Radio-guided resection of residual metastatic lymph node from a previously resected neuroendocrine tumor]

Neuroendocrine tumors are slowly growing and carry a high risk of recurrence. Somatostatin receptor scintigraphy is considered as the gold standard for preoperative evaluation and postoperative follow-up. The use of an intraoperative detection probe makes easier a complete resection of abdominal residual or recurrent tumor. These resections may be incomplete because of the small size of the tumor and the postoperative adhesions. Radio-guided surgery is recommended in order to reduce the need for reoperation.     

Radio-guided surgery for persistent differentiated papillary thyroid cancer: case presentations and review of the literature

Background and aims Persistent differentiated papillary thyroid cancer following radical locoregional surgery with metastases is an indication for limited reoperation or radioiodine therapy. Following injection of radioiodine, radio-guided surgery with application of an intraoperative gamma probe offers detection of metastases not seen by conventional imaging and control of completeness of resection.Patients/methods We demonstrate four patients with locoregional metastases, two of them with additional distant metastases of papillary thyroid cancer following radical neck surgery. Postoperative radioiodine scans demonstrated persistent ipsilateral or contralateral cervical and mediastinal lymph node and isolated rib metastases.Results Radio-guided surgery (RGS) leads to complete clearance of persistent lymph node metastases by limited recurrent neck surgery, resection of metastases not seen by conventional imaging and control of complete mediastinal lymph node dissection. Post-RGS scans allowed early diagnosis of occult diffuse or nodal pulmonary metastases in two patients. At last follow-up, 23 to 48 months following RGS and radioiodine therapy, there was no evidence of disease.Conclusions Radio-guided surgery is an additive surgical technique with low morbidity in selected patients with persistent thyroid cancer individualizing tumor therapy options in multimode oncological therapy.Presented at the International Symposium "Modern Technologies in Thyroid Surgery", 10–11 February 2006, Halle/Saale, Germany     

Iterative surgery in germ cell tumor

Between 1979 and 1988, iterative surgery was performed on 13 patients for a germ-cell tumor. Apart from orchidectomy, surgery was not the first modality of treatment. On the other hand, 21 surgical procedures were performed for residual tumoral masses after chemotherapy or recurrences. In one third of the cases, only necrosis of fibrosis was resected. Out of 13 patients, 7 died of tumor; 6 are alive (3 with complete remission). Surgery is always indicated in stage IIA to IV nonseminomatous tumors in case of residual tumoral deposits after chemotherapy. For seminoma, surgery is carried out only for retroperitoneal residues larger than 3 cm in diameter. Surgery is also indicated for persistent pulmonary or mediastinal metastases following chemotherapy. Complete surgical excision of residual masses may be technically difficult but is of prime importance as combined chemotherapy and surgery doubles the complete remission rate in comparison to chemotherapy alone.     

Use of the sentinel lymph node in gastrointestinal disease

The concept of the sentinel node (SN) arises from the consideration that lymphatic dissemination of tumoral cells is produced in an initial nodular focus before affecting the remaining lymphatic regions. Although this concept has been validated in malignant melanoma and breast cancer, its application to other solid tumors, including gastrointestinal neoplasms, remains controversial. SN detection may play an important role in avoiding the systematic performance of highly invasive surgery. This technique provides individual information and can thus modify the surgical procedure or other therapeutic alternatives. Recently, SN determination has been performed through the laparoscopic approach and this technique could become an important component of the minimally invasive treatment of early-stage gastrointestinal tumors. The reason for SN detection varies according to tumoral localization. Thus, in gastric cancer, the main aim is to broaden the indication for minimally invasive surgery in node-negative patients. In contrast, in colorectal cancer, this technique forms part of the search for methods that help to avoid possible under-staging of the patient, with potential repercussions on the adjuvant therapy required.     

Procedimiento radioguiado en la cirugía mínimamente invasiva del hiperparatiroidismo primario

Minimally invasive parathyroidectomy, of choice in most cases of primary hyperparathyroidism, shows a high detection rate, based on precise preoperative localization by MIBI scintigraphy (SPECT/CT) and neck ultrasound. Radio-guided minimally invasive parathyroidectomy is an even more effective technique, which shortens surgical times, maintains minimal incision and few complications, allows immediate verification of parathyroid adenoma removal and is especially interesting in patients with ectopic lesions or cervical surgical history. In this paper, the indications, protocols and differences between the two available radio-guided parathyroid surgery procedures (MIBI and ROLL) are exposed.     

In patients undergoing video-assisted thoracoscopic surgery excision, what is the best way to locate a subcentimetre solitary pulmonary nodule in order to achieve successful excision?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients undergoing video-assisted thoracoscopic surgery (VATS) excision, what is the best way to locate a subcentimetre solitary pulmonary nodule (PN) in order to achieve successful excision?' Altogether, 107 papers were found using the reported search, of which 19 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. The hook-wire technique showed a varied success rate ranging from 58 to 97.6% and a relatively higher failure rate due to wire dislodgement. The most common complication of this method was pneumothorax. CT-guided spiral-wire localization displayed a success rate of 86% with the added advantage of providing more stability than the hook-wire technique and permitting manipulation. Radio-guided localization techniques and fluoroscopic-aided methods using contrast media displayed consistently high sensitivities with few complications. The radio-guided technique had the benefit of allowing a longer time-period between the staining of the nodule and the operation. Ultrasonography showed sensitivities ranging from 92.6 to 100%; however, it is highly operator-dependent. Finger palpation was shown to achieve suboptimal results and should be avoided. We concluded that radio-guided surgery is a preferable method. It showed high accuracy with minimal complications and operator dependence in detecting subcentimetre PNs when compared with other techniques such as ultrasonography, finger palpation, fluoroscopic, hook-wire, spiral-wire and microcoil localization.     

Novel application for electrochemotherapy: Immersion of nasal cavity in dog

Electrochemotherapy is a new modality of local cancer treatment that increases the delivery of chemotherapy drugs into tumor cells by applying intense electric fields. This novel electrochemotherapy application was applied as an adjuvant to surgery and eliminated intranasal tumors in dog. The treatment challenges are the surgery limitations due to anatomy and residual tumor in the bone cavity. Most of the tumoral mass on nasal cavity was surgically removed. The internal nasal cavity was immersed in liquid and bleomycin before applying electric field. The solution was necessary to increase the superficial contact between plate electrodes and residual tumor. The numerical study demonstrated electrochemotherapy efficiency in different clinical situations. The proximity between electrodes and bone (<3 mm) and bone irregularities affect the electric field distribution on tumoral tissue. The tumoral tissue around bone protuberances tends to be eliminated. Electrochemotherapy with plate electrodes inside the cavity might not be effective. Different values of electric conductivity solution were studied; the ideal value was 0.5 S/m. The numerical and experimental results confirm the successful application of electrochemotherapy on dog nasal cavity.     

Surgery of large residual mass after chemotherapy in advanced testicular germ cell tumor

Treatment for testicular tumours has progress in such a manner in the last years that high cure percentages can at present be achieved. After chemotherapy, in most cases, residual mass can appear. In this cases surgery is considered a viable therapeutic option although it implies an advanced surgical training since it is a complex technique and implies serious implications. We submit the case of a patient who presented a large residual mass from a testicular germ cell tumour after being treated with orquiectomía and chemotherapy. Surgery was performed resulting in total and radical extirpation of residual mass.     

Tumoral calcinosis in bilateral facet joints of the lumbar spine in scleroderma. Case report

Tumoral calcinosis commonly occurs in the articular soft tissues of the extremities but rarely in the spine. The authors performed surgery to treat lumbar tumoral calcinosis in a patient with scleroderma, in whom symptoms of neurological dysfunction had manifested. This 49-year-old woman presented with low-back pain and gait disturbance. Seven years before presentation, scleroderma had been diagnosed, and the patient had received medical treatment ever since. Imaging revealed tumoral calcinosis centered at the bilateral facet joints between L-3 and L-4, marked stenosis of the spinal canal, L-3 spondylolisthesis, and intervertebral instability. Surgery was performed to excise the lesion en bloc. After neural decompression, posterolateral fusion and pedicle screw fixation were undertaken. Symptoms improved after surgery. In this case, the underlying scleroderma that predisposes to calcinosis and facet joint degeneration due to lumbar spondylolisthesis were probably factors leading to the development of tumoral calcinosis in the lumbar spine.     

Management of residual stones

Stone-free status is highly dependent on selection of the appropriate surgical technique, which should be tailored according to the individual stone and patient parameters. Although a stone-free state is the desired outcome of surgical intervention of urolithiasis, the authors believe that the presence of noninfection, nonobstructive, asymptomatic postprocedural residual fragments can be managed metabolically in order to prevent stone growth adequately. Further surgical intervention in the case of residual fragments is warranted if the clinical indications that prompted the original surgery persist.     

Intraoperative transesophageal echocardiography to guide removal of a hypernephroma with vena cava and right atrial extension

We describe the case of a 70-year-old man who underwent resection of a right hypernephroma with vena caval and right atrial extension with continuous monitoring by transesophageal echocardiography. The monitoring technique brought important advantages, providing images that facilitated anatomical and functional evaluation of cardiac structures without obstructing the surgical field. Images of the heart and great vessels obtained in real time allowed the surgeon to make operative decisions based on accurate assessment of the cephalad extension of the tumor to the right chambers. Transesophageal echocardiography also allowed the anesthesiologist to monitor hemodynamic status throughout surgery and watch for tumoral emboli. The imaging technique proved to be highly useful for both anesthetic and surgical management of the patient.     

Device closure of residual postsurgical atrial septal defect by transcatheter technique

Surgical closure of an Atrial Septal Defect (ASD) and transcatheter closure of ostium secundum ASD is an established form of therapy in selected patients. Only a few cases have been reported in literature when transcatheter closure of ASD was achieved successfully in a patient with residual postsurgical ASD. It is less invasive, avoids thoracotomy, requires short hospital stay, yet, hemodynamic benefits, similar to surgery, can be achieved. It may also be considered the procedure of first choice in postsurgical residual atrial septal defect. Present case report describes the technique in a 14 years old girl with residual ostium secundum ASD.     

Correlation of Tumoral Prognostic Factors by Sonoelastography Score in Patients to be Operated Due to Breast Cancer

Predictability of pre-op prognosis on patient with a diagnosis of breast cancer is quite valuable for the choice of both surgical technique and adjuvant therapy. With the aim of evaluation of sonoelastography score utility in this respect, correlation of tumoral prognostic factors by sonoelastography score in patients be operated due to breast cancer was analyzed on our study. Pre-op sonoelastography results and tumoral hystopathological properties of 60 patients operated with a diagnosis of breast cancer in 2011 at Adnan Menderes University Faculty of Medicine General Surgery Department were analyzed retrospectively. As an elastography scoring method, “Tsukuba scoring system” was used. Statistically significant differences(p?<?0,05) were determined between tumor grade and Ki-67 analyzed as prognostic factor with tumors reported as sonoelastography score 4 and score 5, on the other hand there were no statistically significant differences between tumor size, positivity of axillary lymph nodes, significance of lymphovascular invasion, p-53 positivity, CerbB-2 positivity, hormone receptor positivity, tumor hysthologic type and applied surgical technique between tumors reported as elastography score 4 and score 5. (p?>?0.005). Foresee ability of prognostic factors correlation by sonoelastography score will be guide way for the choice of surgery technique, determination of adjuvant therapy and patient follow-up.     

Current status of radical laparoscopic prostatectomy

Laparoscopic surgery can be said to have come of age when it was first indicated for cancer conditions. Advances in this field are largely due to the French school, which has made it a standard practise in prostate cancer. It complies with the principles required for cancer as well as conventional surgery, but it remains to be verified whether its long-term results, both from tumoral and functional perspectives, are not only similar to those of classical surgery, but even better. In fact, increasing numbers of clinical groups are incorporating this technique in their daily work.     

Role of CT/111In-octreotide SPECT digital fusion imaging in the localization of loco-regional recurrence of medullary thyroid carcinoma

The case of a female patient affected by a sporadic medullary thyroid carcinoma (pT1N1aM0 at the onset) is reported. The patient had been initially treated by total thyroidectomy and lymphadenectomy of the central and lateral portions of the neck. During the following 30 years of follow-up, the patient experienced 3 consecutive loco-regional tumoral relapses. At the moment of each relapse, an increase of serum calcitonin levels has anticipated the subsequent detection of tumor deposits at clinical and radiological examination (ultrasound, CT scan). It is well known that, after multiple operations, the structures of the neck can present anatomical distortion and fibrosis that can interfere with ultrasound and CT scan interpretation. In the present patient, a scintigraphic examination with 111In-octreotide, that is a specific radio-tracer for somatostatin receptors, allowed to correctly visualize a tumoral relapse in the left thyroid bed, located in deep para-tracheal planes: in that site the CT scan only showed an unspecific solid mass. Furthermore, the utilization of a digital image fusion technique for CT scan and 111In-octreotide SPECT, furnished useful information for the purpose of planning an accurate re-intervention, both morphologic information (mass size, precise site of the mass and their relationship with the surrounding anatomical structures) and functional information (biological characterization of the mass that was classified as a neuroendocrine tumoral deposit with high density of somatostatin receptors.     

Tumoral calcinosis of the lumbar meninges: case report

OBJECTIVE AND IMPORTANCE: Tumoral calcinosis is a rare disorder of unknown origin. Tumoral calcinosis involving the spine is extremely rare. This is the first case of tumoral calcinosis localized in the dura mater of the lumbar spine. CLINICAL PRESENTATION: This 55-year-old male patient presented with tumoral calcinosis of the lumbar meninges. T1-weighted, sagittal magnetic resonance imaging scans of the lumbar spine revealed a round mass of slightly increased intensity with high-intensity margins, located posterior to the cauda equina at the L4-L5 level. The cauda equina was severely compressed anteriorly. T2-weighted scans revealed that the mass was composed of a high-intensity area with low-intensity margins. T1-weighted magnetic resonance imaging scans obtained after intravenous gadolinium administration revealed some enhancement at the margins. INTERVENTION: The mass lesion was totally resected. Three years after surgery, no recurrence was observed in follow-up magnetic resonance imaging scans. CONCLUSION: Although tumoral calcinosis is a rare cause of mass lesions of the lumbar spine, it should be considered in differential diagnoses. If the lesion can be totally resected, the prognosis should be good, similar to that for general tumoral calcinosis.     

Observations about a case of giant splenic cyst

The Authors, on the basis of a case of giant spleen cyst with positive tumoral markers, analyse some epidemiological and clinical aspects related to splenic non parasitic cysts. They affirm the priority of the conservative surgery, whenever possible, followed by an appropriate follow-up, although in this case their therapeutic choice was radical, due to the lack of residual parenchyma. In accordance with the data of several publications, as well as on the basis of the results obtained, the conservative approaches have been reevaluated, above all in view of the modern findings related to the function of the spleen. The conservative approach cannot be carried out in the following cases: neoplastic diseases, increase of the tumoral markers serum levels, total involvement of the splenic parenchyma by cysts.     

Giant Fibrous Tumor Misdiagnosed as Traumatic Hemothorax

Solitary fibrous tumors of the pleura are neoplasms of the mesenchymal tissue of the pleural mesothelium. The most frequent symptoms are dyspnea, coughing and chest pain. A 45-year-old female patient presented after a thoracic contusion. A radio-opaque image was evidenced on chest X-ray. At the initial hospital, a hemorrhagic fluid was aspirated at thoracocentesis and the patient was transferred to our hospital with diagnosis of traumatic hemothorax. A thoracic CT showed a tumoral formation filling two-thirds of the left hemithorax. The transthoracic biopsy finding was compatible with a fibrous tumor. The patient was taken for surgery and the large pleural tumor was excised. In conclusion, a large pleural fibrous tumor was initially mistaken for hemothorax. A CT-scan revealed the tumoral nature of the thoracic opacity.     

Double-patch technique through right ventriculotomy for residual shunt after infarct exclusion technique for post-infarction ventricular septal perforation

We report a case in which the double-patch technique was used to repair residual shunt after infarct exclusion technique for post-infarction ventricular septal perforation (VSP). A 68-year-old man was diagnosed with post-infarction VSP and surgical interveniton was performed by infarct exclusion technique through left ventriculotomy. Residual shunt was observed by left ventriculography, and he developed cardiac failure in spite of medical therapy. Additional surgery for residual shunt was performed 5 months after the initial operation. The VSP was closed with 2 pericardial patches onto both sides of the septum through right ventriculotomy. Complete closure of the defect was accomplished, and no residual shunt was observed by post-operative left ventriculography. The patient has been doing well with no signs of cardiac failure.     

Risk factors for positive surgical margins following radical prostatectomy: review

The presence of positive surgical margins on radical prostatectomy specimen is an adverse prognostic factor. Parameters supposed to influence surgical margin status includes pathology method analysis, surgical technique, tumoral and non tumoral patient parameters, and neoadjuvant hormonal therapy. Regarding the surgical technique, surgeon's experience and neuro-vascular bundles preservation are the most important factors of margin status, whereas surgical approach, bladder neck conservation, intraoperative frozen analysis, and bleeding are minor factors. Non tumoural patient parameters influencing surgical margin status include patient's age and weight, and prostate gland weight. For tumoural parameters, pathological stage and tumour volume are more important factors than the tumor grade and PSA. Five preoperative tumoral risk factors of positive surgical margins are particularly important, including abnormal digital rectal examination, preoperative PSA 10 ng/mL, biopsy Gleason score >7, number of positive biopsy cores > or = 2, and suspicion of extraprostatic extension on radical prostatectomy specimen.