Cytoreductive surgery for advanced epithelial tumors of the ovary: technical considerations and outcome.

PURPOSE: To study the role of cytoreductive surgery in the management of advanced epithelial tumors of the ovary and its effect on survival. PATIENTS AND METHODS: A prospective study of fifty eight female patients presenting with stage III and VI epithelial ovarian tumors attending the National Cancer Institute, Cairo University during the period from January 2003 to of December 2004. All patients were evaluated clinically, radiologically (including plain chest-X-ray and abdomino-pelvic ultrasound and/or CT), laboratory work up and CA-125. Abdominal exploration under general anesthesia with intent of maximum surgical cytoreduction was performed for all patients. Patients were followed up during the period of the study by history and physical examination, CA-125 measurement and abdomino-pelvic ultrasound or CT. RESULTS: Our study included 58 female patients with advanced epithelial tumors of the ovary. Their age ranged from 18 to 73 years with a mean age of 49 years. Pathological distribution of the lesions were borderline malignancy in 5 patients (8.6%) and malignant in 53 patients (91.4%). According to FIGO classification there were 46 patients stage III (79%) and 12 patients stage VI disease (21%). Eighteen patients (31%) had surgery prior to admission to NCI. Cytoreductive surgery was done for 51 patients (88%), while 7 patients (12%) had exploration and biopsy only, one of whom had palliative colostomy for large bowel obstruction. Intraoperative surgical complications were encountered in 5 patients (8.6%), all were managed intraoperatively. We had no early postoperative mortalities and 8 postoperative morbidities (13.7%). All patients were referred for chemotherapy. Thirteen patients (22.4%) had local recurrence within the follow up period of the study which was between 8-24 months. One patient died from locally advanced disease and the rest of the patients were explored and lesions were surgically resected. CONCLUSION: Surgery remains a major line of therapy in ovarian cancer including advanced lesions. Extensive procedures to maintain a R0 result are crucial to reach a satisfactory local disease control. The NCI, as well as all tertiary cancer centers, has an important role in providing this quality of surgery especially in advanced cases. Chemotherapy remains the hope to ameliorate the survival especially in advanced cases. The close coordination between surgery and chemotherapy in the form of Intra- Peritoneal Hyperthermic Chemotherapy (IPHC) represents a hope for patients with advanced disease and should be introduced and established in all major cancer centers.

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.

Surgical management for giant cell tumor of bones.

PURPOSE: To evaluate the different surgical techniques used in the treatment of giant cell tumor of bone and their effect on the rate of local recurrence. PATIENTS AND METHODS: This is a prospective study of fifty-two patients with giant cell tumor (GCT) of the bones treated at the National Cancer Institute, Cairo University between 1998 and 2002. All patients were evaluated by clinical examination, plain X-ray, CT scan and MRI (in some cases). Biopsy was taken in all cases to confirm the diagnosis and to define the grade of the tumor. All patients underwent surgical treatment including curettage, curettage combined with cryosurgery and bone cement or bone graft, bone resection and amputation. Selection of the surgical technique was based on site and size of the lesion, soft tissue involvement (intra- or extra-compartmental), tumor grade and if recurrent or not. Patients were followed up for a minimum of twenty-four months. RESULTS: Out of 52 patients 14 patients were males and 38 patients were females, (male to female ratio was (1: 2.7). The age of our patients ranged from 13 to 71 years, with a mean age of 32.9 years. Based on Enneking's staging system, 40 patients (77%) were stage IA, 9 patients (17%) were stage IB & 3 were stage IIB. Histopathological examination of all cases revealed giant cell tumor of borderline malignancy. Curettage alone was done in 4 patients, curettage and bone cement in 7 patients, curettage, cryosurgery and bone graft in 4 patients, curettage, cryosurgery and bone cement in 18 patients, resection in 16 patients and amputation in 3 patients. There were no mortalities among our cases. Local recurrence was highest in cases treated with curettage only (50%), lowest in cases treated with curettage and cryosurgery with bone cement (16.6%). CONCLUSION: The main primary treatment of GCT is surgery; the type of which depends on preoperative evaluation, which includes clinical evaluation that involves the site and size of the tumor in relation to surrounding structures, together with plain X-ray, CT scan and/or MRI as indicated, and tissue biopsy to define tumor grade. Curettage alone results in high rate of local recurrence. On the other hand, curettage and adjuvant cryosurgery using bone cement or bone grafts give low rate of local recurrence. Resection is recommended for stages IB and IIB, extremely large lesions, and in cases where resection results in no significant morbidity as proximal fibula and flat bones. Amputation is preserved for massive recurrences and malignant transformation.

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.