Non-radical Surgery Research Articles

Nonradical surgery for small early-stage cervical cancer: Is it time?

Objectives: Radical hysterectomy is the gold standard surgical approach for invasive cervical cancer, but nonradical surgery is now being considered in women with early-stage cervical cancer to avoid morbidity. The goal of this study was to evaluate the outcomes of women with early-stage cervical cancer treated with a nonradical surgical approach.

Radical trachelectomy in early-stage cervical cancer: Is minimally invasive surgery the new standard of care?

morbidity. The goal of this study was to evaluate the outcomes of women with early-stage cervical cancer treated with a nonradical surgical approach. Methods: Between March 1991 and July 2013, 51 women with earlystage cervical cancer were treated with simple hysterectomy or cone biopsy and concomitant bilateral pelvic lymphadenectomy or sentinel lymph node biopsy. Data on patient demographics, clinical stage, perioperative complications, pathology findings, and diseasefree interval were collected prospectively. Results: The median age of the woman was 34 years (range, 19– 77 years). Twenty-five women had squamous cell carcinoma (SCC), 22 had adenocarcinoma (AC), and 3 had adenosquamous (AS) carcinoma. Thirty women had FIGO stage 1A1 disease, 8 women had stage IA2 disease, and 13 women had stage 1B1 disease. Twentytwo (43%) and 29 (57%) women underwent simple hysterectomy with lymphadenectomy and cone biopsy with lymphadenectomy, respectively. Median tumor size was 10 mm (range, 2–11 mm). Lymphovascular space invasion (LVSI) was present in 18 women (35%). The median depth of invasion was 2.0 mm (range, 0.6– 12 mm), 2.0 mm (range, 0.1–4.5 mm), and 2.0 mm (range, 1.7– 4.0 mm) for women with SCC, AC, and AS, respectively. The margins were clear in all women. Two women received adjuvant chemoradiation (one had deep stromal invasion on cone biopsy with LVSI and one had two micrometastases to pelvic nodes). More than 95% (49 of 51 women) of patients had their Foley catheter removed on the day of surgery or postoperative day 1. There were no intraoperative or postoperative complications, and the average blood loss was estimated at 143 mL. Median follow-up was 21 months (range, 1– 112 months). None of the 51 women with early-stage cervical cancer developed a recurrence during their follow-up time (95% CI: 0–6%). Conclusions: Nonradical surgery in appropriately selected early-stage cervical cancer patients appears to be associated with a very low perioperative complication rate and excellent oncologic outcomes. While large phase II and III studies are underway, this approach seems to be a safe and reasonable option in well-selected patients.

Axial skeletal osteosarcoma: a 25-year monoinstitutional experience in children and adolescents

The survival of patients with axial skeletal or pelvic osteosarcoma (OS) remains poor, and the management of these patients is challenging. The object of this study is a cohort of unselected patients aged < 19 years with primary high-grade pelvic/axial OS. Patients were treated with high-dose methotrexate, doxorubicin, cisplatin, ifosfamide followed or preceded by local treatment (surgery and/or radiotherapy). Twenty patients aged 3-19 years were treated. Eight patients had pelvic OS, 8 axial OS and 4 mandible/maxilla OS. All patients received chemotherapy, after which necrosis was evaluable in 9 patients (≥ 90% in 3). Sixteen patients underwent surgery. Radiotherapy was administered to 8 patients (total dose 34-60 Gy). The median follow-up was 35 months (8-276), and the 5-year disease-free survival and overall survival rates were 37 and 40%, respectively. Six patients were alive at the time of this report: 2 with pelvic OS (both responded well to chemotherapy, one underwent hemipelvectomy and the other had non-radical surgery plus radiotherapy); 1 with axial and multicentric OS (with a good histological response and radical surgery); 3 with mandible/maxilla OS. Two patients died of secondary tumors (one bone and one breast cancer). It is worth noting that 4 patients had a p53 mutation: 1 is alive, 2 died of their OS, 1 of breast cancer. Adequacy of local treatment and pathological response influenced the prognosis for axial OS, which remained dismal. A high incidence of p53 mutation emerged in our series of patients.

Non-radical surgery for small early-stage cervical cancer. Is it time?

ObjectivesNon-radical surgery has been proposed in women with early-stage cervical cancer to reduce morbidity. Our objective was to evaluate the outcomes of women with early-stage cervical cancer treated with non-radical surgery. MethodsBetween March 1991 and July 2013, 51 women with early-stage cervical cancer underwent simple hysterectomy or cone biopsy. All patients had assessment of pelvic lymph nodes. Patient demographics, stage, perioperative complications, pathology findings and disease-free interval were collected prospectively. ResultsTwenty-six women had squamous cell carcinoma (SCC), 22 adenocarcinoma (AC) and 3 adenosquamous (AS) carcinoma. Thirty women were FIGO stage 1A1, 8 women IA2, and 13 women 1B1. Twenty-two (43%) and 29 (57%) women underwent simple hysterectomy and cone biopsy respectively. Median measurable tumor size was 10mm (range 2–11), and median depth of invasion was 2.0mm (range 0.1–12mm). Lymphovascular space invasion (LVSI) was present in 18 women (35%). Surgical margins were negative in all women. Two women received adjuvant chemoradiation (one had deep stromal invasion with LVSI, and one had two micrometastases to pelvic nodes). Forty-nine women (96%) had their Foley catheter removed on the day of surgery or post-operative day 1. No intraoperative or postoperative complications occurred and the median blood loss was 100ml. Median follow-up was 21months (range 1–112). None of the 51 women developed a recurrence during follow-up (95% CI: 0–6%). ConclusionNon-radical surgery in appropriately selected early-stage cervical cancer patients results in a low complication rate and excellent oncologic outcomes. This approach seems to be a reasonable option in well-selected patients.

Outcome and prognostic factors of 125 loco-regionally advanced head and neck squamous cell carcinoma treated with multi-modality treatment

To investigate the treatment outcome of loco-regionally advanced squamous cell carcinoma of the head and neck (LA-SCCHN) after been treated with multi-modality approach since 2005 in our hospital and to explore the prognostic factors for treatment outcomes. Clinical data of 125 postoperative LA-SCCHN patients treated in our department with radiotherapy/chemoradiotherapy from May 2005 to December 2011 were collected and reviewed in this study. The radiotherapy technique was intensity-modulated radiotherapy (IMRT) (93.6%) and a minority of patients received 3D-conformal radiotherapy (3D-CRT). Up to January 6th, 2013, 124 patients were followed up with a median follow-up duration of 25 months. The 3-year overall survival (OS), disease-free survival (DFS), loco-regional control (LRC), distant metastasis-free survival (DMFS) were 69.7%, 56.1%, 80.8%, and 73.1%, respectively. A total of 37 patients died during the follow-up period. Among the 43 patients presented with treatment failure, 13 patients had loco-regional relapse, 20 patients had distant metastasis and 10 patients presented with both loco-regional and distant relapses. Distant metastasis accounted for the predominant cause of death. Lung and mediastinal lymph nodes are the most common sites involved by distant metastasis.Univariate analysis indicated that patients who underwent non-radical surgery, with larger size of invaded lymph nodes, higher N stage (N2b and above) and vascular tumor embolism had a lower OS (P = 0.001, 0.000, 0.032, 0.007, respectively). Patients who underwent neck dissection only, or those with higher N stage (N2b and above) or higher TNM stage or vascular tumor thrombi had higher distant metastasis rates (P = 0.017, 0.002, 0.008, 0.001, respectively). The multivariate analysis showed that non-radical surgery was an independent prognostic factor for OS (P = 0.001), larger size of invaded lymph nodes was an independent prognostic factor for poorer LRC (P = 0.001); higher N stage (N2b and above) or T4 stage and vascular tumor thrombi were independent prognostic factors for poorer distant metastasis-free survival (P = 0.035, 0.008 and 0.050, respectively). Our results indicate that multi-modality treatment for LA-SCCHN has achieved better outcome than before. Distant metastasis has become the predominant pattern of failure as well as the primary cause of death instead of loco-regional relapse as a result of improved local control modality. More efforts should be made to decrease the rate of distant metastasis in the future.

Phase I trial of postoperative concurrent capecitabine and intensity-modulated radiotherapy for locally advanced gastric cancer

Objective To determine the maximum-tolerated dose （MTD） and dose-limiting toxicities （DLTs） of capecitabine during postoperative concurrent capecitabine and intensity-modulated radiotherapy （IMRT） for locally advanced gastric cancer. Methods The patients, who had T,N （ ＋ ） M0 gastroesophageal or gastric adenocarcinoma after radical surgery with negative margins （ R0 ） or non-radical surgery with microscopically positive margins （ R1 ） or macroscopically positive margins （ R2 ） , were included in the study. A total of 18 patients （R0 12;R1 2;R2 4） were recruited. IMRT （45 Gy at 1.8 Gy/fraction） was delivered to the tumor bed （T4b only） , anastomosis site, duodenal stump, and regional lymph nodes days per week for 5 weeks. Patients with R1 or R2 resection received additional radiation （ 10. 8 Gy/6 fractions） to the microscopically or macroscopically positive margins. During IMRT, capecitabine was orally administered twice daily at a dose of 625 mg/m2 （ level I, n = 6） , 700 mg/m2 （ level II , n = 6 ） , 800 mg/m2 （ level m , n = 6） , 900 mg/m2 （ level IV, n = 0） , and 1000 mg/m2 （ level V, n = 0）. DLT was defined as grade 3 or 4 hematologic and non-hematologic toxicities. Results Grade 1-3 leukopenia （89%） , anorexia （83%） , and nausea （83%） were the most common toxicities. Grade 3 anorexia/nausea and grade 4 vomiting occurred in one patient at dose level I. Grade 3 anorexia and nausea occurred in one patient at dose level ]I. One patient at dose level ]~ developed grade 4 neutropenia, while another patient at dose level III developed grade 3 radiation esophagitis. Conclusions During postoperative concurrent capecitabine and IMRT for locally advanced gastric cancer, the MTD of capeeitabine is 800 mg/m2 twice daily, and the DLTs are nausea, vomiting, anorexia, neutropenia, and radiation esophagitis. Key words: Capecitabine; Maximum tolerated dose; Dose-limiting toxicity; Gastric neoplasms/concurrent chemoradiotherapy; Radiotherapy, intensity-modulated

Analysis of long-term survival in patients with glioblastoma.

e13007 Background: Adult glioblastoma (GBM) is the most common type of malignant primary brain tumor. Despite advances made in treatment, median survival is between 12 and 15 months. Standard care is concomitant radiotherapy (RT)/temozolomide (TMZ) and adjuvant TMZ for 6 cycles (EORTC/NCIC trial 2005). At progression, subsequent treatments are left to the discretion of the treating physician. Methods: We evaluated retrospective data of GBM patients (pts) treated from 2003 to 2010, focusing on the treatment of patients with longer survival (over 24 months). Results: 139 pts with GBM were treated during the period. Thirty of these showed survival &gt; 24 months: 20 were subjected to macroscopically radical neurosurgery, 9 to non-radical surgery and 1 to biopsy. All pts had a KPS 100%. 11 pts were treated in the period pre-EORTC/NCIC trial (Stupp et all) and 19 in the period “post-Stupp”. In the former group 10 pts underwent RT followed by TMZ ( 2-12cycles) and 1 patient received only RT. All pts in the latter group were treated with concomitant radio-chemotherapy followed by TMZ. 3 pts are currently disease stable. After the first documented evidence of disease progression (PD) 21 pts were treated, one with neurosurgery, 4 with neurosurgery plus chemotherapy (CT), 15 with only CT and 1 with CT and tomotherapy. With regard to chemotherapy, 14 pts received TMZ ( 2-21cycles), 3 fotemustine (4-16 cycles), 1 carboplatin and VP16 (2 cycles) and 1 irinotecan plus bevacizumab (2 cycles). Further progression was treated with another line of CT in only 8 pts, fotemustine in 5 (1-3 cycles), TMZ in 2 (2 cycles) and carboplatin plus VP16 In 1 (5 cycles). Median overall survival (mOS) of our long-term survivors was 36.18 months (CI 95% 28.32 – 42.01). Considering the two groups separately (pre- and post- Stupp), we observed a mOS of 36.18 months (CI 95% 26.45 – 42.01) (1 pt alive) for the first group and of 36.15 months (CI 95% 28.26 – 48.52) (7 pts alive) for the second. Conclusions: Our long-term survivors, independently of treatment, showed an mOS of 36.18 months (CI 95% 28.32 – 42.01). There was no significant difference in mOS between the 2 groups (p=0.6963). Further research is needed to identify the biomolecular and genetic pattern that is responsible for the long survival of some patients.

Letter to the Editor Unexpected cause of syncope in a young woman

Letter to the Editor Unexpected cause of syncope in a young woman

P-0102 Postoperative Radiochemotherapy for Adenocarcinomas of The Gastroesophageal Junction

IntroductionAdenocarcinomas of gastroesophageal junction (GEJ) represent a heterogenic group of tumors with poor prognosis. The principal treatment of nonmetastatic GEJ is surgical resection with 5-year survival rate of approximately 20%. It is clear that the patients with T2, T3 and/or N+ disease need additional treatment. In our institution, nowadays preoperative chemoradiotherapy (RCT) is the treatment of choice. However, there are still patients with locoregionally advanced disease who first undergo surgical resection followed by postoperative RCT. MethodsIn the period from January 2005 to November 2011, 72 patients (56 males and 16 females; aged 33-77 years, mean age 60 years) were treated for non-metastatic adenocarcinoma of GEJ (stage IIa- IIIc) with postoperative RCT. Proximal subtotal resection of the stomach, total resection of the stomach, transhiatal esophagogastrectomy and transthoracal esophagogastrectomy were performed in 4.2%, 69.4%, 19.5% and 6.9% of patients, respectively. Radical resection was performed in 58 (80.6%) patients and in the remaining 14 (19.4%) patients non-radical surgery was performed. Most frequently (in 47.3%), the primary tumor originated in the subcardial stomach (Siewert III). The tumor was staged as pT2 in 33.3%, as pT3 in 58.4% and as pT4 in 8.3% of pateints. Sixty-five patients (92.9%) had N+ disease. Planned treatment schedule consisted of 3D conformal external beam radiotherapy (45 Gy in 25 fractions), with six cycles of chemotherapy (CT) with 5-FU (1000 mg/m2) through 96 hours and cisplatin (75 mg/m2) in bolus on day 2 of each cycle. Radiotherapy was started concomitantly with the second cycle of CT. The main endpoints of this study were as follows: locoregional control (LRC); disease-free survival (DFS); disease-specific survival (DSS) and overall survival (OS) and the rates of acute side-effects were estimated. ResultsTwenty-eight patients (38.9%) completed the treatment according to the protocol. Sixty-three patients (87.5%) reached the total radiation dose of 45 Gy. In six patients (8.3%) the total dose was lower (9-27 Gy) and three (4.2%) patients did not even start with the radiotherapy because of the side effects during the first cycle of CT. All six cycles of CT could be administered in only 28 patients (38.9%). No death occurred due to therapy. Acute toxicity grade 3 or more, such as stomatitis, dysphagia, nausea and vomiting, and infection, occurred in 2.9 %, 34.3%, 38.6% and 41.5% of patients, respectively. The median follow-up time of all 72 patients was 16 months (range: 4-64 months). On the close-out date, 29 (40.3%) patients were still alive, 22 (30.6%) of them being with no signs of disease. Thirty-nine (54.2%) patients died from GEJ adenocarcinoma. After adjuvant RCT, local and/or regional recurrence developed in two (2.8%) patients, locoregional and systemic disease was observed in five (6.9%) patients, and systemic disease alone developed in 39 (54.2%) patients. The 3-year LRC, DFS, DSS and OS were 78.3%, 25.5%, 35.9%, and 33.9%, respectively. ConclusionPostoperative RCT with 5-FU and cisplatin is feasible, although with high toxicity and therefore should be reserved only for selected group of patients, who first underwent surgery due to different reasons.

Intra-operative perforation is an important predictor of local recurrence and impaired survival after abdominoperineal resection for rectal cancer

Abdominoperineal resection for rectal cancer is associated with higher rates of local recurrence and poorer survival than anterior resection. The aim of this study was to evaluate the outcome of conventional abdominoperineal resection in a large national series. The study was based on the Danish National Colorectal Cancer Database and included patients treated with abdominoperineal resection between 1 May 2001 and 31 December 2006. Follow up in the departments was supplemented with vital status in the Civil Registration System. The analysis included actuarial local and distant recurrence, and overall and cancer-specific survival. Risk factors for local recurrence, distant metastases, overall survival and cancer-specific survival were identified using multivariate analyses. A total of 1125 patients were followed up for a median of 57 (25-93) months. Intra-operative perforation was reported in 108 (10%) patients. The cumulative 5-year local recurrence rate was 11% [95% confidence interval (CI), 7-13)], overall survival was 56% (95% CI, 53-60) and cancer-specific survival was 68% (95% CI, 65-71). Multivariate analysis showed that perforation, tumour stage and nonradical surgery were independent risk factors for local recurrence; tumour fixation to other organs, perforation and tumour stage were independent risk factors for distant metastases; and risk factors for impaired overall survival and cancer-specific survival were age, tumour perforation, tumour stage, lymph node metastases and nonradical surgery. Intra-operative perforation is a major risk factor for local and distant recurrence and survival and therefore should be avoided.

Superoxide Dismutase 2 (Sod2) is Overexpressed at an Early Stage During Colorectal Carcinogenesis: A Putative Target for Celecoxib Chemoprevention

Background: The occurence of circulating epithelial cells and cell-free tumor DNA (cfDNA) in peripheral blood of patients suffering from progressive forms of cancers has first been reported already in 1960s. With the great acceleration of genetic diagnostics by methods of polymerase chain reaction (PCR) the field of non-invasive examination of circulating molecular cancer biomarkers has recently been re-discovered. Aims: To investigate occurence of cfDNA as potential marker of regional and distant metastatic progression of colorectal cancer and to trace the source of cfDNA in patients undergoing surgery treatment at different levels of radicality. Methods: In a group of 165 patients in various stages of the disease tissue samples were initially acquired either as biopsies or resections. Samples were tested for a presence of the most frequent somatic colorectal cancer mutations within KRAS, APC, TP53, BRAF and PIK3CA genes. In addition, multiple plasma samples (n=789) were acquired over a time period covering (i) initial examination, (ii) immediately preceding a surgery (iv) postsurgery and (v) subsequent follow-up. Cell-free tumor DNA was traced in patient plasma by targeting mutations previously detected in tumor tissue. Results: Among patients who were positive for at least one of the detected somatic mutations in tumor tissue (102/165, 62%), cfDNA was present in 39 pre-surgery plasma samples. The frequency of cfDNA was correlated to the disease stage with 0% in Stages 0 and I, 9% in Stage II, 29% in Stage III and 94% in Stage IV. All cfDNA-positive patients (n=21) who underwent radical resection (R0) were free of cfDNA in subsequent testing of samples several days following surgery. All but 4 patients undergoing non-radical surgery, such as partial hepatic resections or paliative surgical treatment, remained cfDNA-positive also after the surgery. In some of the R0 patients, the cfDNA has re-appeared after a period of 18 22 months as a result of disease progression though local nodes or newly discovered metastases with continuous monitoring of the remainder of the group still in progress. Conclusion: Examination of a presence of cfDNA based on scanning plasma samples for presence of specific tumor mutations is a suitable tool for non-invasive monitoring of the disease progression as well as evaluation of surgery outcome. Supported by Czech Ministry of Health grant no. NS9809.

Circulating Free Tumor DNA in Patient Plasma is a Near-Perfect Marker for Metastatic Spread of Colorectal Cancer: A Study on 165 Patients Undergoing Surgical Treatment

Background: The occurence of circulating epithelial cells and cell-free tumor DNA (cfDNA) in peripheral blood of patients suffering from progressive forms of cancers has first been reported already in 1960s. With the great acceleration of genetic diagnostics by methods of polymerase chain reaction (PCR) the field of non-invasive examination of circulating molecular cancer biomarkers has recently been re-discovered. Aims: To investigate occurence of cfDNA as potential marker of regional and distant metastatic progression of colorectal cancer and to trace the source of cfDNA in patients undergoing surgery treatment at different levels of radicality. Methods: In a group of 165 patients in various stages of the disease tissue samples were initially acquired either as biopsies or resections. Samples were tested for a presence of the most frequent somatic colorectal cancer mutations within KRAS, APC, TP53, BRAF and PIK3CA genes. In addition, multiple plasma samples (n=789) were acquired over a time period covering (i) initial examination, (ii) immediately preceding a surgery (iv) postsurgery and (v) subsequent follow-up. Cell-free tumor DNA was traced in patient plasma by targeting mutations previously detected in tumor tissue. Results: Among patients who were positive for at least one of the detected somatic mutations in tumor tissue (102/165, 62%), cfDNA was present in 39 pre-surgery plasma samples. The frequency of cfDNA was correlated to the disease stage with 0% in Stages 0 and I, 9% in Stage II, 29% in Stage III and 94% in Stage IV. All cfDNA-positive patients (n=21) who underwent radical resection (R0) were free of cfDNA in subsequent testing of samples several days following surgery. All but 4 patients undergoing non-radical surgery, such as partial hepatic resections or paliative surgical treatment, remained cfDNA-positive also after the surgery. In some of the R0 patients, the cfDNA has re-appeared after a period of 18 22 months as a result of disease progression though local nodes or newly discovered metastases with continuous monitoring of the remainder of the group still in progress. Conclusion: Examination of a presence of cfDNA based on scanning plasma samples for presence of specific tumor mutations is a suitable tool for non-invasive monitoring of the disease progression as well as evaluation of surgery outcome. Supported by Czech Ministry of Health grant no. NS9809.

Giant Malignant Myxoid Fibrous Histiocytoma of the Chest Wall

A 79-year-old woman was admitted with a giant chest wall mass (Figures 1 and 2) and symptoms of dyspnoea that were progressively aggravated during the last 3 months. The mass was initially detected by the patient 1 year earlier, but she did not ask for medical consultation because of its initial small dimensions and the lack of symptoms. The patient underwent uncomplicated resection of the giant mass (measuring 34 cm in its maximal dimension and weighting 6.9 kg) en bloc with the muscles in contact. The tumor destroyed the third through seventh ribs, and these were also resected; the chest wall defect was reconstructed with a 2-mm e-polytetrafluoroethylene mesh. Re-establishment of the chest wall shape and re-expansion of the left lung had as result relief of dyspnoea symptoms and improvement of the quality of life. Histologic and immunohistochemical examination of the tumor established the diagnosis of high-grade myxoid malignant fibrous histiocytoma (MFH)/myxofibrosarcoma. The tumor was predominantly composed of myxoid areas ( 50%) with spindle cells and intermediate atypia and nonmyxoid areas with high cellularity and atypia. The immunohistochemical stainings for vimentin, myoglobulin, CD68, and CD34 (focally) were positive, whereas the stainings for smooth muscle actin and desmin were negative. Despite MFHs are the most common soft tissue sarcomas in adults, primary MFHs of the chest wall are relatively rare tumors.1,2 MFHs tend to reach large dimensions if left untreated within short periods of time. Radical surgery is the optimal treatment for MFHs of the chest wall including all the surrounding structures in contact with the tumor, even if the tumor has large dimensions. Local recurrence is observed in 30% of cases, probably as the result of nonradical surgery or spread of tumor cells within the operative field during resection or extirpation of large tumors.2

Discussion operation and treated therapy on gastrointestinal stromal tumour patients

Objective To explor quality surgery,cell of tumour excise with molecule target to the clinical result that is treated probe into intestines and stomach malignant. Methods Our hospital were retrospectively analyzed 16 patients admitted 2000-2007 gastrointestinal stromal cell tumor surgery and targeted therapy in cases of information. Results Surgery and no perioperative deaths and no serious postoperative complications occurred. 11 cases of radical surgery in 3-year survival in 9 cases (9/11), 5-year survival of 5 cases (5/11). 6 cases of postoperative oral administration of imatinib mesylate (Imatinib) receiving targeted therapy, (radical surgery in 2 cases,4 cases of non-radical surgery, of which 1 case was re-surgery). Re-operation were intra-abdominal GIST, for the first time in November when postoperative bowel obstruction symptoms, the re-operation for local recurrence and the formation of adhesions,line side to side anastomosis, after oral administration of imatinib had a good life. Non-radical surgey in 2 cases without targeted therapy and chemotherapy, died in 18 months,23 months ofter operation. All of the survival of good quality targeted therapy. Conclusion ①gastrointestinal stromal tumor(gastrointestinal stromal tumor GIST)is the source of fat in the gastrointestinal non-epithelial tumors,mesenchymal tumors belong to the digestive tract. ②The treatment of first surgery, the first time, radical surgery must be to achieve the goal. During surgery tend to have more visceral resection. Second, the molecular targeted therapy imatinib mesylate(Imatinib mesylate) treatment of GIST is a successful example of targeted therapy is the treatment of tumors reflects the molecular level. (3) radical surgery + targeted therapy for GIST treatment, the cancer treatment is the best combination and Whether it can greatly improve the clinical results, need to continue to observe. Imatinib mesylate(Imatinib mesylate)-resistant with alternative products. Key words: Gastrointestinal stromal tumor; Operation; Targeted therapy

Treatment results and prognostic analysis of 47 patients with urethral transitional cell carcinoma treated with post-operative adjuvant radiotherapy

Objective To evaluate treatment results and prognostic factors of 47 patients withprimary urethral transitional cell carcinoma treated with post-operative adjuvant radiotherapy. Methods From October 1998 to October 2008, 47 patients with primary urethral transitional cell carcinoma received postoperative adjuvant radiotherapy. Thirty-one patients had stage T_3/T_4 disease, 7 had lymph node metastasis. Thirty-nine patients had G3 tumor, 13 had stump-positive. The median radiotherapy dose was 60 Gy (36-64 Gy). 81% patients (38/47) were treated with regional irradiation. Results The median follow-up time was 21 months (6 -88 months). The follow-up rate was 92%. The median overall survival time was 35 months (5 -88 months). The 2-and 5-year overall survival rates were 57% and 49%, respectively. In univariate analysis, the median overall survival time was better in patients with stage T_1 or T_2 compared with stage T_3 or T_4 tumor (42 months vs. 19 months,Χ~2 =7. 28,P=0. 007), with age of ≤65 years compared with >65 years (28 mouths vs 18 months,Χ~2 =8.23 ,P =0. 004). There was no significantdifference in the long term survival in patients with non-radical surgery compared with radical mastectomy (21 months vs. 20 months, Χ~2 = 0. 90, P = 0. 344). In multivariate analysis, the stage T_3 or T_4 (Χ~2 = 7. 89, P =0. 005), >65 years old (Χ~2 = 4.85, P = 0. 028), renal pelvis involvement (Χ~2= 5.65, P = 0. 018), and tumor located in the mid or inferior segment (Χ~2=6. 08 ,P =0. 014) were factors associated with poorer prognosis. Conclusions Postoperative adjuvant radiotherapy can improve the efficacy of patients with locally advanced urethral transitional cell carcinoma. Advanced T stage and > 65 years age are associated with poorer prognosis. Key words: Urethral neoplasms/surgery; Urethral neoplasms/radiotherapy; Prognosis

Therapeutic Surgery for Nonepithelioid Malignant Pleural Mesothelioma: Is it Really Worthwhile?

Debate remains about the relative prognostic importance of the histologic subtype of malignant pleural mesothelioma. From a prospective database, the details of 312 malignant pleural mesothelioma surgical patients were reviewed. A comparison was made of the survival from the three major cell types. One hundred ninety-five patients underwent radical surgery, and 117 underwent nonradical surgery. Final histologic subtype was epithelioid in 218 patients, biphasic in 66 patients, and sarcomatoid in 28 patients. The median survival was 15.3 months in the epithelioid group, 10.1 months in the biphasic group, and 5.0 months in the sarcomatoid group. On univariate analysis in the epithelioid group, age (p = 0.005), International Mesothelioma Interest Group stage (p = 0.001), radicality of the procedure (p = 0.001), leukocytosis (p = 0.016), and preoperative or postoperative chemotherapy (p = 0.012) were significant prognostic factors influencing postoperative survival. In the biphasic group, preoperative anemia was the only significant factor (p = 0.007). In sarcomatoid patients, International Mesothelioma Interest Group stage and radicality of the surgical procedure were significant prognostic variables (p = 0.012 and p = 0.015, respectively). Multivariate analysis in the epithelioid group identified International Mesothelioma Interest Group stage (p = 0.001), radicality of the procedure (p = 0.008), and preoperative or postoperative chemotherapy (p = 0.007) as significant prognostic factors, whereas in the sarcomatoid group, only the International Mesothelioma Interest Group stage (p = 0.012) was significant and the radicality of surgery had no effect. The extremely poor prognosis of sarcomatoid malignant pleural mesothelioma is independent of the extent of surgery unlike other cell types. Patients with sarcomatoid histology should therefore be considered separately in trials evaluating radical procedures and adjuvant treatment. The treatment of biphasic pleural mesothelioma remains debatable.

Long-term Effects of Mifepristone in the Treatment of Non-radical Postoperative Endometriosis and its Impact on Sex hormones

Objective To explore long-term effects of low-dose mifepristone in non-radical postoperativeendometriosis patients and its impact on sex hormones. Methods 200 cases of endometriosis who underwent non-radical laparoscopic surgery were included in the study. Continuous treatment of oral mifepristone was given to those patients for 6 months(25 mg/d for 3 months and then 12.5 mg/d for another 3 months). B-ultrasound and pelvic examination were conducted before treatment, 3 months and 6 months after medication, 3 months, 6 months and 12 months after discontinuation of treatment respectively. Peripheral blood was collected to evaluate the changes of sex hormones. Results The overall effectiveness after 6 months treatment was 95.5% (191/200). Normal menstruation was resumed 1 month after the discontinuation of treatment. 6 cases relapsed within 6 months, and 27 cases relapsed within 1 year after the discontinuation of treatment respectively ( 6/191,3.1%;27/191,14.1%). After oral administration of mifepristone, serum E2 decreased to the mid-follicular levels. Serum FSH and PRL levels remained unchanged( P ＞ 0.05 ). Serum progesterone levels decreased significantly after treatment ( P ＜ 0.05 ). LH increased insignificantly ( P ＞ 0.05 ). Conclusion Continuous use of low-dose mifepristone can improve long-term effects of non-radical postoperative endometriosis. Reversible changes are expected in menses and serum sex hormone levels. The treatment is safe and its adverse effects are scares. Key words: Endometriosis; Mifepristone; Sex hormones

Hypopituitarism in the elderly: two case-reports with heterogeneous presentation

Hypopituitarism (HYPO) is an under-investigated disease in older patients. Symptoms, which may be life-threatening, are aspecific and often attributed to aging and/or related morbidities. We describe here the cases of two elderly patients who were ultimately diagnosed as having HYPO, the clinical presentations and etiologies of which were different. In the first patient, an invasive non-secreting pituitary macroadenoma causing HYPO was detected on brain morphological evaluation for head trauma secondary to falling. Glucocorticoid replacement therapy was started. Thyroid function evaluation showed hyperthyroidism (due to a known toxic multinodular goiter), which was already on treatment with methimazole; ultimately, after withdrawal of the antithyroid drug, secondary hypothyroidism occurred. The patient underwent non-radical pituitary surgery. Cognitive function, gait impairment and falling, which had previously been attributed only to aging, improved markedly after cortisone acetate and L-thyroxine replacement therapy. The second patient was hospitalized one month after the onset of hypotension, edema and pain in the legs, and progressive psychomotor impairment, which ultimately resulted in an intermittent soporous state. She was diagnosed as having global anterior HYPO secondary to empty sella, which caused severe multifaceted clinical and biochemical abnormalities (hyponatremia, pancytopenia, rhabdomyolysis). After treatment with i.v. fluids and hydrocortisone, the patient's clinical condition and biochemical alterations improved, and normalized over time with oral cortisone acetate and Lthyroxine combination therapy. Several protean symptoms that impair the quality of life of elderly patients are usually ascribed to aging. Such symptoms should be investigated with regard to possible HYPO, treatment of which can result in significant clinical benefit.

Xanthogranulomatous pyelonephritis infiltrating the liver

We report for the first time a patient with a caliceal diverticulum that was detected in early childhood, who in adolescence developed xanthogranulomatous pyelonephritis to the diverticulum and surrounding kidney and infiltrated to the liver. The condition was treated by nonradical organ-sparing surgery and prolonged antibiotic therapy.

Management of recurrent rectal cancer: A population based study in greater Amsterdam

To analyze, retrospectively in a population-based study, the management and survival of patients with recurrent rectal cancer initially treated with a macroscopically radical resection obtained with total mesorectal excision (TME). All rectal carcinomas diagnosed during 1998 to 2000 and initially treated with a macroscopically radical resection (632 patients) were selected from the Amsterdam Cancer Registry. For patients with recurrent disease, information on treatment of the recurrence was collected from the medical records. Local recurrence with or without clinically apparent distant dissemination occurred in 62 patients (10%). Thirty-two patients had an isolated local recurrence. Ten of these 32 patients (31%) underwent radical re-resection and experienced the highest survival (three quarters survived for at least 3 years). Eight patients (25%) underwent non-radical surgery (median survival 24 mo), seven patients (22%) were treated with radio- and/or chemotherapy without surgery (median survival 15 mo) and seven patients (22%) only received best supportive care (median survival 5 mo). Distant dissemination occurred in 124 patients (20%) of whom 30 patients also had a local recurrence. The majority (54%) of these patients were treated with radio- and/or chemotherapy without surgery (median survival 15 mo). Twenty-seven percent of these patients only received best supportive care (median survival 6 mo), while 16% underwent surgery for their recurrence. Survival was best in the latter group (median survival 32 mo). Although treatment options and survival are limited in case of recurrent rectal cancer after radical local resection obtained with TME, patients can benefit from additional treatment, especially if a radical resection is feasible.