Local Surgical Resection Research Articles

Adjuvant or neoadjuvant chemotherapy for NSCLC.

In functionally fit patients with localized disease surgical resection remains the treatment of choice. There is also good evidence to support the use of chemotherapy in stages II-III. However, whether to use neoadjuvant or adjuvant therapy has been the topic of much debate. With its strong evidence base, adjuvant chemotherapy has been adopted in the European Society of Medical Oncology clinical practice guidelines for early and locally advanced stages II-III non-small-cell lung cancer (NSCLC), with consideration of adjuvant therapy in those with stage IB but with tumours >4 cm in size. There are fewer trials comparing neoadjuvant therapy plus surgery with surgery alone. Even less has been carried out directly comparing neoadjuvant with adjuvant therapy. The NATCH trial demonstrated no difference in survival between adjuvant and neoadjuvant arms, whilst others have yet to be completed. Meta-analysis also demonstrates no appreciable difference between the two methods. With such a strong body of evidence, however, postoperative delivery of chemotherapy remains the timing of choice in NSCLC.

P0050 Survival of children with rhabdomyosarcoma: Experience of the National Cancer Institute Egypt

<h3>Background</h3> Survival rates of paediatric rhabdomyosarcoma have improved tremendously during the past decade by the development of risk stratification. This approach has favoured tailoring of treatment using multi-therapeutic modalities. <h3>Methods</h3> Patients were given upfront surgical resection followed by systemic chemotherapy using the vincristine/actinomycin-D/cyclophosphamide (VAC) regimen, with subsequent further local control by surgery or radiotherapy, or both, according to risk stratification into low, intermediate, and high risk groups. <h3>Findings</h3> The study included 40 patients; their median age was 3.5years (range: 8months to 17years), 28 were boys and 12 were girls. 2-year overall survival (OS) and event-free survival (EFS) were 87% and 45% respectively. After univariate analysis, OS was 100% for a complete response versus 92% for only partial response (<i>p</i>=0.03). OS was 94% if there were no distant metastasis versus 66% if metastasis was present (<i>p</i>=0.024). On the other hand, EFS was 88% for complete response versus 46% for partial response (<i>p</i><0.001), and was 80% if upfront surgery was done versus 33% if only simple biopsy was taken (<i>p</i>=0.03). Local radiotherapy versus no radiotherapy was highly associated with EFS, with a difference of 75% versus 0%, respectively (<i>p</i><0.001). <h3>Interpretation</h3> Complete response and extent of disease are two important factors influencing survival in childhood rhabdomyosarcoma. Both local control measures, surgical resection and radiation therapy, and treatment response are important variables predicting EFS. The poor outcome of patients with metastatic disease necessitates further therapeutic approaches to improve survival.

Brain metastasis from ovarian cancer: a systematic review.

To review the existing literature on brain metastasis (BM) from ovarian cancer and to assess the frequency, anatomical, clinical and paraclinical information and factors associated with prognosis. Ovarian cancer is a rare cause of brain metastasis with a recently reported increasing prevalence. Progressive neurologic disability and poor prognosis is common. A comprehensive review on this subject has not been published previously. This systematic literature search used the Pubmed and Yale library. A total of 66 publications were found, 57 of which were used representing 591 patients with BM from ovarian cancer. The median age of the patients was 54.3 years (range 20-81). A majority of patients (57.3 %) had multiple brain lesions. The location of the lesion was cerebellar (30 %), frontal (20 %), parietal (18 %) and occipital (11 %). Extracranial metastasis was present in 49.8 % of cases involving liver (20.7 %), lung (20.4 %), lymph nodes (12.6 %), bones (6.6 %) and pelvic organs (4.3 %). The most common symptoms were weakness (16 %), seizures (11 %), altered mentality (11 %) visual disturbances (9 %) and dizziness (8 %). The interval from diagnosis of breast cancer to BM ranged from 0 to 133 months (median 24 months) and median survival was 8.2 months. Local radiation, surgical resection, stereotactic radiosurgery and medical therapy were used. Factors that significantly increased the survival were younger age at the time of ovarian cancer diagnosis and brain metastasis diagnosis, lower grade of the primary tumor, higher KPS score and multimodality treatment for the brain metastases. Ovarian cancer is a rare cause of brain metastasis. Development of brain metastasis among older patients and lower KPS score correlate with less favorable prognosis. The more prolonged survival after using multimodality treatment for brain metastasis is important due to potential impact on management of brain metastasis in future.

Dermatofibrosarcoma protuberans at an uncommon site.

Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive, cutaneous, malignant tumor characterized by high propensity for local relapse and low metastatic potential. It is seen mainly in the age group of 6-65 years over the trunk and extremities. Immunohistochemically it diagnosed by marker human progenitor cell Ag CD 34. Herein, we present a 40-year-old male with DFSP over the pubic area and extending up to the proximal penile shaft. The biopsy revealed intervening bundles of spindle-shaped cells in the dermis and the diagnostic marker human progenitor cell Ag CD 34 was positive. The patient underwent wide local surgical resection.

English

Cerebriform intradermal nevus is a rare form of cutis verticis gyrata. Clinically it manifests as a scalp deformity resembling the surface of the brain, with cerebriform morphologic characteristics these lesions may become malignant or infected. Here we report a 20 year old boy, with cerebriform and soft fold on right temporo-parietal area present since birth. The clinical and histopathological (solitary or clusters of nevus cells) presentations of cerebriform intradermal nevus are described and the therapeutic possibilities discussed. INTRODUCTION: Cutis verticis gyrata (CVG) is a skin deformity characterized by excessive growth of the skin of the scalp, resulting in furrows and folds which are similar to gyri of the brain cortex. CVG can be classified into two forms: 'primary' (essential and non-essential) and 'secondary'. The primary non-essential type is associated with the neurological and ophthalmological changes, while the primary essential form does not present any other disorder except for the cutaneous alterations. Secondary forms of CVG are much more frequent and accompany other pathologies. The treatment consists of local hygiene and surgical resection of skin excess. Intradermal cerebriform nevus is a rare entity, predominantly affecting females at birth or during the first years of life. The condition usually begins with a macular lesion that develops into parietal and occipital symmetric convolutions, occupying one half to three quarters of the scalp6, 7. It has a growth peak at puberty. The mechanism for the cerebriform pattern on the surface of the intradermal cerebriform nevus is unknown. 12

Wide Excision and Anterolateral Thigh Perforator Flap Reconstruction for Dermatofibrosarcoma Protuberans of the Face

Dermatofibrosarcoma protuberans is a rare cutaneous malignant tumor associated with a high cure rate but with a high incidence of local recurrence. Because of its tentacle-like subcutaneous infiltrating pattern that extends far beyond the clinically visible skin lesion, a wide resection margin is recommended. Hence, its localization to the head-and-neck regions, although rare, represents a real challenge for both the oncologic surgeon and the reconstructive surgeon, who aim to achieve a radical resection of the tumor with the best possible aesthetic outcome.A case of a 21-year-old Mediterranean man who presented with a 7-month history of a slowly growing subcutaneous lesion of the left preauricular region is reported. A diagnosis of dermatofibrosarcoma protuberans CD34+ was confirmed through surgical biopsy, and the patient subsequently underwent a wide en bloc local surgical resection, followed by anterolateral thigh perforator free flap reconstruction. Healing was uneventful. Initially, there was some facial nerve neurapraxia; however, this completely subsided within 3 months after the surgery. At the 13-month follow-up, the patient was completely well and free from the disease.

Radikale Pleurektomie und hypertherme intrathorakale Chemotherapie zur Behandlung pleural metastasierter Thymome

Patients with pleural thymoma spread (Masaoka stage IV a) should be treated within a multimodal treatment regime. However, the extent of local surgical resection to achieve optimal tumour control remains controversial. Prospective analysis between September 2008 and April 2013 of all patients with a Masaoka stage IV a thymoma, who underwent radical pleurectomy/decortication (P/D) followed by hyperthermic intrathoracic chemotherapy (HITHOC). A total of 11 patients (male n = 7; mean age 46.5 ± 11.4 years) with a primary stage IV a thymoma (n = 3) or thymoma with pleural relapse (n = 8) were included after successful transsternal thymoma resection. WHO histological classification was: B1 n = 1, B2 n = 6, B3 n = 3 and C n = 1. A radical P/D (5/11; 45 %) was extended with resection of the pericardium and diaphragm in 6/11 (55 %) patients. After surgical resection (91 % complete macroscopic R0/R1-resection) the HITHOC with cisplatin (100 mg/m2 body surface area (BSA) n = 7; 150 mg/m2 BSA n = 4) was performed for one hour at 42 °C. Operative revision was necessary in two patients (chylo- and hematothorax) with one patient also requiring temporary renal replacement therapy due acute renal failure (cisplatin 150 mg/m2 BSA). 30-day mortality was 0 %. Local recurrence (pulmonary n = 1, paravertebral n = 2) was documented in 3/10 (30 %) patients after R0/R1 resection. After a mean follow-up of 23 months the overall median survival was 27 months and 82 % (9/11) patients are still alive at the end of the study period. Masaoka stage IV a thymoma could be safely treated with lung-sparing radical P/D and HITHOC with cisplatin in a multimodality treatment regime. Early results with respect to recurrence and survival are encouraging, but further studies are warranted and we have to await long-term results.

Impact of Margin Status and Local Recurrence on Soft-Tissue Sarcoma Outcomes

The impact of local recurrence and surgical resection margin status on survival in extremity soft-tissue sarcomas remains to be clearly defined. Our aim was to conduct a retrospective analysis of prospectively collected data to determine the prognostic relevance of positive resection margins and local recurrence for extremity soft-tissue sarcomas for survival. Three hundred and sixty-three patients who underwent resection of localized primary extremity soft-tissue sarcomas with curative intent were selected from the United States Department of Defense Automated Central Tumor Registry. Outcomes for local recurrence, distant recurrence, disease-specific survival, and overall survival were analyzed according to clinical, pathological, and treatment variables with use of the Kaplan-Meier method (log-rank test) and the multivariate Cox regression model. Positive margins (hazard ratio, 1.99 [95% confidence interval, 1.15 to 3.45]), local recurrence (hazard ratio, 2.93 [95% confidence interval, 1.38 to 6.23]), and distant recurrence (hazard ratio, 12.13 [95% confidence interval, 5.97 to 24.65]) were significantly associated with overall survival on multivariate Cox regression analysis. However, for disease-specific survival, local recurrence was not significant and tumor size of >10 cm (hazard ratio, 2.83 [95% confidence interval, 1.15 to 6.95]), positive margins (hazard ratio, 1.95 [95% confidence interval, 1.05 to 3.63]), and distant recurrence (hazard ratio, 9.46 [95% confidence interval, 4.37 to 20.47]) were independent adverse prognostic factors. The disease-specific survival rate for patients with localized soft-tissue sarcomas was 89% (95% confidence interval, 85% to 92%) for five years and 75% (95% confidence interval, 70% to 81%) for ten years. Positive surgical margins are consistently associated with adverse survival-related outcomes in localized soft-tissue sarcomas of the extremity. Local recurrence had a significant impact on overall survival, but not on disease-specific survival.

Treatment Modalities for T1N0 Esophageal Cancers: A Comparative Analysis of Local Therapy Versus Surgical Resection

To investigate the role of nonsurgical treatment for early-stage esophageal cancer, we compared the outcomes of local therapy to esophagectomy, using a large, national database. Five-year cancer-specific and overall survival (OS) of patients, with T1N0M0 squamous cell or adenocarcinoma of the mid or distal esophagus treated with either surgery or local therapy, with ablative and/or excision techniques, in the Surveillance Epidemiology and End Results cancer registry from 1998 to 2008, were compared using the Kaplan-Meier approach, and multivariable and propensity-score adjusted Cox proportional hazard, and competing risk models. Of 1458 patients with T1N0 esophageal cancer, 1204 (83%) had surgery and 254 (17%) had local therapy only. The use of local therapy increased significantly from 8.1% in 1998 to 24.1% in 2008 (p < 0.001). The 5-year OS after local excisional therapy and surgery was not significantly different (55.5% versus 64.1% respectively, p = 0.07), and 5-year cancer-specific survival (CSS) also did not differ (81.7% versus 75.8%, p = 0.10). However, after propensity-score adjustment, CSS was better for patients who underwent local therapy compared with those who underwent surgery (hazard ratio: 0.46, 95% confidence interval: 0.27-0.77, p = 0.003), whereas OS remained similar. The use of local therapy for T1N0 esophageal cancers increased significantly from 1998 to 2008. Compared with those treated with esophagectomy, patients treated with local therapy had similar OS but improved CSS, indicating a higher chance of dying from other causes. Further studies are needed to confirm the oncologic efficacy of local therapy when used in patients whose lifespans are not limited by conditions other than esophageal cancer.

An analysis of 73 cases of pediatric malignant tumors of the thymus

BackgroundTumors of the thymus are very rare in the pediatric population. This study examines the current trends and outcomes of children with thymus tumors. MethodsThe Surveillance, Epidemiology and End Results (SEER) registry was queried for all patients <20 y of age with primary thymic malignancies from 1973 to 2008. ResultsA total of 73 pediatric patients were identified with malignant thymic tumors. The median age at diagnosis was 13 y old. Among the 20 patients that presented with distant disease, 70% died. Conversely, among the 23 patients that presented with locoregional disease, 70% survived. Although the overall mean survival time was 89 ± 116 mo, 45% of patients died over the study period. Patients with Hodgkin lymphomas and germ cell tumors exhibited the highest survival (76% and 60% at 10 y, respectively). Multivariate analysis was used to identify local or regional tumor stage (odds ratio = 4.5, 95% confidence interval = 1.4–14.5) and surgical resection (OR = 3.8, 95% confidence interval = 1.4–10.8) as independent predictors of survival. ConclusionsMalignant thymomas and lymphomas are the most common histological variants of pediatric thymus tumors, and patients with Hodgkin lymphomas exhibit the highest survival. Surgery is more commonly performed on malignant thymomas and is an independent prognostic indicator of survival.

Thymic mucosa-associated lymphoid tissue lymphoma involving lymph nodes

INTRODUCTIONThymic mucosa-associated lymphoid tissue (MALT) lymphoma involving lymph nodes is quite rare with only 13 previous cases reported in the literature. PRESENTATION OF CASEThe 33-years-old female was referred to our department for the investigation of abnormalities on computed tomographic (CT) scans. CT scans showed a 9-cm×3-cm mass composed of a mixture of soft tissue and fat at the anterior mediastinum with lymphadenopathy in the neck, axillary and mediastinal regions. She was underwent complete surgical resection of the mass with regional lymph node dissection through a median sternotomy. Histological examination of the surgical specimens confirmed the diagnosis of MALT lymphoma arising in the thymus with nodal metastasis. She achieved complete remission after postoperative rituximab combined chemotherapy. DISCUSSIONThymic MALT lymphoma occurs most frequently in Asian female aged 40–60 years and commonly appears anterior mediastinal masses on CT scans. The excised tissue is necessary to confirm the accurate histological diagnosis. The disease usually remains localized for a long time, making local surgical resection highly effective. However, when the lymph nodes are involved, effective treatment approaches of the disease is still undefined. CONCLUSIONWe report a case of thymic MALT lymphoma involving lymph nodes, in which the patient was successfully treated with primary site resection with regional lymph node dissection followed by rituximab combined chemotherapy. Surgery provided not only a useful approach for collecting tissue for an accurate histological diagnosis, but also an effective local treatment, even in the case of advanced-stage thymic MALT lymphoma.

Myoepithelial carcinoma inside of maxilla bone: A case report

Myoepithelial carcinoma (MC) is a rare type of carcinoma occurring mainly in the parotid gland, while other carcinomas occur in submandibular or the accessory glands of the oral cavity. They may arise from the glands of the respiratory tract. However, primary MC of the bone is extremely rare. In the present study, a rare case of a 41-year-old woman with MC in the maxilla bone was reported. Following misdiagnosis as a bone cyst, a local excision was performed. The patient then presented with an extremely high malignancy and showed no response to chemoradiation treatment. The bone cyst was thought to be MC, thus early diagnosis with complete surgical excision was highly important. After confirmation of MC, a secondary extensive surgery may be crucial, following the primary local surgical resection.

Postoperative tamoxifen for ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) is a non-invasive carcinoma of the breast. The incidence of DCIS has increased substantially over the last twenty years, largely as a result of the introduction of population-based mammographic screening. The treatment of DCIS tumours involves surgery with or without radiotherapy to prevent recurrent DCIS and invasive carcinoma. However, there is clinical uncertainty as to whether postoperative hormonal treatment (tamoxifen) after surgery confers benefit in overall survival and incidence of recurrent carcinoma. To assess the effects of postoperative tamoxifen in women having local surgical resection of DCIS. We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), the Cochrane Breast Cancer Group's Specialised Register, and the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) on 16 August 2011. Published and unpublished randomised controlled trials (RCTs) and quasi-randomised controlled trials comparing tamoxifen after surgery for DCIS (regardless of oestrogen receptor status), with or without adjuvant radiotherapy. Two authors independently assessed trial quality and extracted data. Statistical analyses were performed using the fixed-effect model and the results were expressed as relative risks (RRs) or hazard ratios (HRs) with 95% confidence intervals (CIs). We included two RCTs involving 3375 women. Tamoxifen after surgery for DCIS reduced recurrence of both ipsilateral (same side) DCIS (HR 0.75; 95% CI 0.61 to 0.92) and contralateral (opposite side) DCIS (RR 0.50; 95% CI 0.28 to 0.87). There was a trend towards decreased ipsilateral invasive cancer (HR 0.79; 95% CI 0.62 to 1.01) and reduced contralateral invasive cancer (RR 0.57; 95% CI 0.39 to 0.83). The number needed to treat in order for tamoxifen to have a protective effect against all breast events is 15. There was no evidence of a difference detected in all cause mortality (RR 1.11; 95% CI 0.89 to 1.39). Only one study, involving 1799 participants followed-up for 163 months (median) reported on adverse events (i.e. toxicity, mood changes, deep vein thrombosis, pulmonary embolism, endometrial cancer) with no significant difference between tamoxifen and placebo groups, but there was a non-significant trend towards more endometrial cancer in the tamoxifen group. While tamoxifen after local excision for DCIS (with or without adjuvant radiotherapy) reduced the risk of recurrent DCIS (in the ipsi- and contralateral breast), it did not reduce the risk of overall mortality.

Abstract 2442: A precise orthotopic rectal tumor model for evaluating therapeutic response of cancer treatment

Abstract We have previously reported a “true” orthotopic rectal model in which tumors start forming in the rectal mucosal tissue from which tumors actually arise. The model was generated by intrarectal transplantation of mouse rectal cancer cells stably expressing fluorescent protein, followed by disrupting the epithelial cell layer of the rectal mucosa by soaking with an acetic acid solution. Early stage tumor was detected on the rectal mucosa from as early as 6 days after transplantation, which then became invasive into the submucosal tissue. The tumor incidence on the rectal mucosa was 100%, and it was proved that this rectal tumor model reflects the natural course of rectal cancer accurately. Spontaneous lymph node metastasis and lung metastasis were observed 4 weeks after transplantation in over 90% of mice. In the present study, we will report whether this model is useful for evaluating therapeutic response of surgical local resection of tumor with combination of anticancer drugs such as a telomerase-specific replicating adenovirus designed for cancer therapy. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2442. doi:1538-7445.AM2012-2442

Leiomyoma of the Trachea

Primary tracheal tumors are rare. Approximately 1% of them are leiomyoma. Given the rarity of these lesions, optimal management has not been defined. Bronchoscopic, local surgical excision and partial tracheal resection have all been described. One report of recurrence after resection has been published. The incidence of recurrence following local excision is unknown. We report a case of an incidental tracheal leiomyoma diagnosed and treated with a combined approach.

Survival in Population-based Pancreatic Cancer Patients: San Francisco Bay Area, 1995-1999

Patient vital status generally is passively obtained by cancer registries, and no previous population-based studies have used extensive active follow-up to compute a more accurate overall survival rate for pancreatic cancer. Therefore, the authors used multiple active and passive follow-up methods to determine vital status and date of death for 1,954 pancreatic cancer patients diagnosed from 1995 to 1999 in a large population-based study in the San Francisco Bay Area, California. Survival rates were estimated by using Kaplan-Meier methods. Hazard ratios and 95% confidence intervals were estimated by using multivariable Cox proportional-hazards models. Vital status was confirmed for >99% of 1,954 patients. The overall 5-year survival rate was 1.3% and was greater in patients who were younger and who had localized disease, well-differentiated tumors, and surgical resection. Shorter survival was associated with older age at diagnosis, male sex, distant/metastatic disease, and poorly differentiated tumors. Longer survival was observed for Asian/Pacific Islanders compared with non-Hispanic whites and for any active treatment regardless of tumor stage. With an almost complete follow-up, the authors observed a low overall 5-year survival rate. Although the results provide further evidence of poor survival among patients with pancreatic cancer, the data also suggest that within-stage-of-disease patients survived somewhat longer with therapy.

Un sarcome cutané congénital rare : la tumeur fibrohistiocytaire plexiforme

We report the unusual case of a three-year-old girl which presented since birth a pigmented tumor of the left side 0.5cm in diameter. Surgical removal was decided given the hypothesis of a congenital naevo-cellular naevus. The histological study ended with the diagnosis of plexiform fibrohistiocytic tumor (PFHT). Two other congenital PFHT have been reported until now. PFHT is a rare mesenchymal neoplasm of intermediate malignancy, first reported by Enzinger and Zhang in 1988 which may be difficult to diagnose, because of its low frequency, particulary in congenital cases. It is important to distinguish it from others childhood cutaneous tumors (particulary plexiform neurofibroma, cellular neurothekeoma, infantile myofibromatosis, and fibrous hamartoma). The tumor has a high local recurrence rate and complete surgical resection of the tumor, with wider margins, is required.

Phase I and pharmacokinetic clinical trial of oral administration of the acyclic retinoid NIK‐333

NIK-333 (an acyclic retinoid) has been reported to prevent recurrence of hepatocellular carcinoma (HCC) in patients after curative treatment. This study was conducted to determine the maximum tolerated dose, dose-limiting toxicities (DLT) and pharmacokinetics of NIK-333 administrated p.o. at doses ranging 300-900 mg/day. Patients who were cancer-free after percutaneous local ablation or surgical resection of HCC were enrolled. The total daily dose was administrated as a single dose (single-dose stage) followed by a week of rest, and then in two equally divided doses administrated after breakfast and supper for 48 consecutive weeks (repeated-dose stage). No patients at the dose levels of 300 mg/day and 600 mg/day developed any DLT. At the final dose level of 900 mg/day, three of the nine patients developed grade 3 hypertension as a DLT. There were no significant difference values of maximum drug concentration (C(max) ) and log(C(max) ) between fasting and postprandial condition. In the repeated-dose stage, there was no significant difference between the start and week 24 of NIK-333 administration within any dose cohort in either the mean area under the blood concentration time curve (0-6 h) or the C(max) . NIK-333 was well-tolerated when administrated p.o. at doses of up to 600 mg/day for 48 weeks. Hypertension was noted as a DLT at the dose level of 900 mg/day, and this dose was considered to be inappropriate. The recommended dose for the phase II/III clinical trial is thought to be 300 mg/day and 600 mg/day.

HCC in 2010; are we offering appropriate therapy?

IntroductionHepatocellular carcinoma (HCC) cases are increasing in UK, related to rising prevalence of chronic liver disease and immigration from areas endemic for viral hepatitis. Treatment options for HCC include local...

Dermatofibrosarcoma protuberans with fibrosarcomatous transformation of the head and neck

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous neoplasm associated with a high cure rate. We present a case of aggressive DFSP with fibrosarcomatous areas in the head and neck. A 28-year-old Mediterranean female presented with a 45-day history of rapidly growing cutaneous lesion of the face. Surgical biopsy confirmed the diagnosis of DFSP. Subsequently, the patient underwent wide local surgical resection, followed by reconstruction. Histopathology report revealed fibrosarcomatous transformation and the patient underwent adjuvant radiotherapy. The patient continues to be disease free at the 35-month follow-up.Although DFSP behave as non-aggressive malignancy, surgery with complete removal of the affected area is the intervention of choice. Moreover, adjuvant treatment and follow-up of the patient is essential in order to prevent recurrence.