Radical versus conservative surgical treatment of liver hydatid cysts.

BACKGROUND: The management of liver hydatid cysts is controversial. Surgery remains the basic treatment, and can be divided into radical and conservative approaches. The purpose of this study was to compare the results of radical and conservative surgery in the treatment of liver hydatid cysts. METHODS: Data from all patients with liver hydatid cyst treated in a hepatobiliary surgical unit, between January 1990 and December 2010, were retrieved from a retrospective database. To minimize selection bias, propensity score matching was performed, based on 17 variables representing patient characteristics and operative risk factors. The primary outcome measure was hydatid cyst recurrence. RESULTS: One hundred and seventy patients were matched successfully, representing 85 pairs who had either a radical or a conservative approach to surgery. At a median (i.q.r.) follow-up of 106 (59­135) and 87 (45­126) months in the radical and conservative groups respectively, the recurrence rate was 4 per cent in both groups (odds ratio (OR) 1.00, 95 per cent confidence interval 0.19 to 5.10). There were no statistically significant differences between conservative and radical surgery in terms of operative mortality (1 versus 0 per cent; P=0.497), deep abdominal complications (12 versus 16 per cent; OR 1.46, 0.46 to 3.49), overall postoperative complications (15 versus 19 per cent; OR 1.28, 0.57 to 2.86), reinterventions (0 versus 4 per cent; P=0.246) and median hospital stay (7 (i.q.r. 5­12) days in both groups; P=0.220). CONCLUSION: This study could not demonstrate that radical surgery reduces recurrence and no trend towards such a reduction was observed.

HIPEC for peritoneal carcinomatosis: does an associated urologic procedure increase morbidity?

PURPOSE: To report the incidence of urinary tract procedures performed during complete cytoreductive surgery (CCRS) plus intraperitoneal chemotherapy, and to report the types of procedure, specific morbidity, risk factors, and treatment. METHODS: Data were extracted from a prospective database of patients with malignant peritoneal disease treated with CCRS plus intraperitoneal chemotherapy who had undergone a resection or suture of the bladder, ureter, or kidney. Patients were eligible whatever the tumor origin. RESULTS: Between 1994 and 2010, among the 598 patients treated with CCRS plus intraperitoneal chemotherapy, 48 (8%) had undergone a resection or suture in the urinary tract. Procedures included 4 nephrectomies, 19 partial cystectomies, 8 surgically repaired bladder injuries, and 18 ureteral resections. Postoperative mortality was 4% and morbidity was 41%. Specific complications included 6 urinary fistulas (12%), two among the 27 bladder sutures (7%) and four among the 18 ureteral sutures (22%) (P = NS). In the multivariate analysis, the risk factors for urinary fistula were severe preoperative malnutrition (P = 0.05, relative risk [RR] = 7.3) and extensive peritoneal disease (peritoneal cancer index ≥20, P = 0.05, RR = 8.3). Urinary fistulas had been treated nonsurgically in most of the cases. CONCLUSIONS: Associated urinary tract procedures had occurred in 8% of the cases but did not greatly increase morbidity. Therefore, urinary tract involvement or injury are not contraindications to performing CCRS plus intraperitoneal chemotherapy. Fistulas had complicated only 12% of urinary sutures, mainly in cases of malnutrition or extensive peritoneal disease.

Liver resection safety in a developing country: Analysis of a collective learning curve.

AIM OF THE STUDY: To analyze the collective learning curve in the performance of safe liver resections, using the decrease of severe postoperative complications (SPC) as a proxy for overall safety competency. MATERIAL AND METHODS: This was a retrospective analysis of a prospective database in the setting of a liver surgery program implementation in a tertiary center in Morocco. The 100 first consecutive cases of elective liver resections starting from January 1st, 2018 were included in the analysis. SPC were defined as CD>IIIa during the first 90 postoperative days. We used a cumulative sum (CUSUM) technique to determine the number of cases required to achieve safety competency. We then compared case characteristics before and after the learning curve completion. RESULTS: SPC occurred in 15 cases (15%), including 5 deaths (5%). The CUSUM chart revealed a learning curve completion at the 49th case, marked by an inflection point towards the decrease in SPC (24.5% vs 5.9%; P=0.009). In period 2 (after), cases were associated with less diabetes, less synchronous digestive resection, more cirrhosis, and more prolonged preoperative chemotherapy. The rates of major resection (30.6% vs 29.9%; P=0.89) and biliary reconstruction were comparable, as were the operating time, and estimated blood loss. CONCLUSION: Approximately 50 cases were required to complete the learning curve and improve the overall safety of liver resection. In our setting, the learning curve chronology was consistent with collective measures, including team stabilization and protocol development.

Two-step pull-through colo-anal anastomosis aiming to avoid stoma in rectal cancer surgery: A "real life" study in a developing country.

BACKGROUND: Delayed colo-anal anastomosis (DCA) is an underused technique rarely performed after resection of primary low rectal adenocarcinoma. The objective of this study was to compare the short-term outcomes of DCA and classical colo-anal anastomosis (CAA). METHODS: This is a retrospective comparative study carried out at two tertiary centres in Morocco and France. It included all patients who underwent colo-anal anastomosis after complete mesorectal excision for primary rectal adenocarcinoma between January 2018 and December 2019. The main outcomes were 90-day morbidity and rates completing the surgical steps of DCA and CAA. RESULTS: Among 215 rectal resections, 45 patients received colo-anal anastomosis, including 19 DCA and 26 CAA. Seventeen patients in the DCA group completed the two steps compared to 16 in the CAA group (89.5% vs. 61.5%, P=0.04). The rates of severe complications (26.9% vs. 26.3%, P=0.96) and anastomotic leakage (42.3% vs. 31.6%, P=0.46) were not different between the two groups. CONCLUSION: This study showed that DCA was associated with a higher rate of completing the two surgical steps, with no difference in overall and severe morbidity. DCA may be a strong alternative to classical colo-anal anastomosis.

Risk factors for major complications after liver resection: A large liver resection study from Morocco and audit of a non-Eastern/non-Western experience.

BACKGROUND AND STUDY AIMS: In developing countries, endemic indications, blood shortages, and the scarcity of liver surgeons and intensive care providers can affect liver resection (LR) outcomes, but these have been rarely addressed in the literature. Therefore, in this study we determined risk factors for major complications after LR in a North African general surgery and teaching department. PATIENTS AND METHODS: From January 2010 to December 2015, 213 consecutive LRs were performed on 203 patients. All patients underwent a postoperative follow-up of >90 days. Postoperative complications were assessed according to the Clavien-Dindo (CD) classification of surgical complications. A score of CD ≥III is considered as major postoperative complications. In this study, we analyzed the variables assumed to affect these complications. RESULTS: The overall 90-day complication rate was 35.7% (n = 76), including a CD ≥III of 14% (n = 30) and a mortality rate of 6.1% (n = 14). According to the multivariate analysis, a preoperative performance status (PS) of ≥2 (P = 0.011; odds ratios [OR], 6.8; 95% confidence intervals [CI], 1.55-29.8), an estimated intraoperative blood loss of >500 ml (P = 0.002; OR, 3.71; 95% CI, 1.23-11.20), and bilioenteric anastomosis (P < 0.004; OR, 7.76; 95% CI, 1.5-3.89) were independent risk factors for major complications after LR. CONCLUSION: We recommend that, in the setting of a non-Eastern/non-Western general surgery and teaching department, patients with a PS of ≥2 should undergo a specific selection and preoperative optimization protocol; intermittent clamping indications should be extended; and special attention should paid to patients undergoing LR associated with biliary reconstruction, such as for perihilar cholangiocarcinoma.

[Fixation of fluorescent estrone derivative on human breast cancer cells. Correlation with age, menopause status and histopathology]. / Fixation d'un dérivé fluorescent de l'oestrone sur les cellules de cancers mammaires humains. Corrélation avec l'âge, le statut ménopausique et l'histopathologie.

Values were determined by means of a ligand binding assay using 17-FE (17-fluoresceinated estrone) in 53 breast cancer patients. 49.1% of the tumors were positive and 50.9 negative. There was no correlation between the positivity and tumor size and localisation. The proportion of positivity increased with advancing age. In the group of postmenopausal women, the incidence of positivity was higher than in the premenopausal group, although the difference was not statistically significant. Histopathologically, tumors with high and intermediate grades of differentiation were often more significatively positive when compared to poorly differentiated tumors.

[Leiomyosarcoma of the vagina: a rare case]. / Le léiomyosarcome du vagin: une observation rare.

Vaginal leiomyosarcoma is unfrequent. We report on a case in a 50-year-old multipara patient who had presented a posterior vaginal swelling since 6 months. The tumor was discovered at the occasion of pains and non hemorragic discharge. The histological pattern of the tumor was well-differentiated spindle cell sarcoma with pleiomorphic areas. The immunohistochemistry confirmed the smooth myogenic differentiation. The treatment consisted of posterior pelvic exenteration extended to the vagina. The patient is alive and free of disease at 20 months of fellow-up.

A rare case of angiosarcoma of the breast in a man: case report.

This is a case report of a 57-year-old man who had primary angiosarcoma of the left breast. Five months after detecting a mass in his breast, he underwent mastectomy with biopsy of the ipsilateral axillary lymph nodes. Three years later, he is still alive without any recurrence. Angiosarcoma of the female breast is rare and exceptional in males. It is a condition with a poor prognosis and there are as yet no established chemotherapeutic regimens.

Male breast cancer. A report of 71 cases.

Male breast cancer is rare; it constitutes 0.2-1.5% of all malignant tumours in men and 1% of all breast cancers. The goal of this retrospective study is to analyse the epidemiologic, clinic, therapeutic and evolutive profiles of this disease in 71 cases collected at the National Institute of Oncology in Rabat, Morocco, between the years 1985 and 1998. The median age was 60 years. No significant risk factor was found. The average consultation's delay was 35 months. The main clinical complaint was a mass beneath the areola in 86% of the cases, associated with ulceration in 18% of the cases. For that, the disease was diagnosed at an advanced stage. Infiltrating ductal carcinoma was the most frequent pathologic type (91.5% of cases). Management consisted especially of radical mastectomy, followed by adjuvant radiotherapy and hormonal therapy with or without chemotherapy. It was possible to follow 58 of the patients. The median of follow-up was 30 months. The evolution has been characterized by local recurrence, after a median delay of 36 months, in five cases (8.5% of all patients). Metastasis occurred, after a median delay of 12 months, in 14 cases (24% of all patients). The site of metastasis was the bone in six cases, lung in five cases, liver in one case, liver and skin in one case and pleura and skin in one case. There were three cases of death. In one case, death was related to lung metastases. In the two remaining cases, death was due to comorbid disease. Progression was observed in one case.

[Is the aggressive treatment of locoregional recurrences of colorectal cancers justified?]. / Un traitement agressif est-il justifié dans les récidives locorégionales des cancers colorectaux?

Fifty-two local recurrences (LR) of colonic (n = 31) or rectal (n = 21) cancers, with synchronous metastases in 19 cases, were treated aggressively between 1981 and 1989. Treatment consisted of extended surgical resection combined with transcutaneous radiation therapy. Intravenous chemotherapy (5 fluorouracil and folinic acid) was delivered to the last 42 patients. The synchronous metastases were resected in all cases, except one. A sufficient high-dose radiation therapy (45 Gy after complete excision and 60 Gy after incomplete excision) was performed in 23 cases only. The majority (29 cases) of the patients underwent a second operation, and some 3, 4, or 5 operations. Global survival and survival without recurrence were 60 percent and 42 percent at 3 years. These good results were not stable and decreased progressively with time. The excision required usually surgery of large magnitude. Postoperative mortality was null but morbidity and functional disorders were important. After complete excision of the LR, radiation therapy doubled the rate of local control when it was greater than 45 Gy. The benefit of radiation therapy was doubtful after incomplete excision, even with high-dose irradiation. The role of systemic chemotherapy could not be analyzed in this study. Study of prognostic factors showed that resectable synchronous metastases and rectal or colonic location of primary tumors were not correlated with survival, Survival was correlated with the local control of LR (P = 0.012) and the presence of invaded neighbouring organs (P = 0.006) which reflected the tumor volume. In conclusion, it was difficult to conclude if aggressive treatment of LR should be mandatory or not.(ABSTRACT TRUNCATED AT 250 WORDS)

[Management of phyllodes tumors of the breast at the National institute of oncology of Rabat, Morocco]. / Prise en charge des tumeurs phyllodes du sein à l'Institut national d'oncologie de Rabat, Maroc.

OBJECTIVES: Phyllodes tumors of the breast (PTB) are rare fibro epithelial tumors. Their terminology, histological classification and their treatment are exposed to controversy. The aim of our work is to underline the epidemiological, clinical, histological, therapeutical, prognostic and evolutive features of these tumours through a retrospective study and a review of the literature. PATIENTS AND METHODS: We reviewed at the National Institute of Oncology of Rabat, Morocco, between 1985 and 1998, all the files of patients with histological certainty of PTB, doubtful PTB were excluded. We collected epidemiological, clinical, histological, therapeutical, prognostic and evolutive features of these tumours. STATISTICS: quantitative parameters were represented by mean +/- S.D. and qualitative parameters by percentage or effective. RESULTS: We studied nine cases of PTB, which represented 0.09% of all primitive tumors of the breast treated at our institution during the study period. All our patients were female. Mean age was 37.3 +/- 10.07 years. Two of our patients (22.2%) had a history of fibroadenoma and 44.4% were nulliparous. Mean delay before consulting was 60.7 +/- 17.56 months and the median tumour size was 13 +/- 7.47 cm. Pathological findings were six benign or borderline phyllodes tumours (66.7%) and three cystosarcomas phyllodes (33.3%). The treatment consisted in simple mastectomy in seven cases (77.8%) and tumorectomy in two cases (22.2%). All the surgical margins were clear. Two of the three cystosarcomas phyllodes received adjuvant external bean radiation therapy 50 Gy on the thoracic chest wall. After a median outcome of 3 +/- 2 years ranging from 3 to 74 months, we did not note any relapse or metastasis. DISCUSSION AND CONCLUSION: In our series, PTB happened exclusively in females. History of fibroadenoma within 22.2% of the patients suggests the hypothesis of a filiation between these two entities. Their distinctive features were young age in diagnosis, long delay before consulting, important tumor size, predominant benign and borderline histological types, treatment mainly surgical and good local and distant control.

[Association of ovarian juvenile granulosa cell tumor with Maffucci's syndrome]. / Association d'une tumeur ovarienne de la granulosa juvénile à un syndrome de Maffucci.

The authors report a rare case of the ovarian juvenile granulosa cell tumor associated with Maffucci's syndrome (enchondromathosis + hemangiomas), no heriditary mesodermal dysplasia. Sarcomatous changes of chondromas are encountered most frequently; however other various typed neoplasma have been reported: ovarian juvenile granulosa cell tumor may occur not infrequently in female patients with Maffucci's syndrome in the first or second decades. Sarcomatous changes of choromas established prognosis of the Maffucci's syndrome.

[Breast angiosarcomas: three case reports]. / Les angiosarcomes du sein: à propos de 3 observations.

Angiosarcoma is a rare type of breast cancer, it has the worst prognosis of all breast malignancies. We report three cases of breast angiosarcoma observed at the National Oncology Institute and the Maternity of Orangers. A preoperative diagnosis was evoked in one case only, after a local recurrence in the second one and histological in the last one. Mastectomy is the reference treatment. The development is distinguished by general metastasis. Based on review of literature, we analysed the different aspects of this disease.

[Bone metastasis revealing a primary prostate cancer]. / Métastase osseuse révélatrice d'un cancer prostatique simulant une tumeur primitive.

Spiculated reactive periosteal bone is usually found in cases of primary malignant bone tumors; rarely in secondary bone lesions. The authors report a case of bone tumor of the clavicle in a 62 year-old patient with "sunburst " periosteal reaction on radiographs. The metastatic nature of this lesion from an unknown prostate carcinoma was confirmed by immunohistochemical studies of the clavicle biopsy. Tumorectomy was performed and the patient's status is stable with a follow-up of 10 months.

[Kidney cancer: report of 47 cases]. / Cancer du rein: à propos de 47 cas.

The authors report a series of 47 cases observed over a 15-years period in the department of carcinological at the national oncological institute of Rabat. Patients consisted of 16 mean and 21 women (57%), with a mean age of 49 years old (range 29 to 70 years). The clinical features were polymorph, firstly loin pain (81%), hematuria is the next (25%). A lumbar mass (10%). The diagnosis was established by ultra-sonography and CT-scan in all the patients. The mean tumour diameter was 10 cm (5-17 cm), it were located in down pole in 53%. The surgical procedure consisted of radical nephrectomy and regional or hailer lymph node dissection in 46 patients. The post operative course was marked by one death due to pulmonary metastases. The mean follow-up was (2 to 15 years). Asynchronies metastases occurred in 6 patients after a mean interval (9 to 36 months). The overall 5 year survival was 100% PT1, 78% PT2, 34% PT3.

[Pelvic actinomycosis simulating adnexal malignant tumor]. / Actinomycose pelvienne simulant une tumeur maligne annexielle.

The purpose of this report is to describe the case of a 35-year-old patient admitted to the National Oncology Institute in Rabat, Morocco for pelvic pain and deteriorating general status ongoing for 8 months. Clinical and ultrasonographic examination showed a heterogenous mass measuring 7 cm in maximum width located inferior and lateral to the inferior aspect of the right side of the uterus. These findings were suggestive of a malignant tumor of the right ovary. Ovariectomy and omentectomy were performed. Histological examination of surgical specimens demonstrated right tubo-ovarian actinomycosis associated with peritonitis. Genital tract actinomycosis is an uncommon finding in women of childbearing age. It is due to colonization by a pyogenic bacteria (Actinomyces) usually secondary to a gastrointestinal infection, e.g. ileocecum, and sometimes in association with the presence of an intrauterine device or foreign body. Based on this case report, the authors discuss abdominopelvic actinomyocosis with emphasis on tumor-like findings that can lead to misdiagnosis by clinicians and radiologists.

[Reno-sigmoid fistula in a tuberculous pelvic ectopic kidney]. / Fistule réno-sigmoïdienne sur un rein ectopique pelvien tuberculeux.

Renocolic fistulas are rare lesions, generally involving the ascending and descending colon. The authors report a case of reno-sigmoid fistula occurring in a tuberculous pelvic ectopic kidney. Nephrectomy with segmental sigmoid resection was completed by antituberculous treatment for 9 months. The patient presents a good general condition with normal renal function and normal intestinal transit with a follow-up of 19 months.