Initial Surgery Group Research Articles

The efficacy of delayed surgery in children with high-risk neuroblastoma.

Surgery is an important part of treatment in children with neuroblastoma; however, exact timing is unclear. Both initial and delayed surgery was suggested as the best by numerous studies. Thus, we aimed to investigate the role of delayed surgery on 31 children with high-risk neuroblastoma. Thirty-one children with high-risk neuroblastoma were enrolled into the study. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) for windows 10.0. There 'were 15 male and 16 female patients with a median age of 3.0 ± 3.2 years. Primary tumor site was adrenal in 27, non-adrenal in two, pelvic in one, and mediastinal in one patient. MYCN gene was amplified in four and non-amplified in 11 children on totally 15 children with available data. Lactate dehydrogenase was elevated in 30 children. The tumor volumes at diagnosis and before surgery in the whole group were 154.3 and 12.5 mL, respectively. The decline in tumor volume was statistically significant (P < 0.0001). Initial surgery was performed in three and delayed in 20 children, and eight children were inoperable. Surgical complication rate was 66.6% (two out of three patients) in initial surgery group; however, the rate was 15% (3 out of 20 patients) in delayed surgery group. The 5-year event-free survival and overall survival rates in the whole group were 44.8% and 50.8%, respectively. Primary tumor area control rate was 95% In conclusion, the delayed surgery with intensive chemotherapy and radiotherapy has been successful for primary control in high-risk neuroblastoma patients.

Completion thyroidectomy in differentiated thyroid cancer: When to perform?

Completion thyroidectomy is recommended in patients who have been diagnosed with differentiated thyroid cancer on histopathological evaluation, if their first operation was a conservative approach. The critical issue is when to do the second operation. The medical records of 66 patients who underwent completion thyroidectomy for the treatment of differentiated thyroid cancer in our clinic between 2006-2013 were retrospectively analyzed. All data were compared after patients were divided into two groups according to the interval between the first surgery and completion thyroidectomy. Fifty-two patients (78.8%) were women and 14 patients (21.2%) were male. Completion thyroidectomy was performed 10-90 days after the initial surgery (group 1) in 26 patients, whereas it was performed later than 90 days in 40 patients (group 2). Temporary hypoparathyroidism occurred in two patients (7.7%) in group 1, and in 3 patients (7.5%) in group 2. Transient recurrent laryngeal nerve palsy was observed in 1 patient (3.9%) in group 1, and in 1 patient (2.5%) in group 2. There were no permanent morbidities in both groups. Residual tumor rate after completion thyroidectomy was 45.5%. There was no statistically significant difference between the two groups in terms of complications after completion thyroidectomy. Although in some studies it is recommended that completion thyroidectomy should be performed either before scar tissue development or after clinical remission of scar tissue, edema and inflammation, we believe that timing of surgery has no effect on morbidity.

Multivariate analysis of prognostic factors in patients with pulmonary actinomycosis

BackgroundThere have been few studies of pulmonary actinomycosis, which is an uncommon anaerobic infection. Consequently, the optimal therapeutic regimen, appropriate duration of treatment, long-term prognosis, and factors predicting prognosis are not well established.MethodsWe retrospectively reviewed the medical records of histopathologically confirmed cases of pulmonary actinomycosis seen between November 2003 and December 2012.ResultsThe study included 68 patients with a mean age of 58.4 ± 11.6 years. Of the 68, initial surgery was performed in 15 patients (22.1%), while the remaining 53 (77.9%) received antibiotic therapy initially. In the initial antibiotic group, 45/53 (84.9%) were cured without relapse (median antibiotic duration 5.3 months). 5/53 (9.4%) patients were refractory medically (median antibiotic duration 9.7 months), and 3/53 (5.7%) experienced a recurrence (median time to relapse 35.3 months). In the initial surgery group, 14/15 (93.3%) were cured and treatment failure occurred in one (6.7%). In the multivariate analysis, the absence of an antibiotic response at 1 month was the only independent factor associated with a poor treatment outcome, with an adjusted odds ratio of 49.2 (95% CI, 3.34–724.30). There was no significant difference in treatment outcome based on the size of the parenchymal lesion, comorbidities, whether intravenous antibiotics were used, antibiotic therapy duration, or whether the initial treatment was surgical.ConclusionsAntibiotic treatment with or without surgery was effective for treatment of pulmonary actinomycosis. Nevertheless, treatment failure or recurrence occurred in a considerable proportion of patients, especially those resistant to the initial antibiotic treatment.

Clinical features and outcomes of neck lymphatic metastasis in ovarian epithelial carcinoma

BackgroundNeck lymph node metastasis (NLNM) in epithelial ovarian cancer (EOC) is rare and treated as advanced stage cancer. However, ovarian cancer with lymphatic metastasis may manifest a different clinical course from peritoneal carcinomatosis.MethodsThe authors retrospectively assessed 20 patients with EOC and pathologically diagnosed as NLNM between January 2001 and December 2010. The patients were divided into two groups according to the time of NLNM identification. Statistical methods included Kaplan-Meier, log-rank, and Cox regression analysis.ResultsEleven patients were diagnosed with NLNM at the same time of surgical exploration of EOC (Group A) and nine patients at cancer recurrence 43.3 months after initial surgery (Group B). In Group A, patients with tumors confined to the pelvic cavity had no recurrence or had isolated lymph node recurrence (ILNR), and survived longer than patients with abdominal tumor spreading (P = 0.0007). In Group B, 2 patients showed ILNR. The median survival time after NLNM was 42 months in Group A and 6 months in Group B (P = 0.01). Cox model demonstrated that non-serous histology, brain metastasis, and NLNM identified at cancer recurrence were major predictors for poor overall survival (Hazard ratio [HR] = 18.67, 6.93, and 4.52; P = 0.01, 0.02, and 0.04, respectively).ConclusionsA subgroup of EOC patients with NLNM who presented limited pelvic cancer had much better overall survival than patients who had cancer spreading beyond the pelvic cavity or were diagnosed with NLNM at cancer recurrence.

The outcome of initial percutaneous drainage versus surgical drainage for intra-abdominal abscesses in Crohn’s disease

Percutaneous drainage (PD) of Crohn's related abscesses is becoming popular with the development of techniques. We retrospectively analyzed the outcome of initial PD versus initial surgical drainage for intra-abdominal abscesses in Crohn's disease. Twenty-three patients of Crohn's disease complicated with intra-abdominal or pelvic abscesses treated in our institution between July 2001 and April 2010 were retrospectively identified from 188 patients with proven Crohn's disease. Outcome measures included abscess recurrence after different treatments, post-drainage complications, ultimate stoma creation, and subsequent surgery for Crohn's disease. Patients were divided into initial PD group (n = 10) and initial surgery group (n = 13): post-drainage complications were more common in initial surgery group (2/10 vs 9/13, P = 0.036), abscess recurred in three patients (2/10 vs 1/13, NS), and subsequent surgery was needed in 10 patients (6/10 vs 4/13, NS). Ultimate stoma creation were significantly more in initial surgery group (1/10 vs 9/13, P = 0.01). Initial PD group had lower rate of post-drainage complications and ultimate stoma creation compared to the initial surgery group. Although subsequent surgery may not be avoided after PD, it can provide safe anastomosis for resections. Long-term follow-up should be done to assess the outcome of PD.

Ascending Aorta and Aortic Root Reoperations: Are Outcomes Worse Than First Time Surgery?

The aim of this study was to analyze surgery and survival data in the midterm after aortic root and (or) ascending aorta reoperations and compare these results with those obtained after first time surgery. Over a 6-year period, 365 patients underwent an aortic root and (or) ascending aorta surgery procedure at our center. Mean patient age was 63.1 + or - 25.5 years; 27.1% were women. Fifty-eight patients had had prior ascending aorta and (or) aortic valve surgery (group I) and the remaining 307 patients were assigned to an initial surgery group (II). The reoperative procedures were Bentall in 45 (77.6%), ascending aorta and valve replacement in 8 (13.8%), and ascending aorta replacement in 5 (8.6%). The reoperation group showed a worse preoperative risk profile indicated by a higher logistic European system for cardiac operative risk evaluation: group I (26.9) versus group II (9.9) (p < 0.0001). Hospital mortality was 7 of 58 (12.1%) in group I and 21 of 207 (6.8%) in group II (p = 0.18; relative risk 1.9 [0.8 to 4.6]). After adjusting for the different variables, reoperation could not be identified as an independent predictor of postoperative morbidity. Survival rates (including in-hospital mortality) were lower in group I at one year (77.9 + or - 1.11% vs 91.9 + or - 0.3%) and at 3 years (75.3 + or - 0.11% vs 88.9 + or - 0.03% [log-rank p = 0.005]). In the multivariate analysis, reoperation (p = 0.01; hazard ratio 2.6 [1.2 to 5.3]) was a determining factor for survival once corrected for variables predicting mortality during follow-up. Reoperations on the ascending aorta and aortic root showed acceptable morbidity and mortality. Their midterm survival was lower than for patients not requiring a repeat operation.

Prognostic factors of localized extremity rhabdomyosarcomas: The results of a pooled analysis from U.S. and European cooperative groups.

9505 Background: We present pooled data from 643 patients (pts) treated in 14 studies conducted by European and American cooperative groups. Methods: Clinical factors, including age, histology, site of primary (hand and foot vs others), size, invasiveness (T), nodal involvement (N) and post surgical group (complete R0, microscopic residue R1 or macroscopic residue / biopsy only R2), chemotherapy (CT) type and duration, radiation therapy (RT) and period of treatment (before or after 1995) were looked at for their impact on survival (OS). Results: The 5 and 10 year OS are 67% (se 1.8) and 62% (se 2) respectively. By univariate analysis, OS is adversely influenced by age > 3 years, size > 5 cm, T2 stage, N1 stage, cooperative group (Europe vs US), incomplete initial surgery and treatment before 1995. Site and alveolar histology are less significant. RT has no impact. Many of these variables are associated. Pts treated by the US group were more often operated on and had more complete surgery at diagnosis than pts treated in Europe. In multivariate analysis OS is strongly correlated to age, T stage, N stage, initial surgery, treatment period and cooperative group. The better survival rate of tumors treated by the US group is observed for grossly resected tumors (R0 or R1) only. OS survival is 86% (se 3) for US pts as compared to 68% (se 4) for European pts (p=0.004). When considering the R0 and R1 tumors separately (n=252) by univariate analysis, OS is significantly influenced by the completeness of initial surgery (R0 vs R1, p=0.05), T stage (p=0.02), and site of the tumour (p=0.02). Longer CT duration (> 27 weeks) is associated with a better OS (p=0.002). RT had no impact. In multivariate analysis, if CT duration is not considered, cooperative group (p=0.001), site (p=0.001) and T stage (p=0.05) are significant. Completeness of initial surgery has no impact. However, adding duration of chemotherapy to the model, site of the primary remains significant (p=0.006) but T status and cooperative group are no longer significant. Conclusions: This analysis confirms the role of many prognostic factors, but in grossly resected tumors it identifies that the duration of chemotherapy has an important impact. No significant financial relationships to disclose.

Surgical Procedures and Morbidities of Diaphragmatic Surgery in Patients Undergoing Initial or Interval Debulking Surgery for Advanced-Stage Ovarian Cancer

Surgical management of advanced-stage ovarian cancer (ASOC) can require diaphragmatic surgery (DS) to achieve complete cytoreduction. The aim of this study was to evaluate modalities and morbidities of DS at the time of initial surgery (INS) and interval debulking surgery (IDS; performed after neoadjuvant chemotherapy). Retrospective review of patients undergoing (unilateral or bilateral) DS at the time of INS or IDS for ASOC. Between 2005 and 2008, 63 patients were studied. Treatment of the diaphragm was unilateral in 31 patients and bilateral in 32 patients. DS was performed respectively at the time of INS in 22 patients (35%) and IDS in 41 (65%) patients. Complete cytoreductive surgery was achieved in 95% (21 of 22 in the INS group and 39 of 41 in the IDS group). Surgical procedures used during DS were (in the INS and IDS groups, respectively) stripping in 14 (64%) and 16 (39%), coagulation in 2 (9%) and 10 (24%), and both procedures in 6 (27%) and 15 (37%). An intraoperative chest tube was placed in 14% of patients in each group. Postoperative chest complications requiring treatment occurred in 6 cases: pulmonary embolism (3 cases), symptomatic pleural effusion requiring chest drainage (1 case), and pneumothorax necessitating chest drainage (2 cases). Rate of overall morbidity related to DS was not statistically different in patients undergoing INS and IDS. Surgical treatment of this upper part of the abdomen is key to achieving complete cytoreductive surgery in ASOC.

11C-acetate PET in the early evaluation of prostate cancer recurrence

The first aim of the study was to investigate the diagnostic potential of (11)C-acetate PET in the early detection of prostate cancer recurrence. A second aim was the evaluation of early and late PET in this context. The study population comprised 32 prostate cancer patients with early evidence of relapse after initial radiotherapy (group A) or radical surgery (group B). The median PSA of group A (n=17) patients was 6 ng/ml (range 2.6-30.2) while that of group B (n=15) was 0.4 ng/ml (range 0.08-4.8). Pelvic-abdominal-thoracic PET was started 2 min after injection of (11)C-acetate and evaluated after fusion with CT. Group A: Taking a SUV(max)> or =2 as the cut-off, PET showed local recurrences in 14/17 patients and two equivocal results. Distant disease was observed in six patients and an equivocal result was obtained in one. Endorectal MRI was positive in 12/12 patients. Biopsy confirmed local recurrence in six of six (100%) patients. PET was positive in five of the six patients with biopsy-proven recurrences, the result in the remaining patient being equivocal. Group B: Among the 15 patients, visual interpretation was positive for local recurrences in five patients and equivocal in four. One obturator lymph node was positive. Endorectal MRI was positive in 11/15 patients and equivocal in two. Positional correlation of positive/equivocal results on PET and endorectal MRI was observed in seven of nine patients. PSA decreased significantly after salvage radiotherapy in 8/14 patients, providing strong evidence for local recurrence. PET of the eight patients responding to RT was positive in three and equivocal in two. (11)C-acetate PET was found to be valuable in the early evaluation of prostate cancer relapse. Optimising scanning time and use of modern PET-CT equipment might allow further improvement.

Factors predictive of having four or more positive axillary lymph nodes in patients with positive sentinel lymph nodes: implications for selection of radiation fields

Purpose The optimal design of radiation fields for patients with positive sentinel lymph nodes (SLNs) who do not undergo axillary dissection is unknown. We have previously shown that modified breast tangent fields can include most axillary Level I-II lymph nodes. We have also reported that irradiation of the axillary apex/supraclavicular fossa is indicated for patients with four or more positive axillary lymph nodes. To determine the optimal arrangement for patients with positive SLNs, we studied what factors predicted for having four or more positive lymph nodes. Methods and materials We reviewed the records of 339 consecutive patients with one to three positive SLNs who underwent complete axillary dissection at our institution between 1995 and 2002. We separately analyzed the outcome for those initially treated with surgery ( n = 265) and those receiving neoadjuvant chemotherapy ( n = 74). A logistic regression model was used to identify independent factors predictive for four or more positive lymph nodes. Results A total of 28 of 265 patients in the initial surgery group and 20 of 74 patients in the neoadjuvant group had four or more positive lymph nodes. In the initial surgery group, the independent factors associated with four or more positive lymph nodes were no drainage seen on lymphoscintigraphy (rate, 38%, odds ratio [OR] = 5.4, p = 0.03), more than one positive SLN (rate, 24–42%, OR = 2.9, p = 0.02), and lymphovascular space invasion (LVSI; rate, 25%, OR = 4.8, p = 0.01). Of the 106 patients without any of these factors, only 2 had four or more positive lymph nodes. For the patients treated with neoadjuvant chemotherapy, the independent factors were clinical Stage III (rate, 48%, OR = 3.1, p = 0.03), more than one positive SLN (rate, 37–67%, OR = 4.8, p = 0.03), and LVSI (rate, 62%, OR = 8.1, p = 0.02). Of the 28 patients without any of these factors, only 1 had four or more positive lymph nodes. Conclusion It is reasonable to treat with modified tangents fields that include most axillary Level I-II nodes for patients with one positive SLN who do not undergo axillary dissection if drainage is seen on lymphoscintigraphy and no LVSI is present. This approach is also reasonable for patients treated with neoadjuvant chemotherapy who have Stage II disease, no LVSI, and only one positive SLN. The remaining patients have a greater risk of having four or more positive lymph nodes, and, therefore, the high axilla/supraclavicular fossa should also be included in the radiation fields.

Selective use of chest tubes in thoracotomies for congenital cardiovascular procedures

Background. Advantages and complications have been reported from the use of chest tubes (CT). To reduce the incidence of complications we have employed a selective use of CT in thoracotomy for congenital cardiovascular procedure; ie, in absence of air leaks and fluid to be drained, no CT was inserted. Methods. The lung was reexpanded and air evacuated during the chest closure. Early and 6 hours chest roentgenograms were performed on every patient. This study retrospectively reviews the results of this selective approach in 546 patients operated on between 1980 and 1998 mainly for patent ductus arteriosum ligation, pulmonary artery band, aortic coarctation, Blalock–Taussig shunt. Four hundred and eighteen patients did not receive a CT at the initial surgery (group I), and 128 patients received a CT either before or at surgery (group II). Results. 40 patients in group I developed an air or fluid collection large enough to require a CT. Only one patient had complication, from an undetected hemothorax. Nine patients in group II required another CT, and one patient developed a pneumothorax upon pulling out the CT. No death in either group was related to the use or lack of use of the CT. A total of 378 CTs and collecting chambers were saved. Conclusions. A selective approach to the use of CT in thoracotomies for cardiovascular procedures can be employed with minimal complications, more comfort for the patient, and cost savings.

Prognostic significance of tumor fixation of rectal carcinoma: Implications for adjunctive radiation therapy

BACKGROUND This study was conducted to assess the prognostic significance of adjunctive radiation in the surgical management of rectal carcinoma patients with tumor fixation. METHODS Two hundred and ninety-seven patients with a histologic diagnosis of adenocarcinoma of the rectum were treated with high dose preoperative radiation (;ce45 Gray [Gy]) followed by surgical resection of the tumor (Group A). One hundred and seventy-four patients underwent initial curative surgery (Group B) followed by selective postoperative radiation (45-50 Gy) for those with pathologic T3, T4, or N+ (B2, C) cancers (N = 143). The two patient groups were compared by presenting clinical stage of the disease to assess the prognostic significance of tumor fixation on results of adjunctive therapy. Follow-up ranged from 24 months to 180 months. RESULTS The 5-year actuarial survival of Groups A and B was similar, 69% and 61% respectively. Survival was significantly better for Group A patients with fixed cancer (57% vs. 33%, P = 0.003). Survival was also better for patients in Group A with tumors located in the distal rectum (70% vs. 56%, P = 0.02). The local recurrence rate for patients with tumors located in the distal rectum was 17% for Group A and 19% for Group B (P = 0.74). The local recurrence rate for fixed cancers was 23% and 50% for Group A and Group B respectively (P = 0.0009). The incidence of small bowel complications (Grade 3 or 4) was lower for patients undergoing preoperative radiation compared with patients treated with postoperative radiation, (4% vs. 13%, P < 0.05). CONCLUSIONS When special considerations of sphincter-preserving surgery are not an issue, mobile rectal carcinoma may be effectively treated with surgery and selective postoperative radiation. However, fixed tumors, especially those located in the distal rectum, are better treated with high dose preoperative radiation. Cancer1996;78:717-22.

Prognostic significance of tumor fixation of rectal carcinoma: Implications for adjunctive radiation therapy

This study was conducted to assess the prognostic significance of adjunctive radiation in the surgical management of rectal carcinoma patients with tumor fixation. Two hundred and ninety-seven patients with a histologic diagnosis of adenocarcinoma of the rectum were treated with high dose preoperative radiation ( > or = 45 Gray [Gy]) followed by surgical resection of the tumor (Group A). One hundred and seventy-four patients underwent initial curative surgery (Group B) followed by selective postoperative radiation (45-50 Gy) for those with pathologic T3, T4, or N+ (B2, C) cancers (N = 143). The two patient groups were compared by presenting clinical stage of the disease to assess the prognostic significance of tumor fixation on results of adjunctive therapy. Follow-up ranged from 24 months to 180 months. The 5-year actuarial survival of Groups A and B was similar, 69% and 61% respectively. Survival was significantly better for Group A patients with fixed cancer (57% vs. 33%, P = 0.003). Survival was also better for patients in Group A with tumors located in the distal rectum (70% vs. 56%, P = 0.02). The local recurrence rate for patients with tumors located in the distal rectum was 17% for Group A and 19% for Group B (P = 0.74). The local recurrence rate for fixed cancers was 23% and 50% for Group A and Group B respectively (P = 0.0009). The incidence of small bowel complications (Grade 3 or 4) was lower for patients undergoing preoperative radiation compared with patients treated with postoperative radiation, (4% vs. 13%, P < 0.05). When special considerations of sphincter-preserving surgery are not an issue, mobile rectal carcinoma may be effectively treated with surgery and selective postoperative radiation. However, fixed tumors, especially those located in the distal rectum, are better treated with high dose preoperative radiation.

Evaluation of whole abdominal irradiation in ovarian carcinoma with a four orthogonal fields technique

Purpose : The purpose of this study is to evaluate the toxicity and the results of abdominopelvic irradiation with a four orthogonal field's technique in patients with ovarian carcinoma. Methods and Materials : Between May 1981 and December 1990, 167 patients with ovarian carcinoma have been treated with whole abdominal irradiation: 62 patients with no or minimal residual disease < 2 cm after initial surgery (group 1) and 105 patients with no residual disease or macroscopic residual disease < 2 cm assessed by second-look surgery after incomplete debulking surgery and cisplatin-based polychemotherapy (group 2). Irradiation was performed by a four orthogonal field's technique. Thirty grays were given with a 25 MV photon beam (1.5 Gy/fraction/day, 20 fractions over 30 days). Boosts were performed in 50 cases (median dose of 15 Gy). Results : With a median follow-up of 68 months, the 5-year actuarial survival rate was 50% in the entire group, 67% in group 1, 40% in group 2, and 84% in T1, 61.5% in T2, 38% in T3. Five-year actuarial survival was analyzed according to the residuum: (a) after initial surgery (no residual disease: 70%, residual disease: 36.5%), (b) after second-look surgery: 76% in patients with a negative second look, 66% in patients with microscopic residual disease, 22% in patients with macroscopic residual disease and secondary surgical reduction, and 10% in patients with small unresectable nodules. Nine percent of the patients failed to complete irradiation acute side effects related. Five percent required surgery for bowel obstruction. Conclusion : The abdominopelvic irradiation with this four orthogonal field's technique was associated with tolerable acute toxicity and a low risk of serious late complications. Similar late results to have been reported whole abdominal irradiation with chemotherapy in patients with negative or microscopic residual disease after surgery. Randomized trials comparing these two adjuvant treatments are warranted.

Late Complications After Glaucoma Filtering Surgery With Adjunctive 5-Fluorouracil

We studied 105 patients (105 eyes) operated on for glaucoma with adjunctive fluorouracil, who were followed up for 12 to 48 months (mean, 34.6 +/- 12.9 months). Fifty eyes that had previous glaucoma or cataract extraction or had inflammatory glaucoma had a high risk for postoperative scarring (high-risk group), and 55 eyes had glaucoma surgery as an initial procedure (initial surgery group). An intraocular pressure of 20 mm Hg or less, with or without hypotensive medications, was found in 42 eyes in the high-risk group (84.0%) and in 53 of the eyes in the initial surgery group (96.4%). Of the 105 eyes, an intraocular pressure of 12 mm Hg or less without medication was achieved in 17 eyes in the high-risk group (34.0%) and in 35 eyes in the initial surgery group (63.6%). Late complications in both groups were as follows: endophthalmitis in four eyes (3.8%) (two of the infected blebs were located superiorly and two inferiorly), transient leaking bleb in two eyes (1.9%), hypotony of an extended period with 180 to 360 degrees of filtration in three eyes (2.9%), giant bleb extending over the cornea in two eyes (1.9%), and a transient, mild iridocyclitis in nine eyes (8.6%). Thus, adjunctive fluorouracil after filtering surgery may entail various, mainly bleb-related, late side effects and complications.