Radical Ablative Surgery Research Articles

Localized operable soft tissue sarcoma of the upper extremity. Presentation, management, and factors affecting local recurrence in 108 patients.

Radical ablative surgery for upper extremity sarcoma often results in significant loss of function. With the recent emphasis on limb preservation, function-sparing excision has been combined with adjuvant radiation and chemotherapy in an increasing number of patients. To assess the effect of changing management on local recurrence rates and identify factors governing local failure, the records of 108 patients with operable, nonmetastatic soft tissue sarcoma of the upper extremity, treated at the Memorial Sloan-Kettering Cancer Center between 1968 and 1978, were reviewed. Median follow-up care was 8.2 years. One third of the patients presented with locally recurrent tumors after initial treatment elsewhere. Over half of the lesions were above the elbow and 62% were high grade. Seventy-three patients (68%) had limb-sparing surgery (LSS), but margins were considered adequate in less than half. Local recurrence was directly related to the adequacy of the surgical margins and was significantly higher in the LSS patients (p = 0.008). Other factors associated with an increased risk of local failure included: presentation with local recurrence, superficial location, and invasion of vital structures (LSS only). Local failure varied significantly with histologic type and was highest in patients with embryonal rhabdomyosarcoma and angiosarcoma. When the data were subjected to multivariate analysis, the following variables emerged as independent predictors of local failure: presentation with local recurrence, surgery by LSS, inadequate margins, angiosarcoma, and invasion of vital structures. These risk factors should be carefully weighed when selecting local treatment for patients with upper extremity soft tissue sarcomas.

Value of computerized tomography and ultrasonography in the preoperative diagnosis of renal cell carcinoma extending into the inferior vena cava.

During a 15-year period, 34 patients with renal cell carcinoma extending into the inferior vena cava were submitted to radical ablative surgery at our institution. 8 patients had caval tumor thrombus (TT) extension at the level of the renal veins, 17 had infrahepatic, 8 retrohepatic and 1 atrial TT extension. Cavography, computerized tomography (CT) and ultrasonography (US) were performed preoperatively on 34, 24 and 16 of these 34 patients, respectively. The sensitivity of the techniques used in diagnosing caval involvement was 100, 97 and 87.5% for US, cavography and CT, respectively. The upper limits of TT were clearly detected by US, CT and cavography in 100, 95 and 76% of diagnosed cases, respectively. From this study it appears that US and CT have a sensitivity comparable to cavography in the detection of caval TT. However, US and CT allow a more precise delineation of the upper limits of TT if compared to cavography. This implies that the role of cavography in diagnosing caval TT and its upper limits must be reappraised in light of the progress of noninvasive outpatient procedures.

Cysts Containing Renal Cell Carcinoma in Von Hippel-Lindau Disease

We report on a patient with von Hippel-Lindau disease. Exploration revealed 15 solid tumors and 18 cysts filled with clear fluid throughout both kidneys. All solid tumors consisted of clear cells consistent with renal cell carcinoma. All cysts were lined with similar clear cells. The solid tumors contained areas of clear cells surrounding small cystic spaces and the large cysts appeared to be an exaggeration of this phenomenon. There is a place for radical ablative surgery in patients with multiple renal cell carcinomas in von Hippel-Landau disease. Unroofing and gross examination of apparently simple cysts may not be adequate to rule out the presence of carcinoma in these patients.

Immunomodulators in the immunotherapy of cancer and other diseases

interest in new approaches to the immunotherapy of canLer has led to the commercial development of several biological substances such as interferon and the thymic hormones and also rn the chemical synthesis of a numher of defined compounds having immunomodulatoty propetties. These immunomodulating agents have in turn been applied expcrimcw tally to a variety of other disease states. including acute and chronic viral and bat terial infections, immunodefciencies and collagen disorders. This ‘prohos. form of therapy has as its primary tberdpeutic objec- tive the auginentation of cellular immune response and consequently the improve ment of a particular disease state. The initial therapeutic effr rts have been sufficiently successful to indicate that growth in this area of ‘biological response mod&atWwiUcontinueatampidrate. f this growth is to be effective in delivering well-applied and safe immunotherapeutic agents to the clinical setting. there will have to be developed a basic, preclinical and clinical science of therapeutic immune rep ulation. The intmduction of immunologically active substances into cancer immunotherapy was plrmised on the notions that human cancers develop within the framework of immunodeticiency or at least of defective immune surveillence and that human tumors Kc. antigenic and. if reacted to by a 4mulated immune system. they would regress or. at least. perhaps not recur so frequently following their removal by surgery, chemotherapy or radio&empy. The initial enthusiasm over the develop men1 of this type of therapy tended to ex- aggerate expectations of a ‘silver bullel’ cure. The last IO years have ptnduced a nzasonable interpretation of the n’alities of the circumstance. It is apparent that cancer. in general, is associated with immunoleficiency which IS progrc~v. with the stage of diwase and compounded by immunosuppression associated u ith other therapies. particularly combmed chemotherapy. Most of the tests of immunrcompetence that were employed to define these deficiencies were developed for congenital immuttodef~iency. and thus looked for the lack of a cell population. of an immunoglobulin class or of a corn plemenr component. It is apparent that the more perceptive tests of immune dysfunc- tion in cancer are those Hhich looked for dysfunction or suppression. As a resu!: of our experience uith the immunological tests which were most effective in detecung the immune disturbances in cancer. onI> recently have UT hen able to perceive con- sistent effects .>f immunotherap> on the immune system itself. The clinical responses to immunothcmpy have almost exclusively been obscrvcd within the context of adjunctive therap). that is, the immunothrmp). ia applied fol- lowing radical ablative therdpy uith surgery. drugs or radiation. In order for the immunotherdpy to have

A New Concept in the Management of Marjolinʼs Ulcers

Marjolin's ulcers have a grave prognosis, especially when regional nodes are involved. Recent studies suggest such cancers are in an immunologically privileges sites due to the dense scar tissue. The prognosis has been shown to be much worse for tumors not having a round cell infiltrate prior to surgery, as in Marjolin's ulcers. The use of topical 5-fluorouracil (5-FU) induces a round cell infiltrate. Three case reports of large Marjolin's ulcers are presented which were first treated with topical 5-FU. Radical ablative surgery was avoided in these patients with a successful outcome.

The sternocleidomastoid muscle flap.

The sternocleidomastoid muscle has significant application in the head and neck following radical ablative surgery about the mandible, face, and oral cavity. It can be used in the following ways to rehabilitate the paralyzed face, to correct a soft-tissue defect about the upper neck and oral cavity, and to protect the major arteries in the head and neck. (a) It may be transposed with a segment of the clavicle and/or sternum as a composite pedicle flap for reconstruction of the mandible. (b) It may be transposed into the lower cheek and jaw to reconstruct a mandibular defect. (c) It may be transposed into the anterior floor of the mouth as a myocutaneous flap following major ablative surgery to assist in correcting the defect and rehabilitating the oral cavity. (d) It may assist in facial paralysis to reanimate the lower third of the face. (e) It may be used to reinforce a suture line and protect the carotid and innominate arteries. (f) It may assist in shoulder elevation following poliomyelitis when transposed to the acromial process of the clavicle.

Lymphangiosarcoma arising in chronic lymphedematous extremities.

Data from 23 cases of lymphangiosarcoma associated with chronic lymphedema seen at the Mayo Clinic and 163 cases from the world literature are reviewed. The available information in 162 cases of postmastectomy lymphedematous lymphangiosarcoma revealed that the lesion occurred at an average age of 63.9 years (range 44 to 84 years) and an average of 10 years 3 months after mastectomy. Fifty per cent of the 129 patients eligible for follow-up were dead within 19 months after treatment, and only 11 patients have survived 5 years or more. Amputation gave a slightly better prognosis than did radiation therapy. Of 24 patients (two from the Mayo Clinic) with lymphangiosarcoma and non-postmastectomy lymphedema, 12 (50%) were dead within 34 months after treatment. Only two of the patients were long-term survivors (5 and 15 years), and both were treated by amputation. Early recognition of the lesion and prompt radical ablative surgery seem to offer the best chance for survival.

Sarcomata of the Osteogenic Series (Osteosarcoma, Fibrosarcoma, Chondrosarcoma, Parosteal Osteogenic Sarcoma, and Sarcomata Arising in Abnormal Bone)

Osteogenic sarcoma is a convenient and generically correct designation for all skeletal conective-tissue neoplasms of mesenchymal origin including: osteosarcoma, chondrosarcoma, fibrosarcoma, parosteal osteogenic sarcoma, and osteogenic sarcomata arising in Paget's disease, irradiated bone, Osteochondroma, fibrous dysplasia, or other bone disease. This report is summary of the clinical, histopathological, and roentgenographic findings, and of the treatment and end-results of treatment in 552 cases of osteogenic sarcoma. Factors which have no influence on prognosis are age, sex, bone of origin, trauma, and the occurrence of fracture. Factors which do influence prognosis include: histological type of sarcoma, tumor size, preoperative and postoperative serum alkaline Phosphatase elevations, lymph-node involvement, and treatment. Absolute five-year survival figures varied from 0.0 per cent for osteogenic sarcoma arising in Paget's disease to 82 per cent for parosteal osteogenic sarcoma; the figures for the other types were as follows: osteosarcoma, 13.2 per cent; chondrosarcoma, 28.1 per cent; fibrosarcoma, 31.7 per cent; and secondary chondrosarcoma, 67 per cent. Only in chondrosarcoma did grading correlate with prognosis; the patients with low-grade and medium-grade chondrosarcoma having considerably better survival rates than those with high-grade tumors. The incidence of late failures (patients dying of sarcoma more than five years after diagnosis) showed an inverse relationship to five-year survival. Prognosis varied directly with tumnor size, and no patient with an osteosarcoma or fibrosarcoma greater than 15.0 centimeters in greatest dimension was cured. When examination of the surgical specimen revealed lymph-node metastases, the outcome was always fatal. Radical ablative surgery is the only curative therapy for osteogenic sarcoma. Irradiation as the sole therapy did not cure a single patient. Preoperative irradiation followed by radical ablative surgical therapy was attended by a worse prognosis than surgery alone. Two patients with unilateral lung metastasis were cured by lobectomy. Adjuvant chemotherapy by perfusion administered prior to radical ablative surgery might be considered for future investigative protocols.