European Journal of Surgical Oncology

Editorial Board

2012-03-01

Correlation between P53 expression and malignant risk of gastrointestinal stromal tumors: Evidence from 9 studies

L. Zong, P. Chen, Y. Xu — 2012-03-01

Abstract: Purpose: The published data about p53 expression and its potential value in malignant risk of Gastrointestinal Stromal Tumors patients seemed inconclusive. To derive a more precise estimation of the relationship between p53 and Malignant risk of GIST, a meta-analysis was performed.Materials and methods: Studies have been identified by searching PubMed and Embase. Inclusive criteria were GIST patients, evaluation of p53 expression and malignant risk. The odds ratio (OR) for positive rate of p53 in NIH very low risk group vs. NIH low risk group, the odds ratio (OR) for positive rate of p53 in NIH low risk group vs. NIH Intermediate risk group and the odds ratio (OR) for positive rate of p53 in NIH Intermediate group vs. NIH high risk group were calculated with 95% confidence interval (CI) for each study as an estimation of potential value of p53 in malignant risk of GIST.Results: A total of 9 studies including 768 patients were involved in this meta-analysis. The meta-analysis of positive rate of p53 in NIH VL group vs. NIH L group did not attain significant difference (OR 0.38 95% CI, 0.11–1.28; P = 0.12 Pheterogeneity = 0.51). However the overall OR for positive rate of p53 in NIH L group vs. NIH I group revealed that significantly elevated risks of positive p53 in NIH I group were achieved (OR 0.44 95% CI, 0.24–0.82; P = 0.009 Pheterogeneity = 0.32). The overall OR for NIH I group vs. NIH H group was 0.62 (95% CI, 0.37–1.02; P = 0.06 Pheterogeneity = 0.25).Conclusion: The results indicate p53 overexpression correlate with the malignant risk increasing of GIST and have a primary and closest relationship within the NIH I risk group of GIST.

Therapeutic mammaplasty – A systematic review of the evidence

J. McIntosh, J.M. O'Donoghue — 2012-03-01

Abstract: Introduction: Therapeutic mammaplasty (TM) is suggested to have a number of advantages by comparison to conventional breast conserving surgery (BCS), but there is a paucity of published data on TM which evaluates oncologic and aesthetic end-points, and outcomes remain uncertain.Methods: Online databases were searched to identify studies regarding TM. Identified studies were scrutinised and key data relating to oncologic and aesthetic outcome, patient reported outcome measures (PROMs) and study design were recorded.Results: Most identified studies were retrospective, and no randomised controlled trials were found. Mean tumour size was reported in nine of 20 studies, with only four of 20 reporting on mean surgical margins obtained at TM. Management of a positive surgical margin following TM varied considerably between studies. With a median follow-up of between 13 and 68 months, rates of local recurrence, metastasis and death were comparable to BCS. Aesthetic assessment was complete in only three of 15 studies. PROMs and aesthetic outcomes were evaluated using non-validated tools. All studies evaluating aesthetic outcome contained evaluation by clinicians, but included patient views in only 10/15 studies. Complication rates ranged between 10% (6/63) and 91% (28/31), but delayed adjuvant treatment in only 6% of cases.Conclusion: Identified studies fail to clarify indications or confirm the suggested improved outcomes from TM over BCS, although oncological outcomes appear comparable. High complication rates impact little on delivery of adjuvant therapies. Prospective data registration is required to define indications and quality assurances, and support development of specific assessment tools for this technique in the future.

Class I versus class III radical hysterectomy in stage IB1-IIA cervical cancer. A prospective randomized study

F. Landoni, A. Maneo, I. Zapardiel, V. Zanagnolo, C. Mangioni — 2012-03-01

Abstract: Objective: The standard treatment for stage IB-IIA cervical cancer over the past three decades has been the Piver–Rutledge type III radical hysterectomy. This surgery implies a high rate of urologic morbidity. The objective was to determine the role of class I radical hysterectomy compared to class III radical hysterectomy in terms of morbidity, overall survival, DFS and patterns of relapse in patients undergoing primary surgery.Materials and methods: 125 patients with stage IB1 and IIA cervical cancer ≤4 cm were randomized between type I and type III hysterectomy. Clinical, pathologic and follow-up data were prospectively collected. Adjuvant radiotherapy was administered when indicated. Univariate and multivariate analyses were carried out.Results: Sixty-two patients were randomized to class I surgery and 63 to class III. No significant differences were observed regarding pathologic findings and adjuvant treatment. Morbidity rates were higher after class III surgery (84% versus 45%). Pelvic recurrences were equal in both groups (8 cases each one). Fifteen-year overall survival rate was 90 and 74% respectively (p = 0.11) and 76 and 80% when cervical size is ≤3 cm (p = 0.88).Conclusions: There are no significant differences in terms of both recurrence rate and overall survival among patients with stage IB-IIA cervical cancer undergoing simple extrafascial hysterectomy (class I) or radical hysterectomy (class III). Morbidity is proportional to the extent of radicality. These data confirm the need of tailoring the extent of resection to the characteristics of the cervical neoplasia and open new interesting pathways to upcoming protocols for the conservative management of these tumors.

Oesophageal cancer: How radical should surgery be?

C. Mariette, G. Piessen — 2012-03-01

Abstract: Introduction: Oesophagectomy for carcinoma can be viewed as comprising two components: resection of the oesophagus and resection of the enveloping lymphatics. Controversy exists regarding how extensive these two components should be.Methods: Through a literature overview, the aim of this educational article is to provide surgeons with arguments to understand which operation is the most oncologically sound according to patient and tumour parameters.Results: Non-randomised comparative studies evaluating radical lymphadenectomy have reported controversial survival benefit. Independent association found between the number of surgically removed lymph nodes and overall survival is an indirect evidence supporting radical lymphadenectomy. The only phase III trial comparing non-radical transhiatal oesophagectomy with transthoracic oesophagectomy for patients with oesophageal adenocarcinoma found 5-year survival rates of 29% vs. 39%, respectively. Although not statistically significant due to underpowered study, specialists would consider less of an increase in survival to be clinically relevant. For squamous OC, the first small randomised controlled trial comparing 2-field lymphadenectomy to 3-field lymphadenectomy did not found significant 5-year survival difference (48% vs. 66%) and the second one comparing 2-field lymphadenectomy to lymph node sampling identified a survival benefit favoring radical resection (36% vs. 25%).Conclusion: Radical transthoracic oesophagectomy with two-field lymphadenectomy appears to offer an optimal balance between benefits and risks to a majority of OC patients, especially in the growing area of neoadjuvant treatments. Non-radical resection should be probably reserved for patients with a poor general status whereas 3-field lymphadenectomy may be reserved to selected patients with loco-regional disease in experienced hands, surely for patients with upper OC.

Invasive extramammary Paget’s disease and the risk for secondary tumours in Europe

J.M. van der Zwan, S. Siesling, W.A.M. Blokx, J.P.E.N. Pierie, R. Capocaccia — 2012-03-01

Abstract: The aim of this study was to determine the incidence and survival of Extramammary Paget’s disease (EMPD) and to describe the possible increased risk of tumours after EMPD.All invasive cases diagnosed between 1990 and 2002 were selected from the RARECARE database. Incidence was expressed in European standardized rates. Relative survival was calculated for the period 1995–1999, with a follow-up until 31st December 2003. Standardized incidence ratios of second primary tumours were calculated to reveal possible increased risk after EMPD.European age standardized Incidence of EMPD within Europe is 0.6 per 1000,000 person years. Five-year relative survival for invasive EMPD was 91.2% (95%CI; 83.5–95.4), 8.6 percent of the EMPD patients developed other malignancies. The highest increased risk of developing a second primary tumour was found in the first year of follow-up (SIR:2.0 95%CI; 1.3–2.9), living in the South European region (SIR:2.3 95%CI; 1.5–3.5) or being female (SIR:1.5 95%CI; 1.1–1.9). Female genital organs displayed greatest increased risk of developing a second primary tumour after EMPD (SIR:15,1 95%CI; 0.38–84.23).Due to the increased risk of a second primary tumour after EMPD a thorough search for other tumours during their follow-up is recommended.

Radioguided occult lesion localization plus sentinel node biopsy (SNOLL) versus wire-guided localization plus sentinel node detection: A case control study of 129 unifocal pure invasive non-palpable breast cancers

2012-03-01

Abstract: Aims: We compared histological patterns after lumpectomy for non-palpable breast cancers preoperatively localized by radioguided occult lesion localization plus sentinel node localization (SNOLL) versus wire-guided localization.Methods: To ensure a homogeneously treated cohort and rigorous comparisons, only patients with invasive cancer and measurable opacity by imaging were included. Exclusion criteria were one or more parameters that could interfere with localization and/or the surgical procedure. Forty-three SNOLL were compared with 86 WGL plus sentinel node (SN) localization. Cancer localization effectiveness was based on careful assessment of histological data from only the first resected glandular specimen, as any additional resection specimens were guided by intraoperative histological examination.Results: Reexcisions to ensure free tissue margins were performed during the same procedure in 13.9% of SNOLL versus 31.3% of WGL; p = 0.02. Significantly more women in SNOLL (53.4%) also had free nearest margins of >9 mm after the first procedure compared with WGL (33.7%); p = 0.03. The median centricity ratio after the first procedure was better in SNOLL (2.8, range 1.3–14) than WGL (5, range 1–50); p = 0.008. The median number of SN detected by lymphoscintigraphy was the same in SNOLL and WGL (1, range 0–9, vs. 1, range 0–8). Intraoperative SN detection by blue dye and/or gamma probe was successful for 97.6% of SNOLL versus 93% of WGL.Conclusion: In this study, SNOLL was effective and safe, and this procedure significantly improved the rate of negative margins in the first specimen and the rate of reexcision for positive margins compared with WGL.

Lymphadenectomy increases the prognostic value of the revised 2009 FIGO staging system for endometrial cancer: A multi-center study

H.S. Kim, H.Y. Kim, C.Y. Park, J.M. Lee, J.K. Lee, C.H. Cho, S.M. Kim, J.W. Kim — 2012-03-01

Abstract: Background: We investigated whether pelvic or para-aortic lymphadenectomy increases the prognostic value of the revised 2009 FIGO staging system in patients with endometrial cancer (EC).Methods: We reviewed 786 patients with EC from six tertiary medical centers between July 1996 and June 2008. All patients were classified according to the 1988 FIGO staging system: IA (n = 234); IB (n = 270); IC (n = 109); IIA (n = 35); IIB (n = 29); IIIA (n = 37); IIIB (n = 3); IIIC (n = 69), and the revised 2009 FIGO staging system was also applied to divide them: IA (=542); IB (=125); II (n = 29); IIIA (n = 18); IIIB (n = 3); IIIC1 (n = 43); IIIC2 (n = 26). Prognostic values between the 1988 and the revised 2009 FIGO staging systems were compared by multivariate Cox’s proportional hazard analysis.Results: The 1988 FIGO stage IC, IIB, IIIA + IIIB and IIIC, and the revised 2009 FIGO stage IB, II, IIIA + IIIB and IIIC2 diseases were prognostic factors for poor PFS, whereas the 1988 FIGO stage IIB and IIIC, and the revised 2009 FIGO stage II, IIIA + IIIB and IIIC2 diseases were unfavorable prognostic factors for OS. Although these results were similar to those in 595 patients who underwent pelvic or para-aortic lymphadenectomy, the revised 2009 FIGO stage IIIC1 disease was an additional prognostic factor for poor PFS and OS (adjusted HRs, 4.19 and 11.25; 95% CIs, 1.39–12.60 and 2.23–36.74).Conclusions: The revised 2009 FIGO staging system had a higher prognostic value than the 1988 FIGO staging system, and pelvic or para-aortic lymphadenectomy increased the prognostic value of the revised 2009 FIGO staging system for EC.

Role of comorbidities in locally advanced cervical cancer patients administered preoperative chemoradiation: Impact on outcome and treatment-related complications

2012-03-01

Abstract: Aims: The study aimed at describing the prevalence, and pattern of comorbidities, as well as their clinical role in a large series of locally advanced cervical cancer (LACC) patients triaged to preoperative chemoradiation.Methods: The Charlson index (CCI), and the ACE27 index were used to retrospectively evaluate comorbidities in 258 LACC patients: life tables were computed by the Kaplan–Meier method; multivariate analysis was performed by Cox’s regression model.Results: A CCI score = 0 was documented in 225 patients (87.2%), while 24 patients (9.3%) had a CCI score = 1, and only 9 patients (3.5%) had a CCI score ≥2. An ACE27 score = 0 was documented in 170 patients (65.9%), and was 1 in 59 patients (22.8%), 2 in 24 patients (9.3%) and 3 in 5 patients (2%). There was no association between the presence of comorbidities and clinico-pathological variables with the exception of a direct association with older age. There was no difference in the distribution of comorbid cases according to the extent of hysterectomy and lymphadenectomy. DFS or OS curves did not differ in patients with or without comorbidities according to both indexes.No difference in the distribution of patients with comorbidities according to presence of complications was documented.Conclusions: The role of comorbidities in the decision-making process relative to the enrollment of LACC patients into this trimodal therapeutic strategy needs to be established in specifically designed prospective trials.

Improving survival following surgery for pancreatic ductal adenocarcinoma – A ten-year experience

D. Hoem, A. Viste — 2012-03-01

Abstract: Objective: Report results following pancreatic surgery at a tertiary referral hospital in Norway, and our experience with the effects of preoperative use of common bile duct stents, the prophylactic efficacy of octreotide, and explore significant survival factors.Material and methods: Prospective observational study of 275 patients during the years 1999–2009.Results: Ninety-two ductal adenocarcinomas were operated, and 183 cases were inoperable. Pylorus preserving pancreatico-duodenectomy (PPPD) was performed in 42 cases, a classic Whipple procedure (WP) in 38, distal resection in 6 and total pancreatectomy in 6 patients. Median size of the tumours was 3 cm R0 resection was obtained in 54 patients. Lymph node metastases were found in 64 patients. 20% experienced postoperative intra-abdominal complications, and 30 days postoperative mortality was 4%. A routine use of somatostatine analogues postoperatively did not reduce the frequency of leakage. Two years survival was 34.6% and 5 years 11.8%, respectively.Conclusions: Patients with ductal adenocarcinomas can be offered potential curative resections with acceptable rates of complication and mortality. Preoperative biliary stenting is still controversial and prophylactic octreotide should be used whenever the anastomosis is considered challenged and in cases of a soft pancreatic remnant. Five years all over survival has improved over the last decade from <5% to >11%.

Patent blue staining as a method to improve lymph node detection in rectal cancer following neoadjuvant treatment

2012-03-01

Abstract: Introduction: Lymph node involvement is one of the most important prognostic factors in rectal cancer. After neoadjuvant treatment the number of retrieved lymph nodes is often reported to be low which impairs reliable tumour staging. This study examines the effect of patent blue staining on the number of harvested lymph nodes and evaluates whether a higher number of retrieved lymph nodes is of prognostic significance.Patients and methods: Between March 2007 and December 2010, 295 consecutive patients with locally advanced rectal cancer following neoadjuvant treatment were included. Specimens were either not stained (NB), injected with patent blue into the mesorectum (MB) or directly into the inferior mesenteric artery (AB). Data were retrieved from a prospective database.Results: The number of evaluated lymph nodes was significantly higher in the stained specimens: mean 6.8 in the NB group (n=89), 11.5 in the MB group (n=86) and 17.4 in the AB group (n=106) (p<0.001). The percentage of patients with a minimum of 12 lymph nodes increased from 15.5% (NB) to 44.2% (MB) to 74.5% (AB) (p<0.001). The three-year cancer specific survival for the lymph node ratio (LNR) was 95% (0), 94.4% (0.01–0.1), 80.1% (0.11–0.4) and 63.7% (0.41–1).Conclusion: The use of patent blue in patients who underwent rectal cancer surgery after neoadjuvant treatment significantly enhanced lymph node harvest. Injection into the inferior mesenteric artery was most effective. This relatively simple and generally applicable method can help to improve lymph node detection which lowers the LNR and allows adequate tumour staging.

Incidence of synchronous liver metastases in patients with colorectal cancer in relationship to clinico-pathologic characteristics. Results of a German prospective multicentre observational study

R. Mantke, U. Schmidt, S. Wolff, R. Kube, H. Lippert — 2012-03-01

Abstract: Background: The aim of this prospective observational multicentre study was to evaluate the incidence of synchronous liver metastases in colon and rectal cancer and to determine clinico-pathologic factors of the colorectal cancer that influenced the development of synchronous liver metastases.Methods: Of 48,894 patients with colorectal cancer and who underwent surgery between January 2000 and December 2004, 7209 developed hepatic metastases and were analyzed.Results: Synchronous liver metastases occurred in 14.7% of the colorectal cancer cases.Colon cancer (15.4%) led significantly more frequently to haematogenous spread to the liver than rectal cancer (13.5%) in a univariate approach. The N, V, and T stage, as well as the number of metastatic-involved local lymph nodes independently influenced the frequency of synchronous liver metastases in colon and rectal cancer in a multivariate analysis. Localization of the cancer in the colon led to a different number of synchronous liver metastases. Localization of the rectal cancer did not influence the rate of synchronous liver metastases. In the case of synchronous liver metastases, patients with colon cancer had significantly more peritoneal metastases (17.9 vs. 9.15%) but less lung (9.7 vs. 14%) and bone (0.7 vs. 1.6%) metastases. Simultaneous curative liver resections were done in 7% of colon cancer cases and in 8.8% of rectal cancer cases.Conclusion: In this national study the incidence of synchronous liver metastases in colon and rectal cancer were different. Independent factors leading to synchronous liver metastases could be identified. Venous infiltration seems to be important for the development of distant metastases.

Two-stage hepatectomy: Who will not jump over the second hurdle?

O. Turrini, J. Ewald, F. Viret, A. Sarran, A. Goncalves, J.-R. Delpero — 2012-03-01

Abstract: Background: Two-stage hepatectomy uses compensatory liver regeneration after a first noncurative hepatectomy to enable a second curative resection in patients with bilobar colorectal liver metastasis (CLM).Objective: To determine the predictive factors of failure of two-stage hepatectomy.Method: Between 2000 and 2010, 48 patients with irresecable CLM were eligible for two-stage hepatectomy. The planned strategy was a) cleaning of the left hepatic lobe (first hepatectomy), b) right portal vein embolisation and c) right hepatectomy (second hepatectomy). Six patients had occult CLM (n = 5) or extra-hepatic disease (n = 1), which was discovered during the first hepatectomy. Thus, 42 patients completed the first hepatectomy and underwent portal vein embolisation in order to receive the second hepatectomy. Eight patients did not undergo a second hepatectomy due to disease progression.Results: Upon univariate analysis, two factors were identified that precluded patients from having the second hepatectomy: the combined resection of a primary tumour during the first hepatectomy (p = 0.01) and administration of chemotherapy between the two hepatectomies (p = 0.03). An independent association with impairment to perform the two-stage strategy was demonstrated by multivariate analysis for only the combined resection of the primary colorectal cancer during the first hepatectomy (p = 0.04).Conclusion: Due to the small number of patients and the absence of equivalent conclusions in other studies, we cannot recommend performance of an isolated colorectal resection prior to chemotherapy. However, resection of an asymptomatic primary tumour before chemotherapy should not be considered as an outdated procedure.

Radiofrequency assisted liver resection: Analysis of 604 consecutive cases

2012-03-01

Abstract: Background: Intraoperative blood loss is an important factor contributing to morbidity and mortality in liver surgery. To address this we developed a bipolar radiofrequency (RF) device, the Habib 4X, used specifically for hepatic parenchymal transection. The aim of this study was to prospectively assess the peri-operative data using this technique.Methods: Between 2001 and 2010, 604 consecutive patients underwent liver resections with the RF assisted technique. Clinico-pathological and outcome data were collected and analysed.Results: There were 206 major and 398 minor hepatectomies. Median intraoperative blood loss was 155 (range 0–4300)ml, with a 12.6% rate of transfusion. There were 142 patients (23.5%) with postoperative complications; none had bleeding from the resection margin. Only one patient developed liver failure and the mortality rate was 1.8%.Conclusions: RF assisted liver resection allows major and minor hepatectomies to be performed with minimal blood loss, low blood transfusion requirements, and reduced mortality and morbidity rates.

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2012-03-01

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2012-03-01