Principles Of Surgical Oncology Research Articles

Perioperative outcomes of robot-assisted pancreatoduodenectomy (PD) and totally laparoscopic PD after overcoming learning curves with comparison of oncologic outcomes between open PD and minimally invasive PD.

Minimally invasive pancreatoduodenectomy (MIPD), such as totally laparoscopic pancreatoduodenectomy (TLPD) or robot-assisted pancreatoduodenectomy (RAPD), is increasingly performed worldwide. This study aimed to compare the perioperative outcomes of TLPD and RAPD, and compare the oncologic outcomes between MIPD and open pancreatoduodenectomy (OPD) for malignant disease. This retrospective study was conducted at two hospitals that followed similar oncological surgical principles, including the extent of resection. RAPD was performed at Seoul National University Hospital, and TLPD at Seoul National University Bundang Hospital. Patient demographics, perioperative outcomes, and oncological outcomes were analyzed. Propensity score matching (PSM) analysis was performed to compare oncologic outcomes between MIPD and OPD. Between 2015 and 2020, 332 RAPD and 178 TLPD were performed. The rates of Clavian-Dindo grade ≥ 3 complications (19.3% vs. 20.2%, p = 0.816), clinically relevant postoperative pancreatic fistula (9.9% vs. 11.8%, p = 0.647), and open conversions (6.6% vs. 10.5%, p = 0.163) were comparable between the two groups. The mean operation time (341 minutes vs. 414 minutes, p < 0.001) and postoperative hospital stay were shorter in the RAPD group (11 days vs. 14 days, p = 0.034). After PSM, the 5-year overall survival rate was comparable between MIPD and OPD for overall malignant disease (58.4% vs. 55.5%, p = 0.180). Both RAPD and TLPD are safe and feasible, and MIPD has clinical outcomes that are comparable to those of OPD. Although RAPD exhibits some advantages, its perioperative outcomes are similar to those associated with TLPD. A surgical method may be selected based on the convenience of surgical movements, medical costs, and operator experience.

Combined use of composite mesh and acellular dermal matrix graft for abdominal wall repair following tumour resection

BackgroundSurgeries for sarcomas in the abdominal wall require wide resections, often radical en bloc resections, which generate major defects involving a very complex repair. The combined use of porcine dermal xenografts, together with composite meshes, may assist in the repair of these defects with minimal complications.MethodWe present a series of 19 patients (10 males and 9 females), with a mean age of 53.2 years (range: 11–86 years) treated in the Sarcoma Unit of the Virgen de la Arrixaca University Hospital from January 2015 to December 2021. Histopathologically, there were four chondrosarcomas (21%), three Ewing sarcomas (15.7%), two desmoid tumours (10.5%), two undifferentiated pleomorphic sarcomas (10.5%), two well-differentiated liposarcomas (10.5%), two leiomyosarcomas (10.5%), one synovial sarcoma, one dermatofibrosarcoma protuberans, one fibromyxoid sarcoma (or Evans tumour), and one metastasis from an adenocarcinoma of unknown origin. All the patients were resected following surgical oncology principles and reconstructed by means of the combined use of a composite mesh acting as a neoperitoneum and a porcine dermal xenograft acting as an abdominal neofascia.ResultsThe mean size of the defects generated after surgery for tumour excision was 262.8 cm2 (range: 150–600 cm2). After a mean follow-up of 38 months, six patients (31.5%) developed complications—two cases of wound dehiscence, one case of surgical wound infection, one case of graft partial necrosis, one case of anastomotic leak and one death due to multiorgan failure secondary to massive bronchoaspiration.ConclusionSurgeries for sarcomas of the abdominal wall require wide oncological resections, which generate major abdominal wall defects. The repair of these defects by means of the combined use of synthetic and biological meshes is a technique associated with minimal complications and excellent medium-term results.

Principles of Pediatric Palliative Surgical Oncology: A Guide To Palliative Care For Pediatric Surgeons.

Principles of Pediatric Palliative Surgical Oncology: A Guide To Palliative Care For Pediatric Surgeons.

A multicenter noninferior randomized controlled study comparing the efficacy of laparoscopic versus abdominal radical hysterectomy for cervical cancer (stage IB3 and IIA2): study protocol of the LAUNCH 3 trial

BackgroundCervical cancer is and will remain to be an important health problem in China, especially with an increasing proportion of younger patients who has more specific needs. In China, surgery to remove tumor burden followed by postoperative treatment with radiotherapy and chemotherapy based on clinicopathologic factors may be the best choice for stages IB3 and IIA2 patients. Radical hysterectomy in cervical cancer has been a classic landmark surgery in gynecology. The current trial is designed to evaluate whether there is a difference between laparoscopic RH and abdominal RH in cervical cancer (stages IB3 and IIA2) patient survival under stringent operation standards and consistent surgical oncologic principles. This paper reports the rationale, design, and implementation of the trial.Methods/designThis is an investigator-initiated, prospective, randomized, open, blinded endpoint (PROBE) controlled trial. A total of 1104 patients with stage IB3 and IIA2 cervical cancer will be enrolled over a period of 3 years. Patients are randomized (1:1) to either the laparoscopic RH or the abdominal RH group. Patients will then be followed up for at least 5 years. The primary end point will be 5-year overall survival, and secondary endpoints include 5-year progression-free survival, recurrence, and quality of life measurements.DiscussionThe study results will provide more convincing evidence-based information for stages IB3 and IIA2 cervical cancer patients and their gynecologic cancer surgeons in their choice of surgical method.Trial registrationClinicalTrials.gov, NCT04939831, retrospectively registered on 25 June 2021.

Changes in Oncological Surgical Principles Driven by Advances in Preoperative Treatments.

From a surgical point of view, the development of preoperative oncological treatment has had a profound effect on the surgical treatment trends of cancer as well as on the outcomes of cancer patients. Consequently, these changes have challenged formerly entrenched oncological surgical principles. In our short report, we aimed to summarize the main shifts regarding the surgical principles of cancer treatment due to the development of preoperative oncological therapy in recent years. As a result of successful preoperative treatment, surgeons may perform less radical surgeries, the required free resection margin has been narrowed down to a few millimeters in dimension and preoperative treatment is justified in both definitely resectable tumors and in oligometastatic tumors as well. For prognosis assessment, the post-preoperative oncological treatment stage is now considered decisive, rather than the pretreatment stage as previously thought. Other changes include the introduction of the watch and wait strategy and the reverse order of treatment of the primary tumor and metastasis. Observing the continuously improving outcomes of cancer patients and the developments in oncological treatment modalities, a further expansion of the indication of preoperative treatments is to be expected.

A simple way of making a cyst trocar

The ideal management of presumably benign ovarian tumors (PBOTs) should be minimally invasive and follow the principles of surgical oncology. We have developed a surgical technique in which a 5 mm diameter balloon trocar (introduced through a 30 mm midline incision) is used to treat a large PBOT. This minimally invasively and easy-to-reproduce technique provides a perfect seal around the bursa during aspiration of the cyst contents.

Novel 3D Custom-Made Silicone Tumor Model as a Support for Teaching Surgical Oncology Principles.

Alternative laboratory teaching methods are becoming increasingly desirable and effective in medical education environments. While ethical concerns associated with the use of live animals in terminal surgery laboratories have been reduced with cadaveric models, availability, and lack of pathology can limit their ability to adequately convey surgical principles and replicate clinical training. We have developed a three-dimensional (3D) custom-made silicone soft tissue tumor model using 3D-printed molds derived from canine soft tissue sarcoma computed tomography images. This novel teaching model allows users to apply surgical oncology principles and perform basic technical tasks such as incisional biopsy, margin demarcation, marginal and wide surgical excision, and inking of surgical margins. A large cohort of students in addition to a small number of professional veterinarians at different levels of specialty training followed the laboratory guidelines and evaluated the simulated tumor model based on a qualitative survey. All participants were able to successfully complete the practical training. The model also allowed the students to identify and correct technical errors associated with biopsy sampling and margin dissection, and to understand the clinical impacts related to those errors. Face and content validity of the model were assessed using Likert-style questionnaires with overall average instructors' scores of 3.8/5 and 4.6/5, respectively. Content validity assessment of the model by the students approximated instructors' evaluation with an overall average score of 4.4/5. This model development emphasizes the efficacy of alternative non-cadaveric laboratory teaching tools and could become a valuable aid in the veterinary curricula.

Nerve-sparing technique in RPLND for testicular cancer.

The management of testicular cancer has evolved over time with multimodal therapy. Retroperitoneal lymph node dissection (RPLND), which is a complex and potentially morbid treatment option, remains the mainstay in surgical treatment. This article reviews the surgical template, approach and anatomical considerations with regards to nerve spare in RPLND. The standard full bilateral RPLND template has evolved over time to include the area between the renal hilum, bifurcation of the common iliac vessels, and the ureters. Morbidity with regards to ejaculatory dysfunction has led to further refinements in this procedure. Advancements in anatomical understanding of the retroperitoneal structures and their relationship to the sympathetic chain and hypogastric plexus has allowed for modification of surgical templates. Further refinements in surgical nerve sparing techniques have improved functional outcomes without sacrificing oncological outcomes. Finally, extraperitoneal access to the retroperitoneum and minimally invasive platforms have been implemented to further reduce morbidity. RPLND requires strict adherence to oncological surgical principles regardless of template, approach and technique. Contemporary evidence shows that outcomes are best for advanced testis cancer patients when managed at high volume tertiary care facilities with surgical expertise and access to multidisciplinary care.

Surgery for hepatocellular carcinoma and intrahepatic cholangiocarcinoma: milestone changes in the last two decades potentially affecting current guidelines

The aim of this review is to describe the relevance of minimally invasive liver resection (MILR) for the treatment of most common primary liver tumors. The uptake has been slow but steady, and thus MILR has become a well-established field of hepatobiliary surgery and is considered a landmark change of the past 30 years. There is evidence that the advantage of MILR regarding specific complications of liver surgery for HCC (reduced incidence of postoperative hepatic decompensation and ascites) can be a tool to potentially expand the indications to surgical treatment. Evidence for intrahepatic cholangiocarcinoma is early and exploratory; however, it is beginning to be documented that the fundamental principles of surgical oncology for this tumor can be respected while offering patients the advantages of minimal invasiveness.

Breast conserving surgery revisited: a narrative review

Background and Objective: Breast cancer surgery has seen a reverse evolution particularly over the last decade. There has been a universal acceptance of the fact that tumour biology and response to systemic treatment dictates risk of breast cancer recurrences and not surgical radicalism. The role of surgery has been “risk adapted” over the years to maintain function, contour and body image without compromising on the principles of surgical oncology. In this article we explore the first major transition from radical ablative mastectomies to breast conserving surgery (BCS) as we know it today comparing the different cancer specific and health related outcome measures for BCS and mastectomy.

Robot-assisted nephroureterectomy for upper tract urothelial carcinoma—feasibility and complications: a single center experience

Background Robot-assisted nephroureterectomy (RANU) is the primary treatment for upper tract urothelial carcinoma (UTUC) at our hospital for patients with clinical stage less than T2, and for patients with invasive tumours, but unfit for major surgery. Objective To assess peri-operative conditions and outcomes of RANU at our unit, and to evaluate the safety of the procedure. Methods The medical records of all 166 patients undergoing RANU for suspected UTUC and followed for more than three months in a large university hospital in Sweden were reviewed retrospectively. After the exclusion of twenty patients because of previous cystectomy, simultaneous surgical procedure, or other tumour types than UTUC in the pathological report, 146 patients remained for the analyses. The primary endpoint was complication rate according to Clavien-Dindo at 90 days. Secondary endpoints were perioperative bleeding, violation of oncological surgical principles, hospital stay, and re-admission within 90 days. Results The median age was 75 [(Inter Quartile Range) IQR 70–80] years and 57% of the patients had an ASA score above 2. According to Clavien-Dindo, one patient had a grade 3 complication, and no patient had a grade 4–5 complication. The median blood loss was 50 (IQR 20–100) ml and the median hospital stay was 6 (IQR 5–7) days. Twelve patients were re-admitted to the hospital within 90 days (eight with urinary tract infection/haematuria, one with hematoma, and three with other diseases). Conclusion Robot-assisted nephroureterectomy is a safe procedure for patients with upper tract urothelial carcinoma, with a low risk of major surgical complications.

International Society of Paediatric Surgical Oncology (IPSO) Surgical Practice Guidelines.

Most children with tumors will require one or more surgical interventions as part of the care and treatment, including making a diagnosis, obtaining adequate venous access, performing a surgical resection for solid tumors (with staging and reconstruction), performing procedures for cancer prevention and its late effects, and managing complications of treatment; all with the goal of improving survival and quality of life. It is important for surgeons to adhere to sound pediatric surgical oncology principles, as they are closely associated with improved local control and survival. Unfortunately, there is a significant disparity in survival rates in low and middle income countries, when compared to those from high income countries.The International Society of Paediatric Surgical Oncology (IPSO) is the leading organization that deals with pediatric surgical oncology worldwide. This organization allows experts in the field from around the globe to gather and address the surgical needs of children with cancer. IPSO has been invited to contribute surgical guidance as part of the World Health Organization Initiative for Childhood Cancer. One of our goals is to provide surgical guidance for different scenarios, including those experienced in High- (HICs) and Low- and Middle-Income Countries (LMICs). With this in mind, the following guidelines have been developed by authors from both HICs and LMICs. These have been further validated by experts with the aim of providing evidence-based information for surgeons who care for children with cancer.We hope that this initiative will benefit children worldwide in the best way possible.Simone Abib, IPSO PresidentJustin T Gerstle, IPSO Education Committee ChairChan Hon Chui, IPSO Secretary

Radical Hysterectomy for Cervical Cancer: the Right Surgical Approach.

Radical hysterectomy with pelvic lymph node assessment is the standard initial therapy for early-stage cervical cancer. Radical hysterectomy via laparotomy (an "open" approach) was first described more than 100 years ago and has been the standard for decades. Minimally invasive surgery (MIS) has been increasingly adopted by many surgeons due to its reported perioperative benefits. MIS was deemed safe for radical hysterectomy for many years based on multiple retrospective publications. Recently, the Laparoscopic Approach to Cervical Cancer (LACC) trial reported that patients randomized to MIS had inferior oncologic outcomes. The results of the LACC trial and subsequent retrospective studies led multiple professional societies to state that open radical hysterectomy should remain the gold standard surgical approach. We acknowledge that the open approach for radical hysterectomy is an appropriate option for all cervical cancer patients eligible for surgical treatment. However, considering the limitations of the LACC trial and the available data from other retrospective studies, we feel the MIS approach should not be simply abandoned. There may still be a role for MIS in cervical cancer surgery for properly and carefully selected cases and with detailed counseling; surgeons should analyze their own outcomes closely in order to perform such counseling. Modification of surgical technique and maintaining proper oncologic surgical principles are key for MIS to remain a viable option. Tumor manipulation and contamination should be avoided. Transcervical uterine manipulators should not be used. Cervical and tumor containment prior to colpotomy, as is performed during an open approach, is required. This will all require validation in future trials. We await the results of ongoing randomized trials to further inform us. A one-size-fits-all approach may be short-sighted; we may need to decide treatment strategy based on the notion of the right surgical approach for the right patient by the right surgeon.

Prognostic implications of surgical specimen quality on the oncological outcomes of open and laparoscopic surgery in mid and low rectal cancer

PurposeDetermine differences in pathologic outcomes between laparoscopic (LAP) and open surgery (OPEN) for mid and low rectal cancer and its influence in long-term oncological outcomes.MethodsRetrospective case matched study at a tertiary institution. Adults with rectal cancer below 12 cm from the anal verge operated between January 2005 and September 2018 were included. Primary outcomes were quality of specimen, overall survival (OS), disease-free survival (DFS), and local recurrence (LR).ResultsThe study included 311 patients, LAP = 108 (34.7%), OPEN = 203 (65,3%). A successful resection was accomplished in 81% of the LAP group and in 84.5% of the OPEN (p = 0.505). No differences in free distal margin (LAP = 100%, OPEN = 97.5%; p = 0.156) or circumferential resection margin (LAP = 95.2%, OPEN = 93.2%; p = 0.603) were observed. However, mesorectum quality was incomplete in 16.2% for LAP and in 8.1% for OPEN (p = 0.048). OS was 91.1% for LAP and 81.1% for OPEN (p = 0.360). DFS was 81.4% for LAP and 77.5% for OPEN (p = 0.923). Overall, LR was 2.3% without differences between groups.ConclusionsLaparoscopic approach could affect the quality of surgical specimen due to technical aspects. However, if principles of surgical oncology are respected, minor pathologic differences in the quality of the mesorectum may not influence on the long-term oncologic outcomes.

Internal hemipelvectomy with ischiectomy, partial acetabulectomy, and femoral head and neck excision in a cat with a pelvic osteochondroma

A 2-year-old 5.1-kg (11.2-lb) castrated male Siberian cat was examined because of a history of an abnormal right pelvic limb gait and a 4- to 5-month history of progressive constipation. Radiographs obtained by the referring veterinarian showed an osteoproductive and osteolytic bony lesion that involved the right ischium and filled the obturator foramen. A hard mass was palpable in the right inguinal area, and rectal examination revealed a smooth bony mass on the ventral aspect of the right pelvic floor with marked reduction in the pelvic canal space. A 3.9 × 3 × 4.6-cm, mineralized mass bridging the right obturator foramen was present on CT images. The ventral component of the mass was slightly larger than its dorsal component, and lysis of the right pubic bone was present. There was no obvious soft tissue involvement. A limb salvage procedure involving internal hemipelvectomy with ipsilateral ischiectomy, contralateral partial ischiectomy, ipsilateral partial acetabulectomy, and femoral head and neck excision was performed. Histologic examination revealed that the mass was an osteochondroma. The cat recovered well and had good functional limb use immediately after surgery. The cat was still alive 1 year after surgery with good limb use. Internal hemipelvectomy involving ischiectomy, partial acetabulectomy, and femoral head and neck excision can result in a good functional outcome in cats if the procedure is planned appropriately with a full understanding of the regional anatomy and adherence to surgical oncologic principles.

Design, implementation, and assessment of an online-based oncology education program for medical students: An ASCO Oncology Student Interest Group initiative.

11024 Background: Undergraduate medical education in oncology is often fragmented and non-standardized among medical schools (BMC Med Educ 17:100, 2017). Oncology education initiatives are thus critically needed to increase cancer awareness and improve medical students’ understanding of the principles and multidisciplinary approach of oncology. We designed and implemented an online education program with the aim of providing medical students with an early exposure to the field of oncology. Our program was adapted from the Australian Ideal Oncology Curriculum for Medical Schools and included six sessions covering the basics of cancer biology, prevention and screening, diagnosis and patient management, principles of treatment modalities, principles of surgical oncology, as well as counselling and communications skills. Methods: Medical students at our institution were invited to participate. We also invited medical students from other faculties via the support of student groups namely the nation’s medical student union and our ASCO Oncology Student Interest Group (OSIG). Invitations were sent by email and/or via social media along with a brochure outlining the conference’s program and instructions to use the Zoom platform. Students were asked to voluntarily fill online pre- and post-conference anonymous surveys. Students self-assessed their competency, personal attributes, future career aspirations, and provided an evaluation of the program. A five-point Likert scale was used for most questions, in which 1 indicated strong disagreement and 5 indicated strong agreement with the statement. Results: Nearly 300 students from over 50 medical schools in Turkey attended the live program. Only students (n = 228) who completed both the pre- and post-conference surveys were included in our study. ASCO OSIG members made up 24.1% (n = 55) of the students. Among the participants, 73.7% (n = 168) were preclinical students (years 1-3) and 26.3% (n = 60) were clinical students (years 4-6). Students’ overall self-reported rating of their knowledge significantly improved in each of the six sessions, with the greatest pre-post difference observed for diagnosis and patient management (2.51 ± 1 vs 3.87 ± 0.81) followed by principles of treatment modalities (2.54 ± 0.96 vs 3.79 ± 0.88), P &lt; 0.001. Most students believed the program was beneficial in improving their current understanding of oncology with a mean of 4.43 ± 0.76. Most students (92.5%) were “likely” or “very likely” to recommend the program to their colleagues. Conclusions: Students’ evaluation of the online oncology program demonstrated significant benefit and knowledge improvement. Our successfully piloted teaching model of oncology for medical students can be adapted and implemented at medical schools globally. Further development and continuation of our educational initiative is undergoing.

Surgical Neuropelviology: Combined Sacral Plexus Neurolysis and Laparoscopic Laterally Extended Endopelvic Resection in Deep Lateral Pelvic Endometriosis

Surgical demonstration of combined sacral plexus neurolysis and laparoscopic laterally extended endopelvic resection for deep lateral infiltrating endometriosis. Video showing principles of neurolysis and laparoscopic laterally extended endopelvic resection applied to endometriotic surgery. University tertiary referral center. Deep infiltrating endometriosis is an underestimated disease with real medical and clinical issues, recently classified as central pelvic endometriosis and lateral pelvic endometriosis further divided into superficial and deep according to the structures' involvement [1]. The surgical removal of endometriotic foci remains the standard treatment. A wide knowledge of neuroanatomy and high skills in minimally invasive surgery are required to manage this challenging surgical scenario [2]. New surgical approach for deep lateral infiltrating endometriosis based on the principles of lateral extended endopelvic resection and neuropelviologic surgery [3,4]. The patient was a 35-year-old woman, para 1, with neuropathic pain radiating to the left leg and a cyclic menstrual disorder. A laparoscopically assisted neuronavigation and subsequent neurolysis allowed the identification of the lateral nodule without damage to the autonomic pelvic innervation [1]. Then, a complete resection of the internal vascular compartment was required to obtain a radical endometriotic eradication. Shaving and bladder resection were also performed to complete removal of the endometriotic foci. The association of neuroanatomic knowledge and surgical oncologic principles applied to minimally invasive surgery should be considered to ensure an adequate surgical radicality and clinical benefit in patients with deep infiltrating endometriosis.

How to make a vaginal cuff before laparoscopic radical hysterectomy

One of the basic principles of surgical oncology is to avoid spilling active tumor cells in a healthy potential host area. A striking demonstration of this principle is available in...

Minimally-invasive Right Hepatectomy for Perihilar Cholangiocarcinoma.

The magnification of images provided by minimally-invasive surgery (MIS) allows a very sharp and precise dissection of the hepatic hilum, allowing to overcome the technical complexity of surgery of perihilar cholangiocarcinoma (PHC). Recently, the feasibility and reproducibility of MIS for PHC are reported: within centers with adequate expertise and respecting the cornerstones of oncological adequacy, it provides short term advantages in a selected population of patients. The video reports the case of a patient with PHC involving the right biliary duct and requiring right hepatectomy with biliary confluence and segment 1 resection, with associated lymphadenectomy. Current evidences, together with feasibility and reproducibility of the technique shown in this video, appear promising and constitute a good prerequisite for the further implementation of this approach to improve patients outcome while following the principles of surgical oncology in hilar cholangiocarcinoma.

A Simulated Tumor for Teaching Principles of Surgical Oncology for Biopsy and Excision of Skin and Subcutaneous Masses to Veterinary Students.

Tumors of the skin and subcutaneous tissues are commonly encountered in primary care practice. The most common of these tumors are mast cell tumors and soft tissue sarcomas, for which the primary treatment is most often surgical excision. Understanding surgical margins, particularly the deep fascial plane, can be difficult for veterinary students. Current techniques to teach these concepts typically rely on cadaver-based laboratories, which require simulated tumors to improve the realism of the laboratory. Tumors can be difficult to replicate in cadaver laboratories; thus a new technique for a simulated tumor was developed. A gelatin-based simulated tumor was injected into the subcutaneous space in two different sites in canine cadavers. Students then practiced incisional biopsy and wide excision of a subcutaneous mass. Students were able to appropriately perform both techniques using the simulated tumors. When the deep margin was not clean on the wide excision, students were able to understand the error by identifying the simulated tumor, reinforcing the concept of obtaining an appropriate deep fascial plane. In summary, this gelatin-based simulated tumor technique was cost-effective, easy to perform, and effective for the teaching laboratory.