World Journal of Surgical Oncology - Latest Articles

Blood neutrophil-lymphocyte ratio predicts survival for stages III-IV gastric cancer treated with neoadjuvant chemotherapy

Hailong Jin — 2013-05-24T00:00:00Z

Background: Accurate predictors of survival for patients with advanced gastric cancer treated with neoadjuvant chemotherapy are currently lacking. In this study, we aimed to evaluate the prognostic significance of the neutrophil-lymphocyte ratio (NLR) in patients with stage III-IV gastric cancer who received neoadjuvant chemotherapy. Methods: We enrolled 46 patients in this study. The NLR was divided into two groups: high (>2.5) and low (<=2.5). Univariate analysis on progression-free survival (PFS) and overall survival(OS) was performed using the Kaplan-Meier and log-rank tests, and multivariate analysis was conducted using the Cox proportional hazards regression model. We analyzed whether chemotherapy normalized high NLR or not, and evaluated the prognostic significance of normalization on survival. Results: The univariate analysis showed that PFS and OS were both worse for patients with high NLR than for those with low NLR before chemotherapy (median PFS 16 and 49 months, respectively, P = 0.012; median OS 21 and 52 months, P = 0.113). PFS and OS were also worse for patients with high NLR than for those with low NLR before surgery (median PFS 12 and 35 months, P = 0.019; median OS 21 and 52 months, P = 0.082). Multivariate analysis showed that both NLR before chemotherapy and surgery were independent prognostic factors of PFS. Neoadjuvant chemotherapy normalized high NLR in 11 of 24 patients, and these 11 patients had better median PFS and OS than the 13 patients who had high NLR both before chemotherapy and before surgery (PFS: 35.0 and 10.0 months, P = 0.003; OS: 60 and 16 months, P = 0.042) . Conclusions: NLR may serve as a potential biomarker for survival prognosis in patients with stage III-IV gastric cancer receiving neoadjuvant chemotherapy.

An intraductal papillary neoplasm of the bile duct mimicking a hemorrhagic hepatic cyst: a case report

Tatsuhiko Kakisaka — 2013-05-24T00:00:00Z

An intraductal papillary neoplasm of the bile duct is a biliary, epithelium-lined, cystic lesion that exhibits papillary proliferation and rarely causes large hemorrhagic cystic lesions. Here, we report a case of an intraductal papillary neoplasm of the bile duct mimicking a hemorrhagic hepatic cyst in a middle-aged man with large hemorrhagic hepatic cysts who experienced abdominal pain and repeated episodes of intracystic bleeding. Following portal vein embolization, extended right hepatic lobectomy was performed, and intraoperative cholangiography revealed communication between the intracystic space and the hepatic duct. Although histological studies revealed that the large hemorrhagic lesion was not lined with epithelium, the surrounding multilocular lesions contained biliary-derived epithelial cells that presented as papillary growths without ovarian-like stroma. A diagnosis of oncocytic-type intraductal papillary neoplasm of the bile duct was made, and we hypothesized that intracystic bleeding with denudation of the lining epithelial cells might occur as the cystically dilated bile duct increased in size. Differential diagnosis between a hemorrhagic cyst and a cyst-forming intraductal papillary neoplasm of the bile duct with bleeding is difficult. However, an intraductal papillary neoplasm of the bile duct could manifest as multilocular hemorrhagic lesions; therefore, complete resection should be performed for a better prognosis.

Use of gluteus maximus adipomuscular sliding flaps in the reconstruction of sacral defects after tumor resection

Yao Weitao — 2013-05-23T00:00:00Z

Background: While performing sacrectomy from a posterior approach enables the en bloc resection of sacral tumors, it can result in deep posterior peritoneal defects and postoperative complications. We investigated whether defect reconstruction with gluteus maximus (GLM) adipomuscular sliding flaps would improve patient outcomes. Methods: Between February 2007 and February 2012, 48 sacrectomies were performed at He Nan Tumor Hospital, Zhengzhou City, China. We retrospectively examined the medical records of each patient to obtain the following information: demographic characteristics, tumor location and pathology, oncological resection, postoperative drainage and complications. Based on the date of the operation, patients were assigned to two groups on the basis of closure type: simple midline closure (group 1) or GLM adipomuscular sliding reconstruction (group 2). Results: We assessed 21 patients in group 1 and 27 in group 2. They did not differ with regards to gender, age, tumor location, pathology or size, or fixation methods. The mean time to last drainage was significantly longer in group 1 compared to group 2 (28.41 days (range 17--43 days) vs. 16.82 days (range 13--21 days, P < 0.05)) and the mean amount of fluid drained was higher (2,370 mL (range 2,000--4,000 mL) vs. 1,733 mL (range 1,500--2,800 mL)). The overall wound infection rate (eight (38.10%) vs. four (14.81%), P < 0.05) and dehiscence rate (four (19.05%)] vs. three (11.11%), P < 0.05) were significantly higher in group 1 than in group 2. The rate of wound margin necrosis was lower in group 1 than in group 2 (two (9.82%) vs. three (11.11%), P < 0.05). Conclusions: The use of GLM adipomuscular sliding flaps for reconstruction after posterior sacrectomy can significantly reduce the risk of infection and improve outcomes.

A comparison of cyst wall curettage and en bloc excision in the treatment of aneurysmal bone cysts

Pawel Flont — 2013-05-23T00:00:00Z

Background: The recurrence rate after aneurysmal bone cyst (ABC) treatment is quite high despite its benign nature. In ABC therapy, curettage is the treatment of choice; en bloc excision results in a lower recurrence rate, but more extensive reconstructive surgery is needed with associated morbidity. The aim of the present study was to compare the outcomes of the two treatment options. Methods: A retrospective analysis was performed on 26 patients treated for ABCs: 16 by curettage and 10 by en bloc excision. Each lesion was classified according to Enneking and patients were followed up for a mean time of 9.2 years. On follow-up, radiological examination and functional assessment (range of motion, muscle strength) were performed. Recurrence was defined as the presence of an osteolytic lesion, especially one with a tendency to grow. Results: On follow-up, the following symptoms were more prevalent in the en bloc excision group compared to the curettage group: pain (en bloc 20% versus curettage 6.25%), limb length differences (en bloc 20% versus curettage 12.5%), reduced range of motion (en bloc 20% versus curettage 6.25%) and muscle strength impairment (en bloc 50% versus curettage 31.2%); however, the differences were not statistically significant (P >0.05). In the curettage group, two cases of postoperative complications and two cases of recurrence were seen, while in the en bloc excision group one case of complications was noted. Conclusions: Curettage is a standard procedure in ABC management. En bloc excision is another option, albeit more technically demanding, that may be considered in recurrent lesions with extensive bone destruction or for cysts in an expendable location.

Castleman's disease in the retroperitoneal space mimicking a paraspinal schwannoma: a case report

Satoshi Nagano — 2013-05-23T00:00:00Z

Background: Castleman’s disease is a rare disease characterized by lymph node hyperplasia. Its occurrence in the retroperitoneal space has rarely been reported, making its preoperative diagnosis difficult. Here, we report a case of retroperitoneal Castleman’s disease, which radiologically resembled paraspinal schwannoma.Case presentationA 33-year-old Japanese man with epigastric discomfort underwent abdominal ultrasonic examination revealing a solid mass next to the right kidney. Computed tomography demonstrated a well-circumscribed mass with central calcification in the right psoas muscle. Because the mass presented a dumbbell-like shape extending to the intervertebral foramen, neurogenic tumor was suspected. Both iodine-123 metaiodobenzylguanidine and gallium-67 scintigraphies were negative in the mass, whereas thallium-201 mildly accumulated in the tumor, suggesting blood flow to the tumor. Positron emission tomography revealed accumulation of fluorine-18-2-fluoro-2-deoxy-d-glucose in the tumor at a standard uptake value of 4.7, whereas no other abnormal uptake suggestive of metastatic lesion was noted. On the basis of imaging studies, we mostly suspected paraspinal schwannoma, although malignancy was not completely excluded. Angiography showed feeding vessels from the right lumbar arteries, which were embolized with porous gelatin particles in order to reduce intraoperative bleeding. Surgical resection was performed using a retroperitoneal approach, which revealed the tumor in the swollen psoas muscle. Intraoperative pathological examination of a frozen section revealed no evidence of malignancy; thus, marginal excision of the tumor was performed. The tumor adhered tightly to surrounding muscle tissues, resulting in 940 g of intraoperative blood loss. The pathological examination demonstrated infiltration of lymphocytes surrounding small germinal centers with extensive capillary proliferation. Immunostaining revealed that proliferated lymphocytes were CD3-negative and CD79a-positive. Conclusions: Although a dumbbell-shaped mass in a paraspinal region is indicative of a schwannoma for orthopedic surgeons, the possibility of Castleman’s disease should be considered if a central low-signal area in fissured and a radial pattern is detected on computed tomography or magnetic resonance imaging. Appropriate preparation for massive bleeding during the treatment of Castleman’s disease, including angiography and embolization, would be helpful for performing surgical procedures safely.

Intracardiac metastasis from known cervical cancer:a case report and literature review

Seung Won Byun — 2013-05-23T00:00:00Z

Cardiac metastasis from known cervical cancer is rare. Even through a routine check-up, this type of metastasis can present as pulmonary emboli. Suspicion of this diagnosis in an oncology patient with complicating pulmonary emboli but no evidence of deep vein thrombosis is important, especially in cervical cancer patients with extensive pelvic lymph node metastasis and vascular invasion of a primary tumor. Early recognition may aid in improving the prognosis. We present a case of intracardiac metastasis arising from a squamous carcinoma of the cervix in a patient with pulmonary tumor emboli and review other cases from the literature.

Middle-preserving pancreatectomy: report of two cases and review of the literature

Kun Cheng — 2013-05-23T00:00:00Z

Background: Middle-preserving pancreatectomy (MPP) is a parenchyma-sparing surgical procedure which has recently been sporadically reported for the treatment of multicentric periampullary-pancreatic lesions. However, a comprehensive recognition of this procedure has not been clearly elucidated.Case presentationWe herein report two patients undergoing MPP due to synchronous multicentric pancreatic neoplasm. Patient one was a 24-year-old woman with a multicentre solid pseudopapillary neoplasm (SPN) and patient two was a 36-year-old woman with a multicentric serous cystic neoplasm (SCN). Simultaneous atypical pancreaticoduodenectomy and atypical left pancreatectomy were performed in patient one; simultaneous standard pancreaticoduodenectomy and atypical left pancreatectomy with spleen preservation were performed in patient two. Approximately 6 cm and 5 cm segments of the middle portion of the pancreas were preserved, respectively. At follow-up at 36 months and 6 months respectively, patient one had developed diabetes and malabsorption requiring dietary control, exercise and pancreatic enzyme supplement whereas patient two showed normal fasting blood glucose without diarrhea. Both patients were disease-free and in good nutritional condition. We reviewed twenty cases of MPP that were previously reported in the literature. Patient characteristics, surgical techniques and short- and long-term outcomes were analyzed. Conclusion: MPP is mainly beneficial for multicentric noninvasive periampullary-pancreatic lesions. However, for multicentric periampullary-pancreatic lesions involving even primary invasive cancers, as long as the invasive cancers affect only one side of the pancreas (proximal or distal), MPP could serve as a rational choice in well-selected patients.

Single-incision video-assisted thoracoscopic resection of a pedunculated solitary fibrous tumor of the pleura: case report

Masaya Tamura — 2013-05-22T00:00:00Z

In this report, we describe the surgical resection of a pedunculated solitary fibrous tumor of the pleura (SFTP) by single-incision thoracoscopic surgery (SITS). SITS may be a suitable surgical option for pedunculated SFTPs.

Feasibility of sentinel lymph node biopsy in breast cancer patients clinically suspected of axillary lymph node metastasis on preoperative imaging

Hee Yong Kwak — 2013-05-21T00:00:00Z

Background: Generally, sentinel lymph node biopsy (SLNB) is performed in patients with clinically negative axillary lymph node (LN). This study was to assess imaging techniques in axillary LN staging and to evaluate the feasibility of SLNB in patients clinically suspected of axillary LN metastasis on preoperative imaging techniques (SI). Methods: A prospectively maintained database of 767 breast cancer patients enrolled between January 2006 and December 2009 was reviewed. All patients were offered preoperative breast ultrasound, magnetic resonance imaging, and positron emission tomography scanning. SI patients were regarded as those for whom preoperative imaging was “suspicious for axillary LN metastasis” and NSI as “non-suspicious for axillary LN metastasis” on preoperative imaging techniques. Patients were subgrouped by presence of SI and types of axillary operation, and analyzed. Results: For 323 patients who received SLNB, there was no statistically significant difference in axillary recurrence (P=0.119) between SI and NSI groups. There also was no significant difference in axillary recurrence between SLNB and axillary lymph node dissection (ALND) groups in 356 SI patients (P=0.420). The presence of axillary LN metastasis on preoperative imaging carried 82.1% sensitivity and 45.9% specificity for determining axillary LN metastasis on the final pathology. Conclusions: SLNB in SI patents is safe and feasible. Complications might be avoided by not performing ALND. Therefore, we recommend SLNB, instead of a direct ALND, even in SI patients, for interpreting the exact nodal status and avoiding unnecessary morbidity by performing ALND.

Prognostic value of the seventh AJCC/UICC TNM classification of non-cardia gastric cancer

Luigina Graziosi — 2013-05-20T00:00:00Z

Background: The TNM staging criteria for gastric carcinoma have seen numerous revisions, the most recent of which are reflected in the seventh edition AJCC TNM cancer staging manual. Methods: A retrospective evaluation of the sixth and seventh TNM classification of gastric cancer on a prospective database, regarding patients operated on for primary gastric cancer, was conducted. The end point of the study was prognosis evaluation in terms of overall survival.Patients operated on for primary gastric cancer between September 2003 and March 2012 at our Department of Emergency and General Surgery, were consecutively retrieved in this study; a total of 114 patients were considered. Cardia gastric cancers, gastric lymphomas and gastrointestinal stromal tumors (GIST) were excluded. Median and mean follow-up periods were 22.5 and 27.7 months (range 15 days to 5 years). Both TNM6 and TNM7 were used to evaluate our patients. Overall survival and survival rates at different stages were analyzed using the Kaplan-Meier method and differences were determined using a log-rank test. Cox's proportional hazard model was used to identify significant factors related to prognosis in a multivariate analysis. Results: Overall survival between the sixth and seventh TNM classification was not significantly different. Both the Kaplan-Meier analysis and the multivariate analysis showed that the major negative prognostic factor was lymphovascular invasion (P < 0.001 in the univariate analysis and P = 0.035 to 0.048 in the multivariate analysis). Stage distribution and stage-related survival changed from the sixth to the seventh edition, especially in T3 stage where median survival for the sixth edition was 720 days versus 1,200 days for the seventh edition. Moreover, differences were shown in the survival rate of N1 versus N2 stages within the seventh TNM. Conclusions: Even though further studies are needed in order to increase the number of patients studied, the seventh edition seems to provide a more accurate prognosis, especially regarding N1 and N2 tumors, showing that the most important prognostic factor is lymphovascular invasion.