Prolonged survival after thoracic metastasectomy in patients with nonseminomatous testicular cancer.

INTRODUCTION: Almost 20 % of patients with Non-Seminomatous Germinative Cell Tumors (NSGCT) will require intrathoracic metastasectomy after chemotherapy. The authors aim to determine their long-term survival rates. METHODS: Retrospective study including patients with NSGCT and intrathoracic metastasis after systemic therapy from January 2011 to June 2022. Treatment outcomes and overall survival were analyzed with the Kaplan-Meier method. RESULTS: Thirty-seven male patients were included with a median age of 31.8 years. Six presented with synchronous mediastinum and lung metastasis, nine had only lung, and 22 had mediastinal metastasis. Over half had retroperitoneal lymph node metastasis. Twenty-two had dissimilar pathologies, with a discordance rate of 62 %. Teratoma and embryonal carcinoma were the prevalent primary tumor types, 40.5 % each, while teratoma was predominant (70.3 %) in the metastasis group. Thoracotomy was the main surgical approach (39.2 %) followed by VATS (37.2 %), cervico-sternotomy (9.8 %), sternotomy (5.8 %), and clamshell (3.9 %). Lung resection was performed in 40.5 % of cases. Overall, 10-year survival rates were 94.3 % with no surgical-related mortality. CONCLUSION: Multimodality treatment with systemic therapy followed by radical surgery offers a high cure rate to patients with intrathoracic metastatic testicular germ cell tumors.

Impact of Intraoperative Molecular Imaging after Fluorescent-Guided Pulmonary Metastasectomy for Sarcoma.

BACKGROUND: Intraoperative molecular imaging (IMI) has been shown to improve lesion detection during pulmonary sarcomatous metastasectomy. Our goal in this study was to evaluate whether data garnered from IMI-guided resection of pulmonary sarcoma metastasis translate to improved patient outcomes. STUDY DESIGN: Fifty-two of 65 consecutive patients with a previous history of sarcomas found to have pulmonary nodules during screening were enrolled in a nonrandomized clinical trial. Patients underwent TumorGlow the day before surgery. Data on patient demographics, tumor biologic characteristics, preoperative assessment, and survival were included in the study analysis and compared with institutional historical data of patients who underwent metastasectomy without IMI. p values < 0.05 were considered significant. RESULTS: IMI detected 42 additional lesions in 31 patients (59%) compared with the non-IMI cohort where 25% percent of patients had additional lesions detected using tactile and visual feedback only (p < 0.05). Median progression-free survival (PFS) for patients with IMI-guided pulmonary sarcoma metastasectomy was 36 months vs 28.6 months in the historical cohort (p < 0.05). IMI-guided pulmonary sarcoma metastasectomy had recurrence in the lung with a median time of 18 months compared with non-IMI group at 13 months (p < 0.05). Patients with synchronous lesions in the IMI group underwent systemic therapy at a statistically higher rate and tended to undergo routine screening at shorter interval. CONCLUSIONS: IMI identifies a subset of sarcoma patients during pulmonary metastasectomy who have aggressive disease and informs the medical oncologist to pursue more aggressive systemic therapy. In this setting, IMI can serve both as a diagnostic and prognostic tool without conferring additional risk to the patient.

Advanced renal cell carcinoma (RCC) management: an expert panel recommendation from the Latin American Cooperative Oncology Group (LACOG) and the Latin American Renal Cancer Group (LARCG).

PURPOSE: The outcome of RCC has improved considerably in the last few years, and the treatment options have increased. LACOG-GU and LARCG held a consensus meeting to develop guidelines to support the clinical decisions of physicians and other health professionals involved in the care of RCC patients. METHODS: Eighty questions addressing relevant advanced RCC treatments were previously formulated by a panel of experts. The voting panel comprised 26 specialists from the LACOG-GU/LARCG. Consensus was determined as 75% agreement. For questions with less than 75% agreement, a new discussion was held, and consensus was determined by the majority of votes after the second voting session. RESULTS: The recommendations were based on the highest level of scientific evidence or by the opinion of the RCC experts when no relevant research data were available. CONCLUSION: This manuscript provides guidance for advanced RCC treatment according to the LACOG-GU/LARCG expert recommendations.

Near-infrared intraoperative imaging for minimally invasive pulmonary metastasectomy for sarcomas.

BACKGROUND: Complete pulmonary metastasectomy for sarcoma metastases provides patients an opportunity for long-term survival and possible cure. Intraoperative localization of preoperatively identified metastases and identification of occult lesions can be challenging. In this trial, we evaluated the efficacy of near-infrared (NIR) intraoperative imaging using second window indocyanine green during metastasectomy to identify known metastases and to detect occult nodules. METHODS: Thirty patients with pulmonary nodules suspicious for sarcoma metastases were enrolled in an open-label, feasibility study (NCT02280954). All patients received intravenous indocyanine green (5 mg/kg) 24 hours before metastasectomy. Patients 1 through 10 (cohort 1) underwent metastasectomy via thoracotomy to assess fluorescence patterns of nodules detected by traditional methods (preoperative imaging and intraoperative visualization/bimanual palpation). After confirming reliability within cohort 1, patients 11 through 30 (cohort 2) underwent video-assisted thoracic surgery metastasectomy with NIR imaging. RESULTS: In cohort 1, 14 out of 16 preoperatively identified pulmonary metastases (87.5%) displayed tumor fluorescence. Nonfluorescent metastases were deeper than fluorescent metastases (2.1 cm vs 1.3 cm; P = .03). Five out of 5 metastases identified during thoracotomy displayed fluorescence. NIR imaging identified 3 additional occult lesions in this cohort. In cohort 2, 33 out of 37 known pulmonary metastases (89.1%) displayed fluorescence. Nonfluorescent tumors were deeper than 2.0 cm (P = .007). NIR imaging identified 24 additional occult lesions. Of 24 occult lesions, 21 (87.5%) were confirmed metastases and the remaining 3 nodules were lymphoid aggregates. CONCLUSIONS: NIR intraoperative imaging with indocyanine green (5 mg/kg and 24 hours before surgery) localizes known sarcoma pulmonary metastases and identifies otherwise occult lesions. This approach may be a useful intraoperative adjunct to improve metastasectomy.

Monosegmental ALPPS after Bilateral Hepatectomy.

Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) has emerged as an alternative for patients with bilobar colorectal liver metastasis and a small future liver remnant (FLR). In cases of extensive disease, ALPPS can be performed, leaving only one segment of the liver as FLR. We describe a case of monosegmental ALPPS using segment 4 as FLR. In conclusion, ALPPS should be reserved for a selected group of patients. Monosegmental ALPPS is feasible, but should be performed by hepatobiliary surgeons in specialized centers.

Ultrasonography During Surgery to Approach Cerebral Metastases: Effect on Karnofsky Index Scores and Tumor Volume.

BACKGROUND: The goals of treating a cerebral metastasis (CM) are to achieve local control of the disease and to improve patient quality of life. The aim of this study was to analyze the effect of conventional surgery supported by intraoperative ultrasound (IOUS) to approach a CM. To perform this analysis, we determined the postoperative Karnofsky Performance Status Scale (KPS) scores and tumor resection grades. METHODS: Patients with a CM diagnosis were included in this study. Surgical treatment was either supported or not by IOUS. Pre- and postoperative KPS scores were determined by the oncology team, and cerebral tumor volume was estimated through pre- and postoperative magnetic resonance imaging. The surgical team determined whether it was possible to perform a total CM resection. RESULTS: There were 78 patients treated using surgical management (35 with and 43 without IOUS). In the IOUS group, the postoperative KPS scores were higher (80 vs. 70, respectively; P = 0.045) and the KPS evolution was superior (P = 0.036), especially in the following subgroups: difficulty of tumor resection ranking score <4 (P = 0.037), tumor in an eloquent area (P = 0.043), tumor not associated with vessels or nerves (P = 0.007), and solitary lesions (P = 0.038). The residual tumor volume was lower in the IOUS group (9.5% and 1.6 mm3 vs. 30.8% and 9 mm3, respectively; P = 0.05). In patients with a KPS score ≥70, 62% of them had <10% residual tumors (76% in the IOUS group and 45% in the non-IOUS group; P = 0.032; odds ratio, 3.8). CONCLUSIONS: IOUS may improve postoperative KPS scores and decrease residual tumor volumes in CM surgeries. These findings should be confirmed in future studies.

[One staged laparoscopic surgery of colon cancer with liver metastasis in the Guillermo Almenara Hospital, Lima, Peru]. / Cirugía laparoscópica en una sola etapa en cáncer de colon con metástasis hepática sincrónica en el Hospital Nacional Guillermo Almenara, Lima, Perú.

We report a patient who was diagnosed sigmoid colon cancer associated with liver metastases in segment III. The patient underwent laparoscopic surgery where the sigmoid colon resection and hepatic metastasectomy were performed in a â€Å“one staged” surgical procedure. The pathological results showed moderately differentiated tubular adenocarcinoma in sigmoid colon, tubular adenocarcinoma metastases also in liver. Oncological surgical results were obtained with free edges of neoplasia, R0 Surgery, T3N0M1. After the optimal surgical results, the patient is handled by oncology for adjuvant treatment. We report here the sequence of events and a review of the literature.

Management of liver metastases of gastrointestinal stromal tumors (GIST).

INTRODUCTION: Liver metastases (LM) are crucial prognostic manifestation of gastrointestinal stromal tumors (GIST). With the advent of tyrosine kinase inhibitors (TKI), management of metastatic GIST has radically changed. Long clinical follow-up provides an increased proportion of GIST patients with LM who are candidates for potentially curative therapy. MATERIAL AND METHODS: Patients who underwent treatment for liver metastases of GIST between 2000-2009 in our department were included in the study. Mean follow-up was 84 months (range 40-145) months. In retrospective analysis we investigated clinical, macro-/microscopic and immunohistochemical criteria, surgical, interventional and TKI therapy as well. RESULTS: In 87 GIST-patients we identified 25 (29%) patients with metastatic disease. Of these, 12 patients (14%) suffered from LM with a mean age of 60.5 (range, 35-75) years. Primary GIST were located at stomach (n = 4, 33%) or small intestine (n = 8, 67%); all of them expressed CD117 and/or CD34. LM were multiple (83%), distributed in both lobes (67%). They were detected synchronously with primary tumor in 33% and metachronously in 77%. All patients with liver involvement were considered to treatment with TKI. LM were resected (R0) in 4 patients (33%). In recurrent (2/4) and TKI resistant cases, interventional treatment (radiofrequency ablation) and TKI escalation were carried out. During a median follow-up of 84 months (range 30-152), 2 patients died (16.5%) for progressive disease and one patient for other reasons. Nine patients (75%) were alive. CONCLUSION: Treatment of LM from GIST needs a multimodal approach. TKI-therapy is required at any case. In case of respectability, surgery must be carried out. In unresectable cases or recurrent/progressive disease, interventional treatment or TKI escalation should be considered. Therefore, these patients need to be treated in experienced centres, where multimodal approaches are established.

Effectiveness of surgery in liver metastasis from colorectal cancer: experience and results of a continuous improvement process.

PURPOSE: The aim of this study was to estimate the effectiveness of surgery in liver metastasis from colorectal cancer. METHODS: We conducted a prospective and observational study of patients with colorectal liver metastasis operated on at the San Cecilio University Hospital of Granada from March 2003 until June 2013. The primary variables of the result were survival and morbidity before 30 days of the post-operative period. We also measured preoperative and surgical variables. RESULTS: A total of 147 patients with liver metastasis of colorectal origin underwent surgical removal during the period of study, 38 of whom had repeat surgery. 34 had a second resection, 3 had a third one and one only patient had a fourth one, for a total of 185 registered operations. The global 5-year survival rate was 38 and 17 % after 10 years. There were 115 patients who had neither radiofrequency nor exploratory laparotomy, 38 % of them survived over 60 months. The average disease-free time was 23.6 months ± 47.3, with significant differences observed between types of procedures. Patients that were operated on just once (n = 25) had a five-year actuarial survival rate of 35 %, a morbidity rate of 24 % and a mortality rate of 0.6 % (1 patient only). The average hospital stay was 13.8 days and the disease-free time was 15.8 months. CONCLUSION: The results obtained in our surgical unit in terms of morbidity, mortality and five-year actuarial survival rates are comparable to those of other units at large institutions, which are currently considered the standards of quality.

Remarkable 23-year survival after bilateral thoracic melanoma metastasectomy.

The prognosis of patients with metastatic melanoma is poor, with an annual risk of death of approximately 20% during the first 3 years. The survival average is only 6 to 8 months, and the 5-year survival rate is around 5%. This report describes a remarkable clinical outcome of complete resection of pulmonary metastatic melanoma. The 72-year-old woman is still alive without relapse 27 years after the initial diagnosis and 23 years after the last tumor excision. This remarkable outcome would indicate that the tumor cell population was composed of a particular metastatic phenotype.

Stereotactic radiosurgery for spinal metastases: a literature review.

OBJECTIVE: The spine is the most common location for bone metastases. Since cure is not possible, local control and relief of symptoms is the basis for treatment, which is grounded on the use of conventional radiotherapy. Recently, spinal radiosurgery has been proposed for the local control of spinal metastases, whether as primary or salvage treatment. Consequently, we carried out a literature review in order to analyze the indications, efficacy, and safety of radiosurgery in the treatment of spinal metastases. METHODS: We have reviewed the literature using the PubMed gateway with data from the MEDLINE library on studies related to the use of radiosurgery in treatment of bone metastases in spine. The studies were reviewed by all the authors and classified as to level of evidence, using the criterion defined by Wright. RESULTS: The indications found for radiosurgery were primary control of epidural metastases (evidence level II), myeloma (level III), and metastases known to be poor responders to conventional radiotherapy--melanoma and renal cell carcinoma (level III). Spinal radiosurgery was also proposed for salvage treatment after conventional radiotherapy (level II). There is also some evidence as to the safety and efficacy of radiosurgery in cases of extramedullar and intramedullar intradural metastatic tumors (level III) and after spinal decompression and stabilization surgery. CONCLUSION: Radiosurgery can be used in primary or salvage treatment of spinal metastases, improving local disease control and patient symptoms. It should also be considered as initial treatment for radioresistant tumors, such as melanoma and renal cell carcinoma.

Pulmonary metastasectomy for colorectal cancer: long-term survival and prognostic factors.

BACKGROUND: Despite the development of novel chemotherapy and biological agents, surgery is still an important option for patients with pulmonary metastases. Predictors of survival usually include disease-free interval, histology of the primary tumor, number of metastases and complete resection. The aim of this study was to report the outcomes of patients with pulmonary metastases from colorectal carcinoma submitted to surgical resection, and to identify prognostic factors that significantly affect overall survival. METHODS: We retrospectively analyzed 120 patients with previously treated colorectal carcinoma that had developed pulmonary metastases, admitted between 1990 and 2006. Overall survival was estimated using Kaplan-Meier analysis. The log-rank and Breslow tests were used to compare survival differences for each variable. Multivariate analyses to determine the independent prognostic factors for overall survival were performed using the Cox proportional hazard model as identified by the univariate analyses. RESULTS: The median follow-up was 20.3 months (range: 3.27-134.2 months). The patients included in this study underwent a total of 165 thoracotomies (mean of 1.37 thoracotomies/patient). The median overall survival for all patients was 34.73 months, with an estimated 5-year survival rate of 24.39%. Multivariate analyses identified unilateral lesions, neoadjuvant chemotherapy at lung resection and complete resection as independent prognostic factors for overall survival. CONCLUSIONS: These results indicate that prognostic factors identified in studies on pulmonary metastasectomy for all primary tumors should be interpreted carefully for patients with possibility of pulmonary metastasectomy from colorectal carcinoma.

Lung metastasectomy: long-term outcomes in an 18-year cohort from a single center.

Lung metastasectomy is an area of interest and controversy in surgical oncology. Most of the available evidence derives from small cohorts with short follow-up. The aim of this study was to evaluate the oncologic outcomes in an 18-year cohort from a single center. We retrospectively reviewed 398 patients with several malignancies who underwent lung metastasectomy between January 1990 and December 2008. Demographic, clinical, and surgical variables were evaluated. Uni- and multivariate analyses were performed to identify factors associated with overall survival (OS). Mean follow-up was 20 months. Wedge resection was performed in 297 cases and 101 required anatomic resections. In 303 patients the disease-free interval (DFI) was >6 months meanwhile 95 patients had a DFI ≤6 months. Complete resection was achieved in 351 patients (88.2%). Median OS for all patients was 81.9 months (95% CI, 36.9-126.9). On multivariate analysis, factors associated with a poor overall survival were DFI <6 months (HR, 1.74; 95% CI, 1.24-2.4; p=0.001) and incomplete resection (HR, 1.58 95% CI, 1.01-2.5; p=0.0047). Independent prognostic factors associated with better survival were DFI >6 months and complete resection. Size and number of metastases as well as re-do metastasectomy were not associated with worse survival.

Pulmonary metastasectomy: a multivariate analysis of 440 patients undergoing complete resection.

Surgical resection is currently a standard approach for isolated lung metastases from different primary tumours. The aim of the present analysis is to evaluate the outcome of patients submitted to complete resection of pulmonary metastases and to determine prognostic factors for long-term survival. A group of 440 consecutive patients previously diagnosed with primary malignant solid tumours and submitted to complete surgical resection of lung nodules with suspected or diagnosed metastatic lesion were retrospectively reviewed. The average follow-up time was 43.2 months (range: 0-192) and the 60-month O.S. was 43.7%. Univariate analysis: patients with adenocarcinoma presented the highest 5-year survival rates (53.4%, P = 0.0001); DFI >36 months (P < 0.0001), number of nodules on CT scan (P = 0.0052), number of malignant nodules resected (P = 0.0252) and the size of the largest resected nodule (P < 0.0001) were also significant. Multivariate analysis: number of malignant nodules resected (P = 0.01), size of the largest nodule resected (P = 0.001), DFI >36 months (P < 0.001) and histology of the primary tumour (P = 0.017) had significant impact on survival. The benefit of such an aggressive surgical approach is only limited to selected subgroups of patients. The decision to consider a patient for resection of metastastic disease should include factors beyond the feasibility of complete removal.

Metastasectomía pulmonar: experiencia de once años / Lung metastasectomy: experience of eleven years

INTRODUCCIÓN. Las metástasis pulmonares son frecuentes tanto en tumores primarios epiteliales como en los mesenquimatosos, y se explican por el hecho de que todo el gasto cardíaco transita por la circulación menor. La indicación quirúrgica es un problema de relación costo-beneficio y está condicionada entre otros aspectos por el intervalo libre de enfermedad, el estado general del paciente, el número de metástasis y el tipo de resección. El objetivo del presente estudio fue presentar nuestra experiencia y resultados con dicho tratamiento. MÉTODOS. Se realizó un estudio descriptivo transversal retrospectivo con 6 pacientes con metástasis en pulmón, tratados en el Hospital Amalia Simoni, de Camagüey, entre 1997 y 2007. Las variables analizadas fueron sexo, edad, histopatología y localización del tumor primario, operación inicial, tiempo transcurrido entre la operación inicial y la metastasectomía, número de metástasis pre y transoperatorias, vía de abordaje, localización de los nódulos, tipo de resección quirúrgica y supervivencia. RESULTADOS. La media de edad fue de 56 años y no hubo diferencias en cuanto al sexo. En tres pacientes las tumoraciones primarias dependían del sistema digestivo, la mayoría fueron nódulos únicos y la lobectomía pulmonar fue el procedimiento más utilizado. La supervivencia promedio fue de 13 meses. No hubo morbilidad importante, ni fallecidos en la serie(AU)

INTRODUCTION. Lung metastases are frequent both in primary epithelial tumors and mesenchymatous tumors due to the fact that the whole cardiac output passes through the minor circulation. The surgical indication is a problem of cost-benefit relationship, and it is conditioned among other aspects by the disease free interval, the general state of the patient, the number of metastases and the type of resection. The objective of this study was to present our experience and results with this treatment. METHODS. A descriptive cross-sectional retrospective study was conducted in 6 patients with lung metastasis treated at Amalia Simoni Hospital in Camaguey between 1997 and 2007. The variables analyzed were sex, age, histopathology and localization of the primary tumor, initial operation, time elapsed between the initial operation and metastasectomy, number of pre- and transoperative metastases, approach route, localization of the nodules, type of surgical resection and survival. RESULTS. Average age was 56 years old and there was no difference as regards sex. The primary tumors depended on the digestive system in 3 patients. Most of them were unique nodules and pulmonary lobectomy was the most used procedure. Average survival was 13 months. No important morbidity was reported and there were no deaths in the series(AU)

Resultados y enfoque de la metastasectomía pulmonar en el Instituto Nacional de Oncología y Radiobiología de Cuba / Results and approach of lung metastasectomy in the National Institute of Oncology and Radiobiology of Cuba

El objetivo de esta presentación fue identificar los factores pronósticos relacionados con mayor supervivencia tras la metastasectomía pulmonar, para todo tipo de tumor primario, practicada en el Instituto Nacional de Oncología y Radiobiología de Cuba. . El intervalo libre de enfermedad fue identificado como el factor más importante para el pronóstico. El análisis de supervivencia nos permitió estratificar a los pacientes en grupos de riesgo según la progresión del tumor y sobre la base del tamaño y número de las lesiones y del intervalo libre de la enfermedad tras la escisión del tumor primario(AU)

The aim of this paper was to identify the prognostic factors related to higher survival after lung metastasectomy for all types of primary tumor performed in the National Institute of Oncology and Radiobiology of Cuba. The disease free interval was identified as the most important factor for prognosis. The survival analysis permitted to stratify the patients into risk groups according to the progression of the tumor and on the basis of the size and amount of lesions and of the disease free interval after the excision of the primary tumor(AU)