A Phase II Study of Partial and Subtotal Thymectomy for Thymoma (JART02)

Background

We believe the merit of preservation of a part of the thymus following surgery for thymoma. We evaluated the efficacy of partial or subtotal thymectomy for early-stage thymoma in the prospective study.

Methods

The Japanese Association for Research on the Thymus conducted a multiple institutional study of thymectomy for thymoma localized in the thymus without total thymectomy. Patients without autoimmune disease who had an anterior mediastinal tumor that had been clinically diagnosed as an early-stage thymoma were enrolled in the study. Patients who were positive for anti-acetylcholine receptor antibodies were excluded.

Results

Sixty-three patients were enrolled preoperatively; 27 patients were judged as being inappropriate based on the other thymic pathologies or tumor invasion. The remaining 36 cases were diagnosed as early-staged thymoma and analyzed. The mean age of the patients was 61 years. The mean maximal tumor diameter in the resected specimens was 3.6 cm. The most common pathological types of thymoma were AB (n = 10) and B1 (n = 10). The Masaoka stages were classified as stage I (n = 22) and II (n = 14). The mean observation period was 63 months. Two patients died due to respiratory dysfunction, which was not related to thymoma. One hundred percent of the patients remained recurrence-free.

Conclusions

This prospective study suggested the efficacy of partial or subtotal thymectomy for early-stage thymoma in patients without any apparent evidence of autoimmune disease. We can preserve a part of the thymus even following surgery for thymoma to prepare the possible second malignancies or diseases in future.

     

Intra-thymic bronchogenic cyst an extremely rare tumor of anterior mediastinum in adults

Background

Intra-thymic bronchogenic cysts are a rare entity but should be considered in the differential of all non-invasive thymic masses.

Case presentation

We describe a 50-year-old patient who was found to have an incidental thymic mass on computer tomography of the chest. Non-invasive thymoma was suspected and a thoracoscopic thymectomy was performed. Final pathology revealed a bronchogenic cyst.

Conclusion

Intra-thymic bronchogenic cysts are extremely rare tumors of the anterior mediastinum. It should be considered in differential diagnosis of anterior mediastinal masses.

     

Assessment of the prognostic role of neutrophil-to-lymphocyte ratio following complete resection of thymoma

Background

The introduction of the new TNM staging system for thymic epithelial malignancies produced a significant increase in the proportion of patients with stage I disease. The identification of new prognostic factors could help to select patients for adjuvant therapies based on their risk of recurrence. Neutrophil-to-lymphocyte ratio (NLR) has recently gained popularity as reliable prognostic biomarker in many different solid tumors. The aim of this study is to assess the utility of NLR evaluation as a prognostic marker in patients with surgically-treated thymoma.

Methods

A retrospective analysis was conducted among patients who underwent resection for thymoma in a single center. Patients were divided in two groups, under (low-NLR-Group?=?47 patients, 60%) and above (high-NLR-Group?=?32 patients, 40%) a ROC-derived NLR cut-off (2.27). Associations with clinical-pathological variables were analyzed; disease-free survival (DFS) was identified as the primary endpoint.

Results

Between 2007 and 2017, 79 patients had surgery for thymoma. Overall 5-year DFS was 80%. Univariate survival analysis demonstrated that NLR was significantly related to DFS when patients were stratified for TNM stage (p?=?0.043). Five-year DFS in the low-NLR-Group and in the high-NLR-Group were respectively 100 and 84% in stage I-II, and 66 and 0% in stage III. TNM stage resulted as the only independent prognostic factor at multivariate analysis, with hazard ratio of 3.986 (95% CI 1.644–9.665, p?=?0.002).

Conclusions

High preoperative NLR seems to be associated to a shorter DFS in patients submitted to surgery for thymoma and stratified for TNM stage.

     

Development of a surgical safety checklist for the performance of radical nephrectomy and tumor thrombectomy

Background

The surgical management of renal cell carcinoma with invasion of the renal vein or inferior vena cava is associated with significant rates of perioperative morbidity and mortality. In this report we propose a surgical checklist aimed at reducing adverse events associated with the resection of these tumors.

Methods

This review describes the development of an evidence- and experience-based surgical checklist aimed at improving the perioperative safety of patients undergoing radical nephrectomy and tumor thrombectomy.

Results

Reducing the risk of complications during the surgical management of renal tumors with venous invasion begins with appropriate pre-operative imaging aimed at defining the cranial extent of the tumor thrombus, thus facilitating accurate preoperative planning. Other key elements of the checklist are aimed at ensuring clear and precise pre-, intra- and postoperative communication between members of the multidisciplinary-care team.

Conclusion

A standardized surgical checklist may help to increase the perioperative safety of patients undergoing radical nephrectomy and tumor thrombectomy. Future validation studies are required to determine the clinical feasibility and post-implementation safety profile of this new checklist.

     

Treatment of tailgut cysts by extended distal rectal segmental resection with rectoanal anastomosis

Purpose

Complete surgical resection is the treatment of choice for tailgut cysts, because of their malignant potential and tendency to regrow if incompletely resected. We report our experience of treating patients with tailgut cysts, and discuss diagnostics, surgical approaches, and follow-up.

Methods

We performed extended distal rectal segmental resection of the tailgut cyst, with rectoanal anastomosis. We report the clinical, radiological, pathological, and surgical findings, describe the procedures performed, and summarize follow-up data.

Results

Two patients underwent en-bloc resection of a tailgut cyst, the adjacent part of the levator muscle, and the distal rectal segment, followed by an end-to-end rectoanal anastomosis. There was no evidence of anastomotic leakage postoperatively. At the time of writing, our patients were relapse-free with no, or non-limiting, symptoms of anal incontinence, respectively.

Conclusions

This surgical approach appears to have a low complication rate and good recovery outcomes. Moreover, as the sphincter is preserved, so is the postoperative anorectal function. This approach could result in a low recurrence rate.

     

Carbon-ion radiotherapy of spinal osteosarcoma with long-term follow

Purpose

Primary spinal osteosarcoma is quite rare, and the 5-year survival rate is very low. Because of its rarity, successful treatment experience with spinal osteosarcoma is limited. The purpose of this study is to report the effect of therapy of primary osteosarcoma of spine by carbon-ion radiotherapy (CIRT) and long-term follow.

Methods

A 70-year-old with primary spinal osteosarcoma who received CIRT underwent combined anterior artificial vertebral body replacement and posterior lumbar fusion (L1–L5) 3 years later.

Results

According to the surgical resection of tumoral lesion, pathological results showed that the intertrabecular space previously filled with tumor cells on the initial biopsy sample now contained necrotic tissue without tumor cells. This means that primary osteosarcoma of the spine was completely eliminated and achieved local control with CIRT, with a 7-year follow-up after the initial treatment.

Conclusions

Carbon ion beam treatment is an effective local treatment for patients with spinal osteosarcoma for whom surgical resection is not a feasible option, especially for elderly patients. However, more patients need to be evaluated over a longer term to assess the curative effect of CIRT.

     

Location Frequency of Missed Parathyroid Glands After Parathyroidectomy in Patients with Persistent or Recurrent Secondary Hyperparathyroidism

Background

Reoperative parathyroidectomy (RPTX) because parathyroid glands have been missed is frequently required in patients with secondary hyperparathyroidism (SHPT). The usual locations of these missed glands in patients with SHPT are yet to be fully elucidated.

Methods

We retrospectively investigated the locations of missed glands in 165 patients who underwent RPTX for persistent or recurrent SHPT at our institution from August 1982 to July 2014. At our institution, total parathyroidectomy with forearm autograft is the routine operative procedure for SHPT. We also routinely resect the thymic tongue.

Results

Of 165 patients, 82 underwent initial parathyroidectomy at our institution (Group A), and the remaining 83 underwent initial parathyroidectomy at other institutions (Group B). A total of 239 parathyroid glands were resected (Group A, 93; Group B, 146). Missed glands were most commonly located in the mediastinum (Group A, 22/93) and the thymic tongue (Group B, 31/146).

Conclusions

In patients with persistent or recurrent SHPT, ectopic parathyroid glands are frequently located in the mediastinum and thymic tongue. Therefore, resecting the thymic tongue during the initial operation may reduce the need for RPTX.

     

Surgical Resection vs. Ablative Therapies Through a Laparoscopic Approach for Hepatocellular Carcinoma: a Comparative Study

Background

When compatible with the liver functional reserve, laparoscopic hepatic resection remains the treatment of choice for hepatocellular carcinoma while laparoscopic ablation therapies appear as a promising less invasive alternative. The aim of the study is to compare two homogeneous groups of patients submitted to either hepatic resection or thermoablation for the treatment of single hepatocellular carcinoma (≤?3 cm).

Methods

We enrolled 264 cirrhotic patients out of 905 cases consecutively evaluated for hepatocellular carcinoma. We performed 59 hepatic resections and 205 thermoablations through a laparoscopic approach, and they were then followed for similar follow-up (41.7 ± 31.5 months for laparoscopic hepatic resection vs. 38.7±32.3 for laparoscopic ablation therapy). Outcomes included short- and long-term morbidities, tumoral recurrence, and overall survival.

Results

Short-term morbidity was significantly higher in the resection group (but the two groups had similar rates for severe complications) while, during follow-up, recurrence was more frequent in patients treated with thermoablation, with a clear disadvantage in terms of survival. At multivariate analysis, only the type of surgical treatment was an independent predictor of disease recurrence, while plasmatic alpha-fetoprotein and Hb values, model for end-stage liver disease score, time to recurrence, and the type of surgical treatment were independent predictors of overall survival.

Conclusion

Our data ultimately support some therapeutic advantages for hepatic resection in patients with a single nodule and preserved liver function. However, thermoablation is an adequate alternative in patients with nodules that would require complex surgical resections or imply a poor prognosis that might therefore better tolerate a less invasive procedure.

     

Surgical Outcomes for the Ruptured Hepatocellular Carcinoma: Multicenter Analysis with a Case-Controlled Study

Background

While spontaneously ruptured hepatocellular carcinoma (HCC) has a poor prognosis, the true impact of a rupture on survival after hepatic resection is unclear.

Methods

Fifty-eight patients with ruptured HCC and 1922 with non-ruptured HCC underwent hepatic resection between 2000 and 2013. To correct the difference in the clinicopathological factors between the two groups, propensity score matching (PSM) was used at a 1:1 ratio, resulting in a comparison of 42 patients/group. We investigated outcomes in all patients with ruptured HCC and compared outcomes between the two matched groups.

Results

Of the 58 patients with ruptured HCC, 7 patients (13 %) died postoperatively. Overall survival (OS) rate at 5 years after hepatic resection was 37 %. Emergency hepatic resection was an independent risk factor for in-hospital death and Child-Pugh class B for unfavorable OS in multivariate analysis. Clinicopathological variables were well-balanced between the two groups after PSM. No significant differences were noted in incidence of in-hospital death (ruptured HCC 12 % vs non-ruptured HCC 2 %, p?=?0.202) or OS rate (5/10-year; 42 %/38 % vs 67 %/30 %, p?=?0.115).

Conclusion

Emergency hepatic resection should be avoided for ruptured HCC in Child-Pugh class B patients. Rupture itself was not a risk for unfavorable surgical outcomes.

     

Reconstruction of anterior chest wall: a clinical analysis

Objective

To investigate the methods and clinical efficacy of reconstruction of chest defects with titanium sternal fixation system after the surgical resection of sternal tumors.

Methods

A total of 6 patients with sternal tumor who were diagnosed and underwent resection and repair of the chest wall defects by titanium plates system, from 2017.3 to 2017.11 in our hospital were reviewed. Their pathological types, surgical reconstruction methods, follow-up results were analyzed.

Results

Six cases of sternal tumor were completely resected and the sternums were reconstructed with titanium sternal fixation system. There was no operative death, postoperative chest wall deformity, abnormal breathing or complications of respiratory circulation. After 3 to 10?months of follow-up, there was no loose screw or plate exposure. Not only the thoracic appearances were good, but patients’ satisfaction was high.

Conclusions

Surgical resection is the best treatment for sternal tumors, no matter it is benign or malignant. Titanium sternal fixation system combine with other soft materials can reconstruct the chest wall well after resection, and this technique is efficient as well as easy to learn.

     

The Predictive Value of Staging Systems and Inflammation Scores for Patients with Combined Hepatocellular Cholangiocarcinoma After Surgical Resection: a Retrospective Study

Background

Combined hepatocellular cholangiocarcinoma (cHCC-CC) is a rare form of primary liver tumor. A specific staging system for predicting survival in patients with cHCC-CC is not available. The aim of the present study was to evaluate the ability of staging systems and inflammation-based scores to predict overall survival (OS) and progression-free survival (PFS) of patients with cHCC-CC after surgical resection.

Methods

The data from 99 patients with cHCC-CC after surgical resection from June 2000 and January 2017 were retrospectively collected. Patients were allocated into HCC (hepatocellular carcinoma)—dominant (IHD) group and ICC (intrahepatic cholangiocarcinoma)—dominant (IID) group based on radiological characteristics. Similarly, patients were also divided into HCC-dominant (PHD) group and ICC-dominant (PID) group based on pathological characteristics. Univariate and multivariate analyses were performed to identify variables associated with OS and PFS. The prognostic value of staging systems and inflammation-based scores were analyzed and compared using receiver operating characteristic (ROC) curves.

Results

The 1-, 2-, and 3-year OS rates were 82.6, 66.3, and 59.6%, respectively. The 1-, 2-, and 3-year PFS rates were 52.2, 38.1, and 31.5%, respectively. Independent prognostic factors identified by multivariate analyses included HCC-TNM staging system and tumor diameter both for OS and PFS analyses. HCC-TNM staging system displayed higher area under ROC curve (AUC) values than the other staging systems or inflammation-based scores.

Conclusions

HCC-TNM staging system was able to adequately predict prognosis of patients with cHCC-CC after surgical resection, especially for patients with HCC-dominant characteristics in clinical practice.

     

Comparison of Hepatectomy for Patients with Metabolic Syndrome-Related HCC and HBV-Related HCC

Background

Metabolic syndrome (MetS) is a group of clinicopathological manifestations. The outcome of liver surgery in metabolic syndrome-related hepatocellular carcinoma (MetS-HCC) still needs to be evaluated. We aim to clarify the outcomes following liver resection in patients with MetS-HCC compared those with hepatitis B virus-related HCC (HBV-HCC).

Methods

All the consecutive patients undergoing hepatectomy for HCC between January 2009 and December 2012 were retrospectively considered. Patients were divided into three groups: MetS-HCC, MetS-HBV-HCC, and HBV-HCC. Data on clinical characteristics, postoperative complications, and long-term outcome were collected and analyzed.

Results

A total of 1352 patients were included in this study. In MetS-HCC group, the severe morbidity rate was 33.33%, which was higher than that of HBV-HCC group (15.68%). In subgroup analysis, patients with MetS-HCC in American Joint Committee on Cancer (AJCC) stage I had superior DFS and OS when compared with those of the other two groups.

Conclusions

We should pay more attention to patients with MetS-HCC perioperatively due to the high rate of surgical complications. Nevertheless, curative treatment should be provided to patients with MetS.

     

Primary chest wall neoplasms—resection and reconstruction

Background

Primary chest wall tumours are rare. We report our experience of primary chest wall neoplasms, their resection and reconstruction treated at our centre.

Methods

We reviewed a prospectively collected data from August 2013 to December 2014. Data included the mode of clinical presentation, imaging, biopsy, type of surgical resection and reconstruction, complications, morbidity and mortality. Recurrences if any and survival outcomes were recorded.

Results

A total of 14 patients were reviewed (M/F ratio was 9:5) with a median age of 35.5 years. Palpable mass (78.5 %) was a common presenting symptom. All patients underwent surgical resection, and reconstruction was required in 11 patients (78.5 %), with bone cement, mesh or greater omentum. Overall, 35.7 % (5 out of 14) received neoadjuvant therapy for downstaging and 14.2 % (2 out of 14) received adjuvant radiotherapy for positive margins. Early post-operative complications were seen in eight patients (57.1 %), and there was no in-hospital mortality. Factors that effected survival were resection margins and type of pathology.

Conclusion

Primary chest wall neoplasms need surgical resection. Multidisciplinary approach is necessary. The extent of tumour resection should not be compromised because of concerns over the ability to reconstruct large and complex defects. Prosthetic reconstruction is a safe and effective surgical procedure for major chest wall defects.

     

Effects of implementing an “enhanced recovery after surgery” program on patients undergoing resection of hepatocellular carcinoma

Purpose

To evaluate the effects of implementing an “enhanced recovery after surgery” (ERAS) program on the feasibility, safety, and effectiveness of extensive and potentially curative liver resection for hepatocellular carcinoma (HCC).

Methods

We compared clinicopathologic factors, surgical factors, and outcomes of patients who underwent extended hepatectomy (defined as resection of more than two sections) for HCC, before and after the introduction of an ERAS program.

Results

Operating times and postoperative hospital stay were significantly shorter, and total volume infused during surgery was significantly lower, for the ERAS group than for the control group. Although the ERAS group had a significantly lower percentage of patients with retention of abdominal drainage, this group had a higher frequency of abdominal paracentesis in patients without intraoperative abdominal drainage. Oral dietary intake and the ability to walk steadily resumed significantly earlier in the ERAS group. Postoperative serum concentrations of albumin and cholinesterase were significantly higher in the ERAS group than in the control group.

Conclusions

The ERAS program was feasible and effective for patients with chronic liver disease undergoing extended liver resection for HCC, because it allowed earlier oral dietary intake and promoted faster postoperative recovery.

     

Laparoscopic versus open distal gastrectomy for locally advanced gastric cancer after neoadjuvant chemotherapy: safety and short-term oncologic results

Background

To compare the safety and efficacy of laparoscopic distal gastrectomy (LDG) versus open distal gastrectomy (ODG) in treating locally advanced distal gastric cancer after neoadjuvant chemotherapy (NACT).

Methods

Forty-four patients with locally advanced distal gastric cancer were enrolled. The patients received neoadjuvant chemotherapy before undergoing surgery. Twenty patients were allocated into LDG after NACT group and 24 patients into ODG after NACT group. Radicalness of oncological resection, surgical safety and recovery were measured and compared.

Results

All operations were successfully performed without severe postoperative complications. There were no significant differences in blood loss, mean operation time, complications, distal and proximal resection margin, and number of retrieved lymph nodes between LDG and ODG groups, but LDG group had shorter length of incision and the first aerofluxus time.

Conclusion

Laparoscopic distal gastrectomy after NACT has comparable results with open distal gastrectomy in safety and efficacy in the short term.

     

Adult-onset intradural spinal teratoma: report of 18 consecutive cases and outcomes in a single center

Study design

Eighteen consecutive patients with adult-onset intradural spinal teratoma underwent surgical treatment in our center from 1998 to 2013.

Background and purpose

Teratoma is defined as a neoplasm composed of elements derived from three germ cell layers (ectoderm, endoderm and mesoderm). Intraspinal teratoma is extremely rare and accounts for 0.2–0.5% of all spinal cord tumors. Moreover, teratoma occurs primarily in neonates and young children. Adult-onset intradural spinal teratoma is even rare. The aim of this study was to discuss the clinical characteristics, diagnosis and therapeutic strategies of adult-onset intradural spinal teratoma.

Methods

This retrospective study included 18 consecutive adult patients with intradural teratoma who were surgically treated in our center between 1998 and 2013. The clinical features, pathogenesis, diagnostic strategies and surgical outcomes were discussed. Neurological function outcomes were evaluated by the JOA scoring system.

Results

Of the 18 included patients, 4 patients received subtotal resection and the other 14 patients received total resection. All the 18 cases were diagnosed with mature teratoma. The mean follow-up period was 79.7 (median 60.5; range 27–208) months. Local recurrence occurred in two of the four patients who underwent subtotal resection and in no patient who underwent total resection. The neurologic status improved in 16 cases and remained unchanged in the other two patients.

Conclusions

Adult-onset intradural spinal teratoma is extremely rare. To the best of our knowledge, this is the largest series of patients with this disease. Despite the slow-growth and indolent nature, radical resection remains the recommended treatment to reduce tumor recurrence.

     

Characteristics and prognosis of rectal gastrointestinal stromal tumors: an analysis of registry data

Purpose

Rectal gastrointestinal stromal tumors (GISTs) are rare. Accordingly, their clinical features are not well-documented and optimal treatment has not been established. The objective of this study is to clarify the rates and patterns of recurrence after surgical resection of rectal GISTs, with a focus on outcomes and therapeutic modalities.

Methods

The registry was designed to collect data on rectal GISTs recorded between January, 2003 and December, 2007 at 40 participating institutions of the Kinki GIST Study Group. The principal variables were the rates and patterns of recurrence of rectal GISTs. Other study variables were age, sex, tumor size, mitotic count, distance from the anal verge, tumor location, surgical procedures, surgical margins, and recurrence-free survival.

Results

Twenty-four cases were registered, 11 (45.8%) of which were classified as high-risk by the modified NIH criteria. Locoregional recurrence (7/23, 30.4%) was the predominant recurrence pattern after curative resection, with rates that did not differ after local excision (33.3%; 3/9) vs. extended resection (28.6%; 4/14). The recurrence rates were high (25.0%) even for patients with low-risk disease. There was only one case of recurrence among patients who received perioperative treatment with imatinib.

Conclusions

Rectal GISTs showed high rates of local recurrence regardless of the surgical procedure. Perioperative treatment with imatinib may improve outcomes.

     

Incidental thyroid cancer in patients undergoing total thyroidectomy for benign disease

Aim

To determine the frequency of incidental thyroid carcinoma (ITC) in patients undergoing surgery for presumably benign thyroid diseases.

Methods

A total of 267 patients submitted to total thyroidectomy were included in the study.

Results

Histology revealed ITC in 31 (11.6%) patients. Papillary carcinoma was the commonest ITC at a percentage of 71% (22/31 patients), while follicular variant accounted for 29%. ITC was more common in patients with toxic goitre and toxic solitary nodule.

Conclusions

The result of this study show a high incidence of ITC (11.6 %). The frequency differs among patients presenting a different thyroid pathology. This is because of the small sample used in the study. Papillary carcinoma was the commonest ITC.

     

Arthroskopische subakromiale Dekompression

Objective

Coracoacromial ligament release to widen the subacromial space, resection of the anterior undersurface of the acromion and, if needed, caudal exophytes at the acromioclavicular joint.

Indications

All types of outlet impingement after 3 months of conservative treatment.

Contraindications

Impingement syndrome with instability/muscular imbalance, massive rotator cuff tear, unstable os acromionale, posterior–superior impingement, joint infection, freezing phase of a secondary frozen shoulder.

Surgical technique

Lateral decubitus position with traction device for the arm. Diagnostic arthroscopy of the glenohumeral joint via standard portals. With arthroscope moved to the subacromial space, bursectomy, electrosurgical release of coracoacromial ligament, resection of acromial hook through standard posterior portal.

Postoperative management

Physiotherapy or self-exercises on postoperative day 1, pain-adapted analgesia to avoid shoulder stiffness.

Results

Several studies present positive long-term results compared to conservative treatment (and open acromioplasty) for partial rotator cuff tears and for elderly patients. With a 20-year follow-up, successful results have been achieved for all patients with isolated impingement syndrome.

     

Role of Angio-Embolization for Renal Cell Carcinoma

Purpose of Review

To provide the technical aspects of, clinical indications for, status of the current literature on, and emerging concepts in trans-arterial embolization (TAE) for renal cell carcinoma.

Recent Findings

TAE has been evaluated in several retrospective series as a neoadjuvant therapy prior to surgical resection of RCC to reduce tumor vascularity and minimize intra-operative blood loss. TAE has also been examined retrospectively as a neoadjuvant therapy prior to the percutaneous ablation of RCC to reduce blood loss and procedural complications. TAE can potentially palliate symptoms of RCC such as pain and hematuria. Trans-arterial chemoembolization and trans-arterial radioembolization are emerging concepts for RCC.

Summary

Although there have been no prospective, randomized trials demonstrating improved clinical or oncologic outcomes from TAE for patients with RCC, several retrospective studies have shown encouraging results.