Skip metastasis at the esophageal resection margin in radical gastrectomy: clinical characteristics of 30 cases / 中华胃肠外科杂志

Objective: To summarize the clinical characteristics of patients with skip metastasis at esophageal resection margin during radical gastrectomy. Methods: This is a descriptive study of case series. Relevant data from 2006 to 2022 were collected from two major gastric cancer consultation and treatment centers: Nanjing Drum Tower Hospital and Jinling Hospital.Characteristics, surgical approach, number of dissected lymph nodes, immunohistochemical staining, and pathological staging were summarized and analyzed. The distribution of residual tumor cells at the esophageal margins was further analyzed at the cellular and tissue levels. Skip metastasis at the esophageal resection margin was defined as a negative esophageal margin with a positive margin in the cephalad donut. Results: Thirty (0.33%, 30/8972) eligible patients, 24 (80.0%) of whom were male, were identified in the two centers. The mean age was 63.9±11.0 years. Seventeen (56.7%) of these patients had papillary or tubular adenocarcinomas, including 13 (43.3%) poorly- and four (13.3%) moderately-differentiated tumors; four (13.3%) had signet-ring cell carcinomas; four (13.3%) mucinous adenocarcinomas; three (10.0%) mixed adenocarcinomas, including two with poorly-differentiated tubular adenocarcinomas mixed with signet-ring cell carcinoma and mucinous adenocarcinoma; and one had a poorly differentiated tubular adenocarcinoma mixed with signet-ring cell carcinoma. Two patients (6.7%) had other types of cancer, namely adenosquamous carcinoma in one patient and undifferentiated carcinoma in the other one. The predominant tumor sites were the lesser curvature (n=26, 86.7%) and the cardia (n=24, 80.0%). The mean tumor diameter was 6.6 cm, mean distance between tumor and esophageal resection margin was 1.5 cm, and proportions of tumor invasion into the dentate line, nerves, and vessels were 80.0% (24/30), 86.7%(26/30), and 93.3% (28/30), respectively. The mean number of lymph nodes resected was 20.4±8.9. The pathological stage was mainly T4 (n=18, 60.0%) and N3 (n=21, 70.0%), the median Ki67 was 52.7%, and the rates of positivity for HER2, EGFR, VEGFR, E-cadherin and PD-L1 were 40.0% (12/30), 46.7% (14/30), 80.0% (24/30), 86.7% (26/30) and 16.7% (5/30), respectively. At the cellular level, cancer cells were mainly distributed in small focal areas, as cell masses, or as tumor thrombi; large numbers of widely distributed atypic cells were seldom observed. At the tissue level, cancer cells were located in the mucosal layer in seven patients (23.3%), in the submucosal layer in 18 (60.0%), and in the muscular layer in five (16.7%); no cancer cells were identified in the outer membrane. Five of the seven tumors were located in the lamina propria, two in the muscularis mucosae, and none in the mucosal epithelium. Conclusion: Patients with skip metastasis at the esophageal resection margin at radical gastrectomy have unfavorable tumor biology and a high proliferation index, are at a late pathological stage, and the residual cancer is mostly located in the submucosa.

Advances in tumor regression patterns and safe distance of distal resection margin after neoadjuvant therapy for rectal cancer / 中华胃肠外科杂志

Neoadjuvant therapy has been widely applied in the treatment of rectal cancer, which can shrink tumor size, lower tumor staging and improve the prognosis. It has been the standard preoperative treatment for patients with locally advanced rectal cancer. The efficacy of neoadjuvant therapy for rectal cancer patients varies between individuals, and the results of tumor regression are obviously different. Some patients with good tumor regression even achieve pathological complete response (pCR). Tumor regression is of great significance for the selection of surgical regimes and the determination of distal resection margin. However, few studies focus on tumor regression patterns. Controversies on the safe distance of distal resection margin after neoadjuvant treatment still exist. Therefore, based on the current research progress, this review summarized the main tumor regression patterns after neoadjuvant therapy for rectal cancer, and classified them into three types: tumor shrinkage, tumor fragmentation, and mucin pool formation. And macroscopic regression and microscopic regression of tumors were compared to describe the phenomenon of non-synchronous regression. Then, the safety of non-surgical treatment for patients with clinical complete response (cCR) was analyzed to elaborate the necessity of surgical treatment. Finally, the review studied the safe surgical resection range to explore the safe distance of distal resection margin.

Analysis of risk factors for depth of invasion and angiolymphatic invasion for circumferential superficial esophageal squamous cell carcinoma and precancerous lesion / 中华肿瘤杂志

Objective: To analyze clinicopathological features of circumferential superficial esophageal squamous cell carcinoma and precancerous lesions and investigate the risk factors for deep submucosal invasion and angiolymphatic invasion retrospectively. Methods: A total of 116 cases of esophageal squamous epithelial high-grade intraepithelial neoplasia or squamous cell carcinoma diagnosed by gastroscopy, biopsy pathology and endoscopic resection pathology during November 2013 to October 2021 were collected, and their clinicopathological features were analyzed. The independent risk factors of deep submucosal invasion and angiolymphatic invasion were analyzed by logistic regression model. Results: The multivariate logistic regression analysis showed that drinking history (OR=3.090, 95% CI: 1.165-8.200; P<0.05), The AB type of intrapapillary capillary loop (IPCL) (OR=11.215, 95% CI: 3.955-31.797; P<0.05) were the independent risk factors for the depth of invasion. The smoking history (OR=5.824, 95% CI: 1.704-19.899; P<0.05), the presence of avascular area (AVA) (OR=3.393, 95% CI: 1.285-12.072; P<0.05) were the independent factors for the angiolymphatic invasion. Conclusions: The risk of deep submucosal infiltration is greater for circumferential superficial esophageal squamous cell carcinoma patients with drinking history and IPCL type B2-B3 observed by magnifying endoscopy, while the risk of angiolymphatic invasion should be vigilant for circumferential superficial esophageal squamous cell carcinoma patients with smoking history and the presence of AVA observed by magnifying endoscopy. Ultrasound endoscopy combined with narrowband imagingand magnification endoscopy can improve the accuracy of preoperative assessment of the depth of infiltration of superficial squamous cell carcinoma and precancerous lesions and angiolymphaticinvasion in the whole perimeter of the esophagus, and help endoscopists to reasonably grasp the indications for endoscopic treatment.

Adenomas gigantes de hipófisis: análisis de variables relacionadas con resultados visuales, endocrinológicos y de resección en cirugía endoscópica transesfenoidal / GIANT PITUITARY ADENOMAS: ANALYSIS OF VARIABLES RELATED TO VISUAL, ENDOCRINOLOGICAL AND RESECTION RESULTS IN TRANSSPHENOIDAL ENDOSCOPIC SURGERY

Introducción. Los adenomas gigantes de hipófisis (AGHs) son aquellos tumores con un diámetro máximo ≥4 cm en cualquier dirección, representando del 5% al 14% del total de los adenomas que se tratan quirúrgicamente. Su manejo terapéutico es desafiante ya que, debido a su extensión hacia otras estructuras cerebrales,está asociado a un riesgo mayor de complicaciones quirúrgicas, con una menor tasa de resección total. El objetivo de este trabajo fue evaluar el impacto de la cirugía endoscópica transesfenoidal en AGHs, analizando las variables asociadas a resultados visuales, endocrinológicos y según el grado de resección. Pacientes y Métodos. Se evaluó en 44 pacientes con AGHs(diámetro ≥4 cm y/o volumen ≥10 ml) la presentación visual, endocrinológica e imágenes. Se analizaron estadísticamente resultados visuales, endocrinológicos, grado de resección y complicaciones quirúrgicas. Resultados. Edad promedio de 48.8 años, 24 mujeres y 20 hombres. Presentación: déficit del campo visual (93.1%), hipopituitarismo (61.3%), cefalea (54.5%). Diámetro, volumen y extensión supraselar promedios: 4.8 cm, 20.3 ml, 1.8 cm, respectivamente. Campo visual: mejoría: 83.3%, sin cambios: 9.5%, mayormente en síntomas bilaterales (p<0.0001). Desmejoríavisual: 0%. En resección total: mayor posibilidad de mejoría visual (p=0.040). Buenos resultados endocrinológicos: 85.7%. Tasa de resección total: 52.3%. Resección subtotal: más frecuente con invasión del seno cavernoso (p=0.014). Sin diferencias en el grado de resección según diámetro, volumen, extensión supraselar, forma ni aspecto. Hipopituitarismo: 4.2%. Diabetes insípida: 9.5%, asociada a mayor diámetro (p=0.038) o extensión supraselar (p=0.010) y aspecto sólido (p=0.023). Fístula de LCR: 7.1%. Conclusión. La resección total puede lograrse en la mitad de los casos, siendo la limitante principal el grado de invasión del seno cavernoso y no el aspecto morfológico del AGH per se. Aun así, los resultados visuales y endocrinológicos son muy buenos. En resecciones incompletas se logra el control de la enfermedad mediante tratamientos complementarios

Introduction. Giant pituitary adenomas (sGAs) are those tumors with a maximum diame- ter ≥4 cm in any direction, representing 5% to 14% of all adenomas that are treated surgi- cally. Its therapeutic management is challenging since, due to its extension to other brain structures, it is associated with a higher risk of surgical complications, with a lower rate of total resection. Te objective of this work was to evaluate the impact of transsphenoidal endoscopic surgery on AGHs, analyzing the variables associated with visual and endocri- nological results and according to the degree of resection. Patients and Methods. Visual, endocrinological and imaging presentation were evaluated in 44 patients with sHAA (dia- meter ≥4 cm and/or volume ≥10 ml). Visual and endocrinological results, degree of resection and surgical complications were statistically analyzed. Results. Average age of 48.8 years, 24 women and 20 men. Presentation: visual field deficit (93.1%), hypopituitarism (61.3%), headache (54.5%). Average diameter, volume and suprasellar extension: 4.8 cm, 20.3 ml, 1.8 cm, respectively. Visual field: improvement: 83.3%, no changes: 9.5%, mostly in bilate- ral symptoms (p<0.0001). Visual impairment: 0%. In total resection: greater possibility of visual improvement (p=0.040). Good endocrinological results: 85.7%. Total resection rate: 52.3%. Subtotal resection: more frequent with invasion of the cavernous sinus (p=0.014). No differences in the degree of resection according to diameter, volume, suprasellar exten- sion, shape or appearance. Hypopituitarism: 4.2%. Diabetes insipidus: 9.5%, associated with greater diameter (p=0.038) or suprasellar extension (p=0.010) and solid appearance (p=0.023). CSF fistula: 7.1%. Conclusion. Total resection can be achieved in half of the cases, the main limitation being the degree of invasion of the cavernous sinus and not the morphological appearance of the HGA per se. Even so, the visual and endocrinological results are very good. In incomplete resections, disease control is achieved through com- plementary treatments

Application of near infrared fluorescence imaging in detection of residual cancer in oral squamous cell carcinoma / 中华肿瘤杂志

Objective: Local recurrence is the main cause of treatment failure in patients with oral squamous cell carcinoma (OSCC). This study was proposed to investigate the feasibility of near infrared fluorescence (NIF) via indocyanine green (ICG) for monitoring surgical marginal in operation for OSCC patients. Methods: In 35 patients with OSCC treated surgically in the Department of Oral and Maxillofacial Surgery, Nanjing University School of Medicine, from January 2019 to June 2020, ICG (0.75 mg/kg) was administered intravenously via elbow vein at (12±1) hours before surgery, and NIF was performed intraoperatively on the surgical field and the cut edge of the surgically excised specimen, and fluorescence intensity was measured for OSCC tissue and normal oral mucosa, abnormal fluorescence signals were taken and subjected to rapid cryopathological examination. Correlation between NIF tumor boundary grading and pathological tumor boundary grading was analyzed by Spearman correlation analysis. Results: Clear ICG NIF was obtained for tumor lesions in all 35 patients, with a positive rate of 100%. The fluorescence intensity of OSCC tissue was (412.73±146.56) au, which was higher than that of normal oral mucosa tissue [(279.38±82.56) au, P<0.01]. Abnormal fluorescence signals were detected at the tumor bed and the cut edge of the surgical resection specimen in 4 patients, of which 2 cases were pathologically confirmed as cancer cell residue and 2 cases as inflammatory cell infiltration. The rate of positive detection of cut margins using ICG NIF technique in OSCC was 5.7% (2/35). Twenty of the 35 OSCC patients had grade 1, 11 of grade 2, and 4 of grade 3 tumor borders revealed by NIF of surgical resection specimens, which was positively correlated with pathological tumor border (r=0.809, P<0.001). Conclusions: ICG NIF technique can effectively detect the residual cancer cells at the incision margin, which is of great clinical value in reducing local recurrence of OSCC after surgery due to intraoperative cancer residue.

Preliminary experience of transoral robotic surgery for oropharyngeal carcinoma / 中华耳鼻咽喉头颈外科杂志

Objective: To investigate the oncological and functional efficacy and safety of transoral robotic surgery (TORS) in the treatment of oropharyngeal carcinoma. Methods: Twenty-six patients with oropharyngeal cancer were enrolled who underwent TORS at Beijing United Hospital from June 1, 2017 to December 31, 2020. Among them, 22 patients were males and 4 were females, aged 39 to 76 years old. T1-2 patients accounted for 88.5% (23/26). Clinicopathological data including the time of removal of gastric and endotracheal tube were collected. The SPSS software package was used for survival analysis, and the overall survival rate and disease-free survival rate were calculated. Results: All the 26 patients with oropharyngeal cancer received TORS without conversion to open surgery, and 20 of them underwent simultaneous cervical lymph node dissection. TORS operation time ranged from 65 to 360 minutes with an average of 215 minutes. Intraoperative blood loss ranged from 5 to 600 ml with an average of 70 ml. Four patients (15.4%) underwent tracheotomy, of whom 3 patients had the removals of tracheal tubes within 1 month after surgery and 1 case remained to wear a tube by the end of follow-up. Twelve patients (46.2%) underwent gastric tube implantation, among them, 11 patients had removals of gastric tubes within 1 month after surgery and 1 patient died of oropharyngeal hemorrhage 13 days after operation. One patient (3.8%) had a positive surgical margin and others had pathologically negative surgical margins. Sixteen patients (61.5%) received postoperative radiotherapy, of whom 11 patients (42.3%) received platinum-based concurrent chemotherapy. The median follow-up time was 21.5 months (0.4 to 45 months). The overall survival and the disease-free survival rates were 83.0% and 75.8%, respectively. Conclusion: The application of TORS in treatment of oropharyngeal cancer can achieve good oncological and functional outcomes in selected patients.

Overlap esophagojejunostomy with multi-mode modifications in totally laparoscopic total gastrectomy: safety and feasibility of 152 cases from a single center / 中华胃肠外科杂志

Objective: Currently, the Overlap anastomosis is one of the most favored reconstruction methods of intracorporeal esophagojejunostomy (EJS). Despite many advantages of the method, it remains some shortcomings to be improved when it comes to the retraction of the esophagus stump, the insertion of the anvil fork of the linear stapler into a "pseudo" lumen, and the closure of the common entry hole. This study aims to investigate the safety and feasibility of a multi-mode modified Overlap anastomosis. Methods: A descriptive case series study was conducted. Medical records of 152 consecutive patients who underwent totally laparoscopic total gastrectomy (TLTG) with our multi-mode modified Overlap EJS method by the same surgical team at our department from February 2017 to June 2020 were retrospectively analyzed. The multi-mode modified Overlap method mainly included (1) After ensuring the safety of tumor resection margin (proximal margin was at least 3 cm from the tumor), the esophagus was partially transected from left to right (with 5-8 mm width esophagus continuation). The specimen was then placed in a plastic bag which was tied up at the mouth using strings with a part of the esophageal wall poking through. Then the plastic bag containing the specimen was transferred to the right lumbar region, while the patient's body position was adjusted so that the abdominal esophagus could be pulled by the gravity of the specimen. (2) Using the "three-direction traction" method. The esophageal lumen was properly exposed, then guided by the gastric tube, the anvil fork was accurately placed into the esophageal lumen for completing the side-to-side EJS. (3) The 3-0 barbed suture was used in the closure of the common entry hole of the stapler from dorsally to ventrally with simple one-layer continuous suture (the stitch going from inside to inside) followed by continuous Lembert's suture (the stitch going from outside to outside). Combined with clinicopathological characteristics, the perioperative outcomes and postoperative complications of the whole group were analyzed and evaluated. Results: The study cohort included 129 men and 23 women, with a mean age of (60.2±9.1) years and a mean body mass index (BMI) of (23.2±3.1) kg/m(2). Of the 152 patients, 23 patients (15.1%) had a history of previous abdominal surgery; dentate line was invaded by tumor in 21 patients (13.8%). The mean length of the proximal resection margin was (3.3±0.3) cm and the postoperative pathological examination indicated negative resection margin tumor. The mean operative time and anastomotic time were (302.1±39.9) minutes and (29.8±5.4) minutes, respectively. The mean estimated blood loss was (87.9±46.4) ml. The mean length of postoperative hospital stay was (12.3±7.3) days. The overall severe postoperative complications (Clavien-Dindo ≥ II) occurred in 22 patients (14.5%). Six cases of pancreatic leakage were successfully recovered by adequate drainage, inhibition of pancreatic exocrine secretion and nutritional support. Ten cases of pneumonia and three cases of abdominal infection were cured with anti-infection and physical therapy. Two patients developed anastomotic leakage postoperatively. One case was caused by excessive tension of the Roux loop of the jejunum and excessive opening on the side of the jejunum after side-to-side anastomosis, and the other case was caused by an accidental intraoperative occurrence of "nasogastric tube stapled to the side-to-side anastomosis". Both of them recovered after conservative treatment including adequate drainage, anti-infection, and adequate nutritional support. One patient underwent immediate open surgery because of Peterson's hernia 7 days after TLTG, and the patient died due to extensive small bowel necrosis. Conclusions: Multi-mode modified overlap method simplifies the operation and reduces the difficulty of EJS. It is a safe and feasible method for EJS.

Resection margin of colorectal cancer surgery / 中华胃肠外科杂志

The judgment of surgical resection margins is an important factor affecting local recurrence and distant metastasis of colorectal cancer, which is crucial to the prognosis of patients. How to select a standard and ideal surgical resection margin is a challenge for colorectal cancer surgeons. Surgical resection margins for colorectal cancer include longitudinal resection margin (LRM) and circumferential resection margin (CRM), and the distance of safe resection margins varies according to different guidelines. Surgical resection margins are mainly evaluated by preoperative imaging, operative experience, operative type, hyperspectral imaging (HPI) and fluorescence angiography (FA), and postoperative pathology. It is the constant pursuit of colorectal cancer surgeons to pay attention to the safe resection margins in colorectal cancer surgery to reduce local recurrence and distant metastasis.

Factors associated with incomplete surgical margins in basal cell carcinoma of the head and neck / Fatores associados a margens cirúrgicas incompletas no carcinoma basocelular de cabeça e pescoço

Abstract Introduction: Cutaneous basal cell carcinoma recurrence is associated with inadequate surgical margins. The frequency of and the factors associated with compromised or inadequate surgical margins in head and neck basal cell carcinoma varies. Objective: The purpose of this study was to evaluate the clinical and pathological factors associated with inadequate surgical margins in head and neck basal cell carcinoma. Methods: We developed a cross-sectional study comprising all patients who had undergone resection of head and neck basal cell carcinoma from January 2017 to December 2019. Data on age, sex, head and neck topography, histopathological findings, and staging were retrieved and compared. Each tumor was considered an individual case. Compromised and close margins were termed ''inadequate'' or ''incomplete''. Variables that were significantly associated with the presence of incomplete margins were further assessed by logistic regression. Results: In total, 605 tumors from 389 patients were included. Overall, sixteen cases (2.6%) were classified as compromised, 52 (8.5%) as close, and 537 (88.7%) as free margins. Presence of scleroderma (p = 0.005), higher Clark level (p < 0.001), aggressive variants (p < 0.001), invasion beyond the adipose tissue (p < 0.001), higher T stage (p < 0.001), perineural invasion (p = 0.002), primary site (p = 0.04), multifocality (p = 0.01), and tumor diameter (p = 0.02) showed association with inadequate margins. After Logist regression, multifocality, Clark level and depth of invasion were found to be independent risk factors for inadequate margins. Conclusion: Gross clinical examination may be sufficient for determining low prevalence of inadequate surgical margins when treating head and neck basal cell carcinoma in highly experienced oncologic centers. Multifocality, Clark level and depth of invasion were found to be independent risk factors for incomplete margins.

Resumo Introdução: A recorrência do carcinoma basocelular (CBC) cutâneo está associada a margens cirúrgicas inadequadas. A frequência e os fatores associados a margens cirúrgicas comprometidas ou inadequadas no carcinoma basocelular de cabeça e pescoço variam. Objetivo: Avaliar os fatores clínicos e patológicos associados a margens cirúrgicas inadequadas no carcinoma basocelular de cabeça e pescoço. Método: Conduzimos um estudo transversal que abrangeu todos os pacientes submetidos à resseçcão de carcinoma basocelular de cabeça e pescoço de janeiro de 2017 a dezembro de 2019. Dados sobre idade, sexo, topografia na cabeça e pescoço, achados histopatológicos e estadiamento foram recuperados e comparados. Cada tumor foi considerado como um caso individual. As margens comprometidas e próximas foram denominadas ''inadequadas'' ou ''incompletas''. As variáveis que foram significantemente associadas à presença de margens incompletas foram avaliadas adicionalmente por regressão logística. Resultados: Foram incluídos 605 tumores de 389 pacientes. No geral, 16 casos (2,6%) foram classificados como comprometidos, 52 (8,5%) como próximos e 537 (88,7%) como margens livres. Presença de esclerodermia (p = 0,005), nível de Clark mais elevado (p < 0,001), variantes agressivas (p < 0,001), invasão além do tecido adiposo (p < 0,001), estágio T mais avançado (p < 0,001), invasão perineural (p = 0,002), sítio primário (p = 0,04), multifocalidade (p = 0,01) e diâmetro do tumor (p = 0,02) mostraram associação com margens inadequadas. Após a regressão logística, a multifocalidade, o nível de Clark e a profundidade de invasão foram considerados fatores de risco independentes para margens inadequadas. Conclusão: O exame clínico macroscópico pode ser suficiente para determinar baixa prevalência de margens cirúrgicas inadequadas no tratamento do carcinoma basocelular de cabeça e pescoço em centros oncológicos altamente experientes. Multifocalidade, nível de Clark e profundidade de invasão foram considerados fatores de risco independentes para margens incompletas.

Variables pronósticas de pacientes con melanomas gruesos. Análisis de 362 casos / Prognostic variables in patients with thick melanomas. Analysis of 362 cases

Resumen Antecedentes: Los estudios sobre factores pronóstico de melanoma están basados en poblaciones caucásicas, con predominio de melanomas delgados (Breslow < 3 mm). Los pacientes mexicanos muestran predominio de melanomas gruesos (Breslow ≥ 3 mm). Objetivo: Identificar factores asociados al pronóstico de pacientes con melanomas gruesos. Material y métodos: Se analizó la influencia pronóstica de factores clinicopatológicos en 362 melanomas gruesos. Resultados: La mediana de Breslow fue de 7 mm, 271 (74.9 %) pacientes tuvieron melanoma acral y 49 (13.5 %) melanoma nodular. El 56.6 % de los pacientes se encontró en etapa clínica [EC] III), 269 (74.3 %) tenía ulceración y 15 (4.1 %) márgenes positivos. Las variables asociadas con menor supervivencia global [SG] fueron la EC (p < 0.001), Breslow (p = 0.044), ulceración (p = 0.004), mitosis (p < 0.001) y margen < 2 cm (p < 0.001) . En el análisis multivariante los factores que influyen en SG fueron la EC, mitosis y el margen quirúrgico. Conclusiones: En pacientes con melanomas gruesos la SG es influida por un margen positive, mitosis y EC.

Abstract Background: Studies on prognostic factors in melanoma are based on Caucasian populations, with a predominance of thin melanomas (Breslow <3 mm). Mexican patients show a predominance of thick melanomas (Breslow ≥ 3 mm). Objective: To identify factors associated with the prognosis of patients with thick melanomas. Material and methods: The prognostic influence of clinicopathological factors was analyzed in 362 thick melanomas. Results: The Breslow median was 7 mm, 271 (74.9 %) patients had acral melanoma and 49 (13.5 %) nodular melanoma. The 56.6 % of patients were found in clinical stage [CS] III), 269 (74.3 %) had ulceration, and 15 (4.1 %) had positive margins. The variables associated with lower overall survival [OS] were CS (p < 0.001), Breslow (p = 0.044), ulceration (p = 0.004), mitosis (p < 0.001) and margin < 2 cm (p < 0.001). In the multivariate analysis, the factors influencing OS were CD, mitosis, and the surgical margin. Conclusions: In patients with thick melanomas, OS is influenced by a positive margin, mitosis and CS.

Partial nephrectomy provides equivalent oncologic outcomes and better renal function preservation than radical nephrectomy for pathological T3a renal cell carcinoma: A meta-analysis

ABSTRACT Purpose: Radical nephrectomy (RN) is the standard surgical type for pathological stage T3a (pT3a) renal cell carcinoma (RCC). Recently, some studies have suggested equivalence between partial nephrectomy (PN) and RN for oncologic control and have shown the benefits of PN for better renal function. We conducted this meta-analysis to assess oncologic outcomes, perioperative outcomes and renal function between two groups among patients with pT3a RCC. Materials and methods: PubMed, Scopus, Web of Science, Science Direct, Ovid MEDLINE, The Cochrane Library, Embase and Google Scholar were searched for eligible articles. The endpoints of the final analysis included overall survival (OS), cancer-specific survival (CSS), recurrence-free survival (RFS), surgical complications, operative time, estimated blood loss (EBL), serum creatinine and estimated glomerular filtration rate (eGFR). Results: Twelve studies of moderate to high quality, including 14.152 patients, were examined. PN showed superiority for renal functional preservation, providing higher eGFR (WMD=12.48mL/min; 95%CI: 10.28 to 14.67; P <0.00001) and lower serum creatinine (WMD=-0.31mg/dL; 95%CI: −0.40 to −0.21; P <0.00001). There were no significant differences between PN and RN regarding operative time, EBL, surgical complications, OS, RFS and CSS. Despite inherent selection bias, most pooled estimates were consistent in sensitivity analysis and subgroup analysis. More positive margins were found in the PN group (RR=2.42; 95%CI: 1.25-4.68; P=0.009). Conclusions: PN may be more suitable for treating pT3a RCC than RN because it provides a similar survival time (OS or RFS) and superior renal function. Nevertheless, this result is still disputed, and more high-quality studies are required.

Escisión de torus mandibular bilateral en paciente sistémicamente comprometido: reporte de caso / Excision of bilateral mandibular torus in a systemically com-promised patient: a case report

Introducción: El torus mandibular es un crecimiento exofítico óseo ubicado en el área lingual de la mandíbula, generalmente bilateral. Puede estar asociado con trastornos temporomandibulares, afectar la pronunciación, producir halitosis, interferir con la deglución y causar dolor en la mucosa cuando está bajo prótesis mal diseñadas. Normalmente, el tratamiento no es necesario, excepto por necesidades protésicas, problemas funcionales, retención de alimentos, trastornos fonéticos o en caso de que se vaya a usar como injerto óseo autólogo. El objetivo de este reporte de caso fue realizar la escisión del torus mandibular bilateral en un paciente sistémicamente comprometido para su posterior rehabilitación con una prótesis parcial removible. Se realizo la atención de una paciente de 66 años sexo femenino, a quien, luego de analizar los medios diagnósticos y la evidencia científica, se le pudo realizar la escisión del torus mandibular bilateral de forma atraumática; esto permitió el correcto asentamiento de una prótesis parcial removible. La escisión del torus mandibular bilateral es un procedimiento seguro y predecible, y ayuda a evitar complicaciones protésicas, como el diseño de la estructura, y biológicas, como úlceras, depósitos de comida o halitosis, lo que devuelve la estabilidad y la función al sistema estomatognático. (AU)

The mandibular torus is a bony exophytic growth located in the lingual area of the mandible. While this growth is generally bilateral, it can be associated with temporomandibular disorders. I It affects pronunciation, produces halitosis, interferes with swallowing, and causes pain in the mucosa under poorly designed prostheses. Normally, treatment is not necessary, except in cases with prosthetic needs, functional problems, food retention, phonetic disorders or if it is to be used as an autologous bone graft. The aim of this study was to perform a bilateral mandibular torus excision in a systemically compromised patient for subsequent rehabilitation with a removable partial denture. A 66-year-old female presenting a bilateral mandibular torus attended our dental clinic. After achieving the diagnosis and analyzing the scientific evidence available, the bilateral mandibular torus was atraumatically excised, allowing correct seating of a removable partial denture. Bilateral mandibular torus excision is a safe and effective procedure, which helps to avoid prosthetic complications involving structural design and biological complications such as ulcers, food deposits and / or halitosis, restoring stability and function to the stomatognathic system. (AU)

5-aminolevulinic Acid and Surgical Margin Analysis in Calvarial Metastasis with Pericranium or Dural Extension: Technical Note

Metastasis to the calvarium with direct pericranium or dural infiltration may be treated with radical surgical removal in selected cases. We describe microsurgical resection of calvarial metastases with fluorescence-guided technique using 5-aminolevulinic acid (5-ALA) in two female patients with breast cancer. Fluorescence findings were positive in both cases. Margins in the scalp and dural layer were 5-ALA negative at the end of surgical removal. Intraoperative pathology was performed in all cases to confirm if oncological limits were free of disease. One case was 5-ALA positive in the outer layer of the dura-mater and another in the pericranium. At the end of the removal in both cases, the surgicalmargins were 5-ALA fluorescence-free. Intraoperative pathology confirmed oncological limits of the resection. 5-aminolevulinic acid fluorescence-guided surgery for calvarial metastases with pericranium and/or dural extension seems to be a safe and reliable method to aid the surgical margins for complete removal, possibly delaying or avoiding adjuvant irradiation for progression control.

Investigation of the relationship between cerebral near-infrared spectroscopy measurements and cerebrovascular event in coronary artery bypass grafting operation in patients without carotid stenosis and patients with carotid stenosis below surgical margins

Abstract Objectives: Stroke is an important cause of mortality and morbidity in surgery. In the present study, we examined the cerebral oximetry values of patients with carotid artery stenosis who did not present surgical indications and those who did not present carotid artery stenosis in coronary artery bypass grafting (CABG) surgery by comparing their cerebral oximetry values with cerebrovascular disease (CVD). Methods: Between January and May 2014, 40 patients who underwent isolated CABG were included in the study. Cerebral oximetry probes were placed prior to induction of anesthesia. Cerebral oximetry values were recorded before induction, in the pump (cardiopulmonary bypass) inlet period, in the post-clamp period, in the pump outlet period, and in the intensive care unit and neurological complications. Results: There was no difference between the groups in terms of demographic data and routine follow-up parameters. Intraoperative surgical data and early postoperative results were similar in both groups. When comparing the groups, there were no statistically significant results in cerebral oximetry values and CVD development. Only one patient in group 2 had postoperative CVD and this patient was discharged from the hospital with right hemiplegia. Mean arterial pressure (MAP)levels were significantly higher in Group 2 (P<0.05). Conclusion: The follow-up of cerebral perfusion with a method like near-infrared spectroscopy (NIRS) will ensure that MAP is adjusted with interventions that will be made according to changes in NIRS. Thus, it will be possible to avoid unnecessary medication and flow-rate increase with cerebral oxygen saturation (rSO2) follow-up.

Margen positivo (R1) en la biopsia intraoperatoria durante una gastrectomía total por cáncer gástrico / Positive margin (R1) in the intraoperative biopsy during a total gastrectomy for gastric cancer

Resumen El cáncer gástrico es una patología de alta incidencia en Chile. Afortunadamente es baja la incidencia de márgenes R1 cuando se realiza una cirugía con intención curativa. Al tener un tumor subcardial o cardial es perentorio realizar una biopsia rápida (intraoperatoria), en caso que ésta resulte positiva, es difícil tomar una decisión sobre qué realizar a continuación, ya que el realizar una esofagoyeyunoanastomosis intratorácica aumenta el riesgo quirúrgico. Para esto, es de suma importancia tener la información de las características histopatológicas del tumor, el riesgo de filtración, la recurrencia, la sobrevida, las terapias adyuvantes y la realidad país. Se realizó una revisión de la literatura con el fin de poder guiar la toma de decisiones.

Gastric cancer is a pathology with a high incidence in Chile, fortunately, the incidence of R1 margins is low when performing surgery with curative intent. When having a sub cardial or cardial tumor, it is essential to perform a rapid (intraoperative) biopsy, if this is positive when cutting the esophagus just under the pillars, it is difficult to make the decision of what to do next, since performing an inthrathoracic esophagojejunostomy increases the surgical risk. For this, it is very important to have information about the histopathological characteristics of the tumor, the leakage risk, there currence, the survival, the adjuvant therapies and the reality of the country. A review of the literature was done in order to guide the decisions.

Effect of pelvimetric diameters on success of surgery in patients submitted to robot-assisted perineal radical prostatectomy

ABSTRACT Objective: Minimally invasive techniques are used increasingly by virtue of advancements in technology. Surgery for prostate cancer, which has high morbidity, is performed with an increasing momentum based on the successful oncological and functional outcomes as well as cosmetic aspects. Materials and methods: Sixty two patients underwent robot-assisted perineal radical prostatectomy (R-PRP) surgery at our clinic between November 2016 and August 2017. Six pelvimetric dimensions were defined and measured by performing multiparametric magnetic resonance imaging (mpMRI) prior to operation in all patients. In light of these data, we aimed to investigate the effect of pelvimetric measurements on surgery duration and surgical margin positivity. Results: By using this technique in pelvic area, we observed that measurements only representing surgical site and excluding other pelvic organs had a significant effect on surgery duration, and pelvic dimensions had no significant effect on surgical margin positivity. Conclusion: In R-PRP technique, peroperative findings and oncological outcomes can vary depending on several variable factors, but although usually not taken into account, pelvimetric measurements can also affect these outcomes. However, there is a need for randomised controlled trials to be conducted with more patients.

Comparación entre los melanomas de cabeza y cuello con los de tronco y extremidades / Comparison between head and neck melanomas with trunk and extremity melanomas

Antecedentes: los melanomas en cabeza y cuello (MCC) han sido asociados con factores pronósticos diferentes de aquellos en otras localizaciones. Objetivo: comparar características demográficas, clínicas y resultados del tratamiento quirúrgico de pacientes con MCC y pacientes con melanomas en tronco y extremidades (MTE). Material y métodos: se llevó a cabo una revisión retrospectiva de las historias clínicas de pacientes operados por melanoma entre enero de 2012 y diciembre de 2017. Quince pacientes (22,3%) tuvieron MCC y 52 (77,7%) MTE. Resultados: ambos grupos tuvieron edad similar (63,8 ± 21,1 versus 58,5 ± 16), pero los MCC mostraron una tendencia con predominio masculino (80% versus 61,3%). Los MCC tuvieron menor espesor tumoral que los MTE (2,07 versus 5,5 mm) y mayor porcentaje de melanoma in situ, 5 (33,3%) versus 8 (15,3%), pero requirieron vaciamientos ganglionares más a menudo (33% versus 25%) así como reconstrucción del defecto primario con colgajos locales y miocutáneos. Durante el seguimiento, en el grupo de MCC, dos pacientes desarrollaron recidivas locales que fueron extirpadas, y otros tres desarrollaron metástasis a distancia en pulmón, intestino delgado y abdomen y fallecieron por la enfermedad; en el grupo de MTE un paciente tuvo recidiva local y cinco fallecieron de metástasis sistémicas. El tamaño de la muestra no permitió aplicar pruebas de significación entre las diferencias encontradas. Conclusión: los MCC se presentan en un amplio rango de edad y estadios, y tuvieron algunas diferencias clínicas con el MTE. Los defectos producidos por la extirpación de la lesión primaria requieren procedimientos reconstructivos más complejos la mayoría de las veces y se aconseja un abordaje multidisciplinario.

Background: Head and neck melanomas (HNMs) have been associated with prognostic factors different from those on other locations. Objective: The goal of the present study was to compare the demographic and clinical characteristics and the outcomes of surgical treatment between patients with HNM and those with trunk and extremity melanoma (TEM). Material and methods: The clinical records of patients undergoing surgery for melanoma between October 2014 and April 2018 were retrospectively reviewed. Fifteen patients (22.3%) had HNM and 52 (77.7) presented TEM. Results: There were no differences in age between both groups (63.8 ± 21.1 versus 58.5 ± 16), but there was a trend toward higher percentage of men in the HNM group (80% versus 61.3%). Patients with HNM had lower tumor thickness than those with TEM (2.07 versus 5.5 mm), higher incidence of melanoma in situ [5 (33.3%) versus 8 (15.3%)]; lymph node resection was more common (33% versus 25%) as well as reconstruction of the primary defect with local and musculocutaneous flaps. During follow-up, two patients in the HNM group developed local recurrences that were excised and three presented distant metastases in the lung, small bowel and abdomen and finally died due to the disease. In the TEM group, one patient had local recurrence and five died due to systemic metastases. The sample size was not sufficient to assess statistically significant differences. Conclusion: Head and neck melanomas occur in a wide age range and stages and has some clinical differences with TEM. The defects produced after the excision of the primary lesion often require more complex procedures and should be managed with a multidisciplinary approach.

Pterygium surgeries at a tertiary hospital, southwest Nigeria: a four-year review

Background: Over the years several pterygium surgical techniques have been developed with the aim of having the least possible recurrence rate. This has been from bare sclera excision which had an unacceptable recurrence rate to the current use of conjunctiva autograft with or without various adjuncts. This study was to review the current practice in a typical multi-specialist ophthalmic department. Method: The ophthalmic theatre operating register was retrospectively reviewed to obtain information on all patients who had pterygium excision at the University College Hospital, Ibadan, over a 4-year period from January 1, 2014, to December 31, 2017. Results: A total of 324 pterygium surgeries were performed and final analysis was on 249 (76.9%) surgeries which met the inclusion criteria, male to female ratio of 0.96:1. The commonest surgical technique was excision + 5-Flourouracil (5FU) + conjunctival autograft accounting for 187(75.1%) eyes. In total, postoperative recurrence was recorded in 40 (16.1%) eyes. The subgroup of excision + 5FU + autograft had the least recurrence rate of 18 (9.6%) eyes. Conclusion: A significant majority of the excision was with conjunctiva autograft with an acceptable low recurrence rate compared with most studies