Non-radical Surgery Research Articles

ADVANCES IN THE NEUROSURGICAL AND COMBINED TREATMENT OF PATIENTS WITH ACROMEGALY

Aim. The study was carried out to identify and analyze the factors of a positive outcome of surgical and radiation treatment of acromegaly. Methods. The work was performed on clinical material and summarizes treatment results of 256 patients (90 males and 166 females). 86% of patients underwent surgical treatment, 14% of patients received radiation therapy during 2002–2018. Significance of factors of a positive outcome of treatment was carried out using the RStudio program. Results. The results of the study revealed that: 1. Significant factors (p <0.05) of a positive outcome of surgical treatment of acromegaly are somatostatin analogs (SSA) therapy before surgery, a small tumor size (microadenomas), and the absence of extrasellar tumor spread. 2. The most significant factor in achieving remission of acromegaly after non-radical adenomectomy is postoperative therapy with SSA (p <0.05). 3. Aggressive pituitary tumors invading surrounding structures, high baseline IGF-1 levels, unfavorable histological findings, macroadenomas, growth hormone levels above 10 μg/L before therapy, and extrasellar tumor spread were associated with less favorable outcomes of acromegaly radiation therapy (RT) (p <0.05). The most significant factor in achieving remission of acromegaly is SSA therapy after RT (p <0.05). Conclusion. Surgical treatment is the optimal primary treatment for acromegaly. Drug therapy with SSA is effective and the preferred treatment after non-radical surgery.

A nationwide comparison of short-term outcomes after transanal, open, laparoscopic, and robot-assisted total mesorectal excision.

Laparoscopic rectal cancer surgery has several limitations. Transanal total mesorectal excision (TaTME) can potentially overcome these limitations. The aim of this study was to compare the rates of non-radical surgery and anastomotic leakage after TaTME, open TME (OpTME), laparoscopic TME (LaTME) and robotic TME (RoTME) procedures in a nationwide cohort. We extracted the demographic, perioperative and pathological data of patients who underwent a curative OpTME, LaTME, RoTME or TaTME procedure between January 2014 and December 2018 from the national database of the Danish Colorectal Cancer Group (DCCG). We conducted multiple group-comparisons, uni- and multivariate analyses to determine the factors associated with positive resection margin (+RM) and anastomotic leakage. We included 2393 patients (OpTME = 205, LaTME = 1163, RoTME = 713 and TaTME = 312). The rate of +RM was 5.7% after TaTME. The lowest rate of +RM was achieved after RoTME (8.2%, 4.7%, 2.52%, and 5.7%, after OpTME, LaTME, RoTME and TaTME respectively, p<0.001). In multivariate analysis, having a T4 tumour and intraoperative bowel perforation were associated with the risk of +RM (p<0.001, p<0.001, respectively). The factors associated with anastomotic leakage in multivariate analysis were male gender, high BMI and intraoperative bowel perforation (p<0.001, p=0.049, p=0.002, respectively). TaTME was associated with the highest rate of sphincter-saving procedures (79.8%, p<0.001), the lowest rate of bowel perforation (2.9%, p=0.028) and the lowest rate of conversion to open surgery (1.3%, p<0.001). In a nationwide audit of TME approaches, the rate of +RM was lowest after RoTME. No differences were found between the four approaches regarding the risk of anastomotic leakage. TaTME offered advantages related to sphincter-saving, perforation and conversion.

ВОЗМОЖНОСТИ ПРОТОННОЙ ТЕРАПИИ В ЛЕЧЕНИИ ХОРДОМ ОСНОВАНИЯ ЧЕРЕПА У ДЕТЕЙ: СЕРИЯ КЛИНИЧЕСКИХ НАБЛЮДЕНИЙ

Chordomas are rare malignant tumors that account for no more than 4% of primary bone tumors. The incidence of chordomas in children does not exceed 5%. Tumor removal is the primary method of treatment, however, due to the high frequency of non-radical surgery, most patients require an adjuvant course of radiotherapy. Photon radiation therapy in doses of 50–60 Gy does not provide the required antitumor effect. At the same time, the use of a proton beam allows delivering a dose of 72 Gy or more with low toxicity. The article presents 4 clinical case reports of base-skull chordoma in children describing their own experience with proton therapy. An analysis of radiation exposure plans was carried out, with an evaluation of the main qualitative indicators characterizing the high-dose coverage of tumours and the radiation load on healthy tissues. The case reports described confirm that the technique of proton irradiation with a pencil beam makes it possible to safely administer ultra-high doses of radiation in close proximity to healthy tissues, including in children. Further improvement of the irradiation planning technique is required, which will improve the target coverage with a high dose of ionizing radiation.

Conservative (non-radical) surgery for stage IB1 cervical cancer.

There has been lively debate in recent years following the publication of various retrospective case series and small cohort studies that suggest certain women presenting with International Federation of Gynecology and Obstetrics (FIGO) stage IB1 cervical cancer (pre-2018 revised classification) may be treated by non-radical surgery, either simple hysterectomy or cone biopsy, where fertility preservation is required. A strictly defined histological criterion is necessary for selecting such cases, incorporating tumour dimensions including estimated tumour volume, lympho-vascular space invasion and pelvic lymph node status. Meta-analyses of these studies show that the oncological outcomes are comparable to the excellent results achieved by radical hysterectomy and radical trachelectomy. In addition, the fertility and pregnancy outcomes for cases treated by conisation are superior to cases managed by radical trachelectomy. Multi-centre, ethically approved, prospective studies are currently on-going, which will provide better quality evidence in an attempt to contribute to this debate, with the intention of improving outcomes, including quality of life, in women presenting with small-volume stage IB1 cervical cancer.

Radiosurgical treatment of patients with intracranial pilocytic astrocytomas

The study objective is to assess the outcomes after stereotactic radiosurgical treatment (SRS) in patients with pilocytic astrocytomas after non-radical surgery and after continued tumor growth.Materials and methods. The report includes 56 patients (37 males and 19 females) who have undergone SRS in N. N. Burdenko National Medical Research Center of Neurosurgery from March 2005 to January 2018.Results. The majority of patients (75 %) were children. Almost 43 % of patients underwent SRS as part of the primary treatment after biopsy or incomplete removal, other patients – in the event of continued tumor growth after non-total surgery. Tumors involved the cerebellum (41 %), brainstem (23 %), thalamus (19.6 %) and cerebral hemispheres (16.1 %). The median tumor volume was 1.9 cm3 (0.14–19.00 cm3), 23 % of patients had cysts in the tumor. The prescribed dose was 12 to 22 Gy (median 18 Gy) over 50–80 % isodose line. The follow-up was available for 54 (96.4 %) patients. The median follow-up was 67 months (3–151 months). All patients were alive at the end of the follow-up examination. In 14 (25 %) patients, the development of pseudo-progression (PSP) was noted. The median detection of PSP is 11 months (3–65 months). Of these, in 7 (50 %) patients PSP was accompanied by clinical deterioration: in 5 – an increase in general cerebral symptoms and in 1 patient – an episode and an increase in cerebellar symptoms. Eight (57 %) patients with PSP were reoperated: 4 underwent removal of the tumor, 4 – emptying of the cyst and placement of the Ommaya reservoir, which led to regression of the existing symptoms. No other toxicity was observed in patients. At the time of the completion of the follow-up examination (with a given median follow-up), no relapses were detected. There was no clinical deterioration after SRS.Conclusion. Radiosurgical treatment is an effective and safe method of radiation treatment for patients with primary pilocytic astrocytomas and recurrent pilocytic astrocytomas, providing control over tumor growth in all patients with a low risk of complications.

Cervical conization and lymph node assessment for early stage low-risk cervical cancer

ObjectiveThere has been a contemporary shift in clinical practice towards tailoring treatment in patients with early cervical cancer and low-risk features to non-radical surgery. The objective of this study was...

Treatment of retroperitoneal echinococcosis: the experience of a single center.

Retroperitoneal echinococcosis (RE) is a rare condition that is associated with a high mortality and disability rate. It is associated with a high rate of misdiagnosis, a high risk of surgery, and is extremely difficult to manage. There is no uniform standard for determining the exact form of surgical method and the timing of surgery.This was a retrospective analysis of the characteristics and surgical management of patients diagnosed with RE in our hospital between 2012 and 2019.Between 2012 and 2019, 1257 cases of echinococcosis and 121 cases of RE were diagnosed in our hospital. Of these, 68 cases involved surgical treatment, 53 involved non-surgical treatment, and 12 cases were lost to follow-up (4 cases in the surgical group and 8 cases in the non-surgical group). Thus, 109 cases were followed-up. RE cases were divided according to different treatment methods into a radical resection group (Group A, 31 cases), a non-radical resection group (Group B, 37 cases), and a non-surgical group (Group C, 53 cases). We carried out a detailed analysis of the 109 cases experiencing surgical intervention with effective follow-up.Our analysis found that radical resection is the first line of treatment of RE, although non-radical surgery can benefit most patients. It is important to emphasize the importance of the first round of surgery, particularly in cases involving hepatic echinococcosis. If the lesion can be removed radically during the first round of surgery, then radical surgery should be performed.

Is primary chemoradiation a better treatment? A retrospective study of early-stage node-positive cervical cancer

Background: Cervical cancer is the second most frequently diagnosed cancer and the third leading cause of cancer death for women in developing countries. Radical hysterectomy with bilateral pelvic lymph node dissection is usually preferred for patients with stage IB1-IIA2 disease. Currently, imaging has certain limitations in the diagnosis of lymph node metastasis, and the accuracy of detection remains unsatisfactory. Indeed, only pathological examination after removal of the suspected metastatic lymph nodes during surgery can conclusively identify the presence of metastasis. Furthermore, if a lymphatic metastasis is detected, there are no clear guidelines regarding whether to complete radical surgery or to conduct a systematic lymphadenectomy followed by adjuvant concurrent chemoradiotherapy. This retrospective study aimed to compare the efficacy and safety of the two treatment modalities in this patient population. Methods: Forty-nine stage IB1-IIA2 cervical cancer patients with lymphatic metastasis confirmed by systematic pelvic and para-aortic lymph node dissection from 2007 to 2018 were reviewed. The patients were treated with either primary chemoradiation or radical hysterectomy followed by adjuvant chemoradiation after lymphadenectomy. Survival states and adverse events of the two treatments were compared. Results: The median follow-up time was 45 (range 11–119 months) months. In the non-radical surgery group, one patient (1/15, 6.7%) relapsed and died, while in the radical surgery group, seven patients (7/27, 25.9%) relapsed and five (5/27, 18.5%) died. A significant difference was found in the mean progression-free survival (PFS) between the two groups, which was 69 (95% confidence interval 49.118–88.882) months in the non-radical surgery group and 44 (95% confidence interval 35.857–52.143) months in the radical surgery group (p &lt; 0.01). There was a significant difference in three-year PFS (86% vs. 71%, p &lt; 0.01) between the groups. Grade 3–4 toxicity was comparable between the two groups (26.7% vs. 25.9%, p = 0.958). Conclusion: For stage IB1-IIA2 cervical cancer patients with positive lymph nodes, primary chemoradiation after pelvic and para-aortic lymphadenectomy seems to have better survival outcomes compared with radical hysterectomy by laparoscopy plus chemoradiation. Since this is a retrospective study with limited cases, evidence from a randomized controlled study is needed to confirm the optimal treatment for early-stage node-positive cervical cancer.

New classification of alveolar echinococcosis of the liver as a base of new surgical strategy. A multicenter study

Aim of study. To improve the results of treatment of patients with hepatic alveolar echinococcosis by developing and introducing into clinical practice a new classification of the disease, which determines the treatment strategy with all available treatment options, including transplant technologies. Material and methods. A total of 323 patients with hepatic alveolar echinococcosis in three high-volume centers with liver transplantation programs were treated by a single protocol and included in the study. Results and discussion. Radical (R0) hepatectomies and liver transplantation were performed in 312 patients. The patients were divided into groups, and the optimal treatment strategy was proposed for each group. In the group of resectable hepatic alveolar echinococcosis there were 79 patients who underwent hepatectomies without vascular reconstruction. In borderline-resectable group there were 168 patients with massive hepatic alveolar echinococcosis with the main liver vessels and (or) the inferior vena cava involvement. Hepatectomies were performed in combination with vascular reconstructions including cases of total vascular exclusion with normo- or hypothermic conservation in vivo or ex vivo . In 65 patients, the lesion was defining as non-resectable. They have hepatic alveolar echinococcosis with critical involvement of the liver parenchyma and (or) with vessels invasion without the possibility of their reconstruction, and (or) cirrhosis of the future liver remnant. The non-alternative method of treatment in this group was liver transplantation. Eleven patients with non-resectable metastases which determined the severity of the condition and made no sense of radical liver surgery were considered incurable. Palliative measures were carried out by such patients. Previously performed non-radical interventions in 43.03% of patients were associated with severe complications (Clavien–Dindo III–V) developed after radical hepatectomies and transplantations. Surgical strategy based on the new classification of hepatic alveolar echinococcosis was effective in 96.6% patients. Conclusion. Routing patients according to the new classification of hepatic alveolar echinococcosis will improve the treatment results by avoiding non-radical surgery associated with the development of complications after further radical surgical treatment.

Radical Hemithoracic Radiotherapy Versus Palliative Radiotherapy in Non-metastatic Malignant Pleural Mesothelioma: Results from a Phase 3 Randomized Clinical Trial

Purpose We conducted a phase 3 randomized clinical trial to assess whether radical hemithoracic radiation therapy (RHR) compared with palliative radiation therapy (PR) can achieve overall survival (OS) advantages in patients with malignant pleural mesothelioma (MPM). Methods and Materials From August 2014 to May 2018, patients with histologically diagnosed nonmetastatic MPM, who underwent nonradical lung-sparing surgery and chemotherapy (CHT), were randomly assigned (1:1) to receive RHR or PR. RHR total dose to the involved pleural cavity was 50 Gy in 25 fractions, and the gross residual disease received a simultaneous integrated boost of 60 Gy. The primary endpoint was OS. Secondary endpoints were local control, distant metastasis-free survival, progression-free survival, and acute and late toxicity rates. A sample size of 108 patients considering a type I error (α) of 0.05 and a statistical power of 80% was calculated to prove that RHR could improve the 2-year OS. OS was estimated with the Kaplan-Meier method and the log-rank test (2-sided) tested differences between arms. The univariate and multivariate analyses were performed using Cox proportional hazard model. Possible prognostic factors investigated: age, sex, performance status, lung surgery, gross residual disease, and histology. Results One hundred eight patients were randomized: 53 to the PR arm and 55 to the RHR arm. Median follow-up was 14.6 months. The 2-year OS rate was 58% in the RHR arm versus 28% in the PR arm (hazard ratio, 0.54; 95% confidence interval, 0.31-0.95; P = .031). In the RHR arm: 11 patients experienced acute toxicity grade ≥3, 17 patients had grade 3 to 4 late toxicity. Nine patients experience a grade ≥2 pneumonitis, including 1 patient with grade 5. Conclusions RHR significantly improves survival in patients with MPM treated with nonradical lung-sparing surgery and CHT compared with palliative treatments, although it is associated with a nonnegligible toxicity profile.

Comparison of the Prognostic Value of Platelet-Related Indices in Biliary Tract Cancer Undergoing Surgical Resection.

PurposePlatelet-related indices, including mean platelet volume (MPV) and plateletocrit (PCT), have been reported as new prognostic factors of overall survival (OS) in many cancers, but not yet in biliary tract cancer (BTC). We intended to assess these indices in predicting OS in BTC patients with the aim to build a new prognostic model for patients with BTC after surgical resection.Materials and MethodsSurvival analysis and time receiver operating characteristic analysis were applied to screen the platelet indices. Univariate and multivariate Cox analyses were used to identify independent prognostic factors and develop a new prognostic model. Harrell’s C-statistics, calibration curves, and decisive curve analysis were used to assess the model.ResultsMPV and platelet distribution width (PDW)/PCT showed the best prognostic accuracy among the platelet indices. In multivariable analysis, factors predictive of poor OS were presence of nodal involvement, Non-radical surgery, poor tumor differentiation, carbohydrate antigen 19-9 > 100 U/mL, MPV > 8.1 fl, and PDW/PCT > 190. The new model was found to be superior to the TNM staging system and our new staging system showed higher discriminative power.ConclusionMPV and PDW/PCT have high prognostic value in BTC patients, and the novel staging system based on these two indices showed good discrimination and accuracy compared with the American Joint Committee on Cancer 7th TNM staging system.

How far should we go in optimal cytoreductive surgery for ovarian cancer?

The treatment of ovarian cancer should be appropriate, since clinical and surgical decisions may affect the prognosis; the surgery must be performed by an expert oncological surgeon or gynecological oncologist, it's fundamental roles are cancer staging and cytoreduction. The concept of staging surgery in early stages has its justification in the fact that up to 11% of "early ovarian cancers" will have metastasis in different sites of the peritoneal cavity at the time of diagnosis. In advanced stages of epithelial ovarian cancer, the goal is the complete cytoreduction of all visible macroscopic disease, since this variable is the most strongly associated with increased overall survival and disease-free period. The ideal time for cytoreductive surgery in relation to chemotherapy (before or after) is still under debate. In 2010 a randomized trial (EORTC) was published, comparing 310 patients initially operated (followed by adjuvant chemotherapy) versus 322 patients initially treated with neoadjuvant chemotherapy (followed by cytoreductive surgery); no significant differences in overall survival between groups were found. Another important factor playing a role in survival and in the probability of surgical cytoreductive success is tumor biology; there has been described a clear difference between serous and mucinous tumors, but some groups advocate that maximal surgical effort in mucinous tumors may compensate morbidity with an increase in survival. The extension of resection in cytoreduction is still controversial; some authors have confirmed that the most important factor is the residual disease and that radical surgery is superior to non-radical surgery in terms of overall survival. The need and extent of lymphadenectomy in advanced cancer will be treated in another chapter of this issue. Undoubtedly, an important factor is to perform procedures in specialized centers.

SOX2 is a promising predictor of relapse and death in advanced stage high-grade serous ovarian cancer patients with residual disease after debulking surgery

ABSTRACT The transcription factor SOX2 is a well-established and important stem cell marker. Its role in cancer biology remains unclear, but it has been proposed to also be a marker of cancer stem cells. We investigated the role of SOX2 protein expression in women with high-grade serous ovarian cancer (HGSOC) to determine its potential prognostic and treatment predictive value. We constructed a tissue microarray of 130 advanced stage HGSOC tumors with an average of 6 cores each, stained for SOX2 protein expression and evaluated survival outcomes. We also treated two HGSOC cell lines with carboplatin and paclitaxel and measured SOX2 expression by RT-PCR and immunoblotting at different doses and time-points. Among patients with non-radical debulking surgery overall and progression-free survival were shorter for patients with SOX2 positive tumors (mean 26 vs. 39 months, log-rank test: p = .0076, and mean 14 vs. 19 months, p = .055, respectively). Knockdown of SOX2 in cell lines did not affect growth inhibition following chemotherapy treatment. Our results show that SOX2 has a strong prognostic potential among HGSOC patients with residual tumor tissue after debulking surgery and suggest that SOX2 expressing cells remaining after non-radical debulking surgery may constitute a subpopulation of cancer stem cells with greater tumor-initiating potential.

Pre-Radiotherapy Progression after Surgery of Newly Diagnosed Glioblastoma: Corroboration of New Prognostic Variable.

Background: The aim of this retrospective study is to assess the incidence, localization, and potential predictors of rapid early progression (REP) prior to initiation of radiotherapy in newly diagnosed glioblastoma patients and to compare survival outcomes in cohorts with or without REP in relation to the treatment. Methods: We assessed a consecutive cohort of 155 patients with histologically confirmed irradiated glioblastoma from 1/2014 to 12/2017. A total of 90 patients with preoperative, postoperative, and planning MRI were analyzed. Results: Median age 59 years, 59% men, and 39 patients (43%) underwent gross total tumor resection. The Stupp regimen was indicated to 64 patients (71%); 26 patients (29%) underwent radiotherapy alone. REP on planning MRI performed shortly prior to radiotherapy was found in 46 (51%) patients, most often within the surgical cavity wall, and the main predictor for REP was non-radical surgery (p < 0.001). The presence of REP was confirmed as a strong negative prognostic factor; median overall survival (OS) in patients with REP was 10.7 vs. 18.7 months and 2-year survival was 15.6% vs. 37.7% (hazard ratio HR 0.53 for those without REP; p = 0.007). Interestingly, the REP occurrence effect on survival outcome was significantly different in younger patients (≤ 50 years) and older patients (> 50 years) for OS (p = 0.047) and non-significantly for PFS (p = 0.341). In younger patients, REP was a stronger negative prognostic factor, probably due to more aggressive behavior. Patients with REP who were indicated for the Stupp regimen had longer OS compared to radiotherapy alone (median OS 16.0 vs 7.5; HR = 0.5, p = 0.022; 2-year survival 22.3% vs. 5.6%). The interval between surgery and the initiation of radiotherapy were not prognostic in either the entire cohort or in patients with REP. Conclusion: Especially in the subgroup of patients without radical resection, one may recommend as early initiation of radiotherapy as possible. The phenomenon of REP should be recognized as an integral part of stratification factors in future prospective clinical trials enrolling patients before initiation of radiotherapy.

A comparative analysis of radical and non-radical surgical treatment of hydatid liver echinococcosis: a single-center analysis

The aim of this study was to compare the postoperative outcome and long-term results after management of liver hydatid cyst by radical and non-radical surgeries. From January 2015 to December 2017, 86 patients were treated with various surgical interventions for liver hydatid cyst. These patients were retrospectively divided into two groups according to the surgical method for treatment: radical methods (e.g., liver resection and pericystectomy) and non-radical methods (e.g., echinococcectomy). Of the 86 patients, 50 (58%) underwent radical treatment and 36 (42%) underwent non-radical treatment. Clinical data and outcomes were retrospectively analyzed. Eighty (93%) patients were considered to have been completely cured of their hydatid disease. Surgery duration in the non-radical treatment group was significantly shorter than in the radical treatment group (p < 0.01). There were no cases of biliary leakage in the liver resection patients during the postoperative period. In contrast, among the echinococcectomy patients, biliary leakage occurred in 6 (16.7%), which was significantly higher than with other modalities (p < 0.05). Recurrence occurred at a median of 32 months after surgery. Recurrent liver hydatid disease occurred in 6 cases (7%): radical group, 1 (2%); non-radical group, 5 (13.9%). There were no mortalities in either group in the postoperative period. Postoperative hospital stay was significantly shorter in the liver resection patients than in the other patients (p < 0.01). Radical surgical treatment of liver hydatid cyst is more effective than non-radical surgery, resulting in a reduced recurrence rate, reduced postoperative complication rate, and early recovery of patients.

Clinicopathological features and prognosis in patients with presacral recurrent rectal cancer

Objective: To investigate the clinicopathological features and prognostic factors in patients with presacral recurrent rectal cancer (PRRC). Methods: PRRC was defined as recurrence of rectal cancer after radical surgery involving posteriorly the presacral soft tissue, the sacrum/coccyx, and/or sacral nerve root. The diagnosis is confirmed with clinical symptoms (pain of pelvis/back/lower limb, bloody stools, increased frequency of defecation, and abnormal secretions), physical examination of perineal or pelvic masses, radiological findings, colonoscopy with histopathological biopsy, and the evaluation by multi-disciplinary team (MDT). Inclusion criteria: (1) primary rectal cancer undergoing radical surgery without distant metastasis; (2) PRRC was diagnosed; (3) complete inpatient, outpatient and follow-up data. According to the above criteria, clinical data of 72 patients with PRRC in Peking University People's Hospital from January 2008 to December 2017 were retrospectively analyzed. The clinicopathological features and follow-up data were summarized. Cox proportional hazard models was used to analyze the prognostic factors of PRRC. Results: Among 72 patients, 45 were male and 27 were female with a male-to-female ratio of 1.7:1.0. The median age at recurrence was 58 (34 to 83) years and the median interval from surgery to recurrence was 2.0 (0.2 to 17.0) years. The main symptom was pain in 48.6% (35/72) of patients. In addition, gastrointestinal symptoms were found in 25.0% (18/72) of patients. The presacral recurrent sites were presacral fascia in 36 (50.0%) patients, lower sacrum (S3~S5 or coccyx) in 25 (34.7%) patients, and higher sacrum (S1~S2) in 11 (15.3%) patients. Forty-seven (65.3%) patients underwent radical surgery (abdominal resection, abdominoperineal resection, sacrectomy, abdominosacral resection), 12 (16.7%) underwent non-radical surgery (colostomy, cytoreductive surgery), and 13 (18.1%) did not undergo any surgery but only receive palliative chemoradiotherapy and nutritional support treatment. Thirty-three (45.8%) patients received radiotherapy and/or chemotherapy (oxaliplatin, 5-fluorouracil, capecitabine, irinotecan, etc.). All the patients received follow-up, and the median follow-up time was 19 (2 to 72) months. The median overall survival time was 14 (1 to 65) months. The 1- and 3-year overall survival rates were 67.1% and 32.0%, respectively. Univariate analysis showed that age at recurrence (P=0.031) and radical resection (P<0.001) were associated with prognosis. Multivariate analysis demonstrated that radical resection was independent factor of good prognosis (RR=0.140, 95%CI: 0.061-0.322, P<0.001). Conclusions: Patients tend to develop presacral recurrent rectal cancer within 2 years after primary surgery. The main symptom is pain. Patients undergoing radical resection have a relatively good prognosis.

Multilocular Cystic Nephroma: Is Radical Nephrectomy The Best Treatment In All Cases? Our Experience After 45 Years Working on a Tertiary Care Center

Introduction: Multilocular cystic nephroma (MCN) is a type of benign renal tumor that is sometimes misdiagnosed with cystic Wilms Tumor. Given that each one has a different treatment, it is essential to make a proper diagnosis. Objective: Our aim was to find the differential characteristics of MCN and to be able to identify these renal masses with low probability of malignancy, which are subsidiaries of a more conservative treatment. Material and Methods: We conducted a retrospective descriptive study were we analyzed the patients with MCN treated in our center between 1971 and 2016. Results: We found 13 patients with a histological diagnosis of MCN, mostly males, with an average age of 46.8 months at the time of surgery. Clinically, 2 cases (15.4%) were asymptomatic, 6 had an abdominal mass (46.1%), 3 had abdominal pain (23.1%) and 2 had hematuria (15.4%). The maximum diameter of the mass was 7.3 cm (mean). 9 nephrectomies (69.2%) and 4 tumorectomies (30.8%) were performed. In two of these (15.4%), neoadjuvant chemotherapy was administered due to presurgical suspicion of Wilms' tumor, which was discontinued after the pathological analysis. In another 4 patients with suspicion of MCN, all of them asymptomatic and with a tumor size &lt;3cm, non-surgical treatment was decided. At the present time all patients (operated or not) stay alive. No. cases of distant metastasis, local recurrence or mass progression (in the non-operated patients) have been recorded. Conclusion: Given its good prognosis, MCN can be treated with a non-radical surgery or even non-surgical conservative treatment in selected cases. In our experience, the clinical and radiological characteristics are the pillars to identify those patients with low risk of malignancy in which this attitude could be carried out.

Significance of Tumour Biological Markers for Overall Survival and Clinical Parameters for Disease-Free Survival in Patients with Prostate Cancer after Radical Prostatectomy

Objective: The aim of the study was to assess the prognostic significance of pretreatment serum PSA level, immunohistochemical expression (labelling index, LI) of Ki-67, prostate-specific membrane antigen (PSMA), glucose-1 transporter (GLUT-1), vascular endothelial growth factor (VEGF), human telomerase reverse transcriptase (hTERT), as well as micro vessel density (MVD) for overall survival (OS), local recurrence-free survival (LRFS), metastatic-free survival (MFS) and disease-free survival (DFS) in a group of 130 prostate cancer (PCa) patients treated with radical prostatectomy (RP) between 2007 and 2011. Methods: In order to investigate the prognostic value of the analyzed variables in univariate and multivariate Cox analysis, the patients were divided into two subgroups based on the marker cut-off points selected by the receiver operating characteristic curves. Results: There were 83 (63.8%) cases staged pT1-2 and 47 (36.1%) staged pT3-4. The majority of tumours (53.1%) were well-differentiated (grade group G1), 49 (37.7%) moderately differentiated (G2-3) and 12 (9.2%) poorly differentiated (G4-5). In 85 patients (65.4%) the surgery was radical, 59 (45.4%) had positive surgical margins (PSM), and in 23 (17.7%) seminal vesicle(s) involvement was diagnosed. Median followup was 79 (1-148) months, during which 55 (42.3%) men died, in 12 (9.2%) local relapse and in 13 (10%) distant metastases occurred. In multivariate Cox analysis, independent negative prognostic factors for OS were: Ki-67LI &gt;6.7% (p=0.010), PSMALI ≤51.7% (p=0.009), hTERTLI ≤20.5% (p=0.004) and lack of adjuvant treatment (AT) (p=0.013), while for MFS: seminal vesicle(s) involvement (p=0.007) and hTERTLI ≤43.8% (p=0.011). However, non-radical surgery (p=0.007), PSM (p=0.005) and AT (p=0.037) were negatively associated with DFS. Conclusion: Tumour biological markers are significant for OS and clinical parameters for DFS in PCa patients’ after RP.

Surgery performed later in the week is associated with failure to achieve complete radical surgical resection in advanced ovarian cancer

Background: The surgical treatment of advanced ovarian cancer aims to resect all visible tumor to no gross residual, these procedures are often extensive with need of prolonged attention to detail. Our objective was to investigate the association between week-day of surgery, time of year (season) when surgery was performed and non-radical surgery (surgical failure) in advanced ovarian cancer.Material and methods: Women diagnosed with primary invasive epithelial ovarian cancer in the Stockholm/Gotland Region, Sweden were identified in the regional Swedish Quality Registry of Gynecologic Cancer (SQRGC). Data of all women with International Federation of Gynecology and Obstetrics (FIGO) stages III and IV were validated against the National Cancer Registry. Women subjected to surgery with curative intent were selected and included in the analysis. Uni- and multivariable regression analyses were performed.Results: Out of 538 women identified in the SQRGC-string ovary between 2014 and 2016, 240 were eligible for analysis. In 29% of women, complete radical resection was not achieved. There was a significant trend of increased non-radical resection when surgery was performed from Monday through Thursday (p = .03). The adjusted odds of non-radical surgery increased if surgery was performed on Thursday rather than Monday (Odds Ratio (OR) 3.04, 95% Confidence Interval (CI) 1.05–8.79, p = .04). Surgery performed during summer compared to the rest of the year, did not significantly increase the adjusted odds of non-radical surgery (OR 1.92, 95% CI 0.91–4.07, p = .09).Conclusion: Complete surgical resection of tumor is one of the strongest prognostic factors for survival in advanced epithelial ovarian cancer. For this reason, advanced ovarian cancer surgery should be scheduled early in the week.

Implementation of a standardized voiding management protocol to reduce unnecessary re-catheterization - A quality improvement project

ObjectiveTo design and implement a standardized postoperative voiding management protocol that accurately identifies patients with urinary retention and reduces unnecessary re-catheterization. MethodsA postoperative voiding management protocol was designed and implemented in patients undergoing major, inpatient, non-radical abdominal surgery with a gynecologic oncologist. No patients had epidural catheters. The implemented quality improvement (QI) protocol included: 1) Foley removal at six hours postoperatively; 2) universal bladder scan after the first void; and 3) limiting re-catheterization to patients with bladder scan volumes >150 ml. A total of 96 patients post-protocol implementation were compared to 52 patients pre-protocol. Along with baseline demographic data and timing of catheter removal, we recorded the presence or absence of urinary retention and/or unnecessary re-catheterization and postoperative urinary tract infection rates. Fisher's exact test and student's t-tests were performed for comparisons. ResultsThe overall rate of postoperative urinary retention was 21.6% (32/148). The new voiding management protocol reduced the rate of unnecessary re-catheterization by 90% (13.5% vs 2.1%, p = 0.01), without overlooking true urinary retention (23.1% vs 20.8%, p = 0.83). Additionally, there was a significant increase in hospital-defined early discharge prior to 11:00 AM (4.0% vs 22.0%, p = 0.022). There was no difference in the postoperative urinary tract infection rate between the groups (p = 1.00). Risk factors associated with urinary retention included older age (p < 0.01), use of medications with anticholinergic properties (p < 0.01), and preexisting urinary dysfunction (p < 0.01). ConclusionsImplementation of this new voiding management protocol reduced unnecessary re-catheterization, captured and treated true urinary retention, and facilitated early hospital discharge.