Results of surgical treatment of uncomplicated colon cancer: case series with follow-up / Resultados del tratamiento quirúrgico del cáncer de colon no complicado: serie de casos con seguimiento

SUMMARY: The standard treatment of colonic cancer (CC) continues to be the radical resection of the intestinal segment compromised with free margins, associated or not with adjuvant therapies. The aim of this study was to determine postoperative morbidity (POM) and 5-year overall survival (OS) in patients with uncomplicated colon cancer surgically treated. Retrospective case series of patients with uncomplicated CC undergoing colectomy and lymphadenectomy, consecutively, at Clínica Red Salud Mayor Temuco, between 2007 and 2019. The outcomes variable were POM and 5-years OS. Other variables of interest were surgical time, number of resected lymph nodes, hospital stay and recurrence. Descriptive statistics was used (measures of central tendency and dispersion), and OS analysis was applying Kaplan Meier curves. In this study, 52 patients (53.8 % men) were intervened, with a median age of 68 years. The most frequent localization and stages were right colon (42.3 %); IIIA and IIIB respectively (78.9 %). Median surgical time, number of resected lymph nodes and hospital stay were 98 min, 34 and 4.5 days respectively. POM was 17.3 % (9 cases). With a median follow- up of 58 months, a recurrence of 19.2 % was verified, and the 5-year OS for stages IIA, IIIA, IIIB and IVA was 83.3 %, 73.6 %, 68.2 % and 40.0 % respectively. The results, in terms of POM, mortality and 5-year OS, were similar to national and international series.

RESUMEN: El tratamiento estándar del cáncer de colon (CC), continua siendo la resección radical del segmento intestinal comprometido con márgenes libres (al menos 5 cm por encima y debajo del tumor), pudiendo asociarse o no a terapias complementarias. El objetivo de este estudio fue determinar morbilidad postoperatoria (MPO) y supervivencia actuarial global (SVAG) a 5 años en pacientes resecados por CC no complicado. Serie de casos con seguimiento, de pacientes con CC no complicado, sometidos a colectomía subtotal y linfadenectomía, de forma consecutiva, en Clínica Red Salud Mayor Temuco, entre 2007 y 2019. Las variables resultado fueron MPO y SV actuarial global (SVAG) a 5 años. Otras variables de interés fueron: tiempo quirúrgico, número de linfonodos resecados, estancia hospitalaria y recurrencia. Se utilizó estadística descriptiva, con medidas de tendencia central y dispersión; y análisis de SV con curvas de Kaplan Meier. Se intervinieron 52 pacientes (53,8 % hombres), con una mediana de edad de 68 años. La localización y estadios más frecuentes fueron colon derecho (42,3 %); IIIA y IIIB respectivamente (78,9 %). La resecabilidad de la serie fue 100 %. La medianas del tiempo quirúrgico, del número de linfonodos resecados y de estancia hospitalaria; fueron de 98 min, 34 y 4.5 días respectivamente. La MPO fue 17,3 % (9 casos). Con una mediana de seguimiento de 58 meses, se verificó una recurrencia de 19,2 %; y una SVAG a 5 años para los estadios IIA, IIIA, IIIB y IVA; de 83,3 %; 73,6 %; 68,2 % y 40,0 % respectivamente. Los resultados obtenidos, en términos de MPO, mortalidad y SVAG a 5 años, fueron similares a series de nacionales e internacionales.

Impacto en la reducción de la morbilidad utilizando la técnica de ganglio centinela en pacientes con cáncer de mama / Impact on the reduction of morbidity using the sen-tinel node technique in patients with breast cancer

Introducción: El cáncer de mama afecta cada vez más a las mujeres a nivel mundial. Los tipos de tratamiento quirúrgico y quimioterápico han evolucionado, consecuentemente es necesaria la correc-ta evaluación del tumor primario y los ganglios linfáticos implicados por ser un importante factor pronóstico y tratamiento. La técnica de ganglio centinela evalúa al primer ganglio en recibir el drenaje linfático del tumor. Métodos: el objetivo fue determinar el impacto en pacientes con cáncer de mama en un estudio cuantitativo, observacional no experimental, correlacional de recolección retrospectiva, de tipo cohorte histórico. Se recuperó 153 pacientes en dos grupos de estudio, los que se sometieron a la técnica de ganglio centinela y los que se realizaron linfadenectomía axilar. Resultados: el tipo histológico de cáncer de mama más frecuente fue el ductal infiltrante de grado histológico 2, un 76.4% y 73.6% de pacientes tuvieron receptores de estrógeno y progesterona positivo respectivamente mientras el receptor 2 de factor de crecimiento epidérmico humano fue positivo en 16.9%. La mediana del número de ganglios metastásicos fue semejante en los dos grupos, no así el número de ganglios libres 3 vs. 14 respectivamente (P < 0.001). En el estudio se evidenció morbilidad en 23.1% de pacientes que se biopsiaron el Ganglio Centinela, en contraste con 45.5% de en quienes no se efectuó dicho procedimiento (P = 0.025), la morbilidad más frecuentemente asociada fue el edema de la extremidad (27%). Conclusiones: se demostró que la linfadenectomía expone tres veces a desarrollar morbilidades en comparación con la técnica de ganglio centinela.

Introduction: Breast cancer affects more and more women worldwide. The types of surgical and chemotherapeutic treatment have evolved, consequently the correct evaluation of the primary tumor and the involved lymph nodes is necessary because it is an important prognostic factor and treatment. The sentinel lymph node technique evaluates the first node in receiving the lymphatic drainage of the tumor. Methods: the objective was to determine its impact in patients with breast cancer in a quantitative, observational, non-experimental, correlational, retrospective, historical cohort study. We recovered 153 patients in two study groups, those who underwent the sentinel lymph node technique and those who underwent axillary lymphadenectomy. Results: the most frequent histological type of breast cancer was the infiltrative ductal of histologi-cal grade 2, 76.4% and 73.6% of patients had positive estrogen and progesterone receptors respec-tively while the receptor 2 of human epidermal growth factor was positive in 16.9 %. The median number of metastatic lymph nodes was similar in the two groups, but not the number of free nodes 3. 14 respectively (P <0.001). In the study, morbidity was evidenced in 23.1% of patients who were sentinel lymph node biopsies, in contrast to 45.5% of those who did not undergo the procedure (P= 0.025), the most frequently associated morbidity was the edema of the extremity (27%). Conclusions: lymphadenectomy was shown three times to develop morbidities compared to the sentinel lymph node technique.

Are there differences in laparoscopic gastrectomy morbidity and mortality between young and older? / Há diferenças na morbimortalidade da gastrectomia laparoscópica entre jovens e idosos?

ABSTRACT Background: Due to the longer life expectancy and consequently an increase in the elderly population, a higher incidence of gastric cancer is expected in this population in the coming decades. Aim: To compare the results of laparoscopic GC surgical treatment between individuals aged<65 years (group I) and ≥ 65 years (group II), according to clinical, surgical, and histopathological characteristics. Methods: A observational retrospective study was performed by analyzing medical charts of patients with gastric cancer undergoing total or subtotal laparoscopic gastrectomy for curative purposes by a single oncologic surgery team. Results: Thirty-six patients were included in each group. Regarding the ASA classification, 31% of the patients in group I was ASA 1, compared to 3.1% in group II. The mean number of concomitant medications in group II was statistically superior to group I (5±4.21 x 1.42±3.08, p<0.001). Subtotal gastrectomy was the most performed procedure in both groups (69.4% and 63.9% in groups I and II, respectively) due to the high prevalence of distal tumors in both groups, 54.4% group I and 52.9% group II. According to Lauren's classification, group I presented a predominance of diffuse tumors (50%) and group II the intestinal type (61.8%). There was no difference between the two groups regarding the number of resected lymph nodes and lymph node metastases and the days of hospitalization and mortality. Conclusion: Laparoscopic gastrectomy showed to be a safe procedure, without a statistical difference in morbidity, mortality, and hospitalization time between both groups.

RESUMO Racional: Devido à maior expectativa de vida, e consequentemente aumento da população de idosos, é esperada uma maior incidência de câncer gástrico nesta população nas próximas décadas. Objetivos: Comparar os resultados do tratamento cirúrgico por via laparoscópica do câncer gástrico entre pacientes com idade <65 anos (grupo I) e ≥65 anos (grupo II), de acordo com características clínicas, cirúrgicas e histopatológicas. Métodos: Foi realizado um estudo retrospectivo, observacional baseado na análise de prontuários médicos de pacientes com câncer gástrico, submetidos à gastrectomia total ou subtotal laparoscópica com finalidade curativa, por uma única equipe de cirurgia oncológica. Resultados: Foram avaliados 36 pacientes em cada grupo. Em relação à classificação ASA, 62,1% dos pacientes do grupo I eram ASA 1 comparado a 3.1% no grupo II. O número médio de medicações concomitantes do grupo II foi superior ao grupo I (5±4,21 x 1.42±3,08, p<0.001). A gastrectomia subtotal foi o procedimento mais realizado nos dois grupos (69,4% e 63,9% nos grupos I e II respectivamente) devido a maior prevalência de tumores distais em ambos os grupos, 54.4% grupo I e 52.9% grupo II. De acordo com a classificação de Laurén, no grupo I houve predomínio de tumores difusos (50,0%) e no grupo II do tipo intestinal (61,8%). Não houve diferença entre os dois grupos em relação a quantidade de linfonodos ressecados e de linfonodos positivos para metástases, assim como o tempo de permanência no CTI, dias de hospitalização e mortalidade. Conclusão: A gastrectomia por via laparoscópica é procedimento seguro, sem haver diferenças em morbidade, mortalidade e tempo de internação entre pacientes jovens e idosos.

Transhiatal esophagectomy in squamous cell carcinoma of the esophagus: what are the best indications? / Esofagectomia transhiatal no carcinoma de células escamosas do esôfago: quais são suas melhores indicações?

ABSTRACT Background: Southern Brazil has one of the highest incidences of esophageal squamous cell carcinoma in the world. Transthoracic esophagectomy allows more complete abdominal and thoracic lymphadenectomy than transhiatal. However, this one is associated with less morbidity. Aim: To analyze the outcomes and prognostic factors of squamous esophageal cancer treated with transhiatal procedure. Methods: All patients selected for transhiatal approach were included as a potentially curative treatment and overall survival, operative time, lymph node analysis and use of neoadjuvant therapy were analyzed. Results: A total of 96 patients were evaluated. The overall 5-year survival was 41.2%. Multivariate analysis showed that operative time and presence of positive lymph nodes were both associated with a worse outcome, while neoadjuvant therapy was associated with better outcome. The negative lymph-node group had a 5-year survival rate of 50.2%. Conclusion: Transhiatal esophagectomy can be safely used in patients with malnutrition degree that allows the procedure, in those with associated respiratory disorders and in the elderly. It provides considerable long-term survival, especially in the absence of metastases to local lymph nodes. The wider use of neoadjuvant therapy has the potential to further increase long-term survival.

RESUMO Racional: O sul do Brasil tem uma das maiores incidências de carcinoma epidermoide do esôfago no mundo. A esofagectomia transtorácica permite linfadenectomia abdominal e torácica mais completa do que a transhiatal. No entanto, esta está associado à menor morbidade. Objetivo: Analisar os desfechos e fatores prognósticos do câncer epidermoide do esôfago que foram tratados com procedimento transhiatal. Métodos: Foram incluídos todos os pacientes selecionados para abordagem transhiatal como tratamento potencialmente curativo correlacionando sobrevida geral, tempo operatório, análise de linfonodos e uso de terapia neoadjuvante. Resultados: Foram avaliados 96 pacientes. A sobrevida geral em cinco anos foi de 41,2%. A análise multivariada mostrou que o tempo operatório e a presença de linfonodos positivos foram associados a pior resultado, enquanto a terapia neoadjuvante contribuiu para melhor resultado. O grupo de linfonodos negativos teve taxa de sobrevivência em cinco anos de 50,2%. Conclusão: A esofagectomia transhiatal pode ser empregada com segurança em pacientes que apresentem desnutrição com grau que permita o procedimento, nos com distúrbios respiratórios associados e nos idosos. Proporciona sobrevida em longo prazo considerável, especialmente na ausência de metástases para linfonodos locais. O uso mais amplo da terapia neoadjuvante tem o potencial de aumentar ainda mais a sobrevida em longo prazo.

External validation of nomogram to predict inguinal lymph node metastasis in patients with penile cancer and clinically negative lymph nodes

ABSTRACT Introduction Penile cancer (PC) occurs less frequently in Europe and in the United States than in South America and parts of Africa. Lymph node (LN) involvement is the most important prognostic factor, and inguinal LN (ILN) dissection can be curative; however, ILN dissection has high morbidity. A nomogram was previously developed based on clinicopathological features of PC to predict ILN metastases. Our objective was to conduct an external validation of the previously developed nomogram based on our population. Materials and methods We included men with cN0 ILNs who underwent ILN dissection for penile carcinoma between 2000 and 2014. We performed external validation of the nomogram considering three different external validation methods: k-fold, leave-one-out, and bootstrap. We also analyzed prognostic variables. Performance was quantified in terms of calibration and discrimination (receiver operator characteristic curve). A logistic regression model for positive ILNs was developed based on clinicopathological features of PC. Results We analyzed 65 men who underwent ILN dissection (cN0). The mean age was 56.8 years. Of 65 men, 24 (36.9%) presented with positive LNs. A median 21 ILNs were removed. Considering the three different methods used, we concluded that the previously developed nomogram was not suitable for our sample. Conclusions In our study, the previously developed nomogram that was applied to our population had low accuracy and low precision for correctly identifying patients with PC who have positive ILNs.

Cáncer gástrico avanzado: resultados de una cirugía resectiva en un centro privado y regional de salud / Advanced gastric cancer: resective surgery results in a private and regional health establishment

El cáncer gástrico (CG), representa el cuarto lugar de enfermedades oncológicas en mujeres y el primero en hombres. La mejor opción de tratamiento para pacientes con CG avanzado (CGA), sigue siendo la cirugía, lo que supone la realización de una gastrectomía total o subtotal, asociado a linfadenectomía D2 (LD2 ). El objetivo de este estudio fue determinar morbilidad postoperatoria (MPO) y supervivencia (SV) en pacientes resecados por CGA sin neoadyuvancia. La metodología usada fue serie de casos en retrospectiva de pacientes con CGA sometidos a gastrectomía total o subtotal con LD2 , de forma consecutiva, en Clínica RedSalud Mayor Temuco, entre 2008 y 2017. La variable resultado fue SV actuarial global (SVAG) a 5 años. Otras variables de interés fueron: tiempo quirúrgico, número de linfonodos resecados, estancia hospitalaria, MPO, y recurrencia. Los pacientes fueron seguidos de forma clínica. Se utilizó estadística descriptiva, con medidas de tendencia central y dispersión; y análisis de SV con curvas de Kaplan Meier y long Rank test. Se intervinieron 29 pacientes (72,4 % hombres), con una mediana de edad de 63 años. La localización más frecuente fue subcardial (51,7 %); el tipo de resección más frecuente fue gastrectomía total (51,7 %). La medianas del tiempo quirúrgico, del número de linfonodos resecados y de estancia hospitalaria; fue de 185 min, 32 y 6 días respectivamente. La MPO fue 17,2 %. Con una mediana de seguimiento de 26 meses, se verificó recurrencia de 37,9 %; y SVAG a 5 años para estadios IIIA, IIIB y IV fue de 47,6 %, 34,3 % y 15,4 % respectivamente (p < 0,05). Los resultados obtenidos, en términos de MPO, mortalidad y SVAG, fueron similares a series de centros de derivación nacionales e internacionales en los que no se ha aplicado terapias neoadyuvantes.

Gastric cancer (CG) represents the fourth place of oncological diseases in women and the first in men. The best treatment option for patients with advanced CG (ACG) is still surgery, which involves making total or subtotal gastrectomies and D2 lymphadenectomy (D2L). The aim of this study is to determine postoperative morbidity (POM) and overall survival (OS) in patients resected by CGA without neoadjuvant therapy. The methodology used was a series of cases in retrospective of patients with CGA undergoing total or subtotal gastrectomies and D2L, consecutively at RedSalud Mayor Temuco Clinic, between 2008 and 2017. The outcome variable was OS at 5 years. Other variables of interest were: surgical time, number of resected lymph nodes, hospital stay, POM, and recurrence. Patients were followed clinically. Descriptive statistics was used, and OS analysis was applied using long Rank test. Twenty-nine patients (72.4% men), with a median age of 63 years, were operated. The most frequent location was subcardinal (51.7%). The most frequent type of resection was total gastrectomy (51.7%). The median of surgical time, number of resected lymph nodes and hospital stay; was 185 min, 32 and 6 days respectively. MPO was 17.2%. With a median follow-up of 26 months, a recurrence of 37.9% was verified; and 5-year OS for stages IIIA, IIIB and IV were 47.6%, 34.3% and 15.4% respectively (p <0.05). The results achieved, in terms of POM and OS series were similar to national and international series in which neoadjuvant therapies have not been applied.

Transhiatal esophagectomy is not associated with poor quality lymphadenectomy / Esofagectomia trans-hiatal não está associada com linfadenectomia de baixa qualidade

ABSTRACT Background: Esophageal cancer neoadjuvant therapy followed by surgery increases the likelihood of treatment success. Aim: To evaluate variables that can influence the number of retrieved lymph nodes, the number of retrieved metastatic lymph nodes and lymphnodal recurrence in esophagectomy after neoadjuvant chemoradiotherapy. Methods: Patients of a single institute were evaluated after completion of trimodal therapy. Univariate and multivariate analyses were performed to evaluate variables that can influence in the number of retrieved lymph nodes and retrieved metastatic lymph nodes. Results: One hundred and forty-nine patients were included. Thoracoscopy access was considered an independent factor for the number of lymph nodes retrieved, but was neither related to the number of positive lymph nodes retrieved nor to lymphnodal recurrence. Pathological complete response on the primary tumor and male were independent variables associated with the number of positive lymph node retrieved. Pathological complete response on the primary tumor site did not statistically influence the likelihood of a lower number of lymph nodes retrieved. Conclusion: Patients submitted to esophagectomy after neoadjuvant chemoradiotherapy, thoracoscopic access is more accurate for pathological staging, even in a complete pathological response. With a proper patient selection, transhiatal surgery may preserve the quality of lymphadenectomy of the positive lymph nodes.

RESUMO Racional: No câncer esofágico a terapia neoadjuvante seguida de procedimento cirúrgico aumenta a probabilidade de sucesso do tratamento. Objetivo: Avaliar variáveis que podem influenciar o número de linfonodos recuperados, o número de linfonodos metastáticos recuperados e a recorrência linfonodal na esofagectomia após quimiorradioterapia neoadjuvante. Métodos: Os pacientes incluídos foram aqueles que terminaram terapia trimodal. Análises univariadas e multivariadas foram realizadas para avaliar as variáveis que pudessem influenciar no número de linfonodos recuperados e nos metastáticos recuperados. Resultados: Cento e quarenta e nove pacientes foram incluídos. O acesso por toracoscopia foi considerado fator independente para o número de linfonodos recuperados, mas não teve relação com o número de linfonodos positivos recuperados, nem com recorrência linfonodal. Resposta patológica completa no tumor primário e homens foram variáveis independentes associadas ao número de linfonodos positivos recuperados. A resposta patológica completa do tumor primário não acarretou em número menor de linfonodos recuperados. Conclusão: Em pacientes submetidos à esofagectomia após quimiorradioterapia neoadjuvante o acesso toracoscópico é mais preciso para estadiamento patológico, mesmo em resposta patológica completa. Com seleção adequada a esofagectomia trans-hiatal pode preservar a qualidade da linfadenectomia dos linfonodos positivos.

Survival and perioperative morbidity of totally laparoscopic versus open gastrectomy for early gastric cancer: analysis from a single latin american centre / Comparação da sobrevida e morbidade perioperatória da gastrectomia totalmente laparoscópica vs. laparotômica para tratamento do câncer gástrico precoce em um centro latino-americano

ABSTRACT Background: Laparoscopic gastrectomy has numerous perioperative advantages, but the long-term survival of patients after this procedure has been less studied. Aim: To compare survival, oncologic and perioperative outcomes between completely laparoscopic vs. open gastrectomy for early gastric cancer. Methods: This study was retrospective, and our main outcomes were the overall and disease-specific 5-year survival, lymph node count and R0 resection rate. Our secondary outcome was postoperative morbidity. Results: Were included 116 patients (59% men, age 68 years, comorbidities 73%, BMI 25) who underwent 50 laparoscopic gastrectomies and 66 open gastrectomies. The demographic characteristics, tumour location, type of surgery, extent of lymph node dissection and stage did not significantly differ between groups. The overall complication rate was similar in both groups (40% vs. 28%, p=ns), and complications graded at least Clavien 2 (36% vs. 18%, p=0.03), respiratory (9% vs. 0%, p=0.03) and wound-abdominal wall complications (12% vs. 0%, p=0.009) were significantly lower after laparoscopic gastrectomy. The lymph node count (21 vs. 23 nodes; p=ns) and R0 resection rate (100% vs. 96%; p=ns) did not significantly differ between groups. The 5-year overall survival (84% vs. 87%, p=0.31) and disease-specific survival (93% vs. 98%, p=0.20) did not significantly differ between the laparoscopic and open gastrectomy groups. Conclusion: The results of this study support similar oncologic outcome and long-term survival for patients with early gastric cancer after laparoscopic gastrectomy and open gastrectomy. In addition, the laparoscopic approach is associated with less severe morbidity and a lower occurrence of respiratory and wound-abdominal wall complications.

RESUMO Racional: A gastrectomia laparoscópica tem numerosas vantagens perioperatórias, mas a sobrevivência em longo prazo após este procedimento tem sido menos estudada. Objetivo: Comparar resultados de sobrevivência, oncológica e perioperatória entre a gastrectomia completamente laparoscópica vs. aberta para câncer gástrico precoce. Método: Este estudo foi retrospectivo e os principais resultados foram a sobrevivência global e específica de cinco anos, contagem de linfonodos e taxa de ressecção R0. Resultado secundário foi a morbidade pós-operatória. Resultados: Foram incluídos 116 pacientes (59% homens, idade 68 anos, comorbidades 73%, IMC 25) que foram submetidos a 50 gastrectomias laparoscópicas e 66 gastrectomias abertas. As características demográficas, a localização do tumor, o tipo de operação, a extensão da dissecção dos linfonodos e do estágio não diferiram significativamente entre os grupos. A taxa geral de complicações foi semelhante em ambos os grupos (40% vs. 28%, p=ns) e complicações classificadas Clavien 2 (36% vs. 18%, p=0,03), respiratórias (9% vs. 0%, p=0,03) e as da parede abdominal (12% vs. 0%, p=0,009) foram significativamente menores após a gastrectomia laparoscópica. A contagem de linfonodos (21 contra 23, p=ns) e a taxa de ressecção R0 (100% vs. 96%; p=ns) não diferiram significativamente entre os grupos. A sobrevida global de cinco anos (84% vs. 87%, p=0,31) e a sobrevida específica (93% vs. 98%, p=0,20) não diferiram significativamente entre os grupos de gastrectomia laparoscópica e aberta. Conclusão: Estes resultados suportam resultados oncológicos similares e sobrevida em longo prazo para pacientes com câncer gástrico precoce após gastrectomia laparoscópica e gastrectomia aberta. Além disso, a abordagem laparoscópica está associada com morbidade menos grave e menor ocorrência de complicações respiratórias e da parede abdominal.

Guided intraoperative scintigraphic tumor targeting of metastatic cervical lymph nodes in patients with differentiated thyroid cancer: a single-center report

ABSTRACT Objective: Our aim was to present our experiences related to performing neck surgery using the guided intraoperative scintigraphic tumor targeting (GOSTT) procedure for patients who had locally recurrent or persistent differentiated thyroid cancer (DTC) and who had undergone previous thyroid surgery. Subjects and methods: We retrospectively evaluated 11 patients who had locally recurrent or persistent DTC, who had undergone previous surgery, and for whom reoperation was planned for metastatic cervical lymph nodes (LNs). We performed the neck surgery using the GOSTT procedure on all patients and at a single academic institution. Results: The 11 patients had a total of 26 LNs, as marked with a radiotracer, and those LNs' mean size was 14.7 ± 8.2 mm (range: 5-34 mm). Histopathological examinations revealed DTC metastasis in all 26 of the preoperatively marked LNs. Of the 11 patients, only one needed a reoperation in the neck; she had another successful surgery (also using the GOSTT procedure). In the evaluation of the patients' final status, all were disease-free in their necks. There also were no GOSTT-associated postoperative complications. Conclusion: The GOSTT procedure is a useful, successful, inexpensive, and comfortable procedure for marking and mapping metastatic LNs, especially in DTC patients who have undergone previous surgery.

Surgical treatment of gastric cancer: a 10-year experience in a high-volume university hospital

OBJECTIVES: Surgery remains the cornerstone treatment modality for gastric cancer, the fifth most common type of tumor in Brazil. The aim of this study was to analyze the surgical treatment outcomes of patients with gastric cancer who were referred to a high-volume university hospital. METHODS: We reviewed all consecutive patients who underwent any surgical procedure due to gastric cancer from a prospectively collected database. Clinicopathological characteristics, surgical and survival outcomes were evaluated, with emphasis on patients treated with curative intent. RESULTS: From 2008 to 2017, 934 patients with gastric tumors underwent surgical procedures in our center. Gastric adenocarcinoma accounted for the majority of cases. Of the 875 patients with gastric adenocarcinoma, resection with curative intent was performed in 63.5%, and palliative treatment was performed in 22.4%. The postoperative surgical mortality rate for resected cases was 5.3% and was related to D1 lymphadenectomy and the presence of comorbidities. Analysis of patients treated with curative intent showed that resection extent, pT category, pN category and final pTNM stage were related to disease-free survival (DFS) and overall survival (OS). The DFS rates for D1 and D2 lymphadenectomy were similar, but D2 lymphadenectomy significantly improved the OS rate. Additionally, clinical factors and the presence of comorbidities had influence on the OS. CONCLUSIONS: TNM stage and the type of lymphadenectomy were independent factors related to prognosis. Early diagnosis should be sought to offer the optimal surgical approach in patients with less-advanced disease.

Laparoscopic radical cystectomy with novel orthotopic neobladder with bilateral isoperistaltic afferent limbs: initial experience

ABSTRACT Purpose To introduce a new method of constructing an orthotopic ileal neobladder with bilateral isoperistaltic afferent limbs, and to describe its clinical outcomes. Materials and Methods From January 2012 to December 2013, 16 patients underwent a new method of orthotopic ileal neobladder after laparoscopic radical cystectomy for bladder cancer. To construct the neobladder, an ileal segment 60cm long was isolated approximately 25cm proximally to the ileocecum. The proximal 20cm of the ileal segment was divided into two parts for bilateral isoperistaltic afferent limbs. The proximal 10cm of the ileal segment was moved to the distal end of the ileal segment for the right isoperistaltic afferent limb, and the remaining proximal 10cm ileal segment was reserved for the left isoperistaltic afferent limb. The remaining length of the 40cm ileal segment was detubularized along its antimesenteric border to form a reservoir. The neobladder was sutured to achieve a spherical configuration. Results All procedures were carried out successfully. The mean operative time was 330 min, mean blood loss was 328mL, and mean hospital stay was 12.5 days. The mean neobladder capacity 6 and 12 months after surgery was 300mL and 401mL, respectively. With a mean follow-up of 22.8 months, all patients achieved daytime continence and 15 achieved nighttime continence. The mean peak urinary flow rate was 11.9mL/s and 12.8mL/s at 6 and 12 months postoperatively, respectively. Conclusions This novel procedure is feasible, safe, simple to perform, and provides encouraging functional outcomes. However, comparative studies with long-term follow-up are required to prove its superiority.

Myiasis associated with penile carcinoma: a new trend in developing countries?

ABSTRACT Objectives The aim of this study is to report an unusual form of penile cancer presentation associated with myiasis infestation, treatment options and outcomes. Materials and Methods We studied 10 patients with suspected malignant neoplasm of the penis associated with genital myiasis infestation. Diagnostic assessment was conducted through clinical history, physical examination, penile biopsy, larvae identification and computerized tomography scan of the chest, abdomen and pelvis. Clinical and pathological staging was done according to 2002 TNM classification system. Radical inguinal lymphadenectomy was conducted according to the primary penile tumor pathology and clinical lymph nodes status. Results Patients age ranged from 41 to 77 years (mean=62.4). All patients presented squamous cell carcinoma of the penis in association with myiasis infestation caused by Psychoda albipennis. Tumor size ranged from 4cm to 12cm (mean=5.3). Circumcision was conducted in 1 (10%) patient, while penile partial penectomy was performed in 5 (50%). Total penectomy was conducted in 2 (20%) patients, while emasculation was the treatment option for 2 (20%). All patients underwent radical inguinal lymphadenectomy. Prophylactic lymphadenectomy was performed on 3 (30%) patients, therapeutic on 5 (50%), and palliative lymphadenectomy on 2 (20%) patients. Time elapsed from primary tumor treatment to radical inguinal lymphadenectomy was 2 to 6 weeks. The mean follow-up was 34.3 months. Conclusion The occurrence of myiasis in the genitalia is more common in patients with precarious hygienic practices and low socio-economic level. The treatment option varied according to the primary tumor presentation and clinical lymph node status.

A novel model to estimate lymph node metastasis in endometrial cancer patients

OBJECTIVES: To evaluate the postoperative pathological characteristics of hysterectomy specimens, preoperative cancer antigen (CA)-125 levels and imaging modalities in patients with endometrial cancer and to build a risk matrix model to identify and recruit patients for retroperitoneal lymphadenectomy. METHODS: A total of 405 patients undergoing surgical treatment for endometrial cancer were retrospectively reviewed and analyzed. Clinical (age and body mass index), laboratory (CA-125), radiological (lymph node evaluation), and pathological (tumour size, grade, lymphovascular space invasion, lymph node metastasis, and myometrial invasion) parameters were used to test the ability to predict lymph node metastasis. Four parameters were selected by logistic regression to create a risk matrix for nodal metastasis. RESULTS: Of the 405 patients, 236 (58.3%) underwent complete pelvic and para-aortic lymphadenectomy, 96 (23.7%) underwent nodal sampling, and 73 (18%) had no surgical lymph node assessment. The parameters predicting nodal involvement obtained through logistic regression were myometrial infiltration >50%, lymphovascular space involvement, pelvic lymph node involvement by imaging, and a CA-125 value >21.5 U/mL. According to our risk matrix, the absence of these four parameters implied a risk of lymph node metastasis of 2.7%, whereas in the presence of all four parameters the risk was 82.3%. CONCLUSION: Patients without deep myometrial invasion and lymphovascular space involvement on the final pathological examination and with normal CA-125 values and lymph node radiological examinations have a relatively low risk of lymph node involvement. This risk assessment matrix may be able to refer patients with high-risk parameters necessitating lymphadenectomy and to decide the risks and benefits of lymphadenectomy.

Extraperitoneal versus transperitoneal laparoscopic radical cystectomy for selected elderly bladder cancer patients: a single center experience

ABSTRACT Objective: This study reports the initial experience of extraperitoneal laparoscopic radical cystectomy (ELRC) and compared with transperitoneal laparoscopic radical cystectomy (TLRC) in the treatment of selected elderly bladder cancer patients. Patients and Methods: A total of forty male bladder cancer patients who underwent ELRC (n=19) or TLRC (n=21) with ureterocutaneostomy were investigated. Demographic parameters, perioperative variables, oncological outcomes and follow-up data were retrospectively analyzed. Results: A significantly shorter time to exsufflation (1.5±0.7 vs 2.1±1.1 d; p=0.026) and liquid intake (1.8±0.9 vs 2.8±1.9 d; p=0.035) were observed in the ELRC group compared with the TLRC group. The incidence of postoperative ileus in the ELRC group was lower than the TLRC group (0 vs 9.5%). However, the difference had no statistical significance (p>0.05). The removed lymph node number in the ELRC group was significantly lower than the TLRC group (p<0.001). No significant differences were observed between the two groups in the overall and cancer-free survival rates (p>0.05). Conclusions: ELRC seems to be a safe and feasible surgical strategy for the selected elderly bladder cancer patients with ≤ T2 disease. The surgical and oncological efficacy of the ELRC is similar to that of the TLRC, but with faster intestinal function recovery. Further studies with a large series including different urinary diversions are needed to confirm our results and to better evaluate the benefit of ELRC in bladder cancer patients.

Robotic pulmonary lobectomy for lung cancer treatment: program implementation and initial experience / Lobectomia pulmonar robótica para tratamento do câncer de pulmão e de metástases pulmonares: implantação do programa e experiência inicial

ABSTRACT Objective: To describe the implementation of a robotic thoracic surgery program at a public tertiary teaching hospital and to analyze its initial results. Methods: This was a planned interim analysis of a randomized clinical trial aimed at comparing video-assisted thoracoscopic surgery and robotic surgery in terms of the results obtained after pulmonary lobectomy. The robotic surgery program developed at the Instituto do Câncer do Estado de São Paulo, in the city of São Paulo, Brazil, is a multidisciplinary initiative involving various surgical specialties, as well as anesthesiology, nursing, and clinical engineering teams. In this analysis, we evaluated the patients included in the robotic lobectomy arm of the trial during its first three months (from April to June of 2015). Results: Ten patients were included in this analysis. There were eight women and two men. The mean age was 65.1 years. All of the patients presented with peripheral tumors. We performed right upper lobectomy in four patients, right lower lobectomy in four, and left upper lobectomy in two. Surgical time varied considerably (range, 135-435 min). Conversion to open surgery or video-assisted thoracoscopic surgery was not necessary in any of the cases. Intraoperative complications were not found. Only the first patient required postoperative transfer to the ICU. There were no deaths or readmissions within the first 30 days after discharge. The only postoperative complication was chest pain (grade 3), in two patients. Pathological examination revealed complete tumor resection in all cases. Conclusions: When there is integration and proper training of all of the teams involved, the implementation of a robotic thoracic surgery program is feasible and can reduce morbidity and mortality.

RESUMO Objetivo: Descrever a implantação de um programa de cirurgia torácica robótica em um hospital terciário público universitário e analisar seus resultados iniciais. Métodos: Este estudo é uma análise interina planejada de um ensaio clínico aleatorizado cujo objetivo é comparar resultados da lobectomia pulmonar por videotoracoscopia com a robótica. O programa de cirurgia robótica do Instituto do Câncer do Estado de São Paulo, localizado na cidade de São Paulo (SP), foi uma iniciativa multidisciplinar que envolveu diversas especialidades cirúrgicas e equipes de anestesia, enfermagem e engenharia clínica. Nesta análise, avaliamos os pacientes incluídos no braço lobectomia robótica durante os primeiros três meses do estudo (de abril a junho de 2015). Resultados: Dez pacientes foram incluídos nesta análise. Eram oito mulheres e dois homens. A média de idade foi de 65,1 anos. Todos apresentavam tumores periféricos. Foram realizadas lobectomia superior direita, em quatro pacientes; lobectomia inferior direita, em quatro; e lobectomia superior esquerda, em dois. Os tempos cirúrgicos variaram bastante (variação, 135-435 min). Não foi necessária a conversão para técnica aberta ou videotoracoscópica em nenhum paciente. Não foram observadas complicações intraoperatórias. Apenas o primeiro paciente foi encaminhado à UTI no pós-operatório. Não houve mortalidade nem reinternações em 30 dias após a alta. A única complicação pós-operatória observada foi dor torácica (grau 3), em dois pacientes. O exame anatomopatológico revelou a ressecção completa do tumor em todos os casos. Conclusões: A implantação de um programa de cirurgia torácica robótica, quando há integração e treinamento adequado de todas as equipes envolvidas, é factível e pode reduzir a morbidade e a mortalidade.

Robot-Assisted Extended Pelvic Lymph Nodes Dissection for Prostate Cancer: Personal Surgical Technique and Outcomes

Objective: Extended pelvic lymph nodes dissection (EPLND) allows the removal of a higher number of lymph nodes than limited PLND. The aims of this study were to describe our robot-assisted EPLND (RAEPLND) technique with related complications, and to report the number of lymph nodes removed and the rate of lymph nodal metastasis. Materials and Methods: 153 patients underwent RAEPLND prior to robot-assisted radical prostatectomy (RARP). Indications were defined according to Briganti nomogram, to predict risk of lymph-nodal metastasis. Lymphatic packages covering the distal tract of the common iliac artery, the medial portion of the external iliac artery, the external iliac vein and the internal iliac vessels, together with the obturator and the presacral lymphatic packages were removed on both sides. Results: Median preoperative PSA was 7.5 ng/mL (IQR 5.5–11.5). Median operative time was 150 min (135–170). Median RAEPLND alone operative time was 38 min (32.75–41.25); for right and left side, 18 (15–29) and 20 min (15.75–30) (p=0.567). Median number of lymph nodes retrieved per patient was 25 (19.25–30); 13 (11–16) and 11 (8–15) for right and left side. In 19 patients (12.41%) metastasis was found at the level of pelvic lymph nodes. Median number of positive lymph nodes was 1 (1–4.6) per patient. Complications occurred in 11 patients (7.3%). Conclusions: the number of lymph nodes removed was comparable to published data about open series, allowing the increase of detection rate of lymph nodal metastasis for minimally invasive approach without compromising complications' rate if performing the procedure following reported technique.

Feasibility, complications and oncologic results of a limited inguinal lymph node dissection in the management of penile cancer

In patients with penile cancer (PeCa) and increased risk of inguinal lymphatic dissemination, inguinal lymphadenectomy offers a direct histological staging as the most reliable tool for assessment of the nodal metastasic status and a definitive oncologic treatment simultaneously. However, peri- and/or postoperative mutilating sequalae often occurn. We report on clinical outcome and complications of a limited inguinal lymph node (LN) dissection.

Should a family history of papillary thyroid carcinoma indicate more aggressive therapy in patients with this tumor? / História familiar de carcinoma papilífero de tireoide deve indicar terapia mais agressiva em pacientes com este tumor?

Objective To determine whether the currently recommended therapy for papillary thyroid carcinoma (PTC) that show no classical factors indicating a poor prognosis is also effective in cases with a family history of this tumor. Subjects and methods: Forty-two patients were studied; 10 were submitted to lobectomy and 32 to total thyroidectomy, including 23 without lymph node dissection and 9 with lymph node dissection. None of the patients received radioiodine or was maintained under TSH suppression. Results No case of recurrence was detected by imaging methods and there was no increase in thyroglobulin or antithyroglobulin antibodies during follow-up (24 to 72 months). Conclusion The treatment usually recommended for patients with PTC does not need to be modified in the presence of a family history of this tumor if no factors indicating a poor prognosis are present (tumor ≤2 cm, non-aggressive histology, no extensive extrathyroid invasion or important lymph node involvement, complete tumor resection, no evidence of persistent disease after surgery). .

Objetivo Avaliar se a terapia atualmente recomendada para o carcinoma papilífero de tireoide (CPT) sem fatores clássicos de pior prognóstico é efetiva também nos casos em que existe história familiar deste tumor. Sujeitos e métodos: Foram avaliados 42 pacientes; dez foram tratados com lobectomia e 32 com tireoidectomia total, sendo 23 sem dissecção de linfonodos e 9 com dissecção linfonodal. Nenhum paciente recebeu radioiodo ou foi mantido com TSH suprimido. Resultados Nenhuma recidiva nos métodos de imagem foi observada, nem incremento da tireoglobulina ou anticorpos antitireoglobulina durante o seguimento (24 a 72 meses). Conclusão Em pacientes com CPT, sem fatores de pior prognóstico (tumor ≤2 cm, histologia não agressiva, sem invasão extratireoidiana extensa ou acometimento linfonodal importante, ressecção tumoral completa, sem indícios de doença persistente após a cirurgia), o tratamento usualmente recomendado não precisa ser modificado quando há história familiar desse tumor. .

Radical nephroureterectomy for pathologic T4 upper tract urothelial cancer: can oncologic outcomes be improved with multimodality therapy?

Purpose To report the outcomes of patients with pathologic T4 UTUC and investigate the potential impact of peri-operative chemotherapy combined with radical nephroureterectomy (RNU) and regional lymph node dissection (LND) on oncologic outcomes. Materials and Methods Patients with pathologic T4 UTUC were identified from the cohort of 1464 patients treated with RNU at 13 academic centers between 1987 and 2007. Oncologic outcomes were stratified according to utilization of perioperative systemic chemotherapy and regional LND as an adjunct to RNU. Results The study included 69 patients, 42 males (61%) with median age 73 (range 43-98). Median follow-up was 17 months (range: 6-88). Lymphovascular invasion was found in 47 (68%) and regional lymph node metastases were found in 31 (45%). Peri-operative chemotherapy was utilized in 29 (42%) patients. Patients treated with peri-operative chemotherapy and RNU with LND demonstrated superior oncologic outcomes compared to those not treated by chemotherapy and/or LND during RNU (3Y-DFS: 35% vs. 10%; P = 0.02 and 3Y-CSS: 28% vs. 14%; P = 0.08). In multivariate Cox regression analysis, administration of peri-operative chemotherapy and utilization of LND during RNU was associated with lower probability of recurrence (HR: 0.4, P = 0.01), and cancer specific mortality (HR: 0.5, P = 0.06). Conclusions Pathological T4 UTUC is associated with poor prognosis. Peri-operative chemotherapy combined with aggressive surgery, including lymph node dissection, may improve oncological outcomes. Our findings support the use of aggressive multimodal treatment in patients with advanced UTUC. .

Extending boundaries in minimally invasive procedures with simultaneous bilateral video endoscopic inguinal lymphadenectomy (veil) for penile cancer: initial Denver health medical center and ABC school of medicine experience and surgical considerations

Purpose To report the surgical technique, procedural outcomes, and feasibility of simultaneous bilateral Video Endoscopic Inguinal Lymphadenectomy (VEIL) in the management of patients with indication for inguinal lymphadenectomy. Surgical Technique: VEIL was applied in all patients using the oncological landmarks (the adductor longus muscle medially, the sartorius muscle laterally and the inguinal ligament superiorly). A 1.5 cm incision was made 2 cm distally to the lower vertex of the femoral triangle. A second incision was made 2 cm proximally and 6 cm medially. Two 10 mm Hasson trocars were inserted in these incisions and the working space was insufflated with CO2 at 5-15 mmHg. The final trocar was placed 2 cm proximally and 6 cm laterally from the first port. Results: A total of 5 VEIL procedures in 3 patients were performed. Two patients underwent simultaneous bilateral VEIL while another underwent simultaneous bilateral surgery with VEIL on the right and open lymphadenectomy on the left side due to an enlarged node. All laparoscopic procedures were successfully performed without conversion and maintained the oncological templates. One lymphocele occurred in the patient who underwent the open procedure. None of the patients presented with skin necrosis after the procedure. Mean number of nodes retrieved was 6 from each side and 2 patients presented with positive inguinal nodes. After one year of follow-up no recurrences were observed. Conclusion: Simultaneous lymphadenectomy procedures are feasible. Improvement in operative and anesthesia time could decrease the morbidity associated with inguinal lymphadenectomy while maintaining the oncological principles. .