Organ-sparing Surgery Research Articles

Recent Therapy of Organ-confined Testis Cancer

In Germany, testicular cancer accounts for about 1-2% of all malignant tumours. Although, therefore, this is a rare tumour, it assumes an exceptional position among malignant tumours in several respects. In male patients aged 20-35 years it is the most common tumour, which directly affects the family and life planning of young men, a matter of prime importance at this age. Another aspect of testicular cancer is its excellent prognosis since the introduction of platinum-based chemotherapy into the armamentarium of testicular cancer therapy. Therefore, therapeutic innovations increasingly focus on reducing the radicality of treatment, even more so since this therapy, in addition to acute toxicity, can cause severe long-term consequences up to and including secondary malignancies. This article gives an overview of the present therapeutic standard of stage I testicular cancer treatment. Selective PubMed research Results and Discussion: Besides potential implications for organ-sparing surgery, the article elucidates the benefits of a risk-adapted therapeutic approach and indications for a surveillance strategy for patients with localised testicular cancer.

Endoscopy and minimally invasive surgery in the diagnosis and treatment of precancerous diseases and cancer of the stomach in the early stages

One of the most urgent problems of modern oncology is cancer of the stomach, which takes one of the leading places in the structure of cancer incidence. Given the high prevalence of gastric cancer and aggressive course of the disease it is extremely necessary to solve the problem of early diagnosis based on evidence-based medicine and meticulously comply with this disease screening protocols. The review highlights the main precancerous processes and conditions prior to the appearance of tumor, especially degeneration of precancerous lesions to cancer. In particular, to precancerous conditions include chronic atrophic gastritis, pernicious anemia, intestinal metaplasia of the gastric epithelium, the appearance of polyps, endured surgery on the stomach, Menetries disease. These diseases with different frequencies give rise to different degrees of severity of dysplasia, and metaplasia of the stomach epithelium, and ultimately cancer. Understanding precancerous states helps to shape risk and carefully carry out the selection of patients for screening activities to develop the tactics of treatment of precancer and early gastric cancer. The standard diagnosis is endoscopy, which allows to perform a biopsy of the alleged pathological focus for subsequent histological examination is necessary for morphological verification of diagnosis and patient management. To improve the method used technique of chromoesdoscopic examination. Thanks to the introduction of new technologies into clinical practice, such as particular zoom magnification endoscopy, endoscopic examination in a narrow spectral range, endoscopic ultrasound, has become possible to more accurately determine the boundaries of the tumor, depth of invasion into the stomach wall and correctly assess the state of the regional lymph nodes. Diagnosis of early forms of gastric cancer has opened opportunities for sparing endoscopic interventions, namely endoscopic mucosal resection of the stomach, endoscopic submucosal dissection by layer, photodynamic therapy and laser destruction. All these techniques can improve patient survival and quality of life by improving the methods for early diagnosis of the disease and organ sparing surgery.

Cirurgia conservadora nos tumores do testículo

IntroductionMalignant germ cell tumors represent the majority of testicular masses; according to current knowledge, radical orchiectomy remains the standard of care in the management of this type of cancer. However, testis‐sparing surgery (TSS) can be an alternative to radical surgery in selected cases, particularly in patients with small testicular masses (STM). ObjectiveThe authors conducted a review of the current indications for performing testicular sparing surgery as well as functional and oncological results of it. Material and methodsWe conducted a literature search in Medline database (PubMed) using the keywords: “testis sparing surgery”, “partial orchiectomy”, ‘testis tumor’, ‘small testicular mass/tumor’. The search was limited to article in English language, published from 2010 to the current date. Resultsrandomized controlled trials/studies with high level of evidence that compare TSS with radical orchiectomy were not found. Indications for TSS are still controversial, particularly in patients with normal contralateral testis. The organ sparing surgery seems a viable therapeutic option for patients with small non‐palpable testicular mass (with <20mm major axis), bilateral tumors or single testicle. The frozen section examination plays a decisive role in the technique, since it allows the distinction between malignant and benign neoplasms, as well as assessing the status of surgical margins. The medium and long follow‐up results of the analyzed retrospective studies revealed no significant risk of local and/or distant relapses. ConclusionRegarding the testis, the organ‐sparing surgery can be adopted safely in the treatment of selected cases. Prospective multicentric and high level of evidence studies are needed in order for TSS become a real alternative to radical surgery, as well to evaluate the oncological safety and real functional benefits of preserving the testis.

The expression of p53, p16 and Ki-67 in penile cancer and their significances

Objective To evaluate the expression of immunohistochemistry markers p53, p16 and Ki-67 in penile cancer and penile intraepithelial neoplasia (PIN). Methods 33 patients who suffered penile cancer and received organ-sparing surgery from Jan 2004 to Dec 2013 were retrospectively analysed. The expression of p53, p16 and Ki-67 were detected by EnVision/HRP two steps immunohistochemistry. Results The positive expression rates of p53 in normal penile epithelium, low-grate penile intraepithelial neoplasia, high-grate penile intraepithelial neoplasia, well-differentiated squamous cell carcinoma and poor-differentiated squamous cell carcinoma were 0, 16.7 %, 38.5 %, 30.0 % and 66.7 % respectively. The expression rates of p16 were 20.0 %, 50.0 %, 53.8 %, 70.0 % and 33.3 % respectively. The expression rates of Ki-67 were 0, 16.7 %, 61.5 %, 65.0 % and 75.0 % respectively. Conclusions The combined detection of p16 and Ki-67 can contribute to discover PIN and penile carcinoma much more earlier. p53 may be related to the occurrence and development of low differentiated squamous cell carcinoma, and p16 may be related to the occurrence and development of well-differentiated squamous cell carcinoma. Key words: Penile neoplasms; Penile intraepithelial neoplasia; p53; p16; Ki-67

An accelerated hypofractionated radiotherapy regimen in patients after organ-sparing surgery for stages I–IIA breast cancer

Objective: to assess the results of accelerated hypofractionated radiotherapy and to comparatively analyze it with the standard radiotherapy in patients with stages I–IIA breast cancer (BC) after organ-sparing surgery. Materials and methods. A total of 203 patients with stages I–IIA BC underwent radiotherapy after organ-sparing surgery. A control group of 91 patients received the standard radiotherapy (the single focal dose (SFD) was 2 Gy 5 times a week, 25 fractions; the total focal dose (TFD) was 50 Gy for 5 weeks). A study group of 112 patients had accelerated hypofractionated radiotherapy (SFD 3 Gy 5 times a week, 13 fractions; TFD 39 Gy for 2.3 weeks). Results. Local recurrences were not detected in any patient after the hypofractionated radiotherapy regimen and were diagnosed in 3.3 % of the patients after the standard regimen. There were no statistically significant differences between the groups in 5-year overall and relapsefree survival rates. Further observation revealed a statistically significant difference in 6-year overall survival rates in the study and control groups: 99.1 and 70.4 %, respectively (p ≤ 0.046). The 6-year relapse-free survival rates in patients who had received the accelerated hypo-fractionated radiotherapy regimen were also significantly higher than in those who had the standard radiotherapy regimen: 97.9 and 71.3 %, respectively (p ≤ 0.043). The rate of post-radiation normal tissue damages after the hypofractionated radiotherapy regimen was significantly lower (15.2 %) than that after the standard regimen (27.5 %). Good and excellent cosmetic results of treatment were achieved in most (95.1 %) patients and did not differ in their frequency after different radiotherapy regimens. Conclusion. The accelerated hypofractionated radiotherapy regimen showed a high efficiency and a favorable toxicity profile in patients with stages I–IIA BC.

Comparative analysis of the frequency of early wound infectious complications due to radical mastectomy and organ-sparing surgery in patients with breast cancer

Comparative analysis of the frequency of early wound infectious complications due to radical mastectomy and organ-sparing surgery in patients with breast cancer

Organ-sparing surgery in a patient with necrotic endometritis and an incompetent uterine scar after cesarean section

Organ-sparing surgery in a patient with necrotic endometritis and an incompetent uterine scar after cesarean section

The systemic approach to the rehabilitation of the patients presenting with laryngeal cancer after the resection of the organ and laryngectomy with tracheoesophageal by-pass and endoprosthetics

The objective of the present study was to enhance the effectiveness of rehabilitation of the patients presenting with laryngeal cancer after the resection of the organ and laryngotomy with tracheoesophageal by-pass and endoprosthetics. Our experience in this field is based on the treatment of 102 patients. They were distributed by the nosological forms as follows: primary laryngeal cancer in 97 patients including T1NoMo - 8 (8.2%), T2NoMo - 63 (65%), T3NoMo - 18 (17.6%), T2N1Mo - 1 (0.9%), T4NoMo - 3 (2.9%), and T4N1M0 - 4 (3.9%), root of the tongue cancer spreading over the vestibular part of the larynx in one patient, laryngeal sarcoma in one patient, relapse of cancer following the full-dose radiotherapy and organ-sparing surgery in 3 patients. Laryngeal resection was performed in 83 patients; 19 patients underwent laryngectomy with tracheoesophageal by-pass and endoprosthetics using a domestically manufactured voice prosthesis. The systemic approach to the rehabilitation of the patients and the use of the proposed treatment algorithm made it possible to restore the function of the larynx by means of organ-sparing surgery in 79 (95.1%) of the 83 patients. The vocal function in the patients following laryngectomy with tracheoesophageal by-pass and endoprosthetics was restored in 18 (94.7%) of the 19 patients.

Laparoscopic ultrasound assisted laparoscopic retroperitoneal schwannoma excision.

Schwannomas are rare, benign tumors that originate from the neural sheath. Rarely, schwannomas can arise from the retroperitoneum and adrenal medulla. We describe a case of a 61-y-old man who presented with an incidentally discovered retroperitoneal tumor near right adrenal gland. A 61 year old male patient presented with a severe right flank pain. He had no hematuria, dysuria or any urological symptoms. Magnetic resonance images and computed tomography scans revealed a 25 mm lesion with solid and cystic areas near the adrenal gland. Metanephrin and normethanephrine levels were increased in 24-hour urine test. The differential diagnosis was pheochromacytoma or paraganglioma. Intraoperative laparoscopic ultrasound assisted laparoscopic resection of retroperitoneal tumor excision was performed to the patient. Right surrenal was spared by using intraoperative laparoscopic ultrasound. The total operative time was 55 minutes and the estimated blood loss was 50 ml. Postoperative period was uneventful, the drainage catheter was removed on the postoperative 1st day and the patient was discharged on the postoperative 2nd day. Pathological examination revealed a retroperitoneal schwannoma. The patient's first year controls were completely normal. The assistance of laparoscopic ultrasound was helpful for adrenal sparing surgery in our case by defining tumor margins. Peroperative laparoscopic ultrasound use could help urologists in providing safety margins especially with endophytic renal mass and operations can be completed with less amount of parenchymal loss. This imaging modality was used in evaluation of pancreatic cancer staging and resectability, identification of endophitic renal tumors. In conclusion, laparoscopic ultrasound is a safety and useful method for organ-sparing laparoscopic surgery.

Laparoscopic organ-sparing surgery in the treatment of patients with uterine myoma

Laparoscopic organ-sparing surgery in the treatment of patients with uterine myoma

Organic hyperinsulinism: radiological diagnostics and surgical treatment.

To optimize the diagnosis and surgical treatment of insulinoma and nesidioblastosis. 42 patients with organic hyperinsulinism (OH) were operated. There were 39 cases of insulinoma including 2 patients with insulinoma combined with nesidioblastosis and 3 cases of nesidioblastosis alone. Preoperative ray imaging consisted of percutaneous, endoscopic and intraoperative sonography, contrast-enhanced computed tomography, magnetic resonance imaging (MRI). Functional test included arterial-stimulated blood sampling (ASBS). Laparotomy and robot-assisted techniques were used in 22 and 20 patients. Sensitivity was 62.0%, 76.9%, 83.3%, 87.5%, 94.8% and 100% in percutaneous sonography, CT, endoscopic sonography, MRI, intraoperative sonography and ASBS respectively. Postoperative complications were observed in 14 and 6 patients after conventional and robot-assisted surgery. 2 patients died. Overall mortality was 4.8%. None patient had recurrent hypoglycemic conditions in long-term postoperative period (mean follow-up 18.7 months). Comprehensive survey allowed to define the cause of OH. Minimally invasive organ-sparing surgery has satisfactory immediate and remote results in these patients.

Feasibility and safety of conservative surgery for the treatment of spermatic cord leiomyosarcoma

ObjectivesTo assess the feasibility and the safety of conservative surgery to treat spermatic cord leiomyosarcoma. MethodsPatients undergoing inguinoscrotal exploration in 10 different Urological Centers with diagnosis of leiomyosarcoma were enrolled. Preoperative evaluation included physical examination, Scrotal US, Abdominal CT and Scrotal MRI in selected cases. Patients underwent organ sparing surgery or orchiectomy in case of intraoperative FSE was positive for a local infiltration. Data collected were: age, presence of infiltration, length of the lesion, number of lesions, definitive histological outcome, pre and postoperative testosterone level. Follow up was performed with abdomen CT scan and scrotal US. ResultsFrom January 2007 to December 2013, 23 patients (mean age: 64.7 yrs) were diagnosed with spermatic cord leiomyosarcoma. Each patients underwent scrotal US. 10 patients underwent radical orchiectomy and 13 patients underwent conservative surgery. Mean follow up was 36.5 months. 5 patients (21.7%) developed a recurrent disease, 18 patients (78.3%) had a negative follow up (mean time: 40.8 months). Statistical analysis reveals that there is a significant correlation between number of lesions, length of the lesions and recurrent disease. ConclusionsSpermatic cord leiomyosarcoma is a rare disease. Conservative surgical treatment of spermatic cord leiomyosarcoma is a feasible therapeutic option for small, single and not infiltrating lesion.

Experiences and outcomes of organ-sparing surgery for testicular tumour with benign tendency.

We retrospectively investigated and summarized our experiences and the outcomes of organ-sparing surgery (OSS) for testicular tumour with benign tendency. From April 2000 to March 2012, 11 selected patients with testicular tumour underwent OSS. Preoperative and postoperative organ functional and oncologic indexes were analyzed and compared. All operations were completed without conversion to radical orchiectomy. Intraoperative frozen section and routine postoperative pathology showed tumours with benign tendency. The normal appearance of the scrotum and functional integrity of the testis were preserved. Preoperative and postoperative serum sex hormone levels, international index of erectile function (IIEF-5) scores, and semen quality were not significantly different. Tumour recurrence or metastasis did not occur during follow-up. Our results showed the feasibility and safety of OSS to treat testicular tumour with benign tendency. With careful selection and rigorous follow-up, some testis tumor can be treated with OSS to maximally maintain normal appearance and function of the testis. The retrospective single-centre study and small sample size are main limitations. More evidence is needed to establish the large-scale application of OSS.

Intraoperative injection of 99mmTc-nanocolloid for localization of nonpalpable intratesticular tumors in organ-sparing surgery

ObjectiveRadical orchidectomy is the standard treatment for malignant testis tumors. Radical orchidectomy results in androgen deprivation, infertility and impaired psychological well-being, especially in synchronous bilateral tumors, metachronous contralateral tumors or tumor in a solitary testis. According to the European Association of Urology Guidelines, if pre-operative testosterone level is normal and the tumor volume is less than 30% of the testicular volume, organ preserving surgery can be performed. For nonpalpable tumors, organ-sparing surgery needs a precise intraoperative localization with high-frequency ultrasound, especially for nonpalpable tumors. Material and methodsWe report two cases of nonpalpable intratesticular tumors successfully localized using 99mmTc nanocolloid injected with intraoperative US and detected with a γ-ray detection probe. ConclusionsThis method is easily reproducible and safe for the patient. This technique could guarantee complete excision of the tumor, especially if the mass is poorly delimited.

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-SPARING BREAST CANCER SURGERY

Aim . The aim of this article is to present review of current trends in organ-sparing treatment of breast cancer. Summary of own 15-year experience of organ-sparing breast cancer surgery and its analysis in the light of global trends. Materials and methods. The analysis of results of radical treatment of 429 patients with invasive breast cancer T1-2N0-3M0 during period 1999-2013 is presented. From 1999 to 2007 quadrantectomy was performed. Since 2007 we stopped to excise fascia, and the boundaries of removed tissues around the tumor was limited by 0.5-1.0 cm. The skin over the tumor was excised only if there was suspicion of its possible tumor involvement. After removal of the specimen its margins were marked and express histological examination was performed. In case of positive margin re-resection of this margin was performed, and in case of repeatedly positive margin mastectomy was performed. Axillary lymph node dissection was performed in all patients with tumors diameter 1.0 cm or more. Until 2007 third level of lymph node dissection was performed. Since 2007, the volume of the procedure was determined depending on the level of attached lymph nodes, which was established by preoperative ultrasound or examination of axillary tissue during surgery. In cases of N0-tumors D1-lymph node dissection was performed, in cases of N1-tumors – D2 and in cases of N2-tumors – D3. Postoperative radiotherapy was used in all patients, except some patients older than 70 years with pT1N0-tumors and favorable morphological characteristics of the tumor. Results . In January 2014 415 patients from 429 were observed. A relapse in saved breast occurred in 18 (4.3%) patients. In 6 (33.3%) cases it was combined with distant metastases. Noteworthy is that all patients with relapse received adjuvant radiotherapy and in 16 (88.9%) cases quadrantectomy was made. Patients with recurrent disease and with absence of distant metastases underwent mastectomy. In January 2014 they were all alive with the time of follow-up ranged from 30 to 162 months. Overall 5-year survival (Kaplan-Meier) was 92,3 ± 1,8% and 10-year survival was 84,2 ± 2,5%. Conclusion . Organ-sparing treatment with careful selection of patients should be the method of choice. A retreat from the visible borders of the tumor 0.5 cm is sufficient. The main goal of breast preserving is to achieve a good cosmetic result, so if this is not feasible - conserving surgery is meaningless.

Ullrich-Turner Syndrome and Tumor Risk: Is There Another Chance to Early Gonadectomy in Positive TSPY and SRY Patients?

The presence of the Y chromosome in the karyotype of patients with disorders of sex differentiation is significantly associated with an increased risk to develop specific types of malignancies, predominantly type II germ cell tumors (GCTs). Gonadoblastoma in the gonads without an obvious testicular differentiation and intratubular germ cell neoplasia of unclassified type in testicular tissue are the precursor lesions of most GCTs. Gonadal dysgenesis, the characteristic feature of Ullrich-Turner syndrome (UTS), further contributes to increase this tumor risk. The reported incidence of Y chromosome material in UTS is 6 to 8% and in these cases an early gonadectomy is strongly recommended to prevent the risk of a malignancy. The aim of this work was to retrospectively analyze the clinical outcome and the histopathological and cytogenetic findings of our UTS patients who underwent gonadectomy to establish strict selection criteria aimed at promoting an organ-sparing surgery.

Efficiency and safety of organ-sparing surgery for locally advanced kidney cancer

Objective: to evaluate the efficiency of surgical treatment in patients with locally advanced kidney cancer (KC), by comparing the immediate and late results of organ-sparing surgery (OSS) and nephrectomies. Subjects and methods. The results of surgical treatment were analyzed in 251 patients with KC who had undergone OSS (n = 124) or nephrectomy (n = 127). The groups were matched for gender, age, stage, and baseline glomerular filtration rate. Surgical complications were evaluated according to the Clavien-Dindo classification. Survival rates were calculated using the Kaplan-Meier method. Results. There were no significant differences between the two patient groups in the amount of blood loss (median 300 ml) and in the hospital length of stay. The median renal ischemia time was 15.0±3.4 min. Complications after OSS and nephrectomies occurred in 10.4 and 4.7% of cases. The OSS group was found to tend to have higher 5-year overall survival rates (89.1%) than the nephrectomy group (70.6%) (p = 0.248). Conclusion. OSS is an effective, safe treatment option for KC, at the same time it is still inadequately frequently used in wide clinical practice. The OSS group was found to tend to have higher 5-year overall and relapse-free survival rates than the nephrectomy group (p > 0.05).

Inyección intraoperatoria de nanocoloide con tecnecio-99 metaestable para la localización de tumores intratesticulares no palpables en orquiectomías parciales

ObjectiveRadical orchidectomy is the standard treatment for malignant testis tumours. Radical orchidectomy results in androgen deprivation, infertility and impaired psychological well-being, especially in synchronous bilateral tumours, metachronous contralateral tumours or tumour in a solitary testis. According to the European Association of Urology Guidelines, if pre-operative testosterone level is normal and the tumour volume is less than 30% of the testicular volume, organ preserving surgery can be performed. For nonpalpable tumours, organ-sparing surgery needs a precise intraoperative localization with high-frequency ultrasound, especially for nonpalpable tumours. Matherial and methodsWe report two cases of nonpalpable intratesticular tumours successfully localised using 99mmTc nanocolloid injected with intraoperative US and detected with a γ-ray detection probe. ConclusionsThis method is easily reproducible and safe for the patient. This technique could guarantee complete excision of the tumour, especially if the mass is poorly delimited

Organ-sparing surgery in urology: partial cystectomy.

While radical cystectomy continues to be the gold standard for surgical management of muscle invasive bladder cancer, there has been a renewed interest in partial cystectomy as a viable treatment alternative. The purpose of this review is to summarize and discuss the recent literature regarding partial cystectomy for bladder cancer. Utilization of partial cystectomy has remained stable, at a rate of 7-10% of all cystectomies performed nationally. Additionally, recent population-based series as well as single institution cohorts have found that partial cystectomy did not compromise survival when compared to radical cystectomy. While patients may recur, those with organ-confined disease had no difference in survival following salvage cystectomy when compared to primary radical cystectomy. Current data indicate 14% of patients experience an in-hospital complication, which is a marked decrease compared to radical cystectomy. Finally, innovations in surgical technique, such as robotics, as well as the inclusion of partial cystectomy into trimodal therapy, offer exciting new frontiers in bladder cancer treatment. Once maligned, partial cystectomy now represents a standard-of-care option for management of bladder cancer. Although additional research is needed to clarify patient selection and outcomes, partial cystectomy is an important treatment option for appropriately selected patients.