Radical Surgical Therapy Research Articles

Long-term Experience With Bacillus Calmette-Guerin Therapy of Upper Urinary Tract Transitional Cell Carcinoma in Patients Not Eligible for Surgery

Carcinoma in situ and urothelial tumors of the upper urinary tract become problematic in cases of bilateral occurrence or solitary kidney. Perfusions with bacillus Calmette-Guerin (BCG) have been reported beneficial, however, only long-term results will determine the validity of this treatment. We retrospectively evaluated the results of BCG therapy for upper urinary tract disease in 37 patients. All 37 patients had undergone previous surgical treatment for urothelial cancer, had a positive cytology or biopsy for upper urinary tract cancer and were ineligible for radical nephroureterectomy with a bladder cuff. After placement of a 10Fr nephrostomy tube with the patient under local anesthesia 6 weekly perfusions of BCG were administered after radiological documentation of unhindered flow from the renal pelvis to the bladder or urinary diversion. A total of 25 renal units were treated with curative intent for carcinoma in situ and 16 renal units were treated for Ta or higher urothelial tumors in an adjuvant setting after endoscopic resection. In 37 patients 41 renal units were treated with BCG perfusions and were followed for a median of 42 months (range 8 to 137). In 1 patient BCG inflammation and in 2 others severe septicemia developed after the first perfusion. There was no tumor seeding along the nephrostomy tract in any patient. BCG perfusion therapy did not alter renal function. Overall median survival was 42 months (range 1 to 137), median recurrence-free survival was 21 months (1 to 137) and progression-free survival was 34 months (1 to 118). Of the 37 patients 14 (38%) died of urothelial cancer, 11 of other causes (29%) and 12 (33%) are alive. BCG perfusion therapy of the upper urinary tract for papillary tumors or carcinoma in situ is a valid treatment option with acceptable side effects for patients not amenable to conventional radical surgical therapy. BCG therapy of upper urinary tract urothelial tumors may prevent patients from requiring dialysis and provides cure in those with carcinoma in situ of the upper urinary tract. In this negatively selected patient population BCG buys time for some but does not provide cure except for carcinoma in situ.

Molecular aspects of bladder cancer III. Prognostic markers of bladder cancer.

The current pathological and clinical parameters provide important prognostic information, yet still have limited ability to predict the true malignant potential of most bladder tumors. In the last years, investigation of the basic mechanisms involved in carcinogenesis and tumor progression by molecular biology has provided a host of markers which are of potential diagnostic or prognostic value for bladder carcinoma. These markers may serve as tools for early and accurate prediction of tumor recurrence, progression and development of metastases and for prediction of response to therapy. The precise prediction of tumor biological behavior would facilitate treatment selection for patients who may benefit from radical surgical treatment or adjuvant therapy. We provide a current, comprehensive review of the literature on bladder tumor markers with a special emphasis on their prognostic potential. The literature suggests that currently no single marker is able to accurately predict the clinical course of bladder tumors and thus would serve as a reliable prognosticator. A combination of prognostic markers could predict which superficial tumors need an aggressive form of therapy and which invasive tumors require adjuvant therapy. Altogether, the most promising markers are, at this point, Ki-67 and p53 expression as well as matrixmetalloproteinase complex and angiogenesis.

Radical surgical therapy of abdominal cystic hydatid disease: factors of recurrence.

A series of 74 consecutive patients (48 women, 26 men) were operated for abdominal hydatid disease between June 1949 and December 1995. The patients ranged in age from 15 to 81 years (median 49 years). In 69 cases only the liver was affected; two patients had concomitant extrahepatic disease (one spleen, one spleen and lung), and 3 had cysts in the spleen only. Cysts were multiple in 11 patients and calcified in 24. Conservative surgical procedures were used for 22 cysts in 20 patients [open partial (n = 3), open total (n = 6), closed total cystectomy (n = 9), marsupialization (n = 2), drainage (n = 2)] and radical surgical procedures for 72 cysts in 54 patients [pericystectomy (n = 41), wedge liver resection or hemihepatectomy (n = 25), splenectomy (n = 5), radical resection of a lung cyst (n = 1)]. Altogether 37 patients (50%) were given perioperative antihelmintic chemotherapy with mebendazole (18 patients) or albendazole (19 patients). Operative mortality rates were 5.0% after conservative surgery and 1.8% after radical surgery. Morbidity rates were 25.0% following conservative surgery and 24.1% following radical surgery. Antihelmintic therapy was well tolerated by all but five patients. All side effects were entirely reversible. Among the 74 patients, 60 (81.0%) were available for long-term follow-up (median 7.2 years; range 2.0-47.0 years). Recurrence of disease was seen in 9 of 60 patients at an interval of 3 months to 20 years from the first operation. The rate of recurrence was significantly lower after radical surgical procedures (p = 0.03) and after closed removal of the cyst (p = 0.04).

165 Radical surgical resection and high dose intra-operative radiation therapy (HDR-IORT) in patients with recurrent gynecologic cancers

165 Radical surgical resection and high dose intra-operative radiation therapy (HDR-IORT) in patients with recurrent gynecologic cancers

Seltene Komplikationen nach erweiterter Tumorchirurgie beim Ovarialkarzinom: Chylaskos und Postsplenektomie-Sepsis

chylascos with legion of cisterna chyli or ductus thoracicus is an uncommon complication after radical surgical therapy of ovarian cancer. Typically patients show milky coloured seroma from abdominal drain or ascites. Treatment consists of conservative management or surgery. Most important is a low fat diet and medium chain triglycerides (mct). A case of chylascos after paraaortic lymphnode dissection in second-line surgical therapy of advanced ovarian cancer is reported to discuss this rare complication and the different options for treatment. Asplenic sepsis or overwhelming postsplenectomy infection (OPSI) is a rare complication in radical surgery of advanced cancer disease. The risk of life-threatening infection after splenectomy, mainly caused by pneumococcus, is increased life-long. Vaccination against pneumococcal infection should be done in all patients, possibly before operation, if splenectomy is planned preoperatively. Vaccination must be done postoperatively, if splenectomy is necessary for debulking procedure, or because of injury of the spleen. Patients must be informed about life-long increased risk of infection. Antibiotics are immediately necessary if signs of infection occur. An asplenic sepsis with death of the patient is described and the risk of splenectomy discussed.

Diagnosis and therapy of cervical squamous epithelial carcinomas

The clinical management of cervical carcinomas is solely based upon the FIGO-staging system. Therefore clinical staging is crucial for primary therapy of cervical carcinomas. Accurate morphologic evaluation of the surgical specimens completes the clinical staging and determines postoperative procedures and the individual prognosis. The most important morphologic prognostic factors include stromal invasion, vascular space involvement, tumor volume and surgical margins (pelvic recurrence, metastasic dissemination, survival). The prognostic and therapeutic importance of tumor biological markers is presently controversial. Radical surgical therapy (Wertheim-Meigs surgery) and primary or adjuvant pelvic radiation are currently the basic therapeutic modalities for invasive cervical carcinomas. The role of chemotherapy still needs to be defined. A less radical therapeutic approach is performed for microinvasive cervical carcinomas depending on the extent of stromal invasion, the presence of vascular space involvement and the surgical margins.

Skull Base Chordomas

Because of their critical location, invasive nature, and aggressive recurrence, skull base chordomas are challenging and, at times, frustrating tumors to treat. Both radical surgical removal and high-dose radiation therapy, particularly proton beam therapy, reportedly are effective in tumor control and improve survival rates. The authors posit that these tumors are best treated with radical surgery and proton-photon beam therapy. During the last 5 years, they treated 25 patients (15 females and 10 males) who harbored pathologically diagnosed skull base chordomas. The mean age of the patients was 38.4 years (range 8-61 years). Previous surgery or radiation therapy was performed at other institutions in seven and two patients, respectively. The authors performed 33 surgical procedures on 23 patients. Radical removal (defined as absence of residual tumor on operative inspection and postoperative imaging) was achieved in 10 patients; subtotal resection (defined as resection of > 90% of the tumor) was achieved in 11 patients; and partial resection (defined as resection of < 90% of the tumor) was achieved in two patients. Radical surgical removal included not only the excision of soft-tumor tissue, but also extensive drilling of the adjacent bone. Adjuvant therapy consisted of postoperative combined proton-photon beam therapy (given to 17 patients and planned for one patient) and conventional radiation therapy (two patients); three patients received no adjunct therapy. To date, four patients have died. One patient who had undergone previous surgery and sacrifice of the internal carotid artery died postoperatively from a massive stroke; one patient died from adenocarcinoma of the pancreas without evidence of recurrence; and two patients died at 25 and 39 months of recurrent tumor. Permanent neurological complications included third cranial nerve palsy (one patient) and hemianopsia (one patient); radiation necrosis occurred in three patients. Of the 21 patients followed for more than 3 months after surgery, 16 have had no evidence of recurrence and five (including the two mortalities noted above) have had recurrent tumors (four diagnosed clinically and one radiologically). The mean disease-free interval was 14.4 months. A longer follow-up period will, hopefully, support the early indication that radical surgical removal and postoperative proton-photon beam therapy is an efficacious treatment. The use of skull base approaches based on the tumor classification introduced in this paper is associated with low mortality and morbidity rates.

Quality of life of patients with renal cell carcinoma or prostate cancer after radical surgery.

To study the impact of radical tumour surgery in prostate and renal cell cancer patients on quality of life (QOL). In 38 male patients suffering from organ-confined prostate or renal cell cancer, a prospective study was performed. For the evaluation of QOL, we used the EMPK (Erfassung multipler psychischer Konstrukte). Urologic symptoms were evaluated with a specially designed symptom score. The test instrument was filled out the day before surgery and one year after operation. The EMPK was able to detect and describe significant changes in certain aspects of QOL in renal cell cancer and prostate cancer patients. Moreover, there seems to be a difference between the two groups. A direct relation between QOL and the different quality and quantity of operation-related symptoms, however, could not be proven. In this pilot study, radical surgical therapy did not significantly change QOL in prostate cancer patients, but seemed to have a positive influence on the QOL of renal cell cancer patients.

Merkel Cell Carcinoma of the Eyelid

To demonstrate the clinical variability and histologic characteristics of Merkel cell carcinoma of the eyelid. We investigated two cases of Merkel cell carcinoma of the eyelid in a 67-year-old man and an 83-year-old woman, respectively. Both lesions were initially misdiagnosed as benign tumors on clinical examination. After the correct diagnosis was made, both lesions were treated with wide resection aided by frozen sections, and reconstructive surgery. Merkel cell carcinoma is an aggressive tumor with variable clinical manifestation. Radical surgical therapy and close follow-up are indicated.

Wide Perineal Dissection and Its Effect on Local Recurrence Following Potentially Curative Abdominoperineal Resection for Rectal Adenocarcinoma

Ninety-three patients underwent a potentially curative abdominoperineal resection (APR) with a wide perineal dissection to the ischial tuberosities and excision of the entire mesorectum. There were 56 males and 37 females. The median follow-up was 67 months (range 7-240 months). The lymph node clearing technique was used and the median number of lymph nodes cleared was 35 (range 6-89). Eighteen of 93 patients (19%) developed a local recurrence, 12 of whom (13%) developed local recurrence only as the first site of recurrence. In 10 of 18 patients (56%) the distal rectum was the site of the primary rectal cancer. Of the 18 patients, 1 patient had stage I disease, 5 stage II, and 12 stage III. Five of the 18 patients (28%) who developed a local recurrence received adjuvant therapy. The median survival from the time of diagnosis of a local recurrence was 12 months. Histological grade (p=.001), patient age (p=.006), and presence of positive lymph nodes (p=.005) had a statistically significant adverse effect on survival. We believe the surgical technique of abdominoperineal resection with wide perineal resection to the ischial tuberosities and total excision of the mesorectum allowed us to achieve a low local recurrence rate (13%) in a high-risk group of patients. Clearly, the best form of prevention for local recurrence from rectal adenocarcinoma is radical surgical therapy of the primary tumor.

Identification of a Low-Risk Subset of Patients with Stage IB Invasive Squamous Cancer of the Cervix Possibly Suited to Less Radical Surgical Treatment

Because of the well-documented morbidity of radical hysterectomy, it would appear desirable to isolate a subset of patients at low risk of parametrial spread or disease recurrence who might thereby be candidates for less radical surgical therapy. To this end, the records of all patients undergoing radical hysterectomy for cervical carcinoma at our institution between 1956 and 1985 were reviewed. Of the 387 patients treated for squamous carcinoma clinically confined to the cervix, 83 (21.4%) had tumors with depth of invasion greater than 3 mm (stage IB) but volume of tumor less than or equal to that of a sphere 2 cm in diameter (4.19 cm3) and no tumor in angiolymphatic spaces. Of the 83 patients, none had parametrial nodal metastasis. Median follow-up of this subgroup was 9.8 years, and the Kaplan-Meier estimate of 5-year disease-free survival was 97.6% (95% confidence interval, 94.3-100%). We consider patients in the subset described above to be candidates for modified radical hysterectomy and pelvic lymphadenectomy, with a decrease in morbidity associated with the less radical dissection, a low risk of failure to excise occult parametrial tumor, and the expectation of an excellent chance of long-term disease-free survival.

Ｂｏｗｅｎｏｉｄ ｐａｐｕｌｏｓｉｓから有きょく細胞癌を発症した１症例

Bowenoid papulosis is clinically characterized by multiple, brown-black papules and plaques, occurring primarily on the genitalia of young adults, almost all under the age 40. The histologic appearance of Bowenoid papulosis is squamous cell carcinoma in situ similar to Bowen's disease. There is a broad consensus in the literature that Bowenoid papulosis is induced by human papilomavirus.It has been documented that the lesions have a tendency toward spontaneous regression, however, the lesions herein reported developed into invasive squamous cell carcinoma.The patient was a 27-year-old woman who had been Bowenoid papulosis on genitalia and bottock since she had been 13. The lesions had been treated by conservative therapy. The lesions developed invasive squamous cell carcinoma on buttock and therefore radical surgical therapy including rectal resection had to be done. We detected human papilomavirus-16 from both brown-black papules of Bowenoid papulosis and hyperkeratotic reddish tumor of squamous cell carcinoma in the method of polymerase chain reaction. We must notice Bowenoid papulosis can develope invasive squamous cell carcinoma.

Liposarcoma: Report of a case and review of the literature

Liposarcoma of the head and neck region is extremely rare. An additional case of pleomorphic liposarcoma of the buccal mucosa is reported, representing an even rarer combination. The importance of combined radiation and radical surgical therapy as a means of improving survival is emphasized.

Quantitative electron microscopic study on grades of atypia in adenomas of the human large bowel.

Clarification of the ultrastructural features of the three different grades of histologic atypia of adenomas (i.e., mild, moderate, and severe atypia) with reference to carcinoma of the human colon and rectum was undertaken using electron microscopic quantitative analysis. Ten normal epithelia, 36 adenomas (14 with mild atypia, 13 with moderate atypia, and 9 with severe atypia) and 14 carcinomas (well-differentiated adenocarcinoma) were examined with light and electron microscopes. Although it has been generally accepted that malignant transformation of an adenoma gradually proceeds with increasing atypia, using light microscopy, ultrastructural quantitative analysis clearly revealed that fine features of individual atypia did not correspond with histologic grades of atypia. Ultrastructural changes occurred abruptly in moderate atypia and showed similar cellular characteristics to carcinoma cells. Mild atypia was almost similar in appearance to normal epithelial cells. Striking changes in the moderate atypic cells were plane apposition of the cell membrane, decrease of the desmosomes, and increase of the lysosomes. These atypical cells were assumed to play a significant role in the adenoma-carcinoma sequence. Therefore, radical surgical therapy would be required for moderate atypic adenoma of the large bowel that is difficult to remove endoscopically.

Das drackgeschwür bei querschnittgelähmten — eine vergleichende klinisch-histologische untersuchung

331 pressure sores of 141 patients with paraplegia were investigated histologically, the results were partly correlated with the roentgenological features. The level of the spinal cord lesion was the segment Th12-L1 in 45%, the decubital ulcers were mostly localized above the os ischiadicum (64%). A pseudocancerosis was diagnosed in 14.2%, one time a cancer in a sacral decubitus has been found. The inflammation was limited to the soft tissue in 56.9%, in 28.5% a chronic osteomyelitis of different severity had developed. In 73.6% of the patients with a histologically proven osteomyelitis this osteomyelitis could be diagnosed roentgenologically too. The high amount and severity of the dermal and bony lesions justifies the radical surgical therapy of the pressure sores, which is practised today. Our investigations of chronic pressure sores did not point out new aspects of aetiology of pathogenesis--this is only possible by experimental models.

Potential for improvement in radiation therapy

A successful strategy for improving the efficacy of radiation therapy has been to improve dose distribution, that is, reduce treatment volume toward target volume. This is so as the smaller treatment volume has permitted a higher dose to the target (hence a high tumor control probability) and a lesser volume of non-target tissues being irradiated (consequently a reduced frequency and severity of treatment related morbidity). There are in place several important means for further improvements in dose distributions. These include: (a) 3D graphic reconstruction of the affected part with definition of the position of the tumor vis-a-vis the adjacent normal structures; (b) explicit inclusion in the treatment plan of the uncertainty band around each isodose contour; (c) on-line contrast enhanced visual monitoring of the target tissue during the individual treatment session; (d) gating of treatment so as to reduce the impact of patient motion on the needed treatment volume; (e) use of computer control systems to execute the treatment; and (f) use of treatment methods which achieve a reduced treatment volume. In an examination for sites for which treatment volumes might be decreased by a substantial factor we have compared treatment volumes for radical surgical and radiation therapy. Results are presented for carcinomas of the cervix (Stage III), breast (Stage II), floor of mouth (Stage II). We describe a system developed here for on-line visual monitoring of the tissues covered by the treatment field. Brief descriptions are given of results of low LET charged particle radiation therapy and of intraoperative electron beam therapy. Also, the program developed here to use computer graphic techniques to display tumor and normal structures and isodose countours with uncertainty bands around each contour is mentioned.

Laser therapy for T1 glottic carcinoma of the larynx.

We treated 21 previously untreated T1 or tumor in situ squamous cell carcinomas of the true vocal cords by carbon dioxide laser excision. The mean follow-up was 42 months, with a range of 26 to 64 months. Recurrent vocal cord carcinomas, with an average interval to recurrence of 21 months developed in four patients. Three of the four recurrences involved the anterior portion of the true vocal cord, including the anterior commissure. One of the patients with recurrence was treated again with the laser, and the other three underwent radiotherapy. All four patients are alive and have retained their larynges. Laser excision of selected T1 and in situ carcinomas of the true vocal cords is a cost-effective and viable alternative to radiotherapy or more radical surgical therapy.

Primary malignant duodenal tumors.

Fourteen patients with primary malignant duodenal tumors are studied. Twelve patients had adenocarcinomas and two patients had malignant lymphomas. Preoperative diagnostic procedures, such as radiographic study of duodenum with hypotonic duodenography, complete duodenoscopy with biopsy and artertiographic studies are discussed. Early diagnosis is the key for curative surgical treatment since these tumors seem to disseminate rather late. In patients with primary duodenal carcinoma the resectability rate was 66.7%-seven Whipple resections and one segmental resection. Only one patient in our series died after a Whipple resection. There was no mortality after other procedures. The five year survival rate was 14.2%. There is a definite correlation between regional lymph node involvement and survival time. The mean survival period after Whipple resection without lymph node invasion is 56.5 months in our series. The survival period after Whipple resection for adenocarcinoma with regional lymph node invasion (6 months) is identical to the survival after palliative internal derivations for duodenal adenocarcinoma (5.8 months). It is concluded that a positive peroperative frozen section of a regional lymph node should exclude resective procedures (except in patients who hemorrhage) because they have a higher mortality rate as derivative procedures. Fifty per cent of the patients treated for malignant duodenal lymphoma is tumor free two years after a radical surgical therapy combined with chemotherapeutical treatment from the early postoperative period.

Malignant melanoma of the oral cavity

Mucosal malignant melanomas of the oral cavity are rare and the present series comprising 23 patients is one of the largest ever published. The poor prognosis of these tumors appears from the fact that only two of the 23 patients could be presumed to have been treated successfully. The survival time of the 21 patients who died during the follow-up period was short in all but one patient, surviving 35 years after the first symptom of the tumor despite regional lymph node metastases in an early stage of the disease and repeated local recurrences. This indicates the importance of a regular lifelong follow-up and surgical activity concerning local recurrences and regional lymph node metastases. The poor prognosis may be explained by the patients' delay in seeking medical advice, which is stressed by the deep and massive infiltration of the extensive primary lesions as well as by the fact that metastases already were demonstrable in most patients at the first examination. A necessary condition for radical surgical therapy, and therefore an improvement in the very bad prognosis of oral malignant melanomas, is an earlier diagnosis than in the present series. As oral malignant melanomas almost exclusively appear in the palate and superior alveolar process, particular attention must be paid to lumps, ulcerations and pigmented spots occurring in this region.

Lymphoid hyperplasia of the colon.

Of 29 double-contrast colon examinations performed on children, 17 revealed lymphoid hyperplasia which could not be correlated with the patient's symptoms, gastrointestinal bleeding, or polyps. Prominent lymphoid follicles in the submucosa are concluded to be not indicative of a specific disease process. Biopsy proof of the nature of nodular colon disease is essential before radical surgical or medical therapy is contemplated.