Oncological Reasons Research Articles

Surgical Sphincter Preservation in Rectal Cancer

Improved understanding of the biological features and advances in diagnostic and surgical procedures have been the basis for increased applications of sphincter preserving operations in lower rectal tumors. The relevant treatment strategies along with their indications will be presented and analyzed. New operative procedures comprise transanal excision of early rectal cancer or trans-sphincteric resection or ultralow anterior resection with colon-pouch creation to improve continence. Recently, for cases in which the removal of the rectal sphincter is indispensable for oncological reasons, a continent perineal colostomy has been developed. Reconstruction of the sphinter function is achieved using a seromuscular cuff. This procedure avoids an abdominal colostomy. The neosphincter can also be formed secondarily, after a prior abdomino-perineal excison with transabdominal colostomy.

Advances for Sphincter Preservation in the Surgical Therapy of Rectal Cancer

Improved understanding of the biological features and advances in diagnostic and surgical procedures have been the basis for increased applications of sphincter-preserving operations in lower rectal tumors. The relevant treatment strategies along with their indications will be presented and analyzed. New operative procedures comprise transanal excision of early rectal cancer or trans-sphincteric resection or ultralow anterior resection with colon-pouch creation to improve continence. Recently, for cases in which the removal of the rectal sphincter is indispensible for oncological reasons, a continent perineal colostomy has been developed. Reconstruction of the sphincter function is achieved using a seromuscular cuff. This procedure avoids an abdominal colostomy. The neosphincter can also be formed secondarily, after a prior abdominoperineal excision with a transabdominal colostomy.

Are laboratory values in bone marrow aspirate predictable for venous blood in paediatric patients?

In an emergency situation, early laboratory results are important, but often difficult to obtain. If venous access cannot be established, the intraosseous route may be used as an alternative. This study investigated the predictive value of bone marrow aspirate in performing laboratory studies. Thirty children underwent general anaesthesia for bone marrow aspiration (iliac crest) for oncologic or haematologic reasons. The aspirate and a peripheral venous blood sample, which was obtained simultaneously, were subjected to different laboratory tests and the results were compared by means of confidence interval analyses of the individual ratios of venous/bone marrow values. Based on these analyses, a high predictability of bone marrow values were found for haemoglobin, sodium, chloride, glucose, bilirubin, urea, creatinine, pH, and standard bicarbonate. Moderate, but clinically useful predictability was found for haematocrit, potassium, and total protein, while bone marrow values of alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, P co 2, P O 2, thrombocytes and leukocytes were systematically different from values in venous blood. Our data suggest that the intraosseous route is not only an important emergency alternative to intravenous access for administering fluids and drugs but may also serve as a reliable alternative for obtaining initial diagnostic laboratory studies when intravascular access is not obtainable.

Video-assisted thoracoscopic surgery--indications, results, complications, and contraindications.

In recent times minimally invasive surgery has secured a firm place among the therapeutic options in thoracic surgery. The experience and results gained from video-assisted surgery on 109 patients between January 1, 1992 and July 31, 1993 are critically discussed. The procedure could be completed thoracoscopically on 94 of them. A change of method was necessary nine times for technical reasons and six times for oncological reasons (two times due to metastasis, four times due to bronchial carcinoma). A total of 154 individual operations were conducted. Sixty-three patients with recurrent spontaneous pneumothorax were successfully treated. The relapse rate was 1.5%. With the exception of three rethoracotomies (one due to postoperative hemorrhaging and two to persistent fistula) no significant complications occurred. Further indications included capsulated pleural empyema (n = 1), persistent hematothorax (n = 2), pleurectomy for malignant pleural effusion (n = 2), pleural tumors (n = 3), pulmonary parenchyma (n = 2), interstitial lung diseases (n = 3), bullous emphysema (n = 2), peripheral lung nodules (n = 18), mediastinal tumors (n = 8), and sympathectomy (n = 2). The advantages of video-assisted thoracoscopic surgery for patients include cosmetic considerations, low pain, earlier postoperative mobilization, and for some indications, a shorter operation period. The significant disadvantages for the surgeon are the loss of binocular vision as well as the impossibility of intraoperative palpation.

Facial nerve management in cranial base surgery

This study reviewed 124 patients who required facial nerve manipulation during cranial base surgery. Most of them underwent only nerve displacement or selective transection for improved surgical access to the cranial base (70 and 34, respectively). Fourteen patients had the facial nerve resected for oncologic reasons and repaired with primary nerve grafting. Most patients regained quite satisfactory facial function with quality correlating with the degree of nerve injury. Six patients had facial nerve resected as part of oncologic palliation and had the facial deficit rehabilitated with regional tissue. A correlation between preoperative facial nerve weakness and the quality of nerve graft function was not found. An oncologic correlation, however, is suggested (patients with preoperative weakness had less favorable prognosis). Overall, patients who require facial nerve resection for oncologic reasons do not do as well as those with normal preoperative function.

Revision of classification of laryngeal cancer, is it long overdue? (Proposals for an improved TN-classification).

The TNM-classification of laryngeal carcinomas of the UICC contains a number of weaknesses which diminish their prognostic relevance. Based on clinical observations and microscopic investigations of surgical specimens, several changes are proposed to improve the existing TN-classification. The larynx is subdivided by the UICC into the supraglottic, the glottic and the subglottic main area and their tumours. There are embryological, anatomical, functional and oncological reasons to divide the larynx into two main areas only--the supraglottis and the glottis (vocal folds) without any further subsites and to abandon a separate group of subglottic tumours. The T size of a tumour should not be assessed according to the extent of an ill-defined anatomical region, but measured in millimetres of greatest surface extent only. The T2 category of vocal fold tumours should not contain those which lead to an inhibited mobility of the fold. All tumours with reduced vocal fold mobility or fixation should be classified as T3 or T4 according to the dimension of invasion. Post-operative pathological examinations (pT/pN) allow an assessment of the true extent of a tumour in three dimensions. A validation study using a 'metric' TpT-classification shows very distinct groups of tumours with a significantly different prognosis from Tis 1 to T4. Studies of lymph node metastases in the neck have shown that, number, size, site of metastasis and the presence of extracapsular tumour spread have a significant influence on the prognosis. An improved N/pN-classification taking these factors in consideration is proposed.

A management plan for tongue base cancer that includes brachytherapy

For physiologic as well as oncologic reasons, there has been an increasing interest in radiation therapy as the primary treatment of base of tongue carcinoma. At Memorial Sloan-Kettering Cancer Center, we have used such a plan, using external beam conventional therapy in combination with an interstitial boost of iridium 192 to the primary site, plus planned neck dissections in selected patients. Between 1981 and 1986, 17 patients with untreated base of tongue squamous cell carcinoma were treated in this manner. Thirteen of the 17 are disease-free as a result of this therapy. Two patients have failed locally, yielding an actuarial local control of 87% at a median followup of 2 years. These data would suggest that primary radiation that includes interstitial therapy as part of the plan, along with neck dissection in certain situations, is a worthwhile method management of base of tongue carcinoma.

Breast reconstruction after mastectomy.

Radical mastectomy inflicts emotional as well as physical scars, and preoperative interviews with the reconstructive surgeon can help to ameliorate some anxiety. There is no evidence of risk to the patient from reconstruction of the breast. Reconstruction is best deferred for four to six months after mastectomy for several oncologic and psychologic reasons. Careful selection of patients is paramount. Reconstruction involves the correction of several functional and structural deficits. The end result has been enhanced by the silicone breast implant and the myocutaneous flap. Although the final result is usually not a cosmetic triumph, the reconstruction may serve to enhance the patient's self-image.