Minimally-invasive surgery in cancer children

Minimally-invasive surgery, or video-assisted surgery, includes laparoscopy, retroperitoneoscopy and thoracoscopy, can be used for diagnosis (biopsies) and treatment (resections) in various malignant solid tumours in children. Potential advantages of MIS techniques include a decreased parietal trauma (cosmetic benefit, bowel adhesions) and less postoperative discomfort (postoperative pain, analgesics requirement, postoperative ileus, length of hospital stay). Main indications of MIS techniques are represented by diagnostic biopsies (mediastinal or lung tumors, retroperitoneal extrarenal masses), resection of the primary tumor in thoracic and abdominal neuroblastic tumors and in post-treatment residual mass in lymphoma.     

Primary hepatic tumours in children: a 26-year review.

Twenty-one children were admitted to a single paediatric institution between 1964-1990 with histologically proven primary liver tumours. The diagnosis was hepatoblastoma (HBL) in 15 patients, hepatocellular carcinoma (HCA) in 2, rhabdomyosarcoma (RMS) in 2, non-Hodgkin's lymphoma (NHL) in 1, and haemangioendothelioma (HE) in 1. The common presenting clinical features were anaemia, abdominal mass, and abdominal pain. Serum alpha-foetoprotein was useful in establishing a diagnosis in HBL and in monitoring disease activity. Computed tomographic (CT) scan, ultrasound, and angiography were useful preoperative investigations for assessing site and resectability of tumour. There were no survivors in patients with malignant hepatic tumours (n = 10) who had surgery alone prior to 1981. Of 7 patients with HBL diagnosed after 1981 who had adequate surgical resection and chemotherapy, 5(72%) are currently alive and disease free between 15 months and 8 years from diagnosis. We conclude that adequate surgical resection and adjuvant chemotherapy can improve disease free survival for children with HBL. Optimal treatment has yet to be devised for other malignant hepatic tumours.     

Uptake and survival effects of minimally invasive surgery for lung cancer: A population-based study

IntroductionDespite growing evidence supporting the safety of minimally invasive surgery (MIS) in the treatment of lung cancer, its uptake is still variable and its outcomes debated. This study examines the factors associated with MIS uptake and its effects on survival in patients with non-small cell lung cancer (NSCLC).MethodsAll patients in the Canadian province of Ontario with early stage NSCLC (stage I/II) from 2007 to 2017 were included. A logistic regression identified the predictors of MIS uptake, and a flexible parametric model was used to estimate survival rates based on MIS versus open resection.ResultsIn total, 8,988 patients underwent surgical resection; 53.6% had MIS. Year of diagnosis was associated with MIS uptake (OR = 1.33, p < 0.001); patients in later years were more likely to receive MIS. Rurality was a significant predictor of MIS, though distance from nearest regional cancer center did not predict MIS utilization. Patients with stage II disease were less likely to receive MIS compared to those with stage I disease (OR = 0.44, p < 0.001). MIS had a significantly higher 5-year survival compared to open resection for stage I and II disease. Patients >70 years had the greatest 5-year survival benefit from MIS.ConclusionsWe observed a substantial long-term survival benefit in patients undergoing MIS for early stage NSCLC. This difference was most pronounced in the oldest age group. These findings support the use of MIS in the treatment of lung cancer and challenge the notion that MIS compromises oncologic outcomes.     

Cystic liver metastases from lung adenocarcinoma: a case report

Cystic hepatic metastases arising from lung cancer are rare. We herein describe a case of a 71-year-old women admitted to our hospital for abdominal pain 6 months after the resection of a lung adenocarcinoma. Two cystic lesions of the liver were discovered at abdominal ultrasonography and computerized tomography scan. An ERCP excluded a biliary adenoma or adenocarcinoma, and an ultrasound-guided liver biopsy was negative for malignant cells. For persistence of symptoms and lack of a diagnosis, the patient underwent an exploratory laparotomy, a surgical biopsy with a diagnosis of adenocarcinoma, and a consequent right hepatectomy. After 2 years of follow-up, the patient is well and disease free. Although cystic liver metastasis are rare and a differential diagnosis difficult, the malignant nature should always be considered in the differential diagnosis of hepatic cysts to offer the patient the best treatment.     

Primary osteosarcoma of ovary

Primary osteosarcoma originating from the ovary is an exceedingly rare, highly malignant tumor. Only a few cases have been reported in the past few decades. We describe a 50-year-old postmenopausal woman who presented with a large abdominal mass. The clinical diagnosis was malignant ovarian cancer. Her disease was aggressive; she had no response to systemic chemotherapy and died within 1 month of presentation. A definitive diagnosis of primary ovarian osteosarcoma was made by histopathological examination of autopsy specimens. Although rare, primary ovarian osteosarcoma should be considered in the differential diagnosis of a large, rapidly progressing pelvic mass in a postmenopausal woman. Early diagnosis provides hope of a complete surgical resection, which is currently the only promising treatment.     

Major surgery in hodgkin's disease and other malignant lymphomas

This is a retrospective and all-inclusive study of 527 patients with malignant lymphoma. A total of 178 major surgical procedures were carried out on 139 patients (an incidence rate of 18.4% for the 163 patients with Hodgkin's disease and 29.9% for the 364 with other lymphomas). There were 101 procedures done initially for diagnosis and 77 carried out after the diagnosis was established. Only 15 patients had laparotomies for staging purposes. The other operations included 59 celiotomies for diagnosis (21 had resection of organs), 42 abdominal operations for complications (malignant or nonmalignant), 11 radical node dissections, 6 radical mastectomies, 5 laminectomies, 4 thoracotomies, 3 bone operations, and 33 various other procedures. With the wider application of the exploratory laparotomy for staging and the improved survival with radiotherapy and chemotherapy, it is obvious that the future role of surgery will be quite different from the past. However, certain patients will still require major surgery for diagnosis. In addition, second cancers, conditions unrelated to lymphoma, complications secondary to aggressive therapy all may need surgical management.     

Role of diagnostic and ablative minimally invasive surgery for pediatric malignancies

BACKGROUND: The use of minimally invasive surgery (MIS) in pediatric cancer is a matter of debate. The diagnostic and ablative roles of MIS were evaluated in a consecutive series of children with malignancies. METHODS: A prospective study, including all patients, who underwent abdominal and thoracic surgery for confirmed or highly suspected pediatric cancer was performed from September, 2000, to December, 2005. An interdisciplinary panel approved the indication for minimally invasive or conventional surgery. RESULTS: At a single institution, 301 operations were performed on 276 children with cancer. A minimally invasive approach was attempted in 90 of these patients (30%) and successfully employed in 69 (77%) of the operations. However, 21 operations (23%) were converted to an open approach. Regarding the abdominal operations attempted laparoscopically, 41 abdominal operations for biopsy or staging purposes were attempted laparoscopically (53%), but 6 were converted. In all, 139 abdominal resections were performed and 24 were attempted laparoscopically. Ten of these (42%) were converted. In 34 thoracic operations requiring biopsy, thoracoscopy was attempted in 14 (41%) and was successful in all but 1 (93%). Fifty-one thoracic tumors were resected and the thoracoscopic approach was attempted in 11 (22%) and successful in 7 (14%). Conversions from a minimally invasive operation to an open procedure occurred mainly due to limited visibility. Three bleeding complications occurred with 1 patient requiring a blood transfusion. In addition, 1 small bowel injury occurred with immediate laparoscopic closure. There were no port site recurrences after a median of 39 months. CONCLUSIONS: MIS is a reliable diagnostic tool for pediatric abdominal and thoracic malignancy. The role of ablative MIS in pediatric cancer remains limited.     

Neoplastic obstruction of the small and large intestine

Obstructive symptoms due to small bowel tumors are the most common indication of primary malignant disease in the small intestine. Primary obstructing tumors of the small bowel are treated best by resection and primary anastomosis. Malignant lesions of the duodenum sometimes will require pancreaticoduodenectomy and those of the distal ileum, right hemicolectomy. Obstruction due to localized metastatic disease can be treated by resection and primary anastomosis but, more frequently, one or more side-to-side enteroenterostomies will be needed, especially in abdominal carcinomatosis.The complication of LBO due to colorectal cancer is an ominous sign. The less favorable prognosis is a result of the higher operative mortality, advanced stage of disease and lower resectability rate. Obstructing neoplasms of the right side of the colon are treated best by immediate resection and primary anastomosis. Left-sided colon obstruction due to malignancy traditionally is treated by preliminary diversion followed later by definitive resection. Insufficient data are available to evaluate any benefit on operative mortality and long-term survival with a more aggressive approach involving decompression and resection of the obstructing carcinoma at the initial operation.It is doubtful that any marked improvement in current mortality and survival figures will result from wide deviations of the current principles of operative management. Early diagnosis of the cancer before obstruction occurs remains the primary means of improving survival rates. This involves not only patient education regarding presenting symptoms, but improvement of physician recognition and response to these complaints so that the appropriate tests are ordered and treatment is initiated.     

Yolk sac tumours of the ovary: an update.

AIMS: Yolk sac tumours of the ovary (YST), also called endodermal sinus tumours (EST) are rare and highly malignant tumours of utmost importance occurring in children and young adults. In the past, outcome was very poor and the disease was almost always fatal. With the refinement of chemotherapeutic regimens in the last several decades, survival rates have improved dramatically and fertility preserving surgery has become possible. The aim of this review is to provide the reader with an analysis of the available literature and a rational approach to patient management. METHODS: We performed a literature search in the PubMed database and the reference lists of relevant articles concerning yolk sac tumours of the ovary. FINDINGS AND CONCLUSION: There are no randomised studies relating to the management of YST of the ovary. The available literature is composed of retrospective reviews and case reports that span several decades. Prognosis nowadays is good in stage I and II but still comparable to that of ovarian epithelial cancer in stage III and IV. The overall good prognosis is due to the fact that most of ovarian YST are diagnosed at an early stage where 5years survival reaches 95%. Appropriate surgical treatment for patients where fertility needs to be preserved consists in laparotomy with unilateral salpingo-oophorectomy, peritoneal cytologic studies, omentectomy, multiple peritoneal and abdominal biopsies and resection of all visible disease. Three courses of BEP (bleomycin, etoposide, cisplatin) is the current standard therapy and four courses is recommended in case of bulky residual disease after surgery. Serum alpha-feto-protein (AFP) is a useful marker for the diagnosis and management of YST.     

电视胸腔镜在胸部肿瘤中的应用

电视胸腔镜外科（ＶＡＴＳ）在胸部肿瘤的临床应用尚存争议。自１９９６年１０月～１９９７年８月，我科共行胸腔镜手术１６例：肺癌切除２例，纵隔肿瘤切除３例，恶性胸水行胸膜固定术２例，恶性心包积液行心包开窗术４例，常规开胸术前诊断性探查５例，初期结果较为满意。结论：ＶＡＴＳ创伤较小，安全有效。可选择性地用于胸部良恶性肿瘤的诊断和治疗。     

双镜技术在左半结肠癌伴梗阻中的应用研究进展

结直肠癌是消化系统中常见恶性肿瘤,约7%-30%的结直肠癌患者会出现急性肠梗阻,其中约70%的结直肠恶性梗阻位于左半结肠或直肠.近年来,随着肠道金属支架的应用,结直肠癌伴梗阻患者获得较好的疗效.双镜技术具有创伤性小、并发症少、肿瘤一期切除率高、患者耐受性好、术后恢复快等优点,但是双镜技术也有各种不足,而且金属支架置入术后手术时机的选择仍存在争议.本文就双镜技术在左半结肠癌伴梗阻中的应用研究进展展开综述.     

Anxiety symptoms and panic attacks preceding pancreatic cancer diagnosis

Cancer of the pancreas is a highly malignant disease with a very poor prognosis. Depression and anxiety occur more frequently in cancer of the pancreas than they do in other forms of intra‐abdominal malignancies and other cancers in general. Yet, the etiology of psychiatric symptoms in patients with cancer of the pancreas may not be traced solely to poor prognosis, pain, or existential issues related to death and dying. In as many as half of patients that go on to be diagnosed with the disease, symptoms of depression and anxiety precede knowledge of the diagnosis. This observation has raised speculation that mood and anxiety syndromes are related to disruption in one of the physiologic functions of the pancreas. In this paper, we present a patient who had no prior psychiatric history and developed panic attacks just prior to diagnosis of her cancer. To our knowledge, this is the first report in the literature where panic attacks, not simply anxiety, presented prior to a pancreatic cancer diagnosis. Her symptoms resolved following resection of the tumor. Implications of such phenomena for the diagnosis and treatment of anxiety and depression in pancreas cancer are discussed. Copyright © 1999 John Wiley & Sons, Ltd.     

胃肠道癌术后腹壁创口种植瘤的临床分析

目的：探讨胃肠道癌术后腹壁创口种植瘤的临床特征、诊断、治疗及预后。方法：回顾性分析川北医学院附属医院收治住院的14例胃肠道癌术后创口种植瘤患者临床资料,并进行相关文献复习。结果：发生腹壁种植瘤的原发性胃肠道癌分期均为 T4期,64.3%（9/14）的病理组织类型为低分化腺癌,常规化疗9例。种植瘤发生于腹腔镜或开腹手术的比例均为50.0%（7/14）,各有5例患者行了单纯的腹壁肿瘤切除、腹壁肿瘤切除+腹壁缺损补片修补术,2例单纯腹壁肿瘤切除的患者因全身扩散后分别于10、16个月后死亡,补片修补腹壁缺损的患者目前均处于生存状态（复发1例）。4例患者因腹壁肿瘤多发或扩散而放弃手术于12个月内死亡。结论：发生腹壁种植瘤的原发性胃肠道癌恶性程度高,分期晚,术后的常规化疗不能有效的预防创口种植瘤,在腹腔镜及开腹手术中均可发生。尚无其他部位广泛转移的创口种植瘤应尽早行足够范围的完整切除术,人工补片修补是治疗肿瘤切除后腹壁缺损的有效方式。     

The role of radiotherapy for high-risk endometrial cancer

High-risk endometrial cancer comprises an uncommon group of tumors, which includes pathological stage III adenocarcinoma and all stages of papillary serous carcinoma. Optimal management of this class of malignant female genital neoplasms is surgical resection, including debulking of any gross abdominopelvic disease. This article analyzes the literature concerning the use of adjunctive radiotherapy. The data presented suggest that postoperative whole abdominal radiotherapy may improve outcome in selected subsets of patients within this high-risk group. Future clinical investigations will greatly benefit from the anticipated published results of two completed prospective cooperative group clinical trials that involve whole abdominal irradiation.     

肺小结节胸腔镜手术常见定位方法研究进展

肺癌是如今全球发病率及死亡率最高的恶性肿瘤,手术切除是肺癌的主要治疗手段。得益于医学影像设备硬件和软件技术的日益进步,肺小结节诊断、治疗与随诊的影像学检查水平一直在不断地提高。电视辅助胸腔镜手术逐渐成为肺小结节诊疗的常规治疗方式,具有微创、住院时间短、并发症少等特点。本文就当前肺小结节的研究热点,综合评价定位肺小结节的各种技术手段,着重于术中超声在肺小结节临床诊疗中的应用作一综述,并对其临床意义进行客观性评价。     

Minimally invasive surgery for neuroblastic tumours: A SIOPEN multicentre study: Proposal for guidelines

IntroductionSurgery plays a key role in the management of Neuroblastic tumours (NB), where the standard approach is open surgery, while minimally invasive surgery (MIS) may be considered an option in selected cases. The indication(s) and morbidity of MIS remain undetermined due to small number of reported studies. The aim of this study was to critically address the contemporary indications, morbidity and overall survival (OS) and propose guidelines exploring the utility of MIS for NB.Materials & Methods: A SIOPEN study where data of patients with NB who underwent MIS between 2005 and 2018, including demographics, tumour features, imaging, complications, follow up and survival, were extracted and then analysed.ResultsA total of 222 patients from 16 centres were identified. The majority were adrenal gland origin (54%) compared to abdominal non-adrenal and pelvic (16%) and thoracic (30%). Complete and near complete macroscopic resection (>95%) was achieved in 95%, with 10% of cases having conversion to open surgery. Complications were reported in 10% within 30 days of surgery. The presence of IDRF (30%) and/or tumour volume >75 ml were risk factors for conversion and complications in multivariate analysis. Overall mortality was 8.5%.ConclusionsMIS for NB showed that it is a secure approach allowing more than 95% resection. The presence of IDRFs was not an absolute contraindication for MIS. Conversion to open surgery and overall complication rates were low, however they become significant if tumour volume >75 mL. Based on these data, we propose new MIS guidelines for neuroblastic tumours.     

Concomitant abdominal aortic aneurysm and malignant disease: A difficult management problem

Medical records of 158 patients with abdominal aortic aneurysms seen between 1972 and 1984 were reviewed. Twenty patients, or 12.6%, had a histologically proven malignant neoplasm in addition to their aneurysm. The mean age of patients with cancer was 69 yr and for those without cancer, 68 yr. The most common cancers in this study were prostate, colorectal, and lung. Patients were placed in five categories according to the chronological presentation of the malignancy in relation to the aneurysm. Our study indicated that the incidence of malignant disease associated with abdominal aortic aneurysms is increasing. Absolute indications for operation initially on the aneurysm are the presence of symptoms or rupture. Absolute indications for operation initially on the malignancy are complications from the presence of the tumor such as hemorrhage, perforation, or obstruction. The type and stage of the cancer are major factors in determining operative treatment and priorities.     

Peripheral primitive neuroectodermal tumor of the posterior mediastinum：A case report

Peripheral primitive neuroectodermal tumor （pPNET） is an extremely rare disease entity of malignant tumors belonging to the Ewing sarcoma family that usually occurs in children and adolescents. We describe a 41-year-old female who presented with right upper abdominal pain. Surgical resection and biopsy revealed small round-cell tumor. Combined with immunohistochemical analysis, pPNET was diagnosed. No evidence of recurrence was noted at 18 months postoperatively. Even thought pPNET is a highly malignant tumor, Wide tumor-free resection and multi-agent chemotherapy can also obtain good clinical outcomes.     

胃恶性间质瘤的诊断与治疗

目的:探讨胃恶性间质瘤的术前诊断方法及有效的治疗手段。方法:回顾性分析我院1995年~2005年间收治的9例胃恶性间质瘤患者的临床表现、理化检查、治疗方法及结果。结果:胃恶性间质瘤患者多表现为反复的消化道出血、腹痛、腹部不适及腹部包块,纤维胃镜、超声内镜、消化道钡透、腹部CT检查有助于手术前诊断。本组患者肿瘤最大直径为5.5cm~21cm,平均为11.8cm,根治性手术7例、姑息性减瘤手术2例,根治性手术患者中2例术后复发接受二次手术,4例无瘤生存5年以上,姑息性手术2例患者均于术后6个月内死亡。免疫组化检查CD117阳性9例(100%)、CD34阳性7例(77.8%)、Vimentin阳性7例(77.8%)S-100阳性5例(55.6%),Actin阳性4例(44.5%)。结论:免疫组化检查可确诊胃恶性间质瘤,根治性手术减少手术后复发及远处转移。     

Imaging-guided curative surgical resection of pancreatic cancer in a xenograft mouse model

Pancreatic cancer is the fourth leading cause of cancer related deaths in North America. The poor survival statistics are due to the fact that there are no reliable tests for early diagnosis and no effective therapies once metastasis has occurred. Surgical resection is the only curative treatment for pancreatic cancer; however, only less than 15% of the patients are eligible for surgery at diagnosis. New therapies are urgently needed for this malignant disease. And combinational therapy including surgery, chemotherapy and molecular targeted therapy may further improve the efficacy of individual therapies. However, a reliable mouse model which mimics the human disease and can be used for testing the surgical treatment and surgery-based combinational therapy is not available. In this study, we have established a mouse model for curative surgical resection of pancreatic cancer. Human pancreatic cancer cells were used to create orthotopic xenografts in nude mice, distal pancreatectomy was performed using imaging-guided technology to remove the pancreatic tumors, and sham surgery was performed in the control group. All mice survived the operation and no complication was observed. Surgical resection at early stage improved the survival rate and quality of life of the mice compared with the sham surgery and surgical resection at the late stage. If combined with other therapies such as chemotherapy and molecular targeted therapy, it could further improve the outcome of pancreatic cancer. This mouse model is a useful tool to study the surgical therapy and the tumor recurrence of pancreatic cancer, and could potentially impact the therapeutic choices for this deadly disease.