International advances in surgical oncology最新文献

Hepatic neoplasms, primary and metastatic, are best treated with surgery. The present report summarizes the results of various surgical procedures used during the last eight years in the management of 310 patients with liver neoplasms. Exploratory laparotomy was the ultimate diagnostic test, determining resectability of the lesion. Percutaneous liver biopsy was discouraged and was used only in the presence of obvious distant metastasis. Primary and metastatic neoplasms confined to the liver were managed with lobectomy, hepatic trisegmentectomy, or left lateral segmentectomy whether they were solitary or multifocal; the choice of procedure depended on their location. Tumors invading major vascular structures were resected using a new method of hepatic isolation/hypothermic perfusion. Neoplasms involving the entire liver were managed with intrahepatic infusion chemotherapy administered directly into the hepatic circulation through percutaneous catheters. Selected individuals with unresectable lesions were treated with vascular isolation and perfusion of the liver with chemotherapeutic agents. Budd-Chiari syndrome caused by malignant obstruction of hepatic outflow was managed either with isolation/hypothermic perfusion and resection or with hepatic artery ligation and infusion of chemotherapeutic agents. Total hepatectomy with orthotopic liver transplantation was reserved for a few highly selected individuals. The results obtained with these procedures were encouraging. Major hepatic resection was performed with a 9% operative mortality and resulted in an 81% 3-year actuarial survival if the disease was limited to the liver. Palliative major resection in a 31% 3-year actuarial survival. Intrahepatic infusion of chemotherapeutic agents was effective when the dosage was adequate and proved superior to peripheral intravenous treatment. Isolation perfusion of the liver permitted resection of lesions which could not have been managed by conventional procedures. The effectiveness of isolation chemotherapy perfusion of the liver was tempered by leakage of Actinomycin-D into the systemic circulation. The results is this series of patients encourage the judicious use of these procedures in the management of the patient with liver cancer. A pessimistic attitude often based on preoperative evaluation alone without the benefit of exploratory laparotomy ought to be discouraged.

The literature on tumor distinctive markers in ovarian cancer has been reviewed. Various immunological and biochemical approaches have been attempted for the diagnosis and management of patients with ovarian cancer. The complex spectrum of antigens that can be detected in human ovarian cancer consists of several tumor-associated antigens, fetal or carcinoembryonic antigens, carcinoplacental markers, and normal tissue antigens. We have described and partially characterized two ovarian tumor-associated antigens designated as OCAA and OCAA-1, which seem to have potential for the immunodiagnosis of ovarian cancer. Several other investigators have carried out similar studies, but in general their serological characterization of these antigens has been limited. The well-defined embryonic proteins that have been examined in the ovarian cancer include carcinoembryonic antigen (CEA), alpha-fetoprotein (alpha-fp), beta-oncofetal antigen (BOFA), Regan and Nagao isoenzymes and human chorionic gonadotropin (HCG). The presence of pregnancy-zone protein (PZP) has also been reported in ovarian cancer. In addition, several normal tissue components include fibrin-fibrinogen degradation products (FDP), alpha 1-globulin, and urokinase have been found associated with ovarian cancer. Both humoral antibodies and cell-mediated immune responses against tumor-associated antigens can be measured in ovarian cancer patients. In addition, serum factors, which block cellular immune reactions, have been identified. However, progress in this area has been hampered by the complexity of the antigens associated with ovarian tumors and the lack of standardized, well-characterized sources of antigens or target cells. Enzymes, especially those involved in glycoprotein biosynthesis, (eg, glycoprotein:glycosyltransferases and glycosidase) have been explored as possible early biochemical indicators of ovarian neoplasia. A serum specific deficiency of alpha-L-fucosidase has been found in patients with ovarian cancers. Of all the glycoprotein:glycosyltransferases studied, galactosyltransferase has been found to be the best enzyme marker for ovarian adenocarcinoma. The determination of serum levels of this enzyme reflected the clinical status of the patient with respect of tumor progression as well as tumor burden. Recently, assay of a phosphodiesterase, which specifically hydrolyzes cytidine 5'-monophospho-N-acetylneuraminic acid, has been found promising in the detection and management of patients with ovarian cancer.

The long term survival rate of gastric cancer has been much improved, and the 5-year survival rate in our institute was 42% with a significant difference between 29% in the advanced stage and 94% in the early stage. This result means that gastric cancer must be detected and treated early as possible. However, the diagnosis of early gastric cancer may remain extremely difficult even for an excellent endoscopist. Therefore, in order to clearly recognize early gastric cancer, an endoscopic staining method with methylene blue has been studied. In this method, one capsule of 150 mg methylene blue is swallowed with a small amount of proteinase solution 3 hours before endoscopy. Gastroscopy is performed routinely after this preparation. This procedure was performed on 153 gastric cancers and 137 of them (89.5%) have been successfully dyed in dark blue. In several cases, with this method, the actual borderline between the normal mucosa and the malignant extent was clearly recognized and resection line was decided. Introduction of methylene blue into the stomach could also stain the intestinalized epithelium of the gastric mucosa. Differential diagnosis of the dyed intestinal metaplasia and the dyed carcinoma seems to be very easy, because both gastric lesions have the characteristic dyed patterns. Mechanism of this phenomenon has been considered to be due to an absorption of the dye in the intestinal metaplasia, and in the gastric cancer, many factors may be involved, among which are the infiltration or diffusion of the dye into the cancerous tissue, the absorption from the abnormal epithelium, and the staining of the necrotic tissue.

The surgical treatment of carcinoma has been likened by some to "a macroscopic attack on a microscopic disease." Until better alternatives of treatment emerge, our best hopes for cure and significant palliation lie in early detection of disease, accurate staging, and appropriate surgical intervention, the last selectively supplemented with irradiation or chemotherapy or both. Oncologic surgery must be guided by accurate staging. Radical resection is appropriate when performed to eradicate malignancy discovered early and when the surgery neither unnecessarily sacrifices organ function nor interferes with an acceptable quality of life. Radical surgery in the presence of distant spread of disease is not always warranted. Other choices exist that may better serve the interests of such direly affected patients.

The overall five year survival of patients with colorectal cancer is excellent compared with other major visceral malignancies. This is attributable to effect surgical treatment, yet the death rate per 100,000 population has improved little in recent decades, stimulating a search for adjuvant treatment modalities until a better understanding of etiology and pathogenesis results in prevention of earlier diagnosis. Combination of the known cancerocidal effect of ionizing radiation and surgical excision has been used sporadically for over six decades, but only recently has this combined modality therapy been studied in a scientific manner. Numerous variables such as source of radiation, total tumor dose, dose-time factors, location of portals of treatment, size and shape of radiation fields, and the radiation-surgery sequence are now being studied. Current information leaves little doubt of the effectiveness of this combined modality therapy in selected patients. Controlled clinical trials must continue in order to obtain more solid data, which hopefully will eventually result in substantially improved survival.

Irradiation can eradicate the microscopic disease that radical surgical procedures cannot remove, but high doses of irradiation fail to control large volumes of cancer. The concept "either irradiation or surgery" for all clinical situations should be eliminated. If irradiation has no place as the sole treatment for a disease, for example soft-tissue sarcomas or parotid tumors, it does not mean that it has no place in the management of the disease. Conservatism in both disciplines is to be preferred. Not only are the chances for cure increased, but also the quality of life is improved. On theoretical grounds, preoperative irradiation is to be preferred, but the sequence of te modalities of treatment depends upon the structures involved, the extent of the surgical procedure, the dose of irradiation, and the volume irradiated. Examples and results of the combined treatment in various disease areas are given.

Between 1952 and 1976 192 consecutive cases of penile epidermoid carcinoma were seen at the Instituto Nacional de Enfermedades Neoplascias of Lima, Peru. The mean age when the disease developed was 60.5 years, with a peak incidence between 60 and 64 years (32 patients). No correlation was observed between extensive lesions of the shaft of the penis to high pathological staging. Clinical examination of the inguino-crural nodes is not a good criterion for staging. We wait six weeks after eradication of primary lesion before lymphadenectomy. No correlation exists between grade and pathological stage. When no lymph node was positive, the overall survival rate over five years was 90.69%; when lymph nodes were metastasized there was an overall survival rate over five years of only 9.39 percent. The coefficient of cancer versus noncancer cause of death was 1.25 for pathological stage I, 3.09 for pathological stage II, 4.83 for pathological stage III, and 10.000 for pathological stage IV. Our patients did have advanced disease, as 57.14% of deaths occurred at two years and 25.21% more at five years.

Following a brief historical introduction to the use of lasers in surgery, the principal characteristics of laser light sources relevant to surgery with lasers are reviewed and the nomenclature most often used in connection with laser devices is explained. The interactions of electromagnetic energy with soft tissues that make possible ablative surgery with carbon dioxide lasers are stressed. The general requirements of laser instruments for clinical surgery are mentioned in conclusion.