatin phantom than Flat, and temperature monitoring identified the optimal treatment condition at an irradiance of 2 W/cm2 for 180 s. In vivo tests showed that the MLA group was accompanied by complete tumor eradication, whereas the Flat group yielded incomplete removal and significant tumor regrowth 14 days after PTT. The proposed MLA-assisted PTT spatially augments photothermal effects with the fractional micro-beams on the tumor and helps achieve complete tumor removal without recurrence. Further investigations are expected to optimize treatment conditions with various wavelengths and photosensitizers to warrant treatment efficacy and safety for clinical translation.

Whole-slide margin control through deep learning in Mohs micrographic surgery for basal cell carcinoma.

Basal cell carcinoma (BCC) is the most common type of skin cancer with incidence rates rising each year. Mohs micrographic surgery (MMS) is most often chosen as treatment for BCC on the face for which each frozen section has to be histologically analysed to ensure complete tumor removal. This causes a heavy burden on health economics. To develop and evaluate a deep learning model for the automated detection of BCC-negative slides and classification of BCC in histopathology slides of MMS based on whole-slide image (WSI). Two deep learning models were developed on the basis of 171 digitized H&E frozen slides from 70 different patients. The first model had a U-Net architecture and was used for the segmentation of BCC. A subsequent convolutional neural network used the segmentation to classify the whole slide as BCC or BCC-negative. Quantitative evaluation over manually labelled ground truth data resulted in a Dice score of 0.66 for the segmentation of BCC and an area under the receiver operating characteristic curve (AUC) of 0.90 for the slide-level classification. This study demonstrates that through WSIs deep learning models may be a feasible option to improve the clinical workflow and reduce costs in histological analysis of BCC in MMS.

Extrapelvic bowel resection and anastomosis in cytoreductive surgery for ovarian cancer.

Ovarian cancer is known as the second most common cause of death among gynecologic cancers. Survival outcome has been reported to be significantly associated with the efforts to minimize residual disease after cytoreductive surgery. As ovarian cancer often invades the small and large bowel without boundary, bowel surgery has been a crucial part of the cytoreductive surgery to achieve complete tumor removal. The scope of surgical resections has progressively expanded to include small and large bowel resections, making advanced surgical skills essential for gynecologic oncologists. In this review, we discuss the extra-pelvic bowel resection in cytoreductive surgery, with a focus on the regional anatomy and surgical techniques.

Changes in hepatocellular carcinoma aggressiveness characteristics with an increase in tumor diameter.

Hepatocellular carcinoma prognosis depends on both liver and tumor determinants, especially on maximum tumor diameter, multifocality, and presence of portal vein thrombosis, despite apparently complete tumor removal by resection or liver transplantation. To examine parameters of hepatocellular carcinoma aggressiveness as tumor size increases. A large hepatocellular carcinoma database was examined for trends in serum alpha-fetoprotein and the percentage of patients with macroscopic portal vein thrombosis or tumor multifocality. A total of 13,016 hepatocellular carcinoma patients were identified having full tumor and survival data. Of these, 76.56% were male and 23.44% were female, with a median age of 64.4 years. We found that as the maximum tumor diameter increased, there was a significant trend for increased alpha-fetoprotein levels (P<0.001) and an increased percentage of patients with either portal vein thrombosis or tumor multifocality, each P<0.0001. Furthermore, the increases of both alpha-fetoprotein and portal vein thrombosis were proportionately greater than the related maximum tumor diameter increases. These trends of increased alpha-fetoprotein, portal vein thrombosis, and multifocality with increasing maximum tumor diameter had non-linear patterns. Within alpha-fetoprotein and multifocality trends, there were identifiable sub-trends associated with specific maximum tumor diameter ranges. The greater fold-increases in alpha-fetoprotein and portal vein thrombosis compared with increases in maximum tumor diameter imply that hepatocellular carcinoma characteristics may change with increasing size to a more aggressive phenotype, suggesting that follow-up tumor sampling might be useful, in addition to baseline tumor sampling, for optimal therapeutic choices to be made.

Complex skin cancer treatment requiring reconstructive plastic surgery: an interview study on the experiences and needs of patients

To provide patient-centered care, it is essential to explore what patients consider important and to adjust care accordingly. This may specifically be relevant for patients with complex skin cancer, for whom the care process is often more complicated and psychological and social problems may play a larger role. The objective was to explore the experiences and needs of patients who had undergone surgical treatment by a dermatologist for a complex skin cancer with a subsequent reconstruction by a plastic surgeon. An interview study was conducted among 16 patients who had undergone surgical treatment by a dermatologist and reconstruction by a plastic surgeon for basal cell carcinoma, cutaneous squamous cell carcinoma, or lentigo maligna. The interviews focused on patients’ experiences and needs regarding care using a predefined topic list. All interviews were audio-taped, transcribed verbatim and inductively analyzed using Atlas.ti. Patients reported a need for a skilled and friendly physician who tailors information and communication to their individual situation. A need for continuity of care and improved collaboration between healthcare providers was also emphasized. Furthermore, patients experienced complications and unmet expectations and expressed a need for shared decision-making at various steps throughout the treatment process (depending on age). Patients also considered completeness of tumor removal, follow-up visits with multiple specialists to be planned the same day and recognition of the psychological impact of the disease on the partner important. To improve patient-centered care for complex skin cancer patients, more efforts should be directed towards improving continuity of care and collaboration. Furthermore, it is advocated for physicians to be sensitive to the individual needs of patients and their partner and adjust information, communication and (supportive) care accordingly.

MIS removal of extraforaminal lumbar spine schwannoma using MAS–TLIF retractor: technical note

Background To report the use of Nuvasive MAS–TLIF retractor for the removal of lumbar spine schwannomas. Methods A 47-year-old man with 1-year history of back pain with progressive left sciatica underwent surgical resection of a left extraforaminal lumbar schwannoma (type IV according to Eden's classification) using the MAS–TLIF retractor. Results The patient completely recovered from the preoperative symptoms and was discharged three days after surgery. The MRI acquired 6 months postoperatively showed complete tumour removal, with no signs of instability. The MAS–TLIF retractor allows for an optimal paraspinal tissues retraction, improving the area of exposure and the manoeuverability angle. Moreover, the stability of the retraction is guaranteed by the positioning of the two transpedicular screws. Spinal fusion is not necessary because the posterior tension band is not jeopardised. Conclusions MAS–TLIF retractor allows for a minimally invasive and safe surgical removal of LSS maximising surgical exposure and avoiding spinal fusion.

Local Anesthetics and Recurrence after Cancer Surgery-What's New? A Narrative Review.

The perioperative use of regional anesthesia and local anesthetics is part of almost every anesthesiologist’s daily clinical practice. Retrospective analyses and results from experimental studies pointed towards a potential beneficial effect of the local anesthetics regarding outcome—i.e., overall and/or recurrence-free survival—in patients undergoing cancer surgery. The perioperative period, where the anesthesiologist is responsible for the patients, might be crucial for the further course of the disease, as circulating tumor cells (shed from the primary tumor into the patient’s bloodstream) might form new micro-metastases independent of complete tumor removal. Due to their strong anti-inflammatory properties, local anesthetics might have a certain impact on these circulating tumor cells, either via direct or indirect measures, for example via blunting the inflammatory stress response as induced by the surgical stimulus. This narrative review highlights the foundation of these principles, features recent experimental and clinical data and provides an outlook regarding current and potential future research activities.

Complete laparoscopic-transhiatal removal of duplex benign oesophageal tumour: case report and review of literature

BackgroundLeiomyoma is the most common benign oesophageal tumour. Half of all leiomyoma patients have oesophagus-associated complaints, such as dysphagia and epigastric pain, and the other 50% are asymptomatic with a diagnosis made on incidental discovery. Endoscopic ultrasonography is essential for an accurate preoperative workup and can enable guided-tissue acquisition for immunohistochemistry in certain cases. Smaller tumours are amenable to traditional and novel endoscopic removal in specialized centres, but some complex cases require surgical enucleation with a minimally invasive approach.Case presentationAn asymptomatic 60-year-old woman was accidentally diagnosed with a bifocal oesophageal mass, which was discovered by chest computed tomography. We report a rare case of a duplicated lower-third oesophageal leiomyoma, which was completely removed via the laparoscopic transhiatal approach. The patient has recovered successfully from the surgery. She has been followed up for six months with a normal oesophagram, adequate oesophageal function and no complaints observed. Pathological examination confirmed the diagnosis of leiomyoma in both lesions.ConclusionsTo the best of our knowledge, this is the first reported case of duplex oesophageal leiomyomas removed laparoscopically. Using the minimally invasive abdominal technique, the lower oesophagus can be mobilised to the mediastinum without pleura injury and offers a good alternative to the thoracoscopic approach in patients with possible intrathoracic difficulties. At experienced centres, laparoscopic transhiatal enucleation of lower oesophageal leiomyomas and other benign tumours with a combination of intraoperative oesophagoscopy is a safe, fast and effective operation.

Surgical treatment and outcomes of intramedullary tumors by minimally invasive approach

Intramedullary tumors are uncommon neoplasms which, without treatment, can cause neurologic morbidity or mortality. The goal of the treatment is complete surgical resection with a minimally invasive approach while preserving neurological status and also spinal stability. Out of 1972 patients with tumors of the spinal canal treated between 1994 and 2017, 168 intramedullary tumors of 417 intradural tumors have been presented. All patients had undergone one surgical resection. The mean age is 43 ± 12 years (range 11–67 years). Tumors were subdivided into 4 groups: cervically located-tumors (n = 43), cervicothoracic-region-tumors (n = 32), thoracic-region-tumors (n = 57), and lumbosacral-region-tumors (n = 36). The mean follow-up time was 37 ± 29 months. Gross-total resection rate was higher in cervical located intramedullary tumors compared to the thoracic intramedullary tumors. Cervical intramedullary tumors showed better postoperative functional outcome than the thoracic intramedullary lesions. In intramedullary tumors, extending more than 3 spinal segments, postoperative worsening was significantly increased. A minimally invasive approach (the bilateral decompression via unilateral hemilaminectomy) was used to remove the tumor while preserving spinal stability. Perioperative permanent morbidity was very low. Intramedullary tumors should be surgically treated as soon as neurological symptoms appear. Patients with thoracic intramedullary tumors and tumor extension of more than three segments were at a higher risk for permanent morbidity. The minimally invasive approach allowed complete removal of the intramedullary tumors, and adequate preservation of vertebral stability while providing a good postoperative course.

Feasibility of transoral endoscopic enucleation for large odontogenic jaw tumors

Objective The aim was to describe a transoral endoscopic approach for large odontogenic jaw tumors and to assess the feasibility of endoscopy in complete enucleation of any tumor remnants. Materials and methods This retrospective cohort study was done on patients presenting with different types of large jaw tumors in the period from 2013 to 2017 at the Department of Otolaryngology – Head and Neck Surgery, Mansoura University, Egypt. All patients were managed endoscopically. with the bony port measured in its largest dimension. Outcome measures were the occurrence of recurrence during the follow up. Follow-up ranged from 6 to 36 months. Results All patients had complete removal of tumor from the cavity with the transoral endoscopic approach through portal opening of the tumor cavity with a mean (SD) of 24.3 (3.12 mm). Various types of odontogenic tumors were included. No recurrence was detected in the follow-up period except for 1 case requiring a second look. Conclusion Management of large jaw tumors varies from incomplete excision as shaving to aggressive excision with greater morbidity requiring reconstruction. Endoscopic transoral route provides a marvelous option that ensures complete excision with functional preservation and less morbidity.

Endoscope-assisted fluorescence-guided resection allowing supratotal removal in glioblastoma surgery.

Several studies have proven the benefits of a wide extent of resection (EOR) of contrast-enhancing tumor in terms of progression-free survival (PFS) and overall survival (OS) in patients with glioblastoma (GBM). Thus, gross-total resection (GTR) is the main surgical goal in noneloquently located GBMs. Complete tumor removal can be almost doubled by microscopic fluorescence guidance. Recently, a study has shown that an endoscope with a light source capable of inducing fluorescence allows visualization of remnant fluorescent tumor tissue even after complete microscopic fluorescence-guided (FG) resection, thereby increasing the rate of GTR. Since tumor infiltration spreads beyond the borders of contrast enhancement on MRI, the aim of this study was to determine via volumetric analyses of the EOR whether endoscope-assisted FG resection enables supratotal resection beyond the borders of contrast enhancement. The authors conducted a retrospective single-center analysis of a consecutive series of patients with primary GBM presumed to be noneloquently located and routinely operated on at their institution between January 2015 and February 2018 using a combined microscopic and endoscopic FG resection. A 20-mg/kg dose of 5-aminolevulinic acid (5-ALA) was administered 4 hours before surgery. After complete microscopic FG resection, the resection cavity was scanned using the endoscope. Detected residual fluorescent tissue was resected and embedded separately for histopathological examination. Nonenhanced and contrast-enhanced 3D T1-weighted MR images acquired before and within 48 hours after tumor resection were analyzed using 3D Slicer. Bias field-corrected data were used to segment brain parenchyma, contrast-enhancing tumor, and the resection cavity for volume definition. The difference between the pre- and postoperative brain parenchyma volume was considered to be equivalent to the resected nonenhancing but fluorescent tumor tissue. The volume of resected tumor tissue was calculated from the sum of resected contrast-enhancing tumor tissue and resected nonenhancing tumor tissue. Twelve patients with GBM were operated on using endoscopic after complete microscopic FG resection. In all cases, residual fluorescent tissue not visualized with the microscope was detected. Histopathological examination confirmed residual tumor tissue in all specimens. The mean preoperative volume of brain parenchyma without contrast-enhancing tumor was 1213.2 cm3. The mean postoperative volume of brain parenchyma without the resection cavity was 1151.2 cm3, accounting for a mean volume of nonenhancing but fluorescent tumor tissue of 62.0 cm3. The mean relative rate of the overall resected volume compared to the contrast-enhancing tumor volume was 244.7% (p < 0.001). Combined microscopic and endoscopic FG resection of GBM significantly increases the EOR and allows the surgeon to achieve a supratotal resection beyond the borders of contrast enhancement in noneloquently located GBM.

Chemoradiation as a nonsurgical treatment option for early-stage esophageal cancers: a retrospective cohort study

BackgroundComplete tumor removal via esophagectomy or endoscopic excision has been associated with the greatest survival in early-stage esophageal cancer. However, patient health, anatomy, or goals of care may render patients ineligible for excision or resection. In this setting, chemoradiation (CRT) may be considered as a nonsurgical approach, however the outcomes associated with CRT in early-stage esophageal cancer are incompletely understood.MethodsThe National Cancer Database was queried for treatment-naïve cT1/T2, N0, M0 esophageal cancer patients managed with concurrent multi-agent CRT (≥50 Gy) between 2004 and 2015. Medically inoperable patients were excluded. Kaplan-Meier curves were generated to estimate 5-year overall survival (OS) from diagnosis in both stages.ResultsOf the 828 patients identified, 279 were cT1 and 549 were cT2. For cases after 2010, cT1 (N=124) was further stratified in cT1a (N=32, 25.8%) and cT1b (N=46, 37.1%). Kaplan-Meier estimates demonstrated a 5-year survival of 21.7% for cT1 and 25.9% for cT2. Sensitivity analyses were performed to mitigate competing survival risk from poor health. Among 589 comorbidity-free patients (i.e., Charlson = score zero), the 5-year survival with CRT was 23.4% for cT1 and 27.8% for cT2. Finally, a subset of patients who refused a recommended surgery were evaluated with 5-year survival cT1 =33.5% and cT2 =33.4%).ConclusionsUp to a third of selected patients with early-stage esophageal cancer may be cured after CRT as definitive non-surgical treatment. However, cure rates may be underestimated in this setting, secondary to persistent health-related bias.

Laparoscopic liver resections for gallbladder cancer and intrahepatic cholangiocarcinoma: the Mayo clinic experience

Presenter: Ron Pery MD | Mayo Clinic, Rochester Background: Gallbladder cancer (GBC) and intrahepatic cholangiocarcinoma (ICC) are aggressive malignancies where surgical resection offers the only meaningful chance of cure. Complete tumor removal with negative margins and adequate porta hepatis lymphadenectomy for tumor staging is the surgical standard of care in resectable cases according to the national comprehensive cancer network (NCCN) guidelines. The safety and oncological adequacy of laparoscopic liver resections for GBC and ICC have been questioned in the past and many surgeons were hesitant to consider it. Being a high-volume center of minimal invasive liver surgeries, this study aimed to describe the Mayo clinic experience with laparoscopic liver resections for GBC and ICC and to specifically ascertain their safety and oncological adequacy. Methods: The Mayo clinic database was used to identify patients who underwent curative intent laparoscopic liver resection for GBC or ICC between 01/2016 to 12/2020. Clinicopathological characteristics, operative details and outcomes of 33 patients were collected and analyzed with specific emphasis on resection margins, porta hepatis lymphadenectomy and post-operative complications. Results: 33 patients with GBC or ICC underwent curative-intent laparoscopic liver resection with or without porta hepatis lymphadenectomy in Mayo clinic between 01/2016 and 12/2020. The median age of patients was 65±11.8. Six (18%) patients underwent major liver resection with porta hepatis lymphadenectomy, fourteen (42%) patients underwent minor liver resection with porta hepatis lymphadenectomy; while five (16%) patients underwent major liver resection and eight (24%) patients underwent minor liver resection without portal lymphadenectomy. The mean operative time was 193 minutes (range 83-881) and the mean estimated blood loss (EBL) was 250cc (range 25-1700). There were two conversions (6%) to laparotomy due to failure to progress. Nineteen (58%) patients had no post-operative complications, five (15%) patients had minor post-operative complications (Clavien Dindo score ≤2) and nine (27%) patients had major post-operative complications (Clavien Dindo score ≥3) including one post-operative mortality (3%) due to portal vein thrombosis leading to fatal liver failure. The median in hospital length of stay was three days (range 1-39). On pathology, the mean tumor size was 36.5mm (range 15-150) and resection margins were negative in all specimens. Amongst the patients who underwent porta hepatis lymphadenectomy, the mean number of harvested lymph nodes was 4.5 (range 1-19) and eight (40%) patients have met the AJCC 8th edition staging manual cutoff of at least six harvested lymph nodes. Conclusion: When done by experienced minimal invasive liver surgeons in a high-volume center, laparoscopic liver resections for GBC and ICC are both feasible, safe and oncologically appropriate. While operative times, EBL and post-operative complications profiles are comparable to historic open controls, the in-hospital length of stay is shorter. As in open surgeries, an effort should be made to meet the AJCC 8th edition recommendation of at least six harvested lymph nodes for adequate tumor staging.

Endoscopic-Assisted Microsurgery for Vestibular Schwannomas: Operative Nuances.

Vestibular schwannoma surgery is a challenging operative procedure. Intricate anatomy of vital neurovascular structures demands a meticulous planning and execution. The cerebellopontine angle is an unforgiving area of skull bases surgery which can have grave implications on patient outcome even after a successful tumor removal. As more and more tumors are being detected at early stage, functional preservation of seventh and eighth nerve complex is increasingly being demanded. The key to any minimally invasive approach is to minimize the collateral damage while ensuring complete tumor removal. Binocular microscopy is the workhorse for illumination and dissection via retrosigmoid approach. However, as instrumentation has improved, endoscopic dissections are increasingly being performed. The following video presents the step-by-step nuances for an endoscope-assisted microsurgery for small vestibular schwannomas with stress on endoscopic drilling of the meatal wall to deliver out intracanacular tumor while preserving the labrynthine structures.

Suboccipital Retrocondylar Approach for an Anterolateral Foramen Magnum Meningioma.

Objectives This study was to demonstrate surgical technique for an anterolateral foramen magnum meningioma. Design Present study is presented through an operative video. Setting This study is conducted at the Department of Neurosurgery, Tîrgu Mureș, Romania. Participants A 62-year-old female is the participant who was diagnosed with a foramen magnum meningioma. Main Outcome Measures Complete surgical resection of the tumor with no postoperative deficits or complications. Results A 62 years-old female was admitted for left hemilingual atrophia, dysphonia, right hemiparesis grade 2 of 5, right hemihypesthesia, and cervical pain. The magnetic resonance imaging (MRI) showed a right foramen magnum meningioma, sized approximately 2 cm in all planes ( Fig. 1 ). This was classified with the Bernard system as an intradural foramen magnum meningioma with anterolateral insertion to the dura mater and below the vertebral artery. A suboccipital, retrocondylar, and c1 right hemilaminectomy approach was performed. Using microsurgical tumoral decompression techniques, ultrasonic aspiration, and following the natural cleavage planes, complete tumor removal was achieved ( Fig. 2 ). The patient presented an uneventful postoperative course with no postoperative new neurological deficits and was discharged at home 7 days following surgery. Control MRI at 6 months ( Fig. 1 ) and 2 years showed no tumor residue or recurrence. Neurologic status at 6 months was excellent, showing complete remission of symptoms. Conclusion Retrocondylar suboccipital approach is a safe and feasible option for anterolateral foramen magnum meningiomas provided that natural corridors and dynamic retraction are used. The link to the video can be found at: https://youtu.be/jpxMcjCpN6E .

Holmium Laser En-bloc Resection Versus Conventional Transurethral Resection of Bladder Tumors for Treatment of Non–muscle-invasive Bladder Cancer: A Randomized Clinical Trial

BackgroundEn-bloc resection of bladder tumors achieves complete tumor removal, improves the quality of resection, decreases perioperative complication, and potentially improves recurrence rates. ObjectiveTo assess the efficacy and safety of holmium laser en-bloc resection (HolERBT) versus conventional transurethral resection of bladder tumor (cTURBT). Design, setting, and participantsBetween September 2015 and September 2018, 100 patients with non–muscle-invasive bladder cancer were randomly allocated to cTURBT or HolERBT. Outcome measurements and statistical analysisThe primary endpoint was detection of residual tumor in reTURBT specimens at 4 wk after the primary resection. Operative parameters, specimen quality, perioperative complications, and recurrence-free survival (RFS) were compared. Independent sample t tests, χ2 tests, and Kaplan-Meier curves were used, as appropriate. Results and limitationsThe patient and tumor baseline characteristics were comparable between the groups. Residual tumors were detected in 7% and 27.7% of cases after HolERBT and cTURBT, respectively (p=0.01). Detrusor muscle was sampled in 98% of HolERBT and 62% of cTURBT cases (p<0.001). Lamina propria invasion substaging was feasible in only 68.2% of HolERBT and 18.4% of cTURBT cases (p<0.001). Following HolERBT, catheterization time (p<0.001) and hospital stay (p=0.001) were shorter when compared to cTURBT. Immediate postoperative instillation of chemotherapy in indicated cases was feasible for 100% of the HolERBT group and 91.5% of the cTURBT group (p=0.04). After follow-up of 20 ± 9.9 mo (13–36), RFS was 31.76 mo (95% confidence interval [CI] 28.67–34.86) in the HolERBT group and 28.25 mo (95% CI 24.87–31.64) in the cTURBT group (hazard ratio 0.43, 95% CI 0.17–1.1; p=0.07). However, this study was not powered to detect a difference in RFS. ConclusionsCompared to cTURBT, HolERBT is a safer procedure for bladder tumor resection. It fulfills the oncological criteria of optimized resection with less residual tumor and better specimen quality. Patient summaryEn-bloc resection of bladder cancer tumors using a holmium laser is safer than the conventional technique. It has the advantages of less residual tumor and better specimen quality, with a similar tumor recurrence rate.This study is registered at ClinicalTrials.gov as NCT02555163.

Outstanding issues of surgical treatment of locally advanced forms of malignant tumors

Nowadays surgery is still the mainstay of solid tumors treatment. En Bloc resection is surgical treatment in amount of complete tumor removal. There remains considerable uncertainty about many aspects of resection boundaries, including definition and influence of anatomical and histological factors. One of the biggest challenges for the surgeon is choosing the right surgery for the «right» patient, taking into account the type of tumor and its biology.

Vestibular Schwannoma Surgery: Outcome and Complications in Lateral Decubitus Position versus Semi-sitting Position—A Personal Learning Curve in a Series of 544 Cases over 3 Decades

To retrospectively evaluate influence of intraoperative positioning (semisitting vs. lateral decubitus) and surgeon's learning curve with regard to functional outcome of patients with vestibular schwannoma. This study included 544 patients (median age 57 years) and spanned 3 decades: 1991-1999 (n= 103), 2000-2009 (n= 210), and 2010-2019 (n= 231). Surgery was performed in the lateral decubitus position in 318 patients and the semisitting position in 163 patients. Large T3 and T4 tumors were present in 77% of patients. Complete tumor removal was achieved in 94.3% of patients. A significant reduction in surgery duration and blood loss was observed over 3 decades for T3 (from 325 to 261 minutes, P < 0.001) and T4 (from 440 to 330 minutes, P < 0.001), but not for T1 and T2, tumors. The semisitting position diminished surgical time in T3 and T4 tumors by 1 more hour (P < 0.001). Over 3 decades, facial nerve outcome improved significantly from 59.8% House-Brackmann grade 1-2 in the first decade to 81.7% in the last decade (P < 0.001). Furthermore, hearing was preserved in 45.3%: 23.3% of patients in the first decade and 50.5% in the last decade (P= 0.03). However, neither facial nerve outcome nor hearing preservation significantly differed in patients operated on in the lateral decubitus versus the semisitting position. The most common complication was cerebrospinal fluid leak (6.1%) followed by hemorrhage (3.5%) and pulmonary embolism (2.2%). Follow-up over 3 decades illustrates a learning curve with significantly improved results. While the semisitting position accelerates the procedure and is associated with reduced blood loss, it does not significantly influence functional outcome.