Latest News on Cancer Surgery : Nov 2020

Latest News on Cancer Surgery : Nov 2020


Impaired immunologic reactivity and recurrence following cancer surgery

One hundred patients were tested for their ability to react to 7 commonly encountered skin test antigens and to develop delayed cutaneous hypersensitivity to 2, 4‐dinitrochlorobenzene (DNCB). Following sensitization, more than 95% of normal patients, but only 60% of patients with potentially resectable neoplasms, exhibited delayed cutaneous hypersensitivity to DNCB. A correlation is suggested between the inability to react to DNCB and the incidence of either inoperability, local recurrence, or distant metastases within 6 months post‐operatively. Ninety‐three percent (27/29) of patients who failed to react to DNCB were inoperable or developed early recurrence, whereas 92% (50/54) of patients who reacted to DNCB were free of disease for 6 months; but many of these patients were nonreactive to all of the common skin test antigens. These studies suggest that there is a significant correlation between cell mediated immunologic reactivity as measured by delayed cutaneous hypersensitivity to DNCB and the course of malignant disease following definitive cancer surgery. [1]

Guidelines 2000 for Colon and Rectal Cancer Surgery

Background: Oncologic resection techniques affect outcome for colon cancer and rectal cancer, but standardized guidelines have not been adopted. The National Cancer Institute sponsored a panel of experts to systematically review current literature and to draft guidelines that provide uniform definitions, principles, and practices. Methods: Methods were similar to those described by the American Society of Clinical Oncology in developing practice guidelines. Experts representing oncology and surgery met to review current literature on oncologic resection techniques for level of evidence (I–V, where I is the best evidence and V is the least compelling) and grade of recommendation (A–D, where A is based on the best evidence and D is based on the weakest evidence). Initial guidelines were drafted, reviewed, and accepted by consensus. Results: For the following seven factors, the level of evidence was II, III, or IV, and the findings were generally consistent (grade B): anatomic definition of colon versus rectum, tumor–node–metastasis staging, radial margins, adjuvant R0 stage, inadvertent rectal perforation, distal and proximal rectal margins, and en bloc resection of adherent tumors. For another seven factors, the level of evidence was II, III, or IV, but findings were inconsistent (grade C): laparoscopic colectomy; colon lymphadenectomy; level of proximal vessel ligation, mesorectal excision, and extended lateral pelvic lymph node dissection (all three for rectal cancer); no-touch technique; and bowel washout. For the other four factors, there was little or no systematic empirical evidence (grade D): abdominal exploration, oophorectomy, extent of colon resection, and total length of rectum resected. Conclusions: The panel reports surgical guidelines and definitions based on the best available evidence. The availability of more standardized information in the future should allow for more grade A recommendations. [2]

Impact of Hospital Volume on Operative Mortality for Major Cancer Surgery

Context.— Hospitals that treat a relatively high volume of patients for selected surgical oncology procedures report lower surgical in-hospital mortality rates than hospitals with a low volume of the procedures, but the reports do not take into account length of stay or adjust for case mix.

Objective.— To determine whether hospital volume was inversely associated with 30-day operative mortality, after adjusting for case mix.

Design and Setting.— Retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked database in which the hypothesis was prospectively specified. Surgeons determined in advance the surgical oncology procedures for which the experience of treating a larger volume of patients was most likely to lead to the knowledge or technical expertise that might offset surgical fatalities.

Patients.— All 5013 patients in the SEER registry aged 65 years or older at cancer diagnosis who underwent pancreatectomy, esophagectomy, pneumonectomy, liver resection, or pelvic exenteration, using incident cancers of the pancreas, esophagus, lung, colon, and rectum, and various genitourinary cancers diagnosed between 1984 and 1993.

Main Outcome Measure.— Thirty-day mortality in relation to procedure volume, adjusted for comorbidity, patient age, and cancer stage.

Results.— Higher volume was linked with lower mortality for pancreatectomy (P=.004), esophagectomy (P<.001), liver resection (P=.04), and pelvic exenteration (P=.04), but not for pneumonectomy (P=.32). The most striking results were for esophagectomy, for which the operative mortality rose to 17.3% in low-volume hospitals, compared with 3.4% in high-volume hospitals, and for pancreatectomy, for which the corresponding rates were 12.9% vs 5.8%. Adjustments for case mix and other patient factors did not change the finding that low volume was strongly associated with excess mortality.

Conclusions.— These data support the hypothesis that when complex surgical oncologic procedures are provided by surgical teams in hospitals with specialty expertise, mortality rates are lower. [3]

The Impact of Body Mass Index on the Surgical Outcomes in Open Rectal Cancer Surgery

Technical difficulties which affect the outcomes of abdominal operations are common in obese patients, especially in rectal and gastric cancer cases. In several studies, it has been shown that increased body mass index (BMI) is associated with increased morbidity, reduced lymph node retrieval and prolonged hospital stay after colorectal surgery. The aim of this study was to assess the influence of obesity on the surgical outcomes (surgical margin, number of lymph nodes excised) of rectal cancer patients who were operated by open surgery. One hundred rectal cancer patients who underwent open surgery in a single center between January 2011 and August 2014 were included in this study. Patients were divided into two groups according to their BMI values. According to their preoperative BMI values, patients with a BMI of ≥30 kg/m2 (n=29) were defined as ‘obese’. Patients with a BMI of <30 kg/m2 (n=71) were placed in the normal (non-obese) group. Demographic data, surgical margins, the number of lymph nodes retrieved and surveillance of both groups were compared. Obese and normal groups were statistically indifferent in terms of age, sex and stage of the disease. Comparison of the obese and normal groups showed no statistically significant difference in terms of surgical margins and the number of lymph nodes retrieved. This study showed that obesity does not affect the surgical outcomes in rectal cancer. However, prospective studies with larger patient series are needed. [4]

Bronchial Sleeve Resection for Lung Cancer Preoperative Empyema

Surgical management of the cancer with empyema has rarely been reported in the literature because few of such cases are operable. Many patients might be misevaluated because of the incorrect staging associated with an acute or sub-acute infection. Even in the presence of an operable tumor mass; surgeons behave timid to these patients because of the possibility of infective postoperative complications. The balance between expected benefits and possible risk of surgical intervention is also important. If it is indicated, by the time pleural empyema is restored, procedures such as resection and even bronchoplasty should be performed.

59-years old patient with squamous cell carcinoma that completely obstructed left basal segments and caused to empyema. A thoracic catheter was inserted. Multiple pleural irrigations were done and proper antibiotherapy. Pathologic diagnosis of pleural fluid and pleural biopsy were benign. Pleural cultures were negative and amount of empyema fluid volume has decreased within two months. Positron emission tomography (PET) revealed a 2.5 cm sized left infrahilar tumor, right paratracheal, prevascular and subcarinal lymph nodes and non-homogeneous increased pleural activity. Mediastinal lymph nodes were evaluated as reactive with mediastinoscopy. Left lower lobectomy and lingulectomy were performed with bronchial resection and pathologic stage was 2A (T1bN1MO). [5]

Reference

[1] Eilber, F.R. and Morton, D.L., 1970. Impaired immunologic reactivity and recurrence following cancer surgery. Cancer, 25(2), pp.362-367.

[2] Nelson, H., Petrelli, N., Carlin, A., Couture, J., Fleshman, J., Guillem, J., Miedema, B., Ota, D. and Sargent, D., 2001. Guidelines 2000 for colon and rectal cancer surgery. Journal of the National Cancer Institute, 93(8), pp.583-596.

[3] Begg, C.B., Cramer, L.D., Hoskins, W.J. and Brennan, M.F., 1998. Impact of hospital volume on operative mortality for major cancer surgery. Jama, 280(20), pp.1747-1751.

[4] Solmaz, A., Gülçiçek, O., Binboğa, E., Biricik, A., Erçetin, C., Yiğitbaş, H., Yavuz, E., Çelik, A. and Çelebi, F. (2016) “The Impact of Body Mass Index on the Surgical Outcomes in Open Rectal Cancer Surgery”, Journal of Advances in Medicine and Medical Research, 14(10), pp. 1-5. doi: 10.9734/BJMMR/2016/25148.

[5] Kuman, N., Çokpınar, S. and Yaman, E. (2015) “Bronchial Sleeve Resection for Lung Cancer Preoperative Empyema”, Journal of Advances in Medicine and Medical Research, 7(1), pp. 82-85. doi: 10.9734/BJMMR/2015/16007.

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