Organ-preserving Surgery Research Articles

Optimal Treatment for Early Glottic Carcinoma

Abstract The management of early glottic cancer has evolved significantly over the past two decades, with transoral laser microsurgery and radiotherapy emerging as the two favored modalities of treatment. Although the role of Open partial conservative surgery has reduced but there are still some specific indications. The preference of one modality over another has generated lot of debate and continues to be controversial. As the survival outcomes are similar in all the modalities, we need to consider factors like professional needs, quality of life, vocal function and cost-effectiveness as regards the modality to be preferred. This manuscript aims at comprehensive overview of the contemporary literature comparing all the treatment modalities. Optimal Treatment for Early Glottic Carcinoma Open conservative laryngeal surgery (CLS), transoral laser microsurgery (TOLMS) and radiation therapy are valid and effective options for treating Tis, T1, and T2 glottic lesions. Although the evidence favoring any of the single modality to another is globally low level, but there is considerable shift towards trans-oral laser microsurgery. Subjective selection bias and opinion affect the decision making. The opportunity for CLS and TOLMS depend on the experience and expertise of the surgical oncology specialists. Three important tumor factors have significant influence on decision making in early glottic cancer: T-stage, true vocal cord mobility and involvement of anterior commissure (AC). Main treatment goal in early laryngeal cancer is to optimize local control, while optimizing preservation of function and hence quality of life. For achieving this goal, a careful initial clinical evaluation is very important. The clinical examination is most often performed using fiberoptic or rigid endoscopy to assess the extent of lesion and laryngeal mobility, which is the main issue in treatment of early glottic cancer. Laryngeal mobility was the only predictor of minor thyroid cartilage invasion treated with conservation laryngeal surgery and for early-stage to mid stage tumors involving the AC [1,2]. AC must be thoroughly evaluated clinically, as the approach and outcomes differ with the disease extension to this critical site. Subglottic extension and proximity of the tumor to the cricoid cartilage must be ascertained in view of organ-preservation surgery, in which a stable cricoid is essentially preserved. Evaluation under general anesthesia with 30 degree angled rigid endoscope helps in assessing AC and subglottic extension. Initial workup should include CT and/or MRI of the larynx especially if there is AC or subglottic extension on laryngoscopy. Guidelines are not generally useful and do not provide detail for selection of optimal treatment modality for particular patient. To optimize patient outcome, current evidence must be combined with experience of the multidisciplinary team managing these patients. Emphasis should be on an honest and open discussion regarding all of the aspects of different treatment options.

Uterine myomata: Organ-preserving surgery

Most women with uterine myoma are asymptomatic and do not require any treatment. However, myoma can also lead to menorrhagia, pressure symptoms, abdominal pain, and infertility. Management of symptomatic women with myoma depends on several factors, including age, desire for fertility, and myoma characteristics. Uterine myoma that distorts the uterine cavity, either submucous myoma or intramural myoma, with a submucous component reduces fertility, and is associated with increased uterine bleeding. The treatment of choice is hysteroscopic myomectomy or abdominal myomectomy, preferably by laparoscopy. Robotic assistance in laparoscopic myomectomy leads to outcomes similar to conventional laparoscopic myomectomy. However, it is expensive. Newer techniques include either laparoscopic or transcervical radiofrequency thermal ablation.

Clinical outcomes with transoral robotic surgery for supraglottic squamous cell carcinoma: Experience of a French evaluation cooperative subgroup of GETTEC.

Transoral, minimally invasive, organ preservation surgeries are increasingly used to treat laryngopharyngeal carcinomas to avoid the toxicity associated with combined chemoradiotherapy (CRT) regimens. This study investigated the efficiency, safety, and functional outcomes of using transoral robotic surgery (TORS) to perform supraglottic laryngectomy (SGL). This was a multicenter study using a case series with planned data collection from 2009 to 2012 for patients with supraglottic squamous cell carcinomas (SCCs) who underwent an SGL using TORS. Eighty-four of the 262 patients underwent TORS for a supraglottic SCC. Within 24 hours of surgery, 24% of the patients began an oral diet. The median use of a feeding tube was 8 days for 76% of other patients. Definitive percutaneous gastrostomy feeding was necessary for 9.5% of the patients. Twenty-four percent of the patients did require a tracheostomy, and the median use was 8 days. One percent of the patients had a definitive tracheostomy. Aspiration pneumonia was observed in 23% of the patients during the postoperative course, and was responsible for the death of 1 patient. Postoperative bleeding occurred in 18% of the patients. Based on the pathology results, 51% of the patients received adjuvant radiation therapy. TORS for SGL, in the intermediate stage of SCC, provides a safe procedure with good functional outcomes and fast recovery times; however, adverse events are possible. Consequently, this technique requires good selection criteria for the patients to reduce the risk of postoperative complications. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1097-E1101, 2016.

Prospective Multicenter Feasibility Study of Laparoscopic Sentinel Basin Dissection for Organ Preserving Surgery in Gastric Cancer: Quality Control Study for Surgical Standardization Prior to Phase III Trial.

The clinical application of sentinel node biopsies in early gastric cancer is still controversial even though it appears promising. This study was conducted as a prerequisite quality control for surgical standardization of laparoscopic sentinel basin dissection (SBD) prior to the initiation of a phase III trial.Laparoscopic SBD was performed in patients with preoperative stage T1-2N0 and tumor size <4 cm in diameter. Intraoperative endoscopic submucosal injection of a standardized dual tracer was administered. All retrieved sentinel basin nodes (SBN) were investigated with intraoperative frozen hematoxylin and eosin (H&E) staining. A strict checklist consisting of 7 essential steps was followed during laparoscopic SBD as the quality control study for a phase III trial. Completion of all essential steps in the checklist for 10 cases was used to define a qualified institution.Seven institutions participated and 112 patients were enrolled in this study. However, 4 patients were excluded owing to screening failure. The mean number of cases required for institutional qualification was 15 cases (range, 13–20 cases). Sentinel basins (SB) were detected and dissected in 100 of the 108 patients (92.6%); the median number of SB and SBN was 2 and 7, respectively. Lymph node metastases were detected in 10 patients by postoperative permanent H&E staining and they were detected by SBD in all 10 patients. Frozen results of SBN were compatible with permanent staining reports.Laparoscopic SBD is feasible and demonstrated improved sensitivity in detecting metastatic lymph nodes compared to the previous study. A future phase III randomized trial comparing laparoscopic SBD with organ-preserving gastrectomy and laparoscopic standard gastrectomy seems promising for qualified institutions.

Is there a place for organ-preserving surgery in managing patients with high-grade bladder cancer?

Is there a place for organ-preserving surgery in managing patients with high-grade bladder cancer?

Surgery volume selection in cervix cancer patients

The study included 26 patients with stage Ia1 – Ib1 cervical cancer who underwent organ-preserving surgery (transabdominal trachelectomy). To visualize sentinel lymph nodes, lymphoscintigraphy with injection of radioactive lymphotropic isotope, 99mTc-labelled nanocolloid, was performed the day before surgery. Intraoperative identification of sentinel lymph nodes using gamma probe was carried out to assess which lymph nodes had taken up the radionuclide. Detection of sentinel lymph nodes in cervical cancer patients can accurately predict the pelvic lymph node status, assess the stage of the disease, individualize the extent of surgery and determine indications for organ-preserving surgery.

Target medical screening as the basis for regional cancer care development

The problem of visually localized tumors, in particularly breast cancer (BC), may be resolved by an integrated approach combining mammographic screening and minimally invasive resection of the detected tumors, which is performed both for diagnostics and prophylactics (removal of potentially dangerous lesions). 25.5% of the patients with surgical intervention had organ preserving or reconstructive surgery, which improves patients ’ quality of life and gains women’s motivation for mammographic screening in the region. Such examples are the most convincing. The integrated approach to solve BC problem resulted in decreasing lethality by 28.8±2.1%.

Outcomes for Organ-Preserving Surgery for Penile Cancer.

AimSquamous cell carcinoma of the penis (PC) has traditionally been treated with partial penectomy with a 2-cm margin. More conservative resection margins have been reported to have no effect on oncologic control, but there is no consensus in the literature regarding functional outcomes after organ-preserving surgery for PC.MethodsSix patients meeting inclusion criteria were retrospectively identified to have received organ-sparing surgery for PC at the Cleveland Clinic from 2003 to 2012. Patient’s sexual and urinary quality of life was assessed retrospectively using the International Index of Erectile Function and the patient-reported outcome measure for urethral stricture surgery.ResultsThree patients (50%) report normal erections but describe intercourse as not very enjoyable and report being dissatisfied with their sex life. The remaining 50% consistently report no sexual activity and denied feeling sexual desire. All report only mild urinary symptoms, including decreased stream (18%) and feelings of incomplete voiding (67%). Eighty-three percent of patients report their sexual symptoms do not interfere with their daily lives. One hundred percent report being satisfied with their procedure.ConclusionOur study is the first to use standardized, validated questionnaires to evaluate sexual and urinary function in a North American penile cancer patient population. We report excellent overall urinary function and quality of life following penile-sparing surgery for PC, and our results depict more realistic sexual outcomes than those reported in studies using non-blinded and non-validated methods.

Organ-Preserving Surgery Using Endografts from Superelastic Titanium-Nickelid-Based Alloy for Patients with Laryngeal Cancer

Our study has demonstrated feasibility of performing larynx preservation surgeries in patients with recurrent laryngeal cancer after failure of radiotherapy. The technique of combined laryngeal reconstruction with endografts from superelastic titanium-nickelid-based alloy results in improvement of life quality by preserving laryngeal functions.

Evaluation of quality of life and function at 1 year after transanal endoscopic microsurgery.

Transanal endoscopic microsurgery (TEM) enables organ preservation after rectal tumour surgery. Its application is being expanded using adjuvant and neoadjuvant treatments. Our objective was to evaluate the changes over time in anorectal function, urinary symptoms and quality of life (QoL) in patients who had TEM surgery for a rectal tumour. Between September 2009 and October 2012, a consecutive series of 102 patients underwent TEM at a single institution. Patients were asked to fill out standardized questionnaires at baseline and then at 6, 12, 26 and 52weeks after surgery. The QoL among these patients was assessed using one generic (EQ-5D) and two disease-specific [European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-CR29] questionnaires. Anorectal and urinary symptoms were studied using the COlo-REctal Functional Outcome (COREFO) and the International Prostate Symptom Score (I-PSS) questionnaires, respectively. The response rate was 90% (92/102 patients). Postoperative complications occurred in 14% (13/92) of patients. The general QoL (as assessed using the EQ-5D) was lower 6 and 12weeks after TEM compared with baseline QoL (P<0.05) but returned towards baseline after 26weeks. Anorectal function (determined using the COREFO) was worse 6weeks postoperatively (P<0.01) but had normalized by 12weeks. Urinary function (determined using the I-PSS) was not affected at any time point after surgery. The total COREFO score and the American Society of Anesthesiologists (ASA) score were correlated with the deterioration in QoL. The study demonstrates that TEM has a temporary and reversible impact on QoL and anorectal function. Intensive interrogation of QoL and function using appropriate questionnaires will help to define the role of organ-preserving surgery for rectal cancer before and after chemoradiotherapy.

Evaluation of Functional Factors and Life Quality of Patients with Parotid Gland Cancer after Multimodal Treatment Including Radiation Therapy

Patients with parotid gland cancer underwent parotidectomy followed by neutron therapy. Organ-preserving surgery with fascial nerve preservation was performed in 28 patients. Dynamics of recovery processes in n. facialis and mimic musculature innerveted by this facial nerve was assessed by electroneuromyographic method. The quantitative evaluation of the quality of life of patients was carried out in accordance with International Protocol of the European Organization for Research and Treatment of Cancer. Organ-preserving surgery followed by neutron therapy for parotid gland cancer was found to result no in significant functional impairments of mimic musculature, speech and eating, thus allowing the terms of social adaptation to be reduced and life quality of patients to be improved.

Risk of hypocalcemia after thyroid surgery

To reveal calcium metabolism disorders that frequently occur after thyroid surgery. The study included 202 patients who underwent thyroid surgery for different diseases and had normal calcium level in peripheral blood at baseline. Based on laboratory data postoperative hypocalcemia was diagnosed in 57 (28.8%) patients. It was not always accompanied by clinical symptoms. Clinical picture depended on degree of hypocalcemia. Symptoms was diagnosed more frequently if calcium concentration was less than 2.1 mmol/l. Clinical manifestations were absent in 64.9% of cases on background of hypocalcemia. Incidence of hypocalcemia was higher after thyroidectomy compared to organ-preserving surgery. Symptoms of hypocalcemia occurred after thyroidectomy only. Casual parathyroidectomy does not always cause hypocalcemia. Only in 14% of patients with hypocalcemia excised parathyroid was identified in specimen. At the same time 7.6% of patients with postoperative normocalcaemia also had excised parathyroids in specimens. Symptoms of hypocalcemia does not always occur at 1 day after surgery. They can appear later, for example at 5 days postoperatively and depend on severity of hypocalcemia. Thyroidectomy has high risk of postoperative hypocalcemia with clinical symptoms (19.6%) that is transient in 15.5% of cases and permanent in 4.1% of patients.

Treatment outcomes of the patients with early glottic cancer treated with initial radiotherapy and salvaged by conservative surgery.

This retrospective study analyzed the oncological and treatment outcomes of the patients with T1-T2N0 glottic cancer, who were treated with radiotherapy as initial treatment and salvaged by conservative surgery for radiation failure. Between May 1999 and December 2010, 115 patients with glottic laryngeal cancer were treated at Kobe University Hospital. At presentation, 54 patients had stage T1a disease, 26 had stage T1b disease and 35 had stage T2 disease. Seventy-nine patients were treated with conventional radiotherapy and 36 patients were treated with hyperfractionated radiotherapy as initial treatment. Median duration of follow-up was 61 months. Five-year local control rates of radiotherapy were 92% in T1a, 83% in T1b and 86% in T2. Of 12 patients who developed local recurrence, larynx was successfully preserved in 3 patients by laryngomicrosurgery, 7 patients by vertical partial laryngectomy and one patient by subtotal laryngectomy. Ultimate 5-year laryngeal preservation rate and local control rate of all cases were 99 and 100%, respectively. Present results suggest that initial treatment with radiotherapy salvaged by organ preservation surgery is an effective strategy for laryngeal preservation in the treatment of T1-T2N0 glottic laryngeal cancer.

53. Organ-preserving surgery in vulvar cancer patients of young age

53. Organ-preserving surgery in vulvar cancer patients of young age

102. Aggressive angiomyxoma of the female perineum: Outcomes after conservative organ-preserving surgery

Background: Aggressive angiomyxoma is a very rare soft tissue tumour that typically arises in the female perineum and is characterised by an infiltrative nature with histological involvement of adjacent perineal organs. It has a propensity for local recurrence but not metastatic spread. In order to confidently gain negative surgical margins histo-pathologically, mutilating exenterative surgery would be necessary as these are large tumours confined to the perineum/pelvis and are often in close proximity to the anal sphincter, uro-genital tract and pelvic floor.

SOCIOHYGIENIC CHARACTERISTIC OF WOMEN WITH BREAST CANCER UNDERGOING ORGAN-PRESERVING SURGERY

Aim. To present the sociohygienic characteristic of women with breast cancer (BC) using the materials of sociological survey. Materials and methods. To assess a typical sociohygienic “portrait”, patients were offered to fill in an individual questionnaire developed by us which contained 28 questions of open, half-open and closed type by four parts: mode and conditions of life, conditions of work, self-rating of somatic and reproductive health, level of knowledge and habits concerning healthy way of life. 200 patients living in Perm and Perm Krai who had undergone organ-preserving operations for BC were surveyed. Results. Analysis of survey results permitted to give a sociodemographic, socioeconomic and sociohygienic characteristic of women suffering from breast cancer. Patients’ social status, living conditions, marital status and its satisfaction were analyzed. Main risk factors for development of breast cancer connected with bad habits, harmful production factors, somatic diseases were revealed. Analysis of obstetric and gynecological anamnesis allowed to make a conclusion about women’s reproductive health. To assess women’s level of knowledge on habits of healthy way of life, the program of questionnaire study included the question concerning the most significant, in women’s opinion, elements of healthy mode of life. Conclusions. According to the data of this study, a complex medicosocial characteristic of women with breast cancer undergoing organ-preserving surgery was given. The detected typical sociohygienic characteristics (medicosocial “portrait”) are of practical significance for timely diagnosis, formation of risk groups and breast cancer management; they also make basis for estimation of women’s quality of life in the nearest and long-term periods.

ДВУСТОРОННИЙ АСИНХРОННЫЙ РАК ПОЧЕК

Among 1430 patients with renal tumors, followed up at the Urology Clinic, I. M. Sechenov Moscow Medical Academy, in 1973 to 2007, 117 (8.2%) patients were found to have bilateral neoplasms, 81 (5.7%) patients being diagnosed as having bilateral renal cell carcinoma (RCC), out of them 51 (3.6%) and 30 (2.1%) patients had synchronous and asynchronous RCC, respectively. Asynchronous tumor was identified in 19 (63.3%) and 8 (26.7%) patients in the period of under 5 and >10 years (including 22 years in 1 case), respectively, after initial tumor removal. Among 30 patients with asynchronous RCC, 27 had previously undergone nephrectomy and 3 had resection of a kidney with tumor. When asynchronous RCC was detected, its treatment policy consisted of organ-preserving surgery. Analysis of the morphological pattern of a tumor in patients with bilateral asynchronous RCC revealed its similar type in 85.2% of cases and the identical degree of tumor cell differentiation in 48.1%; the patients with a varying degree of differentiation were ascertained to have high-grade asynchronous malignancy in 92.9% of cases. Molecular genetic studies showed that all the patients had mutations of VHL and FHIT genes located on the third pair of chromosomes. Our findings indicate that bilateral RCC is a genetically determined primarily bilateral tumor process that can manifest itself at once (synchronously) or after a (frequently considerable) time (asynchronously). In asynchronous carcinoma, overall and adjusted 5-year survival rates were 53.3 and 60%, respectively. The fact that an asynchronous tumor may occur in the contralateral kidney a considerable time after the first surgery necessitates to make a regular purposeful follow-up of patients operated on for unilateral RCC. The minimum control examination should include chest X-ray study, ultrasonography of the remaining kidney, removed tumor bed, and great vessels, which should be performed every 6 months within the first 5 years, then once every year. If a disease relapse is suspected, multispiral computed tomography of the abdomen and retroperitoneal space is to be made.

Biomarker-based treatment selection in early-stage rectal cancer to promote organ preservation.

BackgroundTotal mesorectal excision (TME) remains commonplace for T1–2 rectal cancer owing to fear of undertreating a small proportion of patients with node-positive disease. Molecular stratification may predict cancer progression. It could be used to select patients for organ-preserving surgery if specific biomarkers were validated.MethodsGene methylation was quantified using bisulphite pyrosequencing in 133 unirradiated rectal cancer TME specimens. KRAS mutation and microsatellite instability status were also defined. Molecular parameters were correlated with histopathological indices of disease progression. Predictive models for nodal metastasis, lymphovascular invasion (LVI) and distant metastasis were constructed using a multilevel reverse logistic regression model.ResultsMethylation of the retinoic acid receptor β gene, RARB, and that of the checkpoint with forkhead and ring finger gene, CHFR, was associated with tumour stage (RARB: 51·9 per cent for T1–2 versus 33·9 per cent for T3–4, P < 0·001; CHFR: 5·5 per cent for T1–2 versus 12·6 per cent for T3–4, P = 0·005). Gene methylation associated with nodal metastasis included RARB (47·1 per cent for N− versus 31·7 per cent for N+; P = 0·008), chemokine ligand 12, CXCL12 (12·3 per cent for N− versus 8·9 per cent for N+; P = 0·021), and death-associated protein kinase 1, DAPK1 (19·3 per cent for N− versus 12·3 per cent for N+; P = 0·022). RARB methylation was also associated with LVI (45·1 per cent for LVI− versus 31·7 per cent for LVI+; P = 0·038). Predictive models for nodal metastasis and LVI achieved sensitivities of 91·1 and 85·0 per cent, and specificities of 55·3 and 45·3 per cent, respectively.ConclusionThis methylation biomarker panel provides a step towards accurate discrimination of indolent and aggressive rectal cancer subtypes. This could offer an improvement over the current standard of care, whereby fit patients are offered radical surgery. May assist selection for organ preservation

Controversies of partial nephrectomy for renal cell carcinoma : survey in the German-speaking countries

The goal of this study was to evaluate how partial nephrectomy is technically performed in Germany, Austria, and Switzerland. A one-page anonymous questionnaire was designed to evaluate the indication, the technical procedure, and the follow-up of R1 situation after partial nephrectomy. Furthermore, the size of the hospitals and their catchment areas were recorded. The questionnaire was sent to 341clinics and a statistical analysis was performed. The response rate was 69 %. Up to 99 % of the clinics also perform partial resection in T1b tumors. Of those responding, 58 % perform this surgery laparoscopically, and 83 % of the surgeries are performed in warm ischemia. For the follow-up, 29 % suggest imaging within the first 6weeks. According to this survey, maximum care clinics perform laparoscopic nephrectomy more frequently (p = 0.003). The survey of 236hospitals performing partial nephrectomy shows great variability in the indication, technique, and aftercare of organ-preserving renal tumor surgery. It also shows that a large proportion of tumors >4cm undergo organ-preserving surgery, many of them minimally invasive. The diverse handling with positive instantaneous section and R1 results suggest the need for further studies concerning long-term follow-up after minimally invasive surgery with R1 situation and renal tumors > T1a.

Stimmrehabilitation nach Laryngektomie

Laryngeal and hypopharyngeal carcinomas are among the most common malignant tumours of the head and neck region, accounting for about 3,000 new cases per year. Despite enormous advances in organ preservation surgery and chemoradiotherapy, total laryngectomy is still necessary in approximately one quarter of affected patients. The removal of the larynx results in the loss of 3 important functions, i. e., voice production, the air conditioning mechanism of the nose, and the ability to smell. Whereas voice rehabilitation has been a mainstay of treatment from the very beginning of laryngeal surgery, pulmonary and olfactory rehabilitation has received increasing attention only in the past 2 decades. Today every head and neck surgical oncologist should be familiar with the various methods of voice rehabilitation and the use of heat and moisture exchangers for air conditioning. The objective of this article is to provide an overview of current methods of rehabilitation after total laryngectomy and to introduce young surgeons with an interest in voice rehabilitation to available techniques.