Multiple myeloma: most common end-organ damage and management

End-organ damage is the factor that differentiates plasma cell dyscrasia requiring therapy (active multiple myeloma [MM]) from disease that does not require therapy (monoclonal gammopathy of undetermined significance and smoldering [asymptomatic] MM). Progressive skeletal destruction is the hallmark of MM and responsible for principle morbidity in the disease. The spine is the most afflicted skeletal organ, and vertebral fractures have significantly contributed to its poor prognosis. Early mortality in MM is usually attributed to the combined effects of active disease and comorbid factors. Infection and renal failure are the main direct causes of early mortality. Using bisphosphonates to manage skeletal events mainly by preventing or slowing the destructive process has become an important adjunctive treatment in MM. Advances in minimally invasive surgical techniques, such as percutaneous vertebroplasty and kyphoplasty, offer these patients less-invasive options for treating vertebral collapse and restoring function. The aggressive management of other complications of the disease through more effective and less toxic therapy that targets the primary disease, in addition to supportive care, is resulting in patients experiencing less morbidity and probably lower mortality. This article reviews recent advances in the understanding of bone disease in MM, the role of bisphosphonates in preventing skeletal events, and available data on percutaneous vertebroplasty and kyphoplasty, and discusses the management of infection and renal failure, which seem to be responsible for high initial mortality and thereby compromise the current advances in therapy.     

Minimally invasive approaches for diagnosis and treatment of early-stage breast cancer

Breast cancer management has been evolving toward minimally invasive approaches. Image-guided percutaneous biopsy techniques provide accurate histologic diagnosis without the need for surgical biopsy. Breast conservation therapy has become the treatment standard for early-stage breast cancer. Sentinel lymph node biopsy is a new procedure that can predict axillary lymph node status without the need of axillary lymph node dissection. The next challenge is to treat primary tumors without surgery. For this purpose, several new minimally invasive procedures, including radiofrequency ablation, interstitial laser ablation, focused ultrasound ablation, and cryotherapy, are currently under development and may offer effective tumor management and provide treatment options that are psychologically and cosmetically more acceptable to the patients than are traditional surgical therapies. In this review, we give an overview of minimally invasive approaches for the diagnostic and therapeutic management of early-stage breast cancer.     

Laparoscopic and renal sparing approaches to tumours of the ureter and kidney

Until recently, malignancies of the kidney and ureter were managed with open radical surgery. Over the last decade the urologic community has adopted the skill of laparoscopic surgery for the treatment of these tumours. Parenchymal sparing procedures have become the standard of care in the treatment of selected patients with renal and ureteral tumours and many of these surgical procedures can be performed laparoscopically or ureteroscopically. Due partly to necessity and partly to the advancement of technology, renal and ureteral sparing procedures have become commonplace for definitive treatment and palliation of these tumours. The morbidity of such procedures is significantly less than for open surgery and the future of urologic minimally invasive surgery appears secure. This review article is aimed at updating the reader in the most recent advances in these techniques.     

Emerging techniques in the minimally invasive treatment and management of thoracic spine tumors

Over the past decade, the development and refinement of minimally invasive spine surgery techniques has lead to procedures with the potential to minimize iatrogenic and post-operative sequelae that may occur during the surgical treatment of various pathologies. In a similar manner, parallel advances in other current treatment technologies have led to the development of other minimally invasive treatments of spinal malignancies. These advances include percutaneous techniques for vertebral reconstruction, including vertebroplasty and kyphoplasty, the development of safe and effective spinal radiosurgery, and minimal-access spinal surgical procedures that allow surgeons to safely decompress and reconstruct the anterior spinal column. The advent of these new techniques has given modern practitioners treatment options in situations where they previously were limited by the potentially significant morbidities of the available techniques. Here, the authors discuss the application of current minimally invasive technologies in the treatment of malignancies of the thoracic spine, focusing on vertebral kyphoplasty, spinal radiosurgery, and minimally invasive spinal decompression techniques. The author’s describe how these emerging treatment options are significantly expanding the options open to clinicians in the treatment of thoracic spinal column malignancies. Specific illustrative case examples are provided. The development of these techniques has the potential to improve clinical outcomes, limit surgical morbidity, and also improve the safety and efficiency of treatment pathways.     

Who Benefits from Oncoplastic Surgical Techniques?

Breast-conserving therapy, which includes wide local excision of the tumor followed by irradiation, has become a standard treatment option for women with early-stage invasive breast cancer. The potential advantages of conservative breast surgery include the minor outpatient nature of the procedures, lower incidence of post-operative pain and complications, preservation of the breast and nipple areolar complex, and shorter delay to adjuvant therapy. However, not all patients are optimal candidates for breast-conserving procedures. Oncoplastic techniques combine the removal of breast cancer tumors in combination with either local volume replacement techniques to correct small defects, or by immediate reconstruction of larger defects using techniques of plastic surgery with or without contralateral breast procedures for symmetry. Therefore, oncoplastic techniques offer the potential to perform a wider excision of the tumor with an improved cosmetic result, thus potentially increasing the eligible pool for breast conservation.     

Current status and advances in nephron-sparing surgery

Localized renal cell carcinoma (RCC) remains a surgical disease, with excision of the tumor or tumor-bearing kidney offering the only chance of cure for affected patients. After the widespread acceptance of partial nephrectomy as equivalent treatment to radical nephrectomy in appropriately selected cases of RCC, a range of nephron-sparing procedures has become available to patients. These include laparoscopic partial nephrectomy, thermal ablative techniques, as well as open partial nephrectomy. These techniques offer the attraction of being minimally invasive, in some cases as outpatient procedures under sedation. This review attempts to clarify the current status of these nephron-sparing techniques. Case selection criteria, outcomes, and complications are presented with the aim of helping the modern urologist appreciate the benefits of these procedures as well as their limitations and role in the management of patients with RCC.     

Current Status and Advances in Nephron-Sparing Surgery

Localized renal cell carcinoma (RCC) remains a surgical disease, with excision of the tumor or tumor-bearing kidney offering the only chance of cure for affected patients. After the widespread acceptance of partial nephrectomy as equivalent treatment to radical nephrectomy in appropriately selected cases of RCC, a range of nephron-sparing procedures has become available to patients. These include laparoscopic partial nephrectomy, thermal ablative techniques, as well as open partial nephrectomy. These techniques offer the attraction of being minimally invasive, in some cases as outpatient procedures under sedation. This review attempts to clarify the current status of these nephron-sparing techniques. Case selection criteria, outcomes, and complications are presented with the aim of helping the modern urologist appreciate the benefits of these procedures as well as their limitations and role in the management of patients with RCC.     

Advances in multiple myeloma and spine disease

Progressive bone destruction is the hallmark of multiple myeloma (MM) and is responsible for principal morbidity in the disease. The spine is the most afflicted skeletal organ, and vertebral fractures have significantly contributed to its poor prognosis. The principal underlying pathologic mechanism causing bone disease in MM is a shift in the balance of bone formation and bone resorption toward bone resorption, and eventually total dissociation between the 2 processes occurs in latter stages of the disease. During the past decade bisphosphonates have become an important adjunctive treatment in the management of MM, in which they have shown the ability to reduce bony complications associated with the disease. Advances in minimally invasive surgical techniques, such as percutaneous vertebroplasty and kyphoplasty, offer these patients less-invasive options for the treatment of vertebral collapse and restoration of their normal function. This report reviews recent advances in the understanding of bone disease in MM, the role of bisphosphonates in the prevention of skeletal events, and available data regarding percutaneous vertebroplasty and kyphoplasty.     

经皮穿刺椎体成形术治疗28例脊柱转移瘤

背景与目的脊柱转移瘤的治疗是临床中较常见的棘手问题,保守治疗难以达到有效止痛及稳定脊柱的效果。开放性手术创伤大,并发症多,常需要一段重要的术后恢复期,从而拖延了对原发疾病的治疗,且不适用于多发性脊柱转移瘤。本研究探讨数字减影血管造影(digital subtraction angiography,DSA)机引导下经皮穿刺椎体成形术(percutaneous vertebroplasty,PVP)治疗脊柱转移瘤患者的疗效。方法对58例脊柱转移瘤患者,按患者意愿分为治疗组28例,对照组30例,两组资料经统计学分析,各因素均无差异。治疗组采用PVP合并放、化疗,对照组采用常规放、化疗。治疗2个月后观察患者生活质量、骨痛评分、脊柱稳定性的改变,以及不良反应。结果经统计学分析,两组治疗后生活质量及骨痛评分的变化均有显著性差异(P<0.05,t1=2.74,t2=11.74)。治疗组脊柱稳定,且无明显不良反应。对照组有5例发生椎体病理性压缩性骨折。结论PVP具有创伤小,操作较简单,并发症少的特点,可有效缓解脊柱转移瘤患者疼痛,减少椎体病理性压缩性骨折,改善其生活质量。     

Innovative laparoscopic surgery in gynecologic oncology

Minimally invasive surgery has been performed since the early 1990s, and gynecologic oncology surgeons continue to improve their skills for this procedure. Advanced laparoscopic techniques are used to evaluate and treat cervical, endometrial, and ovarian malignancies. Laparoscopy has significant benefits in selected oncologic patients and may be a more useful technique than the abdominal approach. The benefits of laparoscopy include less postoperative pain, less blood loss, shorter length of hospital stay, and a shorter recovery period with no significant increase in complications or morbidity. With emerging data, it appears that the risk of cancer recurrence does not increase with a minimally invasive approach. The incorporation of laparoscopic pelvic and para-aortic lymphadenectomy has expanded the types of procedures performed for the management of certain gynecologic malignancies. New techniques, including hand-assisted laparoscopic procedures and extraperitoneal lymph node dissections, are expanding the role of laparoscopy in the treatment of all gynecologic malignancies.     

椎体成形术联合放射性粒子治疗椎体转移癌的临床观察

目的 探讨经皮椎体成形术（PVP）联合放射性粒子植入治疗椎体转移癌的有效性和安全性。方法对41例胸腰椎转移癌患者的52个病变椎体,在CT引导下进行经皮椎体穿刺125I粒子组织间植入及骨水泥（PMMA）灌注成形治疗;术后随访1年,应用数字分级法（NRS）观察患者的疼痛缓解程度,EORTC-QLQ-C30问卷调查手术前后生活质量的变化,并观察治疗并发症及1年生存率和局部控制率。结果 41例患者术后1个月疼痛均获不同程度缓解,其中3、4度缓解率为82.9％（34/41）;术后EORTC评分较术前明显降低,生活质量显著提高（P＜0.05）;术后患者6个月内局部控制率为90.2％（37／41）,1年生存率为73.2％（30／41）;在存活的30例患者中,1年局部控制率为93.3％（28／30）;术后有7例出现PMMA向椎体周围组织渗漏,但均无明显临床症状,未出现放疗相关不良反应。结论 在CT监视下,应用PVP联合放射性粒子植入治疗椎体转移癌具有稳定椎体和抑制肿瘤的协同作用,并且微创安全,可作为椎体转移癌的有效联合治疗方法之一。     

肿瘤消融技术联合免疫检查点抑制剂治疗的进展

随着微创手术的广泛应用及微创技术的发展,肿瘤消融技术已成为肿瘤局部治疗的重要替代方法,肿瘤消融在其杀灭肿瘤细胞的同时将肿瘤的自身抗原释放到循环中使机体产生了免疫抗肿瘤反应,但这种作用可能不足以克服一些已经进化出免疫应答的检查点逃逸机制的肿瘤的复发及转移。临床前和临床证据表明肿瘤消融技术联合免疫检查点抑制剂可产生更强的免疫抗肿瘤反应。本文的目的是总结肿瘤消融技术联合免疫检查点抑制剂在原发及继发肿瘤治疗的现状及进展。     

Sphincter preservation in rectal cancer

Opinion statement Distal rectal cancer poses two challenges to the oncologist: local tumor control and sphincter preservation. The abdominoperineal resection (APR), long considered the standard treatment of tumors with a distal edge located up to 6 cm from the anal verge, provides local control in many patients but results in sphincter loss with a permanent colostomy. This is a critical limitation. Consequently, there has been significant interest in sphincter-conserving approaches, frequently combining chemoradiation with surgery. These approaches have evolved along two fronts. For patients with small rectal cancers confined to the rectal wall, local excision techniques with and without chemoradiation may offer comparable local control and survival rates as an APR and preserve sphincter function. For patients with larger and more invasive tumors of the distal rectum where local excision is inappropriate, preoperative chemoradiation promotes tumor regression and may facilitate a resection sparing the sphincter with a coloanal anastomosis. Preliminary results from single institution studies appear promising. In both these settings (favorable and more invasive rectal cancer), chemoradiation is employed to compensate for the limitations of the sphincter-preserving surgical technique. In local excision procedures, the excision margins are invariably small, and the mesorectum (lymphatics, soft tissue) surrounding the tumor is not excised. For patients undergoing resection with coloanal anastomosis, there are narrow radial and distal surgical margins. With these approaches of chemoradiation and sphinctersparing surgery, satisfactory local control and survival with avoidance of colostomy are possible for many patients with distal rectal cancer.     

小剂量骨水泥PVP治疗多节段椎体压缩性骨折

目的 探讨采用小剂量骨水泥椎体成形术治疗多节段骨质疏松伴椎体压缩性骨折的临床效果。方法 回顾性研究自2006年９月至2011年８月我院采用小剂量骨水泥椎体成形术治疗46例多节段骨质疏松伴椎体压缩性骨折的病例。其中,男11例,女35例,年龄56～83岁,平均67.3岁。所有患者术前均行骨密度测定Ｔ值≤-2.5,提示骨质疏松,并行Ｘ线片、CT及MRI检查明确责任椎体及后壁完整情况。本组治疗的病例均为多节段椎体压缩性骨折,责任椎体分别分布在：胸６椎（１个）、胸７椎（１个）、胸８椎（２个）、 胸９椎（２个）、胸10椎（５个）、胸11椎（11个）、胸12椎（31个）、腰１椎（36个）、腰２椎（８个）,腰３椎（９个）、腰４椎（13个）、腰５椎（14个）等,本组治疗的病变椎体最少２个,最多４个,平均2.32个。所有患者均经单侧椎弓根穿刺椎体,１次对２个或２个以上责任椎体行小剂量骨水泥椎体成形术。术前、术后３天、１周、术后６个月随访时进行疼痛视觉类比评分（VAS）,评价临床治疗效果。结果 46例患者共行108个椎体成形术,平均１次2.32个椎体,单个椎体内骨水泥注射剂量约1.2～2.1 ml,平均（1.8±0.38）ml。所有患者定期随访,随访时间6～18个月（平均12.6个月）,术前患者VAS评分为7.95±0.82,术后３天VAS评分为4.48±0.80,随访时VAS评分为2.38±0.55,采用配对 t 检验对术前、术后随访时VAS评分进行统计学分析,差异有统计学意义（P＜0.001,α＝0.05）。结论 小剂量骨水泥椎体成形术作为一种微创手术,可有效地缓解多节段骨质疏松伴椎体压缩性骨折引起的疼痛症状,是一种有效的治疗方法。     

人工椎体置换治疗脊柱转移性肿瘤

目的观察人工椎体置换治疗脊椎转移性肿瘤的疗效。方法采用无磁性的医用钛金属加工成可调式中空人工椎体,用于治疗脊椎转移性肿瘤12例。观察术后疼痛缓解和脊髓功能恢复情况及手术椎节的稳定性。结果随访6～34个月,平均11.5个月。脊髓功能障碍术后明显改善,尤以神经根性疼痛缓解迅速。X线摄片定期观察人工椎体稳定,椎间高度恢复良好。结论可调式中空人工椎体可撑开施术椎节,缓解神经压迫症状,并能提供即刻稳定,可用于治疗脊椎转移性肿瘤。     

Three-dimensional C-arm computed tomography combined with fluoroscopic guided pediculoplasty for treatment of vertebral body metastasis with lytic pedicle

The aim of this retrospective study was to evaluate a percutaneous pediculoplasty (PP) technique, using 3-dimensional C-arm CT reformation combined with fluoroscopic guidance for patients presented vertebral body metastasis with lytic pedicle. Thirteen patients (average age 57.8 years) were treated through lytic pedicle approach in our study. Subjective good and partial pain relief was reported with Visual Analogue Scale reduction ≥4 in 11/13 patients at 1 month after procedure, two patients with insufficient pain relief died from clinical complications unrelated with PP at 3 month follow-up. Pain relief was maintained in 10 patients at 6 month post-procedural follow-up. One patient died from underlying disease unrelated with the procedure at 5 month follow-up. PP through the lytic pedicle approach under 3-dimensional C-arm CT reformation combined with fluoroscopic guidance was a feasible, safe, and minimally invasive procedure that could provide both the precise control of needle placement and cement injection with one imaging system.     

经皮椎弓根内固定开放减压联合微波高温灭活治疗脊柱转移瘤的临床研究

目的 微波治疗四肢和骨盆骨肿瘤已取得满意的临床疗效,由于脊柱解剖结构的特殊性,微波应用面临挑战.本研究探讨经皮椎弓根内固定开放性减压联合微波高温灭活治疗脊柱转移瘤的临床疗效.方法 回顾性分析广西医科大学附属肿瘤医院2013-10-15-2015-02 15收治的23例脊柱转移瘤患者的临床资料.所有患者均采用经皮椎弓根内固定开放减压联合微波高温消灭火治疗脊柱转移瘤.其中男9例,女14例;年龄42～72岁,平均年龄56岁,中位年龄62岁.Tomita预后评分3～6分.采用疼痛视觉模拟评分(VAS)比较术前、术后疼痛情况,Frankel分级评定患者神经功能的改善情况及观察患椎椎体后缘的高度变化.结果 23例患者手术均顺利完成,未发生脊髓和神经根损伤或加重情况.术后3dVAS评分(3.8±1.4)和末次随访VAS评分(4.1±1.5)较术前(7.9±2.6)有明显改善(t=-6.659,P＜0.001;t=-6.071,P＜0.001),术后3d椎体后缘高度(15.6±3.2) mm与术前(10.5±2.5) mm比较差异有统计学意义(t=6.023,P＜0.001),与末次随访(14.6±2.8)比较,差异无统计学意义(t=1.128,P=0.133);末次随访时Frankd分级,A级1例,B级2例,C级6例,D级9例,E级5例,与术前比较差异有统计学意义,x2=10.856,P=0.028.随访过程中无肿瘤复发,无椎体骨折塌陷,无内固定物松动、断裂和移位.结论 经皮椎弓根内固定开放性椎管减压内固定联合微波高温灭活术可迅速减轻患者的疼痛症状,在有效维持脊柱稳定性的同时可充分解除脊髓压迫,控制局部复发,取得满意的治疗效果,但远期效果有待进一步观察.     

经皮椎体成形术治疗脊柱椎体肿瘤的临床应用及疗效观察

目的：探讨经皮椎体成形术治疗椎体肿瘤的疗效和安全性。方法：17例患者共41个椎体肿瘤行经皮椎体后凸成形术治疗,术前临床症状及术后临床效果均采用疼痛视觉模糊评分进行评定。结果：所有患者术后24小时内疼痛症状明显缓解或消失。随访2—6个月,平均3．5个月,患者未诉疼痛加重,未出现严重并发症。结论：椎体日澎术治疗椎体肿瘤能迅速缓解疼痛,改善临床症状及提高生活质量,有较高的临床应用价值。     

Human monoclonal antibodies and engineered antibodies in the management of cancer

In an attempt to obtain more specific and less immunogenic monoclonals for cancer therapy considerable effort has been devoted to the development of human monoclonals. Although this has resulted in the generation of many antibody secreting cell lines they rarely produce useful levels of specific antitumour antibodies. An alternative approach is the humanisation of rodent antitumour monoclonals using genetic engineering techniques. The chimaeric antibodies produced may exhibit reduced immunogenicity and improved Fc mediated interactions. Finally a number of procedures have also been employed to generate so-call bispecific monoclonal antibodies which offer novel therapeutic possibilities.     

The Current Role of Vacuum Assisted Breast Biopsy System in Breast Disease

The gold standard for breast biopsy procedures is currently an open excision of the suspected lesion. However, an excisional biopsy inevitably makes a scar. The cost and morbidity associated with this procedure has prompted many physicians to evaluate less invasive, alternative procedures. More recently, image-guided percutaneous core-needle biopsy has become a frequently used method for diagnosing palpable and non-palpable breast lesions. Although sensitivity rates for core-needle biopsy are high, it has the disadvantage of histological underestimation, which renders the management of atypical ductal hyperplasia, papillary lesions, and fibroepithelial lesions somewhat difficult. Vacuum assisted breast biopsy (VABB) was developed to overcome some of these negative aspects of core-needle biopsy. VABB allows for a sufficient specimen to be obtained with a single insertion and can provide a more accurate diagnosis and completely remove the lesion under real-time ultrasonic guidance. The advantage of complete lesion removal with VABB is to reduce or eliminate sampling error, to decrease the likelihood of a histological underestimation, to decrease imaging-histological discordance, to decrease the re-biopsy rate, and to diminish the likelihood of subsequent growth on follow-up. In recent years, with the advancement of VABB instruments and techniques, many outcome studies have reported on the use of VABB for resecting benign breast lesions with a curative intent. VABB is highly accurate for diagnosing suspicious breast lesions and is highly successful at treating presumed benign breast lesions. Thus, in the near future, VABB will be routinely offered to all appropriately selected patients.