Outcome of surgical management of adenocarcinoma of esophagogastric junction

Adenocarcinoma of the esophagogastric junction [AEG] is a challenging disease for the surgeon. Because of its borderline location, the choice of surgical strategy is controversial. Efforts are currently directed to select patients who may benefit from extensive resection. Therefore, we carried out this prospective study to evaluate the outcome of surgical treatment based on Siewert's classification. From January 2004 to December 2006, 36 patients with AEG underwent resection. The choice of surgical approach was based on the location of the tumor center. The treatment of choice was esophagectomy and proximal gastrectomy for type I tumors and extended gastrectomy and distal esophagectomy for type II and III tumors. The outcome of surgery and prognostic factors were analyzed. Fourteen out of the 36 AEG cases [39%] were diagnosed as having type I tumors, twelve [33%] had type II and 10 [28%] had type Ill AEG tumors. Esophagectomy with proximal gastreetomy was carried out in all patients with type I tumors. Eleven patients with type I tumors underwent transhiatal resection while 3 patients underwent transthoracic resection. All type III tumor patients underwent transabdominal resection by total gastrectomy with transhiatal resection of the distal esophagus. The extent of surgery for type II tumors was the same as type III however, ten patients had a transabdominal resection, while one patient had a thoracotomy and another patient underwent transhiatal esophagectomy. The overall 2-year survival rate was 33.3%. Survival rate was significantly associated with pT stage, pathological node-positive category and tumor stage. Postoperative 30-day mortality and morbidity rates were 30.5%, 36.1%; respectively. Siewert's classification provides a useful tool for selecting the surgical approach but should be tailored to individual patients to achieve R0 resection. Survival is still largely stage dependent and earlier diagnosis holds the key to improve prognosis

Internal hemipelvectomy, a limb saving procedure, NCI experience

Treatment of primary malignant tumors involving the pelvic girdle traditionally necessitated the sacrifice of a healthy lower extremity. Internal hemipelvectomy offers a safe alternative to this problem. With careful selection, the lower limb can be salvaged with acceptable function and hip stability. This study comprised 40 patients with malignant tumors of the pelvic bone treated by different types of internal hemipelvectomy at the National Cancer Institute [NCI], Cairo University in the period extending from 1996 to 2005. According to the location and extent of their tumors, they were ascribed to one of three groups. Group A included 28 patients who underwent type I hemipelvectomy [iliac bone resection], Group B included 8 patients who underwent type I+II hemipelvectomy [iliac and peri-acetabular resection] and group C included 4 patients who underwent type III hemipelvectomy [pubic bone resection]. The mean age for groups A, B and C was 35 +/- 11.9, 39 +/- 17.8 and 33.5 +/- 13 years; respectively. The study comprised 14 patients with Ewing's sarcoma, 12 patients with chondrosarcoma, 6 patients with osteosarcoma, 4 patients with giant cell tumor, 2 patients with aneurysmal bone cysts and 2 patients with malignant fibrous histocytoma. Neoadjuvant chemotherapy was given to 11 patients and 7 received preoperative chemotherapy and radiotherapy; whereas 22 patients received no neoadjuvant treatment. The mean +/- SD duration of the surgical procedure was 2.67 +/- 0.32 hours and the mean +/- SD intra-operative blood loss was 1323 +/- 233 ml. The difference between groups A, B, and C was statistically significant [p <0.05]. Intra-operative complications were encountered in 9 patients where 5 patients had various nerve injuries, 2 patients had vascular injury and 2 had bladder injury. In the postoperative period, 4 patients developed deep vein thrombosis, 7 showed wound infection, 3 had deep pelvic infection and 2 developed hematuria secondary to intra-operative bladder injury. Upon evaluation of the functional results obtained, 50% of the patients were judged to have good results and 30% had fair results and ambulation aids could be discarded after 6-8 months. The remaining 20%, who had undergone type I+II hemipelvectomy, demonstrated a poor functional result in the form of flail hip. At a median follow-up of 18 months, 70% of the patients were alive and free of disease, 17.5% were alive with loco-regional recurrence and 5 died; 3 from lung metastases and 2 of unrelated causes. Internal hemipelvectomy can achieve limb salvage in most cases of pelvic tumors without compromise to surgical margins, local control or survival rates. Functional results obtained with this technique were quite satisfactory when the hip joint could be preserved

Nerve sparing total mesorectal excision for rectal cancer: impact on oncologic results and urogenital functions

The goal of this study was to evaluate the practicability of Total mesorectal excision [TME] and Autonomic nerve preservation [ANP] for patients with rectal cancer, together with their impact on local failure rates and urinary and sexual functions. Surgery for rectal cancer continues to develop towards the ultimate goals of improving local control and overall survival, maintaining quality of life, and preserving sphincter, genitourinary and sexual function. During the planning and conduct of a radical operation for rectal cancer, a number of surgical issues have recently emerged and should be considered. These include: [1] TME; [2] ANP; [3] circumferential resection margin [CRM]; [4] distal resection margin [DRM] and [5] postoperative quality of life. This study was conducted between May 2002 and October 2006 at the department of surgery of the National Cancer Institute and included 50 patients with mid- and low-rectal cancer. Their mean age was 43.7 years. They were 17 males and 33 females. Tumors of the middle 1/3 of the rectum accounted for 54% of cases while those of the lower 1/3 represented 46%. Twenty seven patients had Low anterior resection [LAR] while 23 had Abdomino-perineal resection [APR], all of them with curative intent. These patients were divided into two groups: group A that included 30 patients subjected to subtotal mesorectal excision and that were studied retrospectively and group B that included 20 patients subjected to TME with ANP. Patients were followed up for a period ranging from 6 to 35 months with a median period of 13 months. In group B, median operative duration increased by 45 minutes in LAR and 30 minutes in APR. Blood loss and hospital stay were also higher in group B. Wider CRM and DRM could be achieved in group B. In group A, 20% developed local recurrence of their disease while none of the patients of group B showed recurrence. The postoperative complication rate in group A was 20% whereas in group B it rose to 45%. Postoperatively, 50% of patients in group A and only 15% in group B expressed urinary dysfunction. Abnormal uroflowmetry parameters were found in 33.3% of patients in group A and only 10% of patients in group B. Maintained sexual activity after surgery was noted in only 50% patients in group A while in group B it was maintained in 80% of them. TME with ANP is a tedious procedure requiring painstaking training and it is associated with a higher morbidity rate. Nevertheless the advantages of this technique are so evident as regards the decrease in local recurrence rates and the improvement in voiding and sexual functions that it deserves to be considered as the standard treatment for these tumors

Feasibility of sentinel lymph node detection in nodular thyroid disease

Sentinel lymph node biopsy has been proven to be successful and accurate in predicting the nodal status in melanoma and breast cancer. Occult lymph node metastases are common in well differentiated thyroid cancer [WDTC]. Although the prognostic significance of these occult lymph node metastases remains controversial, identifying these patients may help direct therapy. The purpose of the study was to assess the technical feasibility and the safety of the sentinel lymph node biopsy in uninodular thyroid disease.Patients of previously untreated benign solitary thyroid nodule, diagnosed preoperatively by fine-needle aspiration cytology without any palpable cervical lymph node were prospectively studied. The nodule was injected with isosulfan blue vital dye. Blue stained lymphatics were traced. Then, hemithyroidectomy was performed. A total of 30 patients underwent sentinel lymph node biopsy; lymphtics were observed in 23 patients and sentinel lymph nodes were found in 18. In 5 patients, blue stained lymphatics were traced to the outside of the central compartment but no sentinel lymph node was identified. Sentinel lymph nodes were located in the central compartment in 14 cases, in the lateral compartment in 3 cases and in one patient 2 sentinel lymph nodes were found in both the central and the lateral compartments. Overall detection of sentinel lymph nodes was possible in 60% of cases. There were no intra or postoperative complications. The role of sentinel lymph node biopsy has yet to be determined in the thyroid setting. Certainly the technique can be performed safely, but its accuracy needs further refinement and investigation on larger series of patients before it can be recommended in the routine management of thyroid neoplasia

Lower urinary tract reconstruction following radical cystectomy using ileal neobladder with studor technique; 3 years experience

Between April 1997 and March 2000, 29 men underwent lower urinary tract reconstruction by means of the ileal neobladder of Studor with a modification. All operations were done after radical cystectomy for bladder carcinoma. The median age was 48.5 years. There was 2 perioperative deaths with an operative mortality rate of [6.8%]. The early complication rate for issues indirectly related to the neobladder was [13.7%] compared to a [34.4%] directly neobladder-related complication rate. Neobladder-related late complications have been acceptable including urinary retention [11.1%], metabolic acidosis [7.4%]. Through March 2000, [11.1%] of the patients died of metabolic disease and [3.7%] of unrelated medical problem. Eight patients [29.6%] suffered pelvic recurrence. Diurnal continence was achieved in 85.2%, while the nocturnal continence rate was 48.1%. Two patients [7.4%] required intermittent catheterization because of inability to void. The median neobladder capacity was 447 ml. The upper tract remained stable in [59.2%] of the patients, improved in [11.1%]. Dilatation either unilateral or bilateral occured in [29.6%] of the patients; however, the renal function remained good in [18.1%] and impaired in [11.1%]

Uterine sarcoma: analysis of treatment failure and survival

During the period from January 1985 to June 1999, 75 patients with uterine sarcoma were accrued in the National Cancer Institute, Cairo University. Surgery was the initial therapy for all patients. Of the 75 patients, 34 received postoperative irradiation and/or chemotherapy. Twenty-two [32%] survived 2 years, while 3 patients [4.3%] survived 5 years. The overall recurrence rate was similar in patients who received adjuvant treatment [94%] and in those who did not [97%]. There was no difference in local pelvic recurrence between patients who received adjuvant therapy and those who did not [2 1.4% Vs. 25%]; however the median time to pelvic recurrence was longer, 11 months [range 2-21 months] for the irradiated group versus 6 months [range 2-11 months] for the non irradiated group. There was neither a difference in the incidence of distant relapse [38.2% vs. 34.4%], nor a difference in the median time to relapse, 7 months for both [range 2-17] be-tween patients who received adjuvant therapy and those who did not. Local and distant relapses were observed in 27% of patients who received adjuvant therapy versus 32% in the no adjuvant therapy group, with a median time to relapse of 3 months [1-10 months] for both groups. Most of the failures occurred in the pelvis, followed by lung and abdomen. Relapsing patients did not benefit of either local radiotherapy or chemotherapy. In conclusion, uterine sarcomas have an aggressive clinical behavior, with a propensity to recur both locally and at remote sites. Surgery in the form of total abdominal hysterectomy [TAH] plus bilateral salpingio-oophorectomy remains the treatment of choice. The role of pelvic lymphadenectomy and aortic lymph node sampling may be beneficial especially in early stage disease, although its role in improving survival has not yet been demonstrated. There is no definite evidence that adjuvant pelvic irradiation or systemic chemotherapy improves survival. The policy of adjuvant therapy following surgery for uterine sarcoma needs further evaluation