Total Excision Of Tumor Research Articles

Feasibility and outcome of complete secondary tumor resection for patients with advanced ovarian cancer

From November 1981 to July 1985, 124 women with International Federation of Gynecology and Obstetrics (FIGO) stage III ovarian cancer were treated in prospective studies of surgery and chemotherapy in our institution. Patients with no macroscopic cancer after primary surgery (n = 16) received five cycles of adjuvant cis-platinum; those with residual cancer after primary laparotomy (n = 108) underwent a second surgical debulking after three or five cycles of cis-platinum-based cytoreductive chemotherapy. Total macroscopic tumor clearance was achieved in 26 of these 108 patients. Fourteen patients with total tumor excision at primary laparotomy remain in complete clinical remission a minimum of 36 months after diagnosis, but the median progression-free interval for the other two groups was 9 and 17 months, respectively. The survival for women who have total tumor clearance only at secondary surgery after chemotherapy is inferior to that for women with primary macroscopic tumor excision followed by chemotherapy.

Source of Plasma Chromogranin A Elevation in Gastrinoma Patients

Chromogranin A (Cg A) is a protein that is coreleased with peptide hormones from gut endocrine cells and tumors. Plasma levels of Cg A, pepsinogen group I, and gastrin were measured in 31 patients with gastrinoma. Mean Cg A level in 10 patients with gastrinoma who were not operated on was 169 +/- 32 ng/mL, while in 9 control patients it was 28 +/- 5 ng/mL. In 18 patients with gastrinoma with residual tumor after total gastrectomy, the mean Cg A level was 45 +/- 6 ng/mL, and in 10 patients with normal gastrin levels after total gastrectomy and tumor excision, the mean Cg A level was 40 +/- 4 ng/mL. In 7 patients in whom pregastrectomy and postgastrectomy Cg A levels were measured, the mean reduction was 94 +/- 27 ng/mL, or 66%. There was no correlation between Cg A levels and amount of tumor, presence of metastases, or multiple endocrine neoplasia type I syndrome. There was a significant correlation between Cg A and pepsinogen I levels but no correlation between Cg A and gastrin levels. The results suggest that the elevated plasma Cg A levels in patients with gastrinoma are determined primarily by the trophic effects of gastrin on gastric enterochromaffinlike cells rather than by corelease from the gastrin-producing tumor itself.

Malignant Clear Cell Hidradenoma of the Lip

An interesting variety of cutaneous tumors of the head and neck, tumors of the eccrine differentiation, are seldom recognized. The most recent reports of these tumors appear in the dermatologic literature, probably due to the majority of them being located in the trunk and the extremities. Malignant varieties of these tumors do exist and must be treated as aggressively as more common tumors of the head and neck region. Tumors with eccrine differentiation are among a large variety of cutaneous tumors that present in the head and neck. These tumors are far less common than basal cell and squamous cell carcinomas of the head and neck. Malignant clear cell hidradenomas, a variant of the more common benign clear cell hidradenoma, is one such type of tumor of the eccrine differentiation. This is a rare tumor seldom reported in sites of the head and neck. A case of a 47-year-old white male with such a tumor of the lower half of his lip is presented. This report is particularly concerned with the histopathology of the tumor, its unique etiology, and the applicability of the lip switch flap (Stein-Abbe-Estlander) in the reconstruction of the surgical defect following total tumor excision.

Neurilemomas of the trigeminal nerve.

Sixteen patients with trigeminal neurilemoma have been treated at the University Health Center of Pittsburgh during the last 15 years. Two patients had middle fossa tumors arising from the trigeminal ganglion, four had posterior fossa tumors arising from the trigeminal roots, six had "hourglass" lesions extending above and below the tentorium and involving the trigeminal ganglion and its roots, and four had tumors arising from the trigeminal branches and extending through the superior orbital fissure, foramen rotundum, or foramen ovale. In seven patients, tumor had also invaded the cavernous sinus. The clinical and radiographic features of these tumors, the operative approaches employed, and the postoperative outcome are discussed. Complete tumor excision was achieved in 12 patients; all 12 remain free of recurrence 3 to 157 months after surgery. In contrast, all four patients who underwent subtotal tumor excision showed progressive neurological deterioration from regrowth of residual tumor within 3 years of the initial surgery. Two of these four subsequently had total tumor excision and both are disease-free 23 and 34 months after the second procedure. Major morbidity developed in only one of the 16 patients. There were no operative deaths. Nine patients had preserved or improved trigeminal function after treatment.

Distributions of sulfhydryl borane monomer and dimer in rodents and monomer in humans: boron neutron capture therapy of melanoma and glioma in boronated rodents.

Boron neutron capture therapy (BNCT), a form of radiation therapy based on the 10B(n,α)7Li nuclear reaction,1,2 has been used in Japan for radiation therapy of human malignant gliomas after total or partial neurosurgical excision of visible tumor.3 Japanese data for 10B distribution in the blood and tumor of 30 patients with malignant glioma have been summarized.4 The stable isotope 10B was introduced into the tumor during a 1–2 hour intra-arterial infusion of a 10B-enriched preparation of the sulfhydryl borane monomer Na2B12H11SH to a total dose in the range 30–80 mg 10B per kg total body weight. The tumor bed was irradiated for 5–7 hours at a 100-kW nuclear reactor, 11 to 16 hours after the infusion. The average tumor 10B concentration just before irradiation was 22 μg 10B/g, while the average blood 10B concentration was 18 μg 10B/g.4 Despite low tumor:blood 10B concentration ratios just before irradiation (average ratio = 1.2:1.0), post-operative survival after BNCT was unexpectedly prolonged for some patients--indeed astonishingly so for a 66-year-old Japanese man who is neurologically and neuroradiologically stable nearly sixteen years after visibly incomplete removal of a malignant glioma.4

Juvenile pilocytic astrocytoma of the cerebrum in adults. A distinctive neoplasm with favorable prognosis.

Seven adults (15 years of age or older) with juvenile pilocytic astrocytoma of the cerebrum were treated at Barnes Hospital in St. Louis, Missouri, from 1950 to 1981. This group comprised 7% of the total adult population with well differentiated astrocytoma and astrocytoma with anaplastic foci treated over a 30-year period. All seven patients were less than 30 years old at the time of presentation. The tumors were characterized by distinctive histology, a predilection for the temporal lobe, the presence of a major cyst, and relative gross circumscription making total surgical resection feasible. In contrast to patients with diffusely infiltrating cerebral astrocytoma, those with juvenile pilocytic astrocytoma have had an extremely favorable course, regardless of treatment. Four were treated with surgery alone after total gross tumor excision, and three received postoperative irradiation after subtotal excision. Six were alive 27, 24, 17, 9, 5, and 2 years after initial surgery. One patient died 7 years after surgery and radiation as a result of cerebral radiation necrosis. Juvenile pilocytic astrocytoma of the cerebrum is a recognizable, distinctive entity with natural history and pathological characteristics similar to the relatively benign cerebellar astrocytoma of childhood.

Review of Three Cases and the Presentation of a Characteristic Set of Tumor Markers Defining this Tumor

This study demonstrates the unique clinical and histologic aspects of fibrolamellar hepatic carcinoma, a rare variant of hepatocellular carcinoma. Three cases are reviewed and an extensive study of immunologic and intracellular substances defining this tumor is presented. Length of survival was considerably longer than typical hepatoma. The cause of death generally is due to a lack of control of the primary tumor. Successful treatment appears to relate to the ability to perform a total excision of the primary hepatic tumor. Chemotherapy should be used only in the presence of metastatic disease. Surgical resection of metastatic disease, unlike the usual hepatocarcinoma, may have some beneficial use. Fibrinogen was found in all tumors. It is possible that this tumor produces fibrinogen to create its unique histologic appearance. Carcinoembryonic antigen is described for the first time in this tumor. Both deposits of alpha-1 antitrypsin and copper were found in most of the tissues studied. The presence and amounts of these substances differ markedly from the common type of hepatoma. This unique composition of intracellular components may both facilitate histologic diagnosis, particularly if the amount of tissue is limited, and give further insight into the etiology of this tumor.

Peripheral Nerve Surgery

In treating the three main surgical problems of peripheral nerves--nerve sheath tumors, entrapment neuropathies, and acute nerve injuries--the overriding consideration is the preservation and restoration of neurologic function. Because of this, certain other principles may need to be compromised. These include achieving a gross total excision of benign tumors, employing conservative therapy as long as a disease process is not clearly progressing, and delaying repair of a nerve transection until the skin wound has healed. Only three pathophysiologic processes need be considered: neurapraxia (focal segmental dymyelination), axonotmesis (wallerian degeneration caused by a lesion that does not disrupt fascicles of nerve fibers), and neurotmesis (wallerian degeneration caused by a lesion that interrupts fascicles). With nerve sheath tumors and entrapment neuropathies, the goal is minimize the extent to which neurapraxia progresses to axonotmesis. The compressive force is relieved without carrying out internal neurolysis, a procedure that is poorly tolerated, presumably because a degree of nerve ischemia exists with any long-standing compression. When the nerve has sustained blunt trauma (through acute compression, percussion, or traction), the result can be a total loss of function and an extensive neuroma-in-continuity (scarring within the nerve). However, the neural pathophysiology may amount to nothing more than axonotmesis. Although this lesion, in time, leads to full and spontaneous recovery, it must be differentiated from the neuroma-in-continuity that contains disrupted fascicles requiring surgery. Finally, with open nerve transection, the priority is to match the fascicles of the proximal stump with those of the distal stump, a goal that is best achieved if primary neurorrhaphy is carried out.

Primary Retroperitoneal Soft-Tissue Sarcomas

Of the 98 soft-tissue sarcomas treated between 1973-1978, 12 were retroperitoneal in origin. Fifty percent underwent one to three previous surgical procedures. All patients were operated on. In 75% (nine out of 12), the tumor was completely resected. The operative mortality for total tumor excision was 11%. There were five liposarcomas, three leiomyosarcomas, two neurofibrosarcomas, and one synovial sarcoma and one unclassified sarcoma. Six of the 12 patients survived five years and three (25%) were alive without evidence of disease at 5 years. Three of the completely resected group received no further treatment; 2/3 survived 5 years; three had postoperative chemotherapy; 3/3 survived; and three others had radiation and chemotherapy subsequent to surgery; all three have died. The two most important prognostic factors were tumor grade and surgical excision. Only one patient with high grade tumor survived. Total surgical excision of the tumor offers the only hope for cure. Aggressive surgery in treating retroperitoneal soft part sarcomas is strongly recommended.

Primary retroperitoneal soft-tissue sarcomas.

Of the 98 soft-tissue sarcomas treated between 1973-1978, 12 were retroperitoneal in origin. Fifty percent underwent one to three previous surgical procedures. All patients were operated on. In 75% (nine out of 12), the tumor was completely resected. The operative mortality for total tumor excision was 11%. There were five liposarcomas, three leiomyosarcomas, two neurofibrosarcomas, and one synovial sarcoma and one unclassified sarcoma. Six of the 12 patients survived five years and three (25%) were alive without evidence of disease at 5 years. Three of the completely resected group received no further treatment; 2/3 survived 5 years; three had postoperative chemotherapy; 3/3 survived; and three others had radiation and chemotherapy subsequent to surgery; all three have died. The two most important prognostic factors were tumor grade and surgical excision. Only one patient with high grade tumor survived. Total surgical excision of the tumor offers the only hope for cure. Aggressive surgery in treating retroperitoneal soft part sarcomas is strongly recommended.

Colorectal cancer: the modern treatment of disseminated disease - a review.

Most patients who develop cancer of the large bowel will eventually develop recurrence and will therefore be considered for treatment of that recurrence. There exists very great confusion as to the efficacy of the various treatment options available. This review has attempted to evaluate critically the claim for therapeutic efficacy of the various treatment options, with particular regard to patients with liver metastases from primary tumours of the large bowel. A case can be made out for surgical removal of recurrent or disseminated colorectal cancer, but there is no evidence that any form of treatment other than total surgical excision will result in prolonged patient survival. All forms of treatment can be effective in palliating symptomatic patients. Therefore, with the exception of total surgical excision of recurrent tumour, treatment should be reserved for those patients with symptoms, and the choice of treatment offered should be weighed against possible side-effects.

Endocrine and neurologic outcome in childhood craniopharyngioma: Review of effect of treatment in 42 patients

Forty-two cases of craniopharyngioma in children reviewed. Only 9.5% had sought medical attention because of symptoms suggesting hormonal deficit; however, growth retardation was present in 53% and growth hormone deficiency was documented in 72% before treatment. Multiple hypothalamic-pituitary hormone deficiencies were present in all patients after treatment. Eleven percent had normal skull radiographs at presentation; pneumonencephalograms and computed tomographic brain scans were abnormal on every occasion on which they were performed. Recurrence and mortality rates as well as the neurologic outcome of survivors were similar in children treated by radical excision and those treated by limited excision plus radiotherapy. The neurologic prognosis was poorest in those children who had limited excision or drainage without radiotherapy. Additional hypothalamic-pituitary dysfunction following treatment was less common in children who had limited excision plus radiotherapy than in children who had either limited excision or attempted total removal. Unless gross total tumor excision can be readily achieved, limited excision by transsphenoidal microsurgery or craniotomy plus radiotherapy appears to be the treatment of choice for craniopharyngioma in childhood.

Glomus jugulare tumor surgery with intracranial extension.

Total surgical excision of a glomus jugulare tumor is the treatment of choice for this benign tumor. If the tumor has extended beyond the temporal bone into the intracranial spaces, most often the posterior fossa, the surgical excision becomes more difficult. If the tumor has extended anteriorly and posteriorly into the posterior fossa or if a portion of the tumor is exposed in the external auditory canal with the concurrent infection that is seen with this presentation, the intracranial portion of the tumor should be removed as a first step in a planned two-stage removal of the tumor. If the intracranial extension is limited and there is no infection present with the tumor, a combined otologic-neurosurgical approach using transtemporal and suboccipital access to the temporal bone will allow successful total removal of the tumor in a one-stage procedure. Details are presented to demonstrate this combined otologic and neurosurgical approach to large glomus tumors with intracranial extension.

Recent experience in the treatment of rhabdomyosarcoma

Twenty-two patients with rhabdomyosarcoma have presented in the years 1970--1977. Of 8 patients who had inadequate postoperative chemotherapy and radiotherapy, or none at all, only 2 patients with small completely resectable tumors are alive and well at 6 and 4 yr after surgery. Fourteen patients had intensive combination chemotherapy in addition to appropriate surgery and radiotherapy. Five have died and the remaining nine are well and free of disease at follow up ranging from 9 mo to over 5 yr. A continued place in the treatment regime is advocated for early surgery aimed at total excision of the primary tumor where this is feasible.

The human accessory parotid gland: Its incidence, nature, and significance

Dissections of human parotid glands were undertaken to observe the incidence, size, location, and histologic characteristics of accessory parotid glands. These data were related to the premise that an unusual location and appearance of the accessory gland might preclude complete surgical removal of a parotid tumor. This, in turn, could be a factor in the high recurrence rate after apparently total excision of benign mixed tumors of the parotid gland.

Experimental cancer immunotherapy: modification of tumor cells to increase immunogenicity.

Firmly established transplantable C3H/HeJ mammary carcinomas can be inhibited by host challenge with Vibrio cholerae neuraminidase (VCN)-treated tumor cells. The effect is totally immunospecific, even VCN-treated tumors bearing shared mammary tumor virus (MTV) antigen cannot induce the regression. Thus, VCN is capable of increasing the immunogenicity of the private, unique-unshared tumor antigens on mammary carcinomas; VCN is incapable of increasing the immunogenicity of the shared MTV-associated tumor antigen even in syngeneic C3HeB/FeJ MTV-free mice. The immunoregressive effect of VCN-treated tumor cells can be augmented by subtotal or total surgical excision of large transplantable tumors. Spontaneous mammary tumors in retired breeder C3H/HeJ female mice can be made to regress by two immunological maneuvers: (1) repeated intratumor injections of VCN and/or BCG; and (2) total excision and immunotherapy with VCN-treated autochthonous mammary tumor cells. The use of VCN-treated transplantable mammary tumor cells sharing the MTV-associated antigen was not better than excision alone. The evidence supports the idea that active specific immunotherapy of spontaneous tumors with VCN-altered tumor cells may require the use of autochthonous cells.

Dumbbell neuroblastomas in children.

A "dumbbell" neuroblastoma is a malignant neoplasm usually primary in the mediastinum or retroperitoneum with posterior extension through an intervertebral foramen to additional tumor within the spinal canal. Neurologic deficits are found in almost all cases. Nineteen patients with such tumors were reviewed with respect to diagnosis, management, and results. Treatment consisted of prompt laminectomy with total or subtotal excision of the extradural tumor. The primary tumor in the mediastinum or retroperitoneal area was removed at a second stage. All patients received postoperative radiation therapy. Eleven of the 17 patients observed more than two years are free of disease, a cure rate much higher than the overall experience with neuroblastoma. Substantial recovery of neurologic function occurred in most, but kyphoscoliotic deformities were a disturbingly frequent late complication.

Excision of rectal lesions by the Kraske approach

The Kraske operation is a little used procedure which has value in the treatment of selected benign lesions of the rectum below the peritoneal reflection. The operation is especially suitable for broad-based villous tumors or large adenomatous polyps. Total excision of villous tumors is essential to obviate invasive cancer and to prevent recurrence. The principal complication of the posterior proctectomy is the development of proctocutaneous fistulas (four of twenty cases). In three of the four cases the fistulas closed spontaneously. The Kraske operation is curative for villous adenomas showing atypia or carcinoma in situ and probably is sufficient treatment for tumors showing superficial foci of adenocarcinoma, but it should be emphasized that there is still no place for this procedure in the treatment of invasive carcinoma.