Usefulness of intraoperative radiofrequency thermoablation of liver tumours associated or not with hepatectomy.

INTRODUCTION: A probe emitting radiofrequency (RF) waves is able to destroy tumour tissue by thermal ablation. The purpose of this study was to undertake a prospective estimation of the benefit of RF thermoablation of liver tumours during hepatic and extrahepatic resections aimed at obtaining an R0 status in patients in whom disease is notoriously considered unresectable. METHOD: Twenty-one patients underwent surgery between January 1997 and September 1999. In 17 cases, RF was associated with a hepatectomy and in nine of these cases with resection of extrahepatic lesions. In two cases, extensive resection of extrahepatic lesions was associated with RF to treat liver metastases, and in two cases RF was ultimately performed alone. The mean number of liver metastases was 6.2+/-4.3 (range 1-15) per patient. A total of 32 lesions were treated with RF. The mean size of the 33 RF-thermoablated tumours was 13.6+/-9.7 mm (range 5-52 mm), and in all but one case, a Pringle manoeuvre was performed during the RF procedure. RESULTS: A probable R0-resection was obtained in 18 cases. No operative deaths or any RF-related complications occurred. If we exclude the case in which it was clearly impossible to destroy liver metastases intraoperatively, only one local recurrence occurred (3%) among the 32 thermoablated lesions after a mean follow-up of 17.3 months. The 2-year overall and disease-free survival rates for this initially unresectable population were 94.7% and 22%, respectively. CONCLUSION: Intraoperative use of RF to destroy unresectable liver tumours increases the rate of curative resections. Future progress in RF technology and adequate vascular clamping during RF should increase this rate.

Results of lymphadenectomy for obvious lateroaortic lymph node metastases from colorectal primaries.

BACKGROUND/AIMS: To analyze the results of surgery for macroscopically or radiologically obvious (i.e., easily detectable by computed tomography scan or by palpation) synchronous or metachronous lateroaortic lymph node metastases from colorectal primaries. METHODOLOGY: Thirty-one highly selected patients who underwent a lateroaortic lymphadenectomy for obvious lateroaortic lymph node metastases from January 1989 to January 1999 were analyzed retrospectively. An associated metastatic lesion was present in 68% of the cases before or concomitantly with the lateroaortic lymph node metastases. Ten lateroaortic lymph node metastases were synchronous with the primary, and 21 were metachronous. Decision for lymphadenectomy was taken after a multidisciplinary meeting and a period of observation. Median follow-up after lymphadenectomy was 24.2 months (range: 6-120). All the patients received at least two systemic lines of chemotherapy before or after the lateroaortic lymphadenectomy. RESULTS: There was no postoperative mortality. Resection was macroscopically complete (R0-1 of UICC) in 26 cases (84%). Twenty-six (83.8%) patients developed recurrent lesions or had progressive residual disease. The most frequent first site of recurrence was intrathoracic (54.8%) for the entire series, except for the subgroup of isolated lateroaortic lymph node metastases in which recurrent lesions were mainly lateroaortic. Three-year global and disease-free survival rates were, respectively, 39% and 9.6%. No significant difference was noted in survival between lateroaortic lymph node metastases that were synchronous or metachronous with the primary. However, the most important prognostic factor was the presence of associated metastases. Indeed 3-year survival attained 30% when lateroaortic lymph node metastases were isolated but 0% when lateroaortic lymph node metastases were associated with another metastatic site (P = 0.006). CONCLUSIONS: Obvious lateroaortic lymph node metastasis is rarely isolated. However, when it is isolated, in selected cases (objective response to systemic chemotherapy, good general status), resection can be beneficial whatever its synchronous or metachronous appearance.

[Local treatment of rectal cancer]. / Traitements locaux du cancer du rectum.

Transanal local excision is only indicated in small rectal carcinomas with limited infiltration and high differentiation, and is followed by a 5-year survival rate around 90%. Endo-cavity irradiation has similar indications and results, but can only be performed by trained teams. The main risk of these local treatments is tumoral recurrence. A rigorous selection of patients is necessary and a rigorous postoperative survey.

[Treatment of desmoid tumors of the mesenteric root]. / Traitements des tumeurs desmoïdes de la racine du mésentère.

OBJECTIVE: To elaborate a therapeutic scheme for desmoid tumors developing within the mesenteric root. These uncommon and often unrecognized tumors are difficult to treat as they lie very close to the superior mesenteric vessels. PATIENTS AND METHODS: Retrospective analysis of 14 cases treated in our center over the last 20 years and a review of the literature. RESULTS: The analysis led to the development of a therapeutic scheme. Patients are placed under regular surveillance to detect any progression of the mesenteric root desmoid tumor. In case of progression, surgery should be proposed as often as possible in spite of the real difficulty of this surgery. When the tumor is unresectable, hormone therapy, sulindac, chemotherapy and radiotherapy can be proposed as appropriate. CONCLUSION: Based on the available literature, the proposed decisional tree is a helpful management tool. This scheme should be validated with the help of a National Observatory focusing on this rare disease.

[Breast metastasis revealing cancer of the kidney. Apropos of a new case and review of the literature]. / Métastase mammaire révélatrice d'un cancer du rein. A propos d'un nouveau cas et revue de la littérature.

Metastases are rarely located in the breast. Generally, breast metastases appear during the course of a known primitive cancer and renal origin is very rare. It is even more exceptional that metastasis reveals renal cancer as observed in this case. Five similar cases have been reported in the literature.

Research on the best chemohyperthermia technique of treatment of peritoneal carcinomatosis after complete resection.

BACKGROUND: The complete or almost complete resection of peritoneal carcinomatosis (PC) followed by intraperitoneal chemohyperthermia (IPCH) is potentially capable of curing some patients presenting with disease confined to the peritoneum. AIMS: The aim of this prospective phase I-II study was to develop an efficient IPCH procedure with good thermal homogeneity and good spatial diffusion, that would be reproducible (and thus could be standardized and exported), and to evaluate patient tolerance and its efficiency in eradicating tumor tissue. METHODS: Seven IPCH procedures were tested successively in 32 patients (up to a total of 35 IPCH). Each procedure was tested in at least 4 patients before modifications for technical reasons or due to inacceptable tolerance. Five of them were followed by early postoperative intraperitoneal chemotherapy (EPIC) lasting 4 days. Thermal homogeneity was measured with 6 thermal probes placed in different positions inside the abdominal cavity. Spatial diffusion was studied in the last patients by adding methylene blue to the IPCH liquid. The mean follow-up was 23.85 months for the series. RESULTS: From the technological point of view, we have progressively shown that procedures with closure of the abdomen are not satisfactory: it was impossible to obtain thermal homogeneity when the entire parietal wound was closed, but markedly improved when only the skin was closed. However, these "closed" procedures did not allow us to treat all surfaces at risk. The peritoneal cavity "expander" did not permit treatment of the parietal wound and an indeterminate amount of the perfusion oozed out at its periphery. The open technique with traction of the skin upwards was superior. Using different procedures successively undermined the quality of the postoperative results. Three patients (8.6%) died and morbidity (albeit minimal) occurred in 27 patients (77%) during the postoperative course. Mortality and morbidity were significantly correlated (P = 0.02) with the peritoneal index (scoring the extent of PC). The 2-year survival rate was 60% and PC did not recur in 49% of the patients. The survival rate was correlated with the extent of PC (peritoneal index greater than or below 15) (P = 0.004), and with the absence of extraperitoneal disease (P = 0.01).

Output of chyle as an indicator of treatment for chylothorax complicating oesophagectomy.

BACKGROUND: The management of chylothorax complicating oesophagectomy remains controversial. Even if medical management alone can be successful, some authors advocate early reoperation. The aim of this retrospective study was to identify the clinical variables associated with a high probability of full recovery with medical treatment. METHODS: Among 850 Lewis procedures performed for oesophageal carcinoma, 23 patients (2.7 per cent) developed postoperative chylothorax despite systematic preventive ligation of the main thoracic duct. Patients who responded to conservative management were compared with those requiring reoperation for preoperative radiotherapy, unilateral versus bilateral pleural effusion, delay of occurrence of the chylothorax, and ratio of mean chylous output to body-weight 1 and 5 days after its onset. RESULTS: Conservative management was successful in 14 patients with a mean(s.d.) delay of 12(5) (range 7-21) days and there were no hospital deaths. Reoperation was necessary in nine patients; there were two postoperative deaths and no recurrence of the chylothorax. The only significant difference between reoperated and medically treated patients was the mean(s.d.) chylous output at day 5: 23.5(16.6) versus 6.7(5.5) ml per kg body-weight (P< 0.001). At this time, the output was less than 10 ml/kg in 12 of 14 patients in whom medical treatment was successful (sensitivity 86 per cent), and equal to or greater than this cut-off value in all the patients who underwent reoperation (specificity 100 per cent). CONCLUSION: The ratio of chylous output to body-weight on the fifth day after the onset of a chylothorax complicating oesophagectomy seems to reliably predict the success of continuing medical treatment.