Oncological safety of laparoscopic surgery for urological malignancy: experience with more than 1,000 operations

PURPOSE: Although laparoscopy is being increasingly used to treat urological malignancies, there is still concern regarding the induction of local recurrence and port site metastasis. To our knowledge no major clinical study with long-term followup has been presented in the field of urological laparoscopy. We assessed the oncological safety of laparoscopy with emphasis on incidence of local recurrence and port site metastasis, analyzing the risk factors for such events based on a 10-year experience. MATERIALS AND METHODS: From June 1992 to May 2002 we performed 1,098 laparoscopic procedures for urological malignancies, including 450 radical prostatectomies, 478 pelvic and 80 retroperitoneal lymph node dissections, 45 radical nephrectomies, 22 radical nephroureterectomies, 12 partial nephrectomies and 11 adrenalectomies. In 418 cases of laparoscopic radical prostatectomy pelvic lymphadenectomy was done simultaneously. Of the procedures 917 were performed transperitoneally, including 181 via retroperitoneal or extraperitoneal access. A total of 567 procedures were performed in case of histologically proven cancer, whereas 531 represented only staging operations. RESULTS: Median followup was 58 months (range 4 to 127). Eight local recurrences were observed (0.73% overall, 1.41% of histologically proven cases). There were recurrences after nephroureterectomy for transitional cell carcinoma of the ureter in 1 patient, after radical nephrectomy for renal cell carcinoma in 1, growing teratoma after retroperitoneal lymph node dissection in 2, local recurrence of prostate cancer in 3 and after removal of an adrenal metastasis of melanoma in 1. Two port site metastases (0.18% overall, 0.35% of histologically proved cases) occurred, including metastasis of small cell lung carcinoma after adrenalectomy and a residual mass following 2 cycles of chemotherapy after retroperitoneal lymph node dissection. CONCLUSIONS: According to our experience the incidence of local recurrence and the risk of port site metastases is low and seems to be mainly related to the aggressiveness of the tumor and immunosuppression status of the patient, respectively rather than to technical aspects of the laparoscopic approach.     

Solitary, isolated metastatic disease to the kidney: Memorial Sloan-Kettering Cancer Center experience

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Usually malignant disease involving the kidneys is characterized by bilateral and multiple lesions in association with widespread dissemination of the primary tumour. Metastasis to the kidney as a solitary, isolated renal mass is an extremely rare event and little is known about its characteristics and outcomes. Our study shows that kidney involvement by other tumours can occur as isolated solitary lesions and the kidney can be the first and only site of metastatic involvement. Of the 14 patients included in the study, 8 were alive at the last follow‐up and 4 without evidence of disease after nephrectomy. In this highly selected group of patients nephrectomy can be offered as a therapeutic option.

OBJECTIVE

? To analyse the clinical characteristics and outcomes of patients who underwent nephrectomy for solitary, isolated metastatic disease to the kidney.

PATIENTS AND METHODS

? From July 1989 to July 2009, we identified 13 patients who underwent nephrectomy for solitary metastasis to the kidney. Patients’ demographics, intra‐operative variables and outcomes are reported.

RESULTS

? The median age at nephrectomy was 52 years (range 33–79). Eleven patients (85%) had an incidentally discovered renal mass, whereas two patients (15%) presented with gross haematuria. ? Median time from initial surgery at the primary site to development of metastatic disease to the kidney was 63 months (range 9–136). No patient had evidence of disease at other sites at the time of nephrectomy. In seven patients (54%), the kidney was the first site of recurrence. ? The most common primary site was the lung in five patients (38%), followed by the colon in two (15%), chest wall in two (15%) and bone, brain, breast and salivary gland in one patient each (8%). ? Of the 14 procedures performed, eight (57%) were partial nephrectomy (PN) and six (43%) were radical nephrectomy (RN). ? Four patients died after progression from the primary tumour, all within 2 years of nephrectomy. One patient with a primary chondrosarcoma had no evidence of disease at last follow‐up and died from other causes 50 months after nephrectomy. The median follow‐up for the eight patients who were alive at last follow‐up was 30 months after nephrectomy. Four of these patients had no evidence of disease and four patients were alive with metastatic disease.

CONCLUSION

? Kidney involvement by metastatic disease can occur as isolated solitary lesions. Some patients will also have the kidney as the first and only site of metastatic involvement. The presence of an isolated renal metastasis should not be considered an end‐stage disease, and nephrectomy can be offered for highly selected patients as a therapeutic option.     

Surgical margin and its influence on survival in soft tissue sarcoma

BACKGROUND: The goal of surgeons treating soft tissue sarcoma is to gain local control, to avoid risk of local recurrence and to avoid compromise of the patient's potential survival. The aim of the investigation was to assess the significance of the extent of surgical margin on the chance of death, metastasis and local recurrence. METHODS: Two hundred and seventy-nine patients who presented with soft tissue sarcoma without metastatic disease were analysed. RESULTS: The extent of the surgical margin was not clinically or statistically significant in the development of metastatic disease. The presence of a contaminated surgical margin led to a significantly higher rate of local recurrence (as did a narrow surgical margin less than 1 mm). A margin greater than 1 mm allowed a satisfactory outcome in terms of low local recurrence rates. In terms of overall survival, the failure to achieve a wide surgical margin (wide contaminated margin) led to an increased relative death rate. However, when the margin was not contaminated (even if the margin was very close, less than 1 mm), the overall survival rate was similar across all groups. Patients who had radical resections did poorly; they generally belonged to a group in which palliative surgery was carried out, and they showed very high relative metastasis and death rates. CONCLUSION: The present study provides statistically significant evidence that increasing the width of resection improves local control and overall survival.     

Adenocarcinomas of the jejunum and ileum: A 25-year experience

Adenocarcinomas of the jejunum and ileum are rare gastrointestinal malignancies. Because few large published experiences exist, we reviewed patients with jejunal and ileal adenocarcinoma treated at our institution over the last 25 years. Between January 1976 and December 2001, 77 patients had an operation for a jejunal or ileal adenocarcinoma. Records were retrospectively reviewed for patient, tumor, and treatment variables. Factors affecting disease recurrence and patient survival were investigated. Fifty-two of the adenocarcinomas (67%) occurred in the jejunum and 25 occured in the ileum (33%). Mean patient age was 63 ±14 years. Segmental bowel resection was performed in 50 patients (65%) with curative intent. Palliative operative procedures including resection or bypass were performed in 27 patients (35%). One (1%) patient had stage I, 18 (23%) stage II, 19 (25%) stage III, and 39 (51%) stage IV adenocarcinoma at diagnosis. Postoperatively, 12 patients had palliative and 18 adjuvant chemotherapy (n 5 30), radiation therapy (n = 1), or combination treatment (n = 7). Median patient survival was 19 months. Sixty-six percent of patients who had a curative operation had a tumor relapse. Tumor stage had a highly significant effect (P < 0.0001) on median survival (72 months for stage I and II, 30 months for stage III, and 9 months for stage IV disease). In multivariate analysis of patients having curative treatment, tumor recurrence (P < 0.0001), stage (P < 0.0002), and weight loss (P < 0.001) were significant negative prognostic indicators. Most patients with adenocarcinoma of the jejunum or ileum present with advanced disease. Tumor stage, disease recurrence, and weight loss predicted patient outcome following a curative operation. Early recognition of these tumors requires a high index of suspicion. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisana, May 15–19, 2004 (poster presentation).     

Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy

PURPOSE: We compared outcomes between patients treated with nephron sparing surgery (NSS) without imperative indications for renal preservation and radical nephrectomy (RN) for 4 to 7 cm renal cell carcinoma (RCC). MATERIALS AND METHODS: We identified 91 patients treated with NSS and 841 patients treated with RN for 4 to 7 cm RCC between 1970 and 2000. Cancer specific, distant metastases-free and recurrence-free survivals were estimated using the Kaplan-Meier method. RESULTS: Cancer specific survival rates at 5 years for patients treated with NSS and RN for 4 to 7 cm RCC were 98% and 86%, respectively. On univariate analysis patients treated with RN for 4 to 7 cm RCC were more likely to die of RCC compared to patients treated with NSS. However, after adjusting for features associated with death from RCC including stage, grade, histological tumor necrosis and histological subtype, this difference was no longer statistically significant (risk ratio 1.60, 95% CI 0.50-5.12, p = 0.430). Distant metastases-free survival rates at 5 years for patients treated with NSS and RN were 94% and 83%, respectively. On univariate analysis patients treated with RN were more likely to have tumors that metastasized compared to patients treated with NSS, although this difference was no longer significant after adjusting for the features listed previously (risk ratio 1.76, 95% CI 0.64-4.83, p = 0.273). Recurrence-free survival rates at 5 years for patients treated with NSS and RN were 94% and 98%, respectively. On univariate analysis patients treated with RN were less likely to have recurrence compared to patients treated with NSS (risk ratio 0.32, 95% CI 0.12-0.85, p = 0.022). CONCLUSIONS: There were no statistically significant differences in cancer specific survival and distant metastases-free survival between patients treated with NSS and RN for 4 to 7 cm RCC after adjusting for important pathological features. NSS for 4 to 7 cm RCC results in excellent outcome in appropriately selected patients.     

Partial nephrectomy for patients with a solitary kidney: the Memorial Sloan-Kettering experience

OBJECTIVE: To report the experience of partial nephrectomy in patients with a solitary kidney at one institution, with analysis of renal function, complications, oncological efficacy and survival. PATIENTS AND METHODS: We identified 54 consecutive patients with a solitary kidney who had a partial nephrectomy between December 1989 and July 2003. Variables examined included patient age and gender, renal function, renal ischaemia time, surgical margin status and complications. Pathological features, e.g. tumour size, histological subtype and tumour stage, were also assessed. Disease-free probability and overall and cancer-specific survivals were determined. RESULTS: The histological subtype was clear cell in 35 cases (65%), papillary in 10 (19%), oncocytoma in four (7%), chromophobe in two (4%), unclassified in one (2%) and multiple subtypes in two (2%). The median creatinine level before surgery was 14 mg/L, which increased to 16 mg/L 6 months afterward, and at 1 and 2 years after surgery it was 15 mg/L. Two patients developed end-stage renal disease requiring haemodialysis, one soon after surgery and another 8 years after nephron-sparing surgery. In all, 26% of patients developed at least one perioperative complication, with acute renal failure and urinary fistula being the most common. At 5 years the overall and cancer-specific survival, and disease-free probability were 68%, 88% and 73%, respectively. CONCLUSIONS: Partial nephrectomy is safe in patients with a solitary kidney, with an acceptable decline in renal function and low likelihood of requiring temporary or permanent haemodialysis. After an initial decline, renal function appears to stabilize during the first year.     

Risk factors of rectal cancer local recurrence: population‐based survey and validation of the Swedish rectal cancer registry

Aim Despite advances in rectal cancer treatment, local recurrence (LR) remains a significant problem. To select high‐risk patients for different treatment options aimed at reducing LR, it is essential to identify LR risk factors. Method Local recurrence and survival rates of 4153 patients registered 1995–1997 in the Swedish Rectal Cancer Registry were analysed. LR risk factors were analysed by multivariate methods. For LR patients the registry was validated and additional data retrieved. Results The 5‐year overall and cancer‐specific survival rates were 45% and 62% respectively. LR was registered in 326 (8%) patients. After R0‐resections for tumours in TNM stages I–III, LR developed in 10% of tumours at 0–5 cm, 8% at 6–10 cm and 6% at 11–15 cm above the anal verge. Preoperative radiotherapy (RT) reduced the LR rate irrespective of height [0–5 cm: OR 0.50 (0.30–0.83), 6–10 cm: OR 0.42 (0.25–0.71), and 11–15 cm: OR 0.29 (0.13–0.64)]. Patients without preoperative RT had significantly higher LR risk after rectal perforation [OR 2.50 (1.48–4.24)], and almost significantly decreased LR risk when rectal washout was performed [OR 0.65 (0.43–1.00)]. Preoperative RT prolonged time to LR but did not significantly influence the survival among LR patients. LR was an isolated tumour manifestation in 103 (39%) patients with validated LR. Conclusion Preoperative RT should be considered for rectal cancer also in the upper third of the rectum. Intraoperative perforation should be avoided, and rectal washout is indicated as valuable. Follow‐up for the detection of isolated LR is important. Extended follow up should be considered for patients treated with RT.     

EXTREMITY SOFT TISSUE SARCOMA: FACTORS PREDICTIVE OF LOCAL RECURRENCE AND SURVIVAL

Background : To identify risk factors for local recurrence and overall survival in patients with extremity soft tissue sarcoma. Methods : A retrospective study was performed of all patients with extremity soft tissue sarcoma treated at the Combined Surgical Oncology Clinic in the Institute of Oncology at Prince of Wales Hospital between 1972 and 1992. Variables analysed included clinical presentation, patient characteristics, tumour characteristics, treatment factors and outcome. Results : One hundred and nineteen patients were eligible for the study. The most common type of presentation was with a painless mass, usually in the thigh. Local control rates at 5 and 10 years were 75% and 73%. Local control was higher in patients who had more radical surgery and in those who received adjuvant radiotherapy. Tumour size and high grade were independent risk factors for poorer survival. Patients over 50 had poorer survival than younger patients and those who presented with recurrent tumours also tended to have poor survival compared to patients presenting de novo. The respective 5- and 10-year survival rates were 65% and 62%. Conclusion : This study suggests that local control of extremity soft tissue sarcoma is improved by radical surgery and by the addition of radiotherapy when more conservative procedures are used. Overall survival appeared to be largely determined by patient (age, recurrent presentation) and tumour characteristics (grade, size).     

Partial cystectomy: a contemporary review of the Memorial Sloan-Kettering Cancer Center experience and recommendations for patient selection

PURPOSE: Partial cystectomy is a bladder sparing procedure that has been used to treat invasive bladder cancer in highly selected patients. This study analyzes the outcomes of partial cystectomy in a contemporary cohort of patients to identify appropriate selection criteria for the procedure. MATERIALS AND METHODS: Records were reviewed for 58 patients with a primary bladder tumor who had undergone partial cystectomy at Memorial Sloan-Kettering Cancer Center from 1995 to 2001. Information was collected on tumor size, histology, location, presence of carcinoma in situ (CIS), multifocality, neoadjuvant treatment, clinical stage, pathological stage and disease status. RESULTS: For the 58 patients analyzed, overall 5-year survival was 69% with a mean followup of 33 months (range 1 to 83). Of the patients 43 (74%) are alive with an intact bladder, 39 (67%) are currently disease-free with an intact bladder and 32 (55%) have been continuously disease-free with an intact bladder. Seven patients experienced a superficial recurrence and were treated successfully while 15 patients experienced an advanced recurrence. On univariate analysis CIS and multifocality were related to superficial recurrence, and lymph node involvement and positive surgical margin were related to advanced recurrence. On multivariate analysis concomitant CIS (odds ratio 7.05, p = 0.004) and lymph node involvement (odds ratio 4.38, p = 0.031) were predictors of advanced recurrence. CONCLUSIONS: In highly selected patients with invasive bladder cancer, partial cystectomy offers acceptable outcomes. Concomitant CIS and presence of metastases to regional lymph nodes predict advanced recurrence.     

胃癌根治术后复发与转移的区域及规律分析

目的通过CT诊断,分析胃癌根治术后复发与转移的区域及规律。方法选取2009年6月至2014年6月胃癌患者共81例,均行胃癌根治性手术,随访期间CT发现存在局部区域复发或转移。分析术后复发与转移的区域及规律。用SPSS 19.0软件分析数据,以%表示计数资料,Logistic回归分析检验术后复发时间和临床病理特征和治疗之间的关系;P0.05,差异具有统计学意义。结果在81例术后复发患者中,局部区域复发率最高(37.04%),在18例伴有术后区域淋巴结转移的患者中,Ⅰ区10例,Ⅲ区3例,Ⅳ区1例,Ⅵ区4例。术后7~12个月复发率最高(41.98%)。截止至2015年9月30日,在胃癌根治术后复发的81例患者中,中位总生存时间(OS)为33.18个月,中位复发时间为19.94个月,复发后中位生存期为7.19个月。其中发生腹膜种植后,中位生存期最短,仅为4.24个月。单因素分析结果显示,与OS相关的临床病理因素包括年龄(P=0.024),Borrmann分型(P=0.017)、TNM分期(P=0.009)、淋巴结检出总数(P=0.022)、阳性淋巴结数(P=0.002)、治疗方式(P=0.026)和治疗依从性(P=0.035);与局部无复发生存期(LRFS)相关的临床病理因素包括淋巴结检出总数(P=0.012)、阳性淋巴结数(P=0.008)、治疗方式(P=0.034)和治疗依从性(P=0.016)。结论局部区域复发,特别是区域淋巴结转移是胃癌根治术后复发的主要形式,术后通过CT划分淋巴结转移区域对于放疗靶区确定具有一定指导意义。