Inadequate Primary Surgery Research Articles

The Role of Completion Surgery in Ovarian Cancer.

Patients referred with inadequately staged ovarian malignancies present a clinical dilemma. We report our experience with completion surgery in ovarian cancer. To determine the benefits and risks of completion surgery in women with ovarian cancer who presented after having had inadequate primary surgery. A retrospective case series of 30 women with ovarian cancer and one with fallopian tube cancer who had inadequate primary surgery underwent completion surgery at gynaecologic oncology unit in a tertiary level hospital in Tamil Nadu, India. Electronic medical records of patients with ovarian cancer who underwent completion surgery between January 2011 and September 2014 for ovarian were reviewed. Forty-five patients with initial inadequate surgery were identified of whom 31 underwent completion surgery; the remaining 14 did not return to our hospital. Thirty-one women with a mean age of 37years (17-53) and median parity of 2 (0-4) with inadequately staged ovarian malignancy underwent completion surgery. Complex ovarian mass was the most common indication for initial surgery (94%). The tumours were epithelial in 27 (87%), germ cell in 3 (10%) and sex cord stromal in 1 (3%). In view of extensive disease at presentation, 19% (6/31) were referred for neoadjuvant chemotherapy and underwent interval debulking. With regard to surgical complexity, 52% (16/31), 38% (12/31) and 10% (3/31) underwent simple, intermediate and complex surgeries, respectively. Optimal cytoreduction (R0 and R1) was performed in 25 patients (81%). Twelve (39%) had upstaging of disease. Six patients required no further adjuvant treatment following surgical restaging. Complications included bladder injury (1), iliac vessel injury (1) and surgical site infections (2). During the study period of 45months, 7 patients (23%) presented with disease recurrence. There were 2 recorded deaths. In inadequately staged ovarian malignancies, completion surgery should be considered based on the patients' performance status and disease assessment. Considering the low specificity of imaging and Ca 125, completion surgery provides information to plan adjuvant therapy, besides allowing optimal cytoreduction but delays initiation of adjuvant therapy.

Survival Outcome After Radiation Therapy for Patients With Early Cervical Carcinoma Undergoing Inadequate Primary Surgery

The aim of this study was to investigate the survival outcome after radiation therapy for patients with early cervical carcinoma undergoing inadequate primary surgery. A retrospective analysis of medical charts of all patients with stage IA2 to IIA carcinoma who were referred with inappropriate primary surgery and treated with radiation therapy was reviewed. The collected data include age, presenting symptoms, retrospective stage, lymph node status, histology type, type of surgery, baseline radiologic status before radiotherapy, details of radiation therapy, follow-up, and details of disease recurrence, disease-free survival, and overall survival (OS). Kaplan-Meier survival curves were used to show the OS and recurrence-free survival. A total of 32 patients were treated. The median age of the patients was 48.2 years, with a range of 27.6 to 79.2 years. Twenty-three patients had retrospective stage IB1, and 9 had stage IIA disease. The most common type of surgery (62.5%) was total abdominal hysterectomy with or without bilateral salpingo-oophorectomy. The pelvic lymph node dissection (PLND) status was not determined in 20 patients, 11 had PLND surgical assessment (2 were positive), and 1 had bulky PLND by computed tomographic scan.Baseline assessment showed that 14 patients had no residual disease, 11 had microscopic disease, and 7 had macroscopic disease. The follow-up ranged from 3.3 to 77.8 months, with a median of 24.3 months. Eleven patients developed disease recurrence, and all of them died of their disease. Two- and 5-year OS rates were 79% and 51.7%. Univariate analysis did not show a statistically significant effect of either the disease stage or residual disease survival. Survival outcome after radiation therapy for patients with early-stage cervical cancer undergoing inadequate surgery seems to be markedly worse than that for patients of comparable stage treated initially with radical radiation.

Recent advances in research on epigenetic alterations and clinical significance of para-aortic lymphadenectomy in endometrial cancer: an introduction

Endometrial cancer is the most frequent cancer of the female reproductive organs in industrialized countries. In 2012, the numbers of new cases and deaths from endometrial cancer in the US were estimated to be 47,130 and 8,010, respectively [1]. The incidence of endometrial cancer is also increasing steadily in Japan, where the estimated number of new cases in 2007 was 9,104 [2] and the number of deaths in 2011 was 2,034 [3]. Endometrial cancer is a surgically staged disease and post-operative therapy is offered to patients with a high risk of recurrence according to the extent and aggressiveness of the tumor. Current topics in endometrial cancer include: the therapeutic significance of lymphadenectomy, the role of epigenetic alterations, and revision of the International Federation of Gynecology and Obstetrics staging criteria (FIGO 2008) for this disease. There was a paradigm shift in the treatment strategy for endometrial cancer after the introduction of a surgical staging system (FIGO 1988) that replaced the older clinical staging system. The newer paradigms of extended-surgical staging containing lymphadenectomy with more restricted use of adjuvant therapy and the older paradigm of simple hysterectomy bilateral salpingo-oophorectomy with more frequent use of adjuvant radiotherapy need to be compared prospectively in terms of survival benefits, quality of life, and cost of treatment [4]. Several issues regarding surgical staging need to be clarified. They include: how should suitable patients for complete lymphadenectomy be selected and what is the optimal extent of lymphadenenctomy? The therapeutic significance of lymphadenectomy has long been a matter of great debate. In 1964, Lewis suggested a therapeutic effect of pelvic lymphadenectomy in nodepositive patients [5]. He employed pelvic lymphadenectomy because endometrial cancer often recurred at the pelvic side wall after conventional hysterectomy and bilateral salpingo-oophorectomy, which suggested inadequate primary surgery. Retrospective studies suggest a therapeutic significance for lymphadenectomy, which is a function of removed lymph node count (thoroughness) and area of dissection (pelvic only versus pelvic and para-aortic lymphadenectomy) [6–8]. However, two prospective randomized controlled trials (RCTs) that intended to prove the therapeutic role of pelvic lymphadenectomy failed to show any survival advantage of pelvic lymphadenectomy versus no lymphadenectomy [9, 10]. However, there has been some criticism about the design of these trials because para-aortic lymphadenectomy was not included in the study arm. A retrospective cohort study which compared pelvic lymphadenectomy with combined pelvic and paraaortic lymphadenectomy revealed survival improvement in the pelvic and para-aortic lymphadenectomy group if this treatment was offered to intermediate-/high-risk endometrial cancer patients [11]. Based on these findings, discussions have begun about the design of future clinical trials to validate the therapeutic significance of lymphadenectomy. Topics for discussion include the eligibility of patients (all patients or selected patients at some risk of nodal metastasis), extent of lymphadenectomy (area: pelvic alone versus pelvic plus para-aortic, thoroughness: number of nodes removed), and type of experimental design (RCT versus cohort study). The difficulties and pitfalls of RCTs for validating surgical procedures have often been addressed [12–16]. These include the participating surgeons’ expertise in experimental N. Sakuragi (&) Department of Obstetrics and Gynecology, Hokkaido University School of Medicine, North 15, West 7, Kitaku, Sapporo 060-8638, Japan e-mail: sakuragi@med.hokudai.ac.jp

Treatment efficiency, outcome and surgical treatment problems in patients suffering from localized embryonal bladder/prostate rhabdomyosarcoma: A report from the cooperative soft tissue sarcoma trial CWS‐96

To analyze the clinical course, treatment modalities, complications and outcome of patients suffering from localized embryonal bladder/prostate rhabdomyosarcoma (BPRMS) treated on the CWS-96 trial. There were 85 patients with BPRMS enrolled and 63 patients with embryonal non-metastatic BPRMS were analyzed. Fifty-six patients received neoadjuvant chemotherapy and response was assessed radiographically after 9 weeks. Local therapy with radiation and or surgery was performed based on age, tumor size, and response. Patients were treated with adjuvant chemotherapy following local control. Patient's age ranged from 0 to 16 years with a median follow up of 5.3 years. Eighty nine percent of the patients had IRS group III disease. The 5-year overall survival (OS) for the whole group was 76.3 ± 5.6% and the 5-year event-free survival (EFS) 69.8 ± 6.2%. Seventeen patients underwent preoperative radiochemotherapy followed by tumor resection (5-year-OS: 87.8 ± 8.1%). Eight patients were treated with solely radiochemotherapy (87.5 ± 11.7%). Twenty-five patients received chemotherapy and tumor resection (OS: 83.6 ± 7.5%). Thirteen patients underwent incomplete tumor resection and were treated with radiochemotherapy postoperatively (OS: 39.9 ± 14.8%, P < 0.05 vs. other groups). Local therapy is an important factor for prognosis of localized embryonal BPRMS. Inadequate primary or secondary surgery compromises the outcome and should be avoided. Radiotherapy alone, complete surgical tumor resection or combined preoperative radiotherapy with surgical resection lead to similar good local control rates and prognosis.

Endovenous laser ablation for the treatment of recurrent varicose vein disease – A single centre experience

Introduction Varicose vein surgery for recurrent disease can result from inadequate primary surgery. Redo open surgery is more difficult to perform than primary surgery and can be associated with a higher incidence of neurovascular injury and infection. In this study we evaluate EVLA, a percutaneous technique that uses intra-operative duplex ultrasound as an option for the treatment of recurrent varicose veins. Materials and Methods Data prospectively collected on patients who had EVLA for varicose veins were obtained from our dedicated vascular registry. From November 2004 to December 2008 we performed 586 EVLA procedures, 77 procedures were for recurrent varicose veins. Results The mean age was 52 ± 12.77 years, range 28–80; and 48 (62%) were female. 64 (83%) cases were for recurrent LSV disease, 13 (17%) cases for recurrent SSV disease and all patients had LSV or SSV incompetence confirmed on preoperative duplex assessment. Median duration since primary surgery was 60 months (range 2–360). Mean length of vein treated was LSV – 36 cm ± 14.5 (6–73) and SSV – 14.5 cm ± 7.35 (5–24); mean energy delivered was LSV 3102J ± 1053 (150–4656) and SSV – 693J ± 396 (135–1216). 17 patients had bilateral EVLA for recurrent disease at the same setting with one patient having bilateral procedures under local anaesthetic. There was an incidence of pulmonary embolism 10 days post EVLA and two patients required further phlebectomies post EVLA for residual varices that were present pre-operatively. Median follow-up was 18 months (range 1–38), with no clinical recurrence and no recannalisation of the treated LSV or SSV on duplex ultrasound. Conclusions In our experience EVLA can be safely performed for recurrent varicose vein disease. In our experience Redo EVLA is not more difficult than primary EVLA to perform.

Biochemical Results of Reoperations for Medullary Thyroid Carcinoma

The calcitonin is a sensitive marker for the presence of medullary thyroid carcinoma, therefore, invaluable in the follow-up of patients who have been treated. Biological cure of the medullary thyroid cancer refers to a basal plasma calcitonin of less than 10 ng/l without elevation after stimulation tests. Biochemical results of reoperations for medullary thyroid carcinoma were reviewed from a series of 35 patients who underwent 47 reinterventions. The indications for reoperation were: hypercalcitoninemia with clinical evidence of the disease (32 cases); hypercalcitoninemia after an inadequate primary surgery (6 cases); persistent hypercalcitoninemia with biochemical evidence of the disease (2 cases); liver metastases (1 case); and palliative surgery for relieving symptoms (1 case). Only three patients of the series had biochemical cure after reoperation (patients with an inadequate primary surgery). This study is consistent with the bibliographic reviews supporting that the cervical reoperation, eventually mediastinal, for residual hypercalcitoninemia after primary surgical treatment is indicated when the initial intervention did not follow the French Calcitonin Tumour Study Group (GETC) recommendations or when a specific lesion is evidenced by imaging studies without systemic dissemination.

Neovascularization: An “innocent bystander” in recurrent varicose veins

Varicose vein recurrence after surgery occurs in up to 60% of patients. A variety of technical factors have been implicated, but biological factors such as neovascularization have more recently been proposed. The objective of this study was to characterize the relative contribution of technical and biological factors to recurrence in a large prospective series of recurrent varicose veins. Duplex and operative findings were recorded prospectively in a consecutive series of 500 limbs undergoing surgery for recurrent varicose veins between 1995 and 2005 in a university teaching hospital. Only limbs with previous saphenofemoral junction surgery were included. All limbs had preoperative duplex mapping by an accredited vascular technician who assessed the status of the great saphenous vein (GSV) in the thigh and groin, sought sonographic evidence of neovascularization, and reported on the presence of reflux in the short saphenous vein and perforator sites (typical and atypical). All operations were performed with an attending vascular surgeon as the lead operator. Primary GSV surgery was incomplete in 83.2% of limbs. A completely intact GSV system was present in 17.4% of limbs. An incompetent thigh saphenous vein was present in 44.2% of limbs, 37.6% had GSV stump incompetence with one or more intact tributaries, and 16% had both a residual thigh GSV and an incompetent stump with intact tributaries. Non-GSV sites of reflux were identified in 25% of limbs. Neovascularization was identified on duplex scanning in 41 (8.2%) limbs. However, in 27 of these, surgical exploration revealed a residual GSV stump with 1 or more significant tributaries. Each of the remaining 14 (2.8%) limbs had a residual incompetent thigh GSV. Despite reports to the contrary, neovascularization occurs in a relatively small proportion of patients with recurrent varicose veins. All recurrent varicose veins associated with duplex-diagnosed neovascularization are also associated with persistent reflux in the GSV stump tributaries, thigh GSV, or both. Recurrence after primary varicose vein surgery is associated with inadequate primary surgery or progression of disease, and neovascularization alone is not a cause of recurrent varicose veins.

Adjuvant radiotherapy in carcinomas of the uterine cervix: the prognostic value of hemoglobin levels

Anemia has been associated with a poorer treatment response and reduced survival in women undergoing primary radiotherapy (RT) or radiochemotherapy for advanced cervical carcinoma. This study aimed to determine the influence of anemia on outcome in patients with cervical carcinoma undergoing adjuvant RT. Medical records were reviewed for 183 cervical cancer patients who had received adjuvant RT because of risk factors after radical surgery (n= 109) or inadequate primary surgery (simple hysterectomy; n= 74). Kaplan-Meier and Cox regression analyses were used to study hemoglobin levels before and during adjuvant RT in relation to recurrence-free and overall survival. Hemoglobin values > or =11 g/dL were considered normal, while those <11 g/dL indicated anemia. Hemoglobin levels before RT influenced significantly overall survival and recurrence-free survival across the whole group (overall survival--log rank(all patients)= 7.5; df = 1; P= 0.006). However, subgroup analysis showed that the observed difference was mainly due to the group of women who had undergone inadequate primary surgery (overall survival--log rank(inadequate surgery)= 10.8; df = 1; P= 0.001). Multifactorial regression analyses comparing hemoglobin before RT with grading and tumor stage confirmed the prognostic value of hemoglobin values. Maintaining normal hemoglobin values before and during adjuvant RT seems to be important, especially in patients who have had inappropriate simple hysterectomy, which may resemble a therapeutic situation.

Adjuvant radiotherapy in carcinomas of the uterine cervix: the prognostic value of hemoglobin levels

Anemia has been associated with a poorer treatment response and reduced survival in women undergoing primary radiotherapy (RT) or radiochemotherapy for advanced cervical carcinoma. This study aimed to determine the influence of anemia on outcome in patients with cervical carcinoma undergoing adjuvant RT. Medical records were reviewed for 183 cervical cancer patients who had received adjuvant RT because of risk factors after radical surgery (n= 109) or inadequate primary surgery (simple hysterectomy;n= 74). Kaplan–Meier and Cox regression analyses were used to study hemoglobin levels before and during adjuvant RT in relation to recurrence-free and overall survival. Hemoglobin values ≥11 g/dL were considered normal, while those &lt;11 g/dL indicated anemia. Hemoglobin levels before RT influenced significantly overall survival and recurrence-free survival across the whole group (overall survival—log rankall patients= 7.5; df = 1;P= 0.006). However, subgroup analysis showed that the observed difference was mainly due to the group of women who had undergone inadequate primary surgery (overall survival—log rankinadequate surgery= 10.8; df = 1;P= 0.001). Multifactorial regression analyses comparing hemoglobin before RT with grading and tumor stage confirmed the prognostic value of hemoglobin values. Maintaining normal hemoglobin values before and during adjuvant RT seems to be important, especially in patients who have had inappropriate simple hysterectomy, which may resemble a therapeutic situation.

Repeat Retroperitoneal Lymphadenectomy in Advanced Testicular Cancer

Objectives: Repeat retroperitoneal lymph node dissection (RPLND) for the treatment of metastatic testicular cancer is an uncommonly performed procedure. We evaluated the location, pathohistological results, postoperative complications and therapeutic outcome in 17 patients being referred for repeat RPLND after failure of the primary retroperitoneal approach. Patients and Methods: 18 patients underwent repeat RPLND after failed primary RPLND or residual tumour resection. We retrospectively analyzed preoperative patient characteristics, operative and pathohistological data from primary and repeat RPLND, morbidity and oncological outcome after surgery. Results: All patients had nonseminomatous primaries with metastatic retroperitoneal lymph nodes; 4 and 14 patients had undergone primary RPLND and residual tumor resection (RTR), respectively, for metastatic testicular cancer. Prior to repeat RPLND all patients had undergone 4 cycles of salvage chemotherapy for locoregional recurrences only with negative tumour markers at time of surgery. All patients demonstrated residual masses requiring repeat RPLND. Retroperitoneal recurrences were located at multiple sites: retrocaval area with infiltration of the vena cava, interaortocaval and paraaortic region, retrocrural space, suprahilar region, outfield metastases in the iliac region. Two cases required resection of the vena cava due to infiltration, in one case an aortic graft and an iliac graft was necessary due to tumour infiltration of the adventitial layer of the vessels; nephrectomy and resection of the sigmoid was required in another 2 patients. The most significant complication was chylous ascites 1 and prolonged paralytic ileus in 1 patient. Pathohistological examination of the resected specimen revealed viable germ cell tumour elements in 4 patients (22.2%), necrosis/fibrosis in 8 patients (44.4%) and mature teratoma in 6 patients (33.3%). At a mean follow-up of 22 (1–45) months, the disease specific survival rate was 89% with significant differences between patients with necrosis (100%), mature teratoma (85%) and viable cancer (50%). Conclusion: Recurrences after RPLND usually reflect inadequate primary surgery especially in the retrocaval and suprahilar region. Repeat RPLND is safe and effective in the majority of patients; however, it requires careful preoperative planning with regard to potential involvement of adjacent vascular and visceral structures making close interdisciplinary collaboration necessary in many cases. Repeat RPLND is a mandatory surgery to be performed at centres of expertise.

MR imaging in the assessment of residual tumour following inadequate primary excision of soft tissue sarcomas.

The purpose of this retrospective study was twofold: firstly, to assess the ability of MR imaging in confirming/excluding the presence of residual tumour following inadequate primary excision of soft tissue sarcomas; and secondly, to assess the accuracy of the original radiologists report as compared with a retrospective review of the scan hard copy in confirming/excluding. A total of 111 cases were identified that fulfilled the inclusion criteria of inadequate primary surgery followed by a MR scan and subsequent wide re-excision of the surgical field. The gold standard for the assessment of the MR imaging studies was histological examination of the re-excision specimens. Histological examination revealed residual tumour in 63 (56.7%) cases. In 48 cases the residual tumour was classified macroscopic (maximum diameter >10 mm) and 15 cases microscopic (maximum diameter </=10 mm). The original radiologists reports failed to indicate the presence or absence of tumour in 7 (6.3%) cases. In the remaining 104 cases the diagnostic performance of MR imaging gave a sensitivity of 0.64, specificity of 0.93, positive predictive value of 0.93 and negative predictive value of 0.67. In 12 of the 21 false-negative scans the residual tumour was microscopic. Subjective assessment of the radiologist's reports indicated that the proportion of equivocal reports was much higher in both the false-negative and false-positive groups as compared with the true groups. An unblinded retrospective review of the scan hard copies only differed from the original radiologists report in 8 (7.2%) cases. Contrast-enhanced sequences were not routinely obtained in this series. The results suggest that the poor negative predictive value can be attributed more to limitations of the MR scan and not to failures in observation or interpretation by the radiologists. Despite the low negative predictive value, MR imaging remains useful in planning the re-excision surgery by identifying the site and extent of the original operation and size of major residual tumour.

Synovial sarcoma: identification of low and high risk groups.

Synovial sarcoma, one of the most common soft tissue sarcomas that occur in adolescents and young adults, is generally viewed and treated as a high grade sarcoma. However, the authors' own experience and some previous studies have indicated that it has a wide spectrum of biologic behavior and that low and high risk subgroups of patients with synovial sarcoma can be identified. A total of 121 consecutive patients with synovial sarcoma (including 66 males and 55 females ages 9-74 years), treated primarily or secondarily at 2 large referral centers for musculoskeletal tumors, were included in a statistical analysis conducted to identify independent prognostic factors. There were local recurrences in 38 patients (31%), usually after inadequate primary surgery outside the referral centers; 64 patients (54%) developed metastasis, primarily to the lungs. The estimated 5-, 10-, and 15-year survival rates were 60%, 50%, and 45%, respectively (the mean follow-up for surviving patients was 9.8 years, with a range of 1-30 years). In multivariate analysis, independent risk factors for local recurrence included larger tumor size and primary surgical resection outside the referral center. Independent risk factors for metastasis were older patient age, tumor with poor histologic differentiation, and tumor necrosis. For tumor-related death, the independent risk factors were older patient age, tumor with poor histologic differentiation, and larger tumor size. Local recurrence was associated with a 3.66-fold increased risk of tumor-related death. A low risk group (patient age <25 years, tumor size <5 cm, and no histologic evidence of poorly differentiated tumor) with 88% overall disease free survival was identified, as was a high risk group (patient age > or = 25 years, tumor size > or = 5 cm, and poorly differentiated tumor) with 18% overall disease free survival (P < 0.001). The identification of low and high risk synovial sarcoma patients indicates that synovial sarcomas are not uniformly high grade tumors. It also indicates that treatment strategies should be modified for these risk groups. Adequate primary surgery is essential to both local control and outcome for synovial sarcoma patients.

Secondary orbital tumors.

The authors reviewed their experience with 524 secondary orbital tumor cases diagnosed histopathologically during 1963-1993. Secondary tumors constituted 48.0% of all orbital biopsies during the same period. There were 186 (35.5%) cases with eyelid tumors, 146 (27.9%) cases with intraocular tumors, 137 (26.1%) cases with conjunctival tumors, 26 (5.0%) cases with nasopharyngeal tumors, 22 (4.2%) cases with sinus carcinomas, 3 (0.6%) cases with intracranial meningiomas, 3 (0.6%) cases with esthesioneuroblastomas, and 1 (0.2%) case with chordoma. The three most frequent tumors making secondary orbital invasion were basal cell eyelid carcinoma (129 cases; 24.6%), squamous cell conjunctival carcinoma (125 cases; 23.8%), and retinoblastoma (123 cases; 23.5%). Squamous cell carcinoma, from various sites of origin, was the most frequent histopathologic tumor variant, accounting for 215 (41.0%) cases. Exenteration was performed on 334 (63.7%) of 524 cases with secondary orbital invasion. The ignorance of many lid and conjunctival lesions until the advanced stages, which could otherwise be easily treatable, caused blindness and life-threatening complications under our conditions. Orbital invasion from ocular retinoblastoma and uveal malignant melanoma led to a markedly poor prognosis, again related to the late presentation of many patients. Lack of health consciousness, inadequate primary surgery, and/or insufficient follow-up were the main reasons for secondary orbital invasion in many tumor cases.

SURGICAL RESECTION OF PRIMARY SOFT-TISSUE SARCOMA

We reviewed retrospectively 236 consecutive patients seen in our soft-tissue sarcoma clinic. Of these, 95 had had a primary soft-tissue sarcoma excised elsewhere, but with histologically inadequate resection margins. All these patients had a secondary and wider re-excision. The tissues removed at the secondary re-excision were examined histologically for the presence of residual tumour. Definite tumour tissue was found in 29 of 55 lower-limb specimens, 16 of 25 upper-limb, 7 of 10 trunk and 4 of 5 head and neck specimens. In 31 cases some residual tumour was visible macroscopically, and in 56 of the 95 patients (59%) the primary tumour had been incompletely excised. Our results indicated that surgical assessment of the adequacy of excision is very inaccurate and that most local recurrences are the consequence of inadequate primary surgery. The large number of patients who had inadequate initial treatment emphasises the need for a co-ordinated multidisciplinary approach to the management of patients with soft-tissue sarcoma.

Bone resection in patients with mandibular sarcoma

Thirty-nine cases of mandibular sarcoma were reported to the Finnish Cancer Registry during the period 1953-1985. In 11 of these (nine osteosarcomas, one chondrosarcoma, one leiomyosarcoma), the pre- and postoperative radiographs were still available, and they were analyzed in order to evaluate the radicality of the primary surgical procedure in relation to recurrences during the follow-up. On the basis of several radiological details, the resection was considered inadequate in seven cases. One operation was probably inadequate because of rather scanty margins. In only three cases had an adequate primary resection with proper safety margins been performed. All of the seven patients with inadequate primary surgery had recurrence and five of them died of local disease or metastases, whereas only one of the three patients with adequate resection had recurrence in adjacent soft tissues. It is concluded, that radiological findings of mandibular sarcoma that often are missed include widening of the mandibular canal and disappearance of the lamina dura. Proper preoperative radiological examination resulting in more radical primary surgery would certainly decrease the recurrence and mortality rates in patients with mandibular sarcoma.

Early maxillary orthopaedics as a supplement to conventional primary surgery in complete cleft lip and palate cases — long-term results

29 patients with complete uni- or bilateral cleft lip and palate were followed up the age of 15 to 20 years after having undergone early maxillary orthopaedics as a supplement to conventional primary surgery. Longitudinal changes in their facial pattern are demonstrated by means of Enlow's cephalometric analysis. The ultimate sagittal skeletal imbalance is more than 50% of the cases seems to be related to inadequate primary surgery (lip closure before 5 months of age, complete palatal closure before 2 years of age). Evidently, initial facial pattern and functional habits also play an important role. Functional disturbances due to scarring are discussed with a view to their influence on facial development.

Management of operable breast cancer: the surgeon's view.

There is no ideal single operation for breast cancer. In planning the choice of surgery for breast cancer, one must be aware of its multicentric origin, and of the regional spread from the breast to the axillary and internal mammary lymph nodes. The scope of the surgical attack should be correlated with the clinical pathologic extent of disease in the individual patient with the aim of removing all disease present, while preserving appearance and function to the utmost. The main goal remains removal of all disease from the breast and its regional nodes. Three distinct operative procedures have been utilized--modified radical mastectomy--total mastectomy with axillary dissection, radical mastectomy, and extended radical mastectomy. In all instances, the appropriate operation is applied to the individual, with the concept of removing most efficiently all disease present in the breast and regional nodes. With this plan of therapy, a 10 year survival rate of 61% with a local recurrence rat of 7.7% has been attained in a group of 565 patients with 40% axillary node involvement. These data are crude and uncorrected for age, intercurrent disease and for those lost to follow-up. The best salvage has been attained in the so-called "minimal" breast cancers--95% well 10 years following modified radical mastectomy. The extended radical mastectomy has been superior to the radical mastectomy when axillary node disease is present. In the more complete operation, 54% 10 year survival has been attained in patients with axillary node metastases, compared with only 33% attained in those treated by the conventional radical mastectomy. Adjuvant radiation therapy is applied to the adjacent regional nodes, when indicated. Adjuvant multi-chemotherapy is in its infancy and still to be evaluated. It should be used as a supplement to adequate primary surgical treatment, and should not be used as a crutch for inadequate primary surgery.