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

Salvage surgery for recurrent and locally advanced breast cancer

The results of the excision of local advanced breast cancer [LABC] and locally recurrent breast cancer [LRBC] tumors in 23 women were presented. Good palliation was achieved with the use of the transverse rectus abdominis myocutaneous [TRAM] flap in 19/23 patients and the latissimus dorsi myocutaneous [LDM] flap in 4/23 patients with an average operating time of 230 minutes and average hospital stay of 16 days when chest wall resection was not needed. When rib resection was undertaken, the average operating time was 285 minutes and average hospital stay was 22.5 days. Minor complications were recorded in 43.5%, while major complications occurred in 17.4% of patients. Local recurrence was observed in 22.7%, while distant metastasis developed in 40.9% of patients. An average of 11.7 months disease-free survival and 21.2 months overall patient survival could be achieved with reasonable morbidity and mortality