Incomplete Tumor Resection Research Articles

Surgical outcomes of nephron sparing surgery for renal tumours

Surgical outcomes of nephron sparing surgery for renal tumours

Surgical treatment of intraventricular ependymomas and subependymomas

Background and purposeThe aim of the study was to present our experience in the surgical treatment of intraventricular ependymomas and subependymomas with special consideration to the evaluation of the surgical outcome and risk of tumour recurrence. Material and methodsWe report a series of 36 consecutive patients treated surgically for intraventricular ependymoma or subependymoma in the years 1992–2008. There were 26 lateral ventricle and 10 fourth ventricle tumours. Complete resection was achieved in 19 patients while the remaining 17 patients underwent either subtotal or partial resection. Histopathological evaluation revealed ependymoma, subependymoma and anaplastic ependymoma in 20, 11 and 5 cases, respectively ResultsEight patients died after surgery due to postoperative brain injury. Five patients were severely disabled postoperatively: one patient developed hemiparesis, three patients presented adynamic syndrome, and one patient developed severe cerebellar ataxia subsequent to vermis injury. All patients with posterior fossa tumours presented with lower cranial nerve deficit. Seventeen patients received radiotherapy postoperatively. There were five recurrent tumours during follow-up; three patients underwent subsequent reoperation. Importantly, five patients with supratentorial tumours and a history of incomplete resection with postoperative radiotherapy had no tumour recurrence in over 10 years’ follow-up. ConclusionsIntraventricular ependymomas and subependymomas still remain a surgical challenge due to a relatively high incidence of incomplete tumour resections and/or permanent neurological complications associated with their removal. Still, even incomplete tumour removal with subsequent radiotherapy facilitates long-term progression-free survival in some cases.

Preoperative Breast MRI in the Surgical Treatment of Ductal Carcinoma In Situ

Accurate determination of the size or extent of ductal carcinoma in situ (DCIS) by imaging is uncertain, and incomplete resection of tumor results in involved margins in up to 81% of cases. This study examined the accuracy of magnetic resonance imaging (MRI) for assessment of DCIS size, and evaluated the effect of preoperative breast MRI on achievement of tumor-free surgical margins after breast-conserving surgery (BCS). One-hundred and fifty-eight female patients with DCIS were identified from a prospective database: 60 patients (62 cases) had preoperative breast MRI, and 98 patients did not have MRI. The accuracy of tumor size assessed by MRI was determined by comparison with histopathologic size. All patients underwent BCS initially. The rate of involved margins after resection was compared in MRI and no-MRI groups. The overall correlation between MRI size and histopathologic size was high (p < 0.0001). MRI assessment of size was significantly more accurate when DCIS was high grade (p < 0.0001) or intermediate grade (p = 0.005) versus low grade (p = 0.187). The rate of tumor-involved margins was not significantly different in MRI and no-MRI groups (30.7% and 24.7%, respectively; p = 0.414). The rate of mastectomy was significantly higher in the MRI group than the no-MRI group (17.7% versus 4.1%; p = 0.004). These findings indicate that MRI can detect DCIS, especially when lesions are high or intermediate grade, but that MRI does not accurately predict the size of DCIS. In this study, MRI did not improve the surgeon's ability to achieve clear margins following BCS.

Role of histological type on surgical outcome and survival following radical primary tumour debulking of epithelial ovarian, fallopian tube and peritoneal cancers

Background:To assess the clinical impact of the two histological types as designated in the proposed model for ovarian tumourigenesis in primary epithelial ovarian, fallopian tube or peritoneal cancer (EOC) patients.Methods:All consecutive EOC patients (n=632) after primary tumour debulking in our institution (09/2000–08/2010) were classified into one of two groups: type I tumours (n=100; 15.8%) composed of low-grade serous, low-grade endometrioid, clear cell, mucinous and transitional carcinomas; and Type II tumours (n=532; 84.1%) composed of high-grade serous, high-grade endometrioid, undifferentiated and malignant mixed-mesodermal tumours. Kaplan–Meier and logistic/Cox-regression analyses were performed to assess the impact of histological type on surgical outcome and survival.Results:Type II patients had a significantly higher incidence of advanced disease (FIGO III/IV) than Type I patients (79.8% vs 38%, respectively; P<0.001). Median CA125 values (438 vs 93 U ml−1; P=0.001); operative time (258 vs 237 min; P=0.001); and incidence of incomplete tumour resection (34.4% vs 15% P<0.001) were significantly higher in patients with Type II. During a mean follow-up time of 23 months (range: 1–106), 17% of patients with type I vs 34.8% of patients with type II tumours relapsed and/or died (P<0.001). Overall survival (P=0.021) and progression-free survival (P=0.003) were also significantly higher in patients with type I tumours. Multivariate analysis, while identifying postoperative tumour residuals, positive lymph nodes and extrapelvic dissemination as independent predictors of survival, failed to demonstrate any prognostic significance of histological type.Conclusion:Type I EOC patients appear to present at earlier stages have significantly higher survival and more optimal surgical outcome compared with type II patients. However, in advanced stages, histology loses significance as an independent prognosticator.

Intraoperative MRI for transphenoidal procedures: Short-term outcome for 100 consecutive cases

Background The majority of pituitary lesions are benign and can be cured with complete surgical resection. However, the transsphenoidal technique (the most common approach for pathology in this region) is limited by poor visualization and anatomical constraints. This can lead to incomplete tumor resection and thus increased recurrence rates. The use of iMRI during these procedures offers the advantage of radiographic confirmation during the procedure and may improve extent of resection. We reviewed our experience with this technology in 100 consecutive cases and compared the outcomes to published results. Methods 100 patients were treated via transnasal transsphenoidal approach using the GE Signa SP 0.5 Tesla (double doughnut design) iMRI system between July 2002 and August 2009 and followed prospectively. Intraoperative findings, imaging results, postoperative MRI and clinical outcome were evaluated to determine the extent of tumor resection, monitor for recurrence and determine outcome. Results There were 100 patients studied, 81 macroadenomas, 9 microadenomas, and 10 other pathological diagnosis. The average extent of resection was 96% with gross total resection based on iMRI in 76 patients (76%). Four patients (4%) all with macroadenomas greater than 4 cm experienced major perioperative complications (hydrocephalus 2, thalamic infarct 1, major arterial bleeding 1), six patients (6%) developed post-operative CSF leaks, one patient (1%) had post-operative worsening of visual fields, and five patients (5%) had abdominal fat graft infections. Nine patients (9%) including five with known residual tumor required post-operative adjuvant treatment during the follow-up period secondary to either disease progression or failure to achieve endocrinological cure. Conclusions iMRI-guided transsphenoidal pituitary surgery provides the surgeon with immediate radiographic feedback during the procedure and aides in overcoming the limitations in direct visualization during such procedures. As a result of this it may enable surgeons to perform such procedures with fewer complications and increased rate of gross total resection. However, the impact of this technology on long-term tumor control still needs to be determined with further follow-up.

Adenomatous tumors of the middle ear and temporal bone: clinical, morphological and tumor biological characteristics of challenging neoplastic lesions

Adenomatous tumors of the middle ear and temporal bone are rare tumors. In this retrospective study, we examined nine patients who underwent surgery for an adenomatous tumor of the middle ear, mastoid cavity or eustachian tube. In seven patients, a middle ear adenoma (MEA) and in two patients an aggressive papillary tumor (APT) was diagnosed. We report the clinical, radiologic, morphologic, immunohistochemical and DNA image cytometrical characteristics that can help to correctly classify these tumors. Therapy consisted of surgical excision of the tumors in eight cases. In one elderly patient, only a large biopsy was taken, because this patient suffered from cardial and kidney disorders and was not suitable for an extended surgical approach. This patient received stereotactic radiotherapy. Seven patients underwent planned second look operation. Recurrences occurred in three patients (one with APT, two with MEA), whereas in two of these cases rather a residual tumor due to initial incomplete tumor resection occurred. By image analysis, DNA cytometry MEA were considered benign, whereas the appearance of aneuploid tumor cells in APT confirmed these tumors as low grade malignant lesions. The proliferation rates were equally low in both entities. APT and MEA are tumor entities which can only be correctly classified by a synopsis of histopathology, immunohistochemistry and DNA image cytometry. The recommended therapy is the complete tumor excision. In cases of APT, von Hippel-Lindau syndrome has to be excluded.

Survival and prognostic factors in patients with small bowel carcinoid tumour

Previous studies of small bowel carcinoid tumours usually presented overall or relative survival. This study, in addition, evaluated disease-specific survival in a cohort of patients in a geographically defined population. Patients diagnosed with carcinoid of the jejunum or ileum in Jönköping County between 1960 and 2005 were eligible for inclusion. Available tumour specimens were re-examined to confirm the diagnosis. Medical records and pathology reports were reviewed in detail. A total of 145 patients were included in the study. One hundred and thirty-five patients underwent surgery in connection with the diagnosis. Resection was considered complete (R0) in 74 patients (54·8 per cent). Only two localized tumours recurred, whereas no patient with distant metastases was cured. Patients with regional metastases who underwent R0 resection had a better survival than patients with incomplete resection (P = 0·005), and a majority of patients remained recurrence-free. Median overall survival was 7·2 years and median disease-specific survival 12·3 years. In multivariable analysis, age 61-74 years (hazard ratio (HR) 3·78, 95 per cent confidence interval 1·86 to 7·68), age 75 years or more (HR 3·96, 1·79 to 8·74), distant metastases (HR 14·44, 1·59 to 131·36) and incomplete tumour resection (HR 2·71, 1·11 to 6·61) were associated with worse disease-specific survival. Later time period of diagnosis (HR 0·45, 0·24 to 0·84) was associated with better disease-specific survival. Age, disease stage and complete resection were identified as independent prognostic factors for survival in patients with small bowel carcinoid tumours. The importance of achieving R0 resection is therefore emphasized.

Fibromyalgie : vers une cyber psychothérapie ?

Solid pseudopapillary tumor (Frantz's tumor) of the pancreas is a rare lesion.It is of low-grade malignancy but can cause extensive local invasion.The aim of this study was to assess the outcome of Frantz's tumors after incomplete resection.We contacted all authors who published case reports describing incomplete resection of Frantz's tumor between 1985 and 2008 to request follow-up information.Follow-up information was obtained for 11 out 18 patients who underwent incomplete resection.Estimated median survival rate was 5.7 years (69.5 months).Since Frantz's tumor typically develops mainly in children and young women, a 5.7 year survival rate is unacceptable. Thus complete resection of locally invasive solid-pseudopapillary tumor of the pancreas is always justified, even at the price of difficult, mutilating surgery.

Presurgical evaluation and postoperative seizure-outcome in children and adolescents with intracranial tumors and drug resistant focal epilepsy

Objective: Patients with intractable focal epilepsy due to intracranial tumors are excellent candidates for epilepsy surgery. According to the literature the percentage of seizure-free patients post surgery varies between 65–90%. Incomplete tumor resection and/or insufficient removal of tumor-associated focal cortical dysplasia are risk factors for good seizure outcome. Role of invasive diagnostic is not fully established yet.

Hyperthermia in soft tissue sarcoma

Patients with high-risk soft tissue sarcomas (STS)-FNCLCC grade 2-3, size >5 cm, deep to the fascia-are at risk for developing local recurrence and distant metastasis despite surgical tumor resection. Therefore, the management of high-risk STS requires a multidisciplinary approach. Besides surgery, radiotherapy, and chemotherapy, regional hyperthermia (RHT) has the potential to become the fourth standard treatment modality for the treatment of these patients. RHT means non-invasive selective heating of the tumor area to temperatures within the range of 40-43°C for 60 min by the use of an electromagnetic heating device. Thereby RHT is always applied in addition to radiotherapy or chemotherapy or both but is not effective as a single treatment. Beside direct cytotoxicity, RHT in combination with chemotherapy enhances the drug cytotoxicity mainly by increased chemical reaction and intratumoral drug accumulation. For the neoadjuvant setting, RHT in combination with a doxorubicin- and ifosfamide-based chemotherapy has been shown to dramatically improve the tumor response rate but also prevents from early disease progression as compared to chemotherapy alone. The addition of RHT to a multimodal treatment of high-risk STS consisting of surgery, radiotherapy, and chemotherapy either in the neoadjuvant setting but also after incomplete or marginal tumor resection has been shown to significantly improve local recurrence- and disease-free survival. Based on these results and in conjunction with the low RHT-related toxicity, RHT combined with preoperative or postoperative chemotherapy should be considered as an additional standard treatment option for the multidisciplinary treatment of locally advanced high-grade STS.

Bypass Surgery Versus Intentionally Incomplete Resection in Palliation of Pancreatic Cancer: Is Resection the Lesser Evil?

ObjectiveAs technical expertise increases, the indication for pancreatic resection for advanced pancreatic cancer has been expanded over the last years. Recently, several groups reported their series of unintentionally incomplete tumor resections and reported a potential survival benefit for patients after incomplete resection when compared with palliative bypass surgery. We investigated in a retrospective analysis whether even tumor resection that was intended to be incomplete might provide a better outcome than conventional palliative procedures. MethodsTwenty-two patients with a locally non-resectable or disseminated adenocarcinoma of the pancreas underwent a palliative intentionally incomplete resection. Outcome after resection was compared with that of 46 patients matched for age, sex, and histopathological tumor type who underwent a palliative bypass operation. ResultsOverall surgical morbidity was significantly higher in the resection group (59%) compared with the bypass group (33%, p < 0.05), resulting in a higher relaparotomy rate and a significantly longer postoperative hospital stay (p < 0.001). Surgery-related mortality was significantly higher in the resection group (p < 0.05). Overall survival showed no statistically significant difference between the two groups. ConclusionsBecause of the higher surgery-related morbidity and mortality and lack of survival benefit in cases of advanced adenocarcinoma of the pancreas, intentionally incomplete palliative resection is not advisable.

Chromosome 17 alterations identify good-risk and poor-risk tumors independently of clinical factors in medulloblastoma

Current risk stratification schemas for medulloblastoma, based on combinations of clinical variables and histotype, fail to accurately identify particularly good- and poor-risk tumors. Attempts have been made to improve discriminatory power by combining clinical variables with cytogenetic data. We report here a pooled analysis of all previous reports of chromosomal copy number related to survival data in medulloblastoma. We collated data from previous reports that explicitly quoted survival data and chromosomal copy number in medulloblastoma. We analyzed the relative prognostic significance of currently used clinical risk stratifiers and the chromosomal aberrations previously reported to correlate with survival. In the pooled dataset metastatic disease, incomplete tumor resection and severe anaplasia were associated with poor outcome, while young age at presentation was not prognostically significant. Of the chromosomal variables studied, isolated 17p loss and gain of 1q correlated with poor survival. Gain of 17q without associated loss of 17p showed a trend to improved outcome. The most commonly reported alteration, isodicentric chromosome 17, was not prognostically significant. Sequential multivariate models identified isolated 17p loss, isolated 17q gain, and 1q gain as independent prognostic factors. In a historical dataset, we have identified isolated 17p loss as a marker of poor outcome and 17q gain as a novel putative marker of good prognosis. Biological markers of poor-risk and good-risk tumors will be critical in stratifying treatment in future trials. Our findings should be prospectively validated independently in future clinical studies.

The treatment outcome depending on the extent of resection in skull base and spinal chordomas

The authors tried to assess the treatment outcomes depending on the extent of resection in axial chordomas and compare the outcome of two adjunctive therapies (external beam radiation therapy vs. stereotactic radiosurgery) following incomplete tumour resection in terms of local tumour control. We retrospectively reviewed 30 consecutive patients with chordoma involving skull base, sacrum and mobile spine between 1993 and 2008. Their initial treatments had different extent of resection. Wide resection was performed for 12 (40%), subtotal resection and adjunctive radiotherapy/radiosurgery for 12 (40%), while six patients (20%) were solely treated with radiotherapy/radiosurgery. For these three groups, overall and progression-free survival rate were compared. The overall survival rate was 96% at 5years and 67% at 10years. Tumour progression-free survival (PFS) rates were 73% and 43% at 5 and 10years, respectively. Local tumour progression was seen in 67% in all patients, 58% in wide resection group, 67% in subtotal resection plus radiotherapy/radiosurgery group, and 75% in radiotherapy/radiosurgery group; however, this was not statistically significant (P = 0.69). Neither the extent of resection nor tumour location significantly influenced overall and progression-free survival (P > 0.05). With regard to the type of radiotherapy, tumour progression occurred in all lesions treated with external photon beam radiation therapy (EBRT) but only 38% of lesions treated with stereotactic radiosurgery (SRS) (P = 0.003). Adjunctive radiotherapy/radiosurgery following subtotal resection showed comparable local control and survival to wide resection. SRS offered superior local tumour control compared to EBRT.

Endoscopic Endonasal Surgery in Recurrent and Residual Pituitary Adenomas after Microscopic Resection

Background Despite the increasing interest in endoscopic techniques for pituitary surgery, little has been published on the endoscopic approach for recurrent and/or residual pituitary adenomas. We report the outcome of purely endoscopic endonasal surgery for a series of recurrent and/or residual pituitary tumors after a previous microscopic resection. Methods We reviewed all of the patients in our institution who underwent endoscopic resection for recurrent and/or residual pituitary tumors after previous microscopic resection. All patients had clinical and magnetic resonance imaging follow-up of at least 3 months postoperatively. Careful attention was given to the operative reports documenting the degree of previous microscopic exposure. Our results were compared with published reports of surgery for recurrent and residual pituitary tumors. Results Thirty-nine patients met our inclusion criteria. The mean follow-up was 21 months. Tumors were comprised of 19 nonfunctional, 10 adrenocorticotropic hormone, 9 growth hormone, and 1 prolactin-secreting adenoma. The endoscopic procedure revealed limited previous exposure of the sphenoidal and sellar structures in 30 cases (76%). Sphenoidotomy and sellar opening, in terms of working area and angle of view, were significantly restricted in 64% and 61% of the cases, respectively. Gross total removal was achieved in 46% of cases. Seventeen patients had frank cavernous sinus invasion. Conclusions The restricted exposure of sphenoidal and sellar structures by the microscopic approach may be a contributing factor to incomplete tumor resection. The results observed in this setting make the endoscopic technique a valid option in recurrent and residual pituitary adenomas treated initially by microscopic surgery.

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.

Can complete tumor resection be predicted in advanced primary epithelial ovarian cancer? A systematic evaluation of 360 consecutive patients

Background Postoperative tumor-residual-mass is the most important prognostic factor in epithelial ovarian cancer (EOC). Aim of our study was to define risk factors for incomplete tumor resection in advanced primary EOC. Patients & methods A validated intraoperative documentation tool (“Intraoperative-Mapping of Ovarian-Cancer” = “IMO”) was applied to systematically evaluate intraabdominal tumor dissemination pattern, maximal tumor load, tumor residuals and operative morbidity for all EOC-patients who underwent primary surgery in our institution during 09/2000–08/2009. Univariate- and multivariate analysis were performed to identify independent risk factors of incomplete tumor resection and operative complications. Results We evaluated 360 consecutive EOC-patients of FIGO-stage-III/IV. In 221(61%) patients a complete tumor resection could be obtained. In 50(14%) patients tumor residuals were <0.5 cm. Sixty (17%) patients developed a major (14%) complication. Multivariate analysis identified intestinal resection (OR:2.0; 95%CI:1.14–3.4; p = 0.01) and macroscopical tumor residuals (OR:0.5; 95%CI:0.2–1.2; p = 0.05) as independent predictors of major operative morbidity. Tumor dissemination pattern and maximal tumor load were significantly different between tumor-free and not-tumor-free operated patients, with less extrapelvic tumor involvement in the tumor-free group ( p < 0.001). More than 4 IMO-fields of tumor involvement (OR:3.3; 95%CI:1.5–7.0; p = 0.002) were identified to be of predictive significance for incomplete tumor resection. FIGO-stage, histology, age, CA125-levels, bowel resection and ascites did not affect optimal tumor resectability. Conclusions Tumor expanding in multiple (>4) abdominal quadrants was the major negative predictors for complete tumor resection in primary EOC-patients. Bowel resection and macroscopical tumor residuals were of predictive value for a higher operative major morbidity. Identifying high-risk patients for suboptimal tumor resection and operative complications may improve surgical outcome in advanced primary EOC.

Xeroderma pigmentosum compliqué d’une tumeur intracérébrale : à propos d’un cas

Patients with the genetic disease xeroderma pigmentosum (XP) lack the ability to carry out a specific type of DNA repair process called nucleotide excision repair (NER). The NER pathway plays a critical role in the repair of DNA damage resulting from ultraviolet (UV) radiation. We report a case of a patient presenting a cutaneous form of XP. She presented acute paralysis of the third cranial nerve with cutaneous anesthesia. Nuclear magnetic resonance imaging revealed an intracranial tumor. She underwent surgery with incomplete tumor resection; anatomopathological study showed a schwannoma. Complementary radiosurgery was performed. The association between XP and neurological cancer is rare but not impossible. A priori, it would be assumed that the major medical outcome of hereditary deficiencies in DNA repair processes would be an increased risk of cancer. Indeed, there is an increased risk of cancer in several known DNA repair deficiencies including XP.

Surgical treatment for 140 patients with gastric stromal tumors

To analyze the outcome of the patients with gastric gastrointestinal stromal tumor(GIST) after surgical treatment and identify the associated risk factors. Clinical data and the tissue slices including immunohistochemistry staining of 140 patients with gastric GIST from January 1990 to December 2008 were retrospectively reviewed. SPSS 16.0 for Windows software package was used for statistical analysis. The overall survival rates of 1-, 3-, 5-year were 96.8%, 86.7% and 79.3%, respectively. The survival rates of 1-, 3-, 5-year were 98.1%, 90.0% and 85.4% in patients who underwent complete tumor resection. But the survival rates of 1-, 3-, 5-year were 38.1%, 0 and 0 in patients with incomplete tumor resection. The differences were statistically significant (P<0.05). Gender, preoperative metastasis, tumor size,pathology type,karyokinesis, recurrence and metastasis were associated with survival rates in patients with complete tumor resection by univariate analysis. However, only tumor size, karyokinesis, recurrence and metastasis were associated with survival rates by Cox regression multivariable analysis(P<0.05). Surgery remains the main treatment for gastric GIST. Local complete resection is the principal treatment.

Paclitaxel plus BEP (T-BEP) regimen as induction chemotherapy (CT) in nonseminomatous germ cell tumors (NSGCT) patients with poor prognosis: A phase II study.

4587 Background: Paclitaxel is an active drug in the treatment of patients (pts) with NSGCT. We performed a phase II study to assess the efficacy and toxicity of T-BEP regimen in the first line treatment of NSGCT pts with poor prognosis. Methods: CT-naïve NSGCT pts with poor prognosis (IGCCCG) received T-BEP as follows: paclitaxel 175 mg/m2 d 2, cisplatin 20 mg/m2 d 1-5, etoposide 100 mg/m2 d1-5, bleomycin 30 IU d 1,3,5 with G-CSF support 300 mcg d 6-15. Four–six cycles of CT were administered depending on time to normalization of tumor markers. The primary endpoint was the progression free rate at 1-year after completion of CT. The hypotheses being tested was Ho: p0 = pexp (p0=0.50). Assuming pexp=0.70 with a two-sided type I error of 0.05, a type II error of 0.2 and 10% of pts drop-out rate, 51 pts were required. Results: From 2004 to 2008, 51 pts were treated. Sixteen (30%) pts had primary mediastinal tumor. Median follow-up (f.-up) of survived pts was 26 months (range, 6 – 54). Complete response (CR) after CT and surgery was achieved in 11 (22%) pts. Twenty eight (55%) pts had partial response (PR) marker “-“ status, 3 (6%) pts – PR marker “+”, and 9 (17%) pts were classified as treatment failure (progression disease or incomplete resection of viable tumor). When 27 pts had been treated, an unplanned analysis showed inappropriate toxicity on cycle 1 (6 pts had infection gr. 3/4, which resulted in two toxic deaths). Thereafter, the regimen was modified: the next 26 pts started BEP regimen on cycle 1 followed by T-BEP on subsequent cycles. No more severe infections or toxic deaths were observed in the cohort. For all pts, toxicity (grade 3/4) included neutropenia 70%, febrile neutropenia 34%, mucositis 4% and diarrhea 2%. A patient was lost for follow-up (follow-up <1 year) and efficacy was assessed in 50 pts. At 1-year after completion of CT 26 (58%) pts were free of disease, which was compatible with results of BEP alone. Conclusions: T-BEP regimen does not improve outcome of NSGCT pts with poor prognosis. No significant financial relationships to disclose.

Primary intradural chordoma: report on three cases and review of the literature

Chordomas are rare malignant bone tumors of the skull base or sacrococcygeal region. They derive from notochordal remnants and usually have a chronic progressive course. Even rarer, intradural chordomas with a better biological behavior have also been reported. We present 3 further primary intradural extraosseous chordomas with a favorable clinical outcome. Two patients, a 38-year-old man and a 44-year-old woman, presented with neck pain. In these, intradural extraspinal tumors within intervertebral foramina were found. Both tumors were totally removed and the patients have been free of disease for 7 years and 1 year, respectively. The other patient, a 76-year-old man suffered from an unspecific gait disorder and diplopia as a result of a prepontine space-occupying lesion. In this case, only an incomplete tumor resection was possible but progression has not occurred for 5 years. Paraffin blocks from all cases were examined with classical histopathological stainings and immunohistochemistry for pancytokeratin, CK7, CK8/18, CK19, EMA, CEA, vimentin, S100, aktin, desmin, GFAP, CD117, PDGF-receptor alpha and beta, collagen-type-IV, p63, and Ki67. Fluorescent in situ hybridization was used to exclude EWS translocation. All cases showed the typical histological picture with physaliphorous cells in a myxoid matrix and the characteristic immunohistochemical profile with positivity for vimentin, pancytokeratin, CK19, EMA, and S100. Staining for P63 and type IV collagen was consistently negative. Myxoid extraskeletal chondrosarcoma was excluded by in-situ-hybridization of the EWS gene. Considering our cases in context with so far published literature, we conclude that intradural chordomas are rare and in this location usually have a better prognosis compared to classical intraosseous chordomas.