Phyllodes tumors of the breast: surgical options and outcome

Surgical management of phyllodes tumors is not clearly defined in literatures and even controversial due to the unpredictable biological behavior of these neoplasms. The authors present a prospective cohort of patients who underwent a wide range of tumor excisions to evaluate the oncologic and long term results of these procedures. Starting at June 1990 through September 2004, 64 evaluable female patients were operated for the treatment of PT in our hospital. Patients had a median age of 38 years [16-74] and a median clinical tumor size of 8 cm [3-25]. Preoperative diagnosis was made by the usual triple assessment [clinical examination, mammography and/or ultrasonography and fine needle cytology]. Surgical options included local excision [36 patients], wide local resection [13 patients], simple mastectomy [7 patients], modified radical mastectomy [4 patients], and skin sparing mastectomy [4 patients]. The median follow-up period was 89 months [3-203], where patients were regularly investigated by the same triple assessment together with the metastatic work-up. Histological examination of the surgical specimens showed 39 benign, 10 borderline and 15 malignant phyllodes tumors. Surgical margin was jeopardized in 16/36 44%] after local excision in contrast to the other procedures and consequently local recurrence rate was high 22/36 [61%]. Benign and borderline tumors had less recurrence rate com-wed to malignant lesions [40% Vs. 60%]. Overall 5-year survival rate [73.4%] was not decreased by these high rates of local recurrence because most of them could be resected adequately and the risk of distant metastasis a as low [5 patients or 7.8%]. Tumor grade, tumor margin and age of the patients were significant prognostic factors whereas, tumor size was found non significant. Phyllodes tumor in general should be reacted widely if tumor size to breast size permits clear margins. We encourage re-excision of accidentally discovered tumors after local excision of what was thought as fibroadenomas. Skin sparing mastectomy is an excellent alternative to mastectomy for these tumors provided skin of the breast is intact and away of tumor margin

Outcome of extended radical resection for gallbladder carcinoma

Purpose: The surgical management of gallbladder cancer discovered after cholecystectomy is controversial. There is no consensus as to the indication for reoperation or radical resection. The aim of this study was to review the results of reoperation and results of extended resection of theses patients

Methods: fifty three patients were referred to our center with pathological diagnosis of cancer after cholecystectomy. Ten other cases were added with a clinical diagnosis of gall bladder cancer and had their primary treatment in our side. Of the total 63 cases 17 [27%] cases underwent extended resection while the others had residual disease far extensive for resection. Extended resection included partial resection of segment IV and V together with nodal dissection of the hepatoduodenal ligament. Two cases had extended right hepatectomy

Results: The mean survival period for cases with extended resection was 28.7 months while for simple cholecystectomy it was 11.2 months. Two years and 5-years survival rates were 52.9% and 11.7% respectively for extended resection patients while, for cases treated by simple cholecystectomy alone they were 21.7% and 6.2% respectively. Extended resection had better results for T2 cases than T3 cases and cases with nodal involvement had poor results in comparison to node negative cases

Conclusion: Simple cholecystectomy alone is not enough for gallbladder cancer with deep invasion more than T1. Second surgery should be restricted for cases without nodal involvement and for T2 more than T3 cases provided there is no other sign of dissemination

Ileal orthotopic W-neobladder: functional outcome and complications

Objectives: A prospective clinical trial to assess the functional lower urinary tract voiding outcomes after orthotopic ileal W-neobladder urinary diversion following cystectomy

Material and Methods: Between February 1999 and September 2002, a total of 19 male patients with median age of 49.5 [38-67] years, having bladder cancer, underwent radical cystoprostatectomy and lower urinary tract reconstruction by means of detubularized ileal W-neobladder [Hautmann technique] as an orthotopic diversion. We made a modification at the pouch urethra anastomosis region to create a neobladder neck with funneling to improve continence. The functional voiding outcome was determined by a detailed patient interview, urodynamic studies and radiological investigations

Results: Daytime continence was 53% in the immediate postoperative period and increased to 94% after 12 months. Nighttime dryness was 32% and improved to 74%. The median neobladder pouch capacity was 510 ml 6 months after surgery and the mean voiding volume to reservoir capacity ratio was 53%. This ratio increased to 99% after one year with rapid decrease in residual volume. Continence satisfaction was 32% in the immediate post operative period -increased to 74% after one year. The upper urinary tract function kept stable or improved in 17/19 [89.4%]. Dilatation of the pelvicalyceal and the ureter either unilateral or bilateral occurred in two patients. Six cases [31%] had early postoperative complications and did not required surgical intervention. Early post operative complications related to neobladder included [15.8%] urinary leakage and [21%] prolonged ileus. Late complications related to the neobladder was found in 8 cases [42%] included metabolic acidosis [40%], urinary retention [18%] and ureteric stricture in [10.5%]

Conclusion: Ileal W-neobladder produces good functional results and can be constructed with acceptable easily treatable complications

Salvage surgery for local recurrence after breast cancer conservative mangement: lumpectomy or mastectomy

A cohort of 85 patients with intra-breast tumor recurrences [IBTR] were assigned to either wide local resection [LR] [n=25] or salvage mastectomy [SM] [n=60] using specified criteria of selection during the period 1988-1998. The mean tumor size for LR group was smaller than SM group [1.6 vs. 2.8 cm]. Nevertheless, the two groups were comparable regards other prognostic factors, like relapse-free interval, tumor location relative to the previous resection scar, method of diagnosis and tumor multiplicity. Adjuvant chemotherapy was given to 13 patients post LR and 31 cases post SM. Wide local resection can be considered in selected patients with IBTR as a salvage treatment because the type of surgery did not seem to affect survival. It should be used for late recurrences [>2 years] and noninvasive relapses

Pharyngo-cutaneous fistula following total laryngectomy for laryngeal cancer: incidence, predisposing factors and management

Pharyngo-cutaneous fistula [PCF] is a Common and serious complication following total laryngectomy for laryngeal cancer. Despite its relative frequency, there is still uncertainty about its incidence and predisposing factors. This study was designed to determine the incidence, possible predisposing factors and management of this complication. The records of 150 consecutive patients who underwent total laryngectomy for squamous cell carcinoma of the larynx were reviewed and analyzed. We evaluated the overall Incidence of PCF, factors potentially predisposing to fistula formation [T-stage of the tumor, extent of surgery, concurrent neck dissection, preoperative tracheotomy, preoperative, radiotherapy, postoperative hemoglobin level lower than 12 g dl, type of pharyngeal closure, type of suture material and onset of oral feeding] and the potential management. PCF developed in 32% of patients with a mean time of 9 days following surgery. There was statistically significant association between tumor stage, extent of surgical resection and type of pharyngeal closure and PCF formation. The other contributing factors- such as preoperative radiotherapy, preoperative tracheotomy, concurrent neck dissection and low postoperative hemoglobin level failed to show statistically significant effect. Spontaneous closure with wound care was achieved in 79% of cases. 4 patients [8.3%] required surgical closure by direct suture of the pharyngeal mucosa, while deltopectoral flaps were used in 3 cases [6.2%] pectoral is major myocutaneous flaps in 2 cases [4.1%] and free jejunal interposition flap in 1 case [2%]. Advanced T-stage of the tumor, extended laryngectomy and type of pharyngeal closure were found to have significant role in PCF formation but no statistical significant difference could be demonstrated for other investigated parameters. Our experience confirmed that most fistulas can be successfully managed with conservative treatment except in some cases where surgical suture is appropriate when conservative treatment has failed

Modified radical hysterectomy: an oncologically safe technique for carcinoma of cervix

Objective: Surgical management of cervical carcinoma by radical hysterectomy [Type III] has been proven a highly effective method in treating early stage disease. The purpose of this study was to evaluate the efficacy and safety of modified [Type II] radical hysterectomy for treatment of early stage [I-IIa] cervical carcinoma

Methods: A retrospective analysis on data of 47 patients with cervical carcinoma treated by modified radical hysterectomy during the period 1985 till 1996 with a FIGO clinical stages as la [11], Ib [29], and Ha [7]. 20 patients had radiotherapy in addition to surgery, 11 preoperative and 9 post operative. Patients had a mean follow up period of 91 month [21 -160]

Results: The surgical margins particularly the parametrial were adequate and free of malignancy in all the specimens whereas, the mean tumor size was 3cm [0.4-7], the mean depth of invasion was 9mm [1-18], and 6[12.8%] of patients had pelvic LN metastases. Two cases had parametrial extensions and 9 had vaginal extensions. Six patients [12.7%] developed relapses after a mean follow-up time of 26.5months postsurgery with no central pelvic recurrence. The 5-year disease free survival was 90.3% and the 10-year disease free survival was 87%. Cases with lesions 4cm or less in size [38] had one relapse only [2.5%] and lesions with depth less than 10mm showed no relapses

Conclusions: Modified radical hysterectomy appears to be equivalent to radical hysterectomy for lesions 4cm or less in size, but for larger sizes preoperative chemo-irradiation must be considered if conservative surgery is attempted