Gastrointestinal stromal tumor (GIST)'s surgical treatment, NCI experience.

PURPOSE: To review the clinical presentation, surgical management, and prognostic factors for gastrointestinal stromal tumors. PATIENTS AND METHODS: A prospective study which was carried out between January 2002 and March 2004 on thirty-three patients with gastrointestinal stromal tumor (GIST) at the National Cancer Institute, Cairo University. All patients were evaluated preoperatively and underwent exploratory laparotomy with a curative intent, they were followed up for period ranging between 14-35 months. RESULTS: Among the 33 patients there were 17 males and 16 females. The mean age of patients was 52.8 years. Clinical findings included gastrointestinal bleeding (42.4%), palpable mass (33.3%) and abdominal pain (24.3%). The stomach was the most common site of origin of the disease (39.4%), followed by the colorectal region (24.2%). Tumors were high grade in 63.6% of patients and low-grade in 36.4% of patients. Complete resection of all gross disease was accomplished in 26 patients (78.7%), among whom, multiple adjacent organ resection was required in 6 patients (22.2 %) and metastatic disease was identified in the liver in 3 patients at the time of exploratory surgery of these one could be resected. Immunohistochemical staining for CD117 was positive in 88.9% of patients. The median follow-up period was 20 months (range, 14-35 months). The overall median survival in this study was 25 months, and the cumulative survival at 30 months was 46.9%. Unfavorable prognostic factors were incomplete resection and, high-grade histological features (p<0.05). None of the patients received adjuvant or palliative chemotherapy. Twenty six patients (78.8%) are alive free of disease. Of the 7 patients with incomplete resections or biopsy only; 4 patients (12.1%) are alive with disease and 3 patients died. CONCLUSION: Surgical resection, including en bloc resection of locally advanced tumors, remains the only curative treatment. Overall survival is significantly affected by high-grade tumors and positive resection margin.

Re-operation for the treatment of well differentiated thyroid cancer: necessity, safety and impaction on further management.

BACKGROUND: The diagnosis of thyroid carcinoma during the course of lobectomy for a dominant nodule occasionally cannot be rendered on the basis of frozen section. Once the diagnosis of carcinoma is made, the question of completion thyroidectomy arises. PATIENTS AND METHODS: During a period of 3 years, 28 patients diagnosed with well-differentiated thyroid cancer (WDTC), and operated upon with less than total thyroidectomy, were admitted to our department. Patients had no clinical or radiological evidence of any residual disease at the time of admission. All were submitted for total thyroidectomy. RESULTS: There were 7 men and 21 women (1:3), and the average age was 38.6+/-1.3 years (range, 20 to 62 years). The postoperative morbidity in completion thyroidectomy consisted of transient hypoparathyroidism in 2 patients (7.1 %), permanent hypoparathyroidism in 1 patient (3.5%), there was no recurrent laryngeal nerve palsy, there were haematoma in 2 patients, and seroma in 1 patient. Completion thyroidectomy resulted in detecting 9 patients (32.1%) having residual disease that was not clinically manifest. CONCLUSION: Although many surgeons advocate total or near-total thyroidectomy for differentiated thyroid carcinoma, some of these surgeons hesitate to complete thyroidectomy after lobectomy for thyroid nodule when there is no clinical evidence to suggest bilateral disease, for fear of added morbidity to the patients. However, as demonstrated in this study, completion thyroidectomy was shown to be a fairly safe procedure, which carries a low incidence of complications. It also facilitates further management and follow-up with radioactive iodine. The decision to perform completion thyroidectomy for WDTC should be based on the patient's risk category, and not on a concern for risk of complications from the second procedure.

Sphincter sparing procedures: is it a standard for management of low rectal cancer.

PURPOSE: The purpose of this study is to determine whether the type of operation, sphincter sparing procedures (SSP) or abdomino-perineal resection (APR) for primary adenocarcinoma of the rectum at or below the peritoneal reflection affects survival and recurrence after curative surgery. MATERIAL AND METHODS: A prospective controlled study of seventy nine patients with low rectal carcinoma was done between January 1999 and March 2003. Two types of operations were done; SSP (43 patients) including a low anterior resection with either double-stapling technique (DST) (18) or hand-sewn colorectal anastomosis (HSA) (25), and APR (36 patients). The outcome factors evaluated were operative time, intraoperative blood loss, mortality, morbidity, disease-free survival and tumor recurrence. Patients have been followed-up for a minimum of 12 months (mean time 32 months). RESULTS: Out of 43 patients who underwent SSP, there was one mortality, and 7 morbidities. Anastomotic leakage occurred in 4 cases; one patient needed colostomy. In APR group, no mortalities and 6 morbidities were found. Morbidity was similar in both groups. The local recurrence rates for SSP and APR were 13.8% and 22.2%, respectively (p = 0.540), and the distant metastases rates were 11.1% and 8.3%, respectively (p = 1.000). Two-year disease-free survival rates for SSP and APR patients were 73.3% and 66.7%, respectively (p = 0.121). Intraoperative blood loss was significantly lower in SSP groups. CONCLUSIONS: Sphincter saving procedures can be performed to all patients with rectal carcinoma regardless of the site of the lesion so long the distal and lateral margins are clear. Survival and the risk of local recurrence are similar to that obtained by standard abdomino-perineal resection. Unlike abdomino-perineal resection, sphincter saving procedures preserve the continence and give accepted good quality of life.