Robotic Sphincter-Saving Total Mesorectal Excision for Rectal Cancer Treatment: A Single-Surgeon Experience in 103 Consecutive Male Patients.

BACKGROUND: A robotic surgical approach provides advantages compared to laparoscopy in male patients with mid- and low-lying rectal cancer located in the narrow pelvic space. The aim of this report is to present a single-surgeon experience with robotic sphincter-saving total mesorectal excision of rectal cancer in male patients. METHODS: A series of 103 consecutive male patients who underwent robotic rectal surgery between January 2012 and June 2019 were analyzed retrospectively in terms of demographics, histopathological data, and surgical and oncological outcomes. RESULTS: All of the patients underwent robotic sphincter-saving resection: 76 (73.8%) underwent low-anterior resection and 27 (26.2%) underwent intersphincteric resection with colo-anal anastomosis. There was no conversion. The median distal resection margin of the operative specimen was 3 (0.2-7) cm. The circumferential resection margin was positive in 3 (2.91%) cases. The median number of retrieved lymph nodes was 22 (18-42). The median hospital stay was 4 (3-16) days. Whereas the overall morbidity was 13%, there was no in-hospital or 30-day mortality. The median length of follow-up was 48 (9-80) months. The 5-year overall survival rate was 87%. The 5-year disease-free survival rate was 84%. Local and distant recurrence rates were 3.8% and 5.82%, respectively. CONCLUSIONS: In male patients with rectal cancer, a robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field.

The impact of total neo-adjuvant treatment on nonoperative management in patients with locally advanced rectal cancer: The evaluation of 66 cases.

BACKGROUND: The study aimed to assess if adherence to a total-neoadjuvant-treatment (TNT) protocol followed by observation(watch-and-wait) led to the successful nonoperative-management of low-rectal-cancer. METHODS: In this study, patients with primary, resectable-T3-T4, N0-N1 distal-rectal-adenocarcinoma underwent-chemoradiotherapy + consolidation-chemotherapy (TNT). During the-TNT-period, endoscopy, MRI, and FDG-PET/CT were performed. We allocated patients with complete-clinical-tumor-regression, who underwent endoscopy every two months, MRI every-four-months, and PET/CT every-six-months-after-treatment, to the observation-group(OG). All other patients were referred for surgery. The OG was followed-up. The primary endpoint was local tumor-ecurrence after allocation to the OG. RESULTS: Between 2015 and 2018, we enrolled 66-patients. Of 60-patients who were eligible to participate, 39 had complete-clinical-response(cCR) and were allocated to the OG, six underwent local-excision (LE), and 15 underwent total-mesorectal-excision (TME). The median follow-up duration was 22 (9-42) months. The local-recurrence-rate in the OG was 15.3%, and the LE and TME rates were 16.6% and 0%, respectively. All recurrence cases were salvaged through either LE or TME. The-distant-metastasis rate was 5.1%, 16.6%, and 12.5% in the OG, LE, and TME groups, respectively. The endoscopic negative-predictive-value(NPV) was 50%, and the positive-predictive-value(PPV) was 76.9% in the surgery group (LE + TME). MRI; NPV-50%, PPV-76.9%. PET/CT; NPV-100%, PPV-93.3%. Six patients(28.57%) from surgery group achieved complete pathological response (cPR). CONCLUSION: Our results indicated a high proportion of selected-rectal-cancers with-cCR after neo-adjuvant-therapy could potentially be managed non-operatively, and major surgery may be avoided.

Robotic versus laparoscopic sphincter-saving total mesorectal excision for mid or low rectal cancer in male patients after neoadjuvant chemoradiation therapy: comparison of long-term outcomes.

The aim of our study was to compare long term outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision (TME) in male patients with mid-low rectal cancer (RC) after neoadjuvant chemoradiotherapy (NCRT). The study was conducted as a retrospective review of a prospectively maintained database, and we analyzed 14 robotic and 65 laparoscopic sphincter-saving TME (R-TME and L-TME, respectively) performed by one surgeon between 2005 and 2013. Patient characteristics, perioperative recovery, postoperative complications and pathology results were compared between the two groups. The patient characteristics did not differ significantly between the two groups. Median operating time was longer in the R-TME than in the L-TME group (182 min versus 140 min). Only two conversions occurred in the L-TME group. No difference was found between groups regarding perioperative recovery and postoperative complication rates. The median number of harvested lymph nodes was higher in the RTME than in the L-TME group (32 versus 23, p = 0.008). The median circumferential margin (CRM) was 10 mm in the R-TME group, 6.5 mm in the L-TME group (p = 0.047. The median distal resection margin (DRM) was 27.5 mm in the R-TME, 15 mm in the L-TME group (p = 0.014). Macroscopic grading of the specimen in the R-TME group was complete in all patients. In the L-TME group, grading was complete in 52 (80%) and incomplete in 13 (20%) cases (p = 0.109). Median follow-up 87 months (1-152). Whereas local recurrence was seen in eight cases (10.12%) and distant metastasis was seen in 18 cases (22.7%). Overall, 5 years survival was 83.3% in R-TME, 75% in L-TME groups. R-TME is a safe and feasible procedure that facilitates performing of TME in male patients with mid to low RC after NCRT.

The long-term oncological outcomes of the 140 robotic sphincter-saving total mesorectal excision for rectal cancer: a single surgeon experience.

Robotic surgery became more popularly in the colorectal surgical field. The aim of the study was to evaluate of the oncological outcomes which patients who underwent the robotic total mesorectal excision for rectal cancer. A series of 140 consecutive patients who underwent robotic rectal surgery between January 2012 and June 2019 was analyzed retrospectively in terms of demographics, pathological data, and surgical and oncological outcomes. There were 104 (74.28%) male and 36 (25.71%) female patients. The tumor was located in the lower rectum in 84 (60%) cases, in the mid rectum in 38 (27.14%) cases, and in the upper rectum in 18 (12.85%) cases. Ninety-eight (70%) of the patients has received neoadjuvant chemoradiotherapy. All the patients underwent robotic sphincter-preserving surgery, 101 (72.14%) patients low-anterior resection, and 39 (27.85%) patients underwent intersphincteric resection with colo-anal anastomosis. There were no conversions. The circumferential resection margin was positive in five (3.57%) patients. The median distal resection margin of the operative specimen was 3.2 (0.2-7) cm. The median number of retrieved lymph nodes was 22 (16-42). TME quality in the in our study was rated as complete in 88.57% (n124) of patients, nearly complete in 7.14% (n10) of patients; and 4.28% (n6) of incomplete. The median hospital stay was 3.5 (3-12) days. In-hospital and 1-month mortality was zero. The median length of follow-up was 40 (2-80) months. The 5-year overall survival rate was 92.78%. The 5-year disease-free survival rate was 90%. Locally recurrence and distance recurrence rate was 3.57% (n5/140) and 2.85% (n4/140), respectively. Robotic rectal cancer surgery has a good oncological outcomes and feasible tool in the field of the rectal surgery, but required a steep learning curve.

Standardized Laparoscopic Sphincter-preserving Total Mesorectal Excision For Rectal Cancer: Median of 10 Years' Long-term Oncologic Outcome in 217 Unselected Consecutive Patients.

This study was designed to evaluate the impact of a standardized laparoscopic total mesorectal excision (TME) on the long-term oncologic outcome. Unselected consecutive patients with rectal cancer underwent a standardized laparoscopic TME with medial to lateral approach encompassing 9 sequential steps. From 2005 to June 2012, laparoscopic sphincter-preserving TME was attempted in 217 patients. Mean follow-up of all patients was a median of 91 months (range, 3 to 164 mo). The local recurrence rate was 6.5%, and the distant recurrence rate was 19.8%. The 10-year disease-free survival (DFS) rates were 76.4% and overall survival (OS) was 67.1%. In the converted group, DFS and OS were 50% and 46.7%, respectively. In the laparoscopic group, DFS and OS were 78.3% and 68.5%, respectively. A standardized laparoscopic sphincter-preserving TME resulted in a favorable long-term oncologic outcome in unselected patients with rectal cancer. Conversion to open surgery has impaired OS and DFS.

Management of sentinel node re-mapping in patients who have second or recurrent breast cancer and had previous axillary procedures.

BACKGROUND: In patients with recurrent or second primary ipsilateral breast cancer, axillary staging is the key factor in locoregional control and a strong prognostic characteristic. The efficient evaluation of lymphatic drainage of re-sentinel lymph node biopsies (re-SLNBs) has remained a challenge in the management of ipsilateral primary or recurrent breast cancer patients who are clinically lymph node negative. This study explores whether a SLNB for patients with primary or recurrent breast cancer is possible after previous axillary surgery. It evaluates potential reasons for mapping failure that might be associated with patients in this group. METHODS: Between March 2006 and November 2013, 458 patients were subjected to a breast SLNB. A lymphoscintigraphy procedure was performed on 330 patients for sentinel lymph node (SLN) mapping on the day of surgery. Seven patients with either a second primary cancer in the same breast or recurrent breast cancer were described. Two of these seven patients had axillary lymph node dissection (ALND) during previous treatments and five had SLNB. A dual mapping method was used for all patients. Preoperative lymphoscintigraphy was performed four hours before surgery. RESULTS: SLNs were successfully remapped in six of seven (85.7%) patients, of whom five (71.43%) had previously undergone SLNB and two (28.57%) previous ALND. Localizations of SLNs were ipsilateral axillary in three patients, ipsilateral internal mammary in one patient, and contralateral axillary in two patients. An altered distribution of lymph nodes was discovered in both patients with previous ALND. In one of the two patients, metastases were found in an aberrant lymph drainage basin at the location of a non-ipsilateral axillary node (contralateral axillary SLN). The second previously ALND patient had an internal mammary SLN. In one patient, mapping was unsuccessful and the SLN was not identified. CONCLUSIONS: Altered lymphatic drainage incidence increases following breast-conserving surgery for an initial breast cancer, and the location of SLNs becomes unpredictable at the time of a second primary or recurrent ipsilateral breast cancer. This leads to the necessity of using a radionuclide (lymphoscintigraphy) for a successful re-mapping procedure. A re-SLNB is precise and beneficial even though there are few patients. A lymphoscintigraphy can identify SLNs at their new unpredicted location.

Cardiac angiosarcoma: utility of [(18)F]fluorodeoxyglucose positron emission tomography-computed tomography in evaluation of residue, metastases, and treatment response.

Cardiac angiosarcomas are a rare form of malignancy. The majority of cases arise from the right atrium as mural masses. These tumors have extremely aggressive behavior, with early clinical symptoms that vary depending on location, size, and extent of the tumor. Most of these patients have a very short survival time. Surgical therapy is considered the best choice of therapy approach in cardiac angiosarcoma patients with nonmetastatic disease, even though the disease is rarely cured. Advanced diagnostic techniques facilitate accurate, noninvasive assessments of cardiac sarcomas. We report a case of a 62-year-old man with cardiac angiosarcoma who had multiple distant metastases that were revealed by [(18)F]fluorodeoxyglucose positron emission tomography-computed tomography imaging.

Clinical impact of SPECT-CT in the diagnosis and surgical management of hyper-parathyroidism.

UNLABELLED: Hyper-functioning parathyroid glands with autonomous overproduction of PTH is the most frequent cause of hypercalcemia in outpatient populations with primary hyper-parathyroidism. It is generally caused by a solitary adenoma in 80%-90% of patients. Despite the various methodologies that are available for preoperative localization of parathyroid lesions, there is still no certain preoperative imaging algorithm to guide a surgical approach prior to the management of primary hyper-parathyroidism (P-HPT). Minimally invasive surgery has replaced the traditional bilateral neck exploration (BNE) as the initial approach in parathyroidectomy at many referral hospitals worldwide. In our study, we investigated diagnostic contributions of SPECT-CT combined with conventional planar scintigraphy in the detection of hyper-functioning parathyroid gland localization, since planar imaging has limitations. We also evaluated the efficacy of preoperative USG in adding to initial diagnostic imaging algorithms to localize a parathyroid adenoma. METHODS: A total of 256 consecutive surgically naive patients with hyper-parathyroidism diagnosis were included in the following preoperative localization study. The study consisted of 256 consecutive patients with HPT, with a selected 154 patients who had neck surgery with definitive histology reports. All patients had 99mTc-methoxyisobutylisonitrile (99mTc-MIBI) double-phase scintigraphy. The SPECT-CT procedure, combined with standard 99mTc-MIBI planar parathyroid scintigraphy with a pinhole and parallel-hole collimator to evaluate whether the SPECT-CT procedure was able to provide additional information in the localization of the pathology, caused hyper-parathyroidism in both P-HPT and S-HPT. RESULTS: In the 154 P-HPT patients, 168 lesions (142 adenomas including 2 intrathyroidal and 2 double adenoma, 2 carcinoma, and 22 hyperplastic glands (four patients had MEN I, each with four hyperplastic glands)), were found at surgery. SPECT-CT detected more lesions than planar imaging in P-HPT (97.8% vs. 87.6%). SPECT-CT detected all adenomas and increased sensitivity, particularly in small lesions. Regardless of their size, the number of detected hyperplastic glands by SPECT-CT was remarkably higher than planar imaging.

Diagnostic contribution of (18)F-FDG-PET/CT in fever of unknown origin.

OBJECTIVES: Fever of unknown origin (FUO) remains one of the most compelling diagnostic issues in medicine. We aimed to evaluate the potential clinical contribution of 18-fluoro-2-deoxyglucose positron emission tomography/computed tomography ((18)F-FDG-PET/CT) in the identification of the underlying cause of FUO. METHODS: Fifty consecutive patients (27 men and 23 women; age range 16-88 years) with FUO based on the revised definition criteria were included in the study. A diagnostic protocol including biochemistry, histopathology, and microbiological tests was performed and the patients were followed up. FDG-PET was performed in 25 of the 50 patients (12 males and 13 females; age range 16-88 years) in order to determine the etiology of the patient's fever. PET-CT images were obtained with the Gemini Philips TF (18)F-FDG-PET/CT camera after a 60-min 'standard uptake' period following an injection of a mean 330 MBq (range 290-370 MBq) intravenous (18)F-FDG. RESULTS: A total of 21 patients were available for analysis of the diagnostic contribution of PET/CT (two patients were undiagnosed and two had non-contributory PET/CT findings). (18)F-FDG-PET/CT was able to precisely detect the cause of fever in 60% of the cases (n=15). The accuracy, sensitivity, and specificity of this imaging modality were 90.5%, 93.8%, and 80%, respectively. Among the cases with a true-positive (18)F-FDG-PET/CT finding (i.e., 15 cases), the identified underlying causes of FUO included localized infection (n=7), non-infective inflammatory process (n=5), and malignancy (n=3). CONCLUSIONS: Further studies to confirm the high diagnostic yield of (18)F-FDG-PET/CT observed in the present study would lend support to the inclusion of this imaging modality in the initial diagnostic work-up of patients with suspected FUO.

PET/CT images of bilateral diffuse intraglomerular metastasis of malignant melanoma.

Intraglomerular metastasis is a very rare condition with an underlying cause that is not yet well understood. We present the 18F-FDG PET/CT images of histologically proven intraglomerular metastases from newly diagnosed malignant melanoma with positive sentinel lymph node metastases. During the initial diagnostic evaluation period, the patient also had a sudden increased serum creatinine level. FDG PET/CT demonstrated diffuse glomerular FDG uptake unlike typical physiologic pelvicaliceal activity. Renal biopsy revealed diffuse crescentic lesions containing metastatic melanoma cells.

Role of red blood cell scintigraphy for determining the localization of gastrointestinal bleeding.

BACKGROUND: We aimed to evaluate the role of Tc-99m labeled red blood cell (RBC) scintigraphy for determination of localization of gastrointestinal system (GIS) bleeding. METHODS: Fifty-seven cases (27 females, 30 males; mean age 43.9±24; range 1 to 91 years) who referred to our clinic between 1995-2010 were evaluated for determination of localization of GIS bleeding with RBC scintigraphy. Prior to scintigraphy, gastroscopy in 51, colonoscopy in 45, and angiography in 9 patients were performed. RESULTS: RBC scintigraphies were positive and negative in 31 and 26 patients, respectively. Positive scintigraphic findings were obtained within the 1st hour of dynamic imaging in 19 patients, within the 1st-4th hour static images in 7, and within the 4th-24th hour images in 5 patients. Fourteen patients underwent surgical exploration. In 13 patients, the surgery confirmed the diagnosis by RBC scintigraphy (accuracy: 92.8%). Of 43 patients without surgical exploration, 12 had anemia due to iron deficiency and their scintigraphic evaluation were negative. Four patients died and in 27 patients, GIS bleeding ceased spontaneously or with conservative measures. CONCLUSION: Scintigraphy should be the primary tool for accurate diagnosis of patients with active GIS bleeding. Positive dynamic images obtained within the first hour of imaging may be more accurate for demonstrating bleeding localization and a good predictor of requirement of surgical exploration.

The role of peritoneal scintigraphy in the detection of continuous ambulatory peritoneal dialysis complications.

While continuous ambulatory peritoneal dialysis (CAPD) offers several advantages over hemodialysis in patients with end-stage renal disease, several complications have been recognized. The intraperitoneal instillation of dialysate increases intra-abdominal pressure and consequently predisposes the patient to leaks and herniations through defects in the abdominal wall. The use of an intraperitoneal radiolabeled colloid has been previously described to image entities such as hernias, patent processus vaginalis, abdominal wall, and diaphragmatic leakage. This study shows a simple, non-invasive method of determining the site of dialysate leak and its importance to assist further patient management. There has been a continuing increase in the number of end stage renal disease patients maintained on chronic peritoneal dialysis (CPD). Many patients choose CPD as their preferred chronic dialysis treatment, though approximately 20% of patients who drop out transfer to hemodialysis annually.[1] Although peritonitis remains the major reason for transfer to hemodialysis, other factors such as exit site infections, catheter-related problems, abdominal wall and inguinal hernias, loss of ultrafiltrations, and poor clearance contribute to CPD technique failure.[2] In order to permit the continuation of long-term therapy with CPD, these complications should be resolved. Routine laboratory evaluation or physical examination can detect some CPD-related problems; however, some patients require more complicated investigations to evaluate their problems properly.

Radiosynovectomy in hemophilic synovitis: correlation of therapeutic response and blood-pool changes.

AIM: The aim of this study was to evaluate the efficacy of 90Y and 186Re radiosynovectomy in patients with hemophilic synovitis. METHODS: Radiosynovectomy was performed in 32 joints of 20 patients with hemophilic synovitis by using 90Y citrate colloid in the knee and 186Re sulfide colloid in the elbow, shoulder, and ankle. The indication for radiosynovectomy was the continuous presence of intra-articular blood or effusion and three or more hemorrhages into the same joint within the last 6 months. Response to therapy was first assessed at the 4th month with blood-pool imaging. Patients were followed up by clinical evaluation based on assessments of joint-bleeding frequency, using range of motion measurements at 6-month intervals for an average of 1 year (range, 9-15 months). RESULTS: A marked decrease (an 80%-100% decrease) in bleeding episodes was seen in 24 of 32 (75%) joints, a moderate decrease (51%-79% decrease) in 1 (9%) joint, and a mild decrease (30%-50%) in 3 (13%) joints. Frequency of intra-articular bleeding after treatment was unchanged in only 13% of the joints. The number of hemarthroses significantly decreased after therapy (p < 0.05). The mean bleeding frequency of the joints were 1.7 +/- 0.9 and 0.3 +/- 0.7 per month before and after therapy, respectively. The ratios of joints which had marked improvement after therapy were 86% in the ankle, 73% in the elbow, and 58% in the knee. There was no significant difference between percent joint range of motion limitations measured before and after therapy (p > 0.05). The correlation between therapeutic outcome (in terms of joint bleeding) and the difference of pre- and posttherapeutic blood-pool indices were significant (r = 0.594; p < 0.05), while the correlation between therapeutic outcome and pretherapeutic radiologic scale and pretherapeutic blood-pool indices were not significant (r = 0.095; p > 0.05; r = -0.089; p > 0.05, respectively). CONCLUSION: Radiosynovectomy is a simple but quite effective and efficient procedure in limiting the frequency of joint hemorrhage in patients with hemophilia. Blood-pool imaging may be an objective means for monitoring therapy response in these patients.