Organ-preserving Surgery Research Articles

Low-Grade Mucoepidermoid Carcinoma of the Subglottis Treated with Organ-Preservation Surgery

Mucoepidermoid carcinoma of the subglottis is infrequently reported in the literature. This tumor subtype is more commonly associated with the major and minor salivary glands. Mucoepidertoid carcinoma of the larynx can be difficult to diagnose, and there is no consensus as to appropriate management. We report a case of a low-grade mucoepidermoid carcinoma that was confined to the subglottis and treated with organ-preservation surgery. A conservative surgical approach was taken because of the tumor's low-grade histology and its location and in order to preserve the patient's laryngeal function. At follow-up 15 months postoperatively, the patient remained disease-free, and laryngeal function was intact.

Excellent Long-Term Cancer Control with Elective Nephron-Sparing Surgery for Selected Renal Cell Carcinomas Measuring More Than 4 cm

ObjectivesElective nephron-sparing surgery (NSS) for renal cell carcinoma (RCC)<4cm has been accepted as alternative to radical nephrectomy (RN). However, NSS for tumours >4cm is controversial. We present our experiences and long-term oncologic outcome of RCC>4cm treated with NSS in a retrospective single-institutional analysis of 69 patients. MethodsBetween 1975 and 2004, elective NSS was performed in 368 patients at our institution, including 69 patients with sporadic, nonmetastatic RCC>4cm. Overall and cancer-specific survivals were estimated using the Kaplan-Meier method. ResultsComplications were seen in nine patients (13.0%). After a mean follow-up of 6.2 yr (median, 5.8 yr) seven patients (10.1%) had died, none of them of tumour-related causes. Tumour recurrence was detected in four patients (5.8%). The 5-yr overall survival probability was 94.9%. The 10-yr and 15-yr overall survival rates were both 86.7%. Cancer-specific survival was 100% after 5, 10, and 15 yr. ConclusionsSelected patients with localized RCC even >4cm can be treated with elective NSS providing optimal long-term outcome. The surgeon’s decision for organ-preserving surgery should depend on tumour localisation and technical feasibility rather than on tumour size.

口腔・咽頭癌診療の最前線 下咽頭癌の機能温存手術：術式の選択と予後

口腔・咽頭癌診療の最前線 下咽頭癌の機能温存手術：術式の選択と予後

Diagnostics and treatment of benign ovarian tumors in patients with impaired reproductive function

The urgency of the problem. The problem of diagnosis and treatment of ovarian tumors is complex and relevant, especially when determining the possibility of carrying out organ-preserving surgery in young patients with impaired reproductive function.

Sparing Surgery for an Epidermoid Cyst of the Testis: A Case Report and Literature Review

Epidermoid cyst of the testis is relatively rare and accounts for less than 1% of all testicular neoplasms. This condition usually occurs in young men and it is mostly detected by self-examination or routine physical examination. The case of a 27-year-old male with an epidermoid cyst of the testis is discussed. The diagnosis was based on ultrasonography and management was with testicular-sparing surgery. At 2-year follow-up, the patient had had no relapse or metastasis. In epidermoid cysts of the testis, high-frequency ultrasonography is a reliable diagnostic imaging method. Organ-preserving surgery is recommended in the management of these lesions.

Duodenum preservation in pancreatic head resection to maintain pancreatic exocrine function (determined by pancreatic function diagnostant test and cholecystokinin secretion)

Organ-preserving surgery, such as pylorus-preserving pancreatoduodenectomy (PPPD), duodenum-preserving pancreatic head resection (DPPHR), or medial pancreatectomy (MP), is one of the recent advances in pancreatic surgery. There was a previous report that preservation of the duodenum maintained pancreatic function. However, concerning the resected pancreas, patients were divided into two groups; one group included pancreatic head resections such as Whipple, PPPD, and complete DPPHR, and the other group included MP that removed only the pancreatic neck and preserved the pancreatic head and distal pancreas. The present study was designed to clarify the significance of duodenum preservation, in comparison with duodenum removal, in patients with pancreatic head resection, in terms of pancreatic function, determined by a pancreatic function diagnostant (PFD) test and cholecystokinin (CCK) secretion. The subjects were 61 patients (10 with Whipple, 41 with PPPD, and 10 with complete DPPHR). PFD tests and postprandial plasma CCK secretion were used for evaluation. There was a significant difference between pre- and postoperative PFD values in the patients who received Whipple or PPPD; however, there was no difference in those who had complete DPPHR. Concerning the postoperative PFD value, complete DPPHR was superior to Whipple and PPPD. Regarding postprandial CCK secretion, the pre- and postoperative values were significantly different in the patients with Whipple or PPPD, but there was no difference in those with complete DPPHR. Comparing the three kinds of operations, complete DPPHR was superior to the other two procedures in its maintenance of pancreatic function. There was the significant correlation between CCK and PFD in our patients in the Spearman Rank Correlation (P < 0.0029) and Fisher's r to z (P < 0.0058). When pre- and postoperative pancreatic exocrine function and postprandial CCK secretion were measured in patients with pancreatic head resection, it was found that preservation of the entire duodenum was an important factor for maintaining pancreatic function.

Gibt es Indikationen zur organerhaltenden Tumorresektion bei Urothelkarzinomen des oberen Harntraktes?

Identification of prognostic factors for tumor recurrence in nephronsparing surgery and tumor progression after organ-preserving surgery. From June 1989 to February 2003, 43 patients (47 nephron units) underwent organ-preserving surgery or the upper urinary tract because of urothelial carcinoma, with 26 (60.5 %) having an elective indication (healthy contralateral kidney). The mean follow-up was 39.2 months with a range of 10.6 to 168.3 months. Ipsilateral recurrences occurred in 13 (27.6 %) of reno-ureteral units. Recurrences were significantly more common for tumors located in the renal pelvis or opposite the ureteral origin (p = 0.018). Tumor progression occurred in 8 of 43 patients (18.6 %) and significantly correlated with the T- and G-stage of the primary tumor (p = 0.006 and p = 0.002). Of the 47 conservatively treated reno-ureteral units, 38 (80.8 %) could be preserved. Organ-preserving resection of the urothelial carcinoma of the upper urinary tract is an alternative in some patients with well-differentiated superficial tumors. A follow-up for life and a good patient compliance are necessary. Tumors of the renal pelvis have a significantly higher recurrence rate than ureteral tumors. Poorly differentiated tumors should undergo organ-preserving surgery only if the goal is palliation and in patients with solitary kidney after intensive consultation about the high risk of invasive recurrences and the development of metastases.

Extending the Inferior Limits of Supracricoid Partial Laryngectomy: A Clinicopathological Correlation

The study examined preoperative clinical characteristics that can be used to predict secure inferior margins of glottic squamous cell carcinoma extending toward the cricoid cartilage when performing organ preservation surgery of the larynx. The study was retrospectively performed using 31 serially sectioned whole-organ total laryngectomy specimens with associated preoperative clinical data. Histopathologic and clinical variables including true vocal cord (TVC) fixation, cricoarytenoid joint invasion, subglottic extension (SGE) of tumor, and prior radiation were examined as independent and multivariate correlates of cricoid cartilage invasion. All tumors with subglottic extension of 15 mm or less and without arytenoid fixation were free of cricoid invasion. Of tumors invading cricoid with subglottic extension of 15 mm or less, all had a fixed arytenoid cartilage and local cricoid invasion type only. Correcting for subglottic extension using multivariate analysis, cricoarytenoid joint invasion and fixed true vocal cord independently predicted cricoid invasion. However, in a multivariate model together, true vocal cord mobility adds no predictive power to cricoarytenoid joint invasion. Prior radiation of the larynx did not significantly change the predictive capacity of these variables. Preoperative assessment of arytenoid mobility and extent of subglottic extension are reliable predictors of cricoid invasion by glottic squamous cell carcinoma. Organ preservation surgery is oncologically safe in the setting of glottic squamous cell carcinoma with subglottic extension of 15 mm or less and without arytenoid fixation.

The architecture of the ventricular mass and its functional implications for organ-preserving surgery

It has generally been accepted that the myocardial fibres within the ventricular mass are arranged in syncytial fashion, precluding the identification of discrete and isolated muscular pathways. Recently, however, an entire hypothesis for surgical treatment has been proposed on the basis of the existence of a 'ventricular myocardial band', suggesting that this arrangement in itself points to detrimental results following partial ventriculectomy. In this review, we re-state the evidence supporting the accepted concept of the ventricular mass being made up of an undefined number of wedge-shaped functional units, each of them exerting its individually programmed contribution to the global activity of the ventricular walls. The wedge-shaped units consist of bundles of individual fibres which are arranged tangentially. An important subset of fibres intrudes into the ventricular wall, thus creating oblique pathways. Their angle of intrusion varies, and can be measured at up to 30 degrees . The steeper the angle of their intrusion, the more efficiently do the fibres counteract the systolic mural thickening. The network of supporting connective tissue, nonetheless, provides the necessary steep angulation towards the endocardium. This fibrous matrix serves as continuous chain for the transmission of forces, including that in the direction from the epicardium towards the endocardium, resulting in a dilating force. We have shown, using needle force probes, that in the hypertrophic heart the dynamic equilibrium of dilating and constricting forces acts at elevated diastolic and systolic levels, because the obliquity of the fibres increases due to the thickening of the wall, and there is a concomitant increase in connective tissue, causing an increase in the forces opposing systolic mural thickening. Then, in a vicious cycle, both populations of myocardial fibres stimulate each other to hypertrophy. Eventually, coronary perfusion becomes critically impaired, with still further deposition of connective tissue. Ultimately, the vector of the dilating force comes to dominate the constricting force, and the ventricle dilates. In this setting, partial left ventriculectomy remains a functionally sound intervention, since it is capable of improving global ventricular function by improving the geometrical state of the remaining anatomic myocardial units.

Renal Cell Carcinoma in a Horseshoe Kidney and Preoperative Superselective Renal Artery Embolization: A Case Report

Only rarely is renal cell carcinoma encountered in a horseshoe kidney. This is a case report on renal cell carcinoma in a horseshoe kidney, in which superselective renal artery embolization was performed preoperatively. CT and digital subtraction angiography revealed a horseshoe kidney with a 3-cm tumor in the left side. Superselective renal artery embolization of the tumor was performed as a prerequisite procedure for the organ-preserving surgery of simple enucleation. Preoperative superselective renal artery embolization can be an effective tool to facilitate organ-preserving surgery in a horseshoe kidney.

Pheochromocytoma in children

The results of an examination, treatment, and postoperative follow-up of 520 patients with pheochromocytomas who were operated on at the Endocrinology Research Center, Russian Academy of Medical Sciences, in 1957 to 2002 have been analyzed. The patients’ mean age was 39.3±9.2 years; 50 (9.6%) patients aged less than 16 years. There were 213 (41.0%) males in the total group and 32 (62.0%) in the pediatric group. Bilateral adrenal lesion was detected in 68 (13.1%), including 16 (32%) of the 50 children aged less than 16 years. Extraadrenal tumors were ascertained in 36 (6.9%). The concomitance of pheochromocytoma with hereditary syndromes was observed in 36 (6.9%) cases. Two hundred and sixty patients were followed up for 4 to 25 years (mean 8.4+1.9). Recurrence ofpheochromocytoma was revealed in 49 (18.8%) patients; the genuine recurrence (a tumor at the site of primary surgery or metastasis) was found in 16 (6.15%) patients. The genuine recurrence of pheochromocytoma was seen in 6 (12.0%) of the 50 children; its main cause was organ-preserving surgery for multicenter adrenal lesion.

Extending inferior limits in organ preservation surgery: A clinico-pathologic correlation

Problem: This study examines preoperative clinical characteristics that can be used to predict secure inferior margins of glottic squamous cell carcinoma (SCC) extending toward the cricoid cartilage, when performing organ preservation surgery of the larynx. Methods: Thirty-one serially sectioned whole-organ laryngectomies were histologically analyzed and true vocal cord (TVC) mobility, cricoarytenoid joint invasion, subglottic extension (SGE) of tumor, and prior radiation were examined as independent and multivariate correlates of cricoid invasion. Results: All tumors with SGE. Conclusion: Preoperative assessment of arytenoid mobility and extent of SGE are reliable predictors of cricoid invasion by glottic SCC. Significance: Organ preservation surgery is oncologically safe in the setting of glottic SCC with SGE. Support: None reported.

The expanding role of systemic therapy in head and neck cancer.

Treatment of squamous cell carcinoma of the head and neck (SCCHN) has evolved greatly in the last two decades, owing to the integration of chemotherapy, advances in radiotherapeutic techniques, and organ-preserving surgery. Several randomized trials have established new standards of care that should be adopted. Current efforts are building on these earlier trials in order to improve survival and quality of life. Coincident with this, investigators are developing molecularly targeted approaches that hold promise for the future. This review will focus on current therapy for locally advanced, recurrent, and metastatic SCCHN and discuss controversies and directions for future research.

Assessment of irregular voices after total and laser surgical partial laryngectomy.

To assess the merits of computer-aided voice analysis procedures for very irregular voices of patients after total and laser surgical partial laryngectomy, and to characterize qualitative differences in speech and voice function between these 2 groups of patients. Cross-sectional study. University hospital in Göttingen, Germany Twenty-nine patients with advanced laryngeal carcinomas (T3-T4; according to the Union Internationale Contre le Cancer, TNM staging system, stages III-IVa) were examined: 18 patients with tracheoesophageal speech (voice prosthesis) after total laryngectomy and 11 patients who underwent partial transoral resection of the larynx (by means of laser microsurgery without surgical voice rehabilitation). Speech intelligibility was measured by a standardized and validated telephone test, and voice quality was determined by 2 computerized voice analysis systems (multidimensional voice program and Göttingen hoarseness diagram). The telephone test demonstrated a significantly better speech performance of the patients who had undergone organ-preserving surgery. The voices of both patient groups were too irregular for a qualitative differentiation with the multidimensional voice program. The multidimensional voice program results also failed to show significant correlations to speech intelligibility. The Göttingen hoarseness diagram showed significantly more regular voices in patients with partial laryngectomy than total laryngectomy. These results were correlated with speech intelligibility. The Göttingen hoarseness diagram is suitable for a qualitative assessment even of irregular voices. Voice prosthesis offers a voice quality that at best approaches that of patients with partial laryngectomy.

Long-term morbidity in children treated with fractionated high-dose-rate brachytherapy for soft tissue sarcomas.

The purpose of this study was to determine the long-term local control, disease-free survival, and morbidity of fractionated high-dose-rate brachytherapy (F-HDR) in infants and children with soft tissue sarcomas. Fifteen children (13 girls and 2 boys, ages 5-101 months) with soft tissue sarcomas were treated with chemotherapy, organ-preserving surgery, and F-HDR (36 Gy in 12 fractions) to post-chemotherapy volumes. External beam radiotherapy was not part of the primary treatment, although four patients (27%) subsequently received salvage external beam radiotherapy after treatment failure. Chemotherapy was administered to all patients based on their tumor histology and stage. After a median follow-up of 10 years (range 32-154 months), 12 patients (80%) were alive without evidence of disease. Ten-year overall survival and local control rates were both 80% (12/15 children). The overall survival was better (91%) for children with microscopic residual versus gross residual disease (75%). With longer follow-up, grade 3 to 4 brachytherapy-related late morbidities increased from 8% (1/12) to 20% (3/15) and included trismus/osteonecrosis, vaginal stenosis, and periurethral fibrosis. There were two late complications associated with puberty that occurred 8 to 10 years after the initial treatments. Acute toxicity occurred in five patients (38%) and consisted primarily of grade 1 to 3 skin and mucosal reactions. As the sole radiation modality, F-HDR achieved excellent local control and disease-free survival in properly selected children with soft tissue sarcomas while preserving normal bone and organ development. A significant percentage of patients experience adverse late sequelae as a result of this treatment.

Organ preservation surgery for laryngeal cancer: The evolving role of the surgeon in the multidisciplinary head and neck cancer team

Total laryngectomy is in the doghouse. It is a procedure that was once heralded as a life saving intervention, standing the test of time for over a century. Now largely considered a salvage procedure, total laryngectomy is seen as a second choice following the failure of other approaches. Today, the first line treatment for many patients with advanced laryngeal cancer is the organ-preserving treatment of chemotherapy and radiation therapy. The VA trial showed us that chemotherapy and radiation therapy results in equal survival for patients undergoing total laryngectomy, compared with those who underwent induction chemotherapy and radiation therapy.’ The RTOG 97-l 1 trial demonstrated that concomitant chemotherapy and radiation are superior to either induction chemotherapy or radiation alone in the context of organ preservation for advanced laryngeal cancer. * Both valuable studies have significantly improved the management of laryngeal cancer. It has been suggested that concomitant chemotherapy and radiation therapy should now be the standard of care for laryngeal cancer, replacing total laryngectomy. Patients want to save their larynx, so of course chemotherapy and radiation treatment is good thing. Can there be too much of a good thing?

Management of the superior laryngeal neurovascular bundle in organ preservation surgery for laryngeal carcinoma

Management of the superior laryngeal neurovascular bundle in organ preservation surgery for laryngeal carcinoma

Nephron sparing surgery in renal cancer - individual decision or standard procedure?

AbstractOrgan-preserving surgery has gained widespread acceptance within the international urological community through the last decade. In consequence, the question of radical vs. nephron sparing surgery for the treatment of renal cancer is increasingly discussed in a controversial way. Today, even advocates of a radical nephrectomy must admit that long-term results obtained through nephron sparing surgery are excellent. In consequence, heminephrectomy has become a standard treatment in patients with impaired renal function. However, in patients with a normal contralateral kidney, national and international guidelines still favor radical nephrectomy. An increased morbidity and doubts on the efficacy of heminephrectomy concerning tumor control are the key reasons behind this strategy. Within this analysis the authors stress the hypothesis that the actual differences between organ-preserving surgery and radical nephrectomy concerning survival are marginal if the requirements for heminephrectomy are met. Therefore, the actual controversy appears to be rather based upon assumptions and convictions than on actual facts. To definitively answer this question a prospective randomized trial is suggested, however, the problems of this study may not be underestimated.

Renal cell carcinoma in a kidney transplant: allogeneic genome in the tumor justifies organ-preserving surgery

Renal cell carcinoma in a kidney transplant: allogeneic genome in the tumor justifies organ-preserving surgery

Accuracy of frozen section examination of testicular tumors of uncertain origin.

A total of 80-90% of all testicular masses are malignant germ cell tumors. Benign testicular lesions are recognized in approximately 10-20% enabling a testis-preserving surgery on the findings of frozen section examination (FSE). However, there are only sparse information with regard to the reliability of FSE in testicular tumors of uncertain dignity. Therefore, we retrospectively reviewed our experience concerning the reliability of FSE in primary testicular tumors by comparing each FSE result to the final diagnosis. From 1974 to 2000, 354 patients were operated on a testicular tumor. During inguinal exploration and after clamping of the spermatic cord and appropriate dressing, a representative biopsy of the tumor was taken and sent for FSE. In case of malignancy radical orchiectomy was performed, in case of benign findings or in case of a germ cell tumor in a solitary testicle, the tumor was enucleated. Slides of FSE and the permanent sections were reviewed and compared with regard to the histological diagnosis and presence/absence of malignancy. Based on FSE, 317 tumors (89.5%) were found to be malignant ((100 seminomas (38.5%), 217 nonseminomas (61.5%)) and 37 tumors (10.5%) were benign (17 epidermoid cysts, 14 Leydig cell tumors, two cystadenomas, two simple cysts, two hemangiomas). Comparing FSE and definitive diagnosis, FSE correctly identified all malignant and benign lesions. There was a failure rate of 10 and 8% to differentiate seminomatous from nonseminomatous tumors and vice versa based on FSE, which, however, was irrelevant for the surgical management. Complications of the enucleations (n = 37) were: testicular atrophy in three cases, testicular hematoma in three cases, orchitis/epididymitis in one case. Not a single case disclosed a local relapse after a mean follow-up of 105 (12-240) months. Intraoperative FSE correctly identified all malignant and benign testicular masses including radical orchiectomy or organ-preserving surgery. Surgical management of testicular tumors based on FSE results is clinically practicable.