Tumor Resection Group Research Articles

Overcoming the Challenges of Primary Tumor Management in Patients With Metastatic Colorectal Cancer Unresectable for Cure and an Asymptomatic Primary Tumor

The management of asymptomatic primary tumor in patients with unresectable metastatic colorectal cancer remains inconsistent. This study aimed to determine the rate of symptom-directed surgery after systemic chemotherapy and to estimate the impact of initial primary tumor resection on survival in patients with unresectable metastatic colorectal cancer and an asymptomatic primary tumor. This was a single-institution, retrospective observational study. The study was conducted in a tertiary referral hospital. Between 2005 and 2011, 191 consecutive patients with newly diagnosed stage IV colorectal cancer were identified. Of the 191, we analyzed 94 patients with unresectable, asymptomatic colorectal cancer. We measured symptom-directed surgery and overall survival. Forty-seven patients with an intact primary tumor received systemic chemotherapy (upfront chemotherapy group), 41 underwent primary tumor resection (upfront primary tumor resection group), and 6 underwent diversion enterostomy as first-line therapy. After excluding the 6 patients undergoing diversion enterostomy before systemic chemotherapy, this left 88 patients for final analysis. Twelve upfront chemotherapy patients required symptom-directed late surgery. Overall, 1-year and 2-year rates of symptom-directed surgery were 19.1% and 26.1%. In patients with nontraversable lesions by colonoscope at diagnosis, 64.3% required late intervention within 1 year. Competing risk regression analysis revealed that only colonoscopic traversability at diagnosis was significantly associated with symptom-directed late surgery (subhazard ratio, 7.9; p = 0.004). Median overall survival time was comparable between the 2 groups at 23.9 months for the upfront primary tumor resection group and 22.6 months for the upfront chemotherapy group (HR, 0.84; 95% CI: 0.51-1.39). This study was limited by its retrospective nature and small sample size. Approximately 75% of upfront chemotherapy patients with unresectable, asymptomatic stage IV colorectal cancer can be spared initial resection of the primary tumor. Colonoscopic findings of nontraversable lesions at diagnosis may predict the need for late surgical intervention.

Application value of preoperative embolization in primary retroperitoneal tumor

To evaluate the value of angiography in clarifying the origin of the feeding arteries of primary retroperitoneal tumors and to explore the application of embolization therapy in the treating of primary retroperitoneal tumor. 68 patients with primary retroperitoneal tumor were randomized into conventional tumor resection group (n = 35) and the preoperative embolization group (n = 33). Some clinical data were compared between the preoperative embolization group and the routine operation group, including blood loss, blood transfusion, operation time and adverse reactions after embolization. All the diagnoses were pathologically confirmed. The origins of the tumor-feeding arteries were analyzed. The clinical value of embolization in assisting the surgery as well as in making prognosis was assessed. According to their location and size, primary retroperitoneal tumors had feeding arteries from different origins. In this series of cases the tumor blood supply originated from the lumbar artery (81.8%), internal iliac artery (45.5%) and adrenal artery (27.3%). In the preoperative embolization group and conventional surgery group, the blood loss was 912 ml vs. 2 500 ml (P < 0.001), the blood transfusion was 1 000 ml vs. 2 600 ml (P < 0.001), the operation time was 4.1 h vs. 5.9 h (P < 0.001), and the length of hospital stay was 12.5 d vs. 19.8 d (P < 0.001). The origins of the feeding arteries in primary retroperitoneal tumors are very complex. Preoperative embolization therapy may effectively reduce the intraoperative blood loss, postoperative adverse events, length of hospital stay, and facilitate the patients' recovery.

Influence of primary tumor resection on survival in asymptomatic patients with incurable stage IV colorectal cancer

The influence of resection of the primary lesion on the prognosis of patients with incurable stage IV colorectal cancer is unclear. We retrospectively analyzed 158 asymptomatic patients with incurable stage IV colorectal cancer who received systemic chemotherapy in our center from 2002 to 2009, either without (chemotherapy group; n = 112) or after (resection group; n = 46) primary tumor resection. Primary tumor resection was performed if the fiberscope did not pass through the primary lesion. Survival was compared between the 2 groups, and the actual surgical intervention was assessed. At a median follow-up period of 26 months (range 7-91 months), the median survival times were 19.9 months in the resection group and 19.0 months in the chemotherapy group (HR = 0.81, 95 % CI 0.53-1.19, p = 0.29). Among the tumor resection group, 8 (17 %) experienced postoperative complications, with all showing improvement after conservative treatment. In the chemotherapy group, 18 patients (21 %) required surgical interventions for symptoms associated with progression of the primary tumor. Resection of the primary tumor in asymptomatic patients with incurable stage IV colorectal cancer was safe, but had no effect on prognosis.

Ultrasound-Stimulated Drug Delivery for Treatment of Residual Disease after Incomplete Resection of Head and Neck Cancer

Microbubbles triggered with localized ultrasound (US) can improve tumor drug delivery and retention. Termed US-stimulated drug delivery, this strategy was applied to head and neck cancer (HNC) in a post-surgical tumor resection model. Luciferase-positive HNC squamous cell carcinoma (SCC) was implanted in the flanks of nude athymic mice (N = 24) that underwent various degrees of surgical tumor resection (0%, 50% or 100%). After surgery, animals received adjuvant therapy with cetuximab-IRDye alone, or cetuximab-IRDye in combination with US-stimulated drug delivery or saline injections (control) on days 4, 7 and 10. Tumor drug delivery was assessed on days 0, 4, 7, 10, 14 and 17 with an in vivo fluorescence imaging system, and tumor viability was evaluated at the same times with in vivo bioluminescence imaging. Tumor caliper measurements occurred two times per week for 24 d. Optical imaging revealed that in the 50% tumor resection group, US-stimulated drug delivery resulted in a significant increase in cetuximab delivery compared with administration of drug alone on day 10 (day of peak fluorescence) (p = 0.03). Tumor viability decreased in all groups that received cetuximab-IRDye in combination with US-stimulated drug delivery, compared with the group that received only the drug. After various degrees of surgical resection, this novel study reports positive improvements in drug uptake in the residual cancer cells when drug delivery is stimulated with US.

Clinical analysis of 150 cases with parotid gland tumor

Objective To explore the ideal method of parotid tumors by clinical surgical treatment.Methods 150 patients with parotid gland tumor were divided into parotid gland tumors and total resection of the tumor,partial parotidectomy and parotid gland tumors and shallow lobectomy three groups,fifty cases in each group.After the operation,operation time,cure recurrence and other related projects were observed.Results In 150 patients with parotid gland tumor,benign parotid gland tumors accounted for 84.66％,malignant tumor accounted for 15.34％.The operation time of tumor resection group and partial parotidectomy group was (74.00 ± 12.54) min,which was less than that of the total resection group (112.00 ± 20.37) min and shallow leaf group (98.00 ± 17.35) min.The number of patients satisfied with facial in partial resection group was 48 cases,and 45 cases with parotid gland function reserved,which were significantly better than the other two groups,incidence rate of postoperative complications (3.3％) was obviously less than the other two groups (10.7％,8.7％),the difference was statistically significant (P ＜ 0.05).Conclusion The operation time of patients with parotid gland tumor underwent partial resection is short,the cure condition is ideal,can effectively control the tumor relapse,metastasis and postoperative complications,can keep part of the parotid gland function,has obvious advantages. Key words: Parotid neoplasms; Oral surgical procedures

Multicenter randomized controlled clinical study for the operative treatment of malignant ovarian germ cell tumors

To investigate the operative treatment for first-treated patients with malignant ovarian germ cell tumors who need preservation of fertility. The clinical data of 105 patients who were treated with fertility-sparing surgery in 11 hospitals from 1992 to 2010 were collected to evaluate the outcomes of different primary surgical operative procedures. All 105 cases were performed the surgeries that preserved fertility and divided into three groups according to the surgical approaches, comprehensive staging surgery group: 47 cases (44.8%) received comprehensive staging surgeries that including the ipsilateral oophorectomy + omentectomy + retropertoneal lymph node dissection ± appendectomy + multiple biopsies;oophorectomy group:45 cases (42.9%)received ipsilateral oophorectomy ± biopsy of contralateral ovary ± omentectomy;tumor resection group:13 cases (12.4%) received enucleation of the mass with preservation of the ovary. Differences were compared among the three groups of patients in the surgery-related indicators, complications, fertility and prognosis. (1) Surgery-related indicators:the average blood loss of the comprehensive staging surgery group, the oophorectomy group and the tumor resection group were 496, 104 and 253 ml, the mean operation time were 176, 114 and 122 minutes, respectively, and there were significant differences among three groups (P = 0.011, P = 0.000). (2) Complication:the surgical complication rates of the three groups were 17% (8/47), 0 and 1/13, with significant differences (P = 0.015). (3) Reproductive function status: the pregnancy rate and birth rate of the three groups were no significant differences (9/19 vs. 7/19 vs. 2/3, P = 0.515; 8/19 vs. 5/19 vs. 2/3, P = 0.636). (4) PROGNOSIS: the recurrence rate of the three groups were significant differences [13% (6/47) vs. 0 vs. 2/13, P = 0.013], but the death rate with no significant differences [6% (3/47) vs. 0 vs. 0, P = 0.129]; The five-year survival rate of three different groups were 89%, 100% and 100% (P > 0.05), while disease free survival rate were 85%, 100% and 83% (P < 0.05), respectively. Compared with comprehensive staging surgery, oophorectomy group have higher surgical security and satisfactory prognosis, considerable pregnancy rates and birth rate. The tumor resection security may be reliable, but the prognosis is poor.

Efficacy and Safety of Dexmedetomidine during Anesthesia Induction of Patients with Intracranial Tumor: A Preliminary Observational Trial

Background: The efficacy and safety of dexmedetomidine during the anesthesia induction of intracranial tumor patients remain unknown. We wondered whether loading infusion of dexmedetomidine 1 μg/kg over 10 min to intracranial tumor patients was as efficient and safe as to those abdominal disease patients. Methods: Patients aged 18-60 years, male or female, ASA I or II, scheduled for intracranial tumor resection (Group N, n = 30) or abdominal operation (Group A, n = 30) were enrolled in this observational trial. Dexmedetomidine was administrated with a loading dosage of 1 μg/kg over 10 min following with continuous infusing of 0.5 μg/kg/h. Fentanyl, propofol and rocuronium were sequentially administered for anesthesia induction. Heart rate (HR), blood pressure (BP), pulse oxygen saturation (SpO2), bispectral index (BIS) and other adverse effects were recorded from the beginning of loading infusion of dexmedetomidine to the end of endotracheal intubation. Results: Among with loading infusion, HR and BIS value decreased and were significantly lower at the end of infusion than before infusion (P P > 0.05). One patient of Group N dropped out from this trial because of a serious headache. 14 of 29 patients during dexmedetomidine loading infusion suffered hypoxemia (SpO2 P Conclusion: A loading dosage of 1 μg/kg of dexmedetomidine was not suitable for the anesthesia induction of intracranial tumor patients as compared to patients undergoing abdominal operation.

Does optic nerve sheath diameter on MRI decrease with clinically improved pediatric hydrocephalus?

Serial change in ventricular size is recognized as an imperfect indicator of ongoing hydrocephalus in children. Potentially, other radiographic features may be useful in determining the success of hydrocephalus interventions. In this study, optic nerve sheath diameter (ONSD), optic nerve tortuosity, and optic disk bulging were assessed as indicators of hydrocephalus control in children who underwent endoscopic third ventriculostomy (ETV) or posterior fossa tumor resection. Sixteen children underwent ETV or tumor resection for treatment of hydrocephalus. T2-weighted axial magnetic resonance images of the orbit were obtained, and the ONSD was measured posterior to the optic globe, pre- and post-intervention. Evidence of optic disk bulging and optic nerve tortuosity was also assessed. Ventricular size was estimated using the frontal and occipital horn ratio (FOR). There was a significant reduction in the ONSD post-ETV (n = 9) and after tumor resection (n = 7). Average preoperative ONSD was 6.21 versus 5.71 mm postoperatively (p = 0.0017).There was also an 88% (p = 0.011) and 60% (p = 0.23) reduction in optic disk bulging and tortuosity, respectively. The FOR normalized in the tumor resection group but not the ETV group. After intervention, all patients showed improvement in signs and symptoms of hydrocephalus. In our study population, ONSD decreased in response to measures to reduce hydrocephalus. Optic disk bulging also appears to resolve. Serial reduction in ONSD, and optic disk bulging may be indicators of improved hydrocephalus following pediatric neurosurgical interventions.

Facial Nerve Schwannomas of the Cerebellopontine Angle: The Mayo Clinic Experience

Background There is often controversy regarding the optimal management for patients with facial nerve schwannomas (FNSs) of the cerebellopontine angle (CPA). Methods The clinical and radiological outcomes in 14 patients with CPA FNS were retrospectively reviewed. Results Patients underwent resection with anatomic nerve preservation (n = 3), facial-hypoglossal nerve anastomosis (n = 4), gamma knife radiosurgery (GKS) (n = 6), or observation (n = 1). A total of 83% of tumors that underwent GKS were stable or decreased in size. No patient who underwent resection showed evidence of tumor recurrence; the tumor under observation remained unchanged with normal facial function at the time of the last follow-up. Facial function was decreased in 57%, stable in 14%, and improved in 29% of those who underwent microsurgery. A total of 67% of patients who underwent GKS had stable facial function. Serviceable hearing was maintained in 50% of patients in the GKS group and 67% of the tumor resection group. Mean and median follow-up was 48 and 43 months, respectively (range, 12 to 95 months). Conclusion Observation should be the primary management when encountered with FNS of the CPA in those with good neurologic function. Microsurgery or radiosurgery may be used in those with poor facial function or tumor progression.

Chinese herbal decoction Shiquan Dabu Tang inhibits tumor growth and angiogenesis of metastasis after primary tumor surgical removal in mice

This study aimed to investigate the effects of Shiquan Dabu Tang (SDT) on growth and angiogenesis of subcutaneously implanted tumors, hepatic metastases, and incision-implanted tumors after surgical removal of primary colon tumor in mice. Three experimental models were built after surgical removal of primary colon tumor and the mice were randomly divided into three groups: primary tumor resection (TR) group, primary tumor-preserved (TP) group and SDT group. After resection of the primary tumor and SDT treatment for 10 d, levels of vascular endothelial growth factor (VEGF), angiostatin (AS) and endostatin (ES) were examined by enzyme-linked immunosorbent assay (ELISA); microvascular density (MVD) and cell proliferation of metastasis were detected by streptavidin-peroxidase immunohistochemical staining; tumor cell apoptosis was detected by terminal deoxynucleotidyl transferase-mediated dUTP nick-end-labeling (TUNEL) assay. In the subcutaneously implanted tumor model, the average volume of metastases of the SDT group was significantly lower than that of the TR group (P<0.01); the incidence rate of metastases was 50%. In the hepatic metastases model, the average number of hepatic metastases nodules of the SDT group was significantly lower than that of the TR group (P<0.01); the incidence rate of metastases was 40%. In the incision-implanted tumor model, the average volume of metastases of the SDT group was significantly lower than that of the TR group; the incidence rate of metastases was 30%. MVD was significantly inhibited by SDT and Ki67 expression of the SDT group was significantly lower than that of the TR group (P<0.01). TUNEL apoptotic index of tumor of the SDT group was higher than that of the TR group (P<0.01). ELISA showed that the serum VEGF level was significantly decreased and the serum ES level was significantly increased in the SDT group compared with those in the TR group (P<0.01). Resection of primary tumor in mice causes imbalance of VEGF, AS and ES, thus promoting angiogenesis and metastasis of tumors. SDT can inhibit growth, angiogenesis and cell proliferation of the metastatic tumor and promote cell apoptosis after surgical removal of the primary tumors.

Reduction of intra-operative blood loss by temporary control of external carotid artery in advanced head and neck malignancies

Objective: The study introduces a simple vascular control procedure to minimize intraoperative blood loss during resection of advanced head and neck malignancies through clamping to the external carotid artery (ECA). Patients and methods: This prospective study included 20 patients with different operable head and neck cancer randomized to perform vascular clamping of ECA during neck dissection before tumor resection (group A, n = 11) or classical neck dissection and resection of the tumors without vascular control (group B, n = 9). Results: There was no significant difference between the 2 groups regarding demographic and disease characteristics. Statistically significant decrease of blood loss was observed in the vascular control group. Blood loss in group A was nearly a quarter of that in group B. Conclusion: Temporary intraoperative clamping of the ECA minimizes blood loss, and consequently, the need for blood transfusion with all its complications. In addition, it ensures more optimum survival of the full-thickness graft used for coverage of the head neck defect left after surgery.

To Resect or not the Primary Tumor in Metastatic Colorectal Cancer: Letter to the Editor

Colorectal cancer (CRC) is one of the most common tumors in the US, Europe, and worldwide but with a relatively good prognosis. In the adjuvant setting, high long-term survival rates have been reported, and even in the metastatic setting, with the use of systemic chemotherapy the median survival time has been improved to roughly 20 months. The addition of biologic agents such as cetuximab or panitumab has raised expectation for further survival improvement. With these developments, an old problem in surgical oncology has now been updated. Is the decision to resect the primary tumor, when it is locally completely resectable, correct, or will resection harm patients with a stage IV disease? To highlight this critical question in day-to-day clinical practice, Stillwell et al. [1] performed a meta-analysis and reported the results in the April 2010 issue of this journal. The authors concluded that palliative primary tumor resection in metastatic CRC (mCRC) prolongs survival and benefits patients. Can this report be considered a practicechanging study? Multiple variables complicate robust conclusions and correct decisions about surgery for an individual patient with mCRC. These factors include the extent of metastatic disease, namely, unresectable liver metastasis and/or minimal or extensive peritoneal carcinomatosis and/or other distant metastases; locally advanced or potentially complete removal of the primary tumor; tumor responsiveness or resistance to chemotherapy; general status of the patient; and risk of surgery-related complications that may delay recovery from surgery. For example, a safe performance of a laparoscopic colectomy without morbidity allows rapid recovery and may overcome the problem of surgerydelaying chemotherapy. In the absence of randomized controlled trials (RCTs), Stillwell et al. identified eight retrospective studies, including one with 1062 patients with asymptomatic and minimally symptomatic mCRC. Median overall survival was 6.0 months longer in the primary tumor resection group compared with that in chemotherapy-alone group (RR = 0.55; 95% CI = 0.29– 0.82; p\0.001). Patients managed with chemotherapy alone were seven times more likely to have a complication from the primary tumor. The authors concluded that palliative resection of the primary tumor prolongs survival and reduces the risk of primary tumor-related complications. Although it is thought that meta-analyses provide the highest level of evidence, this study was limited by the inclusion of retrospective studies and their heterogeneity given that several confounding variables reported above were not considered. Moreover, four studies within this series found that there was no significant difference in survival with resection of the primary tumor. For improving overall survival in the metastatic setting, there is much hope with the advent of next-generation DNA sequencing technologies and their promise for completing the somatic mutations of major cancer types such as colorectal cancer and helping us understand how an individual tumor functions as a complete biological and molecular system. These advances may allow identification of novel biomarkers for tailoring new biologic therapies along with standard chemotherapy [2–14].

Transcatheter arterial chemoembolizaion on the expression of nm23, Tissue inhibitor of metalloproteinase-2 and extrahepatic metastasis in hepatocellular carcinoma

Objective To investigate the effects of transcatheter arterial chemoembolization(TACE) on the expression of nm23, tissue inhibitor of metalloproteinase-2 (TIMP-2) and extrahepatic metastasis in hepatocellular carcinoma (HCC). Methods The specimens were collected from resectable HCC in 72 patients. Patients were divided into two groups. In one group, TACE was performed before tumor resection (Group A, n=36). In another group, the tumors were resected directly without preoperative TACE (Group B, n=36). The expression and distribution of nm23, TIMP-2 in the tumor tissue and liver parenchyma in the two groups were compared. All patients were followed up for 24 months,and the incidence of extrahepatic metastasis was compared between the two groups. Chi-square test was applied to compare the expression levels of nm23-H1 and TIMP-2. Results The number of cases of strong, moderate and no expression of nm23 were 24, 6 and 6 cases in group A respectively, and were 9, 6 and 21 cases in group B. Statistical differences were found between the two groups(X~2=15.52, P 0.05). Conclusions TACE could enhance the expression of nm23-H1 and TIMP-2 in tumor tissues. Therefore, the potential of metastasis of tumor cells might be prohibited by TACE. Key words: Carcinoma,hepatocellular; Neoplasm metastasis; nm23-H1; Tissue inhibitor ofmetalloproteinase-2

Persistent hydrocephalus after early surgical management of posterior fossa tumors in children: is routine preoperative endoscopic third ventriculostomy justified?

The authors evaluate the incidence of persistent hydrocephalus after early surgical management of pediatric posterior fossa tumors and the indicators for routine preoperative endoscopic third ventriculostomy (ETV). Between 1989 and 2004, 160 children with a posterior fossa tumor were treated at Erasme Hospital in Brussels, Belgium. Hydrocephalus was present at admission in 114 of the patients. Thirty-one patients had severe hydrocephalus (Evans index [EI] > 0.4). Twenty-four of these and the 83 patients with mild hydrocephalus (EI between 0.3 and 0.4) were treated with early posterior fossa surgery (Group 1; 107 patients). In this group, 93 patients underwent a total or subtotal tumor resection associated with external ventricular drainage (Group 1A), and 14 underwent a stereotactic biopsy associated with an ETV (Group 1B). The 53 remaining patients underwent elective posterior fossa surgery (Group 2). Early tumor resection (Group 1A) resolved hydrocephalus in 85 (91%) of 93 patients, whereas an ETV resolved intracranial hypertension in 11 patients (Group 1B). In Group 1, persistent hydrocephalus affected 11 (10%) of 107 patients, seven of whom had symptoms and were treated (three with shunts and four with ETVs). Persistent hydrocephalus was more frequent in children with severe preoperative hydrocephalus (p = 0.002) and with medulloblastomas (p = 0.0154). A total of 22 technically successful ETV procedures were performed. The ETV success rate for controlling hydrocephalus was 81% (18 of 22) and the rate of severe complications was 9% (two of 22). An ETV is an efficient procedure for controlling hydrocephalus associated with posterior fossa tumor. The authors confirm that a routine postoperative ETV is indicated for treating persistent hydrocephalus. For preventing it, however, they recommend early posterior fossa surgery whenever possible. The low rate of persistent hydrocephalus does not justify adopting routine preoperative ETVs.

Myasthenia gravis appearing after thymectomy for thymoma

A few thymoma patients without myasthenia gravis (MG) have been observed to develop MG after total removal of the thymoma (postoperative MG). However, the cause of this is not yet known because of the rarity of postoperative MG patients. This study evaluated the clinical characteristics of the 8 postoperative MG patients. We compiled 1089 thymoma patients treated between 1990 and 1994 in 115 institutes in Japan, and found 8 cases of postoperative MG. Postoperative MG was found in 8 (0.97%) of 827 thymoma patients without preoperative MG. The postoperative MG patients included 1 male and 7 females, with a mean age of 50.5+/-15.0 years. The thymoma was completely resected in all cases. The surgical method used was extended thymectomy in 2 cases and thymothymectomy in 6 cases. There were 2 cases (0.7%) of postoperative MG in the extended thymectomy group (n = 275), 6 (1.9%) in the thymothymectomy group (n = 321), and none in the tumor resection group (n = 137). The interval between thymectomy and the onset of postoperative MG varied (6 days-45 months, 19.3+/-16.5 months). The type of MG was ocular in 2 cases and general in 5 cases, according to the modified Osserman classification. The postoperative MG was responsive to anti-cholinesterase compounds and/or steroids. The improvement rate was 86%. Postoperative MG was present in about 1% of the patients who underwent total thymoma resection. Resection of the thymus gland does not prevent postoperative MG.

The clinical classification and treatment of arteriovenous malformations of maxilloface

To explore the clinical classification and ideal therapy for maxillofacial AVMs. According to the clinical characteristics, 106 patients with maxillofacial AVMs were divided into the 4 types Of them, 38 cases were cystic dilatation lesions, 22 cases were limited thicken lesions, 42 case were diffuse thicken lesions, 4 cases were central maxillary hemangioma. 106 patients with maxillofacial AVMs were treated in our hospital, of them, 8 cases received operation (group 1); 23 cases received embolization of supplying artery alone (group 2); 37 cases received embolization of supplying artery plus hardener intra-tumorous injection (group 3); 38 cases received embolization of supplying artery plus tumor resection (group 4). Of all the patients were followed up 1 - 11 years, In group 1, 2, 3, and 4, the cure rates is 62.50%, 17.39%, 89.19%, and 97.37% respectively. one patient died of embolization of abnormal communication branches between external carotid and intra-cranical arteries. (1) This new clinical classification is beneficial for selecting method of treatment. (2) It is necessary that a good digital subtraction angiography for maxillofacial AVMs. (3) The embolization of tumor supplying artery alone could cure the small AVM with single branch terminal blood supply. (4) The embolization of supplying artery plus hardener intratumorous injection or the embolization of supplying artery plus tumor resection is an effective method for maxillofacial AVMs.

Multimodal treatment of malignant sacrococcygeal germ cell tumors: a prospective analysis of 66 patients of the German cooperative protocols MAKEI 83/86 and 89.

To evaluate a multimodal approach including surgery and cisplatinum chemotherapy for treatment of children with malignant sacrococcygeal germ cell tumors (GCT) and to compare adjuvant and neoadjuvant strategies in advanced tumors. Between 1983 and 1995, 71 patients with malignant sacrococcygeal GCT were prospectively enrolled onto the German protocols for nontesticular GCT Maligne Keimzelltumoren 83/86 and 89. Five patients who received no chemotherapy (n = 2) or nonplatinum chemotherapy (n = 2) or who did not undergo tumor resection (n = 1) were excluded from this analysis. Among the 66 patients analyzed were 14 boys and 52 girls. The median age was 17.4 months (range, 7 months to 119 months). Median follow-up was 79 months (range, 4 months to 145 months). Fifty-two patients presented with locally advanced stage T2 tumors, and 30 patients had distant metastases at diagnosis. Patients received a median of eight cycles (range, four to nine cycles) of cisplatinum-based chemotherapy. Thirty-five patients underwent tumor resection at diagnosis and received adjuvant cisplatinum-based chemotherapy (group A). Thirty-one patients received up-front chemotherapy followed by delayed tumor resection (group B). Group B included more metastatic tumors than group A (group B, 19 of 31 patients; group A, 11 of 35 patients, P =.01). Preoperative chemotherapy facilitated complete tumor resections (group B, 20 of 31 patients; group A, five of 35 patients, P <.001) and avoided second-look surgery. Metastases at diagnosis and completeness of the first attempt of tumor resection were significant prognostic predictors; however, metastases were not predictive for patients treated with up-front chemotherapy. At 5 years follow-up, event-free survival was 0.76 +/- 0.05 (50 of 66 patients), and overall survival was 0.81 +/- 0.05 (54 of 66 patients). Four patients died as a result of therapy-related complications, and eight patients died of their tumors. Patients with locally advanced and metastatic tumors (T2b M1) fared better with neoadjuvant treatment [overall survival: 0.83 +/- 0.09 (16 of 19 patients) versus 0.45 +/- 0.15 (five of 11 patients), P =.01]. Even locally advanced and metastatic sacrococcygeal GCT can be successfully treated with up-front cisplatinum-based chemotherapy followed by delayed but complete tumor resection.

Complications of combined radiotherapy and isolated limb perfusion with tumor necrosis factor alpha +/- interferon gamma and melphalan in patients with irresectable soft tissue tumors.

Isolated limb perfusion (ILP) with tumor necrosis factor alpha (TNF alpha) +/-interferon gamma (IFN gamma) and melphalan in patients with primarily irresectable soft tissue sarcoma is promising in terms of tumor regression and limb salvage. However, the feasibility of radiotherapy in combination with this treatment modality has not been established. Fifteen patients with irresectable soft tissue tumors of the limb underwent ILP with TNF alpha, +/-IFN gamma, and melphalan. Three groups could be distinguished with respect to the role of radiotherapy. In nine patients, the residual tumor could be resected after ILP, and this was followed by radiotherapy with a total dose of 50-70 Gy (2 Gy/day). In one patient with aggressive fibromatosis, ILP was followed by radiotherapy without tumor resection (Group I). In two patients who underwent ILP for recurrent sarcoma, the primary tumor had been treated before by resection and radiotherapy (60 Gy) (Group II). In three patients whose tumors remained irresectable after ILP, radiotherapy was applied later in the course of disease for local palliation (Group III). In Group I, healing of the resection wound was markedly delayed in four patients, with soft tissue necrosis and infection necessitating amputation in two of them. Following completion of radiotherapy, persistent lymphoceles were encountered in two patients. Radiotherapy-induced fibrosis was encountered in five patients, resulting in a mild limb malfunction in two. Three-patients developed mild edema during radiotherapy. Tumor-associated neuropathy was aggravated by ILP in three patients causing severely disabling motor deficits and limb contractures in two of them. In Group II, ILP did not cause any local problem in the heavily irradiated areas. In Group III, pre-existing limb edema was increased after a total palliative dose of 20 Gy in one patient. Another patient, who had been re-operated for arterial thrombosis immediately after ILP, developed occlusion of the brachial artery 4 months after completion of palliative radiotherapy (36 Gy in 6 Gy fractions). In patients with irresectable soft tissue tumors, multimodality treatment using ILP with TNF alpha +/- IFN gamma and melphalan, tumor resection, and postoperative high-dose radiotherapy is associated with a considerable risk of tissue necrosis and impaired healing. This risk should be weighed against a possible benefit from radiotherapy in local tumor control.

Treatment of spontaneous ruptured hepatocellular carcinoma: A single-center study.

Objectives: Spontaneous rupture of hepatocarcinoma (HCC) is a fatal complication of advanced HCC and is associated with poor prognosis. However, there is no consensus on the best approach to treat hemoperitoneum due to ruptured HCC. In this paper, we evaluate and discuss the outcomes of different treatment methods employed at our center for ruptured HCC. Methods: We reviewed the medical records of 132 patients diagnosed with ruptured HCC at our hospital from January 2003 to December 2012 and evaluated and compared the outcomes of five treatment methods for ruptured HCC: conservative treatment, surgical hemostasis, transarterial embolization (TAE), and one- and two-stage resections. Results: There was no significant difference in the median survival time between the conservative treatment and surgical hemostasis groups. Patients in the TAE alone group had a better prognosis than those in the conservative treatment and surgical hemostasis groups. The survival time of the tumor resection group was obviously better than that of the conservative treatment, surgical hemostasis, and TAE alone groups, but no significant difference was observed between the one-stage and two-stage resection groups. Conclusions: One-stage hepatectomy is a better option for patients with preserved liver function, whereas TAE is a better option for those with poorly preserved liver function.