The role of surgery in primary gastric non-Hodgkin's malignant lymphoma

A total of 15 cases of primary gastric non-Hodgkin's malignant lymphoma (PGML) seen between 1974 and 1985 were reviewed, and data obtained combined with reports in the literature, to define the place of surgery in this affection becoming the monopoly of chemotherapists. The indication for surgery is indisputable when the diagnosis is in doubt, and justified for ulcerated and preperforating forms and in extirpable tumoral forms of loco malignancy. It should be avoided in high grade PGML unless the operation does not delay chemotherapy. Total gastrectomy should not be performed by principle but by necessity. Abdominal exploration should include lymph node and liver biopsies. An effective total care of these patients requires close cooperation between medical and surgical teams.     

The diminishing role of surgery in the treatment of gastric lymphoma

OBJECTIVE: This article reviews the pathogenesis, diagnosis, and treatment of patients with primary gastric lymphoma, with special attention to the changing role of surgery. SUMMARY BACKGROUND DATA: Primary gastric lymphomas are non-Hodgkin lymphomas that originate in the stomach and are divided into low-grade (or indolent) and high-grade (or aggressive) types. Low-grade lesions nearly always arise from mucosa-associated lymphoid tissue (MALT) secondary to chronic Helicobacter pylori (H. pylori) infection and disseminate slowly. High-grade lesions may arise from a low grade-MALT component or arise de novo and can spread to lymph nodes, adjacent organs and tissues, or distant sites. METHODS: A review of the relevant English-language articles was performed on the basis of a MEDLINE search from January 1984 to August 2003. RESULTS: About 40% of gastric lymphomas are low-grade, and nearly all these low-grade lesions are classified as MALT lymphomas. For low-grade MALT lymphomas confined to the gastric wall and without certain negative prognostic factors, H. pylori eradication is highly successful in causing lymphoma regression. More advanced low-grade lymphomas or those that do not regress with antibiotic therapy can be treated with combinations of H. pylori eradication, radiation therapy, and chemotherapy. Nearly 60% of gastric lymphomas are high-grade lesions with or without a low-grade MALT component. These lymphomas can be treated with chemotherapy and radiation therapy according to the extent of disease. Surgery for gastric lymphoma is now often reserved for patients with localized, residual disease after nonsurgical therapy or for rare patients with complications. CONCLUSION: The treatment of gastric lymphoma continues to evolve, and surgical resection is now uncommonly a part of the initial management strategy.     

The role of surgery in the treatment of primary gastric lymphoma

The present retrospective study of 23 patients with primary gastric lymphoma had the objective of determining the role of surgical treatment on survival. All patients were submitted to gastric resection with regional lymph node removal. Nine patients (39.1%) received supplementary treatment (chemotherapy and/or radiotherapy). According to the Kiel classification, the most frequent histological type was the centroblastic (29.1%), and most patients (60.9%) had a low-grade lymphoma. According to the Ann Arbor classification, modified by Musshoff and Schmidt-Vollmer, stages were IE in 52.1%, II1E in 8.7%, II2E in 13.1%, and IV in 26.1% of the cases. Mean survival was 29.3 months. The variables that influenced survival rates were age, advanced stage tumor, and receiving postoperative adjuvant therapy. Analysis of our cases suggests that complete lesion resection along with adjacent lymph nodes, and supplementary postoperative treatment is the best approach for a resectable primary gastric lymphoma.     

The role of surgery in abdominal non-Hodgkin's lymphoma: experience from the Childrens Cancer Study Group.

To determine the appropriate role of surgical intervention in non-Hodgkin's lymphoma primary to the abdomen, we analyzed the effect of multiple prognostic determinants on event-free survival for patients entered into the CCG-551 study. Eighty-four patients were identified with abdominal lymphoma and of these adequate data for analysis was available on 68 (81%). Variables of interest included: extent of disease at diagnosis, completeness of resection, use of bowel resection, radiation to the primary site, and sex/age/race. The median age on study was 8 years; 79% of patients were white and 85% were male. Thirty-three patients (49%) presented with localized disease. Laparotomy was performed in 67 children (99%) with complete gross resection in 28 (42%). Of the 10 reported surgical complications, 8 occurred in those with extensive disease who were incompletely resected. Radiation to the primary site was given in 60% of patients with median dose of 2,000 cGy. Analysis was performed both for the overall group and for the subgroup receiving optimal chemotherapy for histopathology. Variables with significant predictive effect on event-free survival in univariate analysis included extent of disease (P less than or equal to .001), complete resection (P less than or equal to .002), and use of bowel resection (P less than or equal to .004). However, in multivariate analysis, only extent of disease was an independent predictor of outcome. The data support a role for complete operative excision of localized lymphomas especially when accomplished with bowel resection. Aggressive attempts at debulking extensive retroperitoneal or mesenteric lymphomas are contraindicated.     

Primary non-Hodgkin's B-cell lymphoma of the male urethra presenting as stricture disease

Primary urethral lymphoma is exceedingly rare. There are only three cases reported involving the male urethra, with one in an immunocompromised man. We report a case of primary B-cell lymphoma presenting as complex urethral stricture disease.     

The role of surgical intervention in non-Hodgkin's lymphoma of the colon and rectum

BACKGROUND: Gastrointestinal involvement of non-Hodgkin's lymphoma (NHL), although rare, may require surgical intervention. The purpose of the current study was to determine the incidence, presentation, and management of patients with NHL of the colon or rectum. METHODS: Demographic data, signs, symptoms, disease stage, and treatment of patients with a primary gastrointestinal lymphoma treated between 1973 and 2005 were identified. RESULTS: Forty-three of 244 gastrointestinal lymphoma patients (18%) had colon or rectal involvement. Most common symptoms on presentation were pain (49%), hematochezia (49%), change in bowel habits (23%), and weight loss (19%). Most common site of involvement was the ileocecum. Twenty-six patients (60%) required surgery. The majority (56%) had urgent or emergent operations. CONCLUSIONS: Colorectal involvement by NHL occurred in 18% of patients with gastrointestinal lymphoma. Surgery was required for pain, obstruction, and/or bleeding. Physicians caring for patients must be aware of the potential need for surgery in treating this patient population.     

The role of surgery in the management of American Burkitt's lymphoma and its treatment.

Ninety-two patients with American Burkitt's lymphoma were studied retrospectively to elucidate the role of surgery in the complications of treatment of Burkitt's lymphoma. All of the patients reviewed had been treated with at least one chemotherapeutic agent. Seventy-five percent of the patients had predominantly abdominal disease that required a laparotomy for diagnosis and treatment when possible. The postoperative complications, such as infections, were not more frequent when compared with other elective surgical procedures. Ten percent of all the patients had episodes of significant gastrointestinal bleeding secondary to disease or to the chemotherapy. One patient was treated surgically, and two patients had fatal hemorrhages. Further abdominal complications that required surgery included intussusception, cholelithiasis, small bowel obstruction, and bowel perforation. The incidence of renal failure because of electrolyte imbalance from tumor lysis syndrome was 30%. One third of these patients required access for dialysis. Ten percent of patients developed hemorrhagic cystitis, but none required surgery. Surgery was necessary in five patients with life-threatening pericardial effusion. Other surgical treatments are also reviewed. It is concluded that Burkitt's lymphoma has a significant cure rate with the appropriate medical and surgical therapies, and that the surgical approach to the disease and its complication should be optimistic and appropriately aggressive.     

The role of surgery in the management of thyroid lymphoma

The role of surgery in the management of patients with primary lymphoma of the thyroid gland has been addressed after review of 61 patients treated at Princess Margaret Hospital between 1958 and August 1982, 46 of whom had clinical stage I and II disease confined to the thyroid gland or lymph nodes or both above the diaphragm. Postoperative radiation therapy was used in 34 patients, radiation therapy and chemotherapy in 11 patients, and chemotherapy alone in 1 patient. Analysis of disease progression, local relapse, and distant disease recurrence indicated that postoperative residual disease bulk predicted strongly for both local and distant disease progression. Overall cause-specific survival was 59% at 5 years, with a relapse-free rate of 46% at 5 years. Of those with less than 2.5 cm of residual disease after surgery, 80% achieved lifelong local disease control compared with 40% for those with residual disease in excess of 2.5 cm after surgery. Distant relapse rates were 7% and 23% for those with less than 2.5 cm and greater than 2.5 cm after surgery, respectively. The long-term survival rate for those with disease progression during this period was approximately 10%, with a median survival expectancy of 18 months. It is suggested that those patients without an antecedent cytologically based diagnosis of lymphoma undergo biopsy and removal of operable tumor without compromise of parathyroid glands, recurrent laryngeal nerves, or appearance. Those patients with an existing cytologic diagnosis of lymphoma and bulky and/or inoperable tumor may be more effectively managed with a combined chemotherapy-radiation therapy program.     

The role of pediatric surgery in the medical school curriculum

In most medical schools, exposure to pediatric surgery is presented as a subspecialty elective. We have offered it as an integral part of the surgical clerkship for 10 years in the belief that it provides an excellent educational environment. To confirm this concept, the quizzes (Q), final examinations (FE), and grades of students assigned to the pediatric surgical service were prospectively studied. All students (N = 139) in the surgical clerkship entered the study. Thirty-two students were randomly selected and assigned to the surgical service of a major pediatric hospital (P-Surg) for 50% of their clerkship. The other students (N = 107) were assigned to a variety of adult surgical services (G-Surg) and served as the control group. All students attended the same seminars, used the same educational materials, were examined with the same test items, and were evaluated by the same oral examiners. Test items were electronically scored and the database was analyzed on an IBM computer. The statistical analysis was performed using a Student's t test and chi 2 analysis. There was no significant difference in the demonstrated cognitive performance and grades awarded to the two groups of students. We conclude that a pediatric surgical service provides an atmosphere that is educationally comparable to the adult general surgical service.     

Primary cutaneous B-cell lymphoma: Role of surgery

PURPOSE:

To evaluate the role of surgery in patients diagnosed with primary cutaneous B-cell lymphoma (PCBCL) – a rare disease entity. The authors offer a rationale for the use of primary surgical excision in the treatment of isolated cutaneous lymphomas.

METHODS:

A literature review examining the use of primary surgical excision in the treatment of PCBCL was conducted. The lymphoma database at the Juravinski Cancer Centre (Hamilton, Ontario) was searched from January 1995 to July 2008, generating a list of 4924 patients. A simulated computer program was subsequently designed to search for all possible PCBCLs. A retrospective chart review was then conducted on the new list of 1325 patients, identifying 25 patients diagnosed with PCBCL.

RESULTS:

The mean age of the 25 patients with PCBCL was 59.9 years; nine (36%) were treated with surgery, and sixteen (64%) with radiation. The average follow-up period for patients was 3.6 years. Twenty-four of the 25 patients were completely cured, with only one patient recurring in the radiation subgroup. There were no complications in the surgery subgroup. There were two local complications in the radiation subgroup consisting of chronic ulcerations.

CONCLUSIONS:

Primary surgical excision is an effective management option in the treatment of PCBCL, particularly the marginal zone and follicle centre subtypes.     

The role of pediatric surgery in general surgical education

Seventy-four practicing surgeons were surveyed regarding pediatric surgery in their surgical education and practice.Most care for the common surgical diseases of childhood; ten (13.5%) had done major noncardiac neonatal procedure in the preceding year. Sixty-one (82%) considered pediatric surgery to be a valuable component of general surgical education.     

The role of surgery in abdominal Burkitt's lymphoma.

The abdomen is the most frequent site of involvement in nonendemic Burkitt's lymphoma (small noncleaved cell). Some authors have proposed a role for extensive surgical resection or "second look" laparotomy in these patients. We retrospectively reviewed our series of 53 patients with Burkitt's lymphoma (1977 to 1990) to assess the role of surgery in their treatment. Patients were 2.5 to 21 years of age (median, 9.5 years) and 44 were males. The primary site of disease was the abdomen (38), head and neck (12), axilla (1), and bone marrow (2). Twenty-four of the 38 patients with abdominal primaries underwent laparotomy. Twelve of these patients presented with acute abdominal symptoms (right lower quadrant pain or intestinal obstruction) and at exploration underwent resection of the primary tumor. Ten of these 12 patients achieved grossly complete excision of tumor (9 had disease limited to the ileocecal area and adjacent mesentery and one had exophytic tumor adherent to the liver, which was excised). Of note, only 1 of these 12 patients had metastatic disease outside of the abdomen. The remaining 12 patients who underwent laparotomy had an incisional biopsy performed. Of the 14 patients who did not have a laparotomy, the diagnosis was made by bone marrow biopsy (6), and/or cytology of pleural fluid or ascites (6), lymph node biopsy (1), testicular biopsy (1), tibial biopsy (1), and percutaneous biopsy (1). Murphy staging for these 38 patients was: stage II (10), stage III (19), stage IV (5), and B cell acute lymphoblastic leukemia (ALL) (4). All patients received cyclophosphamide-containing combination chemotherapy regimens and stage III/IV/B cell ALL patients received central nervous system (CNS) prophylaxis.(ABSTRACT TRUNCATED AT 250 WORDS)     

The role of tissue expansion in pediatric plastic surgery

The ability to increase available local tissue by controlled soft tissue expansion (TE) has led to a rapid increase in the use of TE in clinical practice. This article reviews some general guidelines when using TE in children and addresses some of the concerns previously expressed regarding the effects of TE on growth in infants and children.     

The role of intraoperative radiotherapy in oncological pediatric surgery

Conventional external beam radiation has proved its profit in pediatric tumors; but its complications have limited it in therapeutical approach. Intraoperative radiotherapy delivers a high single dose in residual tumor or high risk areas during surgery. In our center, during last two years, 7 patients have been candidates to surgery with intraoperative radiotherapy (the age range was between 5 months-17 years; mean 8.5 years). Two patients were excluded of our protocol because of their intraoperative stage. Patients tumors types were: neuroblastoma (n = 3; stage III and IV), soft tissue sarcomas (n = 1) and Ewing's sarcoma (n = 1). The radiation doses ranged from 500 cGyto-1200 cGy. Local control tumor was achieved in 4 patients and no-complications were present secondary to surgery or intraoperative radiotherapy. Intraoperative radiotherapy seems to be a feasible treatment which might promote local control in pediatric tumors with protection of normal tissues and could be an excellent complement in special cases.     

The role of surgery in the treatment of transsexualism

The increasing use of surgery for sex reassignment in the treatment of transsexualism is described. The author's early experience over a twenty-year period with the Gender Identity teams at The Johns Hopkins University and The University of Virginia is summarized. Many of the reasons for slow acceptance of this type of surgery by many members of the medical profession are analyzed. The satisfactory subjective results described by patients who have received sex reassignment continue to exceed the results obtained by other methods. The author concludes that further study of surgical treatment is justified, but that it should be limited to established multidisciplinary teams working in academic settings. Physicians are urged to withhold judgment on the role of surgery in gender disorders until they have had significant personal experience with these desperate and complex patients.     

The role of surgery in American Burkitt's lymphoma in children.

The records of 28 children with the pathological diagnosis of American Burkitt's lymphoma were reviewed. Twenty-three of these children (82%) presented with primary abdominal tumors and 5 with disease located in the head and neck. Twelve required an emergency operation for either intestinal obstruction (3), intussusception (5), or appendicitis (4); the others underwent an elective exploration for tissue diagnosis. Ten patients had disease localized to one particular site. Seven of these 10 children underwent complete resection of the tumor including a right colectomy (4), small bowel segmental resection (1), tonsillectomy (1), and appendectomy (1). Eight children had a subtotal resection of the tumor (less than 90% of tumor burden) and the rest underwent incisional biopsies. Following the diagnosis, all patients received chemotherapy; 8 (29%) also were treated concurrently with radiation therapy. Nineteen patients (70%) remain long-term survivors with a mean survival time of 3.6 years. Eight patients died of either recurrent disease (6) or sepsis secondary to their chemotherapy, with a mean survival time of 6 months. Sixteen patients (57%) developed complications during their hospitalization that required surgical consultation or intervention (acute renal failure [9], pleural effusion [2], intestinal obstruction [5], gastric outlet obstruction [1], and wound infection [1]). No subsequent treatment of these complications resulted in mortality or morbidity. The significant positive determinant for survival was the initial absence of either bone marrow or central nervous system involvement (P less than .05). In those children who had complete resection of their tumor, survival time was greater than 3.7 years.(ABSTRACT TRUNCATED AT 250 WORDS)     

The role of surgery in the treatment of neuroblastoma

The role of surgery varies greatly according to the clinical condition of the patients with neuroblastoma. A surgical resection is the mainstay of treatment for a localized tumor. However, in the era of intense chemotherapy associated with hematopoietic stem cell plant rescue, surgical resections are recommended without sacrificing the kidney or major vessels. Tumor biology further defines the necessity of supportive chemotherapy or radiation after surgical resection. The presence of diverse terminology concerning the range of resection may impose some confusion in the understanding of the previous papers. Therefore, the definition of a surgical resection was initially stated. In high-risk patients, the advantages of surgery for a patient’s survival seem to be limited. This article reviews the efficacy of surgical resections in different clinical situations for a better understanding of the meaning of surgery in the treatment of neuroblastoma. The results of surgical resections are summarized according to the International Neuroblastoma Staging System. Finally, the long-term results regarding the strategy-related survival of the patients in the Niigata tumor board are briefly introduced.